predicting and disrupting the opioid addiction cycle€¦ · source: ny times article "short...

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Predicting and Disrupting the Opioid Addiction Cycle

Ted BorgstadtChief Executive Officer

TrestleTree LLOFayetteville, Arkansas

Bradley Martin, Pharm.D., Ph.D.UAMS College of Pharmacy

Little Rock, Arkansas

Julia NicholsonPrincipal

JN ConsultingFolsom, California

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AGENDA

• HOW BAD IS THE PROBLEM?

• VALUABLE INSIGHTS FROM 20 YEARS OF RESEARCH

• PROACTIVE STRATEGIES TO ADDRESS THE PROBLEM

• Q & A

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HOW BAD IS IT?

• LEADING CAUSE OF DEATH FOR PEOPLE UNDER 50

• 2% OF DEATH = 1 IN 50SOURCE: NY Times article "Short Answers to Hard Questions About the Opioid Crisis" by Josh Katz,

August 2017 citing the CDC and National Center for Health Statistics

• 97 MILLION PEOPLE TOOK PRESCRIPTION PAINKILLERS IN 2015 BUT 12 MILLION WITHOUT A DOCTOR PRESCRIBING

• OVER 2 MILLION PEOPLE ESTIMATED TO HAVE A PROBLEM WITH OPIOIDS

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WIIFM

• “ECONOMIC BURDEN”

• INDIRECT EFFECTS

• PROACTIVE STEPS

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OPIOID USE TRAJECTORIES

WHAT WE HAVE LEARNED FROM BIG DATA

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TERMINOLOGY:Abuse: Self-administration of medications to alter one’s state of consciousness (“get high”)

Addiction: A primary, chronic, neurobiological disease, with genetic, psychologic, and environmental factors influencing its development and manifestations. Addiction is characterized by 4 C’s – behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving

Diversion: Redirection of a prescription drug from its lawful purpose to illicit use; can be done with criminal intent

Misuse (noncompliant use): The intentional or unintentional use of a prescribed medication in a manner that is contrary to directions

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TERMINOLOGY:Physical dependence: A state of adaptation manifested by a drug class-specific withdrawal syndrome that occurs by abrupt cessation of a drug, symptoms generally the opposite of the desire drug effect, and by adaptation so that increasing doses of a drug is needed to achieve the same desired effect.

Tolerance: A state of adaptation in which exposure to a given dose of a drug induces changes that result in diminution of one or more of the drug’s effects over time

Withdrawal: A variety of unpleasant symptoms (e.g., difficulty concentrating, irritability, anxiety, anger, depressed mood, sleep disturbance, and craving) that occur after use of an addictive drugs is reduced or stopped

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CHRONIC PAIN AND PRESCRIPTION OPIOIDS

• 11% of Americans experience daily (chronic) pain

• Opioids frequently prescribed for chronic pain

• Primary care providers commonly treat chronic, non-cancer pain

o account for ~50% of opioid pain medications dispensed

o report concern about opioids and insufficient training

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• Adopted guidance to more

aggressively monitor and treat

paint 1999-2000

Veterans Health Administration

• 1995 Pain as fifth a vital sign

• 90% of American Pain

Society Funding from

PhRMA

American Pain Society

MANAGING PAIN

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OPIOID RELATED ARTICLES AND LETTERS

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N Engl J Med 2017; 376:2194-2195

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EARLY ASSOCIATION BETWEEN CUMULATIVE OPIOID DOSE AND OPIOID DEATH

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Use Big ImagesTo Show Ideas

OPIOID USE COMPARED TO PALLIATIVE CARE NEEDS

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RAPID INCREASE IN DRUG OVERDOSE DEATH RATES BY COUNTY

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SHARP INCREASE IN OPIOID PRESCRIPTIONS INCREASE IN DEATHS

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COMPARISON OF POTENTIALLY LETHAL DOSES

