Educational intervention for physicians to address the risk of opioid abuse

Margaret K. Pasquale, PhD; Richard L. Sheer, BA; Jack Mardekian, PhD; Elizabeth T. Masters, MS, MPH; Nick C. Patel, PharmD, PhD; Amy R. Hurwitch, PharmD, BCPS; Jennifer J. Weber, PharmD, MS, BCPS, CGP, BCACP; Anamaria Jorga, MD; Carl L. Roland, PharmD, MS

doi:10.5055/jom.2017.0399

Authors

Margaret K. Pasquale, PhD
Richard L. Sheer, BA
Jack Mardekian, PhD
Elizabeth T. Masters, MS, MPH
Nick C. Patel, PharmD, PhD
Amy R. Hurwitch, PharmD, BCPS
Jennifer J. Weber, PharmD, MS, BCPS, CGP, BCACP
Anamaria Jorga, MD
Carl L. Roland, PharmD, MS

DOI:

https://doi.org/10.5055/jom.2017.0399

Keywords:

opioid abuse, Medicare population, predictive model, physician intervention

Abstract

Objective: To evaluate the impact of a pilot intervention for physicians to support their treatment of patients at risk for opioid abuse.

Setting, design and patients, participants: Patients at risk for opioid abuse enrolled in Medicare plans were identified from July 1, 2012 to April 30, 2014 (N = 2,391), based on a published predictive model, and linked to 4,353 opioid-prescribing physicians. Patient-physician clusters were randomly assigned to one of four interventions using factorial design.

Interventions: Physicians received one of the following: Arm 1, patient information; Arm 2, links to educational materials for diagnosis and management of pain; Arm 3, both patient information and links to educational materials; or Arm 4, no communication.

Main outcome measures: Difference-in-difference analyses compared opioid and pain prescriptions, chronic high-dose opioid use, uncoordinated opioid use, and opioid-related emergency department (ED) visits. Logistic regression compared diagnosis of opioid abuse between cases and controls postindex.

Results: Mailings had no significant impact on numbers of opioid or pain medications filled, chronic high-dose opioid use, uncoordinated opioid use, ED visits, or rate of diagnosed opioid abuse. Relative to Arm 4, odds ratios (95% CI) for diagnosed opioid abuse were Arm 1, 0.95(0.63-1.42); Arm 2, 0.83(0.55-1.27); Arm 3, 0.72(0.46-1.13). While 84.7 percent had ≥ 1 psychiatric diagnoses during preindex (p = 0.89 between arms), only 9.5 percent had ≥ 1 visit with mental health specialists (p = 0.53 between arms).

Conclusions: Although this intervention did not affect pain-related outcomes, future interventions involving care coordination across primary care and mental health may impact opioid abuse and improve quality of life of patients with pain.

Author Biographies

Margaret K. Pasquale, PhD

Research Manager, Comprehensive Health Insights, Inc., Louisville, Kentucky

Richard L. Sheer, BA

Principal Researcher, Comprehensive Health Insights, Inc., Louisville, Kentucky

Jack Mardekian, PhD

Senior Director, Statistics, Pfizer Inc., New York, New York

Elizabeth T. Masters, MS, MPH

Director, Outcomes & Evidence, Pfizer Inc., New York, New York

Nick C. Patel, PharmD, PhD

Research Manager, Comprehensive Health Insights, Inc., Louisville, Kentucky

Amy R. Hurwitch, PharmD, BCPS

Program Manager, Adverse Events|Pharmacy Patient Safety Programs Humana Pharmacy Solutions, Louisville, Kentucky

Jennifer J. Weber, PharmD, MS, BCPS, CGP, BCACP

Managing Pharmacist, Pharmacy Patient Safety Programs Humana Pharmacy Solutions, Louisville, Kentucky

Anamaria Jorga, MD

Medical Director, US Medical Affairs, Pfizer Inc., New York, New York

Carl L. Roland, PharmD, MS

Senior Director, Global Innovative Pharma Business Clinical Sciences and Outcomes and Evidence Pfizer Inc., Durham, North Carolina

References

Sehgal N, Manchikanti L, Smith HS: Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Phys. 2012; 15(suppl 3): ES67-ES92.

Frenk SM, Porter KS, Paulozzi LJ: Prescription opioid analgesic use among adults: United States, 1999-2012. NCHS Data Brief. 2015; 189: 1-8.

Manubay JM, Muchow C, Sullivan MA: Prescription drug abuse: Epidemiology, regulatory issues, chronic pain management with narcotic analgesics. Primary Care. 2011; 38(1): 71.

McAdam-Marx C, Roland CL, Cleveland J, et al.: Costs of opioid abuse and misuse determined from a Medicaid database. J Pain Palliat Care Pharmacother. 2010; 24(1): 5-18.

Manchikanti L: Prescription drug abuse: What is being done to address this new drug epidemic? Testimony before the Subcommittee on Criminal Justice, Drug Policy and Human Resources. Pain Phys. 2006; 9(4): 287-321.

Sullivan CR: Opioid dependence. W Virginia Med J. 2008; 104(2): 26-27.

Boudreau D, Von Korff M, Rutter CM, et al.: Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009; 18(12): 1166-1175.

Hahn KL: Strategies to prevent opioid misuse, abuse, and diversion that may also reduce the associated costs. Am Health Drug Benefits. 2011; 4(2): 107-114.

