Changes in opioid prescribing for Washington workers' compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010

Association Between Pre-Injury Opioid Use and Opioid Use Patterns After a Work Injury

BACKGROUND

Few studies have assessed long-term opioid prescribing after a work-related injury. There is limited information about opioid prescriptions before an injury and how receipt of opioids before a work injury is associated with long-term opioid prescribing. We present patterns of long-term opioid prescription among workers after an injury, overall, and by pre-injury opioid use.

METHODS

We used linked workers' compensation and prescription drug monitoring program (PDMP) data to identify workers injured between July 2019 and June 2020 with an opioid prescription dispensed within 6 weeks after injury. Opioid prescribing was assessed for the 3 months before injury and for 1 year after injury or claim closure, whichever came first.

RESULTS

Among injured workers with an opioid in the first 6 weeks, 23% had opioids 6-12 weeks after injury, 19% had opioids 3-6 months, 14% had opioids 6-9 months, and 12% had opioids 9-12 months after injury; 19% had opioids in the 3 months before injury. For workers with opioid prescription prior to injury, the percentage with opioids 9-12 months after injury was 34%, versus 7% among workers with no opioids in the 3 months before injury (p < 0.001). Receipt of chronic opioids (for at least 60 days) 9-12 months after injury was substantially higher among those with prior opioid prescription (20%) than in those with no prior opioids (0.4%) (p < 0.001).

CONCLUSIONS

We found a strong relationship between opioid prescription in the 3 months before a work injury and opioid prescribing after an injury. Healthcare providers should be vigilant to the important relationship between prior opioid use and longer-term opioid use after work-related injuries.

Outcomes After a Statewide Policy to Improve Evidence-Based Treatment of Back Pain Among Medicaid Enrollees in Oregon

BACKGROUND

A novel Oregon Medicaid policy guiding back pain management combined opioid restrictions with emphasis on non-opioid and non-pharmacologic therapies.

OBJECTIVE

To examine the effect of the policy on prescribing, health outcomes, and health service utilization.

DESIGN

Using Medicaid enrollment, medical and prescription claims, prescription drug monitoring program, and vital statistics files, we analyzed the policy's association with selected outcomes using interrupted time series models.

SUBJECTS

Adult Medicaid patients with back pain enrolled between 2014 and 2018.

INTERVENTION

The Oregon Medicaid back pain policy.

MAIN MEASURES

Opioid and non-opioid medication prescribing, procedural care, substance use and mental health conditions, and outpatient and inpatient healthcare utilization.

KEY RESULTS

The policy was associated with decreases in the percentage of Medicaid enrollees with back pain receiving any opioids (- 2.68 percentage points [95% CI - 3.14, - 2.23] level, - 1.01 pp [95% CI - 1.1, - 0.92] slope), days of short-acting opioid use (- 0.4 days [95% CI - 0.53, - 0.26] slope), receipt of more than 7 days of short-acting opioids (- 2.36 pp [95% CI - 2.76, - 1.95] level, - 0.91 pp [95% CI - 1, - 0.83] slope), chronic opioid use (- 1.27 pp [95% CI - 1.59, - 0.94] level, - 0.46 [95% CI - 0.53, - 0.39 slope), and spinal surgeries and procedures. Among secondary outcomes, we found no increase in opioid overdose and a small, statistically significant trend decrease in opioid use disorders. There were small increases in non-opioid substance use and mental health diagnoses and visits but no increase in self-harm.

CONCLUSIONS

A state Medicaid policy emphasizing evidence-based back pain management was associated with decreases in opioid prescribing, spinal surgeries, and opioid use disorder trends, but also short-term increases in mental health encounters and an increase in non-opioid substance use disorder trends. Such policies may help reinforce evidence-based care, but must be designed with consideration of potential harms.

Short-acting opioid prescriptions and Workers' Compensation using the National Ambulatory Medical Care Survey

BACKGROUND

Short-acting opioids have been utilized for pain management with little known about their use in patients on Workers' Compensation (WC) insurance. Our goal was to investigate this association in the ambulatory care setting.

METHODS

Using the National Ambulatory Medical Care Survey, visits from patients aged 18-64 during the years 2010 until 2018 were evaluated (excluding 2017 due to data availability). Demographic and co-morbidity data from each visit was obtained along with the visit year. The first short-acting opioid medication prescribed in the database was considered. Survey-weighted frequencies were evaluated. Logistic regression estimated the crude and adjusted odds ratios (OR) with 95% confidence intervals for the use of short-acting opioid prescription.

RESULTS

There were 155,947 included visits with 62.5% for female patients. Most patients were White with 11.7% identifying as Black, and 6% identifying as another race. Over 13% of the sample was of Hispanic descent. WC was the identified insurance type in 1.6% of the sample population. Of these patients, 25.6% were prescribed a short-acting opioid, compared with 10.1% of those with another identified insurance. On multivariable regression, Black patients had increased odds of being prescribed a short-acting opioid compared to white patients (OR: 1.22, 95% CI: 1.11-1.34). Those on WC had 1.7-fold higher odds of being prescribed short-acting opioids (95% CI: 1.46-2.06).

CONCLUSION

Certain patient characteristics, including having WC insurance, increased the odds of a short-acting opioid prescription. Further work is needed to identify prescribing patterns in specific high-risk occupational groups, as well as to elicit potential associated health outcomes.

Opioid Legislation Decreases Opioid Prescribing in Total Knee Arthroplasty

The purpose of this study was to evaluate the impact of opioid-limiting legislation on perioperative opioid prescriptions in total knee arthroplasty. The hypothesis was that opioid legislation has reduced opioid prescription filling above levels anticipated by national trends. This study retrospectively evaluated opioid prescription filling for all patients undergoing total knee arthroplasty in a commercially available insurance database between 2010 and 2018 (n=1,068,764). Initial discharge and 90-day cumulative oxycodone 5-mg equivalents filled were tabulated. Opioid prescription filling was evaluated over time and between states with and without opioid-limiting legislation using analysis of variance and multivariable linear and logistic regression. States with and without opioid legislation had significant reductions in initial and cumulative opioid prescription filling volume (all P<.001). However, the magnitude of this reduction was larger in states with opioid legislation. Legislation targeting duration and volume had the largest impact on initial post-act opioid prescription filling volume compared with states without legislation in an estimated "pre-act" time frame. Legislation targeting duration and volume and no specific target had the largest impact on cumulative post-act opioid prescription filling volume. States without legislation still had large, significant reductions in filling volume, but the magnitude was not as great as in states with opioid legislation. States with and without opioid legislation had significant decreases in initial and cumulative opioid prescription filling volume. However, the magnitude of reduction was larger in states that enacted legislation. Younger age, pre-operative opioid use, and higher comorbidity burden were associated with greater opioid use postoperatively. [Orthopedics. 202x;4x(x):xx-xx.].

