New research on the opioid crisis shows that interventions like provider education can cut overprescribing and that increased availability of medication-assisted therapy can improve treatment access while cutting costs.
Policymakers and healthcare officials have tried to crack down on illegal opioid use by strengthening prescription drug management programs, walking back or regulating pharmaceutical ingredients used to make opioids, launching national education campaigns and innovation challenges, publishing safe prescription practices.
Lawmakers in Congress on Tuesday reached a deal on a wide-ranging opioid bill, expected to pass both houses as early as next month. Reaction was mixed on the contents, with some healthcare players saying it does too much and others saying it doesn't do enough.
One factor difficult to regulate (and a perennial target of reformers' ire) is overprescribing. Though the root cause of the opioid crisis is still being debated, many attribute it to the rapid growth in prescribing starting in the 1990s and peaking in 2012 — a 300% expansion according to some metrics, and one that refuses to peter out.
This linkage between opioid dependency and prescribing patterns is what prompted researchers in JAMA to measure the effects of multilevel interventions on opioid prescribing within a health system.
Researchers measured EHR data from more than 1 million clinical encounters (over 44,000 a month) taking place in Anne Arundel Medical Center in Maryland, which includes an acute care hospital and same-day surgery and outpatient clinics. The study collated pre-intervention data to establish a baseline, then compared the set with data from a 16-month post-intervention period ending in April.
They looked at a variety of interventions, including prescriber education and accountability (which has already yielded some success), enhanced oversight through measurement of individual prescribers and reduction of default amounts on standard opioid prescription orders to see if they had an effect on morphine milligram equivalents (MME) per encounter and prescription or rate of opioid prescriptions.
The study found that total health system MME decreased by 1 MME per encounter per month over the 16 month post-intervention period. At the conclusion of the study, monthly MME per encounter, MME per opioid prescription per month and the opioid prescription rate had all dropped significantly lower than the baseline, by 58%, 34% and 38% respectively.
The percentage of health system clinical encounters resulting in an opioid prescription was reduced by 0.2% each month and, perhaps most importantly, patient satisfaction did not decrease (actually improving marginally).
Multi-factor interventions curb overprescription, the study concludes, by targeting patient and public demand, fostering prescriber awareness and promoting clinical accountability.
Critics, however, may jump on the fact that the study was conducted in one single health system, raising questions around generalizability, and that there is no way of knowing whether patients studied migrated to another provider to receive drugs.
Another concern is that curtailing legal channels to prescription painkillers may push addicts to seek alternative, often more dangerous highs, such as fentanyl, heroin's synthetic (and much more potent) cousin.
"We are aware that reducing a community's opioid reservoir may, in the short run, increase the number of persons who seek illicit street opioids and thus increase their risk of death," researchers wrote, but "we regard cautious prescribing and opioid stewardship as a shared commitment to the long-term health of our community."
Access to medication-assisted therapy
Cracking down on overprescribing is a good practice, many experts agree, but some worry it's a stopgap to a much larger problem. The AMA's preferred solution is medication-assisted therapy.
The Drug Addiction Treatment Act of 2000 attempts to improve access to addiction treatment by involving select physicians in the provision of buprenorphine, a partial opioid agonist used to wane addicts off the stronger narcotic. However, such licensed doctors can only treat up to 30 patients at any given time, sharply limiting access to care, especially in rural areas hard-hit by the crisis. Though that ceiling was raised to 100 patients in 2016, then 275, data suggest that expanding buprenorphine treatment capacity similarly increases patient use and, consequently, reduces the prevalence of opioid addiction.
Medications such as the FDA-approved buprenorphine help addicts deal with the agonizing physical and psychological symptoms of withdrawal, but there's a lack of support for such treatment in the healthcare chassis. Patients can only take the medication in-house in a licensed specialty opioid program, which are all too few and far between in the U.S.
Looking at Medicaid scripts
A second study released Friday, also published in JAMA, embarked upon an economic analysis of state data to examine the relationship between the number of physicians licensed to prescribe buprenorphine, the Medicaid-covered buprenorphine prescribing rate and the opioid prescribing rate among Medicaid FFS and managed care enrollees.
Looking at data from the beginning of 2011 to the end of 2016, the study determined that a 10% increase in buprenorphine-waivered physicians was associated with a 10% higher Medicaid-covered buprenorphine prescribing rate and a 1.2% lower opioid prescribing rate.
Expanding the availability of the physicians by 10% also corresponded with a 9.4% increase in Medicaid buprenorphine spending, but a 3.2% reduction in opioid spending.
Researchers called for an administration strategy to expand the capacity for buprenorphine treatment to more providers, writing that "investment in buprenorphine treatment may generate further savings in health care expenditures, criminal justice costs, and labor productivity."
And finding treatment and solutions is ever more important in light of new data showing the crisis continues unabated.
One-third of Americans (32%) received an opioid prescription in the past two years and almost one-fifth of Americans received a prescription for opioids in the past year alone, even in light of the ongoing public health emergency, according to a new survey of more than 1,000 Americans by nonpartisan research institution NORC at the University of Chicago.
Most opioid prescriptions originated with a patient's surgeon. Next most frequent prescribers were primary care providers, then dentists or oral surgeons.