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
A recent CDC study highlights variances between indication-specific prescribing patterns for opioid drugs and clinical recommendations. The study, published in JAMA Network Open in May, used OptumLabs data to examine prescribing rates, days' supply, and dose across 41 different clinical situations among 18,016,259 privately insured individuals, and separately used data from IBM Marketscan to examine a multistate Medicaid cohort including 11,453,392 people. Researchers studied indications that ranged from a wide set of acute and chronic conditions, surgical procedures, sickle cell disease (SCD), and cancer. The CDC research team—composed of researchers from the group that issued the agency's original 2016 opioid prescribing guidelines—found that indication-specific prescribing varied widely and was not always aligned with existing guidelines and recommendations. Fibromyalgia, chronic and acute back pain, musculoskeletal strains/sprains, and dental pain were conditions for which prescribing often exceeded current guidelines' recommendations of "no more than three to seven days of opioids when needed for acute pain."
Opioid prescribing rates for nonsurgical acute pain were lowest for acute migraines (at 4.6% among privately insured visits and 6.6% among Medicaid visits) and highest for rib fractures (at 44.8% among privately insured visits and 56.3% among Medicaid visits), with variable days' supply but similar daily dosage across most indications. Opioid prescribing for a given chronic pain indication varied depending on a patient's opioid use history. Days' supply for postoperative prescriptions was longest for combined spinal decompression and fusion (at 9.5 days among privately insured patients) or spinal fusion (at 9.1 days among Medicaid patients) and was shortest for vaginal delivery (at 4.1 days among privately insured patients versus 4.2 days among Medicaid patients).
The study's findings also raise different questions related to the adequacy of pain control and the use of opioids to treat cancer pain and sickle cell disease (SCD), and they suggest further research is needed on whether pain is being managed appropriately for those with metastatic cancer pain and SCD.
This important study offers strong signals in the many clinical areas where opioids are used and will be used to help develop and refine more indication-specific guidelines.
Individuals in the United States who weren't born in the country were significantly less likely to be prescribed opioids than U.S.-born individuals, particularly among those with chronic pain, according to a separate study published in JAMA Network Open in June. The study found that, among 48,162 individuals, 14.2% of U.S.-born and 7% of non-U.S.-born individuals received at least one opioid prescription within a 12-month period. For those diagnosed with chronic pain, 25.5% of U.S.-born individuals and 15.6% of non-U.S.-born individuals received at least one opioid prescription. Non-U.S. born patients also generally were treated for a substantially shorter period than U.S. born patients, at an average of 28.7 days compared with 53.1 days. White non-Hispanic individuals who weren't born in the United States had a significantly higher likelihood of receiving opioid prescriptions than did Hispanic or Asian individuals who weren't born in the United States. The reasons for these differences are unclear, and they warrant further research.
Covid-19 and opioid use disorder
The telemedicine boom that's occurred amid America's coronavirus epidemic has improved access to opioid use disorder (OUD) treatment, giving substance use disorder treatment providers unprecedented freedom to prescribe buprenorphine by telemedicine and evaluate patients over the phone. "We're seeing changes in the last six weeks that, in some cases, we've been advocating for a really long time, and in others, that we didn't even really think were possible," Samantha Arsenault, the VP of national treatment quality initiatives for Shatterproof, told STAT News in May.
Prior to the epidemic, organizations that provided home telehealth services for patients with OUD had to comply with many state and federal regulations, such as a required initial in-person visit. The flexibility to now treat OUD remotely means patients can avoid travel, which is especially important for individuals in rural communities where few clinicians are waiver-trained to prescribe buprenorphine.
On the payment side, Medicare and many state Medicaid programs have historically not paid for telehealth visits in the home. Earlier this year, CMS, which is by far the largest funder of U.S. substance use disorder treatment services, announced it would reimburse health providers not just for video telehealth visits, but also for audio-only visits.
Colleen LaBelle, director of Boston Medical Center's Office Based Addiction Treatment Program, in May told WBUR she thinks these changes have helped the field of substance use disorder treatment "We've basically started to treat substance use disorder like other diseases and normalize it somewhat. I hope this [epidemic] helps us look at substance use like any other disease."
Despite improved virtual access to treatment, suspected overdoses nationally jumped 18% in March, 29% in April, and 42% in May, according to the Washington Post. In some jurisdictions, such as Wisconsin's Milwaukee County, dispatch calls for overdoses have increased more than 50%. Emerging evidence suggests that continued isolation, economic devastation, and disruptions to the drug trade in recent months are fueling the surge.