Workers' compensation prescription medication patterns and associated outcomes

BACKGROUND

Opioid use in the treatment of musculoskeletal injuries is a complex decision where benefits must be balanced with risk. Previous research has shown an association between higher opioid doses and adverse health effects. The study's objective was to investigate whether opioid prescriptions are associated with increased costs and deaths through an injury mechanism or as a direct result of the opioid prescription.

METHODS

Data for 144,553 deidentified Ohio Bureau of Workers' Compensation claims from 2010 to 2014 with shoulder, knee, and low back injuries were obtained and followed until 2016. Each claim had associated prescription information. Injury claims were further classified using the allowed diagnoses by single or multiple body areas affected and injury severity ("simple" or "complex"). The outcome variables were medical and indemnity costs, lost days, MaxMED (maximum claim-prescribed daily morphine equivalent dose), and death status. Association between maximum opioid dose with deaths was determined by logistic regression analysis.

RESULTS

Several outcome variables, including claim medical and indemnity costs, and the likelihood of claimant death, showed significant associations with the MaxMED. In the analysis of claim deaths, these associations held for all claim types (except complex), even after adjusting for age, gender, surgery, and lost time.

CONCLUSION

The association between increasing opioid doses and deaths for low-severity diagnoses was disturbing given the lack of demonstrated efficacy of opioids for treatment of minor injuries. A focus on provider education, increased utilization of non-opioids, and early intervention for minor soft-tissue injuries could reduce claims costs, disability, and future deaths.

Early High-Risk Opioid Prescribing Practices and Long-Term Disability Among Injured Workers in Washington State, 2002 to 2013

To estimate associations between early high-risk opioid prescribing practices and long-term work-related disability.

Determining the influence of the Workers Compensation Board of Manitoba's opioid policy on prescription opioid use amongst WCB recipients

BACKGROUND

Opioid medications are commonly used by Workers Compensation Board (WCB) claimants following workplace injuries. The purpose of this study is to describe the impact of an opioid management policy on opioid prescriptions amongst a WCB-covered population compared to changes in the use of these medications in the general population of a Canadian province.

METHODS

We linked WCB claims data from 2006 to 2016 (13,155 claims, 11,905 individuals) to Manitoba provincial health records and compared opioid use amongst this group to 478,606 individuals aged 18-65. Linear regression was performed to examine the change over time in number of individuals being prescribed opioids for various durations and dosages of 50 or more, and 120 or more morphine equivalents (ME)/day for both the WCB and Manitoba population.

RESULTS

WCB claimants totaled 2.5% of Manitoba residents aged 18-65 who were prescribed opioids for non-cancer pain. After the introduction of the opioid use policy for the WCB population in November 2011, the number of people prescribed opioids declined 49.4% in the WCB group, while increasing 10.8% in the province as a whole. The number of individuals using 50 ME/day or more declined 43.1% in the WCB group and increased 5.8% in the province.

CONCLUSIONS

Opioid management programs organized by a compensation board can lead to a substantial reduction in the prescription of opioid medications to a WCB client population, including individuals who were prescribed higher doses of these medications when compared with general trends in the community.

Educational Intervention for Bupropion Abuse Prevention

BACKGROUND

Bupropion is being abused due to effects that are comparable with methamphetamine and cocaine. Current research indicates several interventions that can prevent prescription medication abuse.

OBJECTIVES

A research study was performed at two healthcare organizations to evaluate whether education on prevention-based interventions increased self-efficacy of healthcare staff in addressing potential and ongoing bupropion abuse and whether the education reduced the rate of bupropion prescribing.

METHODS

The study sample consisted of 43 staff members who completed a paper-based preeducation survey, attended a 1-hour educational session, and completed a paper-based posteducation survey.

RESULTS

There was a 42% increase in total staff self-efficacy scores along with significant differences between pre-/postsurvey scores (p ≤ .001). After education prescribers answered they plan to change prescribing practices and the number of bupropion prescriptions filled decreased.

IMPLICATIONS FOR NURSING

Future practice recommendations should include education on bupropion abuse and implementation of prevention interventions to reduce the occurrence of the abuse of bupropion.

CONCLUSIONS

The research findings suggested that education on interventions for bupropion abuse prevention improved healthcare staff self-efficacy in the management of potential and ongoing bupropion abuse, influenced prescribing practices of prescribers, and decreased the number of bupropion prescriptions. This research can be used to continue providing education to help prevent further cases of bupropion abuse.

Changes in early high-risk opioid prescribing practices after policy interventions in Washington State

OBJECTIVE

To test associations between several opioid prescribing policy interventions and changes in early (acute/subacute) high-risk opioid prescribing practices.

DATA SOURCES

Population-based workers' compensation pharmacy billing and claims data, Washington State Department of Labor and Industries (January 2008-June 2015).

STUDY DESIGN

We used interrupted time series analysis to test associations between three policy intervention timepoints and monthly proportions of population-based measures of high-risk, low-risk, and any workers' compensation-related opioid prescribing. We also tested associations between the policy intervention timepoints and five high-risk opioid prescribing indicators among workers prescribed any opioids within 3 months after injury: (a) >7 cumulative (not necessarily consecutive) days' supply of opioids during the acute phase, (b) high-dose opioids, (c) concurrent sedatives, (d) chronic opioids, and (e) a composite high-risk opioid prescribing indicator.

PRINCIPAL FINDINGS

Within 3 months after injury, 9 percent of workers were exposed to high-risk and 12 percent to low-risk workers' compensation-related opioid prescribing; 79 percent filled no workers' compensation-related opioid prescription. Among workers prescribed any early (acute/subacute) opioids, the indicator for >7 days' supply of opioids during the acute phase was present for 30 percent, high-dose opioids for 18 percent, concurrent sedatives for 3 percent, and chronic opioids for 2 percent. Beyond a general shift toward more infrequent and lower-risk workers' compensation-related opioid prescribing, each policy intervention timepoint was significantly associated with reductions in specific acute/subacute high-risk opioid prescribing indicators; each of the four specific high-risk opioid prescribing indicators had significant reductions associated with at least one policy.

