Independence continues to prioritize combating the opioid epidemic in the United States. Effective October 1, 2018, Independence?s opioid management policy for members with a commercial benefit will be updated to align with the most up-to-date Centers for Disease Control and Prevention (CDC) recommendations. By updating our policy, we hope to help ensure safe and appropriate opioid use.

CDC Guidelines for Prescribing Opioids for Chronic Pain¹

The following are some of the most important CDC guidelines providers should use when prescribing opioids:

• Opioids should not be considered first-line or routine therapy for chronic pain; clinicians should discuss benefits and risks and availability of non-opioid therapies with patients.
• An opioid dose of ?90 MME/day* should be avoided, when possible, and the clinicians should carefully justify a decision to titrate dosage to ?90 MME/day.
• Extended-release/long-acting (ER/LA) opioids should not be prescribed for acute pain. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of ER/LA opioids.

Opioid management updates for members with a commercial benefit

The following commercial benefit changes will become effective October 1, 2018:

• Cumulative daily limit of 90 MME will be applied across all opioids:
  • This limit is calculated based on the total daily dose of the opioid drug, by itself or in combination with other opioids.
  • For members whose opioid dose exceeds 90 MME/day, prior authorization is required.
• All long-acting opioid products will require prior authorization. This update only applies to products that do not currently have a prior authorization in place.
• All short-acting opioids will be limited to a 5-day supply. This update only applies to products that do not currently have a prior authorization in place.

Formulary update regarding opioids for members with a commercial benefit

As of October 1, 2018, Xtampza^? XR (Oxycodone ER capsules), which is an extended release, abuse deterrent form of oxycodone similar to OxyContin^?, will be the preferred long-acting oxycodone product. Studies indicate that Xtampza^? XR has the added benefit of being more crush resistant than OxyContin^?/oxycodone ER tablet.^2-3 Both OxyContin^? and oxycodone ER tablet, which is an authorized generic drug for OxyContin^?, will be on the non-preferred drug tier on the Independence Select Drug Program^? Formulary and will be removed from coverage on the Value Formulary. A trial of Xtampza^? XR will be required prior to OxyContin^? and oxycodone ER tablet approval.

Physicians who have members affected by these changes will be notified directly.

Conversion from other oral oxycodone formulations to Xtampza^? XR⁴

Patients receiving OxyContin^? or oxycodone ER tablet may be converted to Xtampza^? XR by administering half of the patient?s total daily oral oxycodone dose as Xtampza^? XR every 12 hours with food. Since Xtampza^? XR is not bioequivalent to OxyContin^{? or oxycodone ER tablet, patients should be monitored during dosage adjustment. For complete dosing information please refer to the FDA?s prescribing information.}

The following therapeutic equivalence table for dosage strengths of OxyContin^? (oxycodone ER) tabs and oxycodone base (Xtampza^{? XR) is set forth in the Xtampza? XR prescribing information4:}

Non-opioid pain management products

In an effort to reduce the number of opioids prescribed, the CDC published a checklist recommending that non-opioid therapies be tried and optimized when considering long-term opioid therapy. The non-opioid therapies listed below can be used as stand-alone therapy or in combination with opioids, as indicated:

• Non-opioid medications:
  • non-steroidal anti-inflammatory drugs (NSAIDs) such as meloxicam and celecoxib
  • tricyclic anti-depressants (TCAs) such as amitriptyline and nortriptyline
  • serotonin-norepinephrine reuptake inhibitors (SNRIs) such as duloxetine
  • anti-convulsants such as gabapentin
• physical treatments including exercise therapy and weight loss
• behavioral treatment including cognitive behavioral therapy (CBT)
• procedural interventions such as intra-articular corticosteroids injections

For additional information, please reference the CDC?s Checklist for prescribing opioids for chronic pain.

*MME/day: morphine milligram equivalents per day.

¹Centers for Disease Control and Prevention. ?Guideline for Prescribing Opioids for Chronic Pain? March 18, 2016 / 65(1);1?49. Accessed July 10, 2018. Available from: www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.

²Gudin J, Levy-Cooperman N, Kopecky EA, Fleming AB. ?Comparing the effect of tampering on the oral pharmacokinetic profiles of two extended-release oxycodone formulations with abuse-deterrent properties.? Pain Med. 2015; 16(11):2142-2151. Doi:10.1111/pme.12834.

³Brennan MJ, Kopecky EA, Marseilles A, et al. ?The Comparative pharmacokinetics of physical manipulation by crushing of Xtampza^? ER compared with OxyContin^?.? Pain Manag. 2017; 7(6):461-472

⁴Xtampza^? XR Prescribing Information. Accessed August 2, 2018. Available from: www.accessdata.fda.gov/drugsatfda_docs/label/2016/208090s000lbl. pdf