Use of Opioids at High Dosage (HDO)

The percentage of persons 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose [MME] ≥90) for ≥15 days during the measurement period.

Why It Matters

The morbidity and mortality associated with opioid use has reached epidemic proportions, and is recognized by the Centers for Disease Control and Prevention, the Surgeon General and the White House as a significant public health problem in the U.S. Prescription opioid pain relievers cause nearly three out of four prescription drug overdoses1. The age-adjusted prescription opioid mortality rate has nearly quadrupled from 1999–2011, from 1.4 per 100,000 to 5.4 per 100,000. In 2011, there were 16,917 fatal overdoses involving prescription opioids2. 

Although prescription opioids are appropriate components of a pain management treatment plan for certain conditions3 4 5. There is limited evidence demonstrating the long-term beneficial effects of opioid use for chronic pain management for nonterminal conditions6 7. In addition, long-term daily use of opioids can lead to increased tolerance, addiction or dependence8 9. Studies suggest a correlation between high opioid dosage and a greater risk of overdoses and fractures10 11 12. 

The 2016 CDC guideline on opioid prescribing recommends the use of “additional precautions” when prescribing dosages ≥50 morphine equivalent dose (MED), and generally recommends avoiding dosages ≥90mg MED. For patients who are already taking doses ≥90mg MED, the CDC recommends that clinicians should “explain in a nonjudgmental manner” the risks and benefits of continuing high-dose opioids, and should offer these patients the opportunity to taper to a safer, lower dose13. 

A lower rate indicates better performance. 

* Adapted with financial support from CMS and with permission from the measure developer, Pharmacy Quality Alliance (PQA). 

Historical Results – National Averages

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References

  1. Centers for Disease Control and Prevention (CDC). 2011. “Vital Signs: Overdoses of Prescription Opioid Pain Relievers—United States, 1999-2008.” MMWR 60: 1–6.
  2. CDC. 2014. “Drug-Poisoning Deaths Involving Opioid Analgesics: United States, 1999–2011” NCHS Data Brief 166. http://www.cdc.gov/nchs/data/databriefs/db166.pdf
  3. Bressler H.B., W.J. Keyes, P.A. Rochon, E. Badley. 1999. “The Prevalence of Low Back Pain in the Elderly. A Systemic Review of the Literature.” Spine 24:1813–19.
  4. Gureje O., M. Von Korff, G.E. Simon, R. Gater. 1998. “Persistent Pain and Well-Being: A World Health Organization Study in Primary Care.” JAMA 280:147–51.
  5. Manchikanti L., P.S. Staats, V. Singh, et al. 2003. “Evidence-Based Practice Guidelines for Interventional Techniques in the Management of Chronic Spinal Pain.” Pain Physician 6:3–80.
  6. Chou R., G.J. Fanciullo, P.G. Fine, et al. 2009. “Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain.” Journal of Pain 10(2):113–30.
  7. Noble M., J.R. Treadwell, S.J. Tregear, et al. 2010. “Long-Term Opioid Management for Chronic Noncancer Pain.” Cochrane Database Syst Rev 1(1). doi: 10.1002/14651858.
  8. King, L. 2007. “Pain Medications: How Long is Too Long.” Pain EDU. http://www.painedu.org/articles_timely.asp?ArticleNumber=10 (Accessed January 5, 2016)
  9. National Institutes of Health (NIH). 2011. “Opioids and Chronic Pain.” Medline Plus. https://www.nlm.nih.gov/medlineplus/magazine/issues/spring11/articles/spring11pg9.html
  10. Dunn, K.M., K.W. Saunders, C.M. Rutter, C.J. Banta-Green, J.O. Merrill, M.D. Sullivan, M. Von Korff. 2010.
  11. “Overdose and Prescribed Opioids: Associations Among Chronic Non-Cancer Pain Patients.” Annals of Internal Medicine 152(2), 85–92. http://doi.org/10.1059/0003-4819-152-2-201001190-00006
  12. Paulozzi, L.J., et al. 2011. “A History of Being Prescribed Controlled Substances and Risk of Drug Overdose Death.” Pain Medicine 13: 87–95. doi: 10.1111/j.1526-4637.2011.01260.x.
  13. Saunders, K.W., K.M. Dunn, J.O. Merrill, M. Sullivan, C. Weisner, J.B. Braden, M. Von Korff. 2010. “Relationship of Opioid Use and Dosage Levels to Fractures in Older Chronic Pain Patients.” Journal of General Internal Medicine 25(4), 310–15. http://doi.org/10.1007/s11606-009-1218-z

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