CONCLUSIONS

Several state-level opioid prescribing policies were significantly associated with safer workers' compensation-related opioid prescribing practices during the first 3 months after injury (acute/subacute phase), which should in turn reduce transition to chronic opioids and associated negative health outcomes.

Utilization Review in Workers' Compensation: Review of Current Status and Recommendations for Future Improvement

: Utilization review (UR) is a process that assesses aspects of a treating provider's care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc, concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers' compensation (WC) system and is mandated in several states and jurisdictions. This guidance statement from the American College of Occupational and Environmental Medicine (ACOEM) reviews structural elements of UR programs and proposes a possible template for operational standards. UR has a unique role in protecting patients and educating providers on evidence-based guidelines, new research, and best practices.

Characterizing non-heroin opioid overdoses using electronic health records

INTRODUCTION

The opioid epidemic is a modern public health emergency. Common interventions to alleviate the opioid epidemic aim to discourage excessive prescription of opioids. However, these methods often take place over large municipal areas (state-level) and may fail to address the diversity that exists within each opioid case (individual-level). An intervention to combat the opioid epidemic that takes place at the individual-level would be preferable.

METHODS

This research leverages computational tools and methods to characterize the opioid epidemic at the individual-level using the electronic health record data from a large, academic medical center. To better understand the characteristics of patients with opioid use disorder (OUD) we leveraged a self-controlled analysis to compare the healthcare encounters before and after an individual's first overdose event recorded within the data. We further contrast these patients with matched, non-OUD controls to demonstrate the unique qualities of the OUD cohort.

RESULTS

Our research confirms that the rate of opioid overdoses in our hospital significantly increased between 2006 and 2015 (P < 0.001), at an average rate of 9% per year. We further found that the period just prior to the first overdose is marked by conditions of pain or malignancy, which may suggest that overdose stems from pharmaceutical opioids prescribed for these conditions.

CONCLUSIONS

Informatics-based methodologies, like those presented here, may play a role in better understanding those individuals who suffer from opioid dependency and overdose, and may lead to future research and interventions that could successfully prevent morbidity and mortality associated with this epidemic.

The Association of State Opioid Misuse Prevention Policies With Patient- and Provider-Related Outcomes: A Scoping Review

Policy Points This scoping review reveals a growing literature on the effects of certain state opioid misuse prevention policies, but persistent gaps in evidence on other prevalent state policies remain. Policymakers interested in reducing the volume and dosage of opioids prescribed and dispensed can consider adopting robust prescription drug monitoring programs with mandatory access provisions and drug supply management policies, such as prior authorization policies for high-risk prescription opioids. Further research should concentrate on potential unintended consequences of opioid misuse prevention policies, differential policy effects across populations, interventions that have not received sufficient evaluation (eg, Good Samaritan laws, naloxone access laws), and patient-related outcomes.

CONTEXT

In the midst of an opioid crisis in the United States, an influx of state opioid misuse prevention policies has provided new opportunities to generate evidence of policy effectiveness that can inform policy decisions. We conducted a scoping review to synthesize the available evidence on the effectiveness of US state interventions to improve patient and provider outcomes related to opioid misuse and addiction.

METHODS

We searched six online databases to identify evaluations of state opioid policies. Eligible studies examined legislative and administrative policy interventions that evaluated (a) prescribing and dispensing, (b) patient behavior, or (c) patient health.

FINDINGS

Seventy-one articles met our inclusion criteria, including 41 studies published between 2016 and 2018. These articles evaluated nine types of state policies targeting opioid misuse. While prescription drug monitoring programs (PDMPs) have received considerable attention in the literature, far fewer studies addressed other types of state policy. Overall, evidence quality is very low for the majority of policies due to a small number of evaluations. Of interventions that have been the subject of considerable research, promising means of reducing the volume and dosages of opioids prescribed and dispensed include drug supply management policies and robust PDMPs. Due to low study number and quality, evidence is insufficient to draw conclusions regarding interventions targeting patient behavior and health outcomes, including naloxone access laws and Good Samaritan laws.

CONCLUSIONS

Recent research has improved the evidence base on several state interventions targeting opioid misuse. Specifically, moderate evidence suggests that drug supply management policies and robust PDMPs reduce opioid prescribing. Despite the increase in rigorous evaluations, evidence remains limited for the majority of policies, particularly those targeting patient health-related outcomes.

Evidence for state, community and systems-level prevention strategies to address the opioid crisis

BACKGROUND

Practitioners and policy makers need evidence to facilitate the selection of effective prevention interventions that can address the ongoing opioid overdose epidemic in the United States.

METHODS

We conducted a systematic review of publications reporting on rigorous evaluations of systems-level interventions to address provider and patient/public behavior and prevent prescription and illicit opioid overdose. A total of 251 studies were reviewed. Interventions studied included 1) state legislation and regulation, 2) prescription drug monitoring programs (PDMPs), 3) insurance strategies, 4) clinical guideline implementation, 5) provider education, 6) health system interventions, 7) naloxone education and distribution, 8) safe storage and disposal, 9) public education, 10) community coalitions, and 11) interventions employing public safety and public health collaborations.

RESULTS

The quality of evidence supporting selected interventions was low to moderate. Interventions with the strongest evidence include PDMP and pain clinic legislation, insurance strategies, motivational interviewing in clinical settings, feedback to providers on opioid prescribing behavior, intensive school and family-based programs, and patient education in the clinical setting.

CONCLUSIONS

Although evidence is growing, further high-quality research is needed. Investigators should aim to identify strategies that can prevent overdose, as well as influence public, patient, and provider behavior. Identifying which strategies are most effective at addressing prescription compared to illicit opioid misuse and overdose could be fruitful, as well as investigating synergistic effects and unintended consequences.

Tracking Opioid Prescribing Metrics in Washington State (2012-2017): Differences by County-Level Urban-Rural and Economic Distress Classifications

PURPOSE

High-risk opioid prescribing is a critical driver of prescription opioid-related morbidity and mortality. This study explored opioid prescribing patterns across urban-rural and economic distress classifications. Secondarily, this study explored the urban-rural distribution of relevant health services, economic factors, and population characteristics.

METHODS

County-level opioid prescribing metrics were based on quarterly Washington State Prescription Monitoring Program data (2012-2017). Counties were classified using the 2013 National Center for Health Statistics Urban-Rural Classification Scheme for Counties, and Washington State unemployment-based distressed areas. County-level measures from Area Health Resources Files were used to describe the urban-rural continuum.

