May 29, 2018

Opioid monthly: How White River Junction VA Medical Center cut opioid prescriptions by 42%

Daily Briefing

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

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    From the literature

    The cost of the opioid crisis: Opioid prescriptions are down, yet the cost of opioid-use disorder (OUD) treatment and opioid overdose among individuals with employer insurance has skyrocketed in just over a decade ($2.6 billion in 2016 from $0.3 billion in 2004), according to a new Kaiser Family Foundation analysis. This cost increase likely stems from wider awareness of addiction and a rise in illicit opioid use (heroin and other opioid street drugs)—a relatively common practice when people who are dependent on opioids can no longer obtain a prescription, among other factors. The KFF survey also found that the highest levels of spending for OUD and overdose treatment among people with employer insurance occurred among young people, ages 18-34 years old—even though they are prescribed fewer opioids than older adults. While prescribing practices are improving, more work is needed to support people with OUD and reduce leftover reservoirs of opioids that may be shared, purchased, or stolen by others.

    Maternal and child health: More than 80% of the neonatal abstinence syndrome (NAS) births in the United States are covered by Medicaid—a program well-positioned to help mothers with OUD and their babies born to opioid withdrawal, according to a recent Health Affairs blog. Key action areas for this growing and vulnerable population—often left out of the conversation—include tailored OUD treatment for pregnant and postpartum women, broad care coordination, and the use of evidence-based practices (e.g. "rooming in" mothers with their NAS infants in the hospital) and policies that reduce the stigma of OUD among mothers (e.g. offering treatment benefits instead of criminal penalties for pregnant women using opioids during pregnancy).

    Alternative pain management: Some patients are filling fewer opioid prescriptions in states with medical cannabis laws, and even more so in states with active cannabis dispensaries, according to a study in JAMA Internal Medicine. Under Medicare Part D, the average state dispensed 23.08 million daily doses of opioids per year from 2010 to 2015. States with active cannabis dispensaries saw 3.742 million fewer daily doses. This difference was most significant for hydrocodone and morphine prescriptions. As stakeholders consider policies to increase access to effective non-opioid pain treatments, more research is needed on the benefits and risks of various chemical compounds found in cannabis.

    Dental opioid prescribing: U.S. opioid prescription rates increased slightly between 2010 and 2015, with the largest increase among 11-18 year olds. In response, the American Dental Association called on dentists to cut back on prescribing opioid painkillers, citing a paper in the Journal of the American Dental Association that found almost one-third of the prescriptions for children weren't even written after surgery, but after regular dental visits. A new American Dental Association policy sets mandates to address this issue, including: continuing education for dentists who prescribe opioids; limits on opioid dosage, with a duration of no more than 7 days for acute pain treatment; and support for dentists registering with and using Prescription Drug Monitoring Programs (PDMPs) to promote appropriate prescribing.

    From the media

    OUD treatment: Medication-Assisted Recovery Anonymous (MARA) meetings are spreading across the United States to support people with OUD using medication-assisted treatment (MAT), Slate's "Medical Examiner" reports. MARA meetings differ from the traditional 12-step groups (Narcotics Anonymous or Alcoholics Anonymous), which discourage the use of anti-craving medications such as methadone or Suboxone. According to research, these medications, when used as prescribed and paired with counseling, are most effective for treating OUD because they prevent patients from getting physically sick from withdrawal, enabling them to focus on their addiction recovery.

    MAT access: Insurance pre-authorization waiting periods for MAT can be a matter of life or death, NPR reports, spotlighting the experience of a couple whose daughter, Katy, overdosed while waiting for her insurer to approve a prescription for the medication that could help her cravings and recovery. There are small windows of opportunity when a person with OUD takes action to get help, and prior authorization requirements are being eliminated in many insurance situations.

    Harm reduction: Naloxone access in New York City is "spotty at best," despite standing orders for wide availability without a prescription, according to a recent New York Times investigation. For the investigation, the Times called the 720 pharmacies in New York City that are listed to provide the overdose antidote and found only one-third had it in stock and would dispense it without a prescription. Pharmacy technicians often required the person having the overdose to make the purchase (it would be hard to make it to the store in person), or stated a prescription was needed to buy it for someone else.

    Last month, U.S. Surgeon General Jerome Adams released a national advisory to Americans to obtain and learn to use naloxone (also known by the brand name Narcan). Broad coordination and training across pharmacies is desperately needed to make it easy for anyone to get this drug in time to save a life.

    Pain management: White River Junction VA Medical Center cuts opioid prescriptions by 42% via alternative pain treatments—physical therapy, acupuncture, tai chi, and yoga—but not without support, the Boston Globe reports. According to the Globe, the facility reduced the number of patients receiving opioids for chronic pain from 2,088 in 2014 to 1,221 in late 2017—with the most dramatic change among vets who were taking the highest doses. The key to success? White River did not cut off patients taking opioids against their will, and the facility offered step-by-step support to wean patients off high doses and find active strategies to cope with pain. According to navy veteran Jake O'Neill, who became dependent on opioids for chronic low back pain, “They're doing anything and everything to keep me from failing … I'm not being dropped like a hot potato at the side of the road."

    From OptumLabs

    OptumLabs' Opioid Key Performance Indicators (KPIs) are live for use via the Advisory Board Opioid Profiler tool. The Opioid Profiler is an interactive analytic tool that enables Advisory Board members to set up geography-specific views of county-level KPIs and get rapid insight into opportunities to address the opioid crisis in their local markets.

    Access the Tool

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