Over the past 20 years, changes in laws governing the prescribing of opioids for the treatment of chronic non-cancer pain has led to dramatic increases in opioid use in the United States.1 This subsequently led to widespread misuse of these medications before it became clear that these medications could be highly addictive.2 The U.S. Centers for Disease Control and Prevention (CDC) estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.2 The consequences of the opioid epidemic include increases in opioid misuse and related overdoses; for example, studies report that between 8 and 12 percent of people using an opioid for chronic pain develop an opioid use disorder.2
The effects of opioids on chronic pain are uncertain. Studies examining patients who underwent low-risk surgery or experienced low back pain from injury revealed that opioid therapy prescribed for acute pain was associated with greater likelihood of long-term use.3 CDC guidelines recommend non-pharmacologic therapy and non-opioid pharmacologic therapy for chronic pain as first-line therapy (Grade A recommendation).3 According to CDC, clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient.3 There are no publications that show long-term benefit of opioids in non-cancer chronic pain and function. 3
Such clear advice from CDC and lack of published evidence of any long-term benefit of opioid use should, in theory, lead to a decline in the prescribing of opioids for non-cancer chronic pain. The authors of this brief, set about to see what the claims data show on opioid use and prescribing patterns.
We used the Milliman MedInsight Health Waste Calculator (HWC) measure of inappropriate opioid prescriptions to study the prevalence of inappropriate opioid prescriptions for non-cancer pain in an administrative claims dataset with over 1.6 million lives (2019). The HWC measure is based on the Choosing Wisely® recommendations from various specialties and societies that recommend against prescribing opioids for acute low back pain, for non-cancer pain, for migraine, neuropathic pain, postoperative dental pain, abdominal pain in inflammatory bowel disease, pain due to osteoarthritis, autoimmune disease or for treatment of knee osteoarthritis, hip osteoarthritis, chronic low back pain, or rotator cuff injury.
The HWC measure identifies inappropriate prescribing of opioid in members aged 18 years and older with non-cancer pain in the outpatient setting as wasteful. Members with inpatient admission or with palliative care/end-of-life care within 30 days on or prior to the opioid prescription were excluded from the measure. Members with a diagnosis of cancer or sickle cell anaemia within 180 days on or prior to the opioid prescription are considered not wasteful. Members with an opioid prescription and a diagnosis of opioid dependence on or within 30 days prior to the prescription of buprenorphine are considered not wasteful. Members prescribed Non-Opioid Medication (Nonsteroidal anti-inflammatory drugs or tramadol or duloxetine, etc.) within 90 days on or prior to the opioid prescription or members with physical or behavioural therapy for more than six months prior to the opioid prescription are considered likely wasteful. Likely wasteful opioid prescription indicate that the appropriateness of the opioid prescriptions cannot be completely ascertained from claims data.
The results included in this section is from our analysis using 2019 data with around 1.6 million lives. A total of 564,284 members had office visits for non-cancer pain. Figure 1 displays the distribution of these members among the HWC classifications (likely wasteful, wasteful, optimal, and not wasteful).
- For this population we found the overall waste index to be 83%. Waste index is the ratio of “Likely wasteful” and “Wasteful” services divided by the total services (Not wasteful + Likely wasteful + Wasteful services).
- 5% of members had an appropriate opioid prescription categorized as “not wasteful”
- 17% of members had a “likely wasteful opioid prescription”. Opioid prescriptions in this group of members indicate that the appropriateness of the opioid prescriptions cannot be completely ascertained from claims data.
- 4% of members had a “wasteful or inappropriate opioid prescription” with total allowed costs of $2,316,492 which is 2% of the total wasteful allowed dollars in 2019.
- 74% of members with non-cancer pain had an outpatient visit but were not prescribed opioids. The HWC identifies such services as “optimal events.” Optimal events allow identification of instances where care was administered in accordance with guidelines (i.e., a low value care service did not occur). Low value care services are services that provide little or no benefit to patients, have potential to cause harm, incur unnecessary cost to patients, or waste limited healthcare resources.
Distribution of opioid use across the US
We analyzed the prevalence of inappropriate prescribing of opioids among the 50 states in the US using the same dataset of 1.6 million lives in 2019. The map in figure 2 shows a breakdown of the HWC waste index by state. We found that:
- The states of Texas and South Carolina showed the highest levels of inappropriate/wasteful opioid prescribing with waste indexes of 85% and 79%, respectively (Figure 2). Texas had 295,277 wasteful opioid prescribed out of total 349,073 opioid services and South Carolina had 95,351 wasteful opioid prescribed out of total 120,896 opioid services.
- Although Oregon had the highest waste index (99%), there were 66 wasteful opioid prescribing services out of a total of 67 opioid prescribing services.
- In terms of spending, South Carolina contributed to 85% of the total wasteful dollars for opioids.
We also reviewed the opioid summaries by State published by the National Institute on Drug Abuse (NIDA)7 for the patterns of opioid prescription in the two states above and found that:
- In 2018, Texas providers wrote 47.2 opioid prescriptions for every 100 persons.7 This is the lowest rate in the state since 2006 when data became available. The average U.S. rate in the same year was 51.4 prescriptions for every 100 persons. 7 Although the rate of opioid prescription was lower than the US average, using our methodology to measure waste in 2019, the data showed that Texas had the highest opioids prescribed in the country.
