Evaluation of a Medicaid performance improvement project to reduce high-dose opioid prescriptions.

BACKGROUND: In 2015, Oregon's Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. METHODS: Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon's high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. RESULTS: There was an immediate reduction in high dose opioid prescriptions after the program was implemented (- 1.55 prescription per 1000 enrollee; 95% CI - 2.26 to - 0.84; p < 0.01). Program implementation was also associated with an immediate drop (- 1.29 percentage points; 95% CI - 1.94 to - 0.64 percentage points; p < 0.01) and trend reduction (- 0.23 percentage point per month; 95% CI - 0.33 to - 0.14 percentage points; p < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. CONCLUSIONS: Although Oregon's high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes.

BACKGROUND: High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes. METHODS: Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy. RESULTS: Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills < 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy. CONCLUSIONS: Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.

Using prescription monitoring program data to characterize out-of-pocket payments for opioid prescriptions in a state Medicaid program.

BACKGROUND: Out-of-pocket payment for prescription opioids is believed to be an indicator of abuse or diversion, but few studies describe its epidemiology. Prescription drug monitoring programs (PDMPs) collect controlled substance prescription fill data regardless of payment source and thus can be used to study this phenomenon. OBJECTIVE: To estimate the frequency and characteristics of prescription fills for opioids that are likely paid out-of-pocket by individuals in the Oregon Medicaid program. RESEARCH DESIGN: Cross-sectional analysis using Oregon Medicaid administrative claims and PDMP data (2012 to 2013). SUBJECTS: Continuously enrolled nondually eligible Medicaid beneficiaries who could be linked to the PDMP with two opioid fills covered by Oregon Medicaid. MEASURES: Patient characteristics and fill characteristics for opioid fills that lacked a Medicaid pharmacy claim. Fill characteristics included opioid name, type, and association with indicators of high-risk opioid use. RESULTS: A total of 33 592 Medicaid beneficiaries filled a total of 555 103 opioid prescriptions. Of these opioid fills, 74 953 (13.5%) could not be matched to a Medicaid claim. Hydromorphone (30%), fentanyl (18%), and methadone (15%) were the most likely to lack a matching claim. The 3 largest predictors for missing claims were opioid fills that overlapped with other opioids (adjusted odds ratio [aOR] 1.37; 95% confidence interval [CI], 1.34-1.4), long-acting opioids (aOR 1.52; 95% CI, 1.47-1.57), and fills at multiple pharmacies (aOR 1.45; 95% CI, 1.39-1.52). CONCLUSIONS: Prescription opioid fills that were likely paid out-of-pocket were common and associated with several known indicators of high-risk opioid use.

A pilot study evaluating alternative approaches of academic detailing in rural family practice clinics.

BACKGROUND: Academic detailing is an interactive, convenient, and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behavior, uncertainty exists about generalizability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting. METHODS: We conducted a pilot project to assess the feasibility, effectiveness, and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. Surveys at midpoint and completion were used to assess effectiveness and satisfaction. RESULTS: Each clinic received four outreach visits over an eight month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90%-100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered. CONCLUSIONS: We found strong support and satisfaction for the program among participating clinicians. Participants favored in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.

Pharmacist Provision of Hormonal Contraception in the Oregon Medicaid Population.

