The Centers for Medicare and Medicaid Services (CMS) have focused for years on identifying opioid-treated beneficiaries at risk for serious harm such as overdose or addiction. Their approach has concentrated on patients prescribed high daily doses of opioids who also have indicators of opioid misuse or abuse, such as ‘doctor shopping’ (multiple prescribers and pharmacies).
A recent U.S. Government Accountability Office (GAO) report found that these criteria detected fewer than five percent (4.6%) of opioid-treated Medicare beneficiaries on high daily doses of opioids in 2015 who were at risk for serious harm, even after CMS reduced its ‘high’ dose threshold from 120 mg morphine equivalents per day to the 2016 CDC bar of 90 mg.
Consistent with the GAO findings, a Venebio study of more than 18 million opioid-treated patients in a commercial health plan database (IMS PharMetrics Plus) found no diagnosed substance use disorder – for opioids, other controlled medications or illegal drugs – in the majority of individuals (61%) who nevertheless experienced a serious opioid overdose. On the contrary, many unintentional overdoses occur in older individuals with certain health conditions or other medications that increase their susceptibility to the adverse effects of prescription opioids – particularly if the total daily dose is high.
We encourage CMS to broaden its efforts to identify and address those at risk for serious harm among the 95% of Medicare patients prescribed high daily doses of opioids who do not have an opioid use disorder (misuse, abuse or addiction). Fortunately, predictive analytic tools such as Venebio Opioid AdvisorTM are available that can accurately predict the risk of overdose in opioid-treated patients based on multiple risk factors. Patients at high risk can be prioritized for implementing risk-reducing measures that can prevent overdose and save lives.
 Nadpara P., A. Joyce, E.L. Murrelle, N.C. Carroll, N.V. Carroll, M. Barnard, B. Zedler. Risk factors for serious prescription opioid-induced respiratory depression or overdose: comparison of commercially insured and Veterans Health Affairs populations. Pain Medicine, 2017.