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The American Journal of Managed Care April 2019
Time to Fecal Immunochemical Test Completion for Colorectal Cancer
Cameron B. Haas, MPH; Amanda I. Phipps, PhD; Anjum Hajat, PhD; Jessica Chubak, PhD; and Karen J. Wernli, PhD
From the Editorial Board: Kavita K. Patel, MD, MS
Kavita K. Patel, MD, MS
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Maureen J. Lage, PhD
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Eric T. Wittbrodt, PharmD, MPH; James M. Eudicone, MS, MBA; Kelly F. Bell, PharmD, MSPhr; Devin M. Enhoffer, PharmD; Keith Latham, PharmD; and Jennifer B. Green, MD
Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
Amy Linsky, MD, MSc; Mark Meterko, PhD; Barbara G. Bokhour, PhD; Kelly Stolzmann, MS; and Steven R. Simon, MD, MPH
The Health and Well-being of an ACO Population
Thomas E. Kottke, MD, MSPH; Jason M. Gallagher, MBA; Marcia Lowry, MS; Sachin Rauri, MS; Juliana O. Tillema, MPA; Jeanette Y. Ziegenfuss, PhD; Nicolaas P. Pronk, PhD, MA; and Susan M. Knudson, MA
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Nick Ladziak, PharmD, BCACP, CDE; and Nicole Paolini Albanese, PharmD, BCACP, CDE
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Deaths Among Opioid Users: Impact of Potential Inappropriate Prescribing Practices
Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
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Sheri A. Keitz, MD, PhD; David C. Aron, MD; Judy L. Brannen, MD; John M. Byrne, DO; Grant W. Cannon, MD; Christopher T. Clarke, PhD; Stuart C. Gilman, MD; Debbie L. Hettler, OD, MPH; Catherine P. Kaminetzky, MD, MPH; Robert A. Zeiss, PhD; David S. Bernett, BA; Annie B. Wicker, BS; and T. Michael Kashner, PhD, JD
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Continuity of Outpatient Care and Avoidable Hospitalization: A Systematic Review
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Deaths Among Opioid Users: Impact of Potential Inappropriate Prescribing Practices

Jayani Jayawardhana, PhD; Amanda J. Abraham, PhD; and Matthew Perri, PhD
Inappropriate prescribing practices of opioids are a major risk factor for mortality among opioid users in the Georgia Medicaid population, although risk is lower in managed Medicaid.

Objectives: To examine the association between potential inappropriate prescribing practices of opioids and deaths among opioid users in the Georgia Medicaid population.

Study Design: A retrospective analysis of individual pharmacy claims data from Georgia Medicaid from 2009 through 2014.

Methods: The sample was restricted to patients without cancer aged 18 to 64 years with an opioid prescription and included 3,562,227 observations representing 401,488 individuals. A descriptive analysis and a multivariate logistic regression analysis were conducted.

Results: Results indicate a total of 14,516 deaths among opioid users in the study sample, of whom approximately 42% experienced at least 1 incidence of potential inappropriate prescribing practices. Regression results indicate that the odds of opioid users experiencing death were 1.76 times higher for those who experienced at least 1 incidence of potential inappropriate prescribing practices of opioids compared with those who did not experience any incidence, even after controlling for other covariates (P <.001). Moreover, opioid users in managed care Medicaid were less likely to experience death compared with fee-for-service (FFS) enrollees.

Conclusions: The results indicate a positive and statistically significant association between potential inappropriate opioid prescribing practices and deaths among opioid users in Georgia Medicaid, with FFS enrollees experiencing higher rates of death compared with managed care enrollees. Appropriate policies and interventions targeted at reducing potential inappropriate prescribing practices may help reduce the risk factors associated with mortality among opioid users in this population.