OBJECTIVE: To describe early utilization of pharmacist prescription of contraception in Oregon's Medicaid program. METHODS: Using Oregon Medicaid claims data, we conducted a retrospective analysis and quantified overall and monthly trends in pharmacist-prescribed contraceptives from January 1, 2016, to December 31, 2017. Our population was restricted to patients obtaining a new prescription for oral and transdermal methods and who had continuous Medicaid coverage during the study period. We summarized demographic and utilization characteristics, including whether patients were continuing or switching methods or initiating contraception. New prescriptions were those written to patients who did not have one for hormonal contraception in the prior 30 days. To assess program safety, we examined rates of prescriptions to patients with medical contraindications to contraceptive use. RESULTS: Among the 3,614 patients receiving a new prescription for oral or transdermal contraceptives in the Oregon Medicaid program from all health care providers, 367 (10%) received their prescription from a pharmacist. Five months after implementation, pharmacists filled an average of 61 prescriptions per month as the prescriber. Most claims originated from retail chain pharmacies (94%) in urban locations (71%). The majority of patients who were prescribed contraception by pharmacists (73.8%) had no history of contraceptive prescriptions in the preceding 30 days (n=252). Ages ranged from 13 to 49 years, fewer patients lived in a rural location (35.7%), most received a combined hormonal pill (90.5%), and the average day's supply dispensed was 65 (range of 21-364 days). Fewer than 5% (12) of patients had a diagnostic code indicating a possible contraindicating comorbidity. CONCLUSION: Among Medicaid enrollees, we found that 10% of all new oral and transdermal contraceptive prescriptions were written by pharmacists.

Effects of a prior authorization policy for extended-release/long-acting opioids on utilization and outcomes in a state Medicaid program.

BACKGROUND AND AIMS: In response to the opioid overdose epidemic, US state Medicaid programs have adopted restrictive policies for opioid analgesics, yet effects on prescribing patterns and health outcomes are uncertain. This study aimed to examine effects of a prior authorization policy for extended-release/long-acting (ER/LA) opioids on opioid use in the Oklahoma, USA state Medicaid program. DESIGN: Retrospective difference-in-differences design study comparing changes in opioid use in Oklahoma Medicaid to control (Oregon Medicaid). SETTING: Oklahoma and Oregon, USA. PARTICIPANTS: Medicaid beneficiaries in the Oklahoma and Oregon fee-for-service Medicaid programs between July 2007 and June 2009 (33 724 in Oklahoma and 13 520 in Oregon) MEASUREMENTS: The primary outcome was incident opioid-naive ER/LA opioid use. Secondary outcomes included other opioid and non-opioid pain medication use. We also examined indicators of high-risk prescribing (e.g. high-dosage opioid use) and opioid-related hospitalizations or emergency department (ED) visits. FINDINGS: The prior authorization policy was associated with a 0.7 percentage point reduction in the likelihood of incident opioid-naive ER/LA opioid use [95% confidence interval (CI) = -1.16 to -0.33 percentage points; 70% pre-policy mean reduction, a 1.4 percentage point decrease in likelihood of any new ER/LA opioid prescriptions (95% CI = -2.1 to -0.7 percentage points; 33% pre-policy mean reduction) and a decline of 0.16 in total ER/LA opioid prescriptions per enrollee (PPE) (95% CI = -0.29 to -0.04 PPE)]. There was a significant increase in the number of short-acting opioids filled after the policy (0.36; 95% CI = 0.22-0.50 PPE), increases in likelihood of having overlapping opioids and benzodiazepines, but significant reductions in likelihood of having overlapping opioids. No significant changes in opioid-related hospitalizations or ED visits were observed. CONCLUSIONS: In Oklahoma, USA's July 2008 prior authorization policy for extended-release/long-acting opioids appears to have reduced the number of opioid-naive patients initiating extended-release/long-acting opioid use by more than half, but may also have increased short-acting opioid prescriptions by 7%.

Rates of adverse events of long-acting opioids in a state Medicaid program.

