Opiate Use among Ohio Medicaid Recipients July 12, 2012 Ohio Colleges of Medicine Government Resource Center The Ohio State University College of Public Health Sponsored by The Ohio Department of Alcohol and Drug Addiction Services In Partnership with Ohio Medicaid
FOCUS I. Prevalence II. III. IV. High Risk Patterns of Use Patterns of Use Related to Poor Patient Outcomes Costs Related to High Risk Patterns and Negative Outcomes
METHODOLOGY Inclusion Criteria Medicaid Claims 2001 through 2010, including beneficiaries not receiving services FFS and MCP monthly eligibility and demographics Age range 12 years and over Non dual eligible Excluding individuals with terminal malignancy and death within one year
MORPHINE EQUIVALENT DOSE (MED) Equianalgesic Dose 120 mg Morphine 6 mg Buprenorphine 800 mg Codeine 120 mg Hydrocodone 30 mg Hydromorphone 40 mg Methadone 80 mg Oxycodone 833 mg Tramadol 800 mg Adetaminophen with Codine 50 mg Fentanyl 1200 mg Meperidine 120 mg Nalbuphine 40 mg Oxymorphone Schedule II and III opiates, plus Tramadol No Daily Dose data for MCPs. Estimated Daily Dose = Total mgs days between scripts (median estimates within 4 mgs) Equianalgesic conversion factors consistent with Washington State
PREVALENCE OF OPIATE USE Opiate use increased steadily over the past 10 years From 1 in 5 beneficiaries in 2001 to 1 in 3 beneficiaries in 2010 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Proportion of all eligible Medicaid beneficiaries with an Opiate Claim
PREVALENCE BY AGE 60% 50% Rate of use tops 50% among beneficiaries ages 45 to 64 40% 30% 20% 10% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total 12 to 17 18 to 29 30 to 44 45 to 64 Proportion of all eligible Medicaid beneficiaries with an Opiate Claim
PREVALENCE BY GENDER Rate of opiate use is higher among women 51% of women between ages 45 and 64 received opiates in 2010 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Male Female Proportion of all eligible Medicaid beneficiaries with an Opiate Claim
Higher rate of use among whites compared to other racial and ethnic groups 40% 35% 30% 25% 20% 15% 10% 5% 0% PREVALENCE BY RACE & ETHNICITY 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total White Black Hispanic Other Proportion of all eligible Medicaid beneficiaries with an Opiate Claim
PREVALENCE BY ELIGIBILITY Opiate use is more prevalent among individuals with ABD Medicaid eligibility status 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total CFC ABD Waiver Proportion of all eligible Medicaid beneficiaries with an Opiate Claim
Among individuals with selected pain diagnoses, the rate of opiate use is higher than that among other eligible beneficiaries Note that the specific reason for opiate use among these groups is unknown PREVALENCE AMONG INDIVIDUALS WITH SELECTED PAIN CONDITIONS 70% 60% 50% 40% 30% 20% 10% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Back Abdominal Ortho Ocular Migraine Proportion of all eligible Medicaid beneficiaries with a pain condition diagnosis and an opiate claim in the same year
Opiate claims following diagnosis of a new pain condition are on the rise, suggesting opiates are increasingly common treatment for pain Opiates are a common treatment for approx. 35% of abdominal, back, and migraine conditions OPIATE USE FOLLOWING DIAGNOSIS OF A PAIN CONDITION 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Back Abdominal Ocular Migraine Ortho Opiate claim within 7 days of the beginning of a diagnostic episode (preceded by a clean period)
OPIATE USE FOLLOWING DIAGNOSIS OF A NEW PAIN CONDITION Opiate claims following diagnosis of a new pain condition are on the rise, suggesting opiates are increasingly common first-line treatment for pain Prescription of opiates at the first diagnosis of a new pain condition increased from < 10% to over 20%. 40% 35% 30% 25% 20% 15% 10% 5% 0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Back Migraine Ortho Abdominal Opiate claim within 4 days of the beginning of a diagnostic episode (preceded by a 90-day clean period)
MORPHINE EQUIVALENT DAILY DOSE Evidence that -50 to 99 MED increases risk of overdose by 370%; - 100 MED increases risk of overdose by 890% (Dunn, K.M. et al., 2010, Annals of Internal Medicine) 120mg MED. Washington State Yellow Flag warning for providers 60% 50% 40% 30% 20% 10% 0% 29.3% 51.8% 10.3% 5.2% YEAR 2010 MEDIAN = 30 MG MEAN = 40.1 MG SD = 54.6 MG 0.7% 0.3% 0.3% 0.4% 0.2% 0.3% 0.3% 0.1% 0 0252550507575100 100 125 125 150 150 175 175 200 200225 225250 250 275 275 300 Daily MED in mgs Table values represent percent of opiate claims
PREVALENCE OF HIGH OPIATE USE High opiate use is rare, but on the rise. PROPORTION OF SCRIPTS* 48% HYDROCO 23% OCYCODO 15% TRAMADO 11% CODEINE <1% MORPHINE <1% METHADO <1% BUPRENO <1% HYDROMO <1% MEPERID <1% OXYMORP <1% NALBUPH 10.0% 9.0% 8.0% 7.0% 6.0% 5.0% 4.0% 3.0% 2.0% 1.0% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 25+ mg 50+ mg 80+ mg 100+ mg 120+ mg 111,319 people 55,602 people 22,308 people *LEVEL II & III OPIATES AND TRAMADOL Proportion of all eligible Medicaid beneficiaries in each use category
Chronic high use is also rare, yet increased since 2001 3.0% 2.5% CHRONIC HIGH USE 120 MG, 90 DAYS 20,518 people 17% of opiate use episodes are greater than 90 days duration Evidence of increased risk of dependence, withdrawal, and hyperalgesia after 90 days of opiate use (Ballantyne J., 2007, Pain Physician) 2.0% 1.5% 1.0% 0.5% 0.0% 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Proportion of beneficiaries with opiate use episode 90 days with a daily dose reaching 120 MED
