This month, learn how Covid-19 affects the ability of patients with opioid use disorder to access treatment, read new CDC data showing that both fatal and nonfatal drug overdoses increased between 2016 and 2017, and learn about a new study showing the relationship between opioid prescriptions among family members and youth overdose.
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.
Trends in opioid prescribing
Patients who don't qualify for high-potency, extended release "opioid-tolerant only" opioids are still being prescribed these drugs off-label at high rates, according to a new study in JAMA Network Open from the Mayo Clinic and OptumLabs. Of more than 153,000 use episodes of opioid analgesics labeled for use only among people who are opioid-tolerant, fewer than half were prescribed for patients considered opioid tolerant. Approximately 30% of these cases involved the use of fentanyl patches. Among patients whose EHR data was linked to claims data, researchers found that the incremental evidence from EHRs for appropriate use was only an additional 1% of opioid prescriptions.
More research is needed to understand the rationale for why providers continue to prescribe high-potency opioids to patients who don't meet the eligibility criteria. The next phase of this Mayo/OptumLabs/Optum Life Sciences work will examine safety impacts (overdose, mortality) associated with potentially inappropriate prescribing.
Lack of coverage for opioid alternatives may encourage higher rates of opioid prescribing among Medicare beneficiaries. The results come from a study—recently published in JAMA Network Open—looking at Medicare Part D formulary designs at the county level to quantify the coverage of opioid alternatives and test whether restrictions and exclusions are associated with increased opioid prescribing to older adults. Among 30 nonopioid analgesics examined in 2015 and 2016, Medicare plans did not cover about 7% of these drugs. For each additional opioid alternative not covered in a county, the rate of opioid prescribing increased by 2.2% to 3.7%, relative to the mean opioid prescribing rate. Additionally, opioid prescribing decreased with fewer opioids covered. These results suggest that policy makers should consider crafting policies for Medicare drug plans to follow that emphasize increasing coverage or reducing restrictions on important opioid-alternative drugs.
Covid-19 and opioid use disorder
Mitigating the spread of Covid-19 has had profound impacts on patients with opioid use disorder (OUD) and their ability to access treatment. In recent weeks, steps have been taken to decrease barriers to OUD treatment through opioid agonist therapy through enhanced use of telemedicine. A recent Health Affairs blog post outlines the move by the Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration to ease regulations to allow patients to be initiated on buprenorphine through a telemedicine visit without an in-person exam. Follow-up visits for existing patients on either buprenorphine or methadone are also now allowed to occur by phone.
New guidelines are also easing restrictions on the process of methadone receipt. SAMHSA is now allowing patients who are quarantined or isolated due to Covid-19 to receive their methadone either through a surrogate take-home pick-up or by delivery. While new rules allow people considered "stable" to take home up to a 28-day supply of methadone, and people considered "less than stable" to take home up to a 14-day supply, STAT News reports that compliance with the new guidelines has been inconsistent. With "stable" not considered a clinical term, SAMHSA is leaving it up to the opioid treatment programs to decide who is stable enough for 28 or 14 days of take-home medications.
Advocates and treatment experts from the National Alliance for Medicated Assisted Recovery, the Drug Policy Alliance, and the North Carolina-based Urban Survivors Union are urging more steps to protect people treated with methadone from Covid-19 and enforce the new methadone guidelines.
The Covid-19 crisis "presents an opportunity to create a healthcare system that truly addresses the needs of vulnerable populations, such as those with opioid use disorder," urged authors of a recent Nature Medicine article. "We must first act quickly to stave off a substantial increase in overdoses, an impending crisis on top of a crisis."
Medications for opioid use disorder
The number of facilities offering methadone or buprenorphine for OUD are associated with the racial/ethnic composition of the community. In a JAMA Network Open study analyzing all 3,142 counties or county-equivalent units in the United States in 2016, counties with highly segregated African American and Hispanic/Latino communities had more facilities that provide methadone per capita, while counties with highly segregated white communities had more facilities that provide buprenorphine per capita. Given that there is little research indicating which patients with OUD will respond better to which medication, and that no single medication has been endorsed as a preferred first-line treatment, the authors argue both medications should be equally accessible to all patients.
