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    Prescribing practices that increase risk of opioid overdose


     Prime Therapeutics study

    During 2015, Prime Therapeutics studied pharmacy claims data from approximately 19 million commercial members aged 18 years or older. They analyzed those members with two or more opioid claims filled on two or more separate days with a 15 days supply or more (buprenorphine/naloxone combination products were excluded while opioid containing cough/cold products were included). Members were also required to have two or more benzodiazepine claims on two or more separate days.

    Buprenorphine/naloxone combination products were excluded and opioid containing cough/cold products were included. Members were also required to have two or more benzodiazepine claims on two or more separate days.

    Concurrent use of opioids and benzodiazepine was defined as 30 or more cumulative days of overlap based on days supply found on the claims. Using medical claims data, concurrent use was also examined after excluding members with one or more medical claims with a cancer diagnosis code in 2015.


    Prime found 17% of commercially insured adult opioid utilizers without cancer used opioids and benzodiazepines concurrently for 30 days or more. The rate of concurrent opioid and benzodiazepine was alarmingly high at 0.9%, or 1 per 100 members, according to Cathy Starner, PharmD, principal health outcomes researcher, Prime.

    “Although the methods are different, and Prime did not examine the associated opioid overdose events, our research relates [to the BMJ study] because it has a similar goal—to identify the prevalence of concurrent use and highlight the need to create programs that can reduce the risk of adverse effects from the misuse of opioids and benzodiazepines together. It is important for providers to understand there is a problem, and it’s not only a problem in the older adult population,” Starner says. 

    Addressing the problem

    One way to the address the problem is through implementation of pharmacy benefit clinical programs, according to Starner. “Advanced knowledge around prevalence of concurrent opioid and benzodiazepine use can help insurers plan for potential quality measures or other prescribing restrictions to improve member safety. Our nation is in an opioid crisis, and several prominent national organizations and federal agencies have expressed concern and provided guidance against concurrent use of opioids and benzodiazepines use. So now is the time to enhance, create and improve clinical programs aimed at safe and appropriate controlled substance use,” she says.

    Based on these studies, Sun and Starner offers these eight rommendations for health plan executives:

    1. Examine your company’s controlled substances policies and programs. “The concern is not only with the opioids,  but with all controlled substances, including but not limited to opioids and benzodiazepines. The Drug Enforcement Agency has classified them as controlled substances for a reason; these drugs have a high potential for abuse, dependence and harm,” Starner says.

    2. Do not stop with the Medicare population. “Concurrent opioid and benzodiazepine use is also occurring in our commercially insured population and reducing risk for this population is equally important,” she says.

    3. Implement system-wide approaches aimed at monitoring the use of both of these drugs then alert patients (and their prescribers) who are using both drugs concurrently, according to Sun.

    4. Begin or enhance current clinical programs aimed at controlled substances misuse. One example is using prescriber letters. This is an inexpensive yet effective method for increasing awareness of potential controlled substance misuse and decreasing the prevalence, according to Starner

    5. Implement pharmacist consultation, which has been shown to reduce controlled substance misuse/overuse. 

    6. Consider identifying at-risk members and developing clinical programs with the goal of reducing combination use. “As the CDC recommends against combination opioid and benzodiazepine use, and the Pharmacy Quality Alliance has developed a pharmacy performance measure, it is anticipated that health insurers’ quality of care will be assessed based on the prevalence of combination use among their membership,” Starner says.

    7. Understand your own data and member use patterns to determine intervention thresholds of concurrent opioid and benzodiazepine use. 

    8.  Don’t stop here. “Future research should continue to include examination of prescribers with high volumes of concurrent opioid and benzodiazepine users within their discipline,” Starner says. “Using a variety of methods to identify misuse and abuse will enhance our ability to make change and improve member safety.”  


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