Comorbidities, Medication Use, and Overdose: A Snapshot of Medicare - - PowerPoint PPT Presentation

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Comorbidities, Medication Use, and Overdose: A Snapshot of Medicare - - PowerPoint PPT Presentation

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Comorbidities, Medication Use, and Overdose: A Snapshot of Medicare Beneficiaries with Substance Use Disorders Aida Kuzucan PharmD, Bilal Khokhar, PhD, Linda Simoni-Wastila BSPharm, MSPH, PhD AcademyHealth (Behavioral Health Services Interest

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Comorbidities, Medication Use, and Overdose: A Snapshot of Medicare Beneficiaries with Substance Use Disorders

Aida Kuzucan PharmD, Bilal Khokhar, PhD, Linda Simoni-Wastila BSPharm, MSPH, PhD AcademyHealth (Behavioral Health Services Interest Group) Characterizing and Combatting the Opioid Epidemic Session June 24, 2017

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Acknowledgments

  • Coauthors

− Dr. Khokar, Research Scientist at General Dynamics − Dr. Simoni-Wastila, Professor at University of Maryland School of Pharmacy and Director of Research for the Peter Lamy Center on Drug Therapy and Aging

  • The Pharmaceutical Research Computing (PRC) center in the Department of

Pharmaceutical Health Services Research at the University of Maryland

  • No funding source
  • No COI to report

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Outline

  • Introduction
  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Future Research

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The Opioid Epidemic in Medicare (I)

  • Despite attention paid to opioid overdose in US, Medicare population largely ignored
  • Growth in opioid use fastest among Medicare beneficiaries

– From 1995-2010:1

  • 14-fold increase in total Medicare population and
  • 9-fold increase in over 65 year olds

– From 2007-2012: Use of ≥90 days of C-II and C-III opioids nearly doubled2

  • Concomitant use also a concern

– From 2004-2013: 53.2% of polypharmacy encounters among older adults involved an opioid and a benzodiazepine3 – From 2015: 27.9% of Part D enrollees of opioid users were concurrently using sedative-hypnotics (SDH)4

  • Mental illness and pain disorders are associated with increased risk of opioid-

related overdose 5,6

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The Opioid Epidemic in Medicare (II)

  • Remaining questions concerning Medicare beneficiaries

– Characteristics associated with SUD? – Outcomes other than fatal overdose (OD)?

  • Reasons for scant research:

– Aged and disabled historically neglected – Stigma of SUD and mental illness – Limitations in administrative claims data

  • SAMHSA redaction of SUD diagnoses

– Bias studies – Prohibit studies of SUD population – This study derives from one examining COPD and depression in Medicare beneficiaries using 2006-2009 unredacted CCW data

  • Observed high prevalence of SUD and opioid use

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Future Research

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Objectives of this Exploratory Study

  • Better understand of Medicare beneficiaries with SUD

by looking at patterns of – Mental illness – Pain syndromes – Opioid and SDH use

  • To see if this information matters when looking at opioid
  • verdose hospitalizations

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Methods: Study Design and Population

  • Cross Sectional Design

– 2008-2009 CCW data

  • Substance abuse diagnoses were not redacted

– Population

  • Inclusion Criteria

– Continuous Medicare parts A, B, and D coverage from January 1, 2008 - December 31, 2009 or until death in 2009.

  • Exclusion Criteria

– Individuals with a hospice start date in or before 2009

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Methods: Defining SUD, Mental Illness, and Pain

SUD (Inpatient and Outpatient ICD-9-CM Codes) “Dependent” and “Non-dependent Abuse”

  • General Abuse
  • Opioids
  • Sedative-hypnotics
  • Stimulants (excluding cocaine)
  • Alcohol
  • Illicit Substances

Overdose (Inpatient ICD-9-CM codes)

  • “Poisoning by opiates”
  • “Accidental poisoning by opiates”
  • “Adverse effects in therapeutic use with
  • piates”

Pain Disorders6

  • Joint pain
  • Back pain
  • Head pain
  • Neck pain
  • Chronic pain

Mental Illness8

  • ADHD
  • Anxiety
  • Bipolar
  • Depression and other depressive disorders
  • Personality
  • PTSD
  • Schizophrenia and other psychotic

disorders

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Methods: Additional Variables of Interest

  • Opioid Exposures*

– Opioid

  • Opioid full and partial agonist (e.g., oxycodone, buprenorphine)

– Anxiolytics, Sedatives and Hypnotics (SDH)

  • Barbiturates (i.e., amobarbital, butabarbital)
  • Benzodiazepines (i.e., Alprazolam, clonazepam)

– Benzodiazepines excluded from Part D Coverage from 2006-2009

  • Hypnotics (i.e., Propofol, zaleplon)
  • Comorbidities8

– Alzheimers and related dementias, Cancer, Cardiovascular diseases (CVD), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disorder (COPD), Diabetes, Rheumatoid/Osteoarthritis, Osteoporosis, and Human immunodeficiency virus (HIV)

