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The American Journal of Accountable Care December 2018
The Cost of Not Taking Our Medicine: The Complex Causes and Effects of Low Medication Adherence
Ellen Harrison, MBA, RN, vice president, HMS
Analysis of 2016 Connecticut ACO Medicare Shared Savings Program Data to Identify Opportunities for Population Health Pharmacist Services
Kathryn Steckowych, PharmD; Marie Smith, PharmD; and Yan Zhuang, PhD
Cost of Delivering Centralized and Decentralized Reminder/Recall for Vaccinations to Children and Adolescents in an ACO
Melanie D. Whittington, PhD; Dennis Gurfinkel, MPH; Laura P. Hurley, MD; Steven Lockhart, MPH; Brenda Beaty, MSPH; Miriam Dickinson, PhD; Heather Roth, MA; and Allison Kempe, MD, MPH
Mental Health and Diabetes Control Among Vulnerable Primary Care Patients
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Increased Healthcare Utilization and Expenditures Associated With Chronic Opioid Therapy
Douglas Thornton, PharmD, PhD; Nilanjana Dwibedi, PhD; Virginia Scott, PhD; Charles D. Ponte, PharmD; Xi Tan, PharmD, PhD; Douglas Ziedonis, MD; and Usha Sambamoorthi, PhD
Health Plan Strategies for Value-Based Care: Closing Gaps in Care Means Getting Serious About Prevention
Joshua Sclar, MD, MPH, Chief Medical Officer, BioIQ
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National Center for Complex Health and Social Needs; Center for Health Care Strategies; and Institute for Healthcare Improvement

Increased Healthcare Utilization and Expenditures Associated With Chronic Opioid Therapy

Douglas Thornton, PharmD, PhD; Nilanjana Dwibedi, PhD; Virginia Scott, PhD; Charles D. Ponte, PharmD; Xi Tan, PharmD, PhD; Douglas Ziedonis, MD; and Usha Sambamoorthi, PhD
The increase in healthcare utilization and expenditures associated with the transition to chronic opioid therapy places increased burden on payers and patients.

Objectives: To assess the association of the transition from incident opioid use to incident chronic opioid therapy (COT) with the trajectories of healthcare utilization and expenditures.

Study Design: We used a longitudinal, retrospective cohort design, including seven 120-day time periods covering preindex (t1, t2, and t3), index (t4), and postindex (t5, t6, and t7) periods with data from adults aged 28 to 63 years at the index date, without cancer, and continuously enrolled in a primary commercial insurance plan (N = 20,201).

Methods: Multivariable analyses were performed on utilization (population-averaged [PA] logistic regression), expenditures (PA generalized estimating equations), and expenditure estimates (counterfactual prediction). The data used were from a commercial claims database (10% random sample from the IQVIA Real-World Data Adjudicated Claims - US database) from 2006-2015.

Results: Patients on COT were more likely to use inpatient services (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21) compared with those who did not. Although expenditures peaked during the index period (t4) for all users, differences in unadjusted average 120-day expenditures between COT and non-COT users were highest in t4 for total ($4607) and inpatient ($2453) expenditures. COT users had significantly higher total (β = 0.183; P <.01) and inpatient (β = 0.448; P <.001) expenditures.

Conclusions: The period after incident opioid prescription but before transition to COT is an important time for payers to intervene.

The American Journal of Accountable Care. 2018;6(4):11-18
Half of Americans have experienced pain in the past year, and approximately 100 million experienced chronic pain.1,2 The majority of these patients have chronic noncancer pain (CNCP) and are of working age.1,3-6 CNCP can be managed using therapy regimens that include pharmacologic options and nonpharmacologic options (eg, electrical stimulation, physical therapy, psychological interventions, exercise), which have been shown effective.7-9 Opioids have been recommended by the CDC to be used only after considering a nonopioid regimen. Nearly 1 in 5 patients who presented to their healthcare provider with a painful condition in 2010 were prescribed an opioid, although the effectiveness of opioids in relieving CNCP has not been proven.10

