The Cost of Pain and Economic Burden of Prescription Misuse, Abuse and Diversion. Angela Huskey, PharmD, CPE

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1 The Cost of Pain and Economic Burden of Prescription Misuse, Abuse and Diversion Angela Huskey, PharmD, CPE

2 Case Bill is a 47 year old man with a history of low back pain and spinal stenosis Not a real patient He initially began conservative treatment with anti-inflammatories and mild opioid therapy as needed Conservative treatment failed to adequately control his pain Over the course of three months, Bill visited his local ED 4 times due to uncontrolled pain 2

3 Case Not a real patient Bill was eventually referred to a pain specialist for additional work-up and treatment Dr. Jones, the pain specialist, started Bill on a more complex regimen consisting of a longacting opioid, an anticonvulsant, and a muscle relaxant Dr. Jones is not aware of Bill s 15 year history of alcohol abuse, which at the time Bill had been sober for 2 years 3

4 Case Not a real patient As his pain got worse, Bill was unable to work and was fired from his job With the increased stress of being fired, he began misusing his opioid and his underlying alcohol abuse relapsed Two months after being referred to the pain specialist, Bill was admitted to the ER for suspected overdose What are the costs associated with Bill s Care? 4

5 Background Economic Cost of Pain in the US Millions of Americans experience chronic pain Approximately 100 million adults in 2008 Limits function and impacts quality of life Difficult to diagnose and treat Complicates treatment for other conditions Leads to significant loss in productivity Pain costs up to $635 billion* annually in medical treatment and lost productivity Direct healthcare expenditures= $ billion Lost productivity = $ billion Not including cost of pain for institutionalized and noncivilian populations (nursing home residents, military personnel, prison inmates) Gaskin DJ and Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):

6 Background Economic Cost of Pain in the US (cont) Diagnosis Cardiovascular Disease Cancer Injury & Poisoning Endocrine & Metabolic Disease Digestive System Disease Respiratory System Disease Annual Estimated Cost of Condition $309 Billion $243 Billion $205 Billion $127 Billion $112 Billion $112 Billion 2010 US Dollars * cost of condition estimates include healthcare costs and cost of pre-mature death and does not include costs of lost productivity Gaskin DJ and Richard P. The economic costs of pain in the United States. J Pain. 2012;13(8):

7 Dramatic Rise in Therapeutic Use of Opioids ~ 127% increase in retail sales between National Institute on Drug Abuse (NIDA) Research Report Series: Prescription Drugs: Abuse and Addiction. Available at: Last accessed 10/18/2012 Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician. 2008;11:S63 S88. 7

8 Rates of Prescription Opioid Sales, Death, and Treatment ( ) 8

9 For Every One Death From Prescription Drug Misuse 10 Treatment admissions for abuse 1 Death 32 Emergency Dept visits 130 People who Misuse/abuse 825 Nonmedical users Source: CDC Vital Signs: Overdoses of Prescription Opioid Pain Relievers in the U.S Atlanta, Ga: Centers for Disease Control and Prevention, November 2011

10 Illicit Drug Use Past Month Users, Age 12 or older Past Month Users, Age 12 or older (Millions) Heroin Hallucinogens Cocaine Psychotherapeutics Marijuana Use of psychotherapeutics is greater than cocaine, hallucinogens, and heroin combined Any Illicit drug Substance Abuse and Mental Health Services Administration, Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration,

11 Sources of Nonmedically Used Analgesics Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA). Results from the 2010 National Survey on Drug Use and Health: National Findings

12 Goals in Managing Chronic Pain Maintain a balance o o Maximize the benefits of prescription opioid therapy Minimize the risks associated with misuse and abuse of opioid therapy Obtaining balance is often challenging for providers and managed care organizations o Requires structured treatment and monitoring

13 Annual Societal Costs of Opioid Abuse Opioid abuse, dependence, and misuse imposes a significant financial burden Total Costs = $55.7 billion Healthcare Criminal Justice Workpplace Birnbaum HG, White AG, Schiller M et al. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med 2011;12:

14 Direct Cost of Opioid Abuse in an Insured Population One study analyzed payer burden of opioid abuse measuring per patient costs incurred arising from all medical and pharmacy payments for patients diagnosed with opioid abuse High costs of opioid abuse are driven primarily by high prevalence rates of costly comorbidities and high utilization rates of medical services and prescription drugs White AG, Birnbaum HG et al. Direct costs of opioid abuse in an insured population in the United States. JMCP 2005;11(6):

