The Burden of Undiagnosed Opioid Abuse Among Commercially Insured Individuals.

OBJECTIVES: Estimate the prevalence and healthcare costs of undiagnosed opioid abuse among commercially insured individuals. STUDY DESIGN: Retrospective analysis of de-identified pharmacy and medical claims data and publicly-available survey data (no IRB approval required). METHODS: This study focused on commercially insured individuals. Rates of prescription pain-reliever abuse/dependence ("abuse") among individuals ages ≥12 were calculated using National Survey on Drug Use and Health (NSDUH) public-use data for 2006-2011 and assumed to capture both diagnosed and undiagnosed opioid abuse. Rates of undiagnosed opioid abuse were calculated as the difference between NSDUH rates and published rates of diagnosed opioid abuse. OptumHealth Reporting and Insights claims data were used to estimate the healthcare costs of undiagnosed abuse. Diagnosed abusers ages 12-64 were identified using ICD-9-CM diagnosis codes for opioid abuse/dependence. Pre-diagnosis costs were assumed to be a proxy for undiagnosed opioid abuse costs. The ratio of undiagnosed to diagnosed abuse costs was calculated as the ratio of annual per-patient healthcare costs between pre-diagnosis and post-diagnosis periods. RESULTS: While rates of diagnosed opioid abuse among commercially insured individuals increased from 0.07% in 2006 to 0.19% in 2011, rates of undiagnosed abuse decreased from 0.42% to 0.38% over the same time period. Annual per-patient healthcare costs of undiagnosed abusers were 69.2% of those of diagnosed abusers. CONCLUSIONS: Per-patient healthcare costs of undiagnosed abusers among the commercially insured are estimated to be lower than those of diagnosed abusers. However, the higher prevalence of undiagnosed opioid abuse implies that undiagnosed abuse represents a substantial burden to commercial payers.

Characterizing downstream healthcare resource utilization and costs based on prior utilization patterns of immediate-release hydrocodone.

OBJECTIVE: To assess downstream healthcare resource utilization (HRU) and costs among immediate release (IR) hydrocodone patients by days' supply and average doses/month in the prior 6 months. METHODS: Retrospective analysis using healthcare claims from Truven MarketScan commercial, Medicare supplemental, and Medicaid multistate databases was performed. Patients prescribed IR hydrocodone during the 6-month baseline (July-December 2011), and with continuous enrollment during baseline and the 12-month follow-up (2012) were selected. HRU and per-patient-per-month (PPPM) costs (2014 US dollars) were assessed at follow-up. Descriptive analyses and multivariate regressions were conducted to compare HRU and costs at follow-up by days' supply (<60 vs ≥60 days) and average doses per month (≤60 vs >60 doses/month) of IR hydrocodone at baseline. RESULTS: In total, 1,698,845 commercial, 264,038 Medicare, and 151,063 Medicaid IR hydrocodone patients were identified. During follow-up, commercial patients with prior ≥60 days' supply were more likely to have an inpatient admission (13.2% vs 7.5%), outpatient hospital visit (69.1% vs 57.0%), office visit (97.6% vs 91.0%), emergency room (ER) visit (28.1% vs 21.4%), and had higher PPPM total costs ($1494 vs $842) than the <60 days' supply sub-group (all p < 0.05). Among commercial patients the adjusted odds ratio for prior ≥60 days' supply of IR hydrocodone vs prior <60 days' supply was 1.62 (inpatient), 1.33 (outpatient), 2.58 (office visit) and 1.48 (ER) (all p-values <0.05). Adjusted all-cause total costs were higher ($1245 vs $851, p <0.05) among commercial patients with longer days' supply than those with shorter days' supply. Trends were similar with ≤60 vs >60 doses per month sub-groups and across all plan types. CONCLUSION: Increased days' supply and higher doses/month of IR hydrocodone in the prior 6 months may help to predict levels of HRU and costs in the following year, providing an opportunity to identify patients in order to implement interventions to improve their quality of care.

Opioid Treatment Patterns Following Prescription of Immediate-Release Hydrocodone.

