Effectiveness of a Retrospective Drug Utilization Review on Potentially Unsafe Opioid and Central Nervous System Combination Therapy

BACKGROUND: Drug overdose deaths are the leading cause of unintentional death in the United States, and opioid-related mortality is the primary contributor (75.2%). Among opioid-related mortalities, opioids are most commonly taken with benzodiazepines (30.1%) and antidepressants (13.4%). The utility of a retrospective drug utilization review (DUR) program initiated by a commercial health plan for members taking potentially unsafe opioid and central nervous system (CNS) combination therapy is currently unknown. OBJECTIVE: To determine the effectiveness of a retrospective DUR program on potentially unsafe opioid and CNS combination therapy. METHODS: This research is a pre-post study utilizing pharmacy claims data from 2.6 million commercially insured members enrolled in a health plan in the Midwest. Members were required to be at least aged 18 years as of August 30, 2013, and continuously enrolled from May 2, 2013, through February 15, 2014. Members with 1 or more paid claims for an opioid at least 200 morphine equivalent dose (MED) daily and a concurrent supply of another opioid, benzodiazepine, or antidepressant from May 2, 2013, through August 30, 2013 (120-day preintervention period) were targeted for the retrospective DUR program. These exclusion criteria were applied: members belonging to commercial groups requiring permission on claims data analyses, missing or invalid prescriber information, or presence of pharmacy claims indicating human immunodeficiency virus or acquired immunodeficiency syndrome during the 2 years prior to the pre-intervention period. Prescribers of high-dose opioids received a mailing (intervention) containing a member-specific letter, medication profile, and satisfaction survey to determine the prescriber-perceived clinical value of the program. To assess the effectiveness of the retrospective DUR program, criteria was reapplied to identify members still meeting criteria 120 days postintervention (February 15, 2014). Paired samples t-test was used to compare pre-post results. RESULTS: Of 2,236,243 eligible members aged 18 years and older, 980 met DUR criteria. Prescribers for these members subsequently received a mailing regarding potentially unsafe opioid and CNS combination therapy. A total of 671 prescribers were sent a mailing regarding these 980 members. Among the 980 members meeting DUR criteria, distribution of prescriber specialty was family medicine (25.9%), physical medicine and rehabilitation (14.4%), internal medicine (13.0%), pain (9.2%), anesthesiology (7.0%), other (8.8%), and unknown (21.7%). High-dose opioids most commonly identified by the DUR were oxycodone extended release (27.6%), morphine sulfate extended release (17.7%), and fentanyl patch (13.1%). After reapplying DUR criteria to identify members still meeting criteria 120 days after the DUR, 528 members remained, representing a 28.1% reduction in high-risk opioid use. Survey response rate was 23.6% (231 of 980 surveys returned). The majority (62.3%) of respondents reported that this retrospective DUR program was useful in their daily practice. CONCLUSIONS: A 28.1% reduction in potentially unsafe opioid and CNS combination therapy was observed after implementing a retrospective DUR program targeting high-risk opioid use. Among members remaining high risk after the DUR, the change in total unique opioids and total daily MED was nonsignificant. Members remaining at high risk after the DUR can be targeted for further interventions such as care management and member education regarding fraud, waste, and abuse. A majority of prescribers (90.5%) self-report using their states’ prescription monitoring programs when prescribing controlled substances.