15 Direct Cost of Opioid Abuse in an Insured Population (continued) Comorbid medical conditions and painful diagnosis were significantly more prevalent in abusers vs. nonabusers Rates of Hepatitis (A,B,C), psychiatric illness and pancreatitis were 36.0, 8.5, and 21.0 times, respectively, as prevalent as those for nonabusers (P<0.01) Nearly half of abusers has a comorbid painful condition (47.6% vs. 17.3%), with low back pain being most prevalent (19.3% vs 3.6%) (P<0.01) White AG, et al. Direct costs of opioid abuse in an insured population in the United States. JMCP 2005;11(6):

16 Direct Cost of Opioid Abuse in a Private Insured Population (continued) Annual Dollars TOTAL Per Patient DIRECT Health Care Payer Costs 0 With Diagnosis* Excess annual cost burden of opioid abuse = $14054 Without Diagnosis* *Diagnosis = Misuse, Abuse, Dependence White AG, et al. Direct costs of opioid abuse in an insured population in the United States. JMCP 2005;11(6):

17 Opioid Drug Diversion Insurance fraud is the main financier and enabler of drug diversion Drains health insurers of over $70 Billion annually Doctor Shopping is largest source of drug diversion A typical doctor shopper generates ~ $10-15k/year in drug and medical claims ~ $41 in medical claims / every $1 paid for opioid RX for suspected doctor shopper (WellPoint, Inc) Insurers could face liability exposure for failure to detect and act (Duty to Warn, FL Supreme Court 2006) Prescription for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs. Coalition Against Insurance Fraud. December

18 Doctor Shopping N = 100 members suspected of doctor shopping Prescriptions N=12 / patient Prescribers N=7 / patient Pharmacies N=5 / patient Office visits N=41 / patient Opioid Prescription Expenses Prescriptions $20,233 Related Medical Services Office visits N=4131 Outpatient facility N=958 Total costs $450,148 $382,024 $832,172 Medical to RX Costs $41 to $1 Prescription for Peril: How Insurance Fraud Finances Theft and Abuse of Addictive Prescription Drugs. Coalition Against Insurance Fraud. December

19 Burden of Prescription Drug Misuse and Overdose on Medicaid Prescription misuse and overdose poses a significant financial burden for Medicaid Fraudulent purchase of controlled substances in Medicaid programs in 5 states cost $63 million in Medicaid payments, not including fees for office visits CA, IL, NY, NC, TX (US GAO 2009) ~45% of fatal overdoses caused by RX opioids in Washington state were people enrolled in Medicaid (CDC; ) National Conference of State legislatures LEGISBRIEF. Vol 20 No. 01. January

20 Direct Cost of Opioid Abuse in a Medicaid Population Annual Dollars TOTAL Per Patient DIRECT Health Care Payer Costs 0 With Diagnosis* Excess annual cost burden of opioid abuse = $6650 Without Diagnosis* *Diagnosis = Misuse, Abuse, Dependence Ghate AR et al. Cost and comorbidities associated with opioid abuse in managed care and medicaid patients in the United States: A comparision of two recently published studies. J Pain Pall Care Pharmacotherapy 2010;24:

21 Clinical Solutions A Multi-Pronged Approach Physician and patient education Utilization review, Peer-to-peer discussions UDT, PDMP, Pill Counts, Technologybased monitoring systems Opioid Agreements, Risk Assessment and Aberrant Behaviors Strassels SA. Economic burden of prescription opioid misuse and abuse. JMCP 2009;15(7): Swedlow A, Young B. Testing Utilization and Cost Trends in California Workers Compensation. CWCI Research Notes May Rosenblum K. Risk and Claims Managers Comprehensive Guide to the Management of Pharmacy Benefits Management Programs. Lockton Companies, August

22 Reducing Cost through Early Implementation of Testing and Recognition of Opioid Misuse Average annual direct healthcare cost to treat ONE patient with chronic pain $12,200 Opioid abusers are 25x more likely to require hospitalizations Monitoring can improve treatment of pain, decrease cost of misuse of opioids McCarberg BH. Chronic pain: reducing costs through early implementation of adherence testing and recognition of opioid misuse. Postgrad Med Nov;123(6):

23 Cost-Benefit of Instituting Routine UDT Early identification is key Projected cost of LUT implementation across patients with chronic pain population LUT Laboratory Urine Test $ 3.5 million Appropriate use of LUT could decrease cost of chronic pain therapy $10 - $52 million in savings 14 fold McCarberg BH. Chronic pain: reducing costs through early implementation of adherence testing and recognition of opioid misuse. Postgrad Med Nov;123(6):

24 Case Not a real patient As his pain got worse, Bill was unable to work and was fired from his job With the increased stress of being fired, he began misusing his opioid and his underlying alcohol abuse relapsed Two months after being referred to the pain specialist, Bill was admitted to the ER for suspected overdose What are the costs associated with Bill s Care? 24

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