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The American Journal of Managed Care August 2013
Cost of Care for Malignant and Benign Renal Masses
Aviva G. Asnis-Alibozek, PA-C; Michael J. Fine, MD; Paul Russo, MD; Trent McLaughlin, BSc(Pharm), PhD; Eileen M. Farrelly, MPH; Norman LaFrance, MD; and William Lowrance, MD, MPH
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Bitya Friedman, MD; Amnon Lahad, MD, MPH; Yizchak Dresner, MD, MS; and Shlomo Vinker, MD
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Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics
Ying Liu, PhD; Joseph E. Logan, PhD; Leonard J. Paulozzi, MD, MPH; Kun Zhang, MS; and Christopher M. Jones, PharmD
False Activation of the Cardiac Catheterization Laboratory for Primary PCI
Geoffrey D. Barnes, MD; Alexander Katz, MD; Jeffrey S. Desmond, MD; Steven L. Kronick, MD, MS; Jamie Beach, RN; Stanley J. Chetcuti, MD; Eric R. Bates, MD; and Hitinder S. Gurm, MD
Option Pricing: A Flexible Tool to Disseminate Shared Savings Contracts
Mark W. Friedberg, MD, MPP; Anthony M. Buendia, BA; Katharine E. Lauderdale, BA; and Peter S. Hussey, PhD
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Caroline S. Carlin, PhD; John Kralewski, PhD; and Megan Savage, BS
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Natan R. Kahan, PhD, RPh, MHA; Daniel A. Vardy, MD, MSc; Dan-Andrei Waitman, MD, MPH; and Gherta Brill, MD

Potential Misuse and Inappropriate Prescription Practices Involving Opioid Analgesics

Ying Liu, PhD; Joseph E. Logan, PhD; Leonard J. Paulozzi, MD, MPH; Kun Zhang, MS; and Christopher M. Jones, PharmD
A quarter of opioid recipients with commercial insurance had at least 1 indicator of potential misuse by patients or inappropriate prescription practices by providers.
Background: Opioid misuse and abuse are growing concerns among the medical and public health communities.

Objectives: To examine the prevalence of indicators for potential opioid misuse in a large, commercially insured adult population.

Methods: We adapted existing indicators developed by expert panels to include having overlapping opioid prescriptions, overlapping opioid and benzodiazepine prescriptions, long-acting/ extended release (LA/ER) opioids for acute pain,and high daily doses of opioids (>100 morphine milligram equivalents). These indicators were assessed among continuously enrolled individuals aged 18-64 years from the 2009 Truven Health MarketScan databases. Analyses were stratified by sex.

Results: We identified 3,391,599 eligible enrollees who received at least 1 opioid prescription. On average, enrollees obtained 3.3 opioid prescriptions, and the average annual days of supply was 47 days. Twice as many enrollees received opioid prescriptions for acute pain as for chronic pain. About a quarter of the enrollees had at least 1 indicator of either potential misuse by patients or inappropriate prescription practices by providers. About 15% of enrollees had high daily doses;7.8% had opioid overlap; and 7.9% had opioid and benzodiazepine overlap. Among those prescribed LA/ER opioids, 24.3% were treated for acute pain. Overlap indicators were more common among women.

Conclusions: Our findings underscore the critical need to develop programs aimed at promoting appropriate use of opioids. Retrospective opioid utilization reviews similar to our analyses can potentially help managed care organizations and healthcare providers improve patient care and reduce the risk of adverse outcomes related to these medications.

Am J Manag Care. 2013;19(8):648-658
Opioid misuse and abuse are growing concerns in the United States.
  • Using a large, fully integrated commercial claims database, we found a substantial prevalence of indicators of potential misuse by patients or inappropriate prescription practice by providers.
  • Our findings underscore the critical need to develop programs to promote appropriate use of opioids.
  • Managed care organizations and other insurers might help monitor opioid use and reduce the risk of adverse outcomes through retrospective opioid utilization reviews similar to our analyses.
The problem of abuse and overdose of prescription drugs has emerged as a major public health issue in the United States.1 In 2010, drug overdoses killed 38,329 Americans, more than the number killed in motor vehicle traffic crashes.2 Misuse or abuse of prescription drugs also led to 1.2 million emergency department (ED) visits, compared with 1.0 million ED visits related to illicit drugs such as heroin and cocaine.3 Opioid analgesics alone or in combination with benzodiazepines or other drugs  accounted for  nearly half of the drug overdose deaths and more than three-fourths of prescription drug–related ED visits in 2009.2,3

