Between 1991 and 2010, prescriptions for opioid analgesics increased from about 75.5 million to 209.5 million, and about 1.9 million people in the U.S. meet abuse or dependence criteria for prescription opioids.* Prescription drug abuse is a significant problem that is becoming increasingly common. In response to growing concerns of prescription drug abuse, ICM developed the Controlled Substance Monitoring Program (CSMP) to identify patients with potentially inappropriate prescription or medical utilization trends and to address costly medication-seeking behaviors.

Cost Savings

The CSMP gives us the ability to holistically assess trends in both prescription and medical utilization, allowing for prompt identification of concerning patterns. When a patient is identified as having inappropriate behavior, enrollment in Mandatory Case Management (MCM) provides the opportunity to encourage the proper use of medication, refer to a pain management clinic, recommend alternative treatments, coordinate with physicians, and, when necessary, establish a limit of one prescribing physician to prevent multiple overlapping or conflicting prescriptions. These efforts result in a variety of savings:

  • Less prescriptions
  • Lower cost drug and treatment alternatives
  • Reduced emergency room and physician visits
  • Fewer tests and procedures

Program Description

Current claims data received from the client’s Pharmacy Benefit Manager (PBM) is analyzed for potentially concerning utilization trends. Once potentially high risk patients have been identified, medical claims data is gathered for each of these patients, and a thorough multidisciplinary evaluation of the patient’s activity is performed. This process provides a method of:

  • Identifying patients who may be misusing drugs
  • Identifying patients who may be overusing drugs
  • Detecting overuse of medical benefits and costly medication seeking behaviors
  • Coordinating addiction treatment services
  • Coordinating alternative pain management treatment options
  • Identifying less costly drug alternatives
  • Providing medication fraud interventions

Patients with the most concerning utilization trends identified through this mechanism are referred to Mandatory Case Management to facilitate the appropriate treatment plan, encourage appropriate medication utilization, recommend potential benefit limitation, and manage costs.

*National Institute of Drug Abuse (December 2011). Prescription Drug Abuse. Retrieved February 25, 2014, from http://www.drugabuse.gov/publications/topics-in-brief/prescription-drug-abuse.