Could the Specialty Pharmacy Model Help to Curb the Opioid Epidemic?

Everywhere you turn, the opioid epidemic continues to be a topic of concern. In 2016, there were 42,249 deaths from an opioid-related overdose, with 40% of those fatalities attributed to prescription opioid use. Every day, more than 1000 people are treated in emergency departments for misusing prescription opioids, with billions of dollars spent each year on medical costs, rehabilitation services, social services, and law enforcement related to the opioid epidemic.
 
With these staggering figures, it’s no wonder the opioid epidemic continues to be of high concern, affecting a large portion of the population and causing a financial strain on the health care system.
           
Industry leaders have begun to act against the epidemic. These actions include imposing quantity limitations on initial and ongoing opioid prescriptions, making drug disposal units and opioid reversal products more readily available, and expanding the reach of educational services that address the addictive potential of opioids to students, parents, and the general public.
 
The US Department of Health and Human Services (HHS) published a 5-prong approach to curb the utilization of opioid medications:
 
1.    better addiction prevention, treatment, and recovery services
2.    better data
3.    better pain management
4.    better targeting of overdose reversing drugs
5.    better research
 
There have also been movement to raise awareness regarding the addictive potential of these medications among prescribers and patients via risk evaluation and mitigation strategies deployed by various manufacturers in conjunction with the FDA; however, we are far from reversing the opioid epidemic any time soon.
 
A Possible Solution?
If we focus on 3 of the 5 pillars from the HHS plan—better prevention and recovery services, better data, and better condition management—and take them out of the context of the opioid epidemic, the specialty model may come to mind. Now you may say, the specialty model typically focuses on rare conditions, and you are absolutely correct.
 
But keep in mind, key operational components of the model include health care expertise in a particular therapeutic area, financial assistance, benefits verification, and educational and clinical services that ensure both access to necessary treatment options as well as positive health outcomes. 
 
You might also suggest that this would be impossible due to the sheer volume of scripts written on a regular basis or the immediate need for many pain medications. I cannot argue the fact that the sheer volume of opioids prescribed on a daily basis certainly exceeds the patient populations typically seen in a specialty pharmacy for most, if not all, specialty conditions. But aren’t a majority of specialty medications needed in a quick and timely fashion as well? Think about oncology or fertility, for example.
 
Patients filling these prescriptions require their medication in a timely fashion, which is able to be accommodated by the specialty model. Finally, you might say, opioids cannot be subjected to a specialty network because they aren’t costly enough.
 
Well, that’s not truly a part of the definition of a specialty drug, according to the National Association of Specialty Pharmacy. Although it is a common characteristic of many specialty medications, there are medication classes, such as HIV and transplant drugs, that are not as expensive as some recently launched agents, yet are in the specialty channel because of the clinical monitoring needed to ensure the best outcomes.
 
Putting aside some of these questions and arguments, could leveraging the specialty model be a reasonable solution to help curb the epidemic? Sounds like a crazy idea but hear me out.
 
The Specialty Process
When we consider specialty medications and the fulfillment process, benefits investigation is the first step. This is where insurance information is verified and it is determined whether a medication should be billed under the pharmacy benefit or medical benefit.
 
Additionally, any plan restrictions, such as formulary preference, prior authorization, or quantity limits, are addressed during this step as well. It is also where co-pays or coinsurances are discussed with patients and where financial assistance is sought after, if necessary. Finally, benefits representatives collect pertinent health information, such as name, address, contact information, and any additional medications used by the patient for both safety and tracking purposes.
 
Benefits verification focuses on initial data collection and ensuring any potential barriers to medication and care are addressed.
 
If we were to apply this operational piece of the puzzle to an opioid prescription, benefits research could be completed to address any utilization management and plan parameters that may be in place, something that will likely continue to increase as more emphasis is placed on the epidemic. Benefits representatives could also serve as a resource to collect pertinent health information such as the patient’s full medication history and potential risk for addiction based on medical history.
 


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