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Medical Costs Triple for High-Risk Opioid Users

Rate of high-risk use low among commercially insured

People 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 benefits manager Prime Therapeutics.

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, Prime reviewed opioid claims from more than 9 million commercially insured members. The research found nearly 1.2 million (13.1%) had at least one opioid claim. While 11,518 (0.13%) met the MED threshold, just 225 (0.0025%) met all three CMS high-risk criteria. The number of commercially insured members considered high risk for prescription opioid abuse was one-fifth of the rate among Medicare Part D members.

Those meeting all three criteria did not have significantly different pharmacy costs. Prime’s study excluded members being treated for cancer, as CMS does.

The average age for members meeting all criteria was 43. Back, neck, and abdominal pain and arthritis pain were among the most common pain diagnoses in this group. Anxiety, bipolar disorder, and depression were more common than in the group that just met the MED criteria.

“Nationally, as many as 2 million people a year use opioids for nonmedical purposes, and identifying high-risk indicators can help prevent abuse and misuse of these medications,” said Pat Gleason, PharmD, BCPS, FCCP, Director of Health Outcomes for Prime.

Prime manages pharmacy benefits for health plans, employers, and government programs, including Medicare and Medicaid. It is collectively owned by 13 Blue Cross and Blue Shield plans, subsidiaries, or affiliates of those plans.

Prime will present the findings at the Academy of Managed Care Pharmacy’s 26th Annual Meeting & Expo in Tampa, Florida.

Source: Prime Therapeutics; April 1, 2014.

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