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SURPRISING TRUTHS ABOUT OPIOID MISUSE Correlating Laboratory and Pharmacy Data to Identify and Monitor High-Risk Patients Richard Stripp, Ph.D. cordantsolutions.com A Provider of Toxicology and Case Management Solutions Abstract Although nationally an estimated 55–86% of all those reviewed are receiving opioids for chronic pain relief,1 many physicians receive only limited and fragmented education on how to treat it,2 leading to the over-prescription of medication. There are three primary options for identifying potentially high-risk patients: • Toxicology drug testing • State-run prescription databases • Physicians’ clinical judgment Cordant conducted a study to determine the efficacy of combining pharmacy and laboratory data to identify high-risk opioid users. In April through June 2014, Cordant conducted 257 toxicology screens on 237 injured subjects across 48 states. Test subjects were selected from the pool of patients meeting key risk identifiers from prescription data. 70.9% of those tested in the study produced results inconsistent with the prescribed medication regimen. Of those tested, 45.6% were deemed high-risk. Only 36% of pain patients tested at random, without using prescription data, showed inconsistent results. High-risk patients exhibited one or more of the following inconsistent outcomes: • Prescribed medication not detected • Illicit drugs or alcohol detected • Non-reported prescription medication detected • An invalid or diluted specimen The study concluded that combining pharmacy and laboratory data to predict risk is highly effective and mitigates the common problem of overtesting. Of patients who had initial inconsistent tests and were tested more than once, 33.3% improved with the second test. This suggests drug testing can help enforce proper medication adherence. For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions. The Problem: Isolated Pharmacy and Laboratory Databases Tens of millions of urine drug tests are performed annually in the United States,3 but when and if drug tests are performed often depends on whether a physician believes a patient needs testing. However, most healthcare providers are not skilled at identifying high-risk patients on their own.4 Consequently, physicians sometimes test every patient at every visit, even when initial test results have been consistent with the prescribed drug regimen. This is medically unnecessary and wastes millions of dollars due to needless testing. Pilot programs that involve integration of siloed data have shown much promise. For instance, a study of medical providers in Ohio emergency departments found that 41% of those given data from the state’s prescription drug monitoring program (PDMP) altered their prescribing for those receiving multiple simultaneous narcotics prescriptions. Of these providers, 61% prescribed no narcotics or fewer narcotics than originally planned. PDMP databases allow prescribers and pharmacists to access prescription data in order to prevent doctor shopping and abuse, and they are the definitive source of information for controlled substances that are filled through insurance or paid in cash outside of insurance. Unfortunately, payers such as health plans, pharmacy benefit managers, and workers’ compensation carriers often have difficulty accessing this data. Using lab and pharmacy data together is key—evaluating each data set individually does not provide a complete picture. Pharmacy data indicates what drugs are dispensed but not necessarily taken as prescribed, and reveals nothing about illicit drug use. Although some states and literature provide testing frequency recommendations, there are no uniform laboratory guidelines for appropriate testing, which leads to unnecessary testing. A Solution for Determining Risk Levels Cordant recently completed a study determining the efficacy of combining pharmacy and laboratory data to identify high-risk opioid users. Scope In April through June 2014, Cordant conducted 257 toxicology screens on 237 patients across 48 states. Test subjects were selected from the pool of those meeting key risk identifiers. Process Cordant applied the following parameters to the study group using the payers’ prescription data to identify potential risk: • Prescribed a high-medication dosage • Filled one or more initial opioid prescriptions • On the prescribed opioid for more than two months Once patients were identified as potentially high-risk, samples were collected at the doctor’s office during their next visit and sent to one of Cordant’s five laboratories for evaluation. Results were reported to the payer and the physician. For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions. Results 70.9% of patients tested in the study produced inconsistent results. An