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Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck

  • Brent A. Metfessel
  • Michelle D. Mentel
  • Amy Phanel
  • Mary Ann Dimartino
  • Mureen Allen
  • Samuel Ho
Original Research Article

Abstract

Background

Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking.

Objective

The objective of this study was to evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States.

Methods

A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18–64 years with non-surgically managed cervical or lumbar degenerative spine disease during 2015–6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications.

Results

Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care.

Conclusions

The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.

Notes

Acknowledgements

The authors thank Ranyan Lu, MD and Anthony Nguyen, MD for their valuable assistance in reviewing the document and Peter Toensing, MD for collaboration on the severity adjustment methodology.

Author Contributions

BAM was responsible for the development and design of the measurement algorithms, he performed data analysis for comparisons between the opioid and non-opioid groups, wrote 40–50% of the Introduction section, wrote the majority of the Methods and Results sections, created the majority of the tables, and wrote the majority of the Discussion section. MMM collaborated on the conception and design of the study, acquired the data, prepared the data, and performed the initial analysis. She also revised data elements requested for revisions, including guidance on the design of the drill-down algorithms. She provided feedback on the interpretation of the data and results, created the initial figures, revised data elements needed for requested revisions, and wrote about 10% of the Methods and Results sections. AP delineated the opioid medication names and classification and national drug codes and provided pharmaceutical expertise for analysis. She also performed about 50–60% of the literature review for the Introduction section and wrote about 50% of the Introduction section. MAD performed the literature reviews and interpretations for the Discussion section, and identified potential clinical drivers of higher costs for opioid users. She wrote about 20–25% of the Discussion section. MA had significant involvement in the conceptualization and design of the study and the development of research methods for comparison of the opioid and non-opioid groups. She also performed the critical review and revision of the draft for intellectual content, and wrote about 5–10% of the Discussion section. SH was responsible for strategic clinical direction and prioritization, as well as providing the research design and opioid vs. non-opioid group definitions; he was also largely responsible for the emphasis on severity adjustment in the study.

Compliance with Ethical Standards

Funding

No other funding outside of UnitedHealthcare was received for the study.

Conflict of Interest

Brent Metfessel, Michelle Mentel, Amy Phanel, Mary Ann Dimartino, Mureen Allen, and Samuel Ho performed research while employed at UnitedHealthcare.

Ethics Approval

The research was performed using a health plan administrative database, thus no direct participation of subjects was needed.

Data Availability

The data that support the findings of this study are available on reasonable request from the corresponding author, pending UnitedHealthcare corporate legal and database administrator approval. The data are not publicly available because of regulatory restrictions on divulging personal health information and patient identifiable information to outside sources, which would compromise member privacy. Opioid abuse and dependence are also considered ‘sensitive conditions’ with additional restrictions on revealing that information to outside sources.

Supplementary material

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Supplementary material 1 (XLSX 27 kb)
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Supplementary material 2 (PDF 152 kb)
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Supplementary material 3 (XLSX 11 kb)
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Supplementary material 4 (XLSX 9 kb)