HIGH RISK DRUG COMBINATIONS Opiate drug combinations known to increase risk of overdose death are rare, but on the rise. 10,000 8,000 6,000 4,000 The most frequent combinations include - opiates with benzodiazapines - opiates with muscle relaxers 2,000 0 Benzo Muscle Relax Sedatives Co-Occur Stimulants Suboxone Sedatives 2001 2004 2007 2010 Number of beneficiaries with at least two co-occurring claims for a benzo, muscle relaxer, sedative, stimulant, or suboxone during the same opiate use episode
BENEFICIARIES WITH MULTIPLE PRESCRIBERS The number of beneficiaries with opiate claims from multiple prescribers is on the rise. Evidence that 16% to 21% of opiate overdose deaths occur among individuals with 5 prescribers in a year (Hall AJ, et al. 2008, JAMA; ODH,www.healthyohioprogram. org/diseaseprevention/dpoison/ drugdata.aspx.) 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0.4% of. beneficiaries 2.9% of beneficiaries 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total number of beneficiaries with opiate claims from 5 or more prescribers within the same year (with MCP rates estimated)
BENEFICIARIES WITH MULTIPLE PHARMACIES The number of beneficiaries with opiate claims from multiple pharmacies is on the rise. 6000 5000 4000.2% of. beneficiaries.4% of beneficiaries 3000 2000 1000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total number of beneficiaries with opiate claims from 5 or more pharmacies within the same year (with MCP rates estimated)
GEOGRAPHIC DISTRIBUTION I. Any Opiate Use II. III. Chronic High Use (120 MED, 90 days) Co-occurring Use of Opiates and Drugs Known to Increase Risk
NEGATIVE OPIATE USE OUTCOMES Negative outcomes of opiate use increased over time, particularly opiate dependence & abuse 20000 18000 16000 14000 12000 10000 8000 6000 4000 2000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 304.0X, 305.5X, 304.7X - Opioid dependence and abuse 965.0X Poisoning by opiates & related narcotics* Total number of beneficiaries with a negative outcome of opiate use * Excluding poisoning by heroin 965.01
NEGATIVE OPIATE USE OUTCOMES 14000 In 2010, 40% of individuals with an opioid dependence diagnosis had no Medicaid claim for opiates CDC reports 25% to 66% of opiate overdose deaths are attributed to opiates obtained without a prescription (CDC Director s Grand Rounds, 2011) 12000 10000 8000 6000 4000 2000 0 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 304.0X - Opioid dependence, no Medicaid script 304.0x - Opioid dependence, with a Medicaid script Total number of beneficiaries with a negative outcome of opiate use
ED VISITS RELATED TO NEGATIVE OPIATE OUTCOMES Increased prevalence of ED visits attributed to negative opiate outcomes (opiate dependence, abuse, poisoning) Cost of nearly $2 million in 2010. 1200 1000 800 600 400 200 0 $1,092,799 per year $1,862,382 per year 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Table values represent the total number and annual cost of ED visits associated with negative opiate outcomes (opiate dependence, abuse, and poisoning)
OPIATES PRESCRIBED IN ED* The emergency department increasingly a source for opiate medication In 2010, a total of176,423 Medicaid beneficiaries (14%) filled an opiate prescription within four days of an ED visit 16% 14% 12% 10% 8% 6% 4% 2% 0% N=24,439 N=90,276 N=176,423 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Proportion of beneficiaries with an opiate claim 4 days of an ED visit. *excluding opiates provided in the ED and ED visits preceding hospitalization
Factors Associated with Negative Outcomes Beneficiaries odds of having a negative outcome* were 1.6 times higher the they used a benxodiazepine and an opiate concurrently 2.1 times higher if they received opiates from 5 or more prescribers or pharmacies 2.9 times higher white versus black 6.8 times higher if they used over 120 MED daily 6.2 times higher if they used over 50 MED daily * Negative outcomes include diagnosis of opiate abuse, dependence or poisoning
CONCLUSIONS I. Prevalence of opiate use among Ohio Medicaid beneficiaries has increased steadily from 2001 to 2010. II. III. Highest use among 45 to 64 year olds, whites, and women. Opiates have become increasingly common treatment for a variety of pain conditions, including back, abdominal, ocular migraine, and orthopedic conditions. IV. High risk patterns of opiate use increased between 2001 and 2010, including High dose, chronic opiate use (120 mg, 90 days) High risk drug combinations Multiple prescribers and multiple pharmacies
CONCLUSIONS V. Steady growth in opiate use and high risk patterns in all geographic regions of Ohio. Annual rates of opiate use above 40% in many SE counties. VI. VII. VIII. Increase in negative outcomes related to opiates (opiate dependence, abuse, and poisoning). Three-fold increase in ED visits for negative opiate use outcomes Factors associated with negative opiate use outcomes include high daily dose, multiple pharmacies, and multiple ordering providers. A three-fold increase in opiates prescribed in the ED, a possible indication of increased opiate seeking
POSSIBLE NEXT STEPS Cohort analysis to assess risk of reaching dosage and chronicity thresholds and outcomes. Engage other health and human service sectors (e.g., BWC, ODH vital statistics). Assess risk to individuals with serious mental illness, particularly depression. Track impact of state policy initiatives on patterns of use.