inconsistent result is due to either of these circumstances: • The prescribed drug is not detected. This often signals that the patient is not taking the medication as prescribed, and necessitates a conversation between the prescribing physician and the patient to understand if the patient is taking the medication on an as-needed basis, whether there is a metabolic issue, or if there is a potential diversion concern. • Non-disclosed medications or other drugs are detected in the sample. This could mean the patient is ingesting illicit substances or non-prescribed medications, or receiving controlled substances from another provider. INCONSISTENT RESULTS CONSISTENT 29.2% INCONSISTENT 70.8% NON-REPORTED PRESCRIPTION MED DETECTED 32.4% REPORTED PRESCRIPTION MED NOT DETECTED 41.75% ILLICIT DRUGS 7.4% ALCOHOL 13.9% INVALID SAMPLE 4.6% Of patients tested, 45.6% were deemed high-risk due to meeting one or more of the following criteria: • Not taking their prescribed medication PERCENTAGE OF PATIENTS IN EACH RISK CATEGORY • Mixing their medication with an illicit drug or alcohol • Exhibiting other aberrant results or behavior Patients were deemed medium-risk if non-reported prescription medications were detected, and low-risk if tests showed the expected results. LOW RISK 29.1% Toxicology testing revealed high degrees of inconsistent test results among the tested patients who fit the parameters outlined above: • Prescribed a high-medication dosage: 70.9% inconsistent test results. • Filled the initial opioid prescription: 100% inconsistent test results. • On the prescribed opioid for more than two months: 73.8% inconsistent test results. (Patients in this group were often prescribed higher doses and for a longer duration than patients in other groups.) For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions. MEDIUM RISK 25.3% HIGH RISK 45.6% Conclusion Combining pharmacy and laboratory data is extremely effective in identifying high-risk opioid users. Getting the right medication to the patient at the right time, in the right dose, and with the right monitoring requires a combination of care coordination, lab and prescription data integration, and clinical expertise. An effective solution, like the one offered by Cordant, is based on several key concepts: • Integrating data and clinical algorithms to identify at-risk patients and help providers determine the correct care plan • Providing physician education on effective opioid-monitoring protocols • Helping physicians understand the patient’s risk of abuse and diversion • Using targeted testing to reduce overutilization and increase efficiency of drug testing • Providing lab reports with insights and evidence-based guidelines, not just data Cordant is a national toxicology network offering comprehensive medication monitoring solutions focused on improving patients’ safety and compliance with their prescription treatment plan to improve outcomes and reduce fraud, abuse and waste. For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions. About Dr. Richard Stripp Dr. Richard Stripp currently serves as the chief scientific and technical officer at Cordant Health Solutions™, providing leadership to Cordant’s five toxicology laboratories across the country. He is also a professor of forensic and clinical toxicology at the City University of New York. Dr. Stripp is a member of many toxicology organizations, including the American Academy of Clinical Toxicology, and is a certified forensic consultant for the American Board of Forensic Examiners. Prior to joining Cordant in 2012, Dr. Stripp served as the CEO and laboratory director of American Forensic Toxicology Services (AFTS) in Long Island, NY. He earned his Ph.D. in pharmacology and toxicology from St. John’s University’s College of Pharmacy and Allied Health Professions. For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions. Endnotes 1Rosenblum, KE. (2012). “Opioids Wreak Havoc on Workers’ Compensation Costs.” Lockton Companies. http://www.lockton.com/Resource_/PageResource/MKT/wc-pbm10-9-2012.pdf. 2Mezei, L., BB Murinson, and Johns Hopkins Pain Curriculum Development Team (2011). “Pain Education in North American Medical Schools,” J Pain 12, vol. 12 (Dec.): 1199–1208. doi: 10.1016/j. jpain.2011.06.006. Epub Sept. 25, 2011. 3Lum, G. and B. Mushlin. (2004). “Urine Drug Testing: Approaches to Confirmation Screening and Urine Drug Testing.” Laboratory Medicine 6, vol. 35 (June). DOI: 10.1309/QHJCKA4235EGPEGF. 4Jung B. and MM Reidenberg. (2007). “Physicians Being Deceived.” Pain Med. 8, no. 5 (July–August): 433-7. For more information, visit www.cordantsolutions.com, email [email protected], or call 1-844-835-5870 ©2015 Cordant Health Solutions™. All Rights Reserved. Do not duplicate or distribute without written permission from Cordant Health Solutions.