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Trends in Opioid Use in Commercially Insured and Medicare Advantage

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Trends in Opioid Use in Commercially Insured and Medicare Advantage RESEARCH Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study Molly Moore Jeffery,1 W Michael Hooten2 Henry J Henk,3 M Fernanda Bellolio,4 Erik P Hess,5 Ellen Meara,6,7 Joseph S Ross,8 Nilay D Shah1,3 1Mayo Clinic Robert D and ABSTRACT use rates (39%) and average daily dose (56 MME) Patricia E Kern Center for the OBJECTIVE were higher at the end of 2016 than the low points Science of Health Care Delivery, To describe trends in the rate and daily dose of observed in 2007 for each endpoint (26% prevalence Division of Health Care Policy Research, Department of Health opioids used among commercial and Medicare and 53 MME). Sciences Research, Mayo Clinic, Advantage beneficiaries from 2007 to 2016. CoNCLUSIONS Rochester, MN 55905, USA DESIGN Opioid use rates were high during the study period of 2Department of Anesthesiology, Mayo Clinic College of Medicine, Retrospective cohort study of administrative claims 2007-16, with the highest rates in disabled Medicare Rochester, MN, USA data. beneficiaries versus aged Medicare beneficiaries and 3 OptumLabs, Eden Prairie, MN, SETTING commercial beneficiaries. Opioid use and average USA daily dose have not substantially declined from their 4 National database of medical and pharmacy claims Department of Emergency peaks, despite increased attention to opioid abuse Medicine, Mayo Clinic, for commercially insured and Medicare Advantage Rochester, MN, USA beneficiaries in the United States. and awareness of their risks. 5 Department of Emergency PARTICIPANTS Introduction Medicine, University of Alabama 48 million individuals with any period of insurance at Birmingham School of The United States has the highest rate of opioid use in Medicine, Birmingham, AL, USA coverage between 1 January 2007 and 31 December the world, consuming 88% more prescription opioids 6Dartmouth Institute for Health 2016, including commercial beneficiaries, Medicare Policy and Clinical Practice, per capita than second ranked Germany and seven Advantage beneficiaries aged 65 years and over, and 1 Dartmouth College, Lebanon, Medicare Advantage beneficiaries under age 65 years times more than the United Kingdom. An average of NH, USA 40 people die in the US every day from a prescription 7 (eligible owing to permanent disability). National Bureau of Economic opioid overdose—a fourfold increase since 1999.2 Research, Cambridge, MA, USA MAIN ENDPOINTS Opioid use has been declared a public health 8Department of Internal Proportion of beneficiaries with any opioid emergency, with legally prescribed drugs contributing Medicine, Yale University School prescription per quarter, average daily dose in of Medicine, New Haven, CT, to substantial morbidity and mortality from addiction milligram morphine equivalents (MME), and USA and overdose.3-5 proportion of opioid use episodes that represented Correspondence to: Studies reporting on population level opioid use M M Jeffery long term use. [email protected] have had some key limitations. Sales and supply (or @mollyjeffery on Twitter) RESULTS data track nearly all legally distributed opioids, but Across all years of the study, annual opioid use 6 7 Additional material is published these data do not link to patient demographics. prevalence was 14% for commercial beneficiaries, online only. To view please visit The National Survey on Drug Use and Health includes the journal online. 26% for aged Medicare beneficiaries, and 52% for patient information, but is limited to patient self report Cite this as: BMJ 2018;362:k2833 disabled Medicare beneficiaries. In the commercial of opioid use and excludes children under age 12 http://dx.doi.org/10.1136/bmj.k2833 beneficiary group, quarterly prevalence of opioid years.8 The most commonly used source of healthcare Accepted: 12 June 2018 use changed little, starting and ending the study claims data—Medicare fee-for-service data—provides period at 6%; the average daily dose of 17 MME excellent patient level data, but is limited to Medicare remained unchanged since 2011. For aged Medicare beneficiaries.9 10 beneficiaries, quarterly use prevalence was also As a result, current knowledge about opioid use in relatively stable, ranging from 11% at the beginning the US is largely derived from studies of a single state of the study period to 14% at the end. Disabled 11-14 Medicare beneficiaries had the highest rates of opioid or healthcare system, or market level information use, the highest rate of long term use, and the largest that limits detailed examination of prevalence, patient 6 15 average daily doses. In this group, both quarterly level use, or subgroup analyses. Market level data from prescriptionfills cannot be used to determine the proportion of people who use opioids in a given year WHAT IS ALREADY KNOWN ON THIS TOPIC unless prescriptions filled by the same person can be identified. Without a unique person level identifier, Population data suggests that opioid use in the United States has fallen since its only the rate of prescriptions per capita can