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The American Journal of Managed Care May 2017
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Drivers of Excess Costs of Opioid Abuse Among a Commercially Insured Population
Lauren M. Scarpati, PhD; Noam Y. Kirson, PhD; Miriam L. Zichlin, MPH; Zitong B. Jia, BA; Howard G. Birnbaum, PhD; and Jaren C. Howard, PharmD
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Ian Randall, PhD; Charles Maynard, PhD; Gary Chan, PhD; Beth Devine, PhD; and Chris Johnson, PhD
State Prescription Drug Monitoring Programs and Fatal Drug Overdoses
Young Hee Nam, PhD; Dennis G. Shea, PhD; Yunfeng Shi, PhD; and John R. Moran, PhD
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Junqing Liu, PhD; Jonathan Brown, PhD; Suzanne Morton, MPH; D.E.B. Potter, MS; Lisa Patton, PhD; Milesh Patel, MS; Rita Lewis, MPH; and Sarah Hudson Scholle, DrPH
The Cost of Adherence Mismeasurement in Serious Mental Illness: A Claims-Based Analysis
Jason Shafrin, PhD; Felicia Forma, BSc; Ethan Scherer, PhD; Ainslie Hatch, PhD; Edward Vytlacil, PhD; and Darius Lakdawalla, PhD
Prescription Opioid Registry Protocol in an Integrated Health System
G. Thomas Ray, MBA; Amber L. Bahorik, PhD; Paul C. VanVeldhuisen, PhD; Constance M. Weisner, DrPH, MSW; Andrea L. Rubinstein, MD; and Cynthia I. Campbell, PhD, MPH
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Robert J. Romanelli, PhD; Laurence I. Ikeda, MD; Braden Lynch, PharmD; Terri Craig, PharmD; Joseph C. Cappelleri, PhD; Trevor Jukes, MS; and Denis Y. Ishisaka, PharmD
The Association of Mental Health Program Characteristics and Patient Satisfaction
Austin B. Frakt, PhD; Jodie Trafton, PhD; and Steven D. Pizer, PhD
Medicaid Prior Authorization and Opioid Medication Abuse and Overdose
Gerald Cochran, PhD; Adam J. Gordon, MD, MPH; Walid F. Gellad, MD, MPH; Chung-Chou H. Chang, PhD; Wei-Hsuan Lo-Ciganic, PhD, MS, MSPharm; Carroline Lobo, MS; Evan Cole, PhD; Winfred Frazier, MD; Ping

Drivers of Excess Costs of Opioid Abuse Among a Commercially Insured Population

Lauren M. Scarpati, PhD; Noam Y. Kirson, PhD; Miriam L. Zichlin, MPH; Zitong B. Jia, BA; Howard G. Birnbaum, PhD; and Jaren C. Howard, PharmD
The healthcare burden of opioid abuse is substantial; abusers often have complex healthcare needs and may require care beyond that which is required to treat abuse.

Objectives: To replicate and extend a recently published analysis of the drivers of excess costs of opioid abuse.

Study Design: Retrospective data analysis using de-identified claims data from the Truven MarketScan Commercial Claims and Encounter database.

Methods: Medical and prescription drug claims from beneficiaries covered by large self-insured US companies were used to select patients with incident diagnoses of opioid abuse between 2012 and 2015. Two cohorts, abusers and nonabusers, were matched using propensity score methods. Excess healthcare costs were estimated over a 6-month baseline period and 12-month follow-up period. Cost drivers were assessed by diagnosis (3-digit International Classification of Diseases, Ninth Revision, Clinical Modification groupings) and place of service. 

Results: The analysis included 73,714 matched pairs of abusers and nonabusers. Relative to nonabusers, abusers had considerably higher annual healthcare costs of $10,989 per patient, or $1.98 per member per month. Excess costs were similar, yet lower, than the previous analysis using another commercial claims database. In both analyses, a ramp-up in excess costs was observed prior to the incident abuse diagnosis, followed by a decline post diagnosis, although not to baseline levels. Key drivers of excess costs in the 2 studies included opioid use disorders, nonopioid substance misuse, and painful and mental health conditions. From 2010 to 2014, the prevalence of diagnosed opioid abuse doubled, with incidence rates exhibiting an increasing, though flatter, trend than earlier in the period.