ILLICIT OPIOIDS

PHOTO: Kensington Police – PEI Canada - 2017

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3

2

1

0

4

5

6

7

2004 2006 2008 2016

Dea

ths

per1

00,0

00po

pula

tion

RISE IN OPIOID DEATHS

Over 350,000 people have died from an opioid overdose since 1999

3 Waves

SOURCE: National Vital Statistics System Mortality File

ILLICIT OPIOIDSHeroin

2000 2002

PRESCRIPTION OPIOIDSNatural and semi-synthetic

opioidsMethadone

2010 2012 2014

OTHER – LIKELY ILLICIT FENTANYLSynthetic Opioids

Excluding Methadone

Overlapping, Entangles but Distinct Epidemics

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STAT forecast: Opioids could kill nearly 500,000 Americans in the next decadeBY MAX BLAU @MAXBLAUJUNE 27, 2017

10 YEAR PROJECTIONS OF OPIOID RELATED DEATHS

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LOOKING BEHIND OPIOID OVERDOSE DEATHS

ForeveryONEperson who diedthere were

15 Disorder involving heroin people reported having a substance use

In 2016,more than42,000Americans died fromoverdoses involvingprescription or illicitopioids.

people reported having a substance use disorder Involving opioids

people reported misusingprescription opioids in the past year

people reported usingprescription opioids in the past year

41

273

2,174

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DRIVERS OF CHANGES IN LIFE EXPECTANCY 2000-201512 Leading causes of Death and Drug Poisoning Deaths

Copyright 2017 American Medical Association. All Rights Reserved.

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LONG-TERM CHRONIC OPIOID THERAPY DISCONTINUATION RATES FROM THE TROUP STUDY

• The study was designed to report chronic opioid therapy discontinuation rates after five years and identify factors associated with discontinuation.

• Commercially insured population (HealthCore plans)

• Publicly Insured population (Arkansas Medicaid)

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DAYS UNTIL OPIOID DISCONTINUATION BY MISUSE SCORE FOR ARKANSAS MEDICAID AND HEALTHCORE, 2001-2005

N = 23,419 and 6,848

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0

5

10

15

20

25

30

35

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0 10 20 30 40 50Pro

babi

lity

of c

ontin

uing

use

in %

Number of days of first episode of opioid useOne year probability Three year probability

CONTINUED USE BY INTIAL DAYS OF THERAPY (N=1,294,247)

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CONTINUED USE BY NUMBER OF PRESCRIPTIONS

0

10

20

30

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0 2 4 6 8 10 12 14 16

Pro

babi

lity

of c

ontin

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use

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%

Number of prescriptions in first episode of opioid useOne year probability Three year probability

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CONTINUED USE BY DAYS SUPPLIED OF FIRST PRESCRIPTION

0

5

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0 5 10 15 20 25 30 35 40 45Pro

babi

lity

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ontin

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use

in

%

Days' supply of the first opioid prescription

One year probability Three year probability

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CONTINUED USE BY CUMULATIVE DOSE (MEQ) OF FIRST EPISODE

0

10

20

30

40

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60

0 500 1000 1500 2000 2500

Pro

babi

lity

of c

ontin

uing

use

in

%

Cumulative dose in first episode of opioid useOne year probability Three year probability

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CONTINUED USE BY INTIAL OPIOID TYPE

0 5 10 15 20 25 30

Long Acting Opioids (6,588; 0.51%)

Tramadol (120,781; 9.33%)

Hydrocodone Short Acting (742,112; 57.33%)

Oxcodone Short Acting (219,224; 16.94%)

Schedule II Short Acting (14,877; 1.15%)

Schedule III-IV and Nalbuphine (190,665;14.74%)

Initial Opioid Type

Three year probability of continued use One year probability of continued use

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COMPARISON WITH ANIMAL MODELS

Schulteis, et.al. Pharmacology Biochemistry and Behavior. 2004

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• Opioids for 13 weeks

have high probabilities of

long term use (61.11%)

and nearly constant after

that

Tramadol appears to be used sometimes when clinicians are thinking of a long term analgesic strategy