In addition to the lack of evidence that opioids effectively treat CNCP, opioid use leads to adverse health consequences.7 Study results have documented increased healthcare utilization and expenditures to patients and payers due to adverse effects of opioids.2,4,5,11 Patients prescribed opioids had higher emergency department (ED), inpatient, and outpatient visits, as well as increased analgesic use, out-of-pocket spending, and third-party spending, compared with patients not prescribed opioid medications.11-14 For example, in 2017, approximately 16 of every 10,000 ED visits in the United States were for suspected opioid overdose.15 The number of annual ED visits due to suspected opioid overdose increased by 27.7% from 2015 to 2016.15 From 1993 to 2012, the rate of hospital inpatient stays related to opioid overuse increased by 153%.16

Patients who receive initial opioid therapy, even for only a few days, are at risk of transitioning to chronic opioid therapy (COT), defined as 90 days of use.7,17 Our preliminary analysis has shown that initial opioid prescription characteristics (parent opioid [eg, hydrocodone, oxycodone, tramadol], duration of action, and standardized dose) are the leading predictors of transitioning to COT.18 Both patients and payers can bear the economic consequences of COT, which result from exacerbation of current medical conditions, development of new physical and mental health conditions, and opioid-related adverse effects, including drug use disorder and opioid overdose.7,13,15,16,19 An estimated $78 billion is spent annually on these adverse consequences of opioids.20

Researchers have estimated the economic burden of patients on opioid therapy who develop an opioid use disorder14,20,21; studies that systematically examine the effect of the transition to COT on healthcare utilization and expenditures are sparse.19,22 Such studies are important because they assess a transition state earlier in the patient’s continuum of care,23 and this earlier period has been identified by the CDC as a time to take action to prevent the adverse consequences of opioid use.7 To date, only 1 study has analyzed the association of long-term opioid therapy and other opioid therapy with healthcare utilization and expenditures.19 Using data from commercial health plans, the study reported that healthcare expenditures were higher among long-term opioid users compared with other opioid users.19 This study had some limitations, such as use of a nonstandard definition of long-term opioid therapy and unequal follow-up time periods between short- and long-term opioid users. The definition for chronic opioid use (>182 days) was different from the commonly used Agency for Healthcare Research and Quality (AHRQ) and CDC definition of at least 90 days.7,24 Furthermore, the study was not restricted to working-aged adults, who may have different transition rates and factors affecting those rates. Our study addresses the limitations of the prior literature and analyzes the impact of transitions from initiation of opioids to COT on economic outcomes in a nationally representative sample of working-aged adults using definitions concordant with definitions used by the CDC, AHRQ, and current literature.7,24-26

Focusing on working-aged adults between 28 and 63 years is important because this group may have higher risk of transition to COT27 and their healthcare utilization patterns may be unique compared with those of elderly patients.28 Therefore, the objective of our study was to assess the association of transitioning from incident opioid use to incident COT with trajectories of healthcare utilization and expenditures using a nationally representative sample of commercially insured working-aged adults in the United States.


Data Source

The data were derived from a 10% random sample of commercial enrollees released under licensing from the IQVIA Real-World Data Adjudicated Claims - US database.

Study Design

A retrospective cohort design, with longitudinal data for seven 120-day time periods covering preindex (t1, t2, and t3), index (t4), and postindex (t5, t6, and t7) periods, was used. The patient cohort consisted of working-aged adults who did not have cancer and who were initiated on opioids between January 2007 and May 2014. The first observed prescription for an opioid represented the index date. The preindex periods were identified before the index date, the index period was identified as the 120 days after the index date, and the postindex periods were identified after the end of the index period.

Study Sample

The sample was restricted to adults who were continuously enrolled in a primary commercial insurance plan (with pharmacy and medical benefits) during their entire observation period. Cancer was identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Patients with at least 1 claim with any cancer code, except for nonmelanoma skin cancer, in any of the 12 diagnosis code fields available in the claims data were considered to have cancer.29 We excluded individuals who had more than 1 opioid prescription on the index date because we were unable to evaluate initial opioid regimen characteristics for these individuals. After applying the exclusion criteria, we observed 3776 adults in the COT group. A 5% random sample, approximately 5 controls per case, of patients without COT was selected to represent the non-COT group (n = 16,425) (eAppendix [available at]).

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