  • Sociodemographic Characteristics
  • Age, gender, race, state of residence, original reason for Medicare

entitlement

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* Drug classifications from American Hospital formulary Service (AHFS) Drug Information 2017 Edition

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Future Research

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Results: Characteristics of Medicare Beneficiaries With and Without SUD (I)

Characteristic With Any SUD, N(%) N=24,058 Without Any SUD, N(%) N=1,214,336 X2 p-value Male Gender 1,4581 (60.6) 437,132 (36.0) <0.0001 Race White Black Other/Missing 17,467 (72.6) 5,064 (21.1) 1,527 (6.4) 993,619 (81.8) 130,180 (10.7) 90,537 (7.5) <0.0001 Original Reason for Entitlement Age Disability and/or ESRD 5,451 (22.7) 18,607 (77.3) 904,754 (74.5) 309,582 (25.5) <0.0001 Age >=64 65-74 75-84 85+ 17,157 (71.3) 4,659 (19.4) 1,865 (7.8) 377 (1.6) 218,066 (29.9) 499,827 (41.2) 363,043 (29.9) 133,398 (11.0) <0.0001

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Results: Characteristics of Medicare Beneficiaries With and Without SUD (II)

Characteristic With Any SUD, N(%) N=24,058 Without Any SUD, N(%) N=1,214,336 X2 p-value CVD* 15,518 (64.5) 435,108 (35.8) <0.0001 COPD 6,307 (26.2) 78,380 (6.5) <0.0001 Diabetes 5,278 (21.9) 153,227 (12.6) <0.0001 CKD 3,743 (15.6) 81,847 (6.7) <0.0001 RA or OA† 2,837 (11.8) 70,889 (5.8) <0.0001 Liver Disorders 2,800 (11.5) 10,150 (0.8) <0.0001 Alzheimer's and Related Dementias 1,727 (7.2) 58,415 (4.8) <0.0001 Cancer 1,157 (4.8) 37,716 (3.1) <0.0001 Osteoporosis 1,068 (4.4) 43,356 (3.7) <0.0001 HIV 756 (3.1) 2,642 (0.2) <0.0001

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*Includes acute myocardial infarction, heart failure, hyperlipidemia, hypertension, heart disease, and stroke

†Rheumatoid arthritis and osteoarthritis

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Future Research

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13.4 8.3 7.7 2.5 3.1 11.3 6.7 7.5 2.8 2.6 8.6 7.3 5.9 2.1 2.4 18.9 12.3 10.0 3.4 3.5 Any SUD Alcohol SUD Drug SUD Drug and Alcohol SUD Opioid SUD Pain Mental Illness Pain and Mental Illness Prevalence

Results: SUD, Pain, and Mental Illness Diagnoses (Rates per 1,000 Beneficiaries: 2008-2009

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Results: Mental Illness and Non-Cancer Chronic Pain Among Medicare Beneficiaries With and Without SUD

Characteristic With Any SUD N(%) Without Any SUD N(%) X2 p-value* Any Mental Illnesses Depressive disorders Bipolar Anxiety Psychotic Disorders Personality Disorders ADHD PTSD 14,411 (59.9) 11,084 (46.1) 5,302 (22.0) 5,470 (22.7) 4,376 (18.2) 2,018 (8.4) 683 (2.8) 1,111 (4.62) 115,455(9.5) 84,060 (6.9) 12,509 (1.0) 31,390 (2.6) 19,167 (1.6) 2,024 (0.2) 2,168 (0.2) 1,436 (0.1) <0.0001 Pain Conditions Joint pain Back pain Chronic pain Neck pain Head pain 17,115 (71.1) 14,461 (60.1) 6,312 (38.7) 5,350 (22.2) 3,863 (16.1) 1,617 (6.7) 412,797 (34.0) 372,926 (30.7) 144,770 (11.9) 23.865 (2.0) 48,842 (4.0) 10,313 (0.9) <0.0001

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*Chi-square tests for differences in proportions were done for all pain and mental diagnoses. All p<0.0001.

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Future Research

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Results: Opioid Use and Opioid OD Hospitalization Among Medicare Beneficiaries with and without SUD

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48.9 73.1 67.6 80.5 91.2 74.9 0.1 2.3 1.4 3.9 7.9 3.1 1 2 3 4 5 6 7 8 9 10 20 30 40 50 60 70 80 90 100 No SUD Any SUD Alcohol SUD Drug SUD Opioid SUD Drug and Alcohol SUD Opioids Opioid Overdose

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Further Research

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Subset Analysis: Characteristics prior to Opioid Overdose Hospitalization – We conducted a subset analysis among individuals with a 2009

  • pioid OD hospitalization
  • Total: 1,225 individuals
  • Retrospective Assessment: 12 months prior to the overdose

to examine SUD/mental illness/pain diagnoses and opioid use

  • Overdose includes fatal and non-fatal events
  • Same criteria from primary analysis

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No Abuse, 84.8% Drug SUD, 9.7% Alcohol SUD, 2.0% Drug and Alcohol SUD, 3.4%

Results: Prior SUD Diagnoses, Opioid use, and Opioid OD Hospitalizations Among Medicare Beneficiaries With Opioid OD Hospitalization in 2009 (N=1,225)

With Any SUD, N=186 N (%) Without Any SUD, N=1,039 N (%) Prior Opioid Rx* 175 (94.1) 860 (82.8) Prior Opioid OD* 27 (14.5) 20 (1.9)

*Chi-square tests for differences in proportions were done. All

p<0.0001.

