RED FLAGS for Chronic Opioid Use Opioid MisuseAbuse
RED FLAGS for Chronic Opioid Use, Opioid Misuse/Abuse, Opioid Use Disorder and Opioid Overdose Hank George, FALU
“We know of no other medication routinely used for a nonfatal condition that kills patients so frequently” Thomas R. Frieden, MD, MPH CDC New England Journal of Medicine 37(2016): 1501[editorial]
RED FLAGS for CHRONIC OPIOID USE
Milligrams/morphine per hospital stay HR Chronic Post-Discharge Use None 1. 00 < 10 1. 65 10 -<51 2. 08 51 -<100 2. 23 ≥ 100 3. 37 Calcaterra. Journal of General Internal Medicine. E-published 2/5/18
Past year opioid prescriptions filled HR Chronic Opioid Use None 1. 00 1 1. 99 2 3. 31 3 4. 19 4 -9 9. 87 Calcaterra. Journal of General Internal Medicine. E-published 2/5/18
Post-operative RED FLAGS for Chronic Opioid Use Risk Increase Age > 50 1. 7 Pre-op antidepressants 1. 7 Pre-op benzodiazepines 1. 8 Total knee arthroplasty 5. 1 Total hip arthroplasty 2. 5 Alcohol abuse history 1. 8 Drug abuse history 3. 2 Sun. JAMA Internal Medicine. 176(2016): 1286
More Red Flags for Chronic Opioid Use • • • Prescription supply ≥ 22 days Long-acting opioids prescribed Osteoporotic/fragility fracture; highest risk in shoulder fracture Major depression – 2 -fold increased risk History of arthritis – 1. 5 -fold increased risk Opioid use < 30 days before surgery – 1. 9 -fold increased risk Trauma surgery – 1. 4 -fold increased risk Long-term benzodiazepine or other sedative hypnotic use Teetotaler Daily cigarette smoker
RED FLAGS for Opioid Misuse
RED FLAGS for Opioid Misuse • • • Chronic opioid use – 2. 3 -fold increased risk Taking higher opioid dose than prescribed Requesting early opioid refills Taking doses more often than prescribed Victim of child abuse – 50% increased risk Carrying a gun for personal protection (31% vs. 4%) Current psychiatric diagnosis – 3. 4 -fold increased risk History of a suicide attempt Family history of substance abuse Non-opioid substance abuse – 1. 7 -fold increased risk
Smoking and Opioid Misuse • 4. 4 -fold greater risk of opioid misuse in cigarette smokers overall • Higher probability if severe nicotine dependence (heavier, longer duration smoking) • Standardized mortality ratio for smoking-related disease in opioid misuse/abuse = 4. 26* *Callaghan. Drug and Alcohol Reviews. 37(2018): 97 Osborne. Addictive Behaviors. 72(2017): 114 Parker. Drug and Alcohol Dependence. 186(2018): 67
Depression and Opioid Misuse Adjusted OR No depression 1. 00 Mild depression 1. 49* Moderate depression 3. 71 Severe depression 14. 66 *Not significant Feingold Journal of Affective Disorders. 235(2018): 293
RED FLAGS for Opioid Abuse
RED FLAGS for Opioid Abuse • Prior DWI - 2. 6 -fold increased risk • History of alcohol abuse - 2. 6 -fold increased risk • Longtime benzodiazepine/ “Z-drug” use • Social anxiety disorder (“social phobia”), agoraphobia • Opioid user monitored with urine testing • Selling/forging prescriptions; frequent “lost” prescriptions • Insistent demands for more prescriptions, early refills • Resisting Rx change despite experiencing adverse effects • Current/recent opioids from ≥ 2 prescribers (excluding dentists) • “CNS polypharmacy” = taking at least 3 psychotropic drugs
More Opioid Abuse RED FLAGS • • • Age 18 -24 with ≥ 12 total opioid prescriptions Filling opioid prescriptions at ≥ 3 pharmacies Posttraumatic stress disorder Diagnosed with hepatitis C under age 40 Increasing number of emergency room visits over a period of years Pain rehab program: refuse to participate, poor performance or dropping out early • Binge drinking • Pain-related catastrophizing (rumination, pain magnification) • Attending electronic dance music (EDM) parties
RED FLAGS for Undiagnosed/Undisclosed Opioid Use Disorder (OUD)
RED FLAGS for OUD • • • Persistent unrelenting pain – 2. 4 -fold increased risk Other substance use disorder at any time – 4 -fold increased risk Major Depression – 60% increased risk ED visit related directly/indirectly to opioids – 7 -fold increased risk 3 or more ER visits in last 12 months Traumatic eye injury (because of links to DWI and assault) Hidradenitis suppurativa Posttraumatic stress disorder – 58% increased risk overall; 2 -fold at ages 18 -34 Persistent/heavy use of prescription sedatives
More RED FLAGS for OUD • • • Family history of OUD in 1 st degree relatives Cannabis use disorder – 2. 6 -fold increased risk ≥ 2 major stressful events in ≤ 1 year – 3. 1 -fold increased risk Daily opioid dose > 100 MME (morphine milliequivalents) Use of fentanyl patch for extended opioid release History of opioid overdose Abandonment/emotional deprivation in childhood/adolescence Current and especially longtime/heavy cigarette smoking Social isolation in elderly prescription opioid users Chronic hepatitis C Suicidality
