America’s opioid epidemic: A public health emergency

Part 2: Take action, but make it count

Cathy Starner, PharmD, BCPS | October 30, 2017

In the first part of this series, we identified the huge scope of the crisis before us. As a pharmacy benefit manager (PBM), we have a responsibility to act. That responsibility starts with looking at the big picture.

Because of Prime’s integration with Blue Plans, we have access to medical and pharmacy data. This provides insights into how controlled substance (e.g., opioids) use impacts members. It helps us identify patterns of use and misuse and target opportunities for intervention.

No other PBM clinical team has produced as much unbiased, peer-reviewed research on the use and misuse of controlled substances in the managed care setting.       

Prime developed a predictive model controlled substance score that can identify members at risk of increasing health care use. The controlled substance score takes its calculation from a point system that uses:

  • The number of unique controlled substance claims
  • Number of unique pharmacies and prescribers and
  • Utilization rate over time

Every one point increase in the controlled substance score is associated with:

  • $1,488 increase in total cost of care
  • $235 increase in controlled substance drug cost
  • 0.9% increase in hospitalization rate
  • 1.5% increase in emergency room visit rate

Prime uses the controlled substance score within the GuidedHealth® rules engine to target and prioritize interventions.

Identifying at-risk users

Opioid abusers frequently use other controlled substance at the same time. This increases the risk of overdose and death.1 It’s helpful to have a variety of tools to identify high-risk controlled substance use.

Centers for Medicare & Medicaid Services Overutilization Monitoring System (OMS) identifies members at risk as those who:

  • Use high-dose opioids
  • Take opioids for extended periods of time
  • Use more than three prescribers
  • Fill prescriptions at more than three pharmacies

A triple threat therapy alert identifies members getting all three drugs from two or more prescribers over time:

  • an opioid
  • a benzodiazepine and
  • a muscle relaxant

Taking action

PBMs can offer plan sponsors many options to address controlled substance misuse and abuse:

  • Utilization management programs support CDC prescribing guidelines1  
  • Claims analysis identifies members at risk for misuse and abuse.
  • Prime’s controlled substance score helps a plan sponsor prioritize members for intervention.

Be sure to look for the next post in our series: Part 3: Success comes from sustainable strategies backed with evidence.

You may also want to look at Thought leadership / Controlled Substances, where you can find more of Prime's work in this area. 

1. Dowell D, Haegerich TM, Chou R,  “CDC Guideline for Prescribing Opioids for Chronic Pain – United States, 2016. Morbidity and Mortality Weekly Reort (MMWR). Recommendations and Reports.  / March 18, 2016. 65(1); 1-49. Accessed at:

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