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Supplements Combating the Opioid Epidemic
Introduction to the Opioid Epidemic: The Economic Burden on the Healthcare System and Impact on Quality of Life
Nicholas E. Hagemeier, PharmD, PhD
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Courtney Kominek, PharmD, BCPS, CPE
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The Role of Managed Care Professionals and Pharmacists in Combating Opioid Abuse
Kirk Moberg, MD, PhD

The Role of Managed Care Professionals and Pharmacists in Combating Opioid Abuse

Kirk Moberg, MD, PhD
Substance misuse is a critical and costly public health problem in the United States. Data as of 2016 show 11,517 cases of opioid analgesic misuse, with the majority (6924 cases) related to hydrocodone misuse. Substance misuse impacts our society significantly with high costs related to healthcare, crime, and lost productivity. Opioid analgesic pain relievers are one of the most prescribed classes of medications and are among the most common drugs related to misuse. Increases in emergency department visits of over 200% have been associated with a dramatic surge in written prescriptions for opioid pain relievers. Mortality with opioid misuse has increased dramatically, with 2016 statistics demonstrating 42,249 deaths from any opioid; 15,469 heroin-related deaths; 14,487 deaths related to natural and semi-synthetic prescription agents; 19,413 deaths caused by mainly illicit use of synthetics (mostly fentanyl); and 3373 deaths related to methadone use. Per the Centers for Disease Control and Prevention (CDC), 3 of 5 drug overdoses are from an opioid, such as heroin, morphine, and prescription pain relievers. In addition, the expenses associated with drug use disorders are comparable to the costs of other chronic diseases, such as diabetes. Policymakers, criminal justice officials, and healthcare providers consider illicit drug and opioid misuse a national epidemic that must be addressed more strongly to improve pain management in the United States, optimize patient outcomes, and decrease unlawful drug use for pain relief.
Am J Manag Care. 2018;24:-S0
The Economic Impact of Opioid Abuse in the United States

The overall undesirable health burden of the misuse of prescribed opioid agents has been documented extensively in terms of drug abuse, dependence, and overdose. However, it can be very difficult to develop optimal policies to address this burden while balancing the needs of patients who need treatment for pain. Strategies to do so must be both clinically appropriate and cost-effective. One important factor in addressing the opioid crisis is addressing the economic burden that results from adverse events (AEs) and poor health outcomes related to opioid abuse and misuse in the United States. One landmark study in this area was performed by Florence et al, covering the economic burden created by opioid misuse/abuse in the calendar year 2013. In this analysis, the investigators calculated cost estimates of prescription opioid overdose, abuse, and dependence based on the incidence of deaths related to overdose and the prevalence of abuse and dependence over the 2013 1-year time period. This was approached from a societal perspective, addressing the costs for those who experienced overdose or abuse and dependence and societal costs, including those related to criminal-justice actions. The actual costs for abuse and dependence were overall annual costs in this study, while those for fatalities were lifetime costs discounted to the 2013 value at a 3% rate. If the most recent year of data used was before 2013, the costs were adjusted for inflation to 2013 dollars. Fatality data were obtained from the National Vital Statistics System, with prevalence data on abuse/dependence from the National Survey of Drug Use. Cost data were derived from several sources, including healthcare claims data from the Truven Health MarketScan Research Databases, with costs of fatalities from Web-based Injury Statistics Query and Reporting System cost module. Criminal-justice costs arose from the Justice Expenditure and Employment Extracts published by the Department of Justice. Lost productivity estimates were adapted from a previous study.1

Results demonstrated that the aggregate costs associated with cases of opioid abuse/dependence and fatal overdose were over $78.5 billion, with a range of $70.1 billion to $87.3 billion. Nearly two-thirds of the total costs were attributed to healthcare, substance abuse treatment, and lost productivity (cases without fatality), with the other third made up of criminal-justice and fatal costs. Total spending surrounding healthcare and substance abuse amounted to more than $28 billion ($21.4 billion to $30.8 billion) from insurance coverage data and $2.8 billion ($2.6 billion to $3.2 billion) from additional sources. Fatalities comprised over 25% of costs ($21.5 billion, range of $21.2 billion to $21.8 billion).1

The healthcare system bears approximately one-third of total costs estimated in this analysis. A significant amount of this cost burden is assumed by the federal government in the United States, with 14% funded by Medicare, Medicaid, and Champus/Veterans Affairs. Approximately 96% of costs ($7.3 billion) related to criminal justice is related to activities directly funded by either local or state governments. When taken together, approximately 25% of the aggregate economic burden is funded by public sources. It is important to note the magnitude of the difference between financing the consequences of abuse/dependence (96% of expenditures) versus financing the treatment of the disease (4%). It should also be noted that the definition of opioid abuse/dependence used in this study was that defined by the 9th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-9) diagnosis codes, and no distinction was made between prescription opioids and heroin in the analysis.1

