CMS Criteria Do Not Accurately Identify Patients at Risk for Opioid Use Disorder, Overdose


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CMS criteria do not accurately identify patients at risk for opioid use disorder, overdose

Wei Y, et al. JAMA. 2019;doi:10.1001/jama.2018.20404.

February 15, 2019

 

The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose, according to a research letter published in JAMA.

“Based on the CMS opioid overutilization criteria, the majority of the Medicare Part D patients diagnosed with opioid use disorder or overdose were not identified as ‘opioid overutilizers,’ and more than half of ‘opioid overutilizers’ did not develop opioid use disorder or overdose during the study period,” Yu-Jung Jenny Wei, PhD, Msc, assistant professor of pharmaceutical outcomes and policy at the College of Pharmacy, University of Florida, told Healio Primary Care Today. “The CMS criteria seem not to be a good clinical marker for identifying patients at risk for opioid-related adverse events.”

To estimate the predictive value of the CMS opioid overutilization criteria in correctly identifying prescription opioid users at risk for opioid use disorder or overdose, researchers used the 5% Medicare sample from 2011 through 2014 from which they identified between 142,036 and 190,320 beneficiaries who had at least one opioid prescription filled every 6 months, were continuously enrolled in Parts A, B and D and who met the CMS criteria as opioid overutilizers. Opioid utilization was defined as receiving prescription opioids with a mean daily morphine equivalent dose 90 mg from more than three prescribers and pharmacists or receiving a mean daily morphine equivalent dose of 90 mg by more than four prescribers.

Breaking the study period into three 6-month cycles, researchers examined the performance measures over time to assess if accuracy changed with increasing efforts to combat the opioid crisis. 

During any 6-month cycle, the proportion of beneficiaries who met CMS overutilization criteria ranged from 0.37% to 0.58%.

Throughout the entire 18-month follow-up, researchers found that the proportion of patients who had a diagnosis of opioid use disorder or overdose increased from 3.91% in the first cycle to 7.55% in the last.

In addition, researchers observed low sensitivity of the criteria which ranged from 4.96% (95% CI, 4.42-5.58) at the beginning of the study period to 2.52% (95% CI, 2.26-2.81) at the end (< .001).

 The CMS opioid overutilization criteria may not accurately identify patients at risk for opioid use disorder or overdose.Source: Adobe Stock

Positive predictive values ranged from 35.2% (95% CI, 32.14-38.38) to 50.95% (95% CI, 47-54.86) and specificity was greater than 99% in all cycles. 

“CMS has required their Medicare Part D plans to implement the criteria,” Wei said. “It’s unclear the effectiveness of such criteria in stopping our national opioid epidemic and whether there are unintended consequences of such implementation. As we are developing solutions to the opioid crisis, it’s important for policymakers, health care providers, hospitals and health insurance companies to be aware that solely relying on opioid prescription data is likely to be ineffective in identifying the high-risk populations for interventions.” – by Melissa J. Webb

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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Ketamine’s effects tied to opioid system in brain


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Stanford announces:

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Ketamine’s antidepressive effects

tied to opioid system in brain

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“Ketamine’s antidepressive effects require activation of opioid receptors in the brain, a new Stanford study shows. The surprising finding may alter how new antidepressants are developed and administered in order to mitigate the risk of opioid dependence.”

 

 

…”The study enrolled adults with treatment-resistant depression, meaning their condition had not improved after multiple treatment efforts. Twelve participants received infusions of ketamine twice — once preceded by naltrexone, an opioid-receptor blocker, and once with placebo. Neither the study participants nor the researchers were told whether active drug or placebo was administered during each test. The researchers found that ketamine reduced depressive symptoms by about 90 percent for three days in more than half of the participants when administered with a placebo, but had virtually no effect on depressive symptoms when it was preceded by naltrexone.”

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The material on this site is for informational purposes only.

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It is not legal for me to provide medical advice without an examination.

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It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

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Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Medicare & Insurers Crack Down on Opioids – Patients Suffer


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Individualized pain management does not exist.

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Correction from reader: 

“Individualized treatment does exist, but insurance companies are not paying for it. This has to change.” 