FINDINGS

Persistent economic distress was associated with higher-risk opioid prescribing. The large central metropolitan category had lower-risk opioid prescribing metrics than the other 5 urban-rural categories, which were similar to each other and not ordered by degree of rurality. High-risk prescribing declined over time, without notable trend divergence by either urban-rural or economic distress classifications.

CONCLUSIONS

The most striking urban-rural differences in opioid prescribing metrics were between large central metropolitan and all other categories; thus, we recommend caution when collapsing urban-rural categories for analysis. Further research is needed regarding geographic and economic patterning of opioid prescribing practices, as well as the dissemination of guidelines and best practices across the urban-rural continuum. Finally, the multiple intertwined burdens faced by rural communities-higher-risk prescribing practices, higher opioid morbidity and mortality rates, and fewer resources for primary care, mental health care, alternative pain treatment, and opioid use disorder treatment-must be addressed as an urgent public health priority.

Opioid Overdose Hospitalization Trajectories in States With and Without Opioid-Dosing Guidelines

OBJECTIVES

High-risk opioid-prescribing practices contribute to a national epidemic of opioid-related morbidity and mortality. The objective of this study was to determine whether the adoption of state-level opioid-prescribing guidelines that specify a high-dose threshold is associated with trends in rates of opioid overdose hospitalizations, for prescription opioids, for heroin, and for all opioids.

METHODS

We identified 3 guideline states (Colorado, Utah, Washington) and 5 comparator states (Arizona, California, Michigan, New Jersey, South Carolina). We used state-level opioid overdose hospitalization data from 2001-2014 for these 8 states. Data were based on the State Inpatient Databases and provided by the Healthcare Cost and Utilization Project (HCUP), Agency for Healthcare Research and Quality, via HCUPnet. We used negative binomial panel regression to model trends in annual rates of opioid overdose hospitalizations. We used a multiple-baseline difference-in-differences study design to compare postguideline trends with concurrent trends for comparator states.

RESULTS

For each guideline state, postguideline trends in rates of prescription opioid and all opioid overdose hospitalizations decreased compared with trends in the comparator states. The mean annual relative percentage decrease ranged from 3.2%-7.5% for trends in rates of prescription opioid overdose hospitalizations and from 5.4%-8.5% for trends in rates of all opioid overdose hospitalizations.

CONCLUSIONS

These findings provide preliminary evidence that opioid-dosing guidelines may be an effective strategy for combating this public health crisis. Further research is needed to identify the individual effects of opioid-related interventions that occurred during the study period.

Influence of opioid prescribing standards on drug use among patients with long-term opioid use: a longitudinal cohort study

BACKGROUND

In mid-2016, the College of Physicians and Surgeons of British Columbia (CPSBC) issued prescribing standards and guidelines relating to opioid drugs. We evaluated the impact of these regulatory standards and guidelines on prescription drug use among patients in the province with long-term opioid use.

METHODS

We conducted a cohort study with monthly repeated measures using administrative health data in British Columbia. Patients with long-term prescription opioid use were followed for a 12-month prepolicy period and 10-month postpolicy period, and were compared with a historical control cohort. We excluded patients with a history of long-term care, palliative care or cancer. We estimated changes in use of opioids, high-dose opioids (> 90 mg of morphine equivalents/d), opioids with sedatives/hypnotics, and opioid discontinuation.

RESULTS

The study population included 68 113 patients in the policy cohort and 68 429 patients in the historical control cohort. Following the introduction of the standards and guidelines, the average monthly use of opioids declined (adjusted difference -57 mg of morphine equivalents, 95% confidence interval [CI] -74 to -39) and discontinuation of opioids increased (odds ratio [OR] 1.24, 95% CI 1.16 to 1.32). Among patients prescribed high-dose opioids, switching to lower-dose opioids increased (OR 1.88, 95% CI 1.63 to 2.17), but discontinuation did not change significantly (OR 1.21, 95% CI 0.91 to 1.59).

INTERPRETATION

The CPSBC's regulatory standards and guidelines were associated with modestly reduced opioid use and increased switching from high-dose to lower-dose opioids among patients with long-term use of prescribed opioids. Assessment of the potential impacts on health outcomes will be necessary for understanding the implications of the standards and guidelines.

Relationship between early prescription dispensing patterns and work disability in a cohort of low back pain workers' compensation claimants: a historical cohort study

Objectives

To examine and compare whether dispensing of prescription opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and skeletal muscle relaxants (SMRs) within 8 weeks after a work-related low back pain (LBP) injury is associated with work disability.

Methods

A historical cohort study of 55 571 workers’ compensation claimants with LBP claims in British Columbia from 1998 to 2009 was conducted using linked compensation, dispensing and healthcare data. Four exposures were constructed to estimate the effect on receipt of benefits and days on benefits 1 year after injury: drug class(es) dispensed, days' supply, strength of opioids dispensed and average daily morphine-equivalent dose.

Results

Compared with claimants receiving NSAIDs and/or SMRs, the incidence rate ratio (IRR) of days on benefits was 1.09 (95% CI 1.04 to 1.14) for claimants dispensed opioids only and 1.26 (95% CI 1.22 to 1.30) for claimants dispensed opioids with NSAIDs and/or SMRs. Compared with weak opioids only, the IRR for claimants dispensed strong opioids only or strong and weak opioids combined was 1.21 (95% CI 1.12 to 1.30) and 1.29 (95% CI 1.20 to 1.39), respectively. The incident rate of days on benefits associated with each 7-day increase in days supplied of opioids, NSAIDs and SMRs was 10%, 4% and 3%, respectively. Similar results were seen for receipt of benefits, though effect sizes were larger.

Conclusions

Findings suggest provision of early opioids leads to prolonged work disability compared with NSAIDs and SMRs, though longer supplies of all drug classes are also associated with work disability. Residual confounding likely partially explains the findings. Research is needed that accounts for prescriber, system and workplace factors.