Manchikanti L, Fellows B, Ailinani H, et al.: Therapeutic use, abuse, and nonmedical use of opioids: A ten-year perspective. Pain Phys. 2010; 13(5): 401-435.

Roland CL, Lake J, Oderda GM: Prevalence of prescription opioid misuse/abuse as determined by International Classification of Diseases Codes: A systematic review. J Pain Palliat Care Pharmacother. 2016; 30(4): 258-268.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies: Treatment Episodes Data Set (TEDS) 2002-2012. Rockville, MD: National Admissions to Substance Abuse Treatment Services. 2014. Available at http://www.samhsa.gov/data/sites/default/files/TEDS2012N_Web.pdf. Accessed October 19, 2016.

FAIR Health: The opioid crisis among the privately insured: The opioid abuse epidemic as documented in private claims data. FAIR Health White Paper. July 2016. Available at http://www.fairhealth.org/servlet/servlet.FileDownload?file=01532000001nwD2. Accessed October 19, 2016.

FAIR Health: The impact of the opioid crisis on the healthcare system: A study of privately billed services. FAIR Health White Paper. September 2016. Available at http://www.fairhealth.org/servlet/servlet.FileDownload?file=01532000001g4i3. Accessed October 19, 2016.

Dufour R, Mardekian J, Pasquale M, et al.: Understanding predictors of opioid abuse: Predictive model development and validation. Am J Pharm Benefits. 2014; 6(5): 208-216.

Drug Enforcement Administration, Department of Justice: Schedule of controlled substances: Rescheduling of hydrocodone combination products from Schedule III to Schedule II. Federal Register. 2014; 79(163): 49661-49682. Available at https://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0822.htm. Accessed October 19, 2016.

Brady KT, McCauley JL, Back SE: Prescription opioid misuse, abuse, and treatment in the United States: An update. Am J Psychiatry. 2016; 173(1): 18-26.

Department of Health and Humana Services Centers for Medicare and Medicaid Services: Supplemental guidance related to improving drug utilization review controls in Part D. Memorandum dated September 6, 2012. Available at https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/HPMSSupplementalGuidanceRelated-toImprovingDURcontrols.pdf. Accessed October 17, 2016.

Daubresse M, Gleason PP, Peng Y, et al.: Impact of a drug utilization review program on high-risk use of prescription controlled substances. Pharmacoepidemiol Drug Saf. 2014; 23(4): 419-427.

Oderda G, Roland C, Stevens V, et al.: Prevalence and direct costs of opioid abuse in Medicare beneficiaries. J Manag Care Spec Pharm. 2010; 21(10a): S71-S72.

Agency Medical Directors Group: Interagency guideline on opioid dosing for chronic non-cancer pain 2010 update. Available at http://www.agencymeddirectors.wa.gov/Files/OpioidGdline.pdf. Accessed October 18, 2016.

Centers for Disease Control and Prevention (CDC): CDC guidelines for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016; 65(RR-1): 1-49.

Available at http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed April 11, 2016.

Means-Christensen AJ, Roy-Byrne PP, Sherbourne CD, et al.: Relationships among pain, anxiety, and depression in primary care. Depression Anxiety 2008; 25(7): 593-600.

Bair MJ, Robinson RL, Katon W, et al.: Depression and pain comorbidity: A literature review. Archives Intern Med. 2003; 163(20): 2433-2445.

DeVeaugh-Geiss AM, West SL, Miller WC, et al.: The adverse effects of comorbid pain on depression outcomes in primary care patients: Results from the ARTIST trial. Pain Med (Malden, Mass.) 2010; 11(5): 732-741.

Watson L, Baird J, Hösel V, et al.: The effect of concurrent pain on the management of patients with depression: An analysis of NHS healthcare resource utilisation using the GPRD database. Int J Clin Pract. 2009; 63(5): 698-706.

Bureau of Clinician Recruitment and Service, Health Resources and Services Administration, US Department of Health and Human Services: Mental Healthcare Health Professional Shortage Areas (HPSAs) as of September 8, 2016. Available at http://kff.org/other/state-indicator/mental-health-care-healthprofessional-shortage-areas-hpsas/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D. Accessed October 17, 2016.

Thomas KC, Ellis AR, Konrad TR, et al.: County-level estimates of mental health professional shortage in the United States. Psychiatric Serv (Washington, DC). 2009; 60(10): 1323-1328.

O'Reilly R, Bishop J, Maddox K, et al.: Is telepsychiatry equivalent to face-to-face psychiatry? Results from a randomized controlled equivalence trial. Psychiatric Serv(Washington, DC). 2007; 58(6): 836-843.

Andrews LB, Bridgeman MB, Dalal KS, et al.: Implementation of a pharmacist-driven pain management consultation service for hospitalised adults with a history of substance abuse. Int J Clin Pract. 2013; 67(12): 1342-1349.

Gugelmann H, Shofer FS, Meisel ZF, et al.: Multidisciplinary intervention decreases the use of opioid medication discharge packs from 2 urban EDs. Am J Emerg Med. 2013; 31(9): 1343-1348.

Bohnert ASB, Bonar EE, Cunningham R, et al.: A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose. Drug Alcohol Depend. 2016; 163: 40-47.

Compton WM, Jones CM, Baldwin GT: Relationship between nonmedical prescription-opioid use and heroin use. NE J Med. 2016; 374(2): 154-163.