MedicalResearch.com Interview with:
Wenjia Zhu, PhD.
Marshall J. Seidman Fellow
Department of Health Care Policy
Harvard Medical School
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The current opioid epidemic continues to cause deaths and tremendous suffering in the United States, driven in large part by overuse of prescription opioids. Of special concern are new opioid prescriptions, i.e. opioids given to patients who have not used opioids before, which research tells us are an important gateway to long-term opioid use, misuse, overdoes and death. Recently, in their efforts to curb over prescribing of opioids, the CDC issued guidelines (December 2015 in draft form; March 2016 in final version) to encourage opioid prescribers to limit the use, duration and dose of opioids, particularly opioids to first-time users. Despite these, little is known about the prescribing of opioids to first-time users on a national scale, particularly among commercially insured patients.
In this study, we examined national monthly trends in the rate at which opioid therapy was started among commercially insured patients. Using administrative claims from Blue Cross Blue Shield Association commercial insurers from 2012 to 2017, we analyzed more than 86 million commercially insured patients across the United States.
MedicalResearch.com: What are the main findings?
Response: Between 2012-2017, the number of new opioid prescriptions per person who had not been prescribed opioids in the prior 6 months (i.e., opioid-naïve patient) declined substantially. More specifically, the monthly rate at which people started opioids declined by more than 50 percent, from 1.63% to 0.75%, with decreasing numbers of providers initiating opioid therapy to any opioid-naïve patient. However, a large subgroup of providers continued to issue high-risk initial opioid prescriptions to opioid-naïve patients. High-risk means either long-duration or high-dose, as defined by the CDC in their recent guidelines.
MedicalResearch.com: What should readers take away from your report?
Response: In some ways this study offers some much-needed good news regarding opioids. First, fewer and fewer opioid-naïve patients have started opioid therapy over the past few years. Additionally, large numbers of providers have responded to the opioid crisis by changing their prescribing behavior.
At the same time, however, there are two reasons for caution. First, large numbers of providers have stopped prescribing opioids to opioid-naïve patients, rather than prescribing opioids when indicated but at safer durations and doses, raising the possibility of inadequate access to safe amounts of opioids when needed for pain control. Second, the persistence of high-risk opioid prescribing raises further concerns of whether some patients who were prescribed opioids were given too much for too long.
Our findings underscore the importance of more nuanced prescribing over an all-or-nothing approach and suggest new challenges and opportunities for solving the current opioid epidemic.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: Our study is not designed to evaluate whether physicians’ decisions to issue high-risk opioid prescriptions were justifiable. Future research is needed to better understand the medical settings in which high-risk opioids are prescribed in order to inform a more nuanced prescribing approach that strikes a balance between preserving adequate treatment of pain and mitigating the risk of inappropriate use of pain medication.
This work was supported by grants from the National Institute on Aging (P01AG005842 and R01AG026290) and a monetary gift from Owen and Linda Robinson. Harvard Medical School participates in the Blue Cross Blue Shield Alliance for Health Research.
March 14, 2019
N Engl J Med 2019; 380:1043-1052
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