The effect of a more strict 2014 DEA schedule designation for hydrocodone products on opioid prescription rates in the United States

Background: From 1999 to 2010, the annual number of US deaths due to opioid overdose increased about 400% as the number of opioids prescribed yearly also increased by approximately 400%. Over this period, hydrocodone combination products drove the opioid epidemic, as they became the most frequently prescribed medication in the United States. Our objective was to determine if the Drug Enforcement Administration's (DEA) 2014 policy change - which made it more difficult to prescribe hydrocodone combination products by moving them from Schedule III to Schedule II - reduced the total amount of opioid prescriptions as intended. Methods: We conducted a longitudinal analysis of the 10 most populous US states, beginning at the time each state began collecting data on opioid prescribing, and concluding at the end of 2016. The exposure was the DEA-mandated October 6, 2014 hydrocodone combination product schedule change. Results: After the DEA's schedule change for hydrocodone combination products, the total number of opioids prescribed each year per 100 people did not substantially change in California, Florida, Michigan, or New York. Although prescription rates dropped for hydrocodone combination products (CA: 43.2, 35.0; MI: 66.8, 55.6; NY: 20.8, 15.1), the reduction was commensurately counteracted by increased rates for tramadol (CA: 0.2, 9.9; MI: 0.1, 17.3; NY: 0.0, 7.6) and oxycodone (CA: 8.7, 9.7; MI: 10.3, 11.9; NY: 18.1, 18.8). Surprisingly, the other 6 states assessed had no viable mechanism in place for assessing state-wide opioid prescription totals, routinely expunged collected data, or only instituted a reporting mechanism toward the end of our study. Conclusion: Total opioid prescriptions were relatively unchanged following the 2014 DEA-mandated schedule change, however, physicians did change their prescribing habits by substituting tramadol for hydrocodone combination products. This substitution of similar medications for hydrocodone suggests alternative approaches are needed to reduce total US opioid prescription rates. Additionally, the current lack of standardized prescription reporting by states makes detailed opioid prescription analysis alarmingly difficult and insufficient to guide policy or monitor the impact of policy changes.

Brief report: Population-based reversal of the adverse impact of opioids on disability in Washington State workers' compensation

BACKGROUND

Evidence has associated opioid use initiated early in a workers' compensation claim with subsequent disability. In 2013, the Washington State Department of Labor and Industries (DLI) implemented procedures based on new regulations that require improvement in pain and function to approve opioids beyond the acute pain period.

METHODS

We measured opioid prescriptions between 6 and 12 weeks following injury, an indicator of persistent opioid use. Actuarial data for the association of any opioid use versus no opioid use with development of lost time payments are reported.

RESULTS

Prior authorization with hard stops led to a sustained drop in persistent opioid use, from nearly 5% in 2013 to less than 1% in 2017. This reduction was also associated with reversal of the increased lost work time patterns seen from 1999 to 2010.

CONCLUSIONS

Prior authorization targeted at preventing transition to chronic opioid use can prevent and reverse adverse time loss development that has occurred on a population basis concomitant with the opioid epidemic.

Effect of an opioid management program for Colorado workers' compensation providers on adherence to treatment guidelines for chronic pain

OBJECTIVE

The aim of this study was to examine adherence of state guidelines for Colorado workers' compensation physicians/providers treating individuals as injured workers with chronic pain after initiation of an opioid management program and provider incentives.

METHODS

A retrospective cohort of chronic, non-cancer pain claims was constructed from the Colorado's workers' compensation database. Adherence to treatment guidelines and opioid prescribing practices were evaluated during implementation of a new billing code to incentivize adherence.

RESULTS

Overall, less than 33% of claims showed evidence of opioid management. Comprehensive opioid management was observed in only 4.4% of claims. In 2010, after implementing the new billing code, the ratio of long acting opioids to short acting opioids decreased from 0.2 to 0.13; returning to 0.2 in one year. Similarly, morphine equivalent doses declined for a short period.

CONCLUSIONS

Incentivizing physicians to adhere to chronic pain management guidelines only temporarily improves prescribing practices.

Physiotherapy for injured workers in Canada: are insurers' and clinics' policies threatening good quality and equity of care? Results of a qualitative study

BACKGROUND

In recent years, significant efforts have been made to improve the provision of care for compensated injured workers internationally. However, despite increasing efforts at implementing best practices in this field, some studies show that policies overseeing the organisation of care for injured workers can have perverse influences on healthcare providers' practices and can prevent workers from receiving the best care possible. The influence of these policies on physiotherapists' practices has yet to be investigated. Our objectives were thus to explore the influence of 1) workers' compensation boards' and 2) physiotherapy clinics' policies on the care physiotherapists provide to workers with musculoskeletal injuries in three large Canadian provinces.

METHODS

The Interpretive Description framework, a qualitative methodological approach, guided this inquiry. Forty participants (30 physiotherapists and 10 leaders and administrators from physiotherapy professional groups and workers' compensation boards) were recruited in British Columbia, Ontario and Quebec to participate in an in-depth interview. Inductive analysis was conducted using constant comparative techniques.

RESULTS

Narratives from participants show that policies of workers' compensation boards and individual physiotherapy clinics have significant impacts on physiotherapists' clinical practices. Policies found at both levels often place physiotherapists in uncomfortable positions where they cannot always do what they believe to be best for their patients. Because of these policies, treatments provided to compensated injured workers markedly differ from those provided to other patients receiving physiotherapy care at the same clinic. Workers' compensation board policies such as reimbursement rates, end points for treatment and communication mechanisms, and clinic policies such as physiotherapists' remuneration schemes and restrictions on the choice of professionals had negative influences on care. Policies that were viewed as positive were board policies that recognize, promote and support physiotherapists' duties and clinics that provide organisational support for administrative tasks.

CONCLUSION

In Canada, workers' compensation play a significant role in financing physiotherapy care for people injured at work. Despite the best intentions in promoting evidence-based guidelines and procedures regarding rehabilitation care for injured workers, complex policy factors currently limit the application of these recommendations in practice. Research that targets these policies could contribute to significant changes in clinical settings.

Impact of a Graduated Approach on Opioid Initiation and Loss of Earnings Following Workplace Injury: A Time Series Analysis

The aim of this study was to explore the impact of the Ontario Workplace Safety and Insurance Board's (WSIB's) graduated approach to opioid management on opioid prescribing and disability claim duration.

Re-assessing the Validity of the Opioid Risk Tool in a Tertiary Academic Pain Management Center Population

OBJECTIVE

To analyze the validity of the Opioid Risk Tool (ORT) in a large. diverse population.

DESIGN

A cross-sectional descriptive study.

SETTING

Academic tertiary pain management center.

SUBJECTS

A total of 225 consecutive new patients, aged 18 years or older.

METHODS

Data collection included demographics, ORT scores, aberrant behaviors, pain intensity scores, opioid type and dose, smoking status, employment, and marital status.

RESULTS

In this population, we were not able to replicate the findings of the initial ORT study. Self-report was no better than chance in predicting those who would have an opioid aberrant behavior. The ORT risk variables did not predict aberrant behaviors in either gender group. There was significant disparity in the scores between self-reported ORT and the ORT supplemented with medical record data (enhanced ORT). Using the enhanced ORT, high-risk patients were 2.5 times more likely to have an aberrant behavior than the low-risk group. The only risk variable associated with aberrant behavior was personal history of prescription drug misuse.