In November 2017, The Council of Economic Advisers (CEA) of the Office of the President of the United States published their own analysis on the economic burden created by the opioid crisis. Despite noting previous data such as the Florence et al study, this analysis presented the concept that previous data showed only a partial account of the actual damage inflicted by opioid misuse/abuse. The premise put forth was that the opioid crisis has worsened over recent years, with heroin abuse playing a larger role, and previous fatality statistics underestimated the true number of opioid-related fatalities. This study quantified the costs for opioid-related overdose deaths based on economic valuations for fatality risk reduction, using the “value of a statistical life” (VSL) measure often used by federal agencies. However, it must be noted that VSL estimates can vary among agencies and may be prone to overstatement. A range of VSL estimates must be considered in fatality cost estimates.2 The CEA analysis adopted an approach proposed by a study by Aldy and Viscusi for preferred estimates for VSL. This study was notable for citing that VSL may vary by age, and the CEA adopted this method to allow VSL to vary with age to control for the age distribution among opioid-related overdose deaths studied.2,3 For nonfatal costs, the CEA study used the Florence et al estimates to obtain a per-individual measure of opioid misuse costs for nonfatal cases and multiplied that per-individual cost by the number of persons with opioid use disorder in 2015.2

Results from the analysis estimated the total economic costs of the opioid epidemic at $504 billion ($239.9 billion to $622.1 billion). This $504 billion estimate was reached by combining $72.3 billion for nonfatal consequences (eg, healthcare costs for substance abuse therapy, criminal-justice costs, reduced productivity of 2.4 million nonfatal cases of opioid use disorder) with $431.7 billion related to lives lost/fatality costs.2,4 The CEA noted that their cost estimate is significantly higher because of their accounting for lives lost based on standard federal methods in cost-benefit analyses for health-related intervention. In addition, the results of the study indicate that the overall opioid crisis itself has worsened substantially with overdose deaths doubling over the past decade. This analysis also considered both prescription and illicit (heroin) opioids, while previous studies tended to concentrate on prescription drugs. The overdose deaths were adjusted upward based on recent research that found significant underreporting of opioid-related overdose fatalities.2,5 This investigation compared reported opioid-involved mortality rates calculated directly from death certificates to corrected rates that attributed drug involvement when no drug was specified. Results showed that corrected opioid mortality rates were 24% greater than those reported.5

Using Step Care in Pain Management Instead of Opioids as First-Line Therapies

One point of argument in this country is the concept that clinicians overprescribe opioids, including as first-line therapy for pain management. It has been estimated that enough prescriptions for opioids were written to provide 1 of every 3 Americans with an opioid prescription in 2015, and nearly 92 million adults (38% of the US population) used a prescribed opioid during the same year according to a survey from the National Survey on Drug Use and Health. The survey also found that 11.5 million people (5% of the population) misused illicitly obtained prescription opioids. Data suggest there is now 4 times the level of opioid prescribing that existed 15 years before the survey.6,7

One approach to provide appropriate pain management without using opioids as first-line therapy is the stepped-care model of pain management (SCM-PM) for those with chronic pain.8 Anderson et al implemented this model at a large, multisite, federally qualified health center (FQHC). This effort was guided by the Promoting Actions on Research Implementation in Health Services framework, and included9:
  • Education on pain care
  • New protocols for pain assessment and management
  • Use of an opioid management dashboard
  • Telemedicine consultations
  • Enhanced onsite specialty resources
Twenty-five primary care physicians (PCPs) and their patients with chronic pain participated (3357 patient preintervention and 4385 patients postintervention). Data were obtained from the electronic medical records (EMRs) and direct chart reviews. The involved PCPs received surveys to analyze their knowledge, attitudes, and confidence in pain management. Three steps were used as part of this SCM-PM effort (Figure).9

Interventions consisted of 6 educational and practice support elements9:
  • Physician continuing medical education (CME)
  • EMR pain templates for initial and follow-up visits
  • Chronic pain and opioid prescribing policy requiring a signed opioid treatment agreement (OTA), 6-month urine drug tests (UDTs), and a standardized pain interference assessment every 3 months for those receiving opioids
  • Opioid management dashboard including the requirements noted above (agreement, urine testing, pain interference assessment)
  • Onsite specialty resources (eg, chiropractic care, pain-focused behavioral health interventions)
  • Project Extension for Community Healthcare Outcomes (ECHO), providing videoconferences for PCPs to present complex pain cases to a multidisciplinary pain management team, with 1 PCP joining in weekly as the onsite pain “champion”
Results demonstrated improvements in multiple documentation elements (Table 1).9 Overall, PCPs’ pain knowledge scores increased 11% from baseline on average, and self-confidence in ability to manage pain was also enhanced. The use of OTAs increased by 27.3%, and the use of UDTs in this patient population increased by 22.6%. Notable improvements were recorded in documentation of pain, pain therapy, and follow-up. In addition, referrals to behavioral healthcare professionals for patients with chronic pain increased by 5.96%.9

Implementation of SCM-PM was also studied by Moore et al. Implementation occurred in the Veterans Health Administration (VHA) healthcare system over 4 years, as well as a non-VHA FQHC over a 2-year period. This study involved a sampling of medical chart progress notes from both facilities from primary care prescribers of opioid therapy to assess results following implementation of stepped care. The progress notes were coded for the presence or absence of pain care quality8:
  • Pain assessment
  • Pain treatment plans
  • Pain reassessment/outcomes
  • Patient education
Within the systems studied, results showed significant improvements in pain assessment, pain treatment plans, and patient education with positive trends seen in all dimensions (Table 2 and Table 3).8

Chronic Pain Management Guidelines/Recommendations

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