The opioid epidemic: How population health analytics can combat the crisis overtaking America

In January 2017, the CDC reported more than 64,000 annual deaths related to drug overdose — a 21 percent increase from 2016 alone.1 To put this statistic into perspective, the number of drug overdose related deaths has now surpassed the peak of deaths from the AIDS epidemic, fatal car crashes and gun violence.2-3 Emergency departments and hospitals are being overloaded, with visits for opioid overdoses in EDs rising 30 percent in all parts of the U.S.4

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On October 26, 2017, the Trump Administration declared the opioid crisis a National Public Health Emergency.5 The economic impact of the opioid epidemic is also staggering. A 2016 study put the estimated total cost of prescription opioid addiction and overdose at $78.5 billion for 2013, with costs associated with lost productivity, criminal justice, substance abuse treatment, health insurance and fatalities.6 More recently Altarum, a healthcare research organization, reported the cost of the opioid epidemic to be $95 billion for 2016.7 When faced with the evidence, it is nearly impossible to disagree on one critical point — the opioid epidemic is real and it is sweeping the nation at an alarming rate, destroying families and communities in the process. This analysis will present a brief overview of the epidemic and how population health analytics can empower healthcare professionals to prevent and treat opioid addiction in communities around the country.

An opioid is an umbrella term for a category of drugs that range from common prescription painkillers such as oxycodone, to fentanyl — a synthetic opioid 100 times more potent than morphine — to street drugs such as heroin. The opioid epidemic includes addiction to prescription painkillers in addition to heroin. While overdose deaths from heroin and fentanyl are on the rise, deaths from prescription overdoses have increased by 400 percent among women and 265 percent among men since 1999. Estimates suggest an alarming 18 women die every day of a prescription painkiller overdose in the U.S.8 It is therefore important to monitor prescription opioids for potential misuse in addition to illicit opioid drug use.

Analyze the problem & set organizational goals

Nationwide, Medicaid patients represent 38 percent of nonelderly adults with opioid addiction, commercial insurance represents 37 percent, uninsured represents 17 percent and 8 percent are unknown.9 Regardless of the type of healthcare organization or health plan, almost all are facing the battle with opioids. As with any other epidemic, the first and most important step is getting access to meaningful, actionable data. A challenge that exists in healthcare today is the misunderstanding of current clinical practice due to a lack of transparency into the data for a provider's patient population. It is critical for data to be actionable, accurate, and easily accessible to formulate a successful plan for changing clinical practice; inaccurate or incomplete data can result in mistrust and impede change management strategies.

In order to evaluate how the opioid epidemic is impacting an organization or population of patients, an initial analysis should be completed to determine how many patients have a diagnosis of substance use disorder and identify those at high risk of potentially developing substance use disorder. Examples of further analysis could include the incidence of patients who are prescribed opioids, the average daily dose of opioids, and/ or the incidence of patients with a history of opioid overdose or chronic pain. Defining the problem specific to the practice, network, health system or health plan gives insight to defining the proposed solution and interventional goals.

Define the population & develop targeted interventions

Once goals are set, it is recommended to identify key stakeholders and clinical champions to drive the initiative and ensure accountability. Population health analytics can be a valuable tool for measuring success through creation of customized reports for provider feedback and audit, and developing patient cohorts, or populations, to do targeted interventions with.

After defining the population of patients, a strategic plan should include preventing the "spread" of substance use disorder to vulnerable populations and providing care to those with a current diagnosis of substance use disorder. This can be broken down into two main categories for the opioid epidemic: 1) Prevention of addiction, including education of prescribing habits and providing alternatives for chronic pain management, and 2) expanding treatment to patients addicted to opioid medications.

Develop a strategic plan for prevention of opioid addiction

After an internal review, it could be discovered there is an opportunity to implement an opioid stewardship program with a goal of reducing the incidence of a new diagnosis of substance use disorder. Population health analytics can be a valuable tool for implementing an opioid stewardship program. For example, a customized report could be created to evaluate prescriber compliance with CDC guidelines with opioid prescribing. This can be leveraged as an audit and feedback tool to educate providers about the prevalence and risk of opioid misuse within the organization, and how to use evidence-based recommendations for prescribing opioids. Morphine milligram equivalents (MMEs), for example, are a standardized way to compare the potency of various opioids compared to morphine. Daily MMEs exceeding 100 are associated with a 9-fold increase in overdose and MMEs exceeding 200 have a nearly 3-fold increase in risk of opioid-related premature death.10 The CDC's opioid prescribing guidelines include initially limiting prescription duration to 7 days and less than 50 MME/day.11

A cohort could also be created using population health analytics to track patients with a diagnosis of chronic pain and identify patients who might be appropriately referred to alternative therapies for chronic pain management, such as non-opioid medications or non-pharmaceutical options such as yoga, mindfulness, chiropractic manipulation, transcutaneous electrical nerve stimulation, acupuncture or physical therapy.

