Narcotic Analgesic Drug Use By Medicare Patients: Continued

What drugs and by which specialties?
When I first looked at the recent release of outpatient prescription drug utilization by Medicare patients, I was immediately struck by how many narcotics were being prescribed by physicians and other medical providers for so many patients. The vast majority of providers prescribed a handful of different and mostly inexpensive opioid drug products to a relatively few patients, On the other hand, a smaller number of providers wrote for many different opioid formulations, some fantastically expensive, for large numbers of patients.  Is good medicine being practiced?  Is it possible to tell? Should we even care?  Of course we should. In this analysis I break down further the utilization of a subset of the most common opioid analgesics, show which medical specialties prescribe the most, and begin to highlight the vast discrepancy in narcotic use among individual providers. From the full CMS database, I extract and make available an Excel file enumerating  prescriptions of selected narcotic analgesics by Kentucky medical providers .

In an initial article, I used aggregated summary files provided by Medicare that focused on what drugs had been prescribed and how often.  In this article, I begin to explore the more extensive provider-specific files to focus on who is doing the prescribing. Before launching into the actual data, I need to emphasize a few caveats.  The CMS data does not include patients in classic fee-for-service Medicare, or those in insurance plans without drug coverage (if there are any such plans). Recall also that patients end up in the Medicare program because they are older than 65 and worked enough quarters in their life, or through the Medicare disability program.  Beneficiaries in the latter category can be expected to have a different set of diagnoses and to be younger than the former.  Furthermore, data from providers who prescribe a given drug to fewer than 11 patients is excluded from the database thereby underestimating total opioid consumption by Medicare beneficiaries.

Disabled vs Aged.
The CMS database does not make it possible to determine with precision which category of Medicare patients is being prescribed for.  The provider-specific files include fields for the number of beneficiaries older than 65 together with the number of claims and total drug costs for each specific provider-drug pairing.  However, on top of the overarching CMS patient-privacy protocol that does not include line item records for individual providers prescribing a specific drug to fewer than 11 patients, the numbers for the 65+ patients are subject to a second application of the restriction. The result is that a very large number of fields for unique total beneficiaries and beneficiaries over 65 are blank. Based on a first-pass estimate that ignores the blank cells, it is possible that as much as half of the opioid utilization is in the disabled group.  It is fair to say that both groups are generously supplied with opioid analgesics. As important for public policy as this distinction is, for the purposes of this analysis, no attempt is made to separate the two Medicare entitlement groups.

What drugs are being prescribed?
Because of limitations in the number of lines the data-analysis program Excel can handle, the following discussion covers a subset of opioids or combination opioid preparations whose generic names in the data set contain the strings cod and morph.  As it happens, this data extraction captures all the commonly used (and abused) opioid narcotics.  Alas, because of size limitations, I could not simultaneously include the other commonly used and abused drugs meperidine, fentanyl, and tramadol in this analysis.  Tramadol is opioid analog and is subject to abuse, but by a triumph of lobbying is not considered a controlled substance.  The fentanyl preparations are probably both the most potent and expensive of the opioid narcotics. Time and interest permitting, I will perform a separate analysis at a later time. Let me know what other drugs should be included in future analyses.

Attached is a list of 24 different opioids or opioid combination preparations from the CMS Part-D database by their generic chemical names, together with the 74 different brand-name and generic products available.  For each product, the number of providers using, the total number of prescriptions written, the total drug cost, and a calculated field containing cost-per-claim are listed. For 7 of these, only a single brand or generic version was available in 2013.  For example, no brand-name option for the basic drug codeine sulfate was present in the database.  Conversely, other products containing the same active ingredients had from 2 to 14 different versions available!  For example, generic hydrocodone/acetaminophen came in 13 different brand-names including the well-known Vicodin and Lorcet.  This table allows comparison of brand-name vs. generic formulations.

The most commonly prescribed opioid drugs in this national population are:
• hydrocodone/acetaminophen as mentioned above with 33.52 million claims;
• oxycodone HCL/acetaminophen (the ingredient in Percocet) at 7.72 million;
• oxycodone HCL (as in Oxycontin at 6.42 million;
• morphine sulfate (in MS Contin) at 3.45 million;
and the last of those with more than 1 million claims,
• acetaminophen-codeine (as in Tylenol #3) with 1.90 million.

Some drugs more expensive than others.
A single category of drug, oxycodone HCL, cost Medicare beneficiaries and their payers $1.04 billion dollars.  The next most expensive category of drugs was hydrocodone/acetaminophen at $559.4 million; oxycodone HCL/acetaminophen at $257.7 million; and morphine sulfate at $224.6 million.

Cost of brand-name vs. generic preparation.
According to these data, collected by pharmacy drug benefit managers who should know, the differences between the prices paid for brand-name vs. generic can be frankly stupendous.  For example, for the commonly marketed and prescribed and hydrocodone/acetaminophen, the generic version costs a mere $17 per claim but Lortab and Vicodin cost $209 and $78 respectively. Other versions of the same drug cost up to $1159 per prescription. The reader will note several examples of similar or even greater differences.

For oxycodone HCL, the opioid category containing the drug OxyContin,  the difference between the generic and brand versions is 12 fold.  I wonder in my own mind why this drug is so much more expensive or for that matter so often prescribed.  Is it more effective for the relief of pain? Are its supposedly abuse-resistant forms worth the extra expense?  Is it solely due to aggressive marketing over the years that has drawn penalties from regulators?  Is it the ultimate value of these drugs on the street?  Who can help educate me?

