Download Premier Research on Opioid Use and Misuse

Premier Research on Opioid Use and Misuse
May 2017
Premier, Inc. works alongside health systems and providers nationwide to improve the health of communities. As
an alliance of more than 3,750 hospitals, hundreds of thousands of clinicians, and 130,000 other sites of care,
Premier focuses on improving population health through the promotion of collaborative learning opportunities,
identification of clinical best practices, and systematic use of data and analytics.
With a large, geographically-diverse provider network, nationwide data, and significant research and clinical
expertise, Premier, Inc. is uniquely positioned to answer important questions on strategies aimed at curbing the
growing opioid epidemic in the United States.
The peer reviewed publications on opioid use reviewed here are based on research conducted with the Premier
Health Database (PHD) that includes 40% of all hospitalizations in the US and information on over 20 million annual
emergency department visits. PHD permits nationwide estimates and also facilitates detailed analytics and insights
based on billing, prescription, provider and clinical records. For example, a recent analysis of PHD data found that
opioid prescriptions were present in 19% of all emergency department visits and 56% of all non-surgical inpatient
admissions.
The published opioid research covered in this review has provided critical detail on opioid use and misuse in a
variety of settings and the resulting impact on opioid-related adverse events, length of stay, and hospitalization
costs for a range of patient populations.
Emergency Department
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In a Premier study of over 9,000 patients presenting to the emergency department (ED) with chronic pain
and a supply of opioids of 60 days or more, 92% of cases were found to have suboptimal opioid
prescribing practices [on medications known to interfere with opioid metabolism- a drug-drug interaction
(DDE)]. One third of the patients with suboptimal prescribing that relied solely on short-acting opioids
were more likely to be seen in the ED a second time- the majority within 72 hours. These patients had
higher average costs of up to $1500 resulting from increases in visits to physician office, outpatient, or ED
and inpatient hospitalizations. (Ernst 2015)
Emergency Department - Implications
Sub-optimal response to opioids –a drug-drug-interaction. It is known that certain drugs (e.g. fluconazole,
diltiazem, clarithromycin, and verapamil) have the potential to inhibit the action of specific short acting opioids (e.g.
oxycodone, fentanyl, methadone, and codeine) when both drugs share the same CYP450 metabolic pathway causing
a drug-drug interaction (DDA) and sub-optimal response to opioids. (Pergolizzi 2014) The FDA now requires
information regarding a drug’s CYP-450 metabolism and its potential for inhibition or induction to be on the drug
label (FDA 2016).
ED providers have opportunities to identify and correct sub-optimal opioid prescribing practices. To improve
patient care and reduce costs, ED providers should be made aware of the concurrent medications a patient is taking
prior to writing a new opioid prescription. In cases where CYP450 precipitant drugs are being taken, physicians may
consider using a multimodal pain treatment approach that incorporates both pharmacological and
nonpharmacological treatments. Based on current guidelines, physicians should also reevaluate patients to
determine whether opioid treatment is necessary.
Clinical alerts in electronic records/systems can reduce the risks associated with these medication errors
(Theradoc).
Pediatrics
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Through an in-depth analysis of pediatric hospitalizations, Premier research found that morphine and
fentanyl were among the top ten medications prescribed to children in the inpatient setting, even though
neither opioid is labeled for pediatric use (Lasky 2011).
In an analysis of opioid utilization across 423 hospitals, Premier research also found that morphine was
administered in approximately 6.2 % of all pediatric hospitalizations. (Lasky 2012).
Pediatrics – Implications
Information about pediatric medication use is critical because of the high level of off-label prescribing with pediatric
patients. Reliable data can inform guideline development, labeling practices, and support efforts to study efficacy
and safety.
Non-Surgical Inpatient Care
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Prescribing practices were examined using Premier data for over 1.1 million patients with non-surgical
admissions to 286 hospitals. This analysis found that opioids were prescribed in over half (51%) of cases
and 52% of patients with an opioid prescription (26% of overall admissions) had charges for opioids on the
day of discharge – indicating a take-home opioid prescription. In addition, patients with daily morphineequivalent dose of 100mg or higher had an increased risk of overdose nearly 9 times that of patients with
doses equivalent to 20mg or less (Herzig 2014).
Post-Surgical Inpatient Care
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Premier data was utilized to examine the impact of opioid-related adverse events (ORADE) following
surgical procedures known to require post-op pain control. The study included more than 300,000 patient
procedures and found that 12% of patients on opioids experienced ORADE complications – including
respiratory, gastrointestinal, central nervous system or other problems. Patient with ORADE had higher
overall costs, longer length of stays, and increased likelihood of readmission (Oderda 2013).
An analysis of Premier data from more than 138,000 gastrointestinal surgeries found that the use of
opioids in patients who develop ileus following abdominal surgeries was associated with prolonged
hospitalization, greater costs, and increased readmissions. In addition, higher doses of opioids were also
associated with a greater incidence of post-op ileus (Gan 2015).
Inpatient Care- Implications
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Hospitals should provide educational resources to all levels of staff regarding pain management
and the safe use of opioids. The CDC guidelines for prescribing opioids, 2016 represents one
source of guidance on opioid prescribing, with information on monitoring the safe use of opioids,
including tracking adverse events, indications, dosing, tapering and duration of use following
discharge.
Hospitals should work to assist prescribers and pharmacists with access to Prescription Drug
Monitoring Programs (PDMP) to include incorporation of inpatient and discharge opioid
prescribing information in PDMP records.
Premier references
Ernst FR, Opioid Medication Practices Observed in Chronic Pain Patients Presenting for All-Causes to Emergency
Departments: Prevalence and Impact on Health Care Outcomes. Journal of Managed Care & Specialty Pharmacy,
2015. https://www.ncbi.nlm.nih.gov/pubmed/26402391
Lasky T, Estimating pediatric inpatient medication use in the United States. Pharmacoepidemiology and Drug
Safety, 2011. https://www.ncbi.nlm.nih.gov/pubmed/21182155
Lasky T, Morphine Use in Hospitalized Children in the United States: A Descriptive Analysis of Data from Pediatric
Hospitalizations in 2008. Clinical Therapeutics, 2012. https://www.ncbi.nlm.nih.gov/pubmed/22381715
Herzig, SJ, Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals. Journal of
Hospital Medicine, 2014. https://www.ncbi.nlm.nih.gov/pubmed/24227700
Oderda GM, Effect of Opioid-Related Adverse Events on Outcomes in Selected Surgical Patients. Journal of Pain
and Palliative Care Pharmacotherapy, 2013. https://www.ncbi.nlm.nih.gov/pubmed/23302094
Gan TJ, Impact of postsurgical opioid use and ileus on economic outcomes in gastrointestinal surgeries. Current
Medical Research & Opinion, 2015. https://www.ncbi.nlm.nih.gov/pubmed/25586296