​HealthChoice Opioid Response Recommendations

According to the Centers for Disease Control and Prevention, inappropriate prescribing practices and opioid prescribing rates are substantially higher among Medicaid patients than among privately insured patients.

In one study based on 2010 data, 40 percent of Medicaid participants with prescriptions for pain relievers had at least one indicator of potentially inappropriate use or overlapping prescriptions for pain relievers, overlapping pain reliever and benzodiazepine or extended release prescription pain relievers for acute pain, and high daily doses.

With more than 20 percent of Marylanders enrolled in the HealthChoice program and six of eight managed care organizations being integrated provider and payer networks, Maryland Medicaid's HealthChoice managed care organizations are a critical partner in helping achieve maximum results in combatting the opioid epidemic.

Maryland Medicaid is moving to implement policy changes recommended by the Centers for Disease Control and Prevention for both Medicaid fee-for-service and all HealthChoice managed care organizations that will:

• Prevent medical and non-medical opioid misuse, abuse, and addiction from developing;
• Identify and treat opioid dependence early in the course of the disease;
• Prevent overdose deaths, medical complications, psychosocial deterioration, transition to injection drug use, and injection-related disease; and
• Use data to monitor and evaluate activities.

As such, Maryland Medicaid recommends to following:

1. Consider non-opioids first-line treatment for chronic pain.

The Centers for Disease Control and Prevention recommends expanding first-line treatment options for non-opioid pain therapies. To address this recommendation, non-steroidal anti-inflammatory drugs, duloxetine (for chronic pain), diclofenac topical; and certain first-line non-pharmacological treatment options (e.g., physical therapy) are all available for prescription within the HealthChoice program.

2. Require prior authorization for long-acting opioids, fentanyl products, methadone for pain, and any opioid prescription that result in a patient exceeding 90 morphine milligram equivalents per day, with a standard 30-day quantity limit for all opioids set at or below 90 milligram equivalents per day.

Providers must obtain a prior authorization every six months to prescribe long-acting opioids, fentanyl products, methadone for pain and opioids above 90 milligram equivalents per day.

Prior authorization will, at a minimum, require the following items:

• Attestation of a patient-provider agreement;
• A medical justification for high-dose and/or long-acting opioid prescription;
• Attestation of screen patient with random drug screen(s) before and during treatment; and
• Attestation that a naloxone prescription was given or offered to the patient/patient's household member.

Patients with sickle cell anemia or patients in Hospice are excluded from the prior authorization process, but should also be kept on the lowest effective dose of opioids for the shortest required duration to minimize risk of harm.

HealthChoice managed care organizations may choose to implement additional requirements or limitations beyond the State's policy.

3. Screen patients for Substance Use Disorder.

Providers should always use caution in prescribing opioids for any patients who are identified as having any type of or history of substance use disorder. Providers should refer any patient identified as having a substance use disorder to a substance use treatment program.

Before prescribing an opioid or any controlled substance, providers should use standardized tool(s) to screen for substance use. Screening, Brief Intervention and Referral to Treatment (SBIRT) is an evidence-based practice used to identify, reduce, and prevent problematic use, abuse and dependence on alcohol and drugs. SBIRT enables providers to systematically screen and assist people who may not be seeking help for a substance use problem, but whose drinking or drug use may cause or complicate their ability to successfully handle health, work or family issues. The provision of SBIRT is a billable service under Medicaid.

4. Refer patients identified as having Substance Use Disorder to substance use treatment.

Maryland Medicaid administers specialty behavioral health services through a single Administrative Services Organization: Beacon Health Options. Referrals for behavioral health treatment resources are available through Beacon Health Options.

5. Prescribe Naloxone to patients who meet certain risk factors.

Both the Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services emphasize that clinicians should incorporate strategies to mitigate the risk of overdose when prescribing opioids. We encourage providers to prescribe naloxone - an opioid antagonist used to reverse opioid overdose - if any of the following risk factors are present:

• History of substance use disorder;
• High dose or cumulative prescription that result in over 50 milligram equivalents per day;
• prescriptions for both opioids and benzodiazepine or non-benzodiazepine sedative hypnotics; or
• other factors, such as drug-using friends/family.

6. Use the Prescription Drug Monitoring Program for all Controlled Dangerous Substance prescriptions.

Administered by the Department of Health and Mental Hygiene, the Prescription Drug Monitoring Program gives health care providers access to their patients' Controlled Dangerous Substance prescription profile. Practitioners can access Prescription Drug Monitoring Program at no cost through the Chesapeake Regional Information System for Our Patients (CRISP) health information exchange. Providers who register with CRISP get access to a powerful virtual health record that includes patient hospital admission, discharge and transfer records, laboratory and radiology reports, clinical documents, as well as Prescription Drug Monitoring Program data.

If you are not already a registered CRISP user, you can register for free. The Prescription Drug Monitoring Program usage is highly encouraged for all Controlled Dangerous Substance prescribers and will become mandatory (by law) on July 1, 2018.