Conclusions: Opioid abuse imposes a considerable economic burden on payers. Many abusers have complex healthcare needs and may require care beyond that which is required to treat opioid abuse. These results are robust and consistent across different data sources.
Takeaway Points
  • Commercially insured patients who receive a diagnosis of prescription opioid abuse, dependence, or overdose/poisoning incur annual excess healthcare costs of $10,989 (or $1.98 per member per month) relative to matched nonabusers, confirming a large burden to commercial payers as shown by the results of a recently published study.
  • An assessment of the key cost drivers associated with opioid abuse highlights that abusers often face multiple mental health, substance use, and/or other health issues beyond opioid abuse, suggesting a need for more comprehensive care. 
  • The prevalence of diagnosed opioid abuse doubled between 2010 and 2014, with incidence rates exhibiting a flatter, although also increasing, trend.
Prescription opioid pain relievers can be highly effective in providing relief for patients suffering from chronic pain.1 At the same time, prescription opioid abuse, dependence, overdose, and poisoning (hereinafter “abuse”) have collectively become a national public health concern. Policy interventions, such as states’ prescription drug monitoring programs and rescheduling certain opioids, as well as technological innovations, such as the introduction of abuse-deterrent formulations, have been implemented with the goal of curbing opioid misuse while trying to maintain appropriate access to care for patients. 

Opioid abuse is also costly; societal costs of opioid abuse in 2007 were estimated at $55.7 billion.2 Payers face a large proportion of these costs; previous estimates of the annual per-patient economic burden to payers of opioid abuse range from $10,000 to $20,000.3-5 Despite growing concern, the current literature has only begun to address the drivers of these excess costs of opioid abuse in terms of place of service and comorbid conditions. 

This paper first seeks to replicate the findings of a newly published study performed using a commercial claims database from OptumHealth Care Solutions, Inc (Optum). The original study presented recent refined estimates of the excess costs of opioid abuse from a payer perspective and investigated the trajectory and drivers of those excess costs. The goal of this study was to replicate the findings using a different, more expansive database: the Truven MarketScan Commercial Claims and Encounter database (Truven). In addition, we extend those findings by presenting updated rates of diagnosed prevalence and incidence of opioid abuse, as well as the incremental per-member-per-month (PMPM) cost of abuse to payers.



We analyzed de-identified administrative claims data from Truven, which cover more than one-third of the US population (ie, 117 million commercially insured beneficiaries, including employees, children, spouses, and retirees) of large, self-insured companies located throughout the United States and in a broad array of industries and job types. The databases aggregate data from a large number of plan types (eg, fee-for-service and health maintenance organizations [HMOs]).6 The data include medical claims (service date, diagnoses received, procedures performed, place of service, and payment amounts), pharmacy claims (fill dates, national drug codes, and payment amounts), and eligibility information (patient demographic characteristics and enrollment history) for the period of January 2010 to September 2015. The Optum data used in the prior study contained a similar commercially insured population from different companies, industries, and regions. 

Study Design and Statistical Analysis 

To ensure replicability, the methodology applied for the replication analysis paralleled that in the original analysis to the extent possible. Full details of the sample selection procedure and baseline characteristics can be found in the original study.7 

Incident abuse diagnoses between January 2012 and September 2015 were identified in the medical claims using the following International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for opioid abuse, dependence, or overdose/poisoning: 304.0x, 304.7x, 305.5x, 965.00, 965.02, and 965.09.7 The index date for abusers was defined as the date of the first abuse, dependence, or overdose/poisoning diagnosis. For nonabusers, the index date was the date of a random medical claim during this same period. 

The follow-up period over which each individual was observed was defined as the 6-month period prior to the index date and 0 to 6 months thereafter. Including the 6 months prior to the index date in the follow-up period was important because abuse may result in greater use of medical resources prior to a formal diagnosis. Claims and costs 7 to 12 months before the incident diagnosis (the baseline period) were used in propensity score matching. A graphical depiction of the study period can be found in the eAppendix (eAppendices available at

Two nonoverlapping cohorts of incident opioid abusers and nonabusers were selected. A 10% random sample of nonabusers was used. Patients in both cohorts had to be aged 18 to 64 years throughout the study period. In addition, we required continuous eligibility in non-HMO plans throughout the baseline and preindex follow-up periods (ie, up to and including the index date). After that, we followed patients for an additional 6 months, regardless of eligibility, to avoid bias from dropping patients who either died or lost healthcare coverage due to their abuse.

Propensity score matching of abusers and nonabusers was used to account for observable confounding factors associated with healthcare costs. A complete list of baseline characteristics, which were used as covariates in the propensity score model, and clinical codes can be found in the eAppendix. Abusers were matched 1:1 to nonabusers based on propensity scores ± one-fourth of a standard deviation using a greedy-matching algorithm.8 Baseline period characteristics for the postmatch cohorts were then compared to assess the quality of the match. 


