Study finds opioid use common amongst disabled Medicare recipients

YouScript_Chronic_Opioid_Infographic_FinalA recent study illuminates the prevalence of opioid painkiller use in a particularly vulnerable population: disabled Americans on Social Security disability insurance.

The article, published in the September edition of the journal Medical Care, found the percentage of Social Security disability insurance (SSDI) recipients younger than 65 receiving any amount of opioid prescriptions rose from 43.9 percent in 2007 to 44.7 percent in 2010, with that figure dipping in 2011 to 43.7 percent.

Study authors Morden et al. reported a steadier rise in what they defined as “chronic use” of opioids (six or more prescriptions filled per year): 21.4 percent in 2007 increased to 23.1 percent in 2011.The authors called the chronic use trend “…worrisome, in light of established and growing evidence that intense opioid use to treat nonmalignant pain may not be effective and may confer important risks.”

The study’s findings are consistent with growing evidence of what some have called an “opioid epidemic” in the U.S. The Centers for Disease Control and Prevention report that 46 people die per day from an overdose of prescription painkillers. Of 22,810 deaths related to pharmaceutical overdose in 2011, 74 percent involved opioid painkillers.

Morden et al. focused on SSDI recipients because growing numbers of Americans are applying for – and receiving – these benefits. The authors report that musculoskeletal conditions, such as back pain, are often treated with opioid pain relievers. In 2011, these conditions were the most common SSDI-qualifying diagnoses, accounting for 33.8 percent of program participants (up from 20 percent in 1996).

The authors write that this shift in the makeup of disabling conditions, combined with increasing national trends in prescription opioid use and overdose deaths, “suggests the potential for substantial opioid use in the SSDI population and raises concern for the overall health and safety of these injured and ill workers.

“Although the best approach to pain management and opioid analgesic prescribing, in particular, are debated,” Modren et al. write, “intense chronic opioid use for non-malignant pain is increasingly recognized as ineffective and potentially hazardous to individuals and to the public.”

In addition to the figures on overall prevalence, the study showed that median daily morphine equivalent doses (MEDs) amongst SSDI recipients per recipient increased overall from 9.8 mg in 2007 to 11 mg in 2010, dropping down slightly in 2011 to 9.9 mg.

Average daily doses remained intense in the growing population of chronic users, with 20 percent of chronic users getting 100 mg of MEDs or more and 10 percent reaching or exceeding 200 mg of MEDs. Studies cited by Morden et al. show that opioid use of this intensity has been associated with risk of overdose death in the general U.S. population.

The study’s authors call for Medicare administrators and clinicians to develop pain management strategies for addressing opioid painkiller use in disabled Medicare recipients, individuals who often already suffer a high burden of illness, injury and low incomes.

When it comes to pain management, prescriber knowledge of DNA sensitivity testing’s role in predicting opioid effectiveness is crucial. An understanding of potential drug-drug interactions is also key, as the study found that about 38 percent of SSDI recipients defined as chronic opioid users also suffered from depression. This raises the possibility of pain medications and anti-depression drugs interacting and decreasing drug effectiveness, causing potentially harmful adverse drug events, or both.

YouScript Personalized Prescribing software can help take some of the uncertainty out of prescribing by identifying drug interactions in a patient’s regimen and suggesting alternatives. YouScript can also identify potential drug-gene and drug-drug-gene interactions when teamed with testing of the body’s highly variable cytochrome P450 pathways. Learn more about how these tools can help here.

3 Comments on “Study finds opioid use common amongst disabled Medicare recipients”

  1. What evidence is available that shows opioid use to treat nonmalignant pain may not be effective? Although I am not on SSDI, I am 64 years old and have suffered from “chronic intractable centralized pain” all of my adult life. See my pain specialist’s articles on centralized pain at:

    and

    For the last five years I have been on an opioid maintenance program and am having the highest quality of life I’ve ever had as an adult. In other words, the treatment is VERY effective and any risks involved are something I am more than willing to take rather than be in agony 24 hours a day, seven days a week. Perhaps the growth in use of opioids is a result of more attention being paid to chronic pain and how devastating it can be to people’s lives. Assuming these numbers presented are correct (74% of 22,810 deaths = 16,880 deaths caused by opioids) yet there is no data presented on how many of these deaths were suicides or were caused by mixing opioids with other drugs or alcohol or any other factors. In that same year of 2011, there were 32,479 deaths from automobile accidents, according to the “National Highway Transportation Safety Administration” or nearly double the amount of deaths from opioids, yet I do not see the hysteria concerning deaths by automobile like I see that surrounds use of opioids. Shall we ban automobiles? What I see is a bias by doctors against opioids that is rampant and much of this bias would disappear if there were more training on pain in our medical schools. Let’s face it – the main reason people go to a doctor is because something hurts yet getting decent pain care is difficult and many times impossible. One other point to make is the safety of opioids vs. other pain relieving medications. Opioids have been used for 100s and 100s of years and they do not cause organ damage like NSAIDS can.

