January 28, 2020

Opioid monthly: NASEM offers framework for developing opioid prescribing guidelines

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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    Medication-assisted treatment

    Paper suggests approaches for insurers to improve access to methadone in outpatient treatment programs:The article, published in Psychiatric Services, suggests the first step is to expand coverage of methadone by commercial health plans, especially among insurers who serve communities hardest hit by the opioid epidemic. Since most commercially insured individuals have self-funded insurance plans, they also point out the need to educate employers on the value of methadone treatment as they determine their employee benefit designs. In addition, the authors recommend eliminating prior authorization and reducing patients’ out-of-pocket costs to improve access. They also suggest increasing reimbursement and managing provider networks to incent methadone treatment.

    They cite the lack of integrated care for behavioral health treatment for substance use disorders as a major barrier that results in a fractured delivery system. “This fractured delivery is reinforced by a fractured payment structure in which behavioral health is often ‘carved-out’ of the medical benefit and managed separately,” the authors said. “The separated system incentivizes acute, intensive episodes of care rather than long-term treatment, and relegating this treatment to separate and distinct facilities does not foster coordination between providers.” They argue that in the long-term, promoting system integration will help catalyze transformation in methadone and addiction treatment more generally. Francisca Azocar, vice president of research for Optum Behavioral Health, co-authored the article with a researcher at Johns Hopkins and with the vice president of national treatment quality initiatives at Shatterproof.

    In rural communities: The burden of treating opioid misuse in rural communities falls on family physicians as addiction treatment specialists and addiction medication such as buprenorphine haven’t been accessible. In fact, more than 10 million rural Americans—more than one-fifth of the country's rural population—live in counties without a single clinician licensed to prescribe buprenorphine for OUD. In a small Wisconsin community, the only full-time family physician has taken steps to become licensed to prescribe buprenorphine. She’s implemented medication treatment agreements to monitor patients taking opioids for chronic pain. She’s also implemented patient contracts with those she’s treating for OUD, encouraging counseling and the use of community support resources. Read more about her efforts to address the opioid epidemic in this NPR article/audio.

    Overdose and overdose prevention

    More than 90% of opioid-related deaths in 2017 were caused by unintentional opioid overdoses: That represents an increase from the 73.8% that were unintentional in 2000 (as the overall death rate has also dramatically escalated), finds a study published in JAMA. The research team looked at trends in U.S. drug overdose deaths involving opioids certified as unintentional, suicide, or undetermined intent. In addition to an increase in the percentage of unintentional opioid overdose deaths, the rate of unintentional deaths increased more than six fold from 2.20 to 13.21 per 100,000 people. In that same time frame, rates of opioid-related suicide deaths more than doubled from 0.27 to 0.58 per 100,000, but the percentage of opioid-related suicide deaths proportionately declined from 9.0% to 4.0%. The authors suggest that recent increases in overdose deaths involving heroin and nonmethadone synthetic opioids, including fentanyl, likely contributed to these trends.

    Concurrent use of benzodiazepine and long-acting opioids increased overdose risk in adolescents and young adults: This is according to results recently published in JAMA Pediatrics. The study looked at opioid prescribing patterns associated with prescription opioid overdose and found that each increase in daily opioid dosage category (<30, 30-59, 60-89, 90-119, or at least 120 morphine milligram equivalents) and co-prescribing with either benzodiazepine and extended-release or long-acting opioids was associated with higher overdose risk. The findings suggest that when prescribing opioids to adolescents and young adults, practitioners could potentially mitigate overdose risk by using the lowest effective dosage, avoiding concurrent opioid and benzodiazepine use, and relying on short-acting opioids.

    Trends in opioid prescribing

    The National Academies of Sciences, Engineering, and Medicine (NASEM) has issued a consensus report that provides a framework for developing opioid prescribing guidelines: However, the report itself doesn’t offer any recommendations to include in such a guideline. Instead, NASEM says any group drafting prescribing guidelines should consider a host of factors, including: 1) the evidence, or lack thereof, for using opioids versus alternatives for a condition or procedure 2) the downstream effects of any prescription, such as refill requests and the possibility that some pills will go unused and 3) the broader potential implications of their plans, including pain relief and improved quality of life, as well as harmful consequences. The FDA originally asked NASEM to come up with a framework for developing evidence-based prescribing guidelines, but the committee that wrote the report took a broader approach, establishing a guidebook that any group can use.

    Nonpharmacologic pain management

    A new consortium at Harvard Medical School is looking to develop safer, effective opioid alternatives for chronic pain: The researchers did this by focusing on the nociceptor neurons responsible for initiating the sensation of pain. Their Laboratory of System Pharmacology has launched its STOP PAIN (Safe Therapeutic Options for Pain and Inflammation) project with the goal of identifying compounds that block the activity of these cells and use computational modeling to develop preclinical drug candidates that can be eventually submitted to the FDA. The research team will use experimental designs and AI. They’re optimistic that they’ll make it possible to develop drug candidates suitable for human clinical trials within a five-year time frame, speeding up the usual slow and arduous drug development pipeline and meeting a critical unmet need for non-opioid medications for patients with chronic pain. Read more on the HMS website.

    Outcomes among long-term opioid users

    Male long-term opioid users with testosterone deficiency who received opioids plus testosterone treatment had better health outcomes: Those outcomes were better than those of men didn’t receive testosterone treatment within the Veterans Health Administration (VHA), according to a new paper in JAMA Network Open. The research team found that those who were treated with opioid and testosterone medications had significantly lower all-cause mortality and significantly lower incidence of major adverse cardiovascular events, femoral or hip fractures, and anemia after a multiyear follow-up. Prescription opioid use has been shown to have an association with testosterone deficiency, but up to now little has been known about health outcomes of patients who take both opioids and testosterone treatment. More research is needed to ascertain whether there is a causal effect.

    Children and the opioid crisis

    The severity of admissions for children with acute opioid ingestions, especially following attempted suicide, increased between 2005 and 2018: This occurred despite efforts to limit and monitor access to prescription opioids. The study, published in the Journal of Toxicology, found that there were over 207,000 cases of opioid poisoning in children between 2005 and 2018, with the percentage admitted to a critical care unit from these exposures increasing from 6.6% to 9.6%, and suicidal intent increasing from 14.0% to 21.2%. Fentanyl, heroin, and methadone were the opioids most associated with having a Pediatric Intensive Care Unit procedure. “Efforts focused on addressing adolescent suicide and mental health are needed to reduce the serious consequences of opioid poisoning in the pediatric population,” the authors said.

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