Utilization Management Strategies to Address the Opioid Crisis

The opioid epidemic does not discriminate, impacting communities and families across the nation. Recognizing our unique reach, expertise, and access to affected and at-risk individuals, CVS Health launched an enhanced enterprise-wide approach to helping prevent opioid misuse and abuse. And initial results show our efforts are helping reduce opioid dispensing.

Preventing Prescription Opioid Abuse through Utilization Management

Statistics show that the longer the supply of opioids, the more likely a first-time user is to become a chronic user.Centers for Disease Control and Prevention. “Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use — United States, 2006–2015.” Accessed February 2018. https://www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm With this in mind, we designed utilization management efforts that ensure opioids are being prescribed and used appropriately.

Our opioid utilization management criteria aligns with the Centers for Disease Control and Prevention (CDC) guidelines.Centers for Disease Control and Prevention. “CDC Guideline for Prescribing Opioids for Chronic Pain.” Accessed February 2018. https://www.cdc.gov/drugoverdose/prescribing/guideline.html Updated standards for CVS Caremark members, unless prior authorization is given, include:

  • Seven-day supply limits for acute pain where appropriate;
  • Morphine milligram equivalent (MME) quantity limits; and
  • Immediate release (IR) before extended release (ER) step therapy.

Our initial findings indicate clients that implemented our opioid utilization management program in 2017 had a number of positive results, including that the number of patients new to opioid therapy with an acute condition who received more than a seven day supply of an opioid decreased 70 percent. For those clients, the number of patients new to opioid therapy who receive a seven-day supply or less is now nearly 94 percent.

Preventing Prescription Opioid Abuse Before and After Dispensing

Complementing utilization management, our efforts to prevent prescription opioid abuse extend to monitoring before and after dispensing. Our pharmacists prospectively monitor use before prescriptions are dispensed for all CVS Caremark mail or retail pharmacy prescriptions, and we retrospectively monitor for fraud, provider shopping, over-utilization, and potential abuse.

While there remains much to be done to address the opioid crisis, strategies like enhanced utilization management, as well as our other prevention and disposal efforts, are working to mitigate the impact of the epidemic across the nation.

For more information about our efforts in the fight against opioid abuse, visit Our Commitment to Fight Opioid Abuse and the CVS Health Impact Dashboard. And to stay informed about the most talked-about topics in health care, register for content alerts and our bi-weekly health care newsletter.