The results of this study suggest that reforms to existing regulations governing supply of these medications are needed to improve equity. The authors suggest methadone could be made available through community pharmacies after an initial prescription by a physician at an outpatient clinic. Buprenorphine access could be improved by eliminating DEA waiver training requirements, as has been recommended by leading experts.
Approximately 40% of those with OUD receive medication-based treatment and 40% access self-help groups, with only 10% accessing both, according to a new study published in Health Affairs looking at data from 2015 to 2017. The analysis, performed with SAMHSA data, found that among nearly 448,000 discharges, equal proportions of people—about 29%—used either only medication or only self-help groups (e.g. Narcotics Anonymous, Alcoholics Anonymous, and similar), while only about 10% used both, and 30.5% used neither. Using only medication for treatment was most common among Medicaid recipients. The authors discuss the fact that medication and self-help groups have often been perceived as mutually incompatible, with self-help groups typically favoring an abstinence-only model. They cite several examples of self-help models that have taken a more balanced approach to promoting the use of evidence-based and clinically recommended OUD medication treatment.
Use of self-help groups without medication was most common in residential facilities, among those with criminal justice referrals, and among uninsured or privately insured patients, as well as in the South and West regions of the United States. These subgroups may be important targets for future efforts to identify and overcome barriers to medication treatment.
Overdose and mortality rates
New CDC data finds that both fatal and nonfatal drug overdoses increased between 2016 and 2017, with fatal overdoses increasing by nearly 10% and the number of ED visits for nonfatal drug overdoses increasing by more than 4%. CDC reports that in 2017, drug overdoses caused 70,237 deaths in the United States and a total of 967,615 nonfatal drug overdoses were treated in EDs. Almost a third of overdoses involved cocaine, while opioids, nonheroin opioids, and heroin each made up less than 4% of these overdoses. Overdoses were most common among females, those ages 15 to 34, and those in Midwestern states.
Alcohol and benzodiazepine co-involvement in opioid-involved overdose deaths is common, and the prevalence and mortality rates of each co-involved substance has increased during the past two decades, according to a recent JAMA study looking at nearly 400,000 poisoning deaths involving opioids. Alcohol co-involvement was highest in heroin and synthetic opioid (e.g. fentanyl; excluding methadone) overdose deaths at 15.5% and 14.9%, respectively, in 2017. Benzodiazepines co-involvement was highest in prescription opioid and synthetic opioid overdose deaths at 33.1% and 17.1%, respectively, in 2017. Significant correlations occurred between state-level binge drinking rates and alcohol co-involvement and between state-level benzodiazepine prescribing rates and benzodiazepine co-involvement in opioid overdose deaths. The results highlight the need for prevention strategies to confront unhealthy alcohol use and decrease benzodiazepine co-prescribing.
Opioid prescriptions among family members were associated with an increased risk of youth overdose, with prescriptions to family members associated with a two-fold increase in the risk of overdose and prescriptions to youth associated with a more than six-fold increase in the risk of overdose, according to a JAMA Open Network study. Concurrent prescriptions to both family members and youth in the past month were associated with a nearly 13-fold increase in overdose risk. Further interventions targeting youth and families are needed, including counseling patients about the risks of opioids to youth in their families.
CVS Health has combined efforts with a community-based program to connect individuals with non-clinical support to aid their recovery, Forbes reports. The effort—by CVS and its Aetna health insurance unit—bolsters Aetna's "Guardian Angel" program with Unite Us, a social care coordination platform, to connect individuals who have suffered an opioid overdose with social service providers. "Through this combination, clinical case managers can use the Unite Us network of social services to connect individuals with non-clinical support that can aid their recovery, such as community resources to help with housing, food insecurity and financial assistance," the companies said. Though the Guardian Angel program already has a 50% engagement rate, CVS hopes working with Unite Us will allow people to more easily access support and resources within their community.