The majority of prescription opioids used for nonmedical reasons are diverted from prescriptions originally written for therapeutic use.4 Yet many opioid abusers obtain them directly from a doctor and/or pharmacy, often by fabricating pain symptoms, forging prescriptions, and engaging in doctor and pharmacy shopping (ie, obtaining multiple prescriptions from multiple providers or pharmacies).4,5 Providers and payers may be in a position to help enhance the safety of prescribed  opioids and protect susceptible patients from becoming addicted to or overdosing  on opioids. Among patients who were prescribed opioids, those receiving multiple opioid prescriptions, overlapping opioids, overlapping opioids and benzodiazepines, and opioids at high dosage levels are at greater risk for abuse and overdose.6-8

Despite the well-documented associations between usage patterns and risk, relatively little is known about the current prescription practices for opioid analgesics and the extent to which they might be contributing to the rising prescription drug abuse problem. A small number of studies using administrative data from a limited number of health plans have described general opioid use (eg, number of opioid prescriptions received, average daily dose, total days of supply) and/or potential misuse (eg, high daily dosage, overlapping opioids, overlapping opioids and benzodiazepines).9-13 However, these studies have generally limited their analyses to long-term (>90 days) opioid users9,10 and/or populations with specific types of  noncancer pain (eg, back pain, headache).11,13

This study examines indicators of potential misuse by patients or inappropriate prescription practices by providers using one of the largest fully integrated commercial claims databases in the United States. The population of interest includes all adults with at least 1 opioid prescription regardless of their length of opioid use or indication for use with the exception of pain associated with cancer. Additional analysis reports differences in these indicators between men and women. Our results could be used to inform the monitoring of opioid use and to promote efforts to improve appropriate prescription practices by providers.


Data Source

We conducted secondary data analyses of the 2009 Truven Health MarketScan Commercial Claims and Encounters databases, which consisted of data from approximately 100 payers and health plans for about 50 million individuals from all 50 states.14 MarketScan contains standardized, fully integrated, enrollee-level, de-identified claims across inpatient, outpatient, and prescription drug services. Our analysis drew data primarily from the pharmaceutical claims, which included outpatient drug name, class, dosage, and quantity for about 17.8 million (10.3 million females and 7.5 million males) enrollees aged 18 to 64 years. In addition, the outpatient service claims and inpatient admission records were used to identify the underlying pain diagnoses related to opioid use. Inpatient admission records were necessary because some opioid prescriptions were prescribed to enrollees at discharge.

Study Population

Overall Study Population. We identified 13,097,589 opioid prescriptions for enrollees who were aged 18 to 64 years, were continuously enrolled in 2009, and did not have a cancer diagnosis in their outpatient or inpatient service claims (Figure). Cancer diagnoses were based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes including 338.3, 140-172.9, 174-215.9, 217-229.10, and 235-239.9. A list of analyzed opioids is provided in Table 1. Buprenorphine was excluded due to its primary use for treatment of opioid dependence. We excluded 1,216,388 (9.3%) opioid prescriptions that lacked the enrollee identification (ID) or dispensing information necessary for the calculation of predetermined outcome indicators. An additional 770,446 (5.9%) refill prescriptions were excluded due to inability to identify their original diagnoses. This selection process resulted in 11,110,755 (84.8%) opioid prescriptions filled by 3,391,599 enrollees as our overall study population.

Subpopulation With Identified Diagnoses. To calculate a subset of outcome indicators that are specific to certain types of pain, we linked opioid prescription claims to the diagnoses on outpatient or inpatient service claims by matching enrollee ID and the date of service. Consistent with the existing literature,15 we linked opioid prescriptions to the outpatient services or inpatient discharges that occurred within 14 days of the prescription dispensing dates. If multiple outpatient or inpatient records existed within this interval, we linked to the ones that occurred on the day closest to the drug dispensing dates. When inpatient and outpatient dates of service overlapped, we used the outpatient claims for the linkage. Prescription refills were assigned the diagnoses on the original prescriptions. We successfully linked 7,714,067 (69.4%) of the 11,110,755 opioid prescriptions to diagnoses for 2,833,224 enrollees (85.3% of the overall study population). Of the remaining 30.6% of prescriptions, 28.0% could not be linked because the outpatient services or inpatient admissions had occurred more than 14 days prior to the prescription dispensing date or in 2008; 2.6% could not be linked because MarketScan did not have the enrollee’s outpatient service claims.

Outcome Indicators

We adapted outcome indicators from clinical guidelines and those developed previously by expert panels.8,11,12,16-19 These indicators captured both general opioid use as well as potential misuse by patients or inappropriate prescription practices by providers.

