AMCP: High-risk opioid users spend 3 times more

April 5, 2014

Costs are more than $14,000 higher in group more likely to abuse opioids

Consumers who are at high-risk for opioid abuse had significantly higher total medical costs ($19,513 vs $5,493) than those who were not at high risk according to a study by Prime Therapeutics, presented at the Academy of Managed Care Pharmacy (AMCP) 26th Annual Meeting & Expo in Tampa, Fla.

The Centers for Medicare & Medicare Services (CMS) defines high risk as “using a daily morphine equivalent dose (MED) of greater than 120 mg for at least 90 consecutive days, plus using more than three pharmacies and more than three unique prescribers.”

During the first half of 2013, the study reviewed opioid claims from more than 9 million commercially insured members to identify those meeting the Medicare Part D criteria for high-risk opioid use. The research found nearly 1.2 million of the study group (13.1%) had at least one opioid claim. Just 225 (0.0025%) met all three CMS high-risk criteria.

“Prime’s study excluded members being treated for cancer, as CMS does in its analysis,” said Pat Gleason, PharmD, BCPS, FCCP, director of health outcomes for Prime.

The average age for members meeting all three CMS criteria was 43 years, and pain diagnosis for back, neck and abdominal were among the most common in this group. Anxiety, bipolar disorder and depression also were more common than in the group that met only the MED measurement.

Ten different ICD-9 diagnosis code groupings (six pain, three psychiatric, and one chemical dependency) had a significantly higher prevalence in the study group, suggesting these diagnoses could be used as potential indicators for identifying high-risk opioid abuse.

Commercial health insurers may wish to explore different high risk criteria, says Dr. Gleason. He says medical costs were three times higher in high-risk members, with a difference of $14,020 per member compared to those only meeting the MED threshold.

“Identifying members meeting all CMS high-risk criteria and intervening could potentially reduce medical costs,” he says.