Drug Utilization Review Newsletter
The direct source of information for Colorado's Drug Utilization Review Program
The mission of the Colorado Drug Utilization Review (CO-DUR) Program, facilitated by the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences in collaboration with the Colorado Department of Health Care Policy & Financing (the Department), is to assure high quality of patient care and provision of rational, high-value, and safe medication management for Health First Colorado's (Colorado's Medicaid Program) members.
DUR Updates
New Preferred Drug List Drug Classes:
The following new drug classes were added to the   Preferred Drug List   (PDL)  (effective July 1, 2018) with recommendations from the Pharmacy and Therapeutics Committee (P&T) and DUR:
  • Acne Agents
  • Acetylcholinesterase inhibitors (ACEi) and ACEi combinations
  • Opioids - Short Acting
The August DUR Board Meeting will also be reviewing new PDL drug classes including:
  • Anticonvulsants
  • Contraceptives, oral
  • Hereditary Angioedema Agents

  • Prenatal Vitamins
     

Opioid Policy Changes:
Effective May 29, 2018: minor, technical changes were made to the opioid naïve policy. Opioid naïve patients are now identified as members who have not had a paid opioid claim within the past 180 days (rather than 365 days). See   PDL  section "opioid utilization policy."
 
Quarterly DUR Board Meetings:
May 2018:
Agents that were reviewed are listed in Figure 1. After the DUR Board Meeting, the Board's recommendations were given to the Department, who then made the final determinations regarding medication use and prior authorization criteria. The  PDL  and Appendix P have been updated accordingly and are effective July 1, 2018.
 
August 2018:
The meeting date is to be determined and will be announced to the public when the Agenda is posted 30 days prior to the meeting day.
 
Figure 1 displays a list of drug classes to be reviewed at the August meeting. There may be changes/additions made to the August 2018 list before it is officially posted. The DUR Board Meeting Agenda is the official announcement of topics and may be found on the DUR web page when posted.
Call for Pharmacists and Physicians for the DUR Board:
CO-DUR is continuously recruiting Physicians and Pharmacists for DUR Board positions, please email  [email protected] or visit our DUR web page if you would like more information.
Opioids in Focus
CO-DUR provides support and recommendations to the Department for the purpose of reducing the burden of the opioid epidemic and improving overdose outcomes of the Medicaid population. Please reference Figure 2 for a summary of the opioid policies the Department has implemented. The official policy verbiage may be found in the PDL in the "Opioids" section. After the implementation of each policy, additional measurements are taken to determine if the policy is having the desired effect.

Opioid Policy IMPACT:

The CO-DUR team measures the impact of these policies and presents the findings to the Department. An example of such a measurement is presented in Figure 3. 

Figure 3 notes the date on which each policy was implemented and then shows the resultant number of Medicaid members receiving more the 250 Morphine Milligram Equivalents (MME) of an opioid.
 
Other indicators regarding opioid policy that have been measured or are in the process of being measured include:
  • Adverse effects related to opioid use
  • Hospitalizations and emergency department visits related to opioid overdose/poisoning
  • Any change that occurs to the total amount of opioid tablets or capsules dispensed to Medicaid members
  • High risk concomitant prescribing (i.e. benzodiazepines, muscle relaxing agents). See "Current Analyses" below
  • Please contact CO-DUR if you have further questions/suggestions

Please see the  Pain Management Resources Page for more information.
Current Analyses
CO-DUR is contracted to conduct ongoing analysis on drug utilization to provide input to the Department regarding pharmacy policies. Below are brief summaries of analyses currently being conducted. 

Multiple Antipsychotic Prescriptions and Psychotropic Medication Polypharmacy in Children:
 
CO-DUR is currently finalizing investigations into children members receiving multiple antipsychotics and psychotropic medication polypharmacy.
  • The Healthcare and Effectiveness Data and Information Set (HEDIS) for "Use of multiple Concurrent Antipsychotics in Children and Adolescents" was used to measure the multiple antipsychotic metric
  • A hybrid metric was created using some definitions of the HEDIS analysis and using that to measure the psychotropic medication polypharmacy measure. Polypharmacy, in this analysis, has two definitions; three or more psychotropic medications and five or more psychotropic medications.
Concomitant Use of Opioids and Benzodiazepines / Impact Analysis for Opioid Naive Policy:
 
CO-DUR is currently in the design and data analysis phase measuring the extent to which opioids and benzodiazepines are being taken concomitantly within Health First Colorado members.
  • This analysis will also include measurements of presence of substance use disorders, type of opioid, multiple benzodiazepines, and high dose opioid combinations. 
     
  • As an addition to this analysis, the impact of the opioid naïve policy (see figure 1) will be investigated in a manner that compares the total tablet/capsule number and days' supply of opioids before the policy was implemented to an equal period of time after the policy was active. This should help determine the impact of the policy.  
Clinical Practice Pearl
Concurrent Opioid and Benzodiazepine Use
  • Additive CNS depression and respiratory depression are possible when opioids and benzodiazepines are taken concurrently.
     
  • The CDC estimates at least 30-61 percent of opioid overdoses involve a benzodiazepine.
     
  • The FDA issued a warning in 2016 about serious risks of death when combining opioid pain or cough medicines with benzodiazepines (1).
     
  • The CDC recommends "clinicians avoid prescribing opioid pain medications and benzodiazepines concurrently whenever possible (2)."
DUR Board Member Spotlight
Ali Shmerling joined the DUR Board in March of 2017 and is a Family Medicine physician practicing full scope family medicine. She sees clinic patients at UCH Westminster Family Medicine and delivers her OB patients as well as takes care of inpatients at the University of Colorado Hospital. She particularly loves women's health, prenatal care, pediatrics, and mental health as well as taking care of whole families. She is finishing her year as a health policy fellow before starting as an Assistant Professor of Family Medicine in August, where she will be spending 30 percent of her time working with medical students as well as continuing her clinical work.
 
Ali completed her undergraduate degree at Northwestern University in Evanston, IL in 2009, majoring in Spanish with a minor in Global Health, her Medical Degree as well as her Masters of Public Health at Tufts University in Boston, MA graduating in 2014, and her post-graduate training at the University of Colorado Family Medicine Residency. In the year between school she worked at a health  policy center in Washington, DC. She loves teaching, learning, and working with teams to accomplish change within the healthcare system.
 
Outside of work, Ali loves spending time with her husband, two dogs, and will be expecting her first child in the fall. You can find her outside year-round, hiking, skiing, swimming and gardening. 
References
  1. New Safety Measures Announced for Opioid Analgesics, Prescription Opioid Cough Products, and Benzodiazepines. https://www.fda.gov/drugs/d
    rugsafety/informationbydrugclass/ucm518110.htm
  2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1-49. DOI: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm 
Resources
Contains PDLs, Appendix Ps, Global Prior Authorization Form, Prior Authorization forms, and instructions.
 
Information about the DUR Board Meetings, Agendas, and past newsletters can be found here.
Please email [email protected] if you would like more information about the DUR team or board activities or have comments on this newsletter or its content.
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