At the enrollee level, indicators of opioid general use included the total number of opioid prescriptions obtained, total days of supply, and medical diagnoses (eg, acute pain, chronic pain, or both) associated with opioid prescriptions. Acute pain and chronic pain diagnoses were based on ICD-9-CM codes (Table 2, footnotes b and c). Benzodiazepine and muscle relaxant use in combination with opioids was also examined. Indicators of potential misuse or inappropriate prescription practices consisted of (1) opioid overlap, defined as opioid prescriptions that overlap by 7 or more days (including early refills); (2) opioid and benzodiazepine overlap, defined as opioid and benzodiazepine prescriptions that overlap by 7 or more days; (3) long acting/extended release (LA/ER) opioid prescriptions written for acute pain conditions; (4) high daily opioid dosage, defined as a prescribed daily dose of 100 morphine milligram equivalents (MMEs) or greater (MME conversion factors are provided in Table 1); and (5) opioid dose escalation, measured as having a 50% or greater increase in mean MMEs per month twice consecutively during the year.

At the prescription level, indicators of opioid general use included the number of days of supply and the prescribed daily doses for opioid prescriptions for acute, chronic, and back pain. Back pain included both acute and chronic back pain and was based on ICD-9-CM codes recommended by the American College of Occupational and Environmental Medicine practice guidelines.20 Indicators of potential misuse or inappropriate prescription practices included the proportion of opioid prescriptions involved in opioid overlap or opioid and benzodiazepine overlap, similar to the enrolleelevel analysis, and 3 indicators specific to LA/ER prescriptions given their elevated risk for addiction and abuse: (1) overlapping LA/ER opioid prescriptions; (2) LA/ER prescriptions written for acute pain; and (3) LA/ER prescriptions obtained by an opioid-naïve person, defined as a person who had no use of an opioid for at least 60 days prior to LA/ER drug initiation.

Statistical Analysis

We calculated the distributions of various levels of usage among all enrollees receiving an opioid prescription overall, by sex, and by pain type. The prevalences of indicators of potential misuse by patients or inappropriate prescription practices by providers were calculated as both percentages of enrollees and percentages of prescriptions. We used x2 tests for comparisons by sex. Because of the large sample sizes, differences by sex might have been statistically significant (P <.05) but not clinically meaningful. Therefore, we only provide test results for sex differences that were considered meaningful.


Enrollee-Level Indicators

Among the overall study population of opioid recipients, 59% were female (Table 2). The mean age of opioid recipients was 44.7 years among males and 43.2 years among females. Males and females received comparable amount of opioids, as measured by the number of prescriptions and total days of supply received per person in 2009. More than half of all recipients had only 1 opioid prescription; fewer than one-third of recipients (28.3%) had 3 or more opioid prescriptions. Notably, 2.3% of enrollees had 20 or more opioid prescriptions during the data year—with nearly 0.1% of enrollees receiving 50 or more opioid prescriptions (data not shown).

More than three-fourths of the recipients (78.5%) received fewer than 30 days of supply of opioids; about 12% of recipients received more than 90 days of supply of opioids. Among all opioid recipients, 16.3% also filled a benzodiazepine prescription during the data year, and 10.3% filled 2 or more such prescriptions. A higher proportion of females than males received both an opioid and benzodiazepine (19.0% vs 12.5%; P <.05).

We were able to identify the underlying medical diagnoses for opioid prescriptions for 82.3% of the overall study population. About 27.9% of the recipients obtained opioids for acute pain conditions only; 13.7% received opioids for chronic pain conditions only; and 24.2% obtained opioids for both acute and chronic pain conditions. Another 17.7% of the recipients received opioid prescriptions for diagnoses not included in the lists of acute or chronic pain conditions. Nearly a quarter of opioid recipients showed at least 1 indicator (Table 3). The most common indicator was having high daily doses; an estimated 15.0% of the study population had daily doses of 100 MMEs of higher. The prevalence of opioid overlap and opioid and benzodiazepine overlap was 7.8% and 8.0%, respectively. About 0.9% of enrollees received LA/ER opioids for acute pain, and 1.2% had opioid  dose escalation. A higher percentage of females versus males (9.1% vs 6.3%; P <.01) had 1 or more incidents of opioid and benzodiazepine overlap. A higher percentage of females versus males also had 1 or more incidents of high daily dose of opioids (16.2% vs 13.2%; P <.01). Overall, females were more likely than males to have any type of indicator (26.7% vs 22.4%; P <.05).

Prescription-Level Indicators

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