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The New York Times reports “Medicare is Cracking Down on Opioids” (link below).

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Last year an insurer denied 10 mg daily Oxycontin for one of my seniors who had been safely taking this for many years. That is less than 1 mg per hour for 12 hour relief. Pharmacy refused to fill unless insurer approved. That’s one way to reduce healthcare costs without an uprising. There is little tolerance for someone with pain. Are they viewing patients as addicts? Would they do this for cancer? 

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The material on this site is for informational purposes only.

.

It is not legal for me to provide medical advice without an examination.

.

It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~

Comments are welcome.

This site is not for email, not for medical questions, and not for appointments.

~~~~~

For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please IGNORE THE ADS BELOW. They are not from me.

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Avoid opioid use in surgery to reduce postop pain


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Science for years has confirmed that opioids trigger inflammation and that creates pain. Trauma and surgery also create inflammation that leads to pain. How logical is it then to continue use of sufentanil for anesthesia when it is the most highly potent opioid 500 to 1,000 times stronger than morphine. Where is the logic in creating pain by using sufentanil as the anesthetic? A new one on the market will be 10,000 times stronger than morphine. Inflammation is not always easy to reset after you strafe the innate immune system with an opioid.

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Why is ketamine not used more often for surgical anesthesia when we know ketamine profoundly lowers the inflammatory response thus reducing pain more than ever. Studies for years have shown that even a small dose of ketamine reduces postop pain. This is not new.

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A study needs to be done comparing patients who receive no opioids. At least this study showed that when fewer opioids are used, pain scores are 37% lower than if more had been given. Patients given higher doses of opioid, had higher analgesic requirements postop. That increases the risk of persistent chronic pain and the tragic risk of addiction.

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Opioids inflict known lasting harm, pain and suffering, perhaps disability and addiction.

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Reduced opioid use in surgery linked to improved pain scores
Written by Brian Zimmerman

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After anesthesiologists at the University of Virginia Health System in Charlottesville began administering fewer opioids to patients during surgeries, patients’ self-reported pain levels dropped, according to a study led by three UVA anesthesiologists.
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For the study, the team examined 101,484 surgeries that took place in the UVA Health System from March 2011 to November 2015. During this time period, the amount of opioids administered via general anesthesia at the system was reduced by 37 percent.
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For the same time period, self-assessed patient pain scores recorded in post-op recovery units dropped from an average of 5.5 on a 10-point scale to an average of 3.8, marking a 31 percent improvement.

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One of the study’s leaders, UVA anesthesiologist Marcel Durieux, MD, PhD, said the impetus behind the pain score improvements is likely attributable to several factors. One, previous research has indicated opioids can ultimately make people more sensitive to pain. And two, the increased use of non-opioid painkillers like lidocaine and acetaminophen during surgeries at UVA was likely effective.

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….”There is very clear evidence that people can become opioid-dependent because of the drugs they get during and after surgery,” said Dr. Durieux. “I think that by substantially limiting opioids during surgery, we’ve made an important step in addressing that problem.”

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The material on this site is for informational purposes only.
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It is not legal for me to provide medical advice without an examination.

.
It is not a substitute for medical advice, diagnosis or treatment provided by a qualified health care provider.

~~
This site is not for email and not for appointments.

If you wish an appointment, please telephone the office to schedule.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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Please IGNORE THE ADS BELOW. They are not from me.

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Pain News: “Reckitt Benckiser sued by 35 US states for ‘profiteering’ from opioid treatment”


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Headlines today from the Guardian:

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“Reckitt Benckiser sued by 35 US states for ‘profiteering’ from opioid treatment”

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There really is no financial advantage for pharmaceutical companies to create medication that helps pain because opioids are for life, and are so valuable some of them can charge each patient $20,000 a month. For life. Explains why every year 2 or 3 new opioids come on the market, year after year after year, more new opioids.

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Opioid profiteering.

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The material on this site is for informational purposes only, and is not a substitute for medical advice,

diagnosis or treatment provided by a qualified health care provider.

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Please understand that it is not legal for me to give medical advice without a consultation.

