Jan L. Losby

Vital Signs: Changes in Opioid Prescribing in the United States, 2006–2015

Background Prescription opioid–related overdose deaths increased sharply during 1999–2010 in the United States in parallel with increased opioid prescribing. CDC assessed changes in national-level and county-level opioid prescribing during 2006–2015. Methods CDC analyzed retail prescription data from QuintilesIMS to assess opioid prescribing in the United States from 2006 to 2015, including rates, amounts, dosages, and durations prescribed. CDC examined county-level prescribing patterns in 2010 and 2015. Results The amount of opioids prescribed in the United States peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015. Despite significant decreases, the amount of opioids prescribed in 2015 remained approximately three times as high as in 1999 and varied substantially across the country. County-level factors associated with higher amounts of prescribed opioids include a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; micropolitan status (i.e., town/city; nonmetro); and higher unemployment and Medicaid enrollment. Conclusions and Implications for Public Health Practice Despite reductions in opioid prescribing in some parts of the country, the amount of opioids prescribed remains high relative to 1999 levels and varies substantially at the county-level. Given associations between opioid prescribing, opioid use disorder, and overdose rates, health care providers should carefully weigh the benefits and risks when prescribing opioids outside of end-of-life care, follow evidence-based guidelines, such as CDC’s Guideline for Prescribing Opioids for Chronic Pain, and consider nonopioid therapy for chronic pain treatment. State and local jurisdictions can use these findings combined with Prescription Drug Monitoring Program data to identify areas with prescribing patterns that place patients at risk for opioid use disorder and overdose and to target interventions with prescribers based on opioid prescribing guidelines.

Cost of informal caregiving for patients with heart failure.

BACKGROUND Heart failure is a serious health condition that requires a significant amount of informal care. However, informal caregiving costs associated with heart failure are largely unknown. METHODS We used a study sample of noninstitutionalized US respondents aged ≥50 years from the 2010 HRS (n = 19,762). Heart failure cases were defined by using self-reported information. The weekly informal caregiving hours were derived by a sequence of survey questions assessing (1) whether respondents had any difficulties in activities of daily living or instrumental activities of daily living, (2) whether they had caregivers because of reported difficulties, (3) the relationship between the patient and the caregiver, (4) whether caregivers were paid, and (5) how many hours per week each informal caregiver provided help. We used a 2-part econometric model to estimate the informal caregiving hours associated with heart failure. The first part was a logit model to estimate the likelihood of using informal caregiving, and the second was a generalized linear model to estimate the amount of informal caregiving hours used among those who used informal caregiving. Replacement approach was used to estimate informal caregiving cost. RESULTS The 943 (3.9%) respondents who self-reported as ever being diagnosed with heart failure used about 1.6 more hours of informal caregiving per week than those who did not have heart failure (P < .001). Informal caregiving hours associated with heart failure were higher among non-Hispanic blacks (3.9 hours/week) than non-Hispanic whites (1.4 hours/week). The estimated annual informal caregiving cost attributable to heart failure was

Contribution of Opioid-Involved Poisoning to the Change in Life Expectancy in the United States, 2000-2015

3 billion in 2010. CONCLUSION The cost of informal caregiving was substantial and should be included in estimating the economic burden of heart failure. The results should help public health decision makers in understanding the economic burden of heart failure and in setting public health priorities.

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

Contribution of Opioid-Involved Poisoning to the Change in Life Expectancy in the United States, 2000-2015 Drug poisoning mortality more than doubled in the United States from 2000 to 2015; poisoning mortality involving opioids more than tripled.1,2 Increases in poisonings have been reported to have reduced life expectancy for non-Hispanic white individuals in the United States from 2000 to 2014.3 Specific contributions of drug, opioid, and alcohol poisonings to changes in US life expectancy since 2000 are unknown.

The Association Between Local Economic Conditions and Opioid Prescriptions Among Disabled Medicare Beneficiaries

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.