CONCLUSIONS

The self-report ORT was not a valid test for the prediction of future aberrant behaviors in this academic pain management population. The original risk categories (low, medium, high) were not supported in the either the self-reported version or the enhanced version; however, the enhanced data were able to differentiate between high- and low-risk patients. Unfortunately, without technological automation, the enhanced ORT suffers from practical limitations. The self-report ORT may not be a valid tool in current pain populations; however, modification into a binary (high/low) score system needs further study.

Preventing Opioid Use Disorders among Fishing Industry Workers

Fishing industry workers are at high risk for work-related musculoskeletal disorders (MSDs) and injuries. Prescription opioids used to treat pain injuries may put these workers at increased risk for developing substance disorders. Using a Community-Based Participatory Research approach, formative research was conducted to inform the eventual development of relevant interventions to prevent and reduce opioid use disorders among fishing industry workers. Qualitative interviews (n = 21) were conducted to assess: knowledge and attitudes about opioid use disorders; features of fishing work that might affect use and/or access to treatment; and community and organizational capacity for prevention and treatment. Participants reported numerous pathways connecting commercial fishing with opioid use. The combination of high stress and physically tasking job duties requires comprehensive workplace interventions to prevent chronic pain and MSDs, in addition to tailored and culturally responsive treatment options to address opioid use disorders in this population. Public health programs must integrate workplace health and safety protection along with evidence-based primary, secondary, and tertiary interventions in order to address opioid use disorders, particularly among workers in strenuous jobs.

Effect of a high dosage opioid prior authorization policy on prescription opioid use, misuse, and overdose outcomes

BACKGROUND

High dosage opioid use is a risk factor for opioid-related overdose commonly cited in guidelines, recommendations, and policies. In 2012, the Oregon Medicaid program developed a prior authorization policy for opioid prescriptions above 120 mg per day morphine equivalent dose (MED). This study aimed to evaluate the effects of that policy on utilization, prescribing patterns, and health outcomes.

METHODS

Using administrative claims data from Oregon and a control state (Colorado) between 2011 and 2013, we used difference-in-differences analyses to examine changes in utilization, measures of high risk opioid use, and overdose after introduction of the policy. We also evaluated opioid utilization in a cohort of individuals who were high dosage opioid users before the policy.

RESULTS

Following implementation of Oregon's high dosage policy, the monthly probability of an opioid fill over 120 mg MED declined significantly by 1.7 percentage points (95% confidence interval [CI]; -2.0% to -1.4%), whereas it increased significantly by 1.0 percentage points (95% CI 0.4% to 1.7%) for opioid fills &lt; 61 mg MED. Fills of medications used to treat neuropathic pain also increased by 1.2 percentage points (95% CI 0.7% to 1.8%). The monthly probability of multiple pharmacy use declined by 0.1 percentage points (-0.2% to -0.0) following the prior authorization, but there were no significant changes in ED encounters or hospitalizations for opioid overdose. Among individuals who were using a high dosage opioid before the policy, there was a 20.3 percentage point (95% CI -15.3% to -25.3%) decline in estimated probability of having a high dosage fill after the policy.

CONCLUSIONS

Oregon's prior authorization policy was effective at reducing high dosage opioid prescriptions. While multiple pharmacy use also declined, we found no impact on opioid overdose were observed.

The impact of practice guidelines on opioid utilization for injured workers

BACKGROUND

Opioid use is rising in the US and may cause special problems in workers compensation cases, including addiction and preventing a return to work after an injury.

OBJECTIVE

This study evaluates a physician-level intervention to curb opioid usage. An insurer identified patients with out-of-guideline opioid utilization and called the prescribing physician to discuss the patient's treatment protocol.

RESEARCH DESIGN

This study uses a differences-in-differences study design with a propensity-score-matched control group. Medical and pharmaceutical claims data from 2005 to 2011 were used for analyses.

RESULTS

Following the intervention, the use of opioids increased for the intervention group and there is little impact on medical spending.

CONCLUSIONS

Counseling physicians about patients with high opioid utilization may focus more attention on their care, but did not impact short-term outcomes. More robust interventions may be needed to manage opioid use.

PERSPECTIVE

While the increasing use of opioids is of growing concern around the world, curbing the utilization of these powerfully addictive narcotics has proved elusive. This study examines a prescribing guidelines intervention designed to reduce the prescription of opioids following an injury. The study finds that there was little change in the opioid utilization after the intervention, suggesting interventions along other parts of the prescribing pathway may be needed.

Prolonged Preoperative Opioid Therapy Associated With Poor Return to Work Rates After Single-Level Cervical Fusion for Radiculopathy for Patients Receiving Workers' Compensation Benefits

STUDY DESIGN

Retrospective comparative cohort study.

OBJECTIVE

Examine the effect of prolonged preoperative opioid use on return to work (RTW) status after single-level cervical fusion for radiculopathy.

SUMMARY OF BACKGROUND DATA

The use of opioids has a dramatic effect in a workers' compensation population. The costs of claims that involved opioids in the management plan are catastrophic particularly for those undergoing spinal surgical procedure.

MATERIALS

Data of patients who underwent single-level cervical fusion for radiculopathy and had received opioid prescriptions before surgery were retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011 after work-related injury. Then, based on opioid use duration, short-term use (STO) group (<3 mo), intermediate-term use (ITO) group (3-6 mo), and long-term use (LTO) group (>6 mo) were constructed. A multivariate logistic regression analysis was used to determine whether successful RTW status was achieved. Chi-square and analysis of variance tests were used to compare other secondary outcomes after surgery.

RESULTS

Prolonged preoperative opioid use was a negative predictor of successful RTW status (odds ratio = 0.73; 95% confidence interval: 0.55-0.98; P value: 0.04). Prolonged preoperative opioid use was associated with increasingly lower rates of achieving stable RTW status (P < 0.05) and RTW within 1 year after surgery (P < 0.05). The odds of achieving successful RTW status were 0.49 (0.25-0.94) for ITO, and 0.40 (0.24-0.68) for LTO compared with STO group. The odds of RTW less than 1 year after surgery were 0.43 (0.21-0.88) for ITO and 0.36 (0.21-0.62) for LTO compared with STO group. Prolonged preoperative opioid use was also associated with increasingly higher net medical costs (P < 0.01), and disability benefits awarded after surgery (P < 0.01).

