Sustained Prescription Opioid Use Among Previously Opioid-Naive Patients Insured Through TRICARE (2006-2014)

The rising number of patients dependent on prescription opioids and illicit narcotics has gained national attention recently.^1-4 Widely referred to as the “opioid epidemic,” the annual cost of treating prescription opioid use and abuse exceeds $50 billion per year.² The initial event associated with exposure to prescription opioids has not been widely explored, but is often maintained to stem from an injury or surgical procedure.^1-4 We sought to evaluate the medical diagnoses linked with an opioid prescription that resulted in sustained opioid use in a large cohort of Americans insured through TRICARE. This population may be comparable to the proportion of the general public at greatest risk of sustained opioid use.⁵

A query of the Military Health Data Repository⁵ was performed to identify all patients (age, 18-64 years) insured through TRICARE (calendar years 2006-2014) who received a prescription for class II or III opioid analgesics and who were also opioid naive (ie, no use of prescription opioids for 6 months before receipt of a new prescription for a class II or III agent)⁴ at the time the prescription was issued. TRICARE is the insurance plan of the US Department of Defense and provides health care coverage for over 9 million beneficiaries.⁵ Approximately 20% of the covered population is active duty military, with the remainder composed of retirees, disabled personnel, and dependents.⁵ Care for TRICARE beneficiaries can be administered through military or civilian medical centers.⁵ This study was approved by the Partners Healthcare Institutional Review Board with a waiver of consent before commencement. Data were deidentified.

Opioid-naive individuals identified as having received an opioid prescription were assessed for sustained opioid use, defined as continuous refills of class II or III opioid medications without a lapse between prescriptions of 7 days or longer for up to or exceeding 6 months. Patients who met these criteria had the primary diagnosis associated with the first opioid prescription recorded, the environment of care where the prescription was issued, and whether the encounter was outpatient or inpatient and/or associated with a procedure. Diagnoses were recorded according to International Classification of Disease, Ninth Revision (ICD-9) codes. Diagnoses with frequencies greater than 10 in the cohort were categorized by class of condition. Patients with a diagnosis of cancer associated with their first opioid prescription were excluded.

We identified 117 118 patients who met the criteria for sustained prescription opioid use. Only 800 individuals (0.7%) received their initial opioid prescription following an inpatient encounter, with 458 (0.4%) having undergone an inpatient procedure. The most common diagnosis associated with the initial opioid prescription for the entire cohort was other ill-defined conditions (35 824 [30.6%]) (ICD-9 code 799.89). The most frequent diagnosis among patients treated in military facilities was lumbago (ICD-9 code 724.2) (Table 1). Spinal conditions were among the most frequent diagnoses in both civilian and military settings. Among specific categories of conditions associated with the initial opioid prescription (Table 2), spine and orthopedic disorders were the most prominent.

As we search for causes of the opioid epidemic, we note that hospital events and associated procedures do not appear to be the main drivers. In this cohort, most of the diagnoses used to support the issue of an opioid prescription that led to sustained use were either nonspecific or associated with spinal or other conditions for which opioid administration is not considered standard of care.^3,6 We acknowledge limitations of the study, including retrospective design and reliance on insurance claims. The population under study may also not be representative of the entire US demographic, especially those 65 years or older. Improved adherence to best practices in opioid prescribing⁶ and requirements for better documentation of the rationale for such prescriptions may reduce the risk of sustained use.

Accepted for Publication: May 14, 2017.

Corresponding Author: Andrew J. Schoenfeld, MD, MSc, Center for Surgery and Public Health, Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115 (ajschoen@neomed.edu).

Published Online: August 16, 2017. doi:10.1001/jamasurg.2017.2628

Author Contributions: Dr Schoenfeld had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Schoenfeld, Chaudhary, Scully, Koehlmoos, Haider.

Acquisition, analysis, or interpretation of data: Schoenfeld, Jiang, Chaudhary, Koehlmoos, Haider.

Drafting of the manuscript: Schoenfeld.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Schoenfeld, Jiang, Chaudhary, Scully, Haider.

Obtained funding: Koehlmoos, Haider.

Administrative, technical, or material support: Schoenfeld, Koehlmoos, Haider.

Study supervision: Schoenfeld, Haider.

Conflict of Interest Disclosures: Dr Schoenfeld has received grants from the Orthopaedic Research and Education Foundation and Robert Wood Johnson Foundation, royalties from Wolters-Kluwer Health and Springer Publishers, and has served as a paid consultant for Arbormetrix LLC and member of the board for the Journal of Bone and Joint Surgery. No other disclosures were reported.

Funding/Support: This research was supported by a grant from the Department of Defense (DoD) and the Henry M. Jackson Foundation of the DoD.

Role of the Funder/Sponsor: The DoD and the Henry M. Jackson Foundation were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.

Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences or the DoD.