BACKGROUND: Immediate-release (IR) hydrocodone is the most widely prescribed opioid in the United States; however, little is known about the utilization patterns and duration of opioid use among patients prescribed IR hydrocodone. A better understanding of the use of IR hydrocodone would result in more appropriate prescribing patterns of extended-release opioids. OBJECTIVE: To assess downstream length of opioid therapy and utilization patterns of extended-release/long-acting (ER/LA) opioids among patients on IR hydrocodone to provide a better understanding of how IR and ER/LA opioids are used to manage pain. METHODS: Retrospective analysis using health care claims from the Truven MarketScan Commercial, Medicare Supplemental, and Medicaid databases was performed. Patients prescribed IR hydrocodone during the 6-month baseline period (July 2011-December 2011) and with continuous enrollment for a 12-month follow-up period (2012) post-index date (January 1, 2012) were selected. Downstream length of therapy, defined as number of days supplied with opioids, and downstream use of ER/LA opioids during follow-up were examined by average pills per month (≤ 60 vs. > 60 pills per month) and days supply (< 60 vs. ≥ 60 days supply) of IR hydrocodone during baseline to mimic intermittent and consistent IR users. RESULTS: At baseline, 1,743,933 commercial, 277,096 Medicare, and 157,922 Medicaid IR hydrocodone patients were identified. During follow-up, 1.7%, 2.9%, and 2.8% of patients initiated (i.e., converted to or newly started) ER/LA opioids for commercial, Medicare, and Medicaid groups, respectively. Approximately 90% of patients were prescribed IR hydrocodone for less than 2 months in the following year, while 10% were high utilizers, averaging nearly 8 months of prescribed opioid use during follow-up. Downstream initiation of ER/LA opioids was significantly higher among commercial patients prescribed IR hydrocodone for > 60 pills per month than with ≤ 60 pills per month (7.8% vs. 1.2%, respectively, P < 0.05) at baseline. For commercial patients initiating ER/LA opioids, length of ER/LA therapy during follow-up was significantly longer among patients with baseline IR hydrocodone > 60 pills per month than with ≤ 60 pills per month. All results were consistent when examined by levels of days supply. CONCLUSIONS: A majority of the population prescribed IR hydrocodone was not prescribed opioid therapy beyond 2 months on average in the 1-year follow-up period. Only a small subset of patients with increased pills per month or days supply of IR hydrocodone in the baseline period continued to be high utilizers in the following year, averaging nearly 8 months of prescribed opioid use. A limited proportion of patients prescribed IR hydrocodone converted to ER/LA opioids. This knowledge can assist policymakers and physicians, providing an opportunity to identify small subsets of patients to improve ER/LA opioid prescribing. DISCLOSURES: Funding and support for this study was provided by Purdue Pharma L.P. Consulting fees were paid to Evidera by Purdue Pharma L.P. for this study. Kansal, Chitnis, and Paramore are employees of Evidera and were paid consultants to Purdue Pharma for this research. Holly is an employee for Purdue Pharma, and Bell and Ben-Joseph were full-time employees of Purdue Pharma during the design, planning, and execution of the studies and during the preparation of this manuscript. Burgoyne and Brixner were consultants on this project. Study design was created by Ben-Joseph, Brixner, Paramore, and Burgoyne. Data were collected by Kansal, Chitnis, Bell, Ben-Joseph, and Holly and interpreted by Ben-Joseph, Bell, Kansal, and Holly, with assistance from Brixner, Paramore, Burgoyne, and Chitnis. The manuscript was written by Ben-Joseph, Bell, Paramore, Chitnis, and Holly, with assistance from Kansal, and revised by Bell and Holly, along with Ben-Joseph, Brixner, Kansal, Paramore, Burgoyne, and Chitnis.

Characteristics of High-Cost Patients Diagnosed with Opioid Abuse.

BACKGROUND: Prescription opioid abuse is associated with substantial economic burden, with estimates of incremental annual per-patient health care costs of diagnosed opioid abuse exceeding $10,000 in prior literature. A subset of patients diagnosed with opioid abuse has disproportionately high health care costs, but little is known about the characteristics of these patients.  OBJECTIVE: To describe the characteristics of a subset of patients diagnosed with opioid abuse with disproportionately high health care costs to assist physicians and managed care organizations in targeting interventions at the costliest patients. METHODS: This retrospective claims data analysis identified patients aged 12 to 64 years diagnosed with opioid abuse/dependence in the OptumHealth Reporting and Insights medical and pharmacy claims database, Quarter 1 (Q1) 1999-Q1 2012. Inclusion criteria required that patients had a diagnosis of opioid abuse during or after Q1 2006, no prior diagnoses of opioid abuse, and continuous non-HMO coverage over an 18-month study period. The study period comprised a 12-month observation period centered on the date of the first opioid abuse diagnosis (index date) and a 6-month baseline period immediately preceding the observation period. Patients in the top 20% of total health care costs in the observation period were classified as "high-cost patients," and the remaining patients were classified as "lower-cost patients." Patient characteristics, comorbidities, health care resource use, and health care costs were compared between high-cost patients and lower-cost patients using chi-square tests for dichotomous variables and Wilcoxon rank-sum tests for continuous variables. In addition, multivariate regression was used to assess the relationship between patient characteristics in the baseline period and total health care costs in the observation period among all patients diagnosed with opioid abuse.  RESULTS: 9,291 patients diagnosed with opioid abuse met the inclusion criteria. The 20% of patients classified as high-cost patients accounted for approximately two thirds of the total health care costs of patients diagnosed with opioid abuse. Compared with lower-cost patients, high-cost patients were older (42.5 vs. 36.1; P less than 0.001) and more likely to be female (55.9% vs. 42.9%; P less than 0.001). They had a higher comorbidity burden at baseline, as reflected in the Charlson Comorbidity Index (0.8 vs. 0.2; P less than 0.001), and rates of conditions such as chronic pulmonary disease (12.9% vs. 5.6%; P less than 0.001) and mild/moderate diabetes (8.4% vs. 3.4%; P less than 0.001). High-cost patients also had higher rates of nonopioid substance abuse diagnoses (12.4% vs. 8.9%; P less than 0.001) and psychotic disorders (26.5% vs. 13.6%; P less than 0.001). In the observation period, high-cost patients continued to have higher rates of nonopioid substance abuse diagnoses (53.0% vs. 47.2%; P less than 0.001) and psychotic disorders (67.1% vs. 47.5%; P less than 0.001). In addition, they had greater medical resource use across all places of service (i.e., inpatient, emergency department, outpatient, drug/alcohol rehabilitation facility, and other) compared with lower-cost patients. The mean observation period health care costs of high-cost patients was $89,177 compared with $11,653 for lower-cost patients (P less than 0.001). High-cost patients had higher medical costs linked to claims with an opioid abuse diagnosis in absolute terms, but the share of total medical costs attributed to such claims was lower among high-cost patients than among lower-cost patients. While many baseline characteristics were found to have a statistically significant (P less than 0.05) association with observation period health care costs, only 27.3% of the variation in observation period health care costs was explained by patient characteristics in the baseline period. CONCLUSIONS: This study found that the costliest patients diagnosed with opioid abuse had high rates of preexisting and concurrent chronic comorbidities and mental health conditions, suggesting potential indicators for targeted intervention and a need for greater awareness and screening of comorbid conditions. Opioid abuse may exacerbate existing conditions and make it difficult for patients to adhere to treatment plans for those underlying conditions. Baseline patient characteristics explained only a small share of the variation in observation period health care costs, however. Future research should explore the degree to which other factors not captured in administrative claims data (e.g., severity of abuse) can explain the wide variation in health care costs among opioid abusers.

