In this episode, Milliman’s Stoddard Davenport and Joseph Boschert discuss their latest research on opioid use in the United States, including underdiagnoses and how how advanced analytics can help predict whether a a patient may develop opioid use disorder.

Transcript

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Rebecca Driskill: Hello, and welcome to Critical Point brought to you by Milliman. I'm Rebecca Driskill and I'll be your host today. We're recording this episode of Critical Point from Milliman's Health Consultants Forum in Orlando, which is a gathering of all the firm's health consultants from around the globe. Joining us today is Stoddard Davenport from Milliman's Denver office and Joseph Boschert from our Milwaukee office. They both do extensive research and analysis around opioids and opioid use disorder. It's a topic that's often in the news. Today we're going to talk about some of Milliman's research on the subject and look at a few key data points around opioid use disorder and what predictive analytics might be able to tell us about opioid use in our country. So Stoddard, Joseph, welcome to the show.

Joseph Boschert: Thanks.

Stoddard Davenport: Thanks for having us.

Rebecca Driskill: Yeah, thanks for coming. We are talking about opioid use disorder, which seems like a newer term, to replace this idea of, this term "opioid addiction." Is that right?

Stoddard Davenport: Yeah, that's right, and I think really that's a reflection of the idea that the language that we use both kind of reflects and influences the way that we approach important health issues. So "opioid use disorder" and using that term is kind of a reflection of our interest in using terms that help us see this as a public health problem and a human problem rather than sort of a problem of criminal justice or other things like that. So opioid use disorder is a term that's both meant to be more inclusive of the various ways that opioid use can be problematic in a person's life, whether that be health effects or overdose or addiction, dependence, or impacts in their school, work, or home life, and we're getting away from words like "addiction" and "abuse" and things like that because that sort of stigmatizes patients and discourages them from seeking help.

Joseph Boschert: Yeah, and some of the terms that have been used in the past, like "substance abuse," today they might use the term "substance use disorder," or things like the person or the patient is "clean"-- instead of that, it might be the person or the patient is "in recovery." So it's just more, like Stoddard was saying, a little bit more inclusive terms, less kind of sharp tones.

Rebecca Driskill: Well, thank you. That makes a lot of sense. That's a great clarification. You guys have done a lot of research around opioid use disorder and one data point that I wanted to mention is that Milliman estimates there are approximately 1.5 million insured people-- and by that we mean commercially insured, Medicare, or Medicaid, is that right?

Stoddard Davenport: Right.

Rebecca Driskill: So who have been diagnosed with opioid use disorder in the U.S.? Can you guys talk a little bit about that number and also the fact that it doesn't actually tell the whole story?

Stoddard Davenport: Yeah, that's right. So within that one and a half million, we see roughly equal numbers of people between Medicaid and commercial insurance. The prevalence rate is higher in Medicaid, but in terms of absolute numbers, we've got a little over 600,000 people with commercial insurance, a little over 600,000 with Medicaid, and then the reminder, about 250,000, with Medicare. And this is kind of a problem that affects everybody all over the United States, all age groups. There's really not a sector of society kind of left unscathed here, but we do see a higher prevalence of opioid use disorder among young men and older women. So it's kind of something that's got some interesting dynamics over time. But interestingly, I wanted to highlight that other data, like National Survey on Drug Use and Health, shows that there are 11.5 million people that report misusing opioids in a year, and so you could say that there's a lot of people with what we might call "high-functioning” opioid use disorder that are perhaps on the verge of developing more severe outcomes. Some of the research that we've done has found about 1.8 million people without diagnosed opioid use disorder who had prescription opioids for 75% of the year, and another 900,000 who had a 360-day supply within a year, and another quarter million that had over 75,000 morphine milligram equivalents in a year. So that's kind of a measure that levels the playing field between different potencies of drugs. So we have a significant number of people that are perhaps kind of on the verge of being recognized as having a diagnosed use disorder here that, I think, should be on our radar as well.

Joseph Boschert: Yeah, and one of the other things that we've been seeing in the data, specifically from the CDC, is that a lot of the opioid prescriptions are stabilizing, or even dropping, but what you're really starting to see is this hockey-stick growth of the illicit drugs, like fentanyl, which are definitely a lot more potent and a lot more dangerous. So those synthetic opioids are really, really starting to take off in a lot of communities around the country.

Rebecca Driskill: So what goes into an opioid diagnosis, like how does somebody-- how is somebody diagnosed with opioid use disorder?

Joseph Boschert: Yeah, so there's a standard criteria that DSM-V uses, and basically there's a set of questions. Some of these questions include like there's a craving or a strong desire or urge to use opioids. There's a persistent desire to-- or unsuccessful efforts to cut down or control opioid use, and basically a clinician will go through these questions and if they have so many of these questions marked, then that's when they formally get the diagnosis.

