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HEDIS® 2020—Managing High-risk Opioid Use

NCQA revised a measure for high-dosage opioids, which we'll discuss here.

Revised Measure: Use of Opioids at High Dosage

The current HEDIS Use of Opioids at High Dosage (HDO) measure assesses the percentage of members 18 years of age and older who receive opioid prescriptions at a high dosage. The denominator for this measure includes members who receive two or more opioid prescriptions on different dates of service with at least 15 total days covered by opioids during the measurement year.

The Pharmacy Quality Alliance (PQA) made updates to this measure for the 2018 measurement year. Those updates will be reflected in the CMS 2020 Display measure.   In order to better align with these updates, NCQA has lowered the high-dosage threshold from >120 morphine milligram equivalent (MME) to ≥90 MME. It has also deleted the index prescription start date (IPSD) definition, and instead will use a revised treatment period definition. The treatment period start date is now defined as the earliest prescription dispensing date for any opioid during the measurement year, regardless of the total daily dosage for that prescription. Lowering the high-dose threshold is expected to increase the number of members in the numerator, while modifying the index prescription start date may lower the number of members in the numerator.

 The Opioid Epidemic: Guidelines on Opioid Use

HEDIS 2020 continues to measure high-risk opioid use and provides plans the opportunity to identify members at risk as a result of their chronic or high-dose opioid use.

When used appropriately, prescription opioid analgesics provide pain relief to patients. However, misuse and overuse of opioids can lead to addiction, opioid use disorders and overdose deaths.

We’ve all seen various stats that tell the story of increasing dependence on opioids. From 1999 to 2017, almost 218,000 people died in the United States from prescription opioid overdoses. Prescription opioid overdose deaths were five times higher in 2017 than in 1999. In 2017, healthcare providers were writing 58 opioid prescriptions for every 100 patients in the United States. However, we are seeing an overall downward trend as healthcare providers have reduced the annual prescribing of opioids by 19% from 2006 to 20171 as awareness of the issue was brought to national attention.

Despite the risk of opioid addiction, patients with chronic or acute pain count on their providers for an appropriate treatment plan. This should begin with a complete evaluation of the patient where the prescriber discusses the risks versus the benefits of opioid use for pain therapy and obtains informed consent and agreement for treatment. All prescribers should then continue to assess the patient’s response periodically during the course of treatment and comply with controlled substances laws and regulations. All healthcare providers play a role in ensuring the appropriate use of opioids to treat chronic pain and in using therapeutic alternatives when treating for acute pain. Ultimately, opioid use for pain therapy should maximize benefits to the patient, while minimizing the risk of harm.2

Best Practices for Opioid Prescribing and Use for Pain3,4

The Centers for Disease Control (CDC) has set forth the following guidelines for opioid prescribing and administration:

  • Evaluate the patient for risk factors for opioid overuse disorder or other harm.
  • Establish and measure goals for pain control and increased functionality with the patient.
  • Use short-acting opioid for initial pain therapy when indicated.
  • Use the lowest effective dosage. 
  • For acute pain in adults, short-acting opioids should not be prescribed for greater than seven days. For acute pain in children, opioids should not be prescribed for greater than three days.5
  • Consider alternatives to opioids in acute pain, such as non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
  • Continue opioids only if the patient experiences significant improvement in pain control and function that outweigh risks to patient safety.
  • Avoid the use of benzodiazepines (such as Valium) prescribed concurrently with opioids for pain.

Next in this blog series, my pharmacy colleague Theresa Lane will discuss risk factors and steps to decrease opioid use and misuse.

If you’re looking for a solution to identify at-risk patients for opioid abuse, contact us for a demo of our NCQA certified HEDIS solution, SS&C® CareAnalyzer.

1  Overview of the Drug Overdose Epidemic:  Behind the Numbers (CDC Opioid Portal)

2Federation of State Medical Boards of the United States, Inc. Model Policy for the Use of Controlled Substances for the Treatment of Pain. 2004.

3 Prescription Opioid Data on CDC website.

4Guidelines for Prescribing Opioids for Chronic Pain. CDC Factsheet.

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