BACKGROUND: Despite widespread use and emerging safety concerns, data on the comparative safety and effectiveness of long-acting opioid (LAO) analgesics are weak. OBJECTIVE: To compare rates of adverse events among patients newly prescribed an LAO. METHODS: A retrospective observational cohort study using Medicaid administrative claims data was conducted examining time until first adverse outcome among patients with new prescriptions for methadone, extended-release (ER) oxycodone, ER morphine, or transdermal fentanyl. Adverse outcomes included emergency department (ED) encounters or hospitalizations for opioid-related adverse events, all-cause ED encounters or hospitalizations, death, and diagnoses for opioid-related adverse effects. Cox proportional hazards models were used to adjust for a variety of measured covariates overall and within subgroups of patients with and without cancer. RESULTS: This study included 5684 subjects. Patients prescribed ER oxycodone were 55[corrected]% less likely (adjusted hazard ratio [HR] 0.45; 95% CI 0.26 to 0.77) to experience an ED or hospitalization involving an opioid-related adverse event, 23% lower risk of hospitalization (adjusted HR 0.77; 95% CI 0.66 to 0.91), 41% lower risk of constipation (adjusted HR 0.59; 95% CI 0.35 to 1.00), and a 29% lower risk of death (adjusted HR 0.71; 95% CI 0.54 to 0.94) compared with those prescribed ER morphine. Among subjects with noncancer pain, fentanyl was associated with a higher risk of ED encounters (adjusted HR 1.27; 95% CI 1.02 to 1.59) and methadone was associated with a greater risk of overdose symptoms (adjusted HR 1.57; 95% CI 1.03 to 2.40) compared with ER morphine. CONCLUSIONS: Our results support a modest safety advantage with ER oxycodone compared with ER morphine. Among subjects with noncancer pain, fentanyl and methadone were associated with an increased risk of an adverse event compared with ER morphine. Additional studies are needed to confirm our findings and further clarify risks associated with different LAOs.

Changes in long-acting ß-agonist utilization after the FDA's 2010 drug safety communication.

PURPOSE: In February 2010, the US Food and Drug Administration (FDA) issued new recommendations for the safe use of long-acting ß-agonists (LABAs) in patients with asthma. The objective of this study was to determine the impact of the FDA's 2010 safety advisory on LABA utilization. METHODS: Using administrative data from the Oregon Medicaid program, we performed an interrupted time series regression to evaluate changes in the trend in new LABA prescriptions before and after the FDA's 2010 advisory. Trends in incident fills were examined among those with and without an asthma diagnosis code and previous respiratory controller medication use; trends were also assessed according to patient age. FINDINGS: The average age of the 8646 study patients was 37 years, 53% had a diagnosis of asthma, 21% had no respiratory diagnosis, and 32% had not used a respiratory controller medication in the recent past. The trend in new LABA prescriptions declined by 0.09 new start per 10,000 patients per month (95% CI, -0.19 to -0.01) after the FDA's advisory. Among those with a diagnosis of asthma, there was an immediate drop of 0.48 (95% CI, -0.93 to -0.03) and a 0.10 (95% CI, -0.13 to -0.06) decline in the monthly rate of new starts per 10,000 patients. Immediately after the FDA's advisory, we observed a statistically significant 4.7% increase (95% CI, 0.8 to 8.7) in the proportion of new LABA starts with history of previous respiratory controller medication use. Utilization of LABAs did not change in those without a diagnosis of asthma. IMPLICATIONS: The FDA's 2010 advisory was associated with modest reductions in LABA utilization overall and in ways highlighted in their recommendations.

Use of administrative data to identify off-label use of second-generation antipsychotics in a Medicaid population.

OBJECTIVE The use of second-generation antipsychotics for conditions not approved by the U.S. Food and Drug Administration (FDA) is a prevalent phenomenon with important implications. The objective of this study was to determine the accuracy of administrative claims for identifying off-label use of second-generation antipsychotics in a Medicaid population in 2009. METHODS The authors estimated the sensitivity, specificity, positive predictive values (PPV), and negative predictive values of Medicaid claims data for detecting off-label use of second-generation antipsychotics in the electronic health records of 788 patients. Separate estimates were calculated for patients without schizophrenia and bipolar disorder, the two most long-standing FDA indications for use of second-generation antipsychotics, and for a subset of patients using a second-generation antipsychotic with indications for treatment-resistant depression. RESULTS Medicaid claims determined a lack of schizophrenia and bipolar disorder in the medical record with a sensitivity of 72% and a specificity of 85%. The prevalence of identifying neither diagnosis was 83%, which was associated with a predictive ability (PPV) of 96%. Among those using a second-generation antipsychotic with an indication for treatment-resistant depression, the sensitivity, specificity, and PPV of Medicaid claims for identifying off-label use were 41%, 86%, and 87%, respectively. CONCLUSIONS Medicaid claims data had high predictive ability for identifying users of second-generation antipsychotics who did not have documentation of schizophrenia or bipolar disorder in the medical record. The predictive utility of the claims was diminished when the analyses were limited to patients using a second-generation antipsychotic with an indication for treatment-resistant depression.