    1. Louis,

      I greatly appreciate your comment and perspective. In the article, the authors cite the following information and studies as support to their claim that “intense opioid use to treat nonmalignant pain may not be effective and may confer important risks.”

      Centers for Disease C, Prevention. Vital signs: overdoses of prescription
      opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal
      Wkly Rep. 2011;60:1487–1492.

      Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med.
      2003;349:1943–1953.

      Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug
      poisoning in the United States. Am J Prev Med. 2006;31:506–511.

      Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among
      unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:
      2613–2620.

      Gomes T, Redelmeier DA, Juurlink DN, et al. Opioid dose and risk of
      road trauma in Canada: a population-based study. JAMA Intern Med.
      2013;173:196–201.

      I’m quite glad to here your opioid regimen is working so well for you. Opioid prescribing and use can be a complex issue, and is far from black and white, as your experience shows. I feel the more the issue is studied, the better. Thanks again for your comment.

  2. I think the analysis of this study is totally off-base and attempts to sensationalize figures that have little or no relevance to the majority of opioid prescription users. An increase of 1.7% over 3 years, with a subsequent drop to 0.1% BELOW the baseline the following year gives a net DECREASE of 0.1% over a 4-year period. 1) This does not constitute “an alarming rise”, but actually shows an overall decrease, or, to be more realistic, a very stable number. Categorizing the final figure as “dipping” is an attempt to trivializing the figure in order to mask it’s significance. The significance, of course, is that, over a FOUR year period, the number of opioid prescriptions actually dropped by 0.1%, and there is no “rise” at all. The authors seem to have a bias toward making their figures support a so-called opioid epidemic, which, in fact, is NOT an epidemic. They state that in 2011, there were 22,810 opiate deaths, of which 74% were prescription drugs deaths (the other 26% being heroin overdoses). However, in 2013, 71.3% of 22,767 prescription drug deaths were opiate-related. This shows that, contrary to the language used by the authors, the absolute and relative numbers have actually remained very stable. The fact is that a certain small percentage has always been involved in drug abuse involving narcotics, either prescription, over-the-counter (when opiates were available OTC) and illegally. The total number of people who died from drug overdose in 2103 was 43,982, of which 22,810 were opiate-related, including prescribed opiates (16,235). This means that 37% of overdose deaths were due to prescribed opiates and a whopping 63% were due to OTHER drugs. Perhaps the focus ought to be on overall drug safety rather than trying to sensationalize opiate use. In the 1990s pain control became more widely understood and treated. Therefore, it is not surprising that an increased number of opioid prescriptions were wriitten. To keep it in some perspective, the number of prescription opiate deaths constitutes just 0.05 %. (5 HUNDREDTHS of one percent) of the population. This is not to say that there hasn’t been an increase in deaths or that efforts shouldn’t be made to stop overdose deaths. However, the vast majority of overdose opiate deaths involved drugs that were obtained illegally by theft from family, friends, neighbors, or doctors or pharmacists, and were taken for “recreational” use. Rather than miscategorizing the drugs themselves, it would seem that greater efforts should be made to educate patients on the need to control and limit access, to properly and promptly dispose of any unused drugs and to educate patients and those at risk, such as “recreational” users about the dangers of mixing different drugs, especially mixing opiates with alcohol and/or bezodiazepines. This study statement that SSDI patients are “particularly vulnerable”, has no support or meaning whatsoever. SSDI patients are under 65, which means they are actually less vulnerable than the elderly, who have metabolic changes that can affect their drug reaction. They are also less vulnerable than teenagers and young adults, who tend to be the population using prescription opiates for “recreational” use without understanding the risks and dangers. The authors cite disabled SSDI patients receiving opioid prescriptions more than once every 2 months as “chronic” users, and call a 1.7% increase in the number of prescriptions over a 4 year period (2007 to 2011) “worrisome”. In fact, such a small percentage increase in the overall number of prescriptions is close to meaningless, statistically speaking, and certainly does not indicate a significantly major “trend”. The authors write “intense chronic opioid use for non-malignant pain is increasingly recognized as ineffective and potentially hazardous to individuals and to the public.” This is bad science and bad medicine at its worst. There is no meaning to the word “intense”–that is a purely subjective term. What is “intense”? A prescription for Vicodin? A prescription for codeine? Morhine? A prescription for a certain dosage as opposed to some other dosage? A prescription lasting longer than 10 