Rebecca Driskill: Got it. So if a person is diagnosed with OUD, or opioid use disorder, are they then cut off from taking opioids? Let's say they were on prescription medication for pain. Is that just it?

Stoddard Davenport: Yeah, so not necessarily, and I think one of the key issues that providers and clinicians need to grapple with is that once a person has developed a dependence on an opioid, it's exceptionally difficult to taper them in a way that is safe and effective. Some of the research that we've done has found that diagnosed opioid use disorder patients are still prescribed a lot of opioids, whether we're looking at supply or potency or coverage over the course of the year. So we found that one in three opioid use disorder patients are still prescribed opioids for 360 days or greater over the course of a year, and most commonly with 30-day supplies. So that's about 12 30-day supplies over the course of a year-- so essentially kind of full coverage there over the entire calendar year-- and over one in six are still prescribed dosages that exceed the CDC's recommended potency guidelines for chronic pain management of about 90 morphine milligram equivalents a day, and there's some kind of debate among clinicians about whether or not that standard is appropriate for folks that have adapted to having opioids in their system, but it's still kind of concerning.

Joseph Boschert: It's very-- there is no silver bullet in terms of, "Boy, you just give them this one therapeutic strategy and that solves everything." Like, "Just go give them physical therapy," or have them go into cognitive behavioral therapy. There is no one single thing, at least that the medical research points to, to show, "Hey, this is what ought to be done." It's likely a combination of all these different things, and it is a very challenging problem to solve.

Rebecca Driskill: There's also-- we talk a little bit about prescriber variation being a problem as well.

Joseph Boschert: Yeah. So, yes, exactly. So there's been some studies that show, even within a certain procedure, there's a wide variation, prescriber variation, in terms of how many opioids patients postoperatively received, and that's just one procedure, for example. There are many, many different procedures and the variation is kind of going all over the place. So physicians and prescribers are really trying to work to figure out what those best practices are, very specifically to help curb some of the problems here.

Rebecca Driskill: So let's talk a little bit about this connection between chronic pain and opioid use. Stoddard, you have a key data point on chronic pain, is that right?

Stoddard Davenport: Yeah, that's right, and I think my interest here is to make sure that we keep the conversation around how we respond to the opioid epidemic, focused on patients, focused on treating those that have significant health needs, and not just sort of have these knee-jerk reactions, and we hear there's a problem and slap the prescription out of somebody's hand. So kind of as a backdrop to everything that's going on here, we need to understand that studies have shown that over 25 million Americans report experiencing chronic pain on a daily basis. That's a significant number and a significant amount of pain, and leaving patients with uncontrolled pain is associated with a range of adverse outcomes. It puts folks at higher risk for depression, PTSD-like symptoms, and even suicidality, and we need to make sure that we keep things like this in mind as we tackle this problem, and responsible prescribing is extremely important, but chronic pain patients can often feel criminalized by the way that we respond to this crisis, if we're overzealous and not thoughtful enough about how to keep the solutions patient-focused. I've been hearing more and more reports lately of patients that have experienced the forced tapering, where a provider lowers their dose of opioids kind of without necessarily their full consent or agreement, and in cases when that happens, there's a higher risk for suicidality and a higher risk of transitioning from prescription opioids to illicits, and when that happens, the risk of overdose is significantly higher, and it can start a whole cascade of significant events that puts people kind of at greater risk than they would have been kind of with managing their existing opioid use. So it's definitely something that we need to be careful of and keep in mind as we figure out how to deal with this crisis.

Joseph Boschert: There is no-- if we look at all the different therapeutic options that are available-- it could be physical therapy, could be an opioid tapering strategy, could be a medication-assisted therapy like buprenorphine, could be some type of psychological support like cognitive behavioral therapy, could be an alternative pain-- like chiropractic and alternative medicine. There is not a study or a bunch of studies that show, "This one path is the path to take." And so that's where the science is not there yet, and we're still trying to figure this out in terms of how to treat these people with chronic pain.

Rebecca Driskill: One of the things you guys had mentioned to me that I think is an interesting fact is that it can actually be much easier to get access to opioids themselves than treatment for opioid use disorder.

Stoddard Davenport: Right. So historically, it has been much easier to access prescription opioids than to access treatment for opioid use disorder, and one of the key sort of front-line, gold-standard treatments for opioid use disorder is called medication-assisted treatment, and this is where patients are provided another opioid in a different class, called partial agonists, that doesn't produce the full opioid effect but binds to the opioid receptors in the body and blocks the reception of full opioids. So they're longer lasting than full opioid drugs are, and they prevent kind of the sense of euphoria or the respiratory depressions that are associated with significant risk for adverse health outcomes. But the problem with Buprenorphine and Methadone and Naltrexone-- these are some of the big three medication-assisted treatment drugs-- the problem is that the number of providers that are able to deliver those is extremely limited. Buprenorphine, for example, requires providers to go through a DEA waiver process. There are stigmas and sort of structural barriers that prevent physicians from being interested in having that kind of a service within their practices. And then, yeah, like you mentioned, kind of the issue of it being easier to work with payers to get opioid prescriptions paid for than to get treatments for opioid use disorder paid for is also kind of a significant driver and kind of alters some of the incentives that providers have around the provision of those kinds of drugs.

