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Initial Opioid Prescribing at High Dosage (IOP-HD)

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Description

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The percentage of individuals ≥18 years of age with ≥1 initial opioid prescriptions with an average daily morphine milligram equivalent (MME) of ≥50.

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A lower rate indicates better performance.

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Additional Information

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Intended Use

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Performance measurement for health plans.

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Data Sources

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Prescription and medical claims data.

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Denominator

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Individuals ≥18 years of age with a negative medication history for any opioid medication during the 90-day lookback period.

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Exclusions

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Hospice, cancer, and sickle cell disease.

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Numerator

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Individuals from the denominator with an average daily morphine milligram equivalent (MME) of ≥50 within any opioid initiation period.

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Rationale

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' + 'Opioid misuse, addiction, and overdose are a public health crisis affecting social and economic welfare in the United States.' + '' + 'More than 130 Americans die each day following an opioid overdose.' + '' + 'Although recent increases in fatal opioid overdose have been driven by illicit drug use' + '' + ', prescription opioids for pain management remain a contributing factor to the crisis.' + '' + ' Approximately 21% to 29% of patients prescribed opioids for chronic pain misuse them,' + '' + ' and the majority of heroin users began with prescription opioids.' + '' + 'In response to the opioid overdose epidemic, a public health emergency was declared in 2017 by the United States Department of Health and Human Services.' + '' + '

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' + 'High-dose initial opioid prescriptions are associated with a higher likelihood of long-term opioid use' + '^,^,^,' + ' which is linked to greater risks of abuse and overdose. The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends that when opioids are started, clinicians should prescribe the lowest effective dosage. The guideline recommends that clinicians use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when increasing dosage to ≥50 morphine milligram equivalents (MME) per day, and avoid increasing dosage to ≥90 MME per day or carefully justify a decision to titrate dosage to ≥90 MME per day. Although a single dosage threshold has not been identified to eliminate overdose risk, by holding dosages to <50 MME per day, a large proportion of patients would have reduced risk.' + '

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' + 'Recent studies provide additional support for the CDC recommendations. In 2017, Shah and colleagues examined the relationship between initial opioid prescription characteristics and the probability of opioid discontinuation in a retrospective cohort study using claims data from a nationally representative database of commercially insured patients.' + '' + ' They found that the higher the dose, the less likely an individual would discontinue opioid use: 25 to 49 MME (Hazard Ratio [HR], 0.97; 95% confidence interval [CI], 0.96-0.97), 50 to 89 MME (HR, 0.95; 95% CI, 0.94-0.95), and ≥90 MME (HR, 0.91; 95% CI, 0.91-0.92) compared with patients prescribed 0 to 24 MME. In addition, a 2018 study by Zhang and colleagues examined the association between initial opioid prescriptions and high-risk opioid use found that initial opioid prescriptions with daily MME of ≥50 (vs. <30) were associated with a 12.5-percentage-point increase (95% CI, 12.1-12.9) in the probability of having a daily dosage of ≥120 MME in the long term.' + '

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' + 'Despite these risks, initial opioid prescribing at high dosages remains prevalent in the United States. In 2019, Zhu and colleagues published an analysis using commercial administrative data to estimate the incidence of initial opioid prescriptions (i.e., no opioid prescription or a diagnosis of opioid use disorder in the 6 months before a given month) in each month between July 2012 and December 2017. Results of the study showed that although the number of initial opioid prescriptions declined and the number of prescribers who initiated opioid therapy decreased over time, a subgroup of prescribers continued to provide high-risk initial opioid prescriptions, defined as ≥50 MME/day, at a monthly rate of 115,378 prescriptions per 15,897,673 enrollees who had not used opioids.' + '

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' + 'Aligned with CDC recommendations and published evidence, this performance measure evaluates the percentage of individuals ≥18 years of age with ≥1 initial opioid prescriptions with an average daily MME of ≥50. Patients with cancer diagnoses and those receiving hospice care are excluded from the measure because of their unique therapeutic goals, ethical considerations, opportunities for medical supervision, and balance of risks and benefits. This measure was designed for retrospectively evaluating health plan performance at the population level and is not intended to guide clinical care for individual patients.' + '

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FAQs

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Individuals initiating opioid therapy must have a negative medication history for opioids—no prescription claims for opioids in the lookback period (90 days prior to each opioid prescription).

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Both the lookback period (45, 60, and 90 days) as well as the allowable days’ supply (no prescription claims vs <7 cumulative days’ supply) during the lookback period were tested. A 90-day lookback period with no prescription claims was identified as most appropriate based upon the testing results, the clinical research, and the consensus of the measure development team.

