Trends in opioid use in commercially insured and Medicare Advantage populations in 2007-16: retrospective cohort study

Abstract

Objective: To describe trends in the rate and daily dose of opioids used among commercial and Medicare Advantage beneficiaries from 2007 to 2016.

Design: Retrospective cohort study of administrative claims data.

Setting: National database of medical and pharmacy claims for commercially insured and Medicare Advantage beneficiaries in the United States.

Participants: 48 million individuals with any period of insurance coverage between 1 January 2007 and 31 December 2016, including commercial beneficiaries, Medicare Advantage beneficiaries aged 65 years and over, and Medicare Advantage beneficiaries under age 65 years (eligible owing to permanent disability).

Main endpoints: Proportion of beneficiaries with any opioid prescription per quarter, average daily dose in milligram morphine equivalents (MME), and proportion of opioid use episodes that represented long term use.

Results: Across all years of the study, annual opioid use prevalence was 14% for commercial beneficiaries, 26% for aged Medicare beneficiaries, and 52% for disabled Medicare beneficiaries. In the commercial beneficiary group, quarterly prevalence of opioid use changed little, starting and ending the study period at 6%; the average daily dose of 17 MME remained unchanged since 2011. For aged Medicare beneficiaries, quarterly use prevalence was also relatively stable, ranging from 11% at the beginning of the study period to 14% at the end. Disabled Medicare beneficiaries had the highest rates of opioid use, the highest rate of long term use, and the largest average daily doses. In this group, both quarterly use rates (39%) and average daily dose (56 MME) were higher at the end of 2016 than the low points observed in 2007 for each endpoint (26% prevalence and 53 MME).

Conclusions: Opioid use rates were high during the study period of 2007-16, with the highest rates in disabled Medicare beneficiaries versus aged Medicare beneficiaries and commercial beneficiaries. Opioid use and average daily dose have not substantially declined from their peaks, despite increased attention to opioid abuse and awareness of their risks.

Fig 1

Adjusted time trends in opioid use by beneficiary type, 2007-16. (A) Quarterly prevalence of opioid use; data represent predictive margins after logistic regression that included the year in which beneficiary insurance coverage started, census division, sex, and race/ethnicity. Maximum and minimum values, and values at the start and end of the study are labelled. (B) Average daily dose of opioids for people using in quarter; data represent predictive margins after negative binomial regression that included the year in which beneficiary insurance coverage started, census division, sex, and race/ethnicity. Appendix 5 gives a description of calculations; appendix 8 includes a table of predictive margins used to create the figures. MME=milligram morphine equivalents

Fig 2

Adjusted time trends in opioid use by age group, 2007-16. (A) Quarterly prevalence of opioid use; data represent predictive margins after logistic regression that included the year in which beneficiary insurance coverage started, census division, sex, and race/ethnicity. (B) Average daily dose for opioid users; data represent predictive margins after negative binomial regression that included the year in which beneficiary insurance coverage started, census division, sex, and race/ethnicity. Owing to small samples, beneficiaries with unknown age, commercial beneficiaries over age 65 years, and disabled Medicare beneficiaries under age 19 years are not shown. Appendix 8 includes a table of predictive margins used to create the figures. MME=milligram morphine equivalents

Fig 3

Concentration of opioids in long term use episodes. Each beneficiary population’s opioid episodes and total volume of opioid use are divided into long term use (white columns) and non-long term use (blue columns); average daily MME observed during the episodes are summarized for long term use versus non-long term use. For example, in the commercial population, 3% of episodes represent chronic opioid use, which accounts for 62% of the total volume of opioid dispensed for that population (in MMEs); the average dose of opioids per day was 51 MME in long term episodes, and 30 MME in non-long term episodes. MME=milligram morphine equivalents