Arriving at Results Efficiently: Using the Enhanced Evaluability Assessment Approach

Background: This paper concerns public health crises today—the problem of opioid prescription access and related abuse. Inspired by Case and Deaton’s seminal work on increasing mortality among white Americans with lower education, this paper explores the relationship between opioid prescribing and local economic factors. Objective: We examined the association between county-level socioeconomic factors (median household income, unemployment rate, Gini index) and opioid prescribing. Subjects: We used the complete 2014 Medicare enrollment and part D drug prescription data from the Center for Medicare and Medicaid Services to study opioid prescriptions of disabled Medicare beneficiaries without record of cancer treatment, palliative care, or end-of-life care. Measures and Research Design: We summarized the demographic and geographic variation, and investigated how the local economic environment, measured by county median household income, unemployment rate, Gini index, and urban-rural classification correlated with various measures of individual opioid prescriptions. Measures included number of filled opioid prescriptions, total days’ supply, average morphine milligram equivalent (MME)/day, and annual total MME dosage. To assess the robustness of the results, we controlled for individual and other county characteristics, used multiple estimation methods including linear least squares, logistic regression, and Tobit regression. Results and Conclusions: Lower county median household income, higher unemployment rates, and less income inequality were consistently associated with more and higher MME opioid prescriptions among disabled Medicare beneficiaries. Geographically, we found that the urban-rural divide was not gradual and that beneficiaries in large central metro counties were less likely to have an opioid prescription than those living in other areas.

Initiatives to Enhance Primary Care Delivery: Two Examples From the Field

Evidence, particularly practice-based evidence, is needed to guide public health practice. With the goal of contributing to practice-based evidence, the Division for Heart Disease and Stroke Prevention at the Centers for Disease Control and Prevention combined and streamlined aspects of an evaluability assessment and an effectiveness evaluation to create the Enhanced Evaluability Assessment (EEA). This approach offers a viable and less costly alternative to evaluators and practitioners by quickly identifying and evaluating models with evidence of effectiveness that can be replicated and expanded. The EEA can be applied to a range of public health topics, not just cardiovascular health. This article provides a step-by-step description of the EEA.

Persistence of Opioid Prescribing after a Forearm or Lower Leg Fracture

Objectives: Increasing demands on primary care providers have created a need for systems-level initiatives to improve primary care delivery. The purpose of this article is to describe and present outcomes for 2 such initiatives: the Pennsylvania Academy of Family Physicians’ Residency Program Collaborative (RPC) and the St Johnsbury Vermont Community Health Team (CHT). Methods: Researchers conducted case studies of the initiatives using mixed methods, including secondary analysis of program and electronic health record data, systematic document review, and interviews. Results: The RPC is a learning collaborative that teaches quality improvement and patient centeredness to primary care providers, residents, clinical support staff, and administrative staff in residency programs. Results show that participation in a higher number of live learning sessions resulted in a significant increase in patient-centered medical home recognition attainment and significant improvements in performance in diabetic process measures including eye examinations (14.3%, P = .004), eye referrals (13.82%, P = .013), foot examinations (15.73%, P = .003), smoking cessation (15.83%, P = .012), and self-management goals (25.45%, P = .001). As a community-clinical linkages model, CHT involves primary care practices, community health workers (CHWs), and community partners. Results suggest that CHT members successfully work together to coordinate comprehensive care for the individuals they serve. Further, individuals exposed to CHWs experienced increased stability in access to health insurance (P = .001) and prescription drugs (P = .000) and the need for health education counseling (P = .000). Conclusion: Findings from this study indicate that these 2 system-level strategies have the promise to improve primary care delivery. Additional research can determine the extent to which these strategies can improve other health outcomes.

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

Understanding the relationship between opioid treatment for acute pain and subsequent long-term use is necessary to inform clinical decisions on pain treatment. Previous research has described long-term opioid use after treatment for acute pain in postoperative and fragility fracture treatment. We carefully examined the association between forearm and lower leg fractures in 2011 and opioid prescription in 2011–2014 among disabled Medicare beneficiaries who did not have opioid prescriptions in 2010. We focused on forearm and lower leg fractures because these injuries to major long bones not directly connected to the torso have limited long-term health consequences and are less likely to cause health complications.

Opioid Prescribing in the United States Before and After the Centers for Disease Control and Prevention's 2016 Opioid Guideline

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.