Defining Non-Medical Use of Prescription Opioids within Health Care Claims: A Systematic Review

Gerald Cochran, PhD 1,2

Bongki Woo, MSW 3

Wei-Hsuan Lo-Ciganic, PhD, MS, MSPharm 2

Adam Gordon, MD, MPH 2,4,5

Julie M. Donohue, PhD 2,6

Walid F. Gellad, MD, MPH 2,4,5

1University of Pittsburgh, School of Social Work; 2University of Pittsburgh, Center for Pharmaceutical Policy and Prescribing, 3Boston College, School of Social Work; 4VA Pittsburgh Healthcare System, 5University of Pittsburgh, School of Medicine; 6University of Pittsburgh, Graduate School of Public Health

Supported by: CDC/NIDA U01CE002496-01

4.9 Million People Misusing Opioid Medications:A Critical Public Health Issue

Increased Physical, Mental and Behavioral Health Issues

50 deaths/day (2010)

Societal cost of $55.7 billion (2007)

Health System, Payer Data could Flag Non-Medical Use of Prescription Opioids (NMPO) for Timely Intervention

To Date, NMPO Definitions Remain Unclear

Purpose

Systematic Review of Publications that Define & Measure NMPO Objectives: Describe definitions of NMPO

Identify areas for improvement

Search Yielded 2,613 Studies 8 Databases 2000-2014

Medicine: CINAHL, Health Source: Nursing/Academic, Medline, PubMed

Psychology: PsychINFO, PsycArticles

Social Work: Social Work Abstracts

Public Affairs: PAIS International

Related Terms in 3 Broad Categories (Boolean AND/OR Queries)

Opioids

Health Insurance Claims

Non-Medical Use/Dependence

Opioid category AB/TI (Analges* OR Buprenorphine OR Fentanyl OR Hydromorphone OR Morphine OR Opi* OR Oxycodone OR Oxymorphone OR Oxycontin OR Painkiller OR Pain Management OR Pain Medication OR Suboxone OR Subtex)

AND

Health insurance claims category

(Admin* OR Benefi* OR Claim* OR Diversion* OR Enrollee OR Insur* OR Medicaid OR Medicare OR Pay*)

AND

Non-medical use category

(Abuse OR Chronic OR Dependence OR Long-term OR Misuse OR Overuse)

a Terms related to opioid medications were searched using the electronic database search engines within the title and abstract, and terms related to claims and misuse were searched using the electronic database search engines from any part of the article. This decision was based on very limited search results generated when all terms were only searched within titles and abstracts. * = Exploded mesh term encompassing all MeSH sub-headings.

Search strings/commanda

The Study Selection Process

Consort flow diagram of selected studies

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Key Data Points Extracted

General: Author, Date, Source

NMPO Conceptualization: the Name of the Problem

Abuse? Misuse? Probable misuse? Rx mentioned?

NMPO Operationalization: Measurement Variables

Dosage? Diagnosis? Prescriptions filled? Number of providers?

Validation Methods

Purpose of Analysis

Rates of NMPO

Results

Data from Publicly Funded Sources N=2; Commercial N=3; Both N=2

NMPO Conceptual Definitions

Identifying prescription opioid abusers n=3

Potential or probable misuse of opioid medications n=3

Persons who chronically misuse opioids and are non-adherent to prescribed regimen n=1

4 General Types of Operational Definitions w/ Varied Combinations

ICD-9 diagnosis codes

Opioid prescription records

Provider/pharmacist records

Urine toxicology

Results    Operationalization of NMPOFirst author/ year

Stated NMPO concept

Diagnosis-based measure

Number of providers and

pharmacies

Prescription-fill based measure

Urine toxicology

Braker 2009 Potential Rxbopioid mis-use

-- Received ≥3 opioid Rxs from ≥2 providers; ≥6 opioid Rxs within 6-months

Yes/no record of opioid Rx

--

Leider 2011 Non-adherence among chronic opioid users

-- -- 120 days of a qualifying opioid within 6-months

Medication match and levels within expected ranges

Logan 2013 Potential opioid misuse/ inappropriate Rx practices

-- -- Opioid Rxs overlapping ≥1 week; overlap-ping opioid and benzodi-azepine Rxs; long-acting/ extended- release opi-oids for acute pain; or ≥100 morphine mil-ligram equivalent/ day

--

Rice 2012 Rx opioid abuse 304.0X (opioid-depen-dence), 304.7X (combina-tions of opioid-type depen-dence with any other drug dependence), 305.5X (non-dependent opioid abuse), and 965.0 (poisoning by opiates/related narcotics)

-- Yes/no record of opioid Rx

--

Roland 2013 Diagnosed Rx opioid abuse

304.0X, 304.7X, 305.5X, 965.00, 965.02 (methadone poisoning), and 965.09 (opiates poi-soning not elsewhere clas-sified)

-- -- --

Sullivan 2010 Probable opioid misuse among chronic opioid users

-- Number of prescribers (≤2, 3-4, ≥5); number of pharmacies (≤ 2, 3-4, ≥5) 

> 90 days of opioid use; days of short acting opi-oids (≤185, 186-240, >240) and days of long acting opioids (≤185, 186-240, >240) within 6-months

--

White 2009 Rx opioid abuse 304.0, 304.7, 305.5, or 965.0

-- Yes/no record of opioid Rx

--

Validity Tests: Varied as Well

Quantitative

Braker: adequate validity predicting >6 Rxs filled in 6 months

Sullivan: OUD diagnosis + NMPO outcome showed adequate validity

White: validity with integrated prescription + diagnosis variables

Qualitative

Leider, Rice, Logan

Based on face and content validity

Rational justification for definitions

Citations of previous work

Rates of NMPO: Varied

From 0.75% to 10.32%

Cause of differences:

Definitions

Cutoff points

Equations

Examples:

(a) Likely non-adherent patients (b) Patients with 1 inappropriate prescription factor Total chronic users Patients w/prescription from ED

(c) “Abusers” Total sample

Conclusion and Recommendation

There is a Need to Identify and Intervene in NMPO

Current Knowledge is Inadequate

Both conceptual and operational definitions vary among studies

Existing definitions and measures have not been convincingly validated

A Prospective Study Would Yield Valuable Data

Recruit subjects through health plans

Assess for NMPO

Validate measures with existing validated measures

Thank you

gcochran@pitt.edu