Opioid Use is Associated with Higher Severity-Adjusted Episode Costs in Patients with Conservatively Managed Degenerative Joint Disease of the Back and Neck
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Opioid use and misuse are urgent health issues. Previous studies suggest that opioid use increases healthcare resource use but severity adjustment is lacking.
The objective of this study was to evaluate the severity-adjusted cost difference between opioid users and non-users among patients with conservatively managed degenerative joint disease of the spine within a large commercial health plan population in the United States.
A retrospective observational study was performed using a national commercial database covering 531,819 patients aged 18–64 years with non-surgically managed cervical or lumbar degenerative spine disease during 2015–6. Patients were grouped based on whether there was evidence for an opioid prescription. Costs for the opioids themselves were excluded. Severity adjustment, on an ascending integer scale from 1 to 4, was performed based on member demographics, clinical comorbidities, disease progression indicators, and complications.
Median episode costs for patients given opioids were approximately twice that for patients not given opioids after severity adjustment. For patients with episodes in both years and stable severity, patients with new prescriptions for opioids in 2016 doubled their median 2015 costs, and patients who had opioids discontinued in 2016 had a 60% cost reduction. Episode costs showed a nearly linear increase based on the length of time taking opioids, as well as with a higher average daily dose. Cost increases with opioids were broad across service categories even when comparing within the same severity-adjusted episodes of care.
The data suggest a clinically and statistically significant increase in episode costs associated with opioid use for degenerative joint disease of the spine, both within and between patients, and higher costs with a longer duration of opioid use as well as with higher daily dosages. Given the health consequences surrounding the overuse of opioids, concerted efforts to move towards a non-opioid pain control strategy are needed.
The authors thank Ranyan Lu, MD and Anthony Nguyen, MD for their valuable assistance in reviewing the document and Peter Toensing, MD for collaboration on the severity adjustment methodology.
BAM was responsible for the development and design of the measurement algorithms, he performed data analysis for comparisons between the opioid and non-opioid groups, wrote 40–50% of the Introduction section, wrote the majority of the Methods and Results sections, created the majority of the tables, and wrote the majority of the Discussion section. MMM collaborated on the conception and design of the study, acquired the data, prepared the data, and performed the initial analysis. She also revised data elements requested for revisions, including guidance on the design of the drill-down algorithms. She provided feedback on the interpretation of the data and results, created the initial figures, revised data elements needed for requested revisions, and wrote about 10% of the Methods and Results sections. AP delineated the opioid medication names and classification and national drug codes and provided pharmaceutical expertise for analysis. She also performed about 50–60% of the literature review for the Introduction section and wrote about 50% of the Introduction section. MAD performed the literature reviews and interpretations for the Discussion section, and identified potential clinical drivers of higher costs for opioid users. She wrote about 20–25% of the Discussion section. MA had significant involvement in the conceptualization and design of the study and the development of research methods for comparison of the opioid and non-opioid groups. She also performed the critical review and revision of the draft for intellectual content, and wrote about 5–10% of the Discussion section. SH was responsible for strategic clinical direction and prioritization, as well as providing the research design and opioid vs. non-opioid group definitions; he was also largely responsible for the emphasis on severity adjustment in the study.
Compliance with Ethical Standards
No other funding outside of UnitedHealthcare was received for the study.
Conflict of Interest
Brent Metfessel, Michelle Mentel, Amy Phanel, Mary Ann Dimartino, Mureen Allen, and Samuel Ho performed research while employed at UnitedHealthcare.
The research was performed using a health plan administrative database, thus no direct participation of subjects was needed.
The data that support the findings of this study are available on reasonable request from the corresponding author, pending UnitedHealthcare corporate legal and database administrator approval. The data are not publicly available because of regulatory restrictions on divulging personal health information and patient identifiable information to outside sources, which would compromise member privacy. Opioid abuse and dependence are also considered ‘sensitive conditions’ with additional restrictions on revealing that information to outside sources.
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