Generic substitution of lamotrigine among medicaid patients with diverse indications: a cohort-crossover study.

BACKGROUND: Controversy exists about the safety of substituting generic antiepileptic drugs (AEDs). Lamotrigine, the prototypical newer AED, is often used for psychiatric and neurological conditions other than epilepsy. The safety of generic substitution of lamotrigine in diverse populations of AED users is unclear. OBJECTIVE: The objective of this study was to evaluate potential associations between generic substitution of lamotrigine and adverse consequences in a population of diverse users of this drug. STUDY DESIGN: This study was a retrospective cohort-crossover design using state Medicaid claims data from July 2006 through June 2009. METHODS: Subjects were included in the cohort if they converted from brand to generic lamotrigine and had 2 years of lamotrigine use prior to conversion. The frequency of emergency department (ED) visits, hospitalizations and condition-specific ED visits or hospitalizations were recorded in the 60 days immediately following the conversion to generic lamotrigine, then compared with the incidence of the same events during a randomly selected time period indexed to one of the patient's past refills of branded lamotrigine. Multivariate conditional logistic regression was used to quantify the association between generic conversion and health services utilization while controlling for changes in lamotrigine dose and concurrent drug use. RESULTS: Of the 616 unique subjects included in this analysis, epilepsy was the most common diagnosis (41%), followed by bipolar disorder (32%), pain (30%) and migraine (18%). Conversion to generic lamotrigine was not associated with a statistically significant increase in the odds of an ED visit (adjusted odds ratio [AOR] = 1.35; 95% confidence interval [CI] 0.92, 1.97), hospitalization (AOR = 1.21; 95% CI 0.60, 2.50) or condition-specific encounter (AOR 1.75; 95 CI 0.87, 3.51). CONCLUSIONS: A statistically significant increase in ED visits, hospitalizations or condition-specific encounters was not observed following the switch from brand to generic lamotrigine, although a type II error cannot be ruled out.

Patterns of atypical antipsychotic subtherapeutic dosing among Oregon Medicaid patients.

OBJECTIVE: To examine a cohort of Medicaid patients with new prescriptions for atypical antipsychotic medication to determine the prevalence of subtherapeutic atypical antipsychotic medication use and to identify patient and prescribing provider characteristics associated with occurrence of subtherapeutic use. METHOD: This observational cohort study examined Medicaid administrative claims data for patients aged 20 to 64 years with a new prescription for an atypical antipsychotic medication (clozapine, olanzapine, quetiapine, risperidone, ziprasidone) between January 1, 2004, and December 31, 2004. Patient diagnostic information was identified using the International Classification of Diseases, Ninth Revision, Clinical Modification codes on submitted medical claims. Patient characteristics, prescribing provider characteristics, length of therapy, and dosing were examined. A logistic regression assessed the probability of subtherapeutic dosing. RESULTS: Among 830 individuals in our sample who began treatment with an atypical antipsychotic, only 15% had a documented diagnosis of schizophrenia, subtherapeutic dosing was common (up to 86% of patients taking quetiapine), and 40% continued less than 30 days with the index prescription. A logistic model indicated that a general practitioner as prescribing provider, length of therapy equal to or less than 30 days, and prescription of quetiapine were significantly associated with a subtherapeutic dose (p < .001, p = .028, and p < .001, respectively). CONCLUSIONS: These results suggest that there is extensive use of expensive atypical antipsychotic medications for off-label purposes such as sedation or for other practice patterns that should be explored further. Approaches that minimize off-label atypical antipsychotic use could be of considerable value to Medicaid programs. In addition, these findings support the need for the introduction or increased use of utilization monitoring and the implementation of medication practice guidelines as appropriate decision support for prescribing providers.