According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 4.3 million Americans engage in non-medical use of prescription opioids each month. Approximately 1.9 million Americans meet criteria for prescription opioid use disorder based on their use of these painkillers over the past year. SAMHSA also estimates that 1.4 million people in the United States used prescription opioids for non-medical reasons for the first time in the past year. In addition, more than 700,000 opioid-related hospitalizations occur in the U.S. each year, creating a significant burden for the healthcare system.
National guidelines recommend that patients who are hospitalized due to opioid-related use receive care that will promote recovery and reduce future risks of opioid misuse or abuse, hospital readmissions, and death. “The FDA has approved three medications to treat opioid dependence: methadone, naltrexone, and buprenorphine,” explains Mir M. Ali, PhD. “These medications can help reduce illicit opioid use, decrease cravings, provide relief from opioid-withdrawal symptoms, and increase treatment adherence. These therapies should be initiated along with screening, brief intervention, and referral to treatment to improve post-discharge outcomes for patients.”
The growing problem of opioid abuse in the U.S. has been well documented, but data are lacking to quantify patterns of post-discharge prescription fills following an opioid-related hospitalization, according to Dr. Ali. Data on the impact of these prescription fills on the hospital system and on healthcare costs are also needed.
For a study published in Psychiatric Services, Dr. Ali and colleagues at SAMHSA studied prescription data on more than 36,000 adults (aged 18 to 64) who had been hospitalized for opioid abuse, dependence, or overdose between 2010 and 2014. “The study sample was privately insured,” notes Dr. Ali. The research team used 2010–2014 MarketScan Commercial Claims and Encounters database and looked at prescriptions filled in the 30 days following discharge for any of the three FDA-approved medications for opioid dependence as well as four other classes of medications: antidepressants, antipsychotics, benzodiazepines, and opioids.
According to the results, 35% of the study sample did not have any prescription fills in the 30-day post-discharge period (Figure). “Alarmingly, only about 17% of patients received any FDA-approved opioid dependence medication in the 30 days after discharge,” Dr. Ali says. Of the other medications assessed in the study, antidepressants were the most commonly filled prescription (about 40%). Antipsychotic prescriptions were filled by only about 16% of patients and benzodiazepines were filled by approximately 14% of patients.
“Importantly, nearly one-quarter of patients in the study filled a prescription for opioids in the 30 days following hospital discharge,” says Dr. Ali. “It’s possible that physicians may not have known about the patients’ hospitalization and continued prescribing the opioids in these cases. In addition, more than 7% of patients in the study sample filled prescriptions for both a benzodiazepine and an opioid medication. The combination of these two drug classes is not recommended because they can increase risks of serious and life-threatening problems.”
Recently, the American Psychiatric Association joined an American Medical Association-led task force aimed at curbing the opioid epidemic. The task force has endorsed the use of state-based prescription drug monitoring programs (PDMPs) to help physicians in their decision-making process when considering treatment options. “PDMPs can make a significant difference in reducing the burden of the opioid epidemic because red flags will be raised if opioid dependence is a possibility,” Dr. Ali says. “However, each state has different variations within their PDMPs, making it challenging for clinicians to know which patients are at risk.”
According to Dr. Ali, greater efforts are needed to ensure that patients who are hospitalized for opioid misuse are receiving recommended services, including approved medication and therapeutic services. “The opioid epidemic continues to grow throughout the country,” he says. “Physicians need to collaborate with other healthcare providers and use this data to inform the development of targeted efforts to prevent, intervene, and treat patients with opioid use disorders.”
The extent to which opioids are prescribed at hospital discharge, variation in prescribing across hospitals, and patient and hospital factors associated with opioid prescribing are still unknown in the U.S., meaning that more research is required. In addition, U.S. hospitals are being measured and financially incentivized on patient perceptions of the quality of pain care during hospitalizations. “Our findings are important to helping us understand the magnitude of the problem of opioid dependence and to developing interventions to improve patient safety,” says Dr. Ali. “This is a significant issue that won’t go away unless concerted efforts are made to address the problem directly.”
Readings & Resources (click to view)
Naeger S, Ali MM, Mutter R, Mark TL, Hughey L. Prescriptions filled following an opioid-related hospitalization. Psych Serv. 2016 Jun 1 [Epub ahead of print]. Available at: http://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.201500538.
Webster LR. Chronic pain and the opioid conundrum. Anesthesiol Clin. 2016;34:341-355.
Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65:1-49. Available at: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm.