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Gotham Johnson D, Lu AY, Kirn GA, Trepka K, Ayana Day Y, Yang SC, Montoy JCC, Juarez MA. Pragmatic Emergency Department Intervention Reducing Default Quantity of Opioid Tablets Prescribed. West J Emerg Med 2024; 25:449-456. [PMID: 39028229 PMCID: PMC11254152 DOI: 10.5811/westjem.18040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 01/24/2024] [Accepted: 02/09/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction The opioid epidemic is a major cause of morbidity and mortality in the United States. Prior work has shown that emergency department (ED) opioid prescribing can increase the incidence of opioid use disorder in a dose-dependent manner, and systemic changes that decrease default quantity of discharge opioid tablets in the electronic health record (EHR) can impact prescribing practices. However, ED leadership may be interested in the impact of communication around the intervention as well as whether the intervention may differentially impact different types of clinicians (physicians, physician assistants [PA], and nurse practitioners). We implemented and evaluated a quality improvement intervention of an announced decrease in EHR default quantities of commonly prescribed opioids at a large, academic, urban, tertiary-care ED. Methods We gathered EHR data on all ED discharges with opioid prescriptions from January 1, 2019-December 6, 2021, including chief complaint, clinician, and opioid prescription details. Data was captured and analyzed on a monthly basis throughout this time period. On March 29, 2021, we implemented an announced decrease in EHR default dispense quantities from 20 tablets to 12 tablets for commonly prescribed opioids. We measured pre- and post-intervention quantities of opioid tablets prescribed per discharge receiving opioids, distribution by patient demographics, and inter-clinician variability in prescribing behavior. Results The EHR change was associated with a 14% decrease in quantity of opioid tablets per discharge receiving opioids, from 14 to 12 tablets (P = <.001). We found no statistically significant disparities in prescriptions based on self-reported patient race (P = 0.68) or gender (P = 0.65). Nurse practitioners and PAs prescribed more opioids per encounter than physicians on average and had a statistically significant decrease in opioid prescriptions associated with the EHR change. Physicians had a lesser but still significant drop in opioid prescribing in the post-intervention period. Conclusion Decreasing EHR defaults is a robust, simple tool for decreasing opioid prescriptions, with potential for implementation in the 42% of EDs nationwide that have defaults exceeding the recommended 12-tablet supply. Considering significant inter-clinician variability, future interventions to decrease opioid prescriptions should examine the effects of combining EHR default changes with targeted interventions for clinician groups or individual clinicians.
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Affiliation(s)
- Drake Gotham Johnson
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Alice Y Lu
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Georgia A Kirn
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kai Trepka
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Yesenia Ayana Day
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Stephen C Yang
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Juan Carlos C Montoy
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Marianne A Juarez
- University of California San Francisco, Department of Emergency Medicine, San Francisco, California
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Davis CS, Carr DH, Stein BD. Drug-related physician continuing medical education requirements, 2010-2020. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 161:209356. [PMID: 38548061 PMCID: PMC11090708 DOI: 10.1016/j.josat.2024.209356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 02/25/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024]
Abstract
INTRODUCTION The crisis of drug-related harm in the United States continues to worsen. While prescription-related overdoses have fallen dramatically, they are still far above pre-2010 levels. Physicians can reduce the risk of overdose and other drug-related harms by improving opioid prescribing practices and ensuring that patients are able to easily access medications for substance use disorder treatment. Most physicians received little or no training in those subjects in medical school. It is possible that continuing medical education can improve physician knowledge of appropriate prescribing and substance use disorder treatment and patient outcomes. METHODS Descriptive legal review. Laws in all 50 states and the District of Columbia were searched for provisions that require all or most physicians to receive either one-time or continuing medical education regarding controlled substance prescribing, pain management, or substance use disorder treatment. RESULTS There has been a rapid increase in the number of states with relevant requirements, from three states at the end of 2010 to 42 at the end of 2020. The frequency and duration of required education varied substantially across states. In all states, the number of hours required in relevant topics is a small fraction of overall required continuing education, an average of 1 h per year. Despite recent shifts in the substances driving overdose, most requirements remain focused on opioids. CONCLUSION While most states have now adopted continuing education requirements regarding controlled substance prescribing, pain management, or substance use disorder treatment, these requirements comprise a small component of the required post-training education requirements. Research is needed to determine whether this training translates into reductions in drug-related harm.
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Affiliation(s)
- Corey S Davis
- Harm Reduction Legal Project, Network for Public Health Law, 3701 Wilshire Blvd. #750, Los Angeles, CA 90010, United States of America.
| | - Derek H Carr
- Network for Public Health Law, United States of America
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Ferreira T. The role of the physician associate in the United Kingdom. Future Healthc J 2024; 11:100132. [PMID: 38766624 PMCID: PMC11101931 DOI: 10.1016/j.fhj.2024.100132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Physician associates (PAs) were introduced in the United Kingdom to address staffing shortages and fill service gaps, aiming to unburden doctors. Notably, in the backdrop of recent high-profile cases involving professional negligence and misconduct by PAs, the government has outlined a plan to expand the PA workforce and broaden their scope of practice. This commentary critically assesses the role, training, and regulation of PAs, juxtaposing the UK's approach with the US model. Concerns regarding disparities in training between PAs and doctors, potential impact on patient care quality, and lessons from the US experience raise substantial questions. Recommendations are provided to align with patient safety, professional standards, and the unique demands of the National Health Service (NHS). Despite the government's efforts to expand the PA workforce and its scope, uncertainties persist regarding their contribution to patient care and the implications for medical profesionals.
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Affiliation(s)
- Tomas Ferreira
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Gaddis G. The Generous Reimbursement of Non-Physician Clinical Services: Part 2: An Indication for Non-Physician Education Reforms. MISSOURI MEDICINE 2024; 121:189-194. [PMID: 38854603 PMCID: PMC11160366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Affiliation(s)
- Gary Gaddis
- Teaching Professor of Biomedical and Health Informatics, at the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Gaddis G. The Generous Reimbursement of Non-Physician Clinical Services: Part I: A Deep Dive into the Resource-Based Relative Value Scale. MISSOURI MEDICINE 2024; 121:105-112. [PMID: 38694606 PMCID: PMC11057855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Affiliation(s)
- Gary Gaddis
- Teaching Professor of Biomedical and Health Informatics, at the University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
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Havlik J, Ososanya L, Lee MS, Wahid S, Heyang M, Sun QW, Ross JS, Rhee TG. Comparison of industry payments to psychiatrists and psychiatric advanced practice clinicians in the USA, 2021: a cross-sectional study. BMJ Open 2024; 14:e081252. [PMID: 38331855 PMCID: PMC10860012 DOI: 10.1136/bmjopen-2023-081252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVES To compare industry payment patterns among US psychiatrists and psychiatric advanced practice clinicians (APCs) and determine how scope of practice laws has influenced these patterns. DESIGN Cross-sectional study. SETTING This study used the publicly available US Centers for Medicare and Medicaid Services Sunshine Act Open Payment database and the National Plan and Provider Enumeration System (NPPES) database for the year 2021. PARTICIPANTS All psychiatrists and psychiatric APCs (subdivided into nurse practitioners (NPs) and clinical nurse specialists (CNSs)) included in either database. PRIMARY AND SECONDARY OUTCOME MEASURES Number and percentage of clinicians receiving industry payments and value of payments received. Total payments and number of transactions by type of payment, payment source and clinician type were also evaluated. RESULTS A total of 85 053 psychiatric clinicians (61 011 psychiatrists (71.7%), 21 895 NPs (25.7%), 2147 CNSs (2.5%)) were reviewed; 16 240 (26.6%) psychiatrists received non-research payment from industry, compared with 10 802 (49.3%) NPs and 231 (10.7%) CNSs (p<0.001) for pairwise comparisons). Psychiatric NPs were significantly more likely to receive industry payments compared with psychiatrists (incidence rate ratio (IRR), 1.85 (95% CI 1.81 to 1.88); p<0.001)). Compared with psychiatrists, NPs were more likely to receive payments of > United States Dollars (US) $) 100 (33.9% vs 14.6%; IRR, 2.14 (2.08 to 2.20); p<0.001) and > US$ 1000 (5.3% vs 4.1%; IRR, 1.29 (1.20 to 1.38); p<0.001) but less likely to receive > US$ 10 000 (0.4% vs 1.0%; IRR, 0.39 (0.31 to 0.49); p<0.001). NPs in states with 'reduced' or 'restricted' scope of practice received more frequent payments (reduced: IRR, 1.22 (1.18 to 1.26); restricted: IRR, 1.26 (1.22 to 1.30), both p<0.001). CONCLUSIONS Psychiatric NPs were nearly two times as likely to receive industry payments as psychiatrists, while psychiatric CNSs were less than half as likely to receive payment. Stricter scope of practice laws increases the likelihood of psychiatric NPs receiving payment, the opposite of what was found in a recent specialty agnostic study.
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Affiliation(s)
- John Havlik
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Megan S Lee
- University of Chicago, Chicago, Illinois, USA
| | - Syed Wahid
- University of Chicago, Chicago, Illinois, USA
| | - Michael Heyang
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Joseph S Ross
- Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Crowley R, Pugach D, Williams M, Goldman J, Hilden D, Schultz AF, Beachy M. Principles for the Physician-Led Patient-Centered Medical Home and Other Approaches to Team-Based Care: A Position Paper From the American College of Physicians. Ann Intern Med 2024; 177:65-67. [PMID: 38145573 DOI: 10.7326/m23-2260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
Team-based care models such as the Patient-Centered Medical Home are associated with improved patient health outcomes, better team coordination and collaboration, and increased well-being among health care professionals. Despite these attributes, hindrances to wider adoption remain. In addition, some health care professionals have sought to practice independent of the physician-led health care team, potentially undermining patient access to physicians who have the skills and training to deliver whole-person, comprehensive, and longitudinal care. In this paper, the American College of Physicians reaffirms the importance of the physician-led health care team and offers policy recommendations on professionalism, payment models, training, licensure, and research to support the expansion of dynamic clinical care teams.
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Affiliation(s)
- Ryan Crowley
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - David Pugach
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - Margo Williams
- American College of Physicians, Washington, DC (R.C., D.P., M.W.)
| | - Jason Goldman
- Charles E. Schmidt College of Medicine, Boca Raton, Florida (J.G.)
| | - David Hilden
- Hennepin Healthcare, Minneapolis, Minnesota (D.H.)
| | | | - Micah Beachy
- University of Nebraska Medical Center, Omaha, Nebraska (M.B.)
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Zerden LDS, Sullivan C, Galloway E, Richman EL, Gaiser MG, Lombardi B. Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians? Am J Addict 2023; 32:574-583. [PMID: 37559344 DOI: 10.1111/ajad.13462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/27/2023] [Accepted: 07/27/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators. METHODS Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed. RESULTS The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels. DISCUSSION AND CONCLUSIONS Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines. SCIENTIFIC SIGNIFICANCE Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.