days? 20 days? 30 days? They have already defined their use of the word “chronic” to mean more than 6 prescriptions per year, but what does that really mean? Those on SSDI are considered to have major disabilities that will last a year or more, many of them are permanent. Isn’t this exactly the group of patients that is likely to have chronic pain, which has been notoriously undertreated in the US? The original author makes the statement that increased SSDI qualifying diagnoses of musculoskeletal conditions, with concomitant prescriptions for opiates for pain relief “suggests the potential for substantial opioid use” in the SSDI population., “raising concern for overall health and safety”. Why? There is absolutely nothing to indicate that this group has a higher incidence of problems, much less deaths, related to opiate use than any other group, nor is there any evidence that these patients misuse or abuse their prescriptions. In fact, this is simply a well-documented population making it relatively easy to study numerically and statistically because all of their information is in government databases. That doesn’t make them more “at risk”. Again, this is entirely subjective and completely misleading. In addition, there is no significant body of evidence that shows that opiate drugs are “ineffective” for musculoskeletal pain as the author states. If they were ineffective, people wouldn’t take them and doctors wouldn’t prescribe them. The author cited a single article from 2003 in support of this statement. There is an unspoken but underlying implication here that people who use opiate drugs for pain are really using the medication to “get high”, rather than for pain. This is untrue. In fact, as many patients can attest, after a fairly short period of regular use all euphoric effects are greatly decreased or disappear. One of the reasons it is important to treat chronic pain correctly, using long-acting opiates, is to prevent the up-and-down-spikes in blood levels that not only contribute to pain flare-ups but also contribute to the euphoric side effects. Once a steady state is achieved, generally there is no euphoric side effect. The vast majority of patients are not going to become “addicted”, a phenomenon that involves psychological dependance and craving the euphoric feelings. It has little to do with pain relief, and it has been well documented that very very few patients who are prescribed opiates will become “addicted”. It is my opinion that those who do would have become addicted to some substance anyway, being part of that small subset of the overall population that has a strong predilection for addictive behavior regardless of the circumstances. No one thinks cancer patients are using drugs to “get high”; why should they think that chronic pain patients are doing so simply because they are not going to die as quickly? There is also the unspoken implication that it doesn’t matter if cancer patients die of a drug overdose because after all, they were going to die soon (presumably) anyway. Both unspoken implications are real, but both are completely unethical and untrue. It seems to me that the much greater area of concern would be the education of doctors in recognizingand treating chronic pain and treating it correctly under consistant national guidelines that have been evaluated for effectiveness and safety. The original author seems greatly concerned that SSDI patients will become “addicts”, recommending much surveillance and provision of “ample addiction coverage”. The fact is, studies have shown that the majority of patients prescribed opiates DO use them correctly, safely, and responsibly. Again, most of those who die from prescription opioids have obtained them illegally. The original author states that SSDI patients MAY be at risk, but points out that no one has actually studied this yet, I agree that it would be extremely
    beneficial to make it more difficult for theft and diversion to occur, but I don’t agree that the drugs themselves are the problem, nor are the patients. As the original author points out, opiate prescription practices vary widely across the country, which does imply that doctors are not using consistant guidelines in their practice. In addition, law enforcement barriers to opiate prescription also vary widely across the country, which may also have a bearing on prescription practices. It should be entirely possible to implement national guidelines for the safe and effective prescription of opiates, both short and long term, both low dose and high dose.
    Unfortunately, I find that the language and conclusions of this article to be biased, narrow-minded, and misleading. The conclusions seem to be feeding off of the current perception that there is an “epidemic” of drug abuse, and that the solution is to severely restrict access to those drugs as well as enact punitive measures towards those who use them, regardless of whether or not the use is legitimate. The general usage synonyms for “epidemic” according to the Miriam-Webster Dictionary are: rife, rampant, widespread, wide-ranging, extensive, pervasive. The MEDICAL use of the word “epidemic” simply means a higher number than would be expected in a given population. It is clear that, while there may be a prescription drug epidemic in the medical sense of the word, there is NO epidemic in the general sense.

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