Post on 15-Dec-2015
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