• 1 or more days 6.00%



Each additional day of opioid therapy increases the risk of chronic opioid use starting with 3rd day

No clear thresholds based on weeks of initial opioid use or cumulative dose

THOUGHTS

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Explore the association between characteristics of the first opioid prescription, patient level factors, and the pain etiology on the

probability of opioid discontinuation among opioid naïve patients

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TIME TO OPIOID DISCONTINUATION BY PAIN ETIOLOGY

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• Medicaid, Long Acting Opioid, Chronic Pain, 3-4 days suppliedModerate Associations (0.6 < HR < 0.8)

• Women, Elderly, Living in South or West, All Mental Health Disorders Studied, Pain types except chronic pain, childbirth, and surgery, Benzodiazepine and Muscle Relaxant Use, High Daily Dose, Use of Oxycodone, Hydrocodone, Tramadol, Short Acting Schedule II

Modest Associations (0.8 < HR < 1.0)

LONGER OPIOID USE IS ASSOCIATED WITH:

Strong Associations (HR < 0.6)• Days supplied greater than 4

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HAZARD OF OPIOID DISCONTINUATION BY DAYS SUPPLIED INTERACTED WITH PAIN ETIOLOGY

0.00

0.10

0.20

0.30

0.40

0.50

0.60

0.70

0.80

0.90

3‐4 DAYS 5‐7 DAYS 8‐10 DAYS 11‐14 DAYS 15‐21 DAYS 22 OR MORE DAYS

Hazard Ratios

Days' Supply of First PrescriptionBURN TRAUMA AND SURGERY TRAUMASURGERY CHILDBIRTH DENTAL PROCEDURECHRONIC PAIN DIAGNOSIS NON‐CHRONIC PAIN OTHER INPATIENT ADMISSIONOTHER EMERGENCY ROOM VISIT

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Persons with mental health disorders and those prescribed muscle relaxants or benzodiazepines used opioids longer

• Persons prescribed 5-7 days are TWICE as Likely to Continue Opioids than persons prescribed 1-2 days

• Persons prescribed 11-14 days are THREE times as Likely to Continue Opioids

Days Supply of Initial Opioid is the STRONGEST Predictor of Long Term Opioid Use

The Effect of Days Supplied persisted across all pain etiologies

THOUGHTS

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• States are implementing initial days supply limits – usually 7 days

or less

Policy

• The Initial Days Supplied of Opioids is the strongest

modifiable factor prognostic for long term use

• Extra Caution for persons with mental health

disorders and those prescribed

muscle relaxants or benzodiazepines

ClinicalIMPLICATIONS

• Supports CDC guidelines limiting initial opioids to

3 days or less and rarely more than 7 days

• PBMs are implementing similar restrictions

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WHO’S AT RISK FOR OVERDOSE?• DEMOGRAPHICS

• SOCIOECONOMICS & GEOGRAPHY

• RISK FACTORS

oMeno35-54 year oldsoWhitesoAmerican Indians / Alaska Natives

oMedicaidoRural

oPatients receiving opioids from multiple prescribers and/or pharmacies

oPatients taking high daily doses of opioidsoDepression, substance use disorder, and prior

overdose

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PREDICTING OPIOID ADVERSE EVENTS

Rates are per 1,000 person years

UAMS Translational Research Institute

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0.00%

0.10%

0.20%

0.30%

0.40%

0.50%

0.60%

0.70%

0.80%

0.90%

1.00%

0

0.2

0.4

0.6

0.8

1

1.2

1 2 3 4 5 6 7 8 9 10

Predicted Risk Observed Overdose Rate


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• Medical Marijuana Legalization Appears to Modestly Decrease Opioid Prescribing and Chronic Opioid Abuse

• Chronic and High Risk Opioid Prescribing appears Highly Concentrated

HOT OFF THE PRESS

• Only 24% of Reproductive Age Women who use Opioids Chronically obtain Prescribed Birth Control