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Affiliation(s)
- Lisa de Saxe Zerden
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Connor Sullivan
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Evan Galloway
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Erica L Richman
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Maria G Gaiser
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Brianna Lombardi
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Family Medicine, School of Social Work, Cecil G. Sheps Center for Health Services Research, UNC Behavioral Health Workforce Research Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Wally MK, Thompson ME, Odum S, Kazemi DM, Hsu JR, Seymour RB. Opioid Prescribing for Chronic Musculoskeletal Conditions: Trends over Time and Implementation of Safe Opioid-Prescribing Practices. Appl Clin Inform 2023; 14:961-972. [PMID: 38057261 PMCID: PMC10700149 DOI: 10.1055/s-0043-1776879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
OBJECTIVES This study aimed (1) to determine the impact of a clinical decision support (CDS) tool on rate of opioid prescribing and opioid dose for patients with chronic musculoskeletal conditions and (2) to identify prescriber and facility characteristics associated with adherence to the Centers for Disease Control and Prevention guideline for prescribing opioids for chronic pain in this population.We conducted an interrupted time series analysis to assess trends in percentage of patients from 2016 to 2020, receiving an opioid and the average opioid dose, as well as the change associated with implementation of the CDS toolkit. We conducted a retrospective cohort study to assess the association between prescriber and facility characteristics and safe opioid-prescribing practices. METHODS We assessed the impact of the CDS intervention on percent of patients receiving an opioid and average opioid dose (morphine milligram equivalents). We operationalized safe opioid prescribing as a composite score of several behaviors (i.e., prescribing naloxone, initiating a pain agreement, prescribing <90 MME, avoiding extended-release prescriptions for opioid-naïve patients, and avoiding coprescribing opioids and benzodiazepines) and used a hierarchical linear regression model to assess associations between prescriber and facility characteristics and safe opioid prescribing. RESULTS This CDS intervention had a modest but statistically significant 1.6% reduction on the percent of patients (n = 1,290,746) receiving an opioid (mean: 15% preintervention; 10% postintervention). The average dose of opioid prescriptions did not significantly change. Advanced practice providers and prescribers with higher percentages of patients aged 18 to 64 exhibited safer opioid prescribing, while prescribers with higher percentages of white patients and larger numbers of patients on opioids exhibited less safe opioid prescribing. CONCLUSION A CDS intervention was associated with a small improvement in percent of patients receiving an opioid, but not on average dose. Clinicians are not prescribing opioids for chronic musculoskeletal conditions frequently, when they do, they are generally adhering to guidelines.
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Affiliation(s)
- Meghan K. Wally
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Michael E. Thompson
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Susan Odum
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Donna M. Kazemi
- School of Nursing, College of Health and Human Services, University of North Carolina at Charlotte, Charlotte, North Carolina, United States
| | - Joseph R. Hsu
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
| | - Rachel B. Seymour
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, North Carolina, United States
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10
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Crowley AP, Sun C, Yan XS, Navathe A, Liao JM, Patel MS, Pagnotti D, Shen Z, Delgado MK. Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med 2023; 30:809-818. [PMID: 36876410 DOI: 10.1111/acem.14717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVES Racial and ethnic minorities receive opioid prescriptions at lower rates and dosages than White patients. Though opioid stewardship interventions can improve or exacerbate these disparities, there is little evidence about these effects. We conducted a secondary analysis of a cluster-randomized controlled trial conducted among 438 clinicians from 21 emergency departments and 27 urgent care clinics. Our objective was to determine whether randomly allocated opioid stewardship clinician feedback interventions that were designed to reduce opioid prescriptions had unintended effects on disparities in prescribing by patient race and ethnicity. METHODS The primary outcome was likelihood of receiving a low-pill prescription (low ≤10 pills, medium 11-19 pills, high ≥20 pills). Generalized mixed-effects models were used to determine patient characteristics associated with low-pill prescriptions during the baseline period. These models were then used to determine whether receipt of a low-pill prescription varied by patient race or ethnicity during the intervention period between usual care and three opioid stewardship interventions: (1) individual audit feedback, (2) peer comparison feedback, and (3) combined (individual audit + peer comparison) feedback. RESULTS Compared with White patients, Black patients were more likely to receive a low-pill prescription during the baseline (adjusted odds ratio [OR] 1.18, 95% confidence interval [CI] 1.06-1.31, p = 0.002) and intervention (adjusted OR 1.43, 95% CI 1.07-1.91, p = 0.015). While combined feedback was associated with an overall increase in low-pill prescriptions as intended (adjusted OR 1.89, 95% CI 1.28-2.78, p = 0.001), there were no significant differences in treatment effects of any of the interventions by patient race and ethnicity. CONCLUSIONS Combined individual audit and peer comparison feedback was associated with fewer opioid pills per prescription equally by patient race and ethnicity. However, the intervention did not significantly close the baseline disparity in prescribing by race.