If you wish an appointment, please telephone my office.

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For My Home Page, click here:  Welcome to my Weblog on Pain Management!

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The advertising below is not recommended by me.

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Opioid Overdoses ~130 every day, the capacity of a Boeing 737 – naloxone $4,500, up from $690 in 2014. You pay


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LA Times reports

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As need grows for painkiller overdose treatment, companies raise prices

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$4,500

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$4,500.

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$4,500 for naloxone manufactured by Kaleo, Richmond Virginia. Naloxone reverses opioid overdose.

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That seems to be their Evzio two-pack, two single-use injectors of naloxone in a hard case handy to carry in a pocket for someone who has an opioid overdose.

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Each has a 0.4 mg injection that last 2 or 3 minutes each, just long enough to call an ambulance.

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A drug that costs pennies, sold as a 2-pack for $690 in 2014, then $900, now $4,500 as of Feb. 1.

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“…Columbus, Ohio, said the city’s firefighters last year used 2,250 naloxone doses, or about 6 doses a day — at a cost of $147,000. Recently, Columbus also stocked the drug in 115 police cruisers….”

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FDA approved Evzio in April 2014 after granting fast-track status. Fast track now means gold mine status. 

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Naloxone was first approved in 1971.

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“In July 2005 its average wholesale price for a vial of the injectible drug was $1.10, according to Truven Health Analytics.

By 2014, the price was almost $19 a vial.” 

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Medical costs are astronomical, insurance premiums are up, insurance deductibles are $5,000 to $10,000 for many. Police, fire department and EMT’s are using naltrexone to save lives and lower ER visits.

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Taxes are high. Where is the initiative and innovation among EMT’s, police, fire? How many hours per day do they get paid full salary to work out at the gym and stay fit while they sit and wait for the next call to rescue an addict who overdosed. Then retire on double pensions if they hold two city jobs. While they wait for next calls, could they not fill syringes from a vial of naloxone? How much do taxpayers pay for these overpriced robotic filled syringes at factories.

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Pharma is raking it in. Pharma’s blood sucking 1% are overdosing on costs. Many of my patients with intractable pain who are on opioids were not able to afford $690. They are not addicts but any dose of opioid can kill. Your tax dollar pays for naloxone for addicts found dead, unresponsive.

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We are all paying a fortune for inexcusable pharma costs. Costs for millions of drug addicts all over the country. Costs for prescription medications. Congress unwilling to address anything that would cut the flow of donations to their coffers from pharma.

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Just remember, in Israel, it is illegal for corporate lobbyists to contact any politician.

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“Late last year, Adapt introduced a naloxone nasal spray named Narcan for a average wholesale price of $150 for two units, according to Truven.”

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That is a BD syringe fitted with a flared BD adapter at the tip to fit the nostril. It requires the user be capable of pushing the 1 mL syringe so the liquid is sprayed into nostril.

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For Pete’s sake. I’ve been prescribing medicine in these BD syringes with nasal adapter for years. Is there no EMT smart enough to make and stock their own supply to use for emergencies?

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“…as the demand for naloxone has risen — overdose deaths now total 130 every day, or roughly the capacity of a Boeing 737 — the drug’s price has soared.
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…Increased access to naloxone is among the measures included in federal legislation that Congress passed last week in response to the painkiller deaths. The White House has said that President Obama plans to sign the bill.
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Last month, U.S. Sens. Susan Collins (R-Maine.) and Claire McCaskill (D-Mo.) wrote to Kaleo, Rancho Cucamonga’s Amphastar Pharmaceuticals and three other drug makers, asking why they had hiked prices for naloxone during a public health crisis.
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“At the same time this epidemic is killing tens of thousands of Americans a year,” said McCaskill, “we’re seeing the price of naloxone go up by 1,000% or more.

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 …Mylan, which sells a vial [how many doses per vial?] for an average wholesale price of $23.70, according to Truven and Adapt Pharma of Dublin, Ireland.”

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The material on this site is for informational purposes only.

It is not a substitute for medical advice, diagnosis or treatment

provided by a qualified health care provider.

Relevant comments are welcome.

~~~~~

For My Home Page, click here: 

Welcome to my Weblog on Pain Management!

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Please be aware any advertising on this free educational website is

NOT advocated by me and NOT approved by me.

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