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November 26, 2019

Opioid monthly: Why—and how—the American Society of Addiction Medicine is redefining 'addiction'

Daily Briefing

    Editor's note: The Opioid Monthly is compiled by OptumLabs. The Daily Briefing is published by Advisory Board, a division of Optum, which also owns OptumLabs.

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    Nonpharmacologic pain management

    UnitedHealthcare has introduced a new benefit for people with acute low back pain: The new benefit makes it more affordable to access conservative treatments with the goal of reducing the number of opioid prescriptions, imaging tests, and spinal surgeries. This new benefit is being offered to E&I clients and was informed by a recent study by OptumLabs and the Boston University School of Public Health that showed higher out-of-pocket costs made it less likely for patients with low back pain to choose clinically recommended conservative treatments, such as physical therapy and chiropractic care. The study also showed that patients who accessed a chiropractor or physical therapist first had greatly decreased odds of both early and long term opioid use. Based on a UnitedHealthcare analysis, by 2021 this benefit design is estimated to have the potential to reduce opioid use by 19%, spinal imaging tests by 22%, spinal surgeries by 21%, and lower the total cost of care for eligible plan participants and employers (United Healthcare press release, 10/29).

    Trends in opioid prescribing and tapering

    New HHS guide provides clinicians with recommendations for appropriate opioid tapering: HHS issued the guide in an effort to avoid rapid tapering, which can be harmful for patients who have been on high doses of opioids for long periods. Tapering too rapidly may lead to acute withdrawal, exacerbation of pain, serious psychological distress, and thoughts of suicide. Patients who are tapered too rapidly may seek other sources of opioids including illicit sources to control their pain. The guide comes amid concerns that CDC's 2016 prescribing recommendations have been misapplied, resulting in a crackdown on high doses of opioids and leaving some chronic pain patients in a lurch. The HHS guide emphasizes the importance of shared decision-making with patients, individualized and slow tapers, and integration of pain management with behavioral support. "Determining when and how to taper opioids can be challenging for clinicians," the authors of the guide said in a recently published JAMA perspectives piece. "There is a need for clear guidance to support clinicians in negotiating challenges with changes in opioid prescribing for patients receiving opioid therapy."

    As the United States tries to wean off prescription opioids, physicians worry about the impact on chronic pain patients: Doctors are concerned that many chronic pain patients will turn to illicit drugs if they do not have access to prescription opioids, according to a new report from Quest Diagnostics. For the report, researchers polled 500 primary care physicians (PCPs) and analyzed 4.4 million lab test results. More than 70% of doctors surveyed said that although the recent opioid restrictions will likely lead to a decrease in opioid-related deaths, more patients will struggle to properly manage their pain. Physicians surveyed recognize they need help monitoring prescription drug use, and at least seven out of 10 said they wish they had more training on how to taper off opioids (Kacik, Modern Healthcare, 10/16).  

    Study finds reducing opioid prescriptions didn't lower patient satisfaction scores: Patient satisfaction scores remained steady even after surgeons reduced opioid prescriptions overall and slashed the mean number of pills prescribed by more than 50%. The retrospective study, published in JAMA Surgery, looked at patient-reported clinician satisfaction scores from Dartmouth-Hitchcock Medical Center in New Hampshire before and after an intervention that resulted in decreased opioid prescribing. These findings should help assuage clinician concerns that satisfaction scores will suffer as a result of reducing prescriptions. The study's co-author Richard Barth Jr., chief of general surgery at Dartmouth-Hitchcock Medical Center, notes that patient education was a major component of the intervention, suggesting that educating patients could help ease the transition (Kuhrt, Fierce Healthcare, 10/17).  

    One-fourth of doctors are not confident they can safely get patients off opioids: A quarter of physicians say they aren't confident they can safely get patients off opioids, even though 86% of them agree that helping people get off of opioids is a fundamental part of stopping the country's epidemic, according to a new survey from U.S. WorldMeds. For the survey, U.S. WorldMeds, a specialty pharmaceutical company, asked 500 doctors and 1,100 U.S. adult consumers about barriers to ending the opioid crisis. Of the physicians surveyed, 80% say there is a lack of education about how to help their patients stop taking opioid painkillers, and 76% say that fear of opioid withdrawal is keeping patients from getting off of opioids (Finnegan, Fierce Healthcare, 10/1).

