Dataset Information

High-Risk Prescribing to Medicaid Enrollees Receiving Opioid Analgesics: Individual- and County-Level Factors.

ABSTRACT: BACKGROUND:Prescription opioid overdoses have increased dramatically in recent years, with the highest rates among Medicaid enrollees. High-risk prescribing includes practices associated with overdoses and a range of additional opioid-related problems. OBJECTIVES:To identify individual- and county-level factors associated with high-risk prescribing among Medicaid enrollees receiving opioids. METHODS:In a four-states, cross-sectional claims data study, Medicaid enrollees 18-64 years old with a new opioid analgesic treatment episode 2007-2009 were identified. Multivariate regression analyses were conducted to identify factors associated with high-risk prescribing, defined as high-dose opioid prescribing (morphine equivalent daily dose ?100 mg for >6 days), opioid overlap, opioid-benzodiazepine overlap. RESULTS:High-risk prescribing occurred in 39.4% of episodes. Older age, rural county of residence, white race, and major depression diagnosis were associated with higher rates of all types of high-risk prescribing. Individuals with prior opioid, alcohol, and hypnotic/sedative use disorder diagnoses had lower odds of high-dose opioid prescribing but higher odds of opioid overlap and opioid-benzodiazepine overlap than individuals without such disorders. High-dose opioid prescribing in Massachusetts was less common than in California, Illinois, and New York, whereas the rate of benzodiazepine overlap in Massachusetts was more common than in other states. Conclusions/Importance: High-risk prescribing was common and associated with several important demographic, clinical, and community factors. Findings can be used to inform targeted interventions designed to reduce such prescribing, and given state variation observed, further research is needed to better understand the effects of state policies on high-risk prescribing.

SUBMITTER: Heins SE

PROVIDER: S-EPMC6033690 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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High-Risk Prescribing to Medicaid Enrollees Receiving Opioid Analgesics: Individual- and County-Level Factors.

Heins Sara E SE Sorbero Mark J MJ Jones Christopher M CM Dick Andrew W AW Stein Bradley D BD

Substance use & misuse 20180105 10

<h4>Background</h4>Prescription opioid overdoses have increased dramatically in recent years, with the highest rates among Medicaid enrollees. High-risk prescribing includes practices associated with overdoses and a range of additional opioid-related problems.<h4>Objectives</h4>To identify individual- and county-level factors associated with high-risk prescribing among Medicaid enrollees receiving opioids.<h4>Methods</h4>In a four-states, cross-sectional claims data study, Medicaid enrollees 18- ...[more]