References

  1. 1.
    McCance-Katz EF. The National Survey on Drug Use and Health: 2017. Rockville, Maryland, USA: Substance Abuse and Mental Health Services Administration (SAMHSA); 2017.Google Scholar
  2. 2.
    Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education and research. Washington, DC: The National Academies Press; 2011.Google Scholar
  3. 3.
    Centers for Disease Control and Prevention. Opioid overdose: prescribing data. Updated August 30. 2017. https://www.cdc.gov/drugoverdose/data/prescribing.html. Accessed 2 May 2018.
  4. 4.
    Daubresse M, Chang H, Yu Y, Viswanathan S, Shah ND, Stafford RS, et al. Ambulatory diagnosis and treatment of nonmalignant pain in the United States, 2000–2010. Med Care. 2013;51(10):870–8.CrossRefGoogle Scholar
  5. 5.
    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Fernandes AW, Kern DM, Datto C, Chen YW, McLeskey C, Tunceli O. Increased burden of healthcare utilization and cost associated with opioid-related constipation among patients with noncancer pain. Am Health Drug Benefits. 2016;9:160–70.PubMedPubMedCentralGoogle Scholar
  7. 7.
    Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long-term opioid use: United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66:265–9.CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Oderda GM, Lake J, Rüdell K, Roland CL, Masters ET. Economic burden of prescription opioid misuse and abuse: a systematic review. J Pain Palliat Care Pharmacother. 2015;29:388–400.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    McAdam-Marx C, Roland CL, Cleveland J, Oderda GM. Costs of opioid abuse and misuse determined from a medicaid database. J Pain Palliat Care Pharmacother. 2010;24:5–18.CrossRefGoogle Scholar
  10. 10.
    Reinhart M, Scarpati LM, Kirson NY, Patton C, Shak N, Erensen JG. The economic burden of abuse of prescription opioids: a systematic literature review from 2012 to 2017. Appl Health Econ Health Policy. 2018;16:609–32.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Kern DM, Zhou S, Chavoshi S, Tunceli O, Sostek M, Singer J, et al. Treatment patterns, healthcare utilization, and costs of chronic opioid treatment for non-cancer pain in the United States. Am J Manag Care. 2015;21:e222–34.PubMedGoogle Scholar
  12. 12.
    Connolly J 3rd, Javed Z, Raji MA, Chan W, Kuo YF, Baillargeon J. Predictors of long-term opioid use following lumbar fusion surgery. Spine. 2017;42:1405–11.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Faour M, Anderson JT, Haas AR, Percy R, Woods ST, Ahn UM, et al. Preoperative opioid use: a risk factor for poor return to work status after single-level cervical fusion for radiculopathy in a workers’ compensation setting. Clin Spine Surg. 2017;31(1):E19–24.CrossRefGoogle Scholar
  14. 14.
    Rundell SD, Gold LS, Hansen RN, Bresnahan BW. Impact of co-morbidities on resource use and adherence to guidelines among commercially insured adults with new visits for back pain. J Eval Clin Pract. 2017;23(6):1218–26.CrossRefGoogle Scholar
  15. 15.
    Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176:958–68.CrossRefGoogle Scholar
  16. 16.
    Wielage RC, Bansal M, Andrews JS, Wohlreich MM, Klein RW, Happich M. The cost-effectiveness of duloxetine in chronic low back pain: a US private payer perspective. Value Health. 2013;16:334–44.CrossRefGoogle Scholar
  17. 17.
    Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 2018;319(9):872–82.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Leider HL, Dhaliwal J, Davis EJ, Kulakodlu M, Buikema AR. Healthcare costs and nonadherence among chronic opioid users. Am J Manag Care. 2011;17:32–40.Google Scholar
  19. 19.
    Gold LS, Strassels SA, Hansen RN. Health care costs and utilization in patients receiving prescriptions for long-acting opioids for acute postsurgical pain. Clin J Pain. 2016;32:747–54.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Wan Y, Corman S, Gao X, Liu S, Patel H, Mody R. Economic burden of opioid-induced constipation among long-term opioid users with noncancer pain. Am Health Drug Benefits. 2015;8:93–102.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Rogers E, Mehta S, Shengelia R, Reid MC. Four strategies for managing opioid-induced side effects in older adults. Clin Geriatr. 2013;21(4). http://www.consultant360.com/articles/four-strategies-managing-opioid-induced-side-effects-older-adults.
  22. 22.
    Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–30.CrossRefPubMedGoogle Scholar
  23. 23.
    Dasgupta N, Funk MJ, Proescholdbell S, Hirsch A, Ribisl KM, Marshall S. Cohort study of the impact of high-dose opioid analgesics on overdose mortality. Pain Med. 2016;17(1):85–98.PubMedPubMedCentralGoogle Scholar
  24. 24.
    Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, O’Brien MA, Wolf F, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009;2:CD003030.Google Scholar
  25. 25.
    Saunders KW, Shortreed S, Thielke S, Turner JA, LeResche L, Beck R, et al. Evaluation of health plan interventions to influence chronic opioid therapy prescribing. Clin J Pain. 2015;31(9):820–9.PubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Clinical Data Services and Analytics, UnitedHealthcareMinnetonkaUSA
  2. 2.Clinical Data Services and Analytics, UnitedHealthcareFentonUSA
  3. 3.AetnaSanta AnaUSA
  4. 4.Clinical Data Services and Analytics, UnitedHealthcareWakefieldUSA
  5. 5.LindenUSA

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