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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
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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
A quarter of opioid recipients with commercial insurance had at least 1 indicator of potential misuse by patients or inappropriate prescription practices by providers.
Among the 7,714,067 prescriptions that were linked to diagnoses, about a quarter of them were written for acute pain conditions. A slightly higher proportion (28.8%) were for chronic pain, and 15.6% were associated with both acute and chronic pain (Table 4). The remaining 30.2% of the prscriptions were linked to diagnoses not included in the lists of acute or chronic pain conditions. In addition, about 6.9% of the opioid prescriptions were written for either acute or chronic back pain conditions.

The median days of supply for acute pain, chronic pain, and back pain were 5, 15, and 20 days, respectively. For acute pain, 22.8% of prescriptions were written for 10 or more days, and 9.5% were written for 30 or more days. For chronic pain, more than one-third of the prescriptions were for 30 or more days. The duration distribution for back pain, whether acute or chronic, was similar to that for chronic pain. The distributions for the days of supply for acute pain, chronic pain, and back pain were similar for males and females.

The median daily opioid dose for prescriptions for acute pain was similar for both sexes at 40 MME. The median daily dose for opioid prescriptions for chronic pain was higher for males (40.0 MME) than for females (37.5 MME). Among both acute pain and chronic pain prescriptions, 11.8% to 14.0% had a daily dose of 100 MME or greater; 1.9% to 4.5% of prescriptions were for 200 MME or greater.

Roughly one-fifth of opioid prescriptions overlapped with other opioid prescriptions, and 15.1% overlapped with a  benzodiazepine prescription (Table 5). Opioid prescriptions written for female versus male recipients were significantly more likely to overlap with 1 or more benzodiazepine prescriptions (17.1% vs 12.4%; P <.05). Among LA/ER opioid prescriptions, nearly a quarter overlapped with other LA/ER opioid prescriptions; more than 6% of LA/ER prescriptions were written for acute pain conditions; and 2.6% were obtained by opioid-naïve patients.

DISCUSSION

In 2009, more than 11 million opioid prescriptions were written for 3.4 million (or 19.1%) of the 17.8 million adults without cancer diagnoses, with continuous enrollment, and with at least 1 outpatient drug claim in the MarketScan Commercial Claims and Encounters databases. Most patients obtained single-opioid prescriptions without also getting prescriptions for benzodiazepines. Although more patients were treated for acute pain, more prescriptions were written for chronic pain. The majority of prescriptions were written for fewer than 30 days, and the average prescription provided roughly 60 MMEs per day. There were signs of potential opioid misuse by patients or providers among the study population: nearly a quarter of patients had at least 1 indicator of potential misuse of opioids and more than 5% had 2 or more indicators of potential misuse.

Patients with misuse indicators probably account for a disproportionate share of adverse outcomes associated with opioid use. Increased numbers of opioid prescriptions, overlapping or early refill prescriptions, dose escalation, and more days of supply of opioids have all been associated with increased risk of clinically recognized abuse.7,8 Higher daily dose has been associated with misuse and overdoses.6,7,21 Opioid dependence has been associated with concurrent opioid and psychotropic drug use.22 Simultaneous prescribing of opioids and benzodiazepines, although it might be appropriate in some cases, has been associated with multiple-provider episodes, also known as doctor shopping.23 Acute pain is not an indication for an LA/ER opioid, and such use is considered inappropriate by clinical guidelines.19,24 Many LA/ER opioids carry warnings against initiation among opioidnaïve patients.25

Other patterns in prescribing for specific types of pain have not been previously flagged as indicators of possible misuse but run counter to the recommendations of some advisory groups.For example, the New York City Department of Health has recommended no more than a 7-day supply for acute pain.24 However, in this study 22.8% of opioid prescriptions for acute pain were for 10 or more days, and 9.5% were for 30 or more days. The American College of Occupational and Environmental Medicine practice guidelines only recommend opioids on a limited basis for treatment of severe, acute low back pain, with treatment to last no more than 2 weeks.20 In this study, 42.3% of opioid prescriptions for back pain were for 30 days or more, clearly much more than recommended.

Comparisons of our findings with the published literature were difficult because of use of different indicators or different study populations. In 1 managed care population with chronic noncancer pain during 1999 through 2005, 3.5% of personyears of opioid use were at dosages of 100 MME or more,7 and in a population of veterans with chronic pain during 2008, 3.4% of those treated with opioids were at dosages of 180 MME or more.26 This compares with 14.0% of prescriptions for chronic pain over 100 MME and 4.5% over 200 MME in this study. In Massachusetts in 2006, 6.9% of patients treated with Schedule II drugs had early refills,27 compared with 7.8% for any opioid overlap in this study.

Our study is consistent with previous literature in finding that women constitute the majority of users of opioids both alone and in combination with benzodiazepines.15,28 However, the number of opioid prescriptions and days of supply received per person per year were comparable between female and male opioid recipients. Despite the fact that men are more likely to use prescription painkillers nonmedically and to abuse opioids,4,8 indicators of possible misuse were not more prevalent among male opioid recipients in our study population. This might indicate that men misusing opioid analgesics are less likely to be commercially insured, or it might reflect changes in the demographics of the problem. Alternatively, the measures used here might reflect prescribing practices more than underlying patterns of patient misuse.