• Qualitative Study of Pharmacists and Physicians Attitudes towards opioid decisions

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Acknowledgements / Disclosers

Anuh Shah, Corey Hayes,

Xiaocong Li, Gary Moore

Access to the Data was supported

by the UAMS TRI (UL1TR000039)

NIDA (R01 DA 022560) Sullivan

Disclosure: TrestleTree

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PREVENTION DISRUPTING THE OPIOID ADDICTION CYCLE

BEFORE IT BEGINS

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“The opioid crisis is just awful and it is getting worse.”

Sarah Bacon, PhDDivision of Unintentional Injury PreventionCenters for Disease Control & Prevention

2018 Opioid Epidemic ForumWashington DCJuly 16, 2018

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“It will take at least 10 years to solve the opioid crisis.”

Theodore A. Christopher, MD, FACEPThomas Jefferson University Hospital

2018 Opioid Epidemic ForumWashington DCJuly 16, 2018

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LOOKING BEHIND OPIOID OVERDOSE DEATHS

ForeveryONEperson who diedthere were

15 Disorder involving heroin people reported having a substance use

In 2016,more than42,000Americans died fromoverdoses involvingprescription or illicitopioids.

people reported having a substance use disorder Involving opioids

people reported misusingprescription opioids in the past year

people reported usingprescription opioids in the past year

41

273

2,174

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CDC RESPONSE

CDC VISION

Prevent Opioid-Related Harms & Overdose Deaths

North Star

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ConnectingCommunity

Infrastructure

COORDINATEDPrevention and

ResponseActivities

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• State Legislative Efforts

• Health Plans

• Hospital Systems

• Pharmacy Benefit Management

• Retail Pharmacies

CURRENT EFFORTS

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STATE LEGISLATURES

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MEMBERS• Identify a member once an

opioid prescription has been written

• Reach out to the member to educate them on the serious risk of taking an opioid

• Expand access to alternative pain management therapies

HEALTH PLANS

PHYSICIANS / PROVIDERS• Identify the number of opioid

prescriptions each physician has written in comparison to their peers via a scorecard

• Educate the physician on the alternative pain management options covered by the health plan

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• Reach out to the member to educate them on the serious risks of taking an opioid

• Disposal of unused opioids

HOSPITAL SYSTEMS


prescriptions each physician has written in comparison to their peers

• Educate the physician on pain management strategies and techniques

• Engage new policy & procedures for Emergency Department opioid utilization

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• Reach out to the member to educate them on the serious risks of taking an opioid

• Monitor doctor shopping

• Repetitive emergency department prescription

PHARMACY BENEFIT MANAGEMENT COMPANIES


prescriptions each physician has written in comparison to their peers

• Educate the physician on step therapy recommendations for pain management

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CUSTOMERS• Identify a member once an

opioid prescription has been received to be filled

• Counsel customer in the store to educate them on the serious risks of opioids

• Restrict the number of days supply of an opioid prescription to 7 days

• Disposal of unused opioids

RETAIL PHARMACY

PHYSICIANS / PROVIDERS

• Identify and contact the physicians that have written over a seven days supply and alert them to the restricted days supplied filled

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• Current Strategies from multiple health care sectors- Identify - Educate

ADDITIVE SOLUTIONS NEEDED

• Focus is on disrupting opioid abuse before the unintentional slippery slope impacts lives and increases avoidable cost

• Additive Disruptive Strategy for all health care sectors- Predict- Prevent

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• This crisis requires an additional approach focused on patient-level insights to predict opioid addiction risk and leverage behavior change methodology to preventopioid misuse and addiction at the individual level

PREDICTION OF OPIOID RISK

• Focus is on disrupting opioid abuse before the unintentional slippery slope impacts lives andincreases avoidable cost

• 323 risk variables (“data features”) spanning demographic pharmacy claims, and medical claims data, each individually weighted for an individual prior to being prescribed an opioid for the first time