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Affiliation(s)
- Aidan P Crowley
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chuxuan Sun
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Xiaowei Sherry Yan
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - Amol Navathe
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Joshua M Liao
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - David Pagnotti
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Zijun Shen
- Center for Health Systems Research, Sutter Health, Walnut Creek, California, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Emergency Medicine and Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Walia B, Banga H, Larsen D. Reply to: comment on increased reliance on physician assistants: an access-quality tradeoff?. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2232192. [PMID: 37426574 PMCID: PMC10324457 DOI: 10.1080/20016689.2023.2232192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
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12
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Osakwe ZT, Liu B, Ankuda CK, Ritchie CS, Leff B, Ornstein KA. The role of restrictive scope-of-practice regulations on the delivery of nurse practitioner-delivered home-based primary care. J Am Geriatr Soc 2023; 71:2256-2263. [PMID: 36855242 PMCID: PMC10363209 DOI: 10.1111/jgs.18300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/23/2023] [Accepted: 01/26/2023] [Indexed: 03/02/2023]
Abstract
BACKGROUND Nurse practitioners (NPs) are the largest group of providers delivering home-based primary care (HBPC) in the U.S. We examined the association of scope-of-practice regulations and NP-HBPC rates. METHODS Using the Centers for Medicare and Medicaid Services Provider Utilization and Payment Data Public Use File for 2019, we conducted a state-level analysis to examine the impact of scope-of-practice regulations on the utilization of NP-HBPC. Healthcare Common Procedure Coding System codes were used to identify the HBPC visits in private residences (99341-99,345, 99,347-99,350) and domiciliary settings (99324-99,328, 99,334-99,337). We used linear regression to compare NP-HBPC utilization rates between states of either restricted or reduced scope-of-practice laws to states with full scope-of-practice, adjusting for a number of NP-HBPC providers, state ranking of total assisted living, the proportion of fee-for-service (FFS) Medicare beneficiaries and neighborhood-level socio-economic status and race and ethnicity. RESULTS Nearly half of NPs providing HBPC (46%; n = 7151) were in states with a restricted scope of practice regulations. Compared to states with full scope-of-practice, states with restricted or reduced scope-of-practice had higher adjusted rates of NP-HBPC per 1000 FFS Medicare beneficiaries. The average level of the utilization rate of NP-HBPC was 89.9, 63, and 49.1 visits, per 1000 FFS Medicare beneficiaries in states with restricted, reduced, and full- scope-of-practice laws, respectively. The rate of NP-HBPC visits was higher in states with restricted (Beta coefficient = 0.92; 95%CI 0.13-1.72; p = 0.023) and reduced scope-of-practice laws (Beta coefficient = 0.91; 95%CI 0.03-1.79; p = 0.043) compared to states with full scope-of-practice laws. CONCLUSION Restricted state NP scope-of-practice regulations were associated with higher rates of FFS Medicare NP-HBPC care delivery compared with full or reduced scope-of-practice. Understanding underlying mechanisms of how scope-of-practice affects NP-HBPC delivery could help to develop scope-of-practice regulations that improve access to HBPC for the underserved homebound population.