CONCLUSION

Prolonged preoperative opioid use was associated with poor functional outcomes after cervical fusion. STO and earlier inclusion of the surgical approach in the management plan may offer better surgical and functional outcomes after cervical fusion.

LEVEL OF EVIDENCE

3.

Prescription opioid poisoning across urban and rural areas: identifying vulnerable groups and geographic areas

AIMS

To determine (1) whether prescription opioid poisoning (PO) hospital discharges spread across space over time, (2) the locations of 'hot-spots' of PO-related hospital discharges, (3) how features of the local environment contribute to the growth in PO-related hospital discharges and (4) where each environmental feature makes the strongest contribution.

DESIGN

Hierarchical Bayesian Poisson space-time analysis to relate annual discharges from community hospitals to postal code characteristics over 10 years.

SETTING

California, USA.

PARTICIPANTS

Residents of 18 517 postal codes in California, 2001-11.

MEASUREMENTS

Annual postal code-level counts of hospital discharges due to PO poisoning were related to postal code pharmacy density, measures of medical need for POs (i.e. rates of cancer and arthritis-related hospital discharges), economic stressors (i.e. median household income, percentage of families in poverty and the unemployment rate) and concentration of manual labor industries.

FINDINGS

PO-related hospital discharges spread from rural and suburban/exurban 'hot-spots' to urban areas. They increased more in postal codes with greater pharmacy density [rate ratio (RR) = 1.03; 95% credible interval (CI) = 1.01, 1.05], more arthritis-related hospital discharges (RR = 1.08; 95% CI = 1.06, 1.11), lower income (RR = 0.85; 95% CI = 0.83, 0.87) and more manual labor industries (RR = 1.15; 95% CI = 1.10, 1.19 for construction; RR = 1.12; 95% CI = 1.04, 1.20 for manufacturing industries). Changes in pharmacy density primarily affected PO-related discharges in urban areas, while changes in income and manual labor industries especially affected PO-related discharges in suburban/exurban and rural areas.

CONCLUSIONS

Hospital discharge rates for prescription opioid (PO) poisoning spread from rural and suburban/exurban hot-spots to urban areas, suggesting spatial contagion. The distribution of age-related and work-place-related sources of medical need for POs in rural areas and, to a lesser extent, the availability of POs through pharmacies in urban areas, partly explain the growth of PO poisoning across California, USA.

SCOPE of Pain: An Evaluation of an Opioid Risk Evaluation and Mitigation Strategy Continuing Education Program

OBJECTIVE

Due to the high prevalence of prescription opioid misuse, the US Food and Drug Administration (FDA) mandated a Risk Evaluation and Mitigation Strategy (REMS) requiring manufacturers of extended-release/long-acting (ER/LA) opioid analgesics to fund continuing education based on a FDA Blueprint. This article describes the Safe and Competent Opioid Prescribing Education (SCOPE of Pain) program, an ER/LA opioid analgesic REMS program, and its impact on clinician knowledge, confidence, attitudes, and self-reported clinical practice.

METHOD

Participants of the 3-h SCOPE of Pain training completed pre-, immediate post- and 2-month post-assessments.

SUBJECTS

The primary target group (n = 2,850), and a subset (n = 476) who completed a 2-month post-assessment, consisted of clinicians licensed to prescribe ER/LA opioid analgesics, who care for patients with chronic pain and who completed the 3-h training between February 28, 2013 and June 13, 2014.

RESULTS

Immediately post-program, there was a significant increase in correct responses to knowledge questions (60% to 84%, P ≤ 0.02) and 87% of participants planned to make practice changes. At 2-months post-program, there continued to be a significant increase in correct responses to knowledge questions (60% to 69%, P ≤ 0.03) and 67% reported increased confidence in applying safe opioid prescribing care and 86% reported implementing practice changes. There was also an improvement in alignment of desired attitudes toward safe opioid prescribing.

CONCLUSIONS

The SCOPE of Pain program improved knowledge, attitudes, confidence, and self-reported clinical practice in safe opioid prescribing. This national REMS program holds potential to improve the safe use of opioids for the treatment of chronic pain.

The 1-Year Treatment Course of New Opioid Recipients in Veterans Health Administration

BACKGROUND

Understanding opioid prescribing trends requires differentiating clinically distinct short- and long-term receipt patterns.

OBJECTIVES

Describe the one-year course of opioid receipt among new opioid recipients and determine the proportion with subsequent long-term opioid therapy. Discern variation in proportion with long-term therapy initiation by geographic region and across Veterans Health Administration (VHA) medical centers.

METHODS

Longitudinal course of opioid receipt was analyzed using a cabinet supply approach. Short-term receipt was defined as index treatment episode lasting no longer than 30 days; long-term therapy as treatment episode of >90 days that began within the first 30 days following opioid index date.

PATIENTS

All VHA pharmacy users in 2004 and to 2011 who received a new prescription for an opioid (incident opioid recipients) preceded by 365 days with no opioid prescribed.

RESULTS

The proportion of all incident recipients who met the definition for long-term therapy within the first year decreased from 20.4% (N = 76,280) in 2004 to 18.3% (N = 96,166) in 2011. The proportion of incident recipients with chronic pain was unchanged between 2004 and 2011. Hydrocodone and tramadol increased as a proportion of initial opioids prescribed. Median days initially supplied decreased from 30 to 20 days. A greater percentage of new opioid prescriptions were for 7 days or fewer (20.9% in 2004; 27.9% in 2011). The proportion of new recipients who initiated long-term opioid therapy varied widely by medical center. Medical centers with higher proportions of new long-term recipients in 2004 saw greater decreases in this metric by 2011.

CONCLUSION

The proportion of new opioid recipients who initiated long-term opioid therapy declined between 2004 and 2011.

Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation

By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used.

PERSPECTIVE

Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.