PMID: 29303393

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Project description:BackgroundThe Pharmacy Quality Alliance (PQA) recently developed 3 quality measures for prescribing opioids: high dosages, multiple providers and pharmacies, and concurrent use of opioids and benzodiazepines.ObjectiveTo examine the prevalence of the PQA measures and identify the patient demographic and health characteristics associated with the measures.MethodsWe conducted a cross-sectional analysis using Pennsylvania Medicaid data (2013-2015). We limited our analyses to noncancer patients who were aged 18-64 years and not dual-eligible for Medicare/Medicaid. Per PQA specifications, patients were required to possess ≥ 2 opioid prescriptions for ≥ 15 days annual supply each year. Outcome measures included (a) high dosages, defined as > 120 morphine milligram equivalents for ≥ 90 consecutive days; (b) multiple providers/pharmacies, defined as receiving opioid prescriptions from ≥ 4 providers and ≥ 4 pharmacies; and (c) concurrent use of opioids and benzodiazepines, defined as ≥ 30 cumulative days of overlapping opioids and benzodiazepines among individuals having ≥ 2 opioid and ≥ 2 benzodiazepine fills. Patient characteristics assessed included demographics; other medication use; and physical, mental, and behavioral health comorbidities. We present descriptive and multivariable statistical analyses of the data to describe trends in quality measure prevalence and associations with enrollee health characteristics.ResultsNumbers of enrollees meeting inclusion criteria ranged from 73,082 in 2013 to 85,710 in 2015. From 2013 to 2015, high dosage prevalence increased from 5.1% to 5.5%; the use of multiple providers/pharmacies decreased from 7.1% to 5.0%; and concurrent use of opioids and benzodiazepines decreased from 29.1% to 28.4% (all P < 0.05). A substantial portion of patients with > 1 PQA measure from 2013 to 2015 was eligible for Medicaid because of disability (41.8%-81.9%). Enrollees with opioid use disorder were more likely to have high dosages (adjusted odds ratio [AOR] = 2.01, 95% CI = 1.83-2.21). Enrollees with anxiety and mood disorders were more likely to have multiple providers/pharmacies (anxiety: AOR = 1.54, 95% CI = 1.43-1.65; mood: AOR = 1.15, 95% CI = 1.06-1.25) and concurrent use of opioids and benzodiazepines (anxiety: AOR = 3.50, 95% CI = 3.38-3.63; mood: AOR = 1.42, 95% CI = 1.36-1.48).ConclusionsGiven high levels of eligibility based on disability and the prevalence of mood, anxiety, and opioid use disorders among those identified by the quality measures, providers may require additional support to care for this patient population.DisclosuresThis project was supported by a grant from the Centers for Disease Control and Prevention and was also supported by an intergovernmental agreement between the Pennsylvania Department of Human Services and the University of Pittsburgh. Lo-Ciganic was supported by the University of Arizona Health Sciences Career Development Award. The other authors have nothing to disclose. The conclusions, findings, and opinions expressed by authors contributing to this article do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the Commonwealth of Pennsylvania. A portion of these results was presented at the Association for Medical Education and Research in Substance Abuse 41st National Conference; November 2-4, 2017; Washington, DC.

Project description:Importance:Opioid-tolerant only (OTO) medications, such as transmucosal immediate-release fentanyl products and certain extended-release opioid analgesics, require prior opioid tolerance for safe use, as patients without tolerance may be at increased risk of overdose. Studies using insurance claims have found that many patients initiating these medications do not appear to be opioid tolerant. Objectives:To measure prevalence of opioid tolerance in patients initiating OTO medications and to determine whether linked electronic health record (EHR) data contribute evidence of opioid tolerance not found in insurance claims data. Design, Setting, and Participants:This retrospective cohort study used a national database of deidentified longitudinal health information, including medical and pharmacy claims, insurance enrollment, and EHR data, from January 1, 2007, to December 31, 2016. Data included 131?756 US residents with at least 183 days of continuous enrollment in commercial or Medicare Advantage insurance (including medical and pharmacy benefits) who had received an OTO medication and who had no inpatient stays in the 30 days prior to starting an OTO medication; of these, 20?044 individuals had linked EHR data within the prior 183 days. Data were analyzed from July 1, 2017, to August 31, 2018. Exposures:Initiating an OTO medication. Main Outcomes and Measures:Prior opioid tolerance demonstrated through pharmacy fills or EHR data on prescriptions written. Results:Among 153?385 OTO use episodes identified, 89?029 (58.0%) occurred among women, 62?900 (41.0%) occurred among patients with Medicare Advantage insurance, 39?394 (25.7%) occurred in the Midwest, 17?366 (11.3%) occurred in the Northeast, 73?316 (47.8%) occurred in the South, and 23?309 (15.2%) occurred in the West. Less than half of use episodes (73?117 episodes [47.7%]) involved patients with evidence in claims data of opioid tolerance prior to initiating therapy with an OTO medication, including 31?392 of 101?676 episodes (30.9%) involving transdermal fentanyl, 1561 of 2440 episodes (64.0%) involving transmucosal fentanyl, 36?596 of 43?559 episodes (84.0%) involving extended-release oxycodone, and 3568 of 5710 episodes (62.5%) involving extended-release hydromorphone. Among 20?044 OTO use episodes with linked EHR and claims data, less than 1% of OTO episodes identified in claims had evidence of opioid tolerance in structured EHR data that was not present in claims data (108 episodes [0.5%]). After limiting the sample to OTO episodes identified in claims with a matching OTO prescription within 14 days in the structured EHR data, only 40 of 939 episodes (4.0%) occurred among patients with evidence of tolerance that was not present in claims data. Conclusions and Relevance:This cohort study found that most patients initiating OTO medications did not have evidence of prior opioid tolerance, suggesting they were at increased risk of opioid-related harms, including fatal overdose. Data from EHRs did not contribute substantial additional evidence of opioid tolerance beyond the data found in prescription claims. Future research is needed to understand the clinical rationale behind these observed prescribing patterns and to quantify the risk of harm to patients associated with potentially inappropriate prescribing.

