Identifying Controlled Substance Patterns of Utilization Requiring Evaluation Using Administrative Claims Data

Am J Manag Care. 2004 Nov;10(11 Pt 1):783-90.


Objectives: To develop a systems approach to identify, for further evaluation, patients with potential controlled substance misuse or mismanagement using software queries applied to administrative health claims data.

Study design: Retrospective validation of the system using insurance claims.

Patients and methods: Data from administrative health claims databases representing nearly 7 million individuals younger than 65 years were used by multidisciplinary expert panels to develop and validate controlled substance patterns of utilization requiring evaluation (CS-PURE) criteria.

Results: Thirty-four CS-PURE queries were developed in SAS and applied to administrative claims records to identify patients with potential controlled substance misuse or mismanagement. From these, we identified 10 CS-PURE with the highest expert agreement that intervention was warranted. Expert panel agree, ment that CS-PURE correctly identified cases ranged from 48% to 100%, with at least 50% agreement in 9 of 10 CS-PURE. The prevalence rates for CS-PURE ranged from 0.001% to 0.252%. This translates to identifying between 5 and 1116 patients for individual CS-PURE in a 500 000-member health plan.

Conclusions: We developed and empirically validated a group of queries using CS-PURE to identify patients with potential controlled substance misuse or mismanagement that would warrant further evaluation by the treating physician, a quality assurance function, or the medical director. Claims-based CS-PURE identification is generalizable to most health insurers with access to medical and pharmaceutical claims records. Although CS-PURE are not direct measures of misuse, they can direct attention to potential problems to determine if intervention is needed.

Publication types

  • Research Support, Non-U.S. Gov't
  • Validation Study

MeSH terms

  • Adolescent
  • Adult
  • Analgesics, Opioid / therapeutic use
  • Benzodiazepines / therapeutic use
  • Butorphanol / therapeutic use
  • Carisoprodol / therapeutic use
  • Clinical Pharmacy Information Systems / statistics & numerical data*
  • Contraindications
  • Databases as Topic
  • Drug Prescriptions / statistics & numerical data
  • Drug Utilization Review / methods*
  • Drug and Narcotic Control / methods*
  • Drug and Narcotic Control / organization & administration
  • Humans
  • Insurance Claim Review*
  • Managed Care Programs / standards
  • Middle Aged
  • Pain / drug therapy*
  • Pattern Recognition, Automated*
  • Prevalence
  • Substance-Related Disorders / diagnosis*
  • Substance-Related Disorders / epidemiology
  • Substance-Related Disorders / prevention & control
  • United States


  • Analgesics, Opioid
  • Benzodiazepines
  • Carisoprodol
  • Butorphanol