The “economic burden” of prescription opioid misuse is nearly $80 million.
We were discussing opioid dependence in my CDI education session last week and it spurred me to write this article. Each week we review a topic often elicited by a real-life case. Opioid misuse and addiction is a public health crisis, and the Centers for Disease Control and Prevention (CDC) estimates that the “economic burden” of prescription opioid misuse is nearly $80 million. This is not even taking into consideration illicit drug use.
- Approximately 25 percent of patients prescribed opioids for chronic pain misuse them
- About 80 percent of people who use heroin first misused opioids
- In the Midwest, opioid overdoses increased by 70 percent from July 2016 through September 2017
- Drug overdoses killed ~70,000 Americans in 2016
To understand this topic, we need some definitions.
Opiates are naturally occurring substances that come from the opium plant, such as morphine and codeine. Opioids include opiates and (semi-)synthetic compounds which bind to the same receptors such as oxycodone, hydrocodone, and heroin. Buprenorphine and methadone are also opioids.
ICD-10-CM still uses terminology of use, abuse, and dependence. The Diagnostic and Statistical Manual of Mental Disorders, DSM, is the American Psychiatric handbook, and the current version is 5 (DSM-V or DSM-5). DSM-5 utilizes substance use disorder terminology. There was not a direct crosswalk between ICD-10-CM and the updated DSM-5 conditions until 2018 when the Official Guidelines added:
Mild substance use disorders in early or sustained remission are classified to the appropriate codes for substance abuse in remission, and moderate or severe substance use disorders in early or sustained remission are classified to the appropriate codes for substance dependence in remission.
Opioid use disorder is a pathological condition reflecting compulsive, prolonged self-administration of opioid substances with no legitimate medical purpose, or in the case of a medical condition requiring opioid treatment, use of opioids in doses greatly in excess of the amount needed and prescribed for that medical condition. The diagnosis is based on the following criteria (I am listing the criteria for generic substance use disorder (SUD)):
[Mild SUD is defined as having 2-3 criteria; moderate SUD meet 4-5 criteria; severe SUD ≥ 6 criteria]
- Taking substance in larger amounts or over longer period than intended
- Persistent desire or failed efforts to control use
- Much time spent obtaining, using, or recovering from effects
- Craving, strong desire, or urge to use
- Failure to fulfill major roles at home, work, or school
- Continued use despite social or interpersonal problems related to use
- Giving up or reducing important social, occupational, or recreational activities due to use
- Recurrent use in physically hazardous situations (e.g., operating machinery, driving)
- Continued use despite awareness of a physical or psychological problem due to substance
- Tolerance: need for larger amount to achieve desired effect or diminished effect with same amount
- Withdrawal: occurrence of a characteristic withdrawal syndrome or continued use of substance to avoid withdrawal symptoms.
In terms of opioid use disorder, there is a disclaimer that tolerance and withdrawal criteria do not apply to patients properly taking prescription opioids under appropriate medical supervision.
This disclaimer is extremely important. Some of you may have been querying providers for opioid dependence for patients on long-term narcotics for pain control.
If a patient is being prescribed medication for their cancer, and they are taking it at the intervals and in the dosage prescribed, they may have physiological dependence (that is, their body is accustomed to the medication and will have withdrawal symptoms at cessation), but they are not considered to have a substance use disorder. There may be no psychological dependence.
Coding Clinic Q2 2018 addresses this. It states that without provider documentation of an associated physical, mental, or behavioral disorder, “opioid use” is not coded. Do not generalize this to the patient who has no diagnosed SUD who comes in intoxicated. They should get a code of (at least) substance use (uncomplicated or with pertinent complication). It will meet secondary diagnosis criteria by requiring drug testing or supportive therapy.
In the Centers for Medicare & Medicaid Services (CMS) ICD-10-CM v.36 Definitions Manual, opioid use/abuse/dependence with intoxication delirium, perceptual disorder, or psychotic disorder are all comorbid conditions (CCs). I think CCs are sometimes whimsical because I do not see why F11.20, Opioid dependence, uncomplicated would be a CC but F11.220, Opioid dependence with intoxication, uncomplicated is not. It seems like the consumption of resources would actually increase with substance intoxication. I wonder if this was just an oversight. Withdrawal also renders F11.- a CC.
This leads me to the most fascinating point I discovered in my attempt to clarify this topic for you. I understood the original indexing and coding rule to specify that having withdrawal was indicative of substance dependence, which I think stemmed from DSM-5 coding recommendations. Remember that tolerance and withdrawal are not used as SUD criteria in properly prescribed medication. So, if a patient is taking their medication right and has no substance use disorder diagnosis, what do you do if they experience withdrawal? How do you code that?
I found some guidance from the American Psychiatric Association (APA) which states that the diagnostic code for substance withdrawal that develops in individuals who take medications under appropriate medical supervision is F11.93, Opioid use, unspecified with withdrawal (https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2018.9a23). This makes sense to me, because mild SUD goes to abuse and moderate or severe SUD codes to dependence. “Use” has no corresponding SUD designation.
I should also mention that at the ICD-10-CM Coordination and Maintenance Committee Meeting, the American Psychiatric Association proposed new codes for specific substance abuse (mild substance use disorder) causing withdrawal. Their issue is that there are patients who only meet a few criteria for substance use disorder who experience withdrawal upon abstinence.
Finally, for patients who are using opioids as prescribed by their clinician, you use the code, Z79.891, Long-term (current) use of opiate analgesic. This includes methadone for pain management. However, if the methadone is to treat heroin addiction, the appropriate code would be F11.2- (Opioid dependence). The last piece of the puzzle is whether or not a patient is in remission.
Remission indicates that a patient who previously met the criteria for SUD, no longer does so, with the exception of craving or a strong desire. Craving may be present long-term. Three months up to a year is considered early remission; twelve months or longer constitutes sustained remission.
It should go without being said that none of this can be coded without appropriate documentation from your clinician. If you query and they feel they need more information, you might consider referring them to the American Osteopathic Academy of Addiction Medicine’s information packet, https://www.aoaam.org/resources/Documents/Clinical%20Tools/DSM-V%20Criteria%20for%20opioid%20use%20disorder%20.pdf.
I thought it was pretty helpful. I hope this has been helpful to you!