With research indicating that the risk for fatal overdose dramatically increases when people take higher doses of opioids, two of California's major health players - an HMO and an insurance company - are launching efforts aimed at getting doctors to prescribe the painkillers in smaller amounts.
The HMO - Kaiser Permanente of Southern California - is working closely with the doctors who practice at its hospitals to gradually reduce the dosages of opioids they prescribe until they're below a level that the Centers for Disease Control and Prevention has determined constitutes a high overdose risk.
The insurance company - Blue Shield of California - is using its power as a treatment authorizer to bring the dosage of its network doctors' opioid prescriptions down to the same level targeted by Kaiser.
Different opioids have different potencies, so to get apples-to-apples comparisons, they are measured in "morphine equivalent doses" (MED). For example, 50 milligrams of oxycodone is as potent as 75 mg of morphine.
The CDC says the overdose risk jumps at 90 mg MED per day, and above 100 mg MED a day the overdose risk increases by a factor of almost nine.
Beginning this month, doctors at Kaiser Southern California will identify those patients taking high levels of opioids and begin tapering their dosages by five to 10 percent a month until they get below 90 mg MED per day, according to Dr. Steven Steinberg, Kaiser’s regional chief of family medicine and the leader of the anti-overdose initiative.
About 6,000 of Kaiser’s Southern California members are on daily doses of 90 mg MED or higher, he said, adding that cancer patients will not be affected by the new guidelines.
Kaiser doctors - and physicians in general - might have once resisted reducing dosages, but their attitude has shifted with all of the national attention on the opioid epidemic, Steinberg said.
He does expect some patients will push back against this effort, however.
"That's where the physician has to say, 'you're going to overdose and die,'" said Steinberg. "'I can't give you treatment that's going to lead to your death. It's not right. Ethically, I must taper you down.'"
For its part, Blue Shield decided to attack the overdose problem after recognizing that it is playing a key role in the opioid epidemic, said Chief Health Officer Dr. Marcus Thygeson.
"We realized that a large number of our members were being prescribed high and dangerous doses of opioids, most of them for chronic pain," he said. "Most of these folks are getting medications provided by one of our network doctors, dispensed by one of our network pharmacies and paid for through our claims system."
The insurer is using its prior authorization system to reduce the number of patients who start taking high doses of opioids or remain on them long enough to become addicted, said Thygeson.
When prescribing opioids to people covered by Blue Shield, doctors currently must get approval from the plan before starting them on daily doses of 120 mg MED or more. Within the next six months, the company will start requiring authorization for doses above 90 mg MED, he said.
The prior authorization protocol "is the strongest lever we have, if you will, to change the system," said Thygeson.
Doctors in Blue Shield's network must also get approval before prescribing highly potent extended-release and long-acting opioids, he said.
Blue Shield and Kaiser are taking steps to address the widespread problem of opioid addiction as well. They're both focused on keeping patients from taking the painkillers longer than three months, known by experts as the "90-day cliff." Studies show a higher risk of addiction for those who stay on opioids longer than that.
To reduce the addiction threat, Blue Shield is requiring its network doctors to get prior authorization for opioid refills.
Kaiser is also strongly encouraging its doctors to prevent patients from staying on opioids for more than 90 days, said Steinberg.
This story was updated to reflect that doctors working at Kaiser hospitals are not on the Kaiser Foundation Health Plan's payroll. They work for the Southern California Permanente Medical Group, which has an exclusive contract with the Kaiser Foundation Health Plan.