[MUSIC] With this module we're going be talking about engaging pharmacy benefit managers and pharmacies. Let's start off with the definition of what pharmacy benefit managers are, or PBMs. PBMs manage the pharmacy benefits for health plans and for large employers. They are a third party administrator that develops plan formularies, negotiates with prescription drug manufacturers, contracts with pharmacies and processes prescription drug claims. So they have an important role in the processing of prescription drugs, what's available to patients and to how those prices are negotiated. So why are they important in the opioid epidemic? PBMs are important to understanding the opioid epidemic and identifying strategies to better manage access to prescription opioids for several reasons. First, they develop formularies, or a list of drugs that will be covered by the health plan, and at what cost to the patient. This can have the effect of incentivizing patients and prescribers to favor certain drugs. Ideally, formularies should serve to ensure safe, cost effective therapies and high quality care that is consistent with the CDC prescribing guideline that we discuss elsewhere in this course. PBMs can also provide oversight of how medications are being prescribed and filled. Such initiatives are geared toward preventing unsafe or nonmedical use and diversion, and identifying patterns that suggest diversion in order to intervene with safer plans for managing medical needs. For example, a review of prescription fills can identify patients who are filling prescriptions at multiple locations or exceeding a daily threshold for opioid prescriptions. PBMs can also reduce forged and fraudulent prescriptions by implementing electronic prescribing. PBMs are at the center of managing pharmacy benefits for health plans, and as such are well positioned to intervene with regard to the supply of prescription opioids and monitor how they are prescribed and filled by participants in the plans they support. In addition to PBMs, pharmacies and pharmacists are also important to the opioid epidemic. While PBMs are positioned behind the scenes, making decisions that affect how patients access prescription opioids and can monitor their use, pharmacies and pharmacists are on the front lines of patient access. They help patients understand the prescriptions they are receiving, including the risks and benefits associated with their use. This front line perspective also positions them well to look for signs of misuse and to provide ready access to information about treatment resources and naloxone. With increasing attention to illicit forms of opioids, you may be wondering why we are devoting attention to prescriptions. While the dramatic rise in heroin and fentanyl are certainly cause for concern, it's important to remember that prescription opioids are still implicated in a large number of overdose events, and are often reported as their initial exposure to opioids among people who are currently using heroin. This infographic from the CDC captures the challenges that remain with regard to the supply of prescription opioids in this country. When we look nationally, the average number of days that opioids are prescribed was increasing as recently as 2015. That same year, the number of prescriptions issued was enough to supply every American with enough opioids for 24 hours a day, for three weeks. And while dosing has decreased, the average morphine milligram equivalent still exceeds the recommended dose. Finally, we know these excesses and prescribing don't need to be the reality. Comparisons among states reveal dramatic differences in the amount of opioids prescribed among counties in this country. The highest prescribing counties are prescribing more than six times the amount of opioids than the lowest prescribing counties. While prescribing across these metrics remains excessive, change is possible. So let's talk about some recommendations to change the current reality. We talked a lot about the ways in which PBMs and pharmacies can affect the supply of prescription opioids and monitor how they are prescribed and used. There is some evidence to suggest these strategies matter, but additional evaluations by researchers external to the companies involved is needed to understand how PBM initiatives affect prescribing, use and the prevalence of people with opioid use disorders. With these recommendations, we are also advocating for continuing to improve upon methods to identify those in the health plan data systems who are at elevated risk for opioid use disorders or overdose. Importantly, in addition to identifying these individuals who are acting in risky ways, providing access to interventions that will support less harmful behaviors is an opportunity for PBMs to engage in a more proactive way. We also want to emphasize the importance of continuing to innovate and improve upon current management and oversight of people who are prescribed opioids for chronic, non-cancer pain. Ensuring safe opioid prescribing consistent with the CDC guidelines should be a priority. Lock-in programs are one strategy that are used to place additional access controls on high risk patients. This approach is generally used sparingly and as a way to better assure that access is available in a safe and controlled system of oversight. Finally, we also recommend efforts to improve monitoring of pharmacies, prescribers and patients who are prescribed opioids. Prescription opioids remain an important source for people with opioid use disorders. Efforts to better assure that these medications are dispensed in a way that addresses patients' needs without increasing risk is critical. And that does it for our recommendations in this module, thank you very much for your attention.