The Impact of Opioid Risk Reduction Initiatives on High-Dose Opioid Prescribing for Patients on Chronic Opioid Therapy

Avoiding high opioid doses may reduce chronic opioid therapy (COT) risks, but the feasibility of reducing opioid doses in community practice is unknown. Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. The group practice physicians were exposed to both initiatives, whereas contracted physicians were exposed only to statewide changes. Using interrupted time series analyses, we assessed whether these initiatives reduced opioid doses among COT patients in group practice (n = 16,653) and contracted care settings (n = 5,552). From 2006 to June 2014, the percentage of COT patients receiving ≥120 mg morphine equivalent dose declined from 16.8% to 6.3% in the group practice versus 20.6 to 13.6% among COT patients of contracted physicians. The proportion receiving excess opioid days supplied declined from 24.0 to 10.4% among group practice COT patients and from 20.1 to 14.7% among COT patients of contracted physicians. Reductions in prescribing of high opioid dose and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

PERSPECTIVE

Washington State and a health plan's group practice implemented initiatives to reduce high-dose COT prescribing. Group practice physicians were exposed to both initiatives, whereas the health plan's contracted physicians were exposed to only the statewide changes. Reductions in prescribing of high opioid dose, average daily dose, and excess opioid days supplied followed state and health plan initiatives to change opioid prescribing. Reductions were substantially greater in the group practice setting that implemented additional initiatives to alter shared physician expectations regarding appropriate COT prescribing, compared with the contracted physicians' patients.

Evaluation of Health Plan Interventions to Influence Chronic Opioid Therapy Prescribing

OBJECTIVES

Evaluate health plan interventions targeting physician chronic opioid therapy (COT) prescribing.

MATERIALS AND METHODS

In 2006, Group Health's (GH) Integrated Group Practice (IGP) initiated diverse interventions targeting COT prescriber norms and practices. In 2010, the IGP implemented a COT guideline, including a mandated online course for physicians managing COT. These interventions were not implemented in GH's network practices. We compared trends in GH-IGP and network practices for 2006 to 2012 in the percent of patients receiving COT and their opioid dose. We compared physician beliefs before versus after the mandated course and precourse to postcourse changes in COT dosing for IGP physicians who took the course.

RESULTS

From 2006 to 2012, mean (SE) daily opioid dose among IGP COT patients (intervention setting) declined from 74.1 mg (1.9 mg) morphine equivalent dose (MED) to 48.3 mg (1.0 mg) MED. Dose changes among GH network COT patients (control setting) were modest-88.2 mg (5.0 mg) MED in 2006 to 75.7 mg (2.3 mg) MED in 2012. Among physicians taking the mandated course in 2011, we observed precourse to postcourse changes toward more conservative opioid prescribing beliefs. However, COT dosing trends did not change precourse to postcourse.

DISCUSSION

Following initiatives implemented to alter physician prescribing practices and norms, mean opioid dose prescribed to COT patients declined more in intervention than control practices. Physicians reported more conservative beliefs regarding opioid prescribing immediately after completing an online course in 2011, but the course was not associated with additional reductions in mean daily opioid dose prescribed by physicians completing the course.

Trends in prevalent and incident opioid receipt: an observational study in Veterans Health Administration 2004-2012

BACKGROUND

Improved understanding of temporal and regional trends may support safe and effective prescribing of opioids.

OBJECTIVE

We describe national, regional, and facility-level trends and variations in opioid receipt between fiscal years (FY) 2004 and 2012.

DESIGN

Observational cohort study using Veterans Health Administration (VHA) administrative databases.

PARTICIPANTS

All patients receiving primary care within 137 VHA healthcare systems during a given study year and receiving medications from VHA one year before and during a given study year.

MAIN MEASURES

Prevalent and incident opioid receipt during each year of the study period.

KEY RESULTS

The overall prevalence of opioid receipt increased from 18.9% of all veteran outpatients in FY2004 to 33.4% in FY2012, a 76.7% relative increase. In FY2012, women had higher rates of prevalent opioid receipt than men (42.4% vs. 32.9%), and the youngest veterans (18-34 years) had higher prevalent opioid receipt compared to the oldest veterans (≥ 80 years) (47.6% vs. 17.9%). All regions in the United States saw increased rates of prevalent opioid receipt during this time period. Prevalence rates varied widely by facility: in FY2012, the lowest-prescribing facility had a rate of 13.5%, and the highest of 50.8%. Annual incident opioid receipt increased from 8.8% in FY2004 to 10.2% in FY2011, with a decline to 9.8% in FY2012. Incident prescribing increased at some facilities and decreased at others. Facilities with high prevalent prescribing tended to have flat or decreasing incident prescribing rates during the study time frame.

CONCLUSIONS

Rates of opioid receipt increased throughout the study time frame, with wide variation in prevalent and incident rates across geographical region, sex, and age groups. Prevalence and incidence rates reflect distinct prescribing practices. Areas with the highest prevalence tended to have lower increases in incident opioid receipt over the study period. This likely reflects facility-level variations in prescribing practices as well as baseline rates of prevalent use. Future work assessing opioid prescribing should employ methodologies to account for and interpret both prevalent and incident opioid receipt.

A comprehensive approach to address the prescription opioid epidemic in Washington State: milestones and lessons learned

An epidemic of morbidity and mortality has swept across the United States related to the use of prescription opioids for chronic noncancer pain. More than 100,000 people have died from unintentional overdose, making this one of the worst manmade epidemics in history. Much of health care delivery in the United States is regulated at the state level; therefore, both the cause and much of the cure for the opioid epidemic will come from state action. We detail the strong collaborations across executive health care agencies, and between those public agencies and practicing leaders in the pain field that have led to a substantial reversal of the epidemic in Washington State.

What we know, and don't know, about the impact of state policy and systems-level interventions on prescription drug overdose

BACKGROUND

Drug overdose deaths have been rising since the early 1990s and is the leading cause of injury death in the United States. Overdose from prescription opioids constitutes a large proportion of this burden. State policy and systems-level interventions have the potential to impact prescription drug misuse and overdose.

METHODS

We searched the literature to identify evaluations of state policy or systems-level interventions using non-comparative, cross-sectional, before-after, time series, cohort, or comparison group designs or randomized/non-randomized trials. Eligible studies examined intervention effects on provider behavior, patient behavior, and health outcomes.

RESULTS

Overall study quality is low, with a limited number of time-series or experimental designs. Knowledge and prescribing practices were measured more often than health outcomes (e.g., overdoses). Limitations include lack of baseline data and comparison groups, inadequate statistical testing, small sample sizes, self-reported outcomes, and short-term follow-up. Strategies that reduce inappropriate prescribing and use of multiple providers and focus on overdose response, such as prescription drug monitoring programs, insurer strategies, pain clinic legislation, clinical guidelines, and naloxone distribution programs, are promising. Evidence of improved health outcomes, particularly from safe storage and disposal strategies and patient education, is weak.

CONCLUSIONS

While important efforts are underway to affect prescriber and patient behavior, data on state policy and systems-level interventions are limited and inconsistent. Improving the evidence base is a critical need so states, regulatory agencies, and organizations can make informed choices about policies and practices that will improve prescribing and use, while protecting patient health.