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Summary of Research Brief

  • Using an extensive database of ~1.9 million short-term disability and workers’ compensation claims, we investigated for leave claims where opioids were prescribed contrary to the MDGuidelines’ Formulary recommendation.
  • We found ~3% of the claims had an opioid prescription that was either moderately or strongly recommended against in our Formulary.
  • We found opioids were prescribed contrary to our Formulary recommendations for ~7% of the claims with disorders of the peripheral nervous system including ulnar nerve lesions and carpal tunnel syndrome.
  • We recommend the use of opioid prescription guidelines to inform on judicious opioid prescribing and help prevent unnecessary exposure to potentially addictive narcotics.

Introduction

The United States is in the middle of an opioid epidemic. Drug overdoses are now the leading cause of injury death in the United States and the majority of overdoses currently involve an opioid.1,2 In addition to the impact on families and communities due to the tragic loss of life, opioid use has contributed significantly to healthcare and work-leave costs.3,4 The use of evidence-based guidelines has been recommended to inform on judicious prescribing of opioids and research has shown that guidelines can significantly reduce opioid doses and the number of opioid-related deaths.1,5

To help guide providers’ opioid prescribing patterns and reduce inappropriate opioid prescriptions, MDGuidelines has developed a formulary based on our American College of Occupational and Environmental Medicine (ACOEM) Clinical Practice Guidelines. Our Formulary offers opioid prescribing recommendations by medical condition, phase of treatment (acute and chronic), pain classification, and the evidence supporting the recommendation. In this research brief, we describe preliminary work on mining a large database of disability claims for opioid prescribing patterns contrary to our Formulary recommendations.

Methods

Using the MDGuidelines’ Formulary, we found medical conditions by ICD-9-CM code that had “moderate” or “strong” evidence suggesting that specific opioids should not be prescribed across all pain classifications for either an acute or chronic condition. These medical conditions can be viewed as conditions where specific opioids should likely not be prescribed under most circumstances. We then conversely found conditions where there is evidence that specific opioids could be potentially beneficial under certain conditions (e.g., for acute severe pain, post-operative).  Next, we identified all the short-term disability (STD) and workers’ compensation (WC) cases between the years 2007 and 2014 in the MarketScan Health and Productivity Management Database, from Truven Health Analytics, where the reason for leave was a condition where at least one opioid was not recommended for pain management (n = 112,975). Using these records, we linked the claim records with inpatient services, outpatient services, and outpatient drug claims from the  MarketScan Commercial Claims and Encounters Database (CCAE).

This produced a dataset where we had diagnoses and prescribed drugs per individual across a leave episode. Next, we found the claims who were prescribed opioids contrary to the MDGuidelines’ Formulary recommendation, without any additional comorbidities that opioids could potentially be beneficial. It should be noted that the CCAE database does not specify which medical condition each opioid was prescribed to treat for pain management. Therefore, we used the primary reason for work leave to group claims by disability episode for this analysis.

Results

We found 84 ICD-9-CM conditions across five diagnostic categories and 14 diagnostic subcategories where at least one opioid was not recommended for pain management. Across all conditions, we found that 3.1% of the STD/WC claims were prescribed an opioid contrary to MDGuidelines’ Formulary recommendation. The diagnostic categories with the highest probability of being prescribed an opioid against MDGuidelines’ Formulary recommendation were “Ill-Defined Conditions” and “Congenital anomalies” (Table 1). The diagnostic subcategories with the highest probability of being prescribed an opioid against MDGuidelines’ Formulary recommendation were “Symptoms” and “Other congenital musculoskeletal anomalies” (Table 2).

Table 1. Probability of an opioid being prescribed contrary to MDGuidelines’ Formulary recommendation by diagnostic category

Table 1

Table 2. Probability of an opioid being prescribed contrary to MDGuidelines’ Formulary recommendation by diagnostic subcategory

Table 2

The top ICD-9-CM conditions with the greatest percent of claims with an opioid prescribed contrary to our formulary were 780.96 (Generalized pain) and 354.2 (Lesion of ulnar nerve) (Table 3). For the top ten conditions, we found hydrocodone bitartrate was the most common opioid prescribed contrary to our recommendations.

Table 3. Probability of an opioid being prescribed contrary to MDGuidelines’ Formulary recommendation by ICD-9-CM: Top 10

Table 3

Future Work

We plan on researching the impact of improper opioid prescriptions on both work-leave and medical costs. We will also research the impact of using MDGuidelines’ Formulary on work-leave and medical costs beyond opioid prescribing patterns.

References

  1. Department of Health and Human Services. Opioid Abuse in the U.S. and HHS actions to address opioid-drug related overdoses and deaths. 2015:12. https://aspe.hhs.gov/sites/default/files/pdf/107956/ib_OpioidInitiative.pdf.
  2. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths — United States , 2000 – 2014. MMWR Morb Mortal Wkly Rep. 2016;64(50-51):1378-1382. doi:10.15585/mmwr.mm6450a3.
  3. Meyer R, Patel AM, Rattana SK, Quock TP, Mody SH. Prescription opioid abuse: a literature review of the clinical and economic burden in the United States. Popul Health Manag. 2014;17(6):372-387. doi:10.1089/pop.2013.0098.
  4. White J a, Tao X, Talreja M, Tower J, Bernacki E. The effect of opioid use on workers’ compensation claim cost in the State of Michigan. J Occup Environ Med. 2012;54(8):948-953. doi:10.1097/JOM.0b013e318252249b.
  5. Franklin GM, Mai J, Turner J, Sullivan M, Wickizer T, Fulton-Kehoe D. Bending the prescription opioid dosing and mortality curves: Impact of the Washington State opioid dosing guideline. Am J Ind Med. 2012;55(4):325-331. doi:10.1002/ajim.21998.

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Fraser Gaspar

Fraser Gaspar

Dr. Fraser Gaspar is an Epidemiologist with MDGuidelines at ReedGroup since July 2016. His research focuses on the factors that influence a patient’s successful return-to-activity and the use of evidence-based treatment guidelines in improving health outcomes. Dr. Gaspar completed his PhD and MPH at University of California- Berkeley’s School of Public Health in Environmental Health Sciences.

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