Am J Manag Care. 2019;25(4):e98-e103
Takeaway Points

This study indicates that incidences of potential inappropriate prescribing practices of opioids are significantly and positively associated with deaths among opioid users in the Georgia Medicaid population.
  • The odds of experiencing death were 76% higher for opioid users with incidences of potential inappropriate opioid prescribing practices compared with those without any incidences.
  • Being in managed care Medicaid decreased the odds of experiencing death by 69% for opioid users compared with being in fee-for-service (FFS) Medicaid.
  • Policies and interventions targeted at reducing inappropriate opioid prescribing practices, especially among FFS enrollees, could help curb the risk factors associated with prescribing opioids.
Deaths related to opioid overdose continue to rise at an alarming rate in the United States. Drug overdose mortality is now the leading cause of death for Americans younger than 50 years and has been largely attributed to deaths associated with prescription opioids.1 The Medicaid population in particular has been significantly affected by the opioid crisis, experiencing high rates of opioid prescribing, opioid-related overdose deaths, and opioid use disorder (OUD).1-3 Prior studies have examined opioid prescribing among Medicaid enrollees2,4-9 and the relationship between opioid prescribing and mortality in this population.3,10-17

Several studies have identified risk factors associated with risk of opioid overdose and mortality, including some indicators of potential inappropriate use and prescription of opioids.3,11,14-16 One such study, by Ray et al,14 used data from the Tennessee Medicaid program (1999-2012) to examine the risk of mortality associated with prescription of long-acting opioid therapy compared with a set of control medications. Results showed that the risk of all-cause mortality was greater for patients receiving prescriptions for long-acting opioids for chronic noncancer conditions compared with patients in the control medication group.14

In a study by Yang et al,11 multistate Medicaid claims data were used to examine the relationships between pharmacy shopping and overlapping prescriptions of opioids and opioid-related overdose events using data from 2008 to 2010. This study defined overlapping prescriptions of opioids as 2 prescriptions for the same opioid drug type that overlapped by at least 25% of the days prescribed, with the initial dispensed prescription having at least 5 days of supply. Results indicated that the adjusted risks of an overdose event were higher for patients with overlapping opioid prescriptions and for patients engaging in pharmacy shopping.11

Another study, by Cochran et al, examined the association between nonmedical use of prescription opioids and opioid medication overdose using data from the Pennsylvania Medicaid program (2007-2012).16 Opioid overdose was higher among patients with opioid abuse, probable misuse, and possible misuse compared with patients with no misuse. The study used a 3-category measure of misuse based on the number of opioid prescribers, number of pharmacies used for medication filling, days’ supply of short-acting opioids, and days’ supply of long-acting opioids over a 6-month period (no misuse, 0-1; possible misuse, 2-4; and probable misuse, ≥5). The results indicated that doses of 100 morphine milligram equivalents (MME) per day or greater were associated with a higher rate of overdose compared with doses below 20 MME per day. Further, any use of benzodiazepines or muscle relaxants was associated with overdose.16

Two additional studies3,15 found support for the relationship between potential inappropriate use or prescription of opioids and prescription opioid overdose mortality. Using data from the Colorado Medicaid program (2009-2014), Dilokthornsakul and colleagues found in 2016 that mean morphine equivalent dose of more than 50 mg per day, methadone use, benzodiazepine use, and number of pharmacies used by the beneficiary (≥4 vs 1) were associated with an increased risk of prescription opioid overdose.15 In 2017, Garg and colleagues3 found that risk of opioid overdose death increased at doses of 50 mg to 89 mg, 120 mg to 199 mg, and 200 mg or greater compared with 1 mg to 19 mg per day among Medicaid patients in the state of Washington. Risk of opioid overdose death was also greater for patients using both long-acting and short-acting Schedule II opioids compared with non–Schedule II opioids alone. Finally, patients receiving overlapping prescriptions of opioids and benzodiazepines, or opioids and skeletal muscle relaxants, had a higher risk of opioid overdose.3

To date, studies investigating mortality associated with opioid prescribing have focused primarily on identifying risk factors associated with opioid overdose mortality. However, most of these studies rely on older data that predate the sharp increase in prescription opioid mortality. Further, there is some question as to how accurately death due to opioid overdose is captured in death certificates.18 In addition, to our knowledge, no single study has examined a comprehensive set of indicators of inappropriate opioid prescribing and how these indicators are related to mortality. Finally, most prior studies examined the Medicaid fee-for-service (FFS) population. However, a majority of Medicaid patients are enrolled in managed care plans; therefore, the results of these studies may not extend to Medicaid managed care. To better understand how potential inappropriate prescribing of opioids is associated with all-cause mortality in the Medicaid population, we used the Georgia Medicaid pharmacy claims database (2009-2014) to examine the impact of 5 indicators of potential inappropriate opioid prescribing practices on all-cause mortality among patients in both FFS and managed care plans.

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