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Initial Opioid Prescribing for Long Duration (IOP-LD)

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Description

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The percentage of individuals ≥18 years of age with ≥1 initial opioid prescriptions for >7 cumulative days' supply.

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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 >7 cumulative days' supply for all opioid prescription claims 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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' + 'The duration of initial opioid exposure is associated with a higher likelihood for 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 used for acute pain (i.e., pain with abrupt onset and caused by an injury or other process that is not ongoing), no greater quantity should be prescribed than is needed for the expected duration of pain severe enough to require opioids.' + '' + ' According to the guideline, three days or less will often be sufficient and more than seven days will rarely be needed.' + '

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' + 'Published studies support the CDC recommendations to limit the duration of initial opioid use. In 2017,Shah and colleagues published a retrospective cohort study using claims data from a nationally representative database of commercially insured patients, examining the relationship between initial opioid prescription characteristics and the likelihood of opioid discontinuation.' + '' + " Increasing days' supply of the first prescription was consistently associated with a lower likelihood of opioid discontinuation: 3-4 days' supply (Hazard Ratio [HR], 0.70; 95% Confidence Interval [CI], 0.70-0.71); 5-7 days' supply (HR, 0.48; 95% CI, 0.47-0.48); 8-10 days' supply (HR, 0.37; 95% CI, 0.37-0.38); 11-14 days' supply (HR, 0.32; 95% CI, 0.31-0.33); 15-21 days' supply (HR, 0.29; 95% CI, 0.28- 0.29); ≥22 days' supply (HR, 0.20; 95% CI, 0.19-0.20). In addition, Brat and colleagues published a study in 2018 evaluating the effects of varying opioid prescribing patterns after surgery on misuse or overdose in a retrospective cohort study of an opioid naïve population." + '' + ' Total duration of opioid use was the strongest predictor of misuse, with each refill and additional week of opioid use associated with an adjusted increase in the rate of misuse of 44.0% (95% CI, 40.8-47.2, P<0.001), and 19.9% increase in hazard (95% CI, 18.5-21.4, P<0.001), respectively.' + '

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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 >7 cumulative days' supply. 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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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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