- Similarly, in 2018, South Carolina providers wrote 69.2 opioid prescriptions for every 100 persons compared to the average U.S. rate of 51.4 prescriptions.7This result is in line with our analysis that showed that the State of South Carolina had the second highest opioids prescribed in 2019.
Downstream impact of inappropriate opioids
The CDC guideline for prescribing opioids for chronic pain3 and other publications highlight many conditions associated with opioid abuse as a cascading effect of prescribing opioid. To analyze this effect, we identified members with a diagnosis of opioid dependence, opioid abuse and conditions associated with opioid abuse if they occur within 45 days after a likely wasteful or wasteful opioid prescription. Members with diagnosis of opioid dependence or abuse prior to the likely wasteful or wasteful opioid prescription service were excluded. Other adverse events due to opioid prescription such as central nervous system adverse events (headache, somnolence, dizziness), gastrointestinal tract adverse events (constipation, nausea, vomiting), and autonomic adverse events, such as dry mouth were not included as they are difficult to ascertain from claims data.
- We found that 0.7% of members with inappropriate opioid prescription had opioid dependence, opioid abuse and conditions associated with opioid abuse. This indicates that the vast majority of opioid prescriptions were not prescribed to members with known opioid dependence.
- The services for the opioid dependence resulted in additional allowed cost of $968,592. The cost of the downstream event when added to the cost of the likely wasteful and wasteful event ($14,674,191) increased the overall wasteful spending to 7%.
Specialties with high opioid prescriptions
To study the specialties with high opioid prescriptions, we further analyzed the administrative claims data set that showed a similar pattern in opioid prescriptions as found in IMS Health’s National Prescription Audit6 from 2007-2012. Figure 3 displays the percentage of opioid prescriptions dispensed by the top 10 specialties according to our analysis. The family medicine specialty has the highest prescription of opioids at 21%, followed by emergency medicine and internal medicine at 11%.
In the analysis from IMS Health’s National Prescription Audit from 2007-2012, three primary care specialty groups (family practice, internal medicine, and general practice) accounted for nearly half (44.5%) of all dispensed opioid prescriptions.6 Non-physician prescribers, including physician assistants, and nurse practitioners contributed 10.5% of all prescriptions and 11.2% of opioid prescriptions.6 The rate of opioid prescribing was highest in the specialties of pain medicine (48.6%); surgery (36.5%); and physical medicine/rehabilitation (35.5%).6
We also wanted to study the prevalence of obtaining opioids from multiple healthcare providers by the same member (such as physicians, dentists, or, less commonly, physician assistants). Our analysis identified that 5% of members with wasteful prescriptions received opioids from three or more providers in the administrative claims data set.
This is in line with the previously reported pattern of patients receiving opioid prescriptions from multiple healthcare providers who do not or cannot communicate with one another. It is particularly concerning among elderly patients because of increased adverse events associated with opioid use.5 Per the California PMP (prescription monitoring program), 12.8% of opioid prescribed were most frequently involved in multiple provider episodes than other controlled substances.4
Our analysis of an administrative data set of around 1.69 million members from 2019 confirmed many of the reported statistics in literature using the MedInsight Health Waste Calculator. Due to the limitations of clinical data within claim records the MedInsight Health Waste Calculator approach is very conservative in terms of its definitions of waste, i.e., the algorithm errs on the side of defining services as not wasteful vs. wasteful. Although the analysis was conducted on a relatively small dataset and with conservative assumptions, the MedInsight Health Waste Calculator was able to identify potentially inappropriate prescribing of opioids in people with non-cancer pain. The growing problem or the continuing prevalence of high wasteful services in opioid prescribing is a matter of concern for all. The U.S. Department of Health and Human Services (HHS) is already working on initiatives to tackle the opioid crisis.2 In addition, health care payers can continue their efforts to reduce inappropriate prescriptions by using such analysis in monitoring providers with high inappropriate opioid prescribing patterns and also educating both physicians and members on the long-term impact of unnecessary opioid use.
- Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, Boswell MV. Opioid epidemic in the United States. Pain Physician. 2012 Jul;15(3 Suppl):ES9-38. PMID: 22786464. Available at: https://pubmed.ncbi.nlm.nih.gov/22786464/
- Opioid Overdose Crisis. National Institute on Drug Abuse. Available at: https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016. JAMA. 2016;315(15):1624–1645. doi:10.1001/jama.2016.1464 Available at: https://jamanetwork.com/journals/jama/fullarticle/2503508?resultClick=1
- Wilsey BL, Fishman SM, Gilson AM, Casamalhuapa C, Baxi H, Zhang H, Li CS. Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics. Drug Alcohol Depend. 2010 Nov 1;112(1-2):99-106. doi: 10.1016/j.drugalcdep.2010.05.007. Epub 2010 Jun 20. PMID: 20566252. Available at: https://pubmed.ncbi.nlm.nih.gov/20566252/
- Jena A B, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: retrospective observational study of insurance claims BMJ 2014; 348 :g1393 doi:10.1136/bmj.g1393. Available at: https://www.bmj.com/content/348/bmj.g1393
- Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic-Prescribing Rates by Specialty, U.S., 2007-2012. Am J Prev Med. 2015;49(3):409-413. doi:10.1016/j.amepre.2015.02.020. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6034509/
- Opioid Summaries by State. Available at: Opioid Summaries by State | National Institute on Drug Abuse (NIDA)