    Treatment for patients with substance use disorder and opioid use disorder

    PCP engagement program in Oregon increases PCPs waivered to prescribe buprenorphine and medication-assisted treatment (MAT) access for patients: Patients with opioid use disorder (OUD) whose PCP obtained a waiver during the 18-month intervention had more than four-fold greater odds of being treated with buprenorphine, according to a new study in JAMA Network Open. The intervention was conducted in primary health clinics within a large, integrated health care system in Oregon and consisted of a PCP survey to identify barriers, educational outreach, direct face-to-face meetings with PCPs, and educational toolkits. Outcome measures were: number of new sites now prescribing MAT, number of new PCPs with a waiver to treat with buprenorphine, number of patients receiving buprenorphine, and number of patients on treatment for 12 weeks or longer. The study was supplemented by a 10 minute video of the PCP authors describing treating patients with suboxone and the satisfaction of supporting these patients in their efforts to recover.

    In a letter to CMS, the American Academy of Family Physicians (AAFP) calls for greater investment in primary care to help mitigate the opioid crisis: AAFP in the letter wrote that "family physicians have a unique opportunity to be part of the solution." The letter was the AAFP's response to CMS' request for information on developing an action plan to prevent opioid addiction and enhance access to MAT. The AAFP urges CMS to expand coverage of MAT within the primary care setting. The group also calls for improved residency training on management of chronic pain and opioid dependence, as well as CME offerings that address these issues (AAFP press release, 10/21).  

    The American Society of Addiction Medicine (ASAM) has redefined "addition": ASAM redefined the term in order to better address the complexity and nuance of addiction, suggesting it is a chronic disease as amenable to treatment as many other chronic diseases. The updated definition reads: "Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases." In Medium, the co-authors explain that this definition recognizes the interplay of biological, psychological, and environmental conditions that play a role in addiction, and clarify the difference between addiction and "substance use disorder" (SUD).

    Drive times to opioid treatment programs may be as much as six times longer in rural U.S. counties compared to urban ones: In a research letter published in JAMA, a team from Yale School of Medicine found that drive times hit in rural counties to get to a clinic that could dispense methadone hit nearly 50 minutes, compared with 8 minutes in urban settings. For their research, the team examined urban and rural counties in five U.S. states with the highest county rates of opioid-related overdose mortality. They calculated the minimum drive times from each county's population center to the nearest opioid treatment program, as well as the nearest federally funded qualified health center. The findings highlight the barriers to treatment in rural areas and the need for expanded access in these settings.

    Sesame Street introduces a new storyline about parental addiction: Sesame Street introduced the storyline as part of a new initiative from the show's nonprofit and education arm to explain addiction to children. In addition to a series of videos which feature the muppet Karli, whose mother is struggling with addiction, there will be a storybook, a coloring activity, and articles that parents, educators, and health care providers can use to talk to children about addiction. "We emphasize that it is a sickness and it is something that children do not cause," said Jeanette Betancourt, SVP for U.S. social impact at Sesame Workshop, in a recent interview with STAT News. "For children, we particularly want them to know what parental addiction is, but also provide a sense of hope and help them feel they're not alone" (Chakradhar, STAT News, 10/10).

    Overdose and overdose prevention

    CDC data shows that fentanyl, heroin, and cocaine were among the most common drugs behind U.S. overdose deaths in 2017: CDC's report finds that nationally, nearly 40% of the 70,000 overdose deaths in 2017 were due to fentanyl, followed by heroin, cocaine, and methamphetamine. This number is up from 2016 when fentanyl was responsible for nearly 30% of all overdose deaths nationwide. Regionally, fentanyl was the leading cause of drug overdose deaths in eastern regions, spanning from New England to Minnesota, while methamphetamine was most frequently involved in four regions that include Texas and most states west of it. This report comes out amid newer data from CDC that indicates fentanyl overdoses in the East dropped in 2018, likely due to implementation of naloxone. Meanwhile, fentanyl overdose deaths are on the rise in the West, suggesting fentanyl is migrating (Edwards, NBC News, 10/25).  

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