RED FLAGS for Transition to Heroin • Opioid use disorder • History of nonmedical opioid use at any time • Oral opioid use on any basis under age 15 • Alcohol use disorder • Illicit drug use disorders • Long-term/extensive use of sedatives or stimulants
RED FLAGS for Opioid Overdose
RED FLAGS for Opioid Overdose • • • Co-prescribed naloxone with opioid Rx Daily opioid dose ≥ 100 MME – 11 -fold increased risk Long-acting/extended release opioid – 2 -fold increased Substance use disorder diagnosis at any time – 3. 5 -fold increased risk Current significant mental health diagnosis – 3. 4 -fold increased risk Getting opioids from ≥ 4 providers – 6. 5 -fold increased risk Filling opioid scripts at ≥ 4 pharmacies – 6 -fold increased risk Also taking gabapentin – 50% increased risk Using long-acting opioids on an extended basis Current chronic pain disorder treated with antipsychotic or mood stabilizer Current use of benzodiazepine while also taking opioids Taking opioids to get “high”
Opioids and Mortality
“Across North America, the devastating crisis of prescription opioid-related addiction and overdose has led to escalating mortality rates that have surpassed national mortality rates due to motor vehicle accidents and HIV-related mortality” Pauline Voon, MD University of British Columbia Substance Abuse Treatment, Prevention and Policy 12(2017): 36
Leading Causes of Death Changes in Mortality Rate/100, 000 (2000 -2015) Heart Disease - 89. 1 Cancer - 41. 1 COPD - 2. 5 Unintentional + 8. 3* Stroke - 23. 3 * Drug poisoning deaths increased 3 -fold over this interval Dowell. Journal of the American Medical Association. 318(2017): 1065[letter]
Opioids & Suicide • Risk increased in chronic prescription opioid if there is any suicidality component history = prior ideation, planning, gesture or attempt • Suicide rate with OUD is 6 times higher than in the general population
HEADS UP for Claims Managers! A substantial share of opioid OD deaths that are actually suicides are being adjudicated as “cause undetermined. ” Claims managers should read this paper (available free online): Ian R. H. Rockett “Discerning Suicides in Drug Intoxication Deaths…” PLo. S One 13(2018): e 0190200
Pain and Opioid Deaths Among 13, 089 opioid-related decedents, 61. 5% were diagnosed with a chronic pain condition within 12 months prior to death. This included 59. 3% with back pain, 24. 5% with headaches and 6. 9% with neuropathies. Virtually all (99. 6%) were also diagnosed with additional comorbid bodily pain conditions
Classic RED FLAG Pain History for Opioid OD death ≥ age 40 with chronic moderate-severe unremitting multisite pain, perceived by patient as increasingly unresponsive to higher dose and/or long-acting opioids …plus 1 or more of the following: Current longtime (30+ pack-year) and/or heavy (≥ 15/day) smoker, Current heavy drinker or ex-drinker with reason for quitting not known Unexplained isolated GGT or MCV elevation History DWI or equivalent within last 10 years Diagnosis of other substance abuse including alcohol use disorder at any time Frequent/long-term or heavy benzodiazepine or “Z” drug) Current, recent or longstanding history of a major psychiatric disorder.
Drug Use Mortality Hazard Ratio (m. HR) Swedish General Population Registry Study m. HR Opioids 24. 57 Sedatives 14. 19 Cocaine/stimulants 12. 01 Kendler. Social Psychiatry and Psychiatry Epidemiology. 52(2017): 877
Long-acting Opioids Mortality in Non-Cancer Pain 22, 912 community-dwelling patients prescribed long-act opioids for non-cancer pain matched to controls taking anticonvulsants for chronic pain or low-dose tricyclic antidepressants (not general population controls!) Mortality Hazard Ratio All opioid users 1. 64 Opioids prescribed ≤ 30 days 4. 16 31 -180 days 1. 56 > 180 days 1. 03 Ray. Journal of the American Medical Association. 315(2016): 2415
Mortality 1 -year post-nonfatal OD • • • SMR all-cause mortality 24. 2 26% of deaths due to substance abuse SMR suicide mortality 25. 9 SMR viral hepatitis mortality 30. 6 SMR chronic respiratory disease mortality 41. 1 Anybody want to issue coverage within 12 months of surviving on opioid OD? Olfson. JAMA Psychiatry. 75(2018): 820
Epilogue Let’s not toss out the baby with the bathwater! The substantial majority of applicants prescribed an opioid on a short-term basis do not pose significant mortality or morbidity risks. We are obligated to use the available criteria to identify the higher risk cases or we will throw away good business while incurring the wrath of producers, clients, and their physicians!
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