SS&C's Theresa Lane looks at the HEDIS® 2020 guidelines and the preventive measures plans can take under the pharmacy benefit to manage opioid overuse.

This is the third in a SS&C series on HEDIS 2020 guidelines, discussing some preventive measures plans can take under the pharmacy benefit to manage opioid overuse with their patients.

In the United States, the total economic burden of opioid overdose, abuse and dependence is estimated at $78.5 billion (2013 data year).1 Seventy-five percent of the people who misused these drugs developed an opioid use disorder by taking prescription medications.2 

There are some risk factors for prescription opioid abuse and overdose, including overlapping prescriptions from multiple prescribers/pharmacies and taking high daily dosages of prescription opioid pain relievers.3 Health plans can take steps to address these risk factors and decrease opioid abuse and misuse through simple restrictions to the drug formulary and benefit design and by using an MTM program.  Here are some recommendations:

For short-acting opioid use for acute pain, the health plan can implement the following measures to prevent opioid abuse and misuse:

  • A maximum daily limit of 49 morphine milligram equivalents (MME) for opioid-naïve members
  • A maximum daily limit of 90 MME for experienced members
  • A days supply limit of 7 days for treating acute pain in naïve adult members
  • A days supply limit of 3 days for treating acute pain in naïve pediatric members

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  1. Florence, Curtis S., PhD; Zhou, Chao, PhD; Luo, Feijun, PhD; Xu, Likang, MD. The Economic Burden of Prescription Opioid overdose, Abuse, and Dependence in the United States, 2013. Medical Care: October 2016. 54(10): 901-906.
  2. Cicero, Theodore J., PhD; Ellis, Matthew S., MPE; Surratt, Hilary L. PhD; Kurtz,
  3. Steven P., PhD. The Changing Face of Heroin Use in the United States; A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014. 71(7): 821-826


About the author
Theresa Lane is the manager of clinical programs for SS&C Health, managing the drug use review program and the team responsible for drug updates in the pharmacy claims processing system. Dr. Lane also develops and maintains the programs for adherence analytics, and the comprehensive medication review. 

Dr. Lane is a clinical pharmacist with over 23 years’ experience in pharmacy benefit management. She began her career in hospital pharmacy, and then moved to a HMO health plan, and on to pharmacy benefit management.  She previously worked as pharmacy director for Trillium Community Health Plan, a local Medicare plan in Oregon, and has experience at two major PBMs, Catamaran, and WellPoint. Dr. Lane joined pharmacy solutions in 2014 and since then has developed medication therapy management, prior authorization, and star ratings quality programs for a local Medicare plan.  She has also created reporting and analytics tools to affect health behaviors and engage members.