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The opioid initiation period is the period of time when the numerator is assessed. The opioid initiation period starts with any claim having a negative medication history for opioids and ends after 3-7 days, depending on the measure.

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The 7-day of the opioid initiation period, for the IOP-LA and IOP-HD measures, is based upon the CDC recommendation that ≤3 days of opioids will often be sufficient and that ≥7 days will rarely be needed for initiation of opioid therapy. However, for the IOP-LD measure, the measure development team considered the risks of including refills in the cumulative days' supply for the numerator and determined that 3 days would be most appropriate.

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If the opioid initiation period extends beyond the end of the measurement year, the opioid initiation period is truncated to the last day of the measurement year.

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Yes, individuals can have more than one opioid initiation period during the measurement year. Each prescription claim should be evaluated for a negative medication history for opioids.

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Individuals, not opioid initiation periods, should be counted for the eligible population/denominator. If an individual has more than one opioid initiation period, count him/her in the numerator if he/she meets the criteria for the numerator for any opioid initiation period.

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Yes, both individuals in hospice and with a cancer diagnosis are excluded from these measures.

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Other exclusions such as sickle cell disease were considered and voted on by the Measure Update Panel (MUP) and Quality Metric Expert Panel (QMEP) for our other opioid-related measures. PQA also sought out expert opinion on these exclusions.

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If an individual is not continuously enrolled in the 90 days prior to the index prescription start date (IPSD)—which is earliest date of service for an opioid medication during the measurement year—it is not possible to determine if he/she is initiating opioid therapy and should not be counted in the denominator. Enrollment data from the prior year is required if the IPSD occurs within the first 90 days of the measurement year.

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Buprenorphine, as a partial agonist is not expected to be associated with overdose risk in the same dose-dependent manner as for full agonist opioids. And, specific to the Initial Opioid Prescribing at High Dosage (IOP-HD) measure, buprenorphine products do not have an associated MME conversion factor provided by the CDC for analytic purposes where prescription data are used to calculate MME to inform analyses of risks associated with opioid prescribing for pain.

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The CDC's MME conversion factors are used in PQA's measures. For clinical guidance on dosage of opioids for treatment of chronic pain, including conversion factors for commonly prescribed opioids, see the CDC's provider resources on calculating daily dose for commonly prescribed opioids.

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Examples:

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10 mg oxycodone tablets X (120 tablets / 30 days) X 1.5 = 60 MME/day
25 mcg/hr fentanyl patch X (10 patches / 30 days) X 7.2 = 60 MME/day

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Note: The CDC's MME conversion factors are intended only for analytic purposes where prescription data are used to calculate MME to inform understanding of population-level risks associated with opioid prescribing for pain.

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For each opioid prescription claim during the opioid initiation period, calculate the daily morphine milligram equivalents (MME) using the MME conversion factors provided in the NDC code file and apply the MME to the days from the date of service to the date of the last dose or the end of the opioid initiation period, whichever occurs first. Then, using all opioid prescription claims, calculate the total MME during the opioid initiation period by summing up the MME applied to the days in the opioid initiation period. Lastly, calculate the average MME by dividing the total MME within the opioid initiation period by the days covered by an opioid during the opioid initiation period.

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Decisions related to the numerator criteria for the IOP-LD measure were made by consensus from the measure development team and based upon the CDC recommendation that ≤3 days of opioids will often be sufficient and that ≥7 days will rarely be needed for initiation of opioid therapy.1 For additional information about the clinical research that supports this measure, please see the IOP-LD rationale document.

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Most measures have the risk of unintended consequences—such as use of cash claims to avoid detection of inappropriate initial opioid prescribing. However, these risks must be balanced with the potential for improved clinical outcomes that are expected from the use of these measures when used as intended.

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PQA intends to monitor the use of these measures in accountability programs. Additionally, we will continue to refine the measures with the input of its users and through our measure update process.

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These measures provide standardization that is not currently available in the marketplace for the reporting of initial opioid prescribing.

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PQA measures and the CDC's MME conversion factors are not intended for clinical decision-making. PQA measures evaluate prescribing patterns that correlate with an increased risk of opioid overdose. Efforts to prevent opioid overdose should include a multi-faceted approach, including strategies that focus on monitoring and reducing opioid prescribing that has an unfavorable balance of benefit and harm for most patient populations. These measures are for retrospective evaluation of populations of patients and should not be used to guide clinical decisions for individual patients.

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The CDC's MME conversion factors are intended only for analytic purposes where prescription data are used to calculate MME to inform understanding of population-level risks associated with opioid prescribing for pain. For clinical guidance on dosage of opioids for treatment of chronic pain, including conversion factors for commonly prescribed opioids, see the CDC’s provider resources on calculating daily dose for commonly prescribed opioids.

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