Drug rehab facilities around the country also have been experiencing flare-ups of coronavirus or Covid-19-related financial difficulties that have forced them to close or limit operations. Of the facilities that have remained open, many have become hot spots for coronavirus cases, such as the Haymarket Center, a 380-bed treatment and sober-living facility in Chicago, which earlier this year reported an outbreak of 55 coronavirus cases among clients and staff members. To keep clients safe, some substance use disorder treatment centers have been following safety precautions similar to hospitals, such as testing all incoming patients for Covid-19. Amesh Adalja, a senior scholar at the Johns Hopkins University Center for Health Security, said in July told the Los Angeles Times that he hopes safety measures make people feel more comfortable about seeking substance use disorder care.
Disparities in OUD Treatment
Black non-Hispanic and Hispanic women with OUD were significantly less likely to receive any medication for OUD treatment and were less likely to receive buprenorphine during pregnancy when compared with white non-Hispanic women with OUD, according to another study published in JAMA Network Open in May. The study of a large population-level sample of women with OUD in Massachusetts found that 69.9%, or 3,181, white non-Hispanic women received any type of medication for OUD (MOUD) in the year before delivery, compared with 49.4%, or 228, Hispanic women and 46.2%, or 108, Black non-Hispanic women. Compared with white non-Hispanic women, Black non-Hispanic and Hispanic women also had a substantially lower likelihood of consistent use of MOUD and of receiving buprenorphine compared with methadone. Given that MOUD with buprenorphine or methadone combined with behavioral therapy is the recommended management for women with OUD during pregnancy, work is needed to ensure all women receive this standard of care.
The study's authors hypothesize that a confluence of current and historical factors may be associated with their findings (see references in paper). Increasingly punitive policy responses toward pregnant women who use drugs, which were implemented in response to the high rates of cocaine and crack use in the 1980s and 1990s, may make women of color distrustful about disclosing substance use during pregnancy and result in avoidance of treatment. Barrieres to the consistent use of medication for the treatment of OUD may include delayed identification of OUD, racial discrimination by clinicians, cultural barriers, perceived stigma, and minimal social supports, all factors associated with low substance use disorder treatment program completion among Hispanic and black non-Hispanic people. Persistent racial inequities in maternal morbidity and mortality, even after adjusting for other maternal comorbid conditions, suggest that structural racism may be associated with a lower standard of care and fewer treatment options for women of color.
Among commercially insured patients discharged from the ED for a nonfatal opioid overdose, only 16.6% obtained follow-up treatment in the 90 days following overdose, and Black patients were half as likely to obtain follow-up compared with non-Hispanic white patients. Follow-up treatment was defined as an outpatient visit, inpatient treatment, or filled prescriptions for a buprenorphine or naltrexone. Follow-up was more common among those who were receiving active substance use disorder treatment in the 90 days prior to the overdose, with 62.5% of this cohort obtaining follow-up compared with 11.1% of those who were not receiving treatment before the overdose. Patients with prescription opioid overdose were less likely to obtain follow-up when compared with those who experienced a heroin overdose.
This research identifies a racial disparity in follow-up treatment that hadn't previously been documented and highlights the need for designing systems that seek to improve engagement and equity in treatment. Read more in this study published in JAMA Network Open in May.
Online access to opioids
FDA in June launched a pilot program to crack down on the growing numbers of illegal opioids sold online. The 120-day pilot program, in partnership with the National Telecommunications and Information Administration (NTIA), will notify three companies that manage and maintain registries of Internet domain names—Neustar, Verisign, and the Public Interest Registry—when FDA issues warning letters to sites illegally selling opioids. The NTIA will work with the companies to review FDA's letters and decide whether to take further action, including possibly suspending or blocking the domains. At the end of the pilot, the agencies will analyze its effectiveness as a potential solution to dealing with the illegal sale of unapproved opioids online. Read more on FDA's website.
Opioid use for chronic pain
A new infographic provides guidance for individuals taking opioids for chronic pain. The patient education infographic outlines steps those with chronic pain can take to reduce their risk while taking opioids, including proper storage, monitoring for side effects, and dose tapering if appropriate. An accompanying article published in JAMA Internal Medicine emphasizes that taking opioids should not be the first choice for chronic pain that is not caused by cancer. The article's authors also advise patients to talk to their provider if they develop cravings for opioids, which could be indicative of an OUD.