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SLIPPERY SLOPE OF OPIOID ABUSE: 5+ DAYS

• 14% likelihood of continued opioid use 1 year after initial 7 day supply• 25% likelihood of continued opioid use 1 year after initial 11 day supply• No previous opioid use in the proceeding 6 months for ~1.3m patients studied

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• Breaking the cycle of abuse and addiction before it begins

• Helping people change tough health behaviors who do not want to change

• Behavior change intervention for high-risk individuals who are being prescribed an opioid for the first time, before a refill, pre-and post-surgery, post-ER visit, work comp injury, etc.

• Need a full contextual understanding of patient predisposition for opioid abuse, such as family, culture, finances, social, etc.

• Holistic approach to health behavior change allows influence on co-morbidities and foster referrals/access to all available resources

PREVENTION OF OPIOID RISK

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EXAMPLE: PRE- & POST-SURGERY

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EXAMPLE: WORK COMP PT

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FINAL THOUGHTS

• “The opioid crisis is just awful and it is getting worse.”

• Over 2 million people estimated to have a problem with opioids

• This crisis requires an additional approach focused on patient-level insights to predict opioid addiction risk and leverage behavior change methodology to prevent opioid misuse and addiction at the individual level

• Focus is on disrupting opioid abuse before the unintentional slippery slope impacts lives and increases avoidable cost

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QUESTIONS?

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Back Up Slides with Additional Methods and Data

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OPIOID WITHDRAWAL

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• Study Measures:

• Data: IMS Lifelink+ database for 2006-2015

• Subjects: Opioid naïve, cancer and substance

abuse free patients

DATA, SUBJECTS, KEY STUDY MEASURES

• Opioid Discontinuation at 1 and 3 years

• Opioid Prescription Characteristics

• Initial Days of Opioid Use

• Number of Opioid

prescriptions

• Cumulative Dose

• Type of opioid

• Initial Days Supply

of Opioid

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SUBJECTSTotal = 1,294,247 N / Mean (% / s.d.)Age 44.52 (14.56)Gender Females 698950 (54.00)Enrollment duration (years) 2.48 (2.04)

Pain Diagnoses Back Pain 226681 (17.51) Neck Pain 90352 (6.98) Head Pain 30123 (2.33) Joint Pain 389700 (30.11)

Patient Region South 476565 (36.74) Midwest 376520 (29.09) East 279595 (21.60) West 142698 (11.03) Missing/Other 19869 (1.54)Payer Type Commercial 866815 (66.97) Self‐Insured 387122 (29.91) Other / Unknown 40310 (3.11)

Opioid Episode Characteristics First Prescription >= 90 MEQ 89438 (6.91) First Prescription >= 120 MEQ 22895 (1.77) First Prescription of Long Acting Opioid 6588 (0.51) Duration of first episode 14.81 (65.00)

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Opioid naïve, cancer and substance abuse free patients

IMS Lifelink+ database for 2006-2015• 10% random sample (approximately 6.5M lives)

DATA AND SUBJECTS

• At least one OPR prescription between June 06 and Dec 14

• At least 6 months of continuous enrollment without an opioid prescription

prior to first opioid prescription

• At least 14 years of age

• Excluded:

• Any non-melanoma cancer, substance abuse diagnosis or

buprenorphine/naloxone prescription in the 6 month prior period

• Missing data on demographics (gender, region, age, payer)

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Initial Opioid Episode• Days supply of first prescription, average daily dose, opioid type

Opioid Discontinuation

STUDY MEASURES

Pain Etiology• (a) Trauma and surgery (b) Trauma (c) Surgery (d) Burn (e) Childbirth (f)

Dental (g) Chronic pain conditions (headache, back/neck pain, joint pain, neuropathic pain, fibromyalgia) (h) Other pain conditions (chest pain, abdominal pain, others) (i) Other inpatient admissions (j) Other Emergency Department visit (k) Unknown

Patient and System Characteristics• Age, Gender, Region, Year, Insurance Type (Medicaid, Medicare,

Commercial), Mental Health (mood, personality, adjustment, anxiety), Prior Benzodiazepine/Muscle Relaxant.

