Multiple Providers Prescribing Opioids in Medicare Patients

The expansion of prescription opioids among adults >65 years of age may be an indication of a fragmented healthcare system, in which patients receive opioids from multiple physicians who do not or cannot communicate with one another, according to a recent study [BMJ. 2014; DOI:10.1136/bmj.g1393].

The study focused on the prescription drug claims of a 20% random sample of Medicare beneficiaries who had Medicare Part D coverage in 2010. The data was obtained through the Centers for Medicare & Medicaid Services. Beneficiaries were included in the study if they resided in the United States, were continuously enrolled in Medicare during 2010, filled at least 1 prescription for an opioid that year, and had provider information for all filled opioid prescriptions.

Of the 20% sample, 5,214,910 Medicare beneficiaries had continuous enrollment during 2010. Only 34.7% of individuals with continuous enrollment filled at least 1 opioid prescription within the year, resulting in a final sample group of 1,808,355 Medicare beneficiaries.

The most commonly prescribed opioids among this group were hydrocodone with acetaminophen (paracetamol; 42.9% of all claims), oxycodone with acetaminophen (11.6%), tramadol (11.9%), oxycodone (7.4%), morphine sulfate (4.5%), and fentanyl (4.2%). Formulations for antidiarrheal and antitussive purposes were excluded, and information on the indication for which the opioid was prescribed was unavailable.

Beneficiaries were categorized based on if they filled only 1 prescription for an opioid or filled ≥2 prescriptions from a single provider or from 2, 3, or ≥4 providers. The researchers conducted 4 descriptive analyses: (1) after determining the frequency with which beneficiaries filled opioid prescriptions from multiple providers, they described the characteristics of patients who filled prescriptions from a single provider versus multiple providers; (2) they estimated the mean number of opioid prescriptions provided by a beneficiary’s dominant provider versus other providers; (3) they estimated the proportion of beneficiaries who received concurrent opioid prescription from ≥2 providers; and (4) they analyzed the distribution of opioid prescriptions across physician specialties and nonphysician providers.

Of the 1,808,355 Medicare beneficiaries with at least 1 filled opioid prescription in 2010, 418,530 beneficiaries (23.1%) filled opioid prescription from 2 providers, 171,420 (9.5%) from 3 providers, and 143,344 (7.9%) from ≥4 providers. The average number of opioid prescriptions increased as the number of providers increased from 2, 3, and ≥4 providers, with 7.1 (standard deviation [SD], 7.1), 10.1 (SD, 7.9), and 15.2 (SD, 9.8), respectively. The frequency of concurrent prescribing increased with the number of providers.

In total, women filled more opioid prescriptions than men (1,144,080 vs 1,808,355; 63.3%), and of the participants who were <45 years of age, 16.3% filled prescriptions from ≥4 providers, 6.5% from 3 providers, and 8.9% from 2 providers.

Beneficiaries who lived in nonmetropolitan areas, received low-income subsidies, or were dually eligible for Medicare and Medicaid were less likely to fill opioid prescriptions from multiple providers.

A positive association between multiple provider prescribing and annual rates of admission to the hospital-related opioid use was observed in both the unadjusted and adjusted analyses (Please see Table below). Of the beneficiaries with 1 unique provider, 1.63% (unadjusted) had an opioid admission in 2010 compared to 2.08% of beneficiaries with 2 providers, 2.87% of beneficiaries with 3 providers, and 4.83% of beneficiaries with ≥4 providers.

Limitations noted by the researchers included: (1) the sample of prescribed opioid information was restricted to Medicare patients rather than all individuals in the United States who were prescribed opioids; and (2) the reason for multiple provider prescribing could not definitively be determined as appropriate prescribing, fragmented care, or doctor shopping.

The researchers concluded that educating patients about the risks of obtaining prescription opioids from multiple providers combined with “enhancement of state efforts to monitor prescription drugs that allow access by providers to prescription databases at the point of care might be useful in curbing this practice.”