Sources of prescription opioids among diagnosed opioid abusers.

OBJECTIVE: Diversion and abuse of prescription opioids are important public health concerns in the US. This study examined possible sources of prescription opioids among patients diagnosed with opioid abuse. METHODS: Commercially insured patients aged 12-64 diagnosed with opioid abuse/dependence ('abuse') were identified in OptumHealth Reporting and Insights medical and pharmacy claims data, 2006-2012, and required to have continuous eligibility over an 18 month study period surrounding the first abuse diagnosis. We examined whether abusers had access to prescription opioids through their own prescriptions and/or to diverted prescription opioids through family members' prescriptions obtained prior to the abuser's first abuse diagnosis. For comparison, we examined access to prescription opioids of a reference population of non-abusers. Sensitivity analyses focused on patients initially diagnosed with opioid dependence and, separately, abusers not previously treated with buprenorphine. RESULTS: Of the 9291 abusers meeting the selection criteria, 79.9% had an opioid prescription prior to their first abuse diagnosis; 20.1% of abusers did not have an opioid prescription prior to their first abuse diagnosis, of whom approximately half (50.8%) had a family member who had an opioid prescription prior to the abuser's first abuse diagnosis (compared to 42.2% of non-abusers). Similar results were found among patients initially diagnosed with opioid dependence and among abusers not previously treated with buprenorphine. LIMITATIONS: The study relied on the accuracy of claims data to identify abusers, but opioid abuse is often undiagnosed. In addition, only prescription claims that were reimbursed by a health plan were included in the analysis. CONCLUSIONS: While most abusers had access to prescription opioids through their own prescriptions, many abusers without their own opioid prescriptions had access to prescription opioids through family members and may have obtained prescription opioids that way. Given the study design and data source, this is likely a conservative estimate of prescription opioid diversion.

The economic burden of diagnosed opioid abuse among commercially insured individuals.

The abuse of prescription opioids imposes a substantial public health and economic burden. Recent research using administrative claims data has substantiated the prevalence and cost of opioid abuse among commercially insured individuals. Although administrative claims data are readily available and have been used to effectively answer research questions about the burden of illness for many different conditions, an important issue is the reliability, replicability, and generalizability of estimates derived from different databases. Therefore, this study sought to assess whether the findings of a recently published study of opioid abuse in a commercial claims database (original analysis) could be replicated in a different commercial claims database. The original analysis, which analyzed the prevalence and excess health care costs of diagnosed opioid abuse in the OptumHealth Reporting and Insights Database, was replicated by applying the same approach to the Truven MarketScan Commercial Claims and Encounters Database (replication analysis). In the replication analysis, the prevalence of diagnosed opioid abuse increased steadily from 15.8 diagnosed opioid abusers per 10,000 in 2009, to 26.6 diagnosed opioid abusers per 10,000 in 2012. Although the prevalence of diagnosed opioid abuse was higher than reported in the original analysis, the trend of increasing prevalence over time was consistent across analyses. Additionally, diagnosed abusers had excess annual per patient health care costs of $11,376 in the replication analysis, which was consistent with the excess annual per patient health care costs of diagnosed abuse of $10,627 reported in the original analysis. The replication analysis also found an upward trend in the prevalence of diagnosed opioid abuse over time and substantial excess annual per patient health care costs of diagnosed opioid abuse among commercially insured individuals, suggesting that these findings are generalizable to other commercially insured populations.