Expand access to care for treating substance use disorder

In addition to methods for prevention of addiction, expanding treatment to patients who have substance use disorder is recommended. Drug addiction is primarily defined by compulsive use despite harmful consequences — including the loss of work or harm to family units.12 Medication-assisted therapy (MAT) programs utilize methadone, buprenorphine and naltrexone to treat opioid dependence and addiction. These medications can help prevent the cycle of addiction that include euphoria, crash, and craving. Combining MAT therapy with support for psychosocial and behavioral needs, such as access to food, housing and employment is an ideal holistic approach. Using population health analytics, a cohort can be created to identify patients enrolled in a MAT program. Trackable procedures can also be monitored during treatment such as pill count, a prescription monitoring program, drug addiction treatment program agreement or contract and urine toxicity screening to check for illicit drug use.

Summary

Access to meaningful, actionable information across a large population of patients is the primary benefit of a population health analytics solution. Access to this data is critical for successfully combatting any epidemic, and the opioid epidemic is no different. Without access to data, healthcare professionals not only struggle to have a clear understanding of the problem, but they lack proper tools that provide a solution for preventing and treating opioid addiction.

Population health analytics can be used alongside MAT and opioid stewardship programs and can even assist with risk stratifying patients based on social determinants of health data to facilitate connection of patients to community resources. This data can help healthcare providers lead comprehensive and holistic health and wellness programs and improve care coordination. With the proper resources, population health analytics can empower healthcare professionals to combat the epidemic, relieve the economic burden, and prevent tragic consequences for patients and families across the nation.

References

  1. Centers for Disease Control and Prevention. Drug Overdose Data. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm (accessed 2018 May 22).
  2. The New York Times. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years (September 2017). https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html (accessed 2018 May 22).
  3. Centers for Disease Control and Prevention. CDC Fact Sheet: Today's HIV/AIDS Epidemic. https://www.cdc.gov/nchhstp/newsroom/docs/factsheets/ todaysepidemic-508.pdf
  4. Centers for Disease Control and Prevention. Vital Signs-Prescription Drug Overdoses. https://www.cdc.gov/vitalsigns/prescription-drug-overdoses.html (accessed 2018 May 22).
  5. White House Briefings Statements (October 2017). (https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-taking-actiondrug-addiction-opiod-crisis/ (accessed 2018 May 22).
  6. Florence C, Luo F, Xu L, Zhou C. The Economic Burden of Prescription Opioid Overdose, Abuse and Dependence in the United States, 2013. Med Care. 2016 October; 54(10): 901–906.
  7. Rhyan C. Altarum. The Potential Societal Benefit of Eliminating Opioid Overdoses, Deaths, and Substance Use Disorders Exceeds $95 Billion Per Year. https://altarum.org/sites/default/files/uploaded-publication-files/Research-Brief_Opioid-Epidemic-Economic-Burden.pdf (accessed 2018 June 6).
  8. Centers for Disease Control and Prevention. Prescription Painkiller Overdoses. https://www.cdc.gov/vitalsigns/prescriptionpainkilleroverdoses/index.html (accessed 2018 May 22).
  9. The Henry J. Kaiser Family Foundation. Medicaid's role in addressing the opioid epidemic (2018 February). http://files.kff.org/attachment/INFOGRAPHIC-MEDICAIDS-ROLE-IN-ADDRESSING-THE-OPIOID-EPIDEMIC (accessed 2018 May 22).
  10. Dunn K, Saunders K, Rutter C et al. Overdose and prescribed opioids: associations among chronic non-cancer pain patients. Ann Intern Med. 2010; 152:85-92.
  11. Centers for Disease Control. CDC Guidelines for Prescribing Opioids for Chronic Pain – United States, 2016. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm (accessed 2018 May 25).
  12. National Institutes of Health - U.S. Department of Health and Human Services. Principles of Drug Addiction Treatment, 3rd Edition.

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