Vue.component('iop-la-overview', { template: '
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Initial Opioid Prescribing for Long-Acting or Extended-Release Opioids (IOP-LA)

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Description

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The percentage of individuals ≥18 years of age with ≥1 initial opioid prescriptions for long-acting or extended-release opioids.

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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 ≥1 prescription claims for a long-acting or extended-release (LA/ER) opioid within any opioid initiation period.

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' }); Vue.component('iop-la-ref-1', { template: '' + 'NIH/NIDA. Opioid Overdose Crisis [Internet]. 2019 [cited 2019 Mar 29]. Available from: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis.' + '1' + '' }); Vue.component('iop-la-ref-2', { template: '' + 'CDC/NCHS, National Vital Statistics System, Mortality [Internet]. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2018 [cited 2019 Mar 27]. Available from: https://wonder.cdc.gov.' + '2' + '' }); Vue.component('iop-la-ref-3', { template: '' + 'Hedegaard H, Minino AM. Warner M. Drug overdose deaths in the United States, 1999-2017 [Internet]. NCHS Data Brief. 2018 [cited 2019 Mar 28]; 329:1-8. Available from: https://www.cdc.gov/nchs/data/databriefs/db329-h.≥. ' + '3' + '' }); Vue.component('iop-la-ref-4', { template: '' + 'Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015; 156:569-76. PMID: 25785523.' + '4' + '' }); Vue.component('iop-la-ref-5', { template: '' + 'Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The changing face of heroin use in the United States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014; 71:821-6. PMID: 24871348.' + '5' + '' }); Vue.component('iop-la-ref-6', { template: '' + 'HHS. National Rx Drug Abuse and Heroin Summit. Secretary Price Announces HHS Strategy for Fight Opioid Crisis [Internet]. 2017 [cited 2019 Mar 27]. Available from: https://www.hhs.gov/about/leadership/secretary/speeches/2017-speeches/secretary-price-announces-hhs-strategy-for-fighting-opioid-crisis/index.html. ' + '6' + '' }); Vue.component('iop-la-ref-7', { template: '' + 'Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017; 66:265-269. PMID: 28301454.' + '7' + '' }); Vue.component('iop-la-ref-8', { template: '' + 'Shah A, Hayes CJ, Martin BC. Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies. J Pain. 2017; 18:1374-83. PMID: 28711636.' + '8' + '' }); Vue.component('iop-la-ref-9', { template: '' + 'Deyo RA, Hallvik SE, Hildebran C, et al. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J Gen Intern Med. 2017; 32:21-27. PMID: 27484682.' + '9' + '' }); Vue.component('iop-la-ref-10', { template: '' + 'Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015; 175(4):608-15. PMID: 25686208.' + '10' + '' }); Vue.component('iop-la-ref-11', { template: '' + 'Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep. 2016; 65:1-49. PMID: 26987082.' + '11' + '' }); Vue.component('iop-la-ref-12', { template: '' + 'Food and Drug Administration. Extended-release (ER) and long-acting (LA) opioid analgesic risk evaluation and mitigation strategy (REMS) [Internet]. June [cited 2019 Mar 31]. Available from: https://www.fda.gov/downloads/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm311290.≥.' + '12' + '' }); Vue.component('iop-la-rationale', { template: '
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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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' + 'When initiating opioid therapy, starting with long-acting/extended-release (LA/ER) opioids is associated with an increased risk of continued opioid use' + ',,' + ' and an increased risk of overdose.' + '' + ' The 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends that when opioids are started, immediate-release opioids should be prescribed instead of LA/ER opioids.' + '' + ' LA/ER opioids should be reserved for severe, continuous pain and should be considered only for patients who have received immediate-release opioids daily for at least one week. Similarly, the Food and Drug Administration (FDA) defines opioid tolerance, or the time when a long acting or extended release product may be considered, as a certain dosage of opioid (e.g., 60 mg daily of oral morphine, 30 mg daily of oral oxycodone, or equianalgesic dosages of other opioids) for at least one week.' + '' + '

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' + 'Published studies support the CDC recommendation to start therapy with immediate-release opioids instead of LA/ER opioids. 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 observed that patients with initial prescriptions for LA/ER opioids (Hazard Ratio [HR], 0.79; 95%; 95% Confidence Interval [CI], 0.77-0.82) had a lower likelihood of opioid discontinuation compared to those with initial prescriptions for short-acting opioids. Starting with LA/ER opioids also is associated with a higher risk for overdose compared with starting with immediate-release opioids. In 2017, Deyo and colleagues examined the association between initial opioid prescribing patterns and the likelihood of long-term use in a retrospective cohort study using data from the Oregon Prescription Drug Monitoring Program.' + '' + ' Patients who initiated therapy with a long-acting opioid had markedly higher probability of long-term use (overall 24.5% with long-acting vs. 3.5% with short-acting, P<0.001). Even among those with a single fill for long-acting opioids in the initiation month, 15.7% became long-term users, versus 2.0% among those initially prescribed short-acting drugs. In another study, Miller and colleagues evaluated the risk of overdose comparing short-acting vs. LA/ER opioids in a cohort study in a Veterans Affairs population.' + '' + ' The researchers found that patients initiating therapy with LA/ER opioids were more than twice as likely to overdose compared with those initiating therapy with short-acting opioids. After adjusting for age, sex, opioid dose, and other clinical characteristics, patients receiving LA/ER opioids had a significantly higher rate of overdose injury than those receiving short-acting opioids (HR, 2.33; 95% CI, 1.26-4.32), with the highest risk observed within the first two weeks after starting treatment with long-acting opioids (HR,5.25;95% CI, 1.88-14.72).' + '

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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 for LA/ER opioids. Patients with cancer diagnoses and those receiving hospice care are excluded from the measures 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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' }); Vue.component('iop-la-faqs', { template: '
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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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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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