We compared abusers’ and nonabusers’ average healthcare costs to payers during 6-month increments of the study period: 1) the baseline period (7 to 12 months before the index event), the preindex period (1 to 6 months before the index event), and the postindex period (0 to 6 months following the index event). Medical costs were categorized by place of service: inpatient, emergency department (ED), outpatient/other (eg, skilled nursing facilities), and rehabilitation facilities (costs attributed to rehabilitation facilities include those for care received in inpatient and outpatient substance abuse facilities, including all treatment received for other, both abuse and non–substance abuse-related conditions). All costs were inflated to 2015 US dollars using the medical care component of the Consumer Price Index. To assess cost drivers, the top diagnoses contributing to excess medical costs were reported by 3-digit ICD-9-CM groupings.

We also calculated annual prevalence and incidence rates of opioid abuse for 2010 to 2014. Prevalence and incidence rates for 2015 were not available due to the incomplete year of data available at the time of the study. Prevalence rates reflect all patients with at least 1 claim for opioid abuse within a given year, whereas incidence rates reflect patients with incident diagnoses within a given year. The denominator for both incidence and prevalence comprises patients with at least 1 month of coverage within a year. 

Incidence rates for those aged 18 to 64 years (ie, a rate of episodes per member) for 2012 to 2014 were averaged and combined with the estimate of annual, incremental excess costs due to opioid abuse to arrive at a PMPM estimate. Because annual excess costs of abuse were calculated for patients experiencing incident abuse episodes, incidence rates were considered more appropriate than prevalence for calculating a PMPM estimate of the burden of opioid abuse to payers. 


Prematch Cohort Characteristics 

Figure 1 describes the sample selection criteria that resulted in an analytic sample of 79,593 abusers and 1,817,395 nonabusers, for which prematch baseline characteristics were computed. The eAppendix Table (section i) compares baseline characteristics between the abusers and nonabusers prior to matching. Abusers were statistically different from controls on key demographic measures, with abusers more likely to be male (53.9% vs 45.5%; P <.0001) and younger (39.0 vs 43.0; P <.0001). There were also significant differences in the prematch comorbidity profile and healthcare resource utilization. During the baseline period, abusers were substantially more likely to have been diagnosed with abuse of nonopioid substances (15.3% vs 2.0%; P <.0001), major depressive disorder (8.5% vs 1.8%; P <.0001), other psychoses (7.9% vs 1.1%; P <.0001), and other mental health disorders (30.2% vs 9.1%; P <.0001). A complete list of the clinical codes and diagnoses used to construct these categories can be found in the eAppendix.

Overall, abusers used significantly more healthcare resources during the baseline period. For example, abusers spent more days in an inpatient hospital (0.8 vs 0.1 days; P <.0001) and more time in the ED (0.6 vs 0.1 visits; P <.0001) than nonabusers. These differences resulted in average baseline healthcare costs among abusers being nearly 4 times that of nonabusers ($8563 vs $2371; P <.0001). 

Postmatch Cohort Characteristics 

The propensity score procedure successfully matched 73,714 abusers 1:1 with nonabusers for a 93% match rate. These matched samples were well balanced with respect to the baseline characteristics (eAppendix Table [section ii]). There were 3 notable differences between the 2 cohorts, although the magnitude of these differences was small: 1) abusers were less likely to be the child of a primary beneficiary than nonabusers (27.3% vs 30.2%; P <.0001), 2) a larger proportion of abusers had extended-release opioid use during the baseline period (9.6% vs 7.9%; P <.0001), and 3) abusers had 2% higher costs than nonabusers during the baseline period ($7306 vs $7149; P = .0209).

Costs of Abuse 

Figure 2 displays the average monthly excess costs during the study period. As observed in the original analysis, monthly excess costs increased during the 9 months leading up to the index date, from $7 eight months before to $774 in the month prior to the index date. Excess costs reached their maximum, $3628, in the index month, and although they dropped subsequently, remained well above baseline levels (between $1289 and $861) thereafter.

Tables 1 and 2 present the costs of abusers and controls during the two 6-month segments of the follow-up period (preindex, and postindex) by place of service, as well as the leading conditions driving excess medical costs. The average per-patient healthcare costs of abusers were $3018 more than nonabusers in the 6 months before the abuse episode and $7971 more than nonabusers in the 6 months after the abuse episode. Stated differently, abusers’ annual costs were estimated to be $25,069 compared with $14,080 for matched controls, resulting in an extra $10,989. In the 6-month preindex period, most excess healthcare costs were incurred in an inpatient setting (49%; $1471), followed by ED (18%; $531), rehabilitation facilities (17%; $503), outpatient (12%; $371), and prescription drugs (5%; $143). During the preindex period, the most costly conditions associated with opioid abuse included those related to nonopioid drug/alcohol abuse and dependence (19% of preindex excess costs), back pain (11%), and mental health-related disorders (6%).

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