Project description:BackgroundIn the past two decades, the U.S. saw an alarmingly increasing trend of benzodiazepine prescribing. Mandatory use of Prescription Drug Monitoring Programs (PDMPs) was suggested to have the potential to reduce opioid prescribing, but little is known about its impacts on benzodiazepines. This study examined whether PDMP data use mandates were associated with changes in benzodiazepine prescribing in the U.S. Methods: Aggregate state quarterly prescription drug records of benzodiazepines for Medicaid enrollees during 2010-2017 were obtained from the U.S. Medicaid State Drug Utilization Data. Three population-adjusted outcome variables were evaluated, including quantity, dosage, and Medicaid spending of benzodiazepine prescriptions per quarter per 100 Medicaid enrollees. The primary policy variable was the state-wide implementation of PDMP data use mandates for benzodiazepines. To account for between-state variations in mandates, an additional policy variable was considered to indicate strong mandates on PDMP data use, which required all prescribers to query a patient's PDMP records for first prescribing and subsequent prescribing at least every 12 months. Linear regressions with difference-in-difference approach were used to assess the associations between PDMP data use mandates and benzodiazepine prescribing, controlling for state-level time-varying policy and socioeconomic covariates. Results: The state-wide implementation of PDMP data use mandates for benzodiazepines was not associated with quantity, dosage, or Medicaid spending of benzodiazepine prescriptions. Strong mandates on PDMP data use were not associated with any benzodiazepine prescribing outcomes, either. Conclusions: There was no evidence for the associations between PDMP data use mandates for benzodiazepines and changes in benzodiazepine prescribing among Medicaid enrollees. Future research is warranted to replicate the study in other populations using individual patient records and continuously monitor the trends in benzodiazepine prescribing in association with PDMPs.

Project description:INTRODUCTION:Recent U.S. trends demonstrate sharp rises in adverse opioid-related health outcomes, including opioid use disorder (OUD), overdose, and death. Yet few affected people receive treatment for OUD and a minority of those who receive treatment are effectively retained in care. The purpose of this study was to examine duration of buprenorphine treatment for OUD following treatment initiation to identify risk factors for early discontinuation. METHODS:We analyzed insurance claims from the 2013-2015 MarketScan multi-state Medicaid database. The sample included adults 18-64?years old with an OUD diagnosis in the 6 months before initiating buprenorphine treatment, defined as 6 months without a buprenorphine claim prior to the index buprenorphine claim (N?=?17,329 individuals). We used Cox proportional hazards regression to estimate risk of discontinuing treatment (>30 days without buprenorphine supply), and logistic regression to estimate the odds of persistent treatment for a minimum of 180 days. RESULTS:Over one-quarter of the sample discontinued buprenorphine in the first month of treatment (N?=?4928; 28.4%) and most discontinued before 180 days (N?=?11,189; 64.6%). In the proportional hazards model, risk factors for discontinuation included a lower initial buprenorphine dose (?4?mg; Hazard Ratio [HR]?=?1.72, p?<?.001), male sex (HR?=?1.19, p?<?.001), younger age (HR?=?1.34, p?<?.001), minority race/ethnicity (black HR?=?1.31, p?<?.001; Hispanic HR?=?1.24, p?=?.01; other HR?=?1.09, p?<?.001), capitated insurance (HR?=?1.21, p?<?.001), comorbid substance use disorders (alcohol HR?=?1.07, p?=?.04; non-opioid drugs HR?=?1.14, p?<?.001), hepatitis C (HR?=?1.06, p?=?.01), opioid overdose history (HR?=?1.20, p?=?.001), or any inpatient care (HR?=?1.22, p?<?.001) in the 6-month baseline period. In logistic models, these risk factors were similarly associated with significantly lower odds of treatment retention for at least 180 days. CONCLUSION:For Medicaid beneficiaries with OUD treated with buprenorphine, there is a need to implement treatment models that more effectively address barriers to treatment retention. These barriers are particularly challenging for minorities, younger individuals, and those with additional substance use disorders.