be peak in 2012 calculated, rather than the proportion of people using Rates of opioid use and daily doses have not been well characterized for some opioids in a given year; the two estimates can diverge patient populations if a small number of people fill a large proportion of WHAT THIS STUDY ADDS prescriptions. As a result, relatively little is known about person level opioid use in large national samples Opioid use and average daily dose measured at the individual level have not outside of Medicare fee-for-service beneficiaries. There substantially fallen from their peaks, despite increased attention to opioid abuse are few sources of claims data for Medicare Advantage and awareness of their risks beneficiaries, who are believed to be healthier than the bmj | BMJ 2018;362:k2833 | doi: 10.1136/bmj.k2833 1 RESEARCH fee-for-service beneficiaries,16 but have not been We amended that list of conversion factors to convert studied in depth; there are also few datasets that propoxyphene napsylate at a different rate from cover a geographically diverse group of commercially propoxyphene hydrochloride, taking into account insured beneficiaries. Both of these populations are the differences in molecular weight between the two included in the OptumLabs Data Warehouse. salts.19 Appendix 3 provides details of opioids used Accordingly, our objective was to describe the and conversion factors. prevalence of use, dose, and duration of prescription For all opioid prescriptions filled during the study opioids used in a large population, including both period, we linked the prescribed dose in MME and commercially insured and Medicare Advantage the total days supplied to an individual beneficiary. beneficiaries (31% of all Medicare beneficiaries17), Prescriptions written for the same active ingredient from 2007 to 2016. Using a national claims database, and filled on the same day were consolidated and we aimed to explore the prevalence of opioid use and treated as one prescription, using the maximum trends over the study period in subpopulations defined count days’ supply across the fills. We calculated the by insurance type (commercial, aged Medicare, and average daily prescribed dose for each drug fill as the disabled Medicare) and by age. The primary goal of total MME dispensed divided by the number of person this paper was to estimate the change in opioid use days of insurance enrollment in that period (that is, across age and coverage types since 2007, in the face of quarter).20 Opioid drug fills that were calculated as increasing emphasis on improving prescribing patterns having a dose of over 1000 MME per drug per day were and preventing adverse outcomes. As a secondary excluded as potential recording errors (n=40 674 fills; goal, we also assessed the extent of concentration of 0.05% of consolidated fills for beneficiaries eligible for opioid use in long term use episodes and among the enrollment). Appendix 4 shows the cohort flowcharts beneficiaries with the greatest use of opioids. of drug fills and beneficiaries. Opioid prescriptions were allocated to a year and Methods quarter, on the basis of the fill date and days supplied. Participants For example, a 30 day prescription filled on 31 We drew pharmacy claims from the OptumLabs Data December 2008 would have been allocated as one Warehouse (OLDW), a database of claims for healthcare day in quarter 4 of 2008 and 29 days in quarter 1 of services, insurance enrollment, and demographic 2009. Opioid use was measured quarterly as a binary information. The OLDW includes both commercially indicator of use, using pharmacy claims as a proxy for insured and Medicare Advantage beneficiaries, opioid fills. including age eligible beneficiaries (age ≥65 years) and We constructed episodes of opioid use by grouping individuals eligible for Medicare before age 65 years all contiguous opioid fills by a single beneficiary. An owing to permanent disability. Our study included all episode of opioid use was defined as the time from the beneficiaries with medical and pharmacy coverage for fill date of the first prescription in the episode to the last any period of time between 1 January 2007 and 31 day of the final prescription. Each episode ended when December 2016. 30 days lapsed without an opioid fill after the last day The OLDW includes 20% of the commercially of the last prescription in the episode. An alternative insured population in the US and 24% of the Medicare episode definition allowing 40 days to lapse between Advantage population. The distributions of age, sex, the end of one prescription and the beginning of the and race or ethnicity in the database are similar to the next did not substantially change the distribution of US commercial and Medicare Advantage populations. chronic and non-chronic episodes. Using criteria from People from all census divisions are represented in the Von Korff and colleagues,20 we categorized episodes OLDW, with a higher proportion of OLDW beneficiaries of opioid use as long term if the prescription dates in the West North Central and South Atlantic census spanned at least 90 days and included either at least divisions than in the entire insured population.
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