Opioid prescribing by multiple providers drives up patient hospitalization rate

More than 30% of Medicare Part D beneficiaries who receive opioid prescriptions are prescribed them from multiple providers, according to a study published in the British Medical Journal. This practice, which goes against recommended guidelines of a single provider prescribing opioids for a patient, was found to be associated with higher rates of opioid-related hospitalization.

“Among patients utilizing the same quantity of prescribed opioid medications over the course of a year, those who received prescription opioids from four or more unique providers had twice the annual rate of hospitalization than those who received prescription opioids from only one provider [3.2% vs 1.6% hospitalized in a year],” said study co-author Pinar Karaca-Mandic, assistant professor at the University of Minnesota School of Public Health, and colleagues, in the Feb. 19 report published online.

Through an agreement with the Centers for Medicaid & Medicaid Services (CMS), the researchers obtained data on the prescription drug claims of a 20% random sample of Medicare beneficiaries who had Part D coverage in 2010. They identified prescription claims corresponding to an opioid medication (complete or partial opioid agonists and combination formulations) according to National Drug Code. Drug claims were linked to information on each individual provider who prescribed the medication, according to a unique encrypted provider identifier.

The study included all beneficiaries who lived in the United States, were enrolled in Medicare during 2010, filled at least one prescription for an opioid that year, and had provider information for all filled opioid prescriptions. More than 1.8 million beneficiaries were included in the study. 

Study adverse outcomes

In order to study adverse outcomes associated with prescribing of opioids by multiple providers, the researchers estimated a beneficiary-level logistic regression of the association between multiple-provider prescribing and any opioid-related hospitalization in 2010.  Hospitalizations were identified from the linked Medicare Provider Analysis and Review file–a data file obtained through agreement with CMS–which includes claims for all inpatient services used by traditional Medicare beneficiaries. Based on prior studies, opioid-related hospitalizations were identified from inpatient diagnosis codes for opioid drug dependence, opioid poisoning, respiratory failure, drug-induced mental disorders (including alternation of consciousness and hallucinations), constipation, and malaise, fatigue, or lethargy.

According to Karaca-Mandic, while prescribing by multiple providers may often be appropriate, nearly one-quarter of Medicare beneficiaries with more than one opioid prescription in 2010 received prescriptions from two providers, 9.5% from three providers, and 7.9% from four or more providers. Receiving concurrent opioid prescriptions from multiple providers was common, with almost 29% receiving them from two providers, with more than 50% from patients who had three providers, and more than 75% receiving them who had four providers.

“Opioid prescribing by multiple providers is associated with higher rates of opioid-related hospitalizations,” Karaca-Mandic said.

 The researchers found that the more providers prescribing opioids, the higher the rate of opioid-related hospitalizations. Among beneficiaries with one provider, the opioid rate of hospitalization was 1.63%, compared to a rate of  2.87% with three providers and 4.83% with four or more providers.

“For physicians and other healthcare professionals, our findings not only highlight the dramatic prevalence of multiple-provider opioid prescribing among the elderly and disabled, but more importantly demonstrate the adverse health outcomes associated with this fragmented prescribing,” Karaca-Mandic continued.  “Our findings reinforce the need to educate patients about the risks associated with obtaining opioid prescriptions from multiple providers, combined with enhancement of state prescription drug monitoring efforts which allow access by providers to prescription databases at the point of care, may be useful in curbing opioid prescribing by multiple providers.”

“Beneficiaries receiving opioids from multiple providers are also more likely to be prescribed other medications that have high rates of adverse effects and misuse,” Karaca-Mandic said.  

These other medications that are potentially inappropriate for the elderly and disabled included benzodiazepines, antipsychotic drugs, and skeletal muscle relaxants, she noted.