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The American Journal of Managed Care April 2019
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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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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.
RESULTS

Results indicate a total of 14,516 all-cause deaths among opioid users in the study sample. About 42% of these deaths were among opioid users who experienced at least 1 incidence of potential inappropriate prescribing practices of opioids. Descriptive statistics of the study sample are presented in Table 1 by whether an individual experienced any incidences of potential inappropriate prescribing practices of opioids. Individuals who experienced any incidences of potential inappropriate opioid prescriptions were more likely to be male, older, non-Hispanic white, and FFS enrollees. They also had higher average CCI scores (2.36), indicating higher severity of health conditions, compared with individuals who did not experience any incidences of potential inappropriate prescriptions (0.96). Individuals who experienced any incidences of potential inappropriate opioid prescriptions received higher numbers of prescriptions of opioids, LA/ER opioids, benzodiazepines, and BUP-NX compared with individuals who did not experience any incidences. Higher proportions of individuals with potential inappropriate opioid prescriptions were diagnosed with chronic pain, acute pain, and OUD. Additionally, a higher proportion of these individuals experienced death (8.65%) compared with those who did not experience any incidences of inappropriate opioid prescriptions (2.56%).

The number of deaths among individuals who experienced any incidences of potential inappropriate opioid prescriptions increased over time (2009-2014), with a slight drop in 2015 (Figure 1). Although the number of deaths was higher among women than men, the rate of death was higher among men (Figure 2). In addition, the rate of death was higher among FFS enrollees compared with managed care enrollees (Figure 3). Moreover, the rate of death was higher among older individuals (aged 55-64 years) compared with other age groups (eAppendix Figure 1 [eAppendix available at ajmc.com]). However, the rate of death was not higher among a specific race/ethnic group throughout all years (eAppendix Figure 2).

Table 2 presents the results from the multivariate logistic regression analysis. The odds of opioid users experiencing death were 1.76 times higher for those who experienced 1 or more incidences of inappropriate opioid prescribing practices compared with those who did not have this experience during the study period (P <.001). In addition, the odds of experiencing death were higher among opioid users who were older, were diagnosed with acute pain or OUD, and had a higher severity of health conditions; meanwhile, the odds were lower among opioid users who were female and managed care enrollees. Moreover, the odds of experiencing death were lower among opioid users who belonged to all other races (Hispanic, non-Hispanic black, non-Hispanic other, missing race) compared with non-Hispanic white opioid users.

DISCUSSION

The number of deaths caused by opioid overdoses is increasing in the United States,27 and prescribers, dispensers, and other stakeholders are aware of the wide range of implications associated with the use of these medications—from their impact on relief of pain to morbidity and mortality (usually caused by respiratory depression). Because patients with legitimate prescriptions for opioids are also at risk of opioid overdose and death,28 we sought to examine (1) if the appropriateness of the prescribing practices for opioids presents another risk factor for death from all causes within the population of opioid users and (2) differences between traditional FFS Medicaid and managed care Medicaid.

With more than 14,500 opioid deaths over the study period, we found that 42% of these deaths occurred in patients with 1 or more incidences of inappropriate prescribing. Using 5 established criteria for identifying potential inappropriate prescriptions for opioids, we identified an increasing trend in the death rate for patients who used opioids between 2009 and 2014, with male, white, and older patients dying at higher rates. In fact, patients had a 76% greater chance of dying during the study period if they had 1 or more incidences of inappropriate opioid prescriptions. Comparatively, severity of health conditions increased the odds of dying during the study period by 31%, whereas being in managed care Medicaid decreased the odds of death by 69%. Our results also showed that regarding insurance type, death rates among FFS Medicaid enrollees were significantly higher than among managed care enrollees who experienced at least 1 incidence of potential inappropriate prescribing of opioids.

Although these trends are generally consistent with those found in other descriptive studies that have identified risk factors for opioid overdose deaths,3,14,15 the finding that insurance type affects death rates was concerning. This is of interest because it is possible that structural differences in the payment system (FFS vs managed care) could be affecting opioid use. In particular, FFS may be imposing fiscal controls (eg, formulary status, limits on the numbers of prescriptions or quantity per prescription) at the point of payment to curb opioid use. In contrast, managed care plans may use these same methods but employ additional strategies for patient education and shared decision making.


 
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