MH3 - Geographic Variation of High-Risk Opioid Use and Risk of Overdose Among Disabled Medicare Beneficiaries in the US from 2011 to 2015

Abstract

The Pharmacy Quality Alliance (PQA) has developed quality measures of high-risk opioid prescribing/use that address 1) high-dose use, 2) receipt of opioid prescriptions from multiple providers, and 3) concurrent benzodiazepine use. We examined the patterns of high-risk opioid use across regions and the association with subsequent overdose risk in Medicare from 2011 through 2015. Among 249,594 non-cancer, disabled Medicare beneficiaries who had >2 opioid prescriptions, we identified beneficiaries with high-dose use (>120 daily morphine milligram equivalents for ≥90 consecutive days) and multiple providers (≥4 prescribers and ≥4 pharmacies) each year; and concurrent benzodiazepine use (≥30 cumulative days) from 2013-2015 when Part D began coverage for benzodiazepines. We obtained adjusted annual rates of high-risk measures across 306 hospital referral regions (HRRs) using multivariable logistic regression and examined the association between these measures and overdose risk(claim-based) in the subsequent year using Cox proportional regression, adjusting for sociodemographic, health status, and access-to-care factors. Adjusted annual rates of high-dose use (~9%), having multiple providers(~5%), and concurrent benzodiazepine use (~34%) remained stable over five years. In 2015, the ratio of 75th-to-25th percentile rates of high-risk measures across HRRs were 1.80 for high-dose use, 1.87 for having multiple providers, and 1.33 for concurrent benzodiazepine use. The top 3 HRRs with the highest rate of: high-dose use were Sarasota, FL(17.2%), Sun City, AZ(17.2%) and Clearwater, FL(16.9%); multiple providers were Slidell, LA(14.0%), Muskegon, MI(12.5%), and Bryan, TX(12.0%); and concurrent benzodiazepine use were Dearborn, MI(58.0%), Miami, FL(55.4%), and Spartanburg, SC(55.1%). These measures were associated with subsequent overdose risk for high-dose (hazard ratio [HR]=2.19, 95%CI=1.86-2.57); multiple providers (HR=1.58, 95%CI=1.30-1.92); and concurrent benzodiazepine use (HR=1.82, 95%CI=1.58-2.10). High-risk opioid use measures were associated with overdose risk among disabled Medicare beneficiaries. Areas and individuals with prevalent high-risk opioid use may benefit from targeted interventions (e.g.,lock-in programs) to prevent overdose.