Project description:ImportanceThe COVID-19 pandemic disrupted medical care, impacting prescribing of opioid analgesics and buprenorphine for opioid use disorder. Understanding these patterns can help address barriers to care.ObjectiveTo evaluate how prescribing of opioid analgesics and buprenorphine for opioid use disorder changed throughout the COVID-19 pandemic among both new and existing patients.Design, setting, and participantsIn this cross-sectional study, use of opioid analgesics and buprenorphine for opioid use disorder from March 18 to September 1, 2020, was projected using a national database of retail prescriptions from January 1, 2018, to March 3, 2020. Actual prescribing was compared with projected levels for all, existing, and new patients.ExposuresThe data include prescriptions to patients independent of insurance status or type and cover 90% of retail prescriptions, 70% of mail-order prescriptions, and 70% of nursing home prescriptions.Main outcomes and measuresPrescriptions for opioid analgesics and buprenorphine for opioid use disorder. Outcomes included total number of prescriptions, total morphine milligram equivalents, mean morphine milligram equivalents per prescription, mean dispensed units per prescription, and number of patients filling prescriptions.ResultsA total of 452 691 261 prescriptions for opioid analgesics and buprenorphine for opioid use disorder were analyzed for 90 420 353 patients (50 921 535 female patients [56%]; mean [SD] age, 49 [20] years). From March 18 to May 19, 2020, 1877 million total morphine milligram equivalents of opioid analgesics were prescribed weekly vs 1843 million projected, a ratio of 102% (95% prediction interval [PI], 94%-111%; P = .71). The weekly number of opioid-naive patients receiving opioids was 370 051 vs 564 929 projected, or 66% of projected (95% PI, 63%-68%; P < .001). Prescribing of buprenorphine was as projected for existing patients, while the number of new patients receiving buprenorphine weekly was 9865 vs 12 008 projected, or 82% (95% PI, 76%-88%; P < .001). From May 20 to September 1, 2020, opioid prescribing for new patients returned to 100% of projected (95% PI, 96%-104%; P = .95), while the number of new patients receiving buprenorphine weekly was 10 436 vs 11 613 projected, or 90% (95% PI, 83%-97%; P = .009).Conclusions and relevanceIn this cross-sectional study, existing patients receiving opioid analgesics and buprenorphine for opioid use disorder generally maintained access to these medications during the COVID-19 pandemic. Opioid prescriptions for opioid-naive patients decreased briefly and then rebounded, while initiation of buprenorphine remained at a low rate through August 2020. Reductions in treatment entry may be associated with increased overdose deaths.

Dataset Information

High-Risk Prescribing to Medicaid Enrollees Receiving Opioid Analgesics: Individual- and County-Level Factors.

Publications

High-Risk Prescribing to Medicaid Enrollees Receiving Opioid Analgesics: Individual- and County-Level Factors.

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