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44.6% 6.5% 58.1% 12.9% 21.0% 36.0% 54.8% 45.2% General/Not Specified Stimulant Opioid Sedative Illicit Alcohol Only 1 SUD More than 1 SUD

69.9% had both a Mental Illness and Pain Disorder Diagnosis

Results: Among Medicare Beneficiaries with a SUD Diagnosis Prior to Opioid OD in 2009 (N=186)

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Outline

  • Objective and Methods
  • Results

– Characteristics and Comorbidities – Pain and Mental Illness – Opioid Use and Opioid Overdose Hospitalizations – Subset Analysis

  • Discussion and Further Research

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Discussion

  • We provided estimates of a national sample of Medicare beneficiaries with SUD

regarding mental illness, pain syndromes, opioid use, and opioid-related hospitalizations – Used 2008-2009 data that was not redacted

  • SUD is a prevalent problem in the Medicare population

– Mental illness and pain disorders highly correlated with both SUD and opioid

  • verdose hospitalizations

– Other chronic conditions, such as COPD, are also more common

  • Some limitations:

– Cross-sectional – Inaccurate or under coded SUD

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Future Research

  • SUD claims are now available for Medicare and Medicaid data

– Ability to research this problem in a more current sample

  • Next steps:

– Longitudinal cohort to assess direction of associations between substance abuse diagnosis, mental illness, pain diagnosis, overdose, and opioid and benzodiazepine use – Differentiate patterns by original reason for Medicare eligibility – Inclusion of benzodiazepines

  • coverage under Medicare part D effective 1/2013

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References

1. Olfson, M., Wang, S., Iza, M., Crystal, S., & Blanco, C. (2013). National Trends in the Office-Based Prescription of Schedule II Opioids. Journal Of Clinical Psychiatry, 74(9), 932-939. Sullivan, M. D., Edlund, M. J., Fan, M. Y., DeVries, A., Braden, J. B., & Martin, B. C. (2008). Trends in use of opioids for non-cancer pain conditions 2000–2005 in commercial and Medicaid insurance plans: the TROUP study. Pain, 138(2), 440-449. 2. Kuo, Y., Raji, M. A., Chen, N., Hasan, H., & Goodwin, J. S. (2016). Trends in Opioid Prescriptions Among Part D Medicare Recipients From 2007 to 2012. The American Journal Of Medicine, 129(2), 221.e21-30. doi:10.1016/j.amjmed.2015.10.002 3. Gerlach, L. B., Olfson, M., Kales, H. C., & Maust, D. T. (2017). Opioids and Other Central Nervous System–Active Polypharmacy in Older Adults in the United States. Journal of the American Geriatrics Society. 4.

  • CMMS. Concurrent Use of Opioids and Benzodiazipine in a Medicare Part D Population. 2017 announcement available

at: https://www.cms.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Downloads/Concurrent-Use-

  • f-Opioids-and-Benzodiazepines-in-a-Medicare-Part-D-Population-CY-2015.pdf

5. Webster, L. R., Cochella, S., Dasgupta, N., Fakata, K. L., Fine, P. G., Fishman, S. M., ... & Peppin, J. (2011). An analysis

  • f the root causes for opioid‐related overdose deaths in the United States. Pain Medicine, 12(s2), S26-S35.

6. Toblin, R. L., Paulozzi, L. J., Logan, J. E., Hall, A. J., & Kaplan, J. A. (2010). Mental illness and psychotropic drug use among prescription drug overdose deaths: a medical examiner chart review. Journal of Clinical Psychiatry, 71(4), 491. 7. Sullivan, M. D., Edlund, M. J., Fan, M. Y., DeVries, A., Braden, J. B., & Martin, B. C. (2008). Trends in use of opioids for non-cancer pain conditions 2000–2005 in commercial and Medicaid insurance plans: the TROUP study. Pain, 138(2), 440-449. 8. Chronic Conditions Warehouse. Condition Categories. https://www.ccwdata.org/web/guest/condition-categories

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Thank You Contact information: Aida Kuzucan, PharmD akuzucan@umaryland.edu Linda Simoni-Wastila, BSPharm, MSPH, PhD lsimoniw@rx.umaryland.edu

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