Texas’ age-adjusted drug overdose death rate fortunately has been one of the lowest in the nation in recent years, according to the Cen- ters for Disease Control and Prevention (CDC). Opioids are “the main driver of drug overdose deaths,” CDC said.

Year 2015 2014 2013

Drug Overdose Deaths in Texas 2,588 2,601 2,446

Death Rate per 100,000 People 9.4 9.7 9.3

State Rank in Death Rate 47 45 46

Source: Centers for Disease Control and Prevention, dose/data/statedeaths.html

pain medicines initially, most patients didn’t want them. They didn’t like the side effects,” he said. “But by about 2014, and ’15 and ’16 and ’17, patients expected it.” The increases in opioid overdoses

and related deaths have caused phy- sicians, lawmakers, and advocacy groups to pay attention, propose so- lutions, and take action. Increasingly, health plans are taking their own steps. Recent changes by Cigna Health

Insurance to its drug formulary and prior authorization processes are one example of how health plans are at- tacking the opioid crisis. But those changes — including required prior authorization of new prescriptions for long-acting opioids and quantity limits for short-acting opioids — high- light how one solution can create new obstacles for physicians. Dallas psychiatrist Leslie Secrest,

MD, chair of the Texas Medical As- sociation’s Task Force on Behavioral Health, says the focus needs to be on the best interest of patients. “It’s one of those things where you begin to ask physicians to carry that extra time and burden, and not nec-

38 TEXAS MEDICINE November 2017

O]]K\SVc KVaKc] Q_\O S^ SX^Y ^ROS\ \O- munerations necessary to go through these hoops,” he said.


In August, President Donald Trump announced his preliminary intention to declare the opioid crisis a national emergency. That announcement was a reaction to a problem commanding more and more attention from medi- cine, policymakers, and other inter- ested parties.

While the Centers for Disease

Control and Prevention (CDC) says the number of opioids prescribed in the United States peaked in 2010, the number of opioid deaths quadrupled from 1999 to 2015. And 2015 saw more than 33,000 opioid-involved drug overdose deaths nationally, more than any year on record. Most of the basic reasons for the

trend are well-documented: Studies in the 1980s cast doubt on the danger of treating chronic pain with opioids; a feeling emerged that the medical community was undertreating pain; KXN ^RO XY^SYX YP ZKSX K] K u P^R `S^KV sign” gained currency. Opioid use and abuse exploded.

The shift in thinking resulted in a landscape where “prescribing prac- tices may have become too lax,” says John Nguyen, MD, medical director of Integral Care, an organization that treats substance use disorders and mental illness in Travis County. “More doctors were afraid to treat pain with non-opioids or nonpharma- cologic interventions,” he said. Fortunately, Texas has one of the

lowest rates of overall drug overdose deaths, according to CDC data. (See “Drug Overdose Deaths in Texas,” at left.)

During the past year, several health

plans have publicly announced adjust- ments in their approaches to dealing with opioids. Cigna instituted changes effective July 1 as part of a “coordinat- ed, comprehensive response” to the opioid crisis. Those changes included:

• Applying prior authorization re- quirements to prescription claims for customers new to long-acting opioid therapy — those who haven’t had long-acting opioids under a Cigna plan in the past 120 days;

• Applying quantity limits to claims for customers who haven’t had short-acting opioid therapy in the past 90 days, with supplies exceed- ing 15 days requiring preauthoriza- tion; and

• Applying quantity limits to high- dose prescriptions and cough agents with codeine, both per Food and Drug Administration drug safety dosing recommendations.


introduce prior authorization for opi- oids, and insurers have instituted vari- ous initiatives to battle opioids. (See “Plans for Prevention,” page 43.) Rick Watson, DO, Cigna’s senior

medical director for North Texas, told Texas Medicine that examining new opioid claims was part of Cigna’s goal to reduce opioid prescriptions by 25 percent by 2019. Cigna said in April that 158 medical groups in Cigna Col- laborative Care, which represents

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