Money well spent?
I must again ask the question, why is anything other than the generic version prescribed, dispensed, or paid for at all by any insurer?  Is this the cost our legislators were content to pass on to the rest of us by forbidding Medicare to negotiate the price of drugs?  In my opinion, this story– which can be retold a thousand times– is a national scandal.  What a colossal waste of money that comes directly out of our tax- and insurance premium dollars.  We are all paying for it.  Why do we as professionals and citizens alike tolerate this waste– driven as it is purely by the pharmaceutical marketing engine.  In my view, a provider or pharmacist who prescribes or dispenses by brand-name when reasonable generic alternatives are available, or who does not otherwise protect their patient from financial drug toxicity, is not doing their job.  In the case of prescription of narcotics, I must wonder if demand from the patient or the street is playing any role in what specific drug is prescribed.  Such unsavory factors are certainly involved in illegal or unethical pill-mills where profit is the underlying motive.  Note that all of this is occurring under the supervision and supposed patient protection of the health insurers that manage Medicare drug plans.  God only knows what is happening to traditional Medicare beneficiaries or to the public at large.  Enough of this specific rant for now.

Who is writing prescriptions for all these drugs?
Attached is a list of 149 different provider specialties as recognized by Medicare in this database– together with the total number of prescriptions written, their total cost, and a calculated field of cost per prescription.  The list is ranked by total claim (prescription) count. (Here is an Excel file of the data you can play with.)  Some may be surprised that more prescriptions for these opioids are written not by cancer doctors or pain specialists, but family practitioners and internists.  These two specialties provide the bulk of primary care, along with the nurse practitioners and physician assistants that occupying the number 3 and 4 slots in terms of total number of opioid prescriptions written.  Given the legislative battles in Kentucky over prescribing privileges for nurses in general, and for controlled drugs specifically, I was personally surprised to see nurses and physicians assistants so far up on the national list.  Interestingly, the cost per prescription for these latter two classes of providers was higher than that for most of the physician provider groups. It is often argued that nurses and physician assistants provide more economical medical care.  These numbers call that assumption into question. It must be recognized however, that internists, nurse practitioners and physician assistants also include individuals working in specialty areas.

Interventional pain management and pain management are at numbers 9 and 11 respectively tending to use more expensive drugs. I suppose no one will be surprised by this.  The four different oncology specialties listed– in which practices narcotic analgesics are said to have their most defendable value– are further down the list.  Hospice and Palliative Care is number 50 on the list.

Given my bias, I was disappointed to see orthopods and rheumatologists high on the list of opioid prescribers.  Orthopods are of course surgeons, and much of their utilization is likely to be for post-operative reasons. However, the fact that rheumatologists and physical medicine specialists are heavy users of opioid analgesics suggests that only a tiny proportion of Medicare beneficiaries are taking narcotic analgesics because they have cancer or other terminal diseases and for whom drug dependence is not much of an issue.  We as a profession are using narcotics to treat moderate musculoskeletal pain or less objectively defined disease just like the drug companies told us to.  We knew better.  Shame on us.

Do dentists do it better?
Sticking out like a sore tooth are dentists at #14 by prescription volume but at peanuts for cost.  Are these clinicians under-treating their patients? Their drug of choice is generic hydrocodone/acetaminophen (675,616 claims); and much further down the list, generic acetaminophen/codeine (105,063 claims); and oxycodone/acetaminophen (29,776 claims). Only a handful of dentists used brand-name narcotics. Do dentists only prescribe a few pills at a time?  In my opinion these professionals are teaching us physicians something about cost-effective practice.  Having a bias consequent to tooth troubles of my own in the past, I offer no judgment about the clinical indications for these dental prescriptions!

How many drugs does one provider need?
There were 388,192 unique providers in the CMS database who prescribed one or more of these 74 different products to more than 10 patients.  I have not yet figured out how to count the number of unique practitioners in each specialty category within the provider-specific file because a single practitioner can appear in the list up to 21 different times, depending on the number of different drugs prescribed. This later statistic is of interest in itself.  Of the total number of providers, 82.6% prescribed 3 or fewer different opioid formulations.  Only 7.9% prescribed 5 or more different formulations. Rather amazingly in my view is the fact that 206 providers prescribed 15 or more different formulations of these codeine and morphine derivatives.  A single provider prescribed 21 different drug products, and 39 used 17 or more!  These figures have bearing on the cost and safety of medical practice.  In my medical teaching, I adhered to the principle that a physician should use a limited number of drugs, but to know each of them well.  In the case of these narcotics, I cannot believe so many narcotic analgesics stand out because of efficacy, safety, cost, or even convenience!  In my opinion prescription drug use is driven in large measure by the commercial success of marketing, or alas, for even unprincipled reasons.  Other opinions in the comment section below are welcome.

A last thought.
When someone from a third-world or even our own country markets and sells narcotics to addicted or abusing Americans in a non-medical endeavor, we call them pushers and drug dealers. We criminalize their activities.  Much harm to us as a society and to individuals results from this illegal activity.  How then should we feel when the same basic products are promoted, prescribed, and sold to the same public by high-profile advertising agencies, pharmaceutical companies, pharmacies, and providers within the healthcare marketplace?  Are these two commercial enterprises clearly distinguishable?  I want to believe that they are, but I cannot. Our newspapers are too full of evidence to the contrary.

I will continue to slice and dice the CMS files in an effort to determine what kind of useful information can be extracted.  I urge any of you readers to do the same and I welcome your ideas and comments. I provide a manageable-sized subset Excel file (1 MB) of opioid prescription by Kentucky providers for your use to this end.  I already provided a larger Excel file (36 MB) containing all drugs prescribed by a Kentucky provider to these patients.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
June 12, 2015

I extracted the opioid prescriptions for all U.S providers that serves as the basis for the discussion above, but it yields an unwieldy Excel file that makes even my machine crash. If there is a reader who would like related files from another state, feel free to contact me.  Perhaps I can help.