Irene B. Murimi

Financial Conflicts of Interest and the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain

HEALTH CARE POLICY AND LAW Financial Conflicts of Interest and the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain An increase in opioid prescribing for chronic, noncancer pain has been associated with large increases in addiction and overdose deaths in the United States. In response, the US Centers for Disease Control and Prevention (CDC) developed guidelines for prescribing opioids for chronic pain.1 When the draft guidelines were released, there was criticism. Some organizations argued that the development of the guidelines was not transparent and the recommendations were based on weak evidence.2,3 Subsequently, the CDC postponed the release of the guidelines and opened them to public comment for a 30-day period. More than 150 organizations formally submitted comments. We analyzed these comments to identify levels of support for the guidelines and whether financial relationships with opioid manufacturers were associated with opposition to the guidelines. The final guidelines were released in Marrch 2016.4 Methods | We extracted data from publicly available comments that 158 organizations submitted to the CDC’s docket.1 Two reviewers independently classified each comment into 1 of 4 mutually exclusive levels of support: supportive, generally supportive with recommendations, generally not supportive with recommendations, and not supportive. Comments from 9 organizations (5.7%) were coded as supportive by 1 reviewer and not supportive by the other; a third reviewer adjudicated these cases. Blinded to level of support, we classified each organization’s financial relationship to opioid manufacturers using their self-reported relationships and public websites, annual reports, and federal tax returns. We used the Wilcoxon rank sum test to assess the association between organizations’ final relationship to opioid manufacturers and their level of support for the proposed guidelines.

Prescription Drug Coverage for Treatment of Low Back Pain Among US Medicaid, Medicare Advantage, and Commercial Insurers

Key Points Question Among US insurers, what are the coverage policies for pharmacologic treatments for low back pain? Findings In this cross-sectional study of 62 products used to treat low back pain examined across 50 Medicaid, Medicare Advantage, and commercial insurance plans, utilization management strategies were common for nonopioids and opioids alike. Key informant interviews with plan executives underscored the frequent absence of comprehensive strategies to improve chronic pain treatment and to better integrate pharmacologic and nonpharmacologic opioid alternatives. Meaning Our findings underscore important opportunities among insurers to redesign coverage policies to improve pain management and reduce opioid-related injuries and deaths.

Quality of Prescribing by Physicians, Nurse Practitioners, and Physician Assistants in the United States

Nurse practitioners (NPs) and physician assistants (PAs) have increasingly broad prescribing authority in the United States, yet little is known regarding how the quality of their prescribing practices compares with that of physicians. The objective of this study was to compare the quality of prescribing practices of physicians and nonphysician providers.

Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis

We quantified the effects of Floridas prescription drug monitoring program and pill mill law on high‐risk patients.

Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers

Key Points Question Among US insurers, what are the coverage and utilization management policies for nonpharmacologic treatments for chronic, noncancer low back pain? Findings In this cross-sectional study of 45 Medicaid, commercial, and Medicare Advantage plans, most plans covered at least physical and occupational therapy and chiropractic care for chronic noncancer pain, but there was little evidence of coverage of acupuncture and psychological interventions. Utilization management strategies such as visit limits and prior authorization were common, but criteria varied widely across the plans examined. Meaning The lack of consistent coverage and utilization management policies underscores the need for best practices to improve comprehensive, multimodal coverage of treatments for chronic, noncancer low back pain.

Using trajectory models to assess the effect of hydrocodone upscheduling among chronic hydrocodone users

In October 2014, the US Drug Enforcement Agency moved hydrocodone combination products (HCPs) from schedule III to II of the Controlled Substances Act, further restricting their access. The aim of the study is to quantify the effect of hydrocodones “upscheduling” on the use of opioid and nonopioid analgesics among chronic users.

Effect of Direct-to-Consumer Advertising on Statin Use in the United States

Importance: The value of direct-to-consumer advertising (DTCA) of prescription drugs is widely debated, as is the effect of DTCA on prescription sales and health care utilization. Objective: We examined the association between DTCA intensity for statin medications and prescription sales and cholesterol-related health care utilization. Design, Setting, and Participants: We conducted an ecological study for 75 designated market areas from 2005 to 2009 in the United States using linked data regarding televised DTCA volume, non-DTCA marketing and promotion, retail, mail order and long-term care prescription drug sales, prescription drug and ambulatory care health care utilization, and contextual factors such as health care density and socioeconomic status. Main outcomes and measures were volume of sales, number of dispensed prescriptions, and high cholesterol-related outpatient visits. Analyses were conducted in 2016. Results: The intensity of rosuvastatin and atorvastatin ad exposures per household varied substantially across designated market areas. After adjustment for socioeconomic, demographic, and clinical characteristics, each 100-unit increase in advertisement viewership was associated with a 2.22% [95% confidence interval (CI), 0.30%–4.19%] increase in statin sales. Similar patterns were observed between DTCA and statin dispensing among the commercially insured. DTCA was associated with increases in high cholesterol-related outpatient visits among adults 18–45 years of age (3.15% increase in visits per 100-unit increase in viewership, 95% CI, 0.98%–5.37%) but not among those 46–65 years of age (0.51%, 95% CI, −1.49% to 2.55%). Conclusion: DTCA for statins is associated with increases in statin utilization and hyperlipidemia-related outpatient visits, especially for young adults.

Capsule Commentary on D’Onofrio et al., Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention

M ore than two million Americans have an opioid abuse disorder. For each person who dies from an opiate overdose, many more require emergency care or hospitalization to survive. Central to the goal of reversing this epidemic is the challenging task of improving linkage to treatment for opioid-dependent patients. Despite strong clinical evidence, the use of buprenorphine-naloxone as maintenance therapy for opioid dependence remains low. In this issue, D’Onofrio et al. explored whether emergency department (ED)-initiated buprenorphine-naloxone with continued primary care is better for promoting treatment engagement, deterring illicit drug use and reducing HIV risk behaviors over the long term (at 2, 6 and 12 months) than treatment referral only or a brief intervention with referral to treatment. Results of the study indicate that adult patients in the EDinitiated study armwere more likely to still be in treatment and to report less illicit opioid use at 2 months than those in the comparator arms. Benefits of ED-initiated buprenorphine-naloxone treatment at the 2-month mark should be interpreted cautiously. First, the veracity of self-reported drug use may have been influenced by the fact that patients in the ED-initiated treatment arm were still receiving 10 weeks of continued care through the study. Second, there was no statistical difference in the urine toxicology test results across the three groups. The absence of differences in any of the outcomes at the 6and 12-month assessment points raises even broader questions regarding the discontinuation of buprenorphine-naloxone therapy and its associated consequences. Previous studies have shown that patients who use buprenorphine for 12 months are less likely to be hospitalized or to visit the ED than those who discontinue treatment within 5 months. Treatment barriers including scarcity of buprenorphine prescribers and coverage gaps have been well documented, particularly within marginalized groups. The results at the 2-month mark indicate that patients offered continued treatment were more likely to use it. This finding suggests the need for concerted efforts by clinicians, payers and policymakers alike to address not only the barriers to buprenorphine therapy initiation, but also the challenges that limit its continued use.