Joseph Boschert: Yeah, and after somebody has been diagnosed with opioid use disorder, some of our analysis both internally as well as some of the external literature shows that it's a lot more expensive after they've been diagnosed, anywhere between $7000 to $10,000 per year. So it's an expensive problem, and payers have to deal with this, whether you're a commercial payer or you're an employer or you're a Medicare program or Medicaid. They're all grappling with this issue. So I think the more we can get ahead of the problem, the better, because there's nothing worse than a bunch of adverse events that increase the cost and then obviously lead to worse health outcomes.

Rebecca Driskill: Is there often like a common event that leads to a diagnosis?

Joseph Boschert: Yeah. I mean, oftentimes it'll be a hospitalization of some sort. Maybe there's some type of respiratory failure because they overdosed. Stoddard, I don't know if you have any other insight on that.

Stoddard Davenport: Yeah, I agree. I think for a lot of patients, it's kind of a low point in their experience with opioids that leads to some kind of encounter with the healthcare system where the problem is finally recognized, and the good news after that happens though, if there could be any good news, is that then that person's significant health concern they have here with opioid use disorder has now entered kind of into their administrative record, and it's something that we can now see and we can understand that they are at risk and we can begin to work and manage that more. So they sort of come from being in this population of folks that are at risk to a population of folks that we actually know about and can begin to try to work with to improve outcomes.

Rebecca Driskill: Well, and I think that that's interesting because it sort of ties back to what you were saying at the beginning of the podcast, which is that there is this sort of-- it's almost like this iceberg underwater of a population that is at risk for opioid use disorder but it hasn't been formally diagnosed. One of the things that's been-- that I think is really interesting about some of the research you guys are doing is that there are ways of looking at risk factors for developing opioid use disorder. Is that right, and can you talk a little bit about that?

Joseph Boschert: Yeah. So whether it's our analysis or, again, just some of the medical literature out there, there's a lot of things that contribute. One, if they have a history of behavioral or mental health issues, whether that's mood disorders or anxiety disorders, bipolar-- those things definitely have a role. If they have a previous history of substance abuse problems, no matter the drug, that can often be an indicator. If they have a lot of chronic pain conditions, like back pain-- another big signal there. Certainly certain geographic areas where it's more socially acceptable-- so a lot of the Appalachian areas, where it's just more prevalent, the use-- that can be an indicator. And then obviously if you are prescribed a high amount of what's called milligrams morphine equivalent, MME, that's going to be another-- a high risk factor as well. So yeah, all of these things can play into an increased risk of OUD for an individual.

Rebecca Driskill: Is there a way that technology or predictive analytics can be applied here to benefit patients?

Joseph Boschert: Yeah, absolutely. I think this is an area that's ripe for machine learning and predictive analytics. So we've been working with some cutting-edge predictive analytics tools that basically very quickly, efficiently, accurately screen all of those individuals, or those patients at risk, considering all of their prior medical history, all of the diagnoses they've had and the procedures and drugs they're taking. And so you can think of it like a risk score, right? When you go to a bank and you take out a loan, there's generally a credit risk score-- same type of thing here, where you can have an opioid risk score to identify what that risk is of continuing to prescribe them opioids or even starting them on that type of therapy, and really help inform prescribers to make the best decision possible. Also it can be used in the context of payers, when they have a medical management team that helps manage the members on a plan-- again, a perfect use case for using machine learning, using large amounts of data to identify what the risk is for that specific individual. But again, pain is one of those things that's really hard to objectively measure, and it really comes down to the prescriber and the patient relationship and figuring out what the best path forward is.

Stoddard Davenport: Yeah, I just want to underscore again that I think-- the importance of seeing this as a public health problem that we can approach through the healthcare system and through addressing determinants of health rather than sort of relegating it to the substance abuse and to the criminal system, and sort of externalizing it to other parts of society. We don’t do that with other health conditions, and we'll be better off if we don't do that here as well, and I think we want to keep the way that we address this patient-centered and focused on supporting those that are working on recovery, and make sure that we're thoughtful in our responses and not respond in a knee-jerk fashion to all the-- what can be scary information about the way things are going right now.

Rebecca Driskill: Thank you, Stoddard and Joseph for joining us. You've been listening to Critical Point, presented by Milliman. To listen to other episodes of our podcast, visit us at Milliman.com, or you can find us on iTunes, Google Play, Spotify, and Stitcher. We'll see you next time.