Providers Are Inappropriately Prescribing Opioid-Tolerant Only Medications

Molly Moore Jeffery, PhD

Most patients who initiated in opioid-tolerant only medications did not have evidence of prior tolerance, according to new study findings.

The findings suggested that such patients were at an increased risk of opioid-related harms, including fatal overdose.

Molly Moore Jeffery, PhD, and colleagues used a national database of deidentified longitudinal health information to measure prevalence of opioid tolerance in patients who initiated opioid-tolerant only medications. The team aimed to determine whether linked electronic health record (EHR) data contributed evidence of tolerance not found in insurance claims.

Jeffery, from the Division of Health Care Policy Research at Mayo Clinic, and a team of investigators collected data from the OptumLabs Data Warehouse, which included >100 million individuals. The team used 3 types of data: insurance claims, structured EHR data, and unstructured clinical notes. With the data, the team was able to collect information on inpatient stays; opioid analgesic prescription fills; clinical procedures; treatment details; and diagnoses.

The investigators used 3 cohorts in the study, 1 created using only claims data, a second using structured EHR data linked to claims; and a third using a subset of the structure EHR data and unstructured clinical notes linked to claims. The goal in each cohort was to select patients initiating the use of 1 of the medications included in the analysis between January 2007 and December 2016.

The primary measure was opioid tolerance at the beginning of opioid-tolerant only episodes. Tolerance was defined based on the labeling requirements for the medications: >30 mg oxycodone equivalents on each of 7 days prior to the start of the episode.

Overall, the investigators identified 153,385 opioid-tolerant only medication episodes. More than half (58%) occurred among women, 41% among patients with Medicare Advantage insurance, and 47.8% occurred in the South.

Less than half of the episodes (47.7%) involved patients with evidence from claims data of opioid tolerance before starting treatment with an opioid-tolerant only medication. Nearly 31% of the episodes involved transdermal fentanyl, 64% involved transmucosal fentanyl, 84% involved extended-release oxycodone, and 62.5% involved extended-release hydromorphone.

Less than 1% of episodes identified in claims linked with EHR and claims data had evidence of opioid tolerance in structured EHR data that were not present in claims data (.5%).

Jeffery and the team limited the sample to opioid-tolerant only episodes identified in claims with a matching prescription within 14 days in the structured EHR data. Only 4% happened among patients with evidence of tolerance that was not present in claims data.

Because most patients who initiated opioid-tolerant only medications did not have evidence of prior tolerance, the findings suggested they were at increased risk of opioid-related harms and fatal overdose. EHR data did not lead to substantial additional evidence of tolerance aside from what was found in prescription claims.

Additional research should be conducted to learn the clinical rationale behind such prescribing patterns and to quantify risk of harm to patients associated with potentially inappropriate prescribing.

The study, “Assessment of Potentially Inappropriate Prescribing of Opioid Analgesics Requiring Prior Opioid Tolerance,” was published online in JAMA Network Open.