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DATA AND SUBJECTS

• At least one OPR prescription between June 06 and Sep 15




• Excluded:

• Any non-melanoma cancer, substance abuse diagnosis or


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Initial Opioid Episode• Continuous use of opioids with a gap no greater than 30 days• Duration (days and weeks)• Number of opioid prescriptions• Cumulative dose (expressed in morphine milliequivalents)

Opioid Discontinuation• At least 180 days without opioid use• Followed until loss of enrollment, study end date, or

discontinuation of opioids.

STUDY MEASURES

Initial Prescription• Days supply• Average daily dose (MME)• Prescription type

• Long Acting, Oxycodone Short Acting, Hydrocodone Short Acting, Other Schedule II Short Acting, Schedule III-IV, Tramadol

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Sensitivity analyses• Discontinuation required 90 instead of 180 opioid free days

• Initial opioid episode used 7 instead of 30 maximum gap

• Excluded patients whose initial prescription exceeded 90 MME

Kaplan Meier curves• Median time to discontinuation

• Probability of continued OPR use at one and three years

ANALYSIS

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SUBJECTSTotal = 1,294,247 N / Mean (% / s.d.)Age 44.52 (14.56)Gender Females 698950 (54.00)Enrollment duration (years) 2.48 (2.04)

Pain Diagnoses Back Pain 226681 (17.51) Neck Pain 90352 (6.98) Head Pain 30123 (2.33) Joint Pain 389700 (30.11)

Patient Region South 476565 (36.74) Midwest 376520 (29.09) East 279595 (21.60) West 142698 (11.03) Missing/Other 19869 (1.54)Payer Type Commercial 866815 (66.97) Self‐Insured 387122 (29.91) Other / Unknown 40310 (3.11)

Opioid Episode Characteristics First Prescription >= 90 MEQ 89438 (6.91) First Prescription >= 120 MEQ 22895 (1.77) First Prescription of Long Acting Opioid 6588 (0.51) Duration of first episode 14.81 (65.00)

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Unable to account for opioids that were paid for out of pocket or obtained illicitly

Unable to separate intentional and un-intentional long term chronic opioid use

Data do not capture pain intensity of duration

Did not account for the etiology of pain• Acute (post-op, trauma) or chronic pain conditions

LIMITATIONS

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DATA AND SUBJECTS

• At least one OPR prescription between June 06 and Dec 14




• Excluded:• Any non-melanoma cancer, substance abuse diagnosis or


• Missing data on demographics (gender, region, age, payer)

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Initial Opioid Episode• Days supply of first prescription, average daily dose, opioid type

Opioid Discontinuation

STUDY MEASURES

Pain Etiology• (a) Trauma and surgery (b) Trauma (c) Surgery (d) Burn (e) Childbirth (f)

Dental (g) Chronic pain conditions (headache, back/neck pain, joint pain, neuropathic pain, fibromyalgia) (h) Other pain conditions (chest pain, abdominal pain, others) (i) Other inpatient admissions (j) Other Emergency Department visit (k) Unknown

Patient and System Characteristics• Age, Gender, Region, Year, Insurance Type (Medicaid, Medicare,

Commercial), Mental Health (mood, personality, adjustment, anxiety), Prior Benzodiazepine/Muscle Relaxant.

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Cox Proportional Hazards Model• General Model

• Interacted Model

• Stratified Model

Kaplan Meier curves

ANALYSIS

• Pain etiology and days supplied

• Chronic vs Non-Chronic Pain

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TIME TO DISCONTINUATION

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PREDICTING OPIOID ADVERSE EVENTS Statistical Approach


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predicting and disrupting the opioid addiction cycle€¦ · source: ny times article "short...

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