Limitations

Our study has several limitations. The potential misuse indicators were based on expert panels and validated by their association with misuse or abuse in other studies. In some cases, of course, such behaviors represent appropriate care for patients (eg, overlapping prescriptions resulting from changes in dosage or in drug type as a result of some adverse effect, legitimate early refills due to schedules, high daily dosagesin palliative care situations). Claims data were designed to support financial transactions rather than to capture clinical information. Pharmacy claims represent filled prescriptions reimbursed by health insurance rather than actual drug consumption. Due to large numbers of missing values for pharmacy ID and physician ID variables, we were not able to calculate doctor-shopping or pharmacy-shopping indicators, which are often considered strong indicators of opioid misuse.11,12 Lastly, reliance on ICD-9-CM codes to determine the reason for a prescription is subject to error. Many conditions are painful but are not usually counted among common causes of pain. Type of pain might also have been misclassified. Despite these limitations, our analysis represents a first comprehensive look at opioid use and potential misuse in the largest fully integrated commercial claims database in the United States.

CONCLUSIONS

While the majority of opioid prescriptions among this large commercially insured population might have been appropriate, a substantial number were prescribed in a manner that suggests potential patient misuse or inappropriate prescription practice by providers. Robust prescription opioid utilization review programs using integrated claims data, similar to our analyses, might help managed care organizations, third-party payers, professional societies, and governmental organizations (through guidelines) improve quality of care and reduce unnecessary healthcare costs.11,12 Managed care organizations and third-party payers can also use similar indicators to flag patients who might benefit from improved, coordinated pain management.

In addition, evidence-based clinical guidelines have suggested a number of tools and approaches clinicians should use to safely prescribe opioids. These include checking prescription drug monitoring programs, which track information on controlled substance prescriptions filled in a state,29 taking a careful history of substance abuse and other mental health problems, conducting routine urine drug screens in concert with pain management agreements, and making use of pain medicine consultants when problems arise.16-20 Such safeguards might help providers avoid improper opioid use and thereby reduce the risk of adverse outcomes related to opioid medications.

Author Affiliations: From the Centers for Disease Control and Prevention (YL, JEL, LJP, KZ, CMJ), National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, Atlanta, GA.

Funding Source: All work for this study was funded by the Centers for Disease Control and Prevention, and none of the authors had conflicts of interest.

Author Disclosures: The authors (YL, JEL, LJP, KZ, CMJ) report no relationshipor financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (YL, JEL, LJP, CMJ); analysis and interpretation of data (YL, JEL, LJP, KZ); drafting of the manuscript (YL, JEL, LJP, CMJ); critical revision of the manuscript for important intellectual content (YL, JEL, LJP, KZ, CMJ); statistical analysis (YL, JEL, KZ); administrative, technical, or logistic support (YL); and supervision (LJP).

Address correspondence to: Leonard J. Paulozzi, MD, MPH, 601 Sunland Park Dr, Ste 200, El Paso, TX 79912. E-mail: lbp4@cdc.gov.
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14. Thomson Reuters MarketScan Database. Commercial Claims and Encounters Medicare Supplemental: Data Year 2009 Edition.

15. Campbell CI, Weisner C, Leresche L, et al. Age and gender trends in long-term opioid analgesic use for noncancer pain. Am J Public Health. 2010;100(12):2541-2547.

16. Agency Medical Directors’ Group. Opioid Dosing Guideline for Chronic Non-Cancer Pain. http://www.agencymeddirectors.wa.gov/opioiddosing.asp. Published March 2007. Accessed August 19, 2011.

17. Emergency Department Opioid Abuse Work Group, Washington State Department of Health. Washington Emergency Department Opioid Prescribing Guidelines. http://washingtonacep.org/Postings/edopioidabuseguidelinesfinal.pdf. Accessed August 19, 2011.

18. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.

19. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. 2009.

20. Hegmann K. Occupational Medicine Practice Guidelines: Evaluation and Management of Common Health Problems and Functional Recovery in Workers. Elk Grove Village, IL: American College of Occupational and Environmental Medicine; 2011.

21. Paulozzi LJ, Kilbourne EM, Desai HA. Prescription drug monitoring programs and death rates from drug overdose. Pain Med. 2011;12(5):747-754.

22. Boscarino JA, Rukstalis M, Hoffman SN, et al. Risk factors for drug dependence among outpatients on opioid therapy in a large US health care system. Addiction. 2010;105(10):1776-1782.

23. Wilsey B, Fishman S, Gilson A, et al. Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics. Drug Alcohol Depend. 2010;112(1-2): 99-106.

24. Paone D, Heller D. Preventing Misuse of Prescription Opioid Drugs. Long Island City, NY: The New York City Department of Health and Mental Hygiene; 2011.

25. OxyContin [medication guide]. Stamford, CT: Purdue Pharma; 2010. http://www.fda.gov/downloads/Drugs/DrugSafety/UCM208530.pdf. Accessed February 13, 2011.

26. Morasco BJ, Duckart JP, Carr TP, Deyo RA, Dobscha SK. Clinical characteristics of veterans prescribed high doses of opioid medications for chronic non-cancer pain. Pain. 2010;151(3):625-632.

27. Katz N, Panas L, Kim ML, et al. Usefulness of prescription monitoring programs for surveillance—analysis of Schedule II opioid prescription data in Massachusetts, 1996-2006. Pharmacoepidemiol Drug Saf. 2010;19(2):115-123.

28. Parsells Kelly J, Cook SF, Kaufman DW, Anderson T, Rosenberg L, Mitchell AA. Prevalence and characteristics of opioid use in the US adult population. Pain. 2008;138(3):507-513.

29. Office of National Drug Control Policy. Prescription Drug Monitoring Programs. Rockville, MD: Office of National Drug Control Policy; 2011.
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