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Affiliation(s)
- Zainab Toteh Osakwe
- College of Nursing and Public Health, Adelphi University, Garden City, NY, USA
| | - Bian Liu
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Claire K. Ankuda
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christine S. Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA, USA
| | - Bruce Leff
- Center for Transformative Geriatric Research, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katherine A. Ornstein
- Center for Equity in Aging, Johns Hopkins University School of Nursing, Baltimore, MD, USA
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Eufemio CM, Hagedorn JD, McCall KL, Piper BJ. An Analysis of Oxycodone and Hydrocodone Distribution Trends in Delaware, Maryland, and Virginia Between 2006 and 2014. Cureus 2023; 15:e38211. [PMID: 37252511 PMCID: PMC10224754 DOI: 10.7759/cureus.38211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023] Open
Abstract
Objective Opioid medications are widely recognized for their use in analgesia and their addictive properties that have led to the opioid epidemic. Areas with historically high prescribing patterns have been shown to suffer more from the crisis. There is also regional variability in these trends. This study is a county level analysis of oxycodone and hydrocodone use in Delaware, Maryland, and Virginia between 2006 and 2014. Materials and methods A retrospective analysis of oxycodone and hydrocodone distributed as collected by the Drug Enforcement Administration's (DEA) Washington Post Automation of Reports and Consolidated Orders System (ARCOS) in Delaware, Maryland, and Virginia. Raw drug weights in each county were adjusted to "daily average dose" (grams/county population/365) using publicly available population estimates for all state counties. Purchasing data collected from ARCOS was used to compare distribution trends during this period. This study was limited in that ARCOS report quantity of drug distribution rather than average dose of script written. Results There was a 57.59% increase in the weight of oxycodone and hydrocodone prescribed between 2006 and 2014. Oxycodone prescriptions increased by 75.50% and hydrocodone by 11.05%. Oxycodone increased across all three states between 2006 and 2010 and declined until 2014. Hydrocodone also increased but to a lesser extent than oxycodone. There was substantial variability in daily average dose of both opioids at the county level in all states. Pharmacies accounted for largest portion of oxycodone (69.17%) and hydrocodone (75.27%) purchased in the region. Hospitals accounted for 26.67% of oxycodone and 22.76% of hydrocodone purchased. Practitioners and mid-level providers, including Nurse Practitioners and Physician Assistants, did not significantly contribute to this increase. Conclusion In the states of Maryland, Delaware, and Virginia, the distribution of the prescription opioids oxycodone and hydrocodone increased by 57.59%. Daily average dose increased between 2006 and 2010 in all three states, followed by a decline until 2014. Variability in daily average dose by county highlights the relationship between geography and likelihood of receiving high-dose opioids. Increased monitoring at regional health centers and improving substance abuse treatment infrastructure at the county level may be a more efficient strategy in combating the opioid epidemic. Future research is needed to understand the socioeconomic trends that may influence prescribing trends of opioid medications.
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Affiliation(s)
- Conor M Eufemio
- School of Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Joseph D Hagedorn
- School of Medicine, Geisinger Commonwealth School of Medicine, Scranton, USA
| | - Kenneth L McCall
- School of Pharmacy, University of New England, Biddeford, USA
- School of Pharmacy, Binghamton University, Johnson City, USA
| | - Brian J Piper
- Medical Education, Geisinger Commonwealth School of Medicine, Scranton, USA
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14
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Schuller KA, Dunson-Dillard T. Pain management: A deeper look at rural and urban nurses' perceptions and experiences. J Rural Health 2023; 39:320-327. [PMID: 36721332 DOI: 10.1111/jrh.12742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE About 11.4 million individuals admitted to misusing an opioid in the past year. The purpose of this study was to determine if nurses' definitions of pain management differed by location, and to assess the challenges treating patients with pain management concerns. This study fills a gap by comparing quantitative and qualitative feedback from nurses on pain management concerns in their practice location. METHODS Data were collected using an electronic survey emailed to licensed nurses across the United States. The mixed methods survey used multiple choice, select all that apply, and open-ended responses to gather data on nurses' perceptions of pain management. One hundred and eighty nurses completed the survey and were included in the study. Sixty-six percent practiced in an urban hospital. FINDINGS Rural and urban nurses defined pain management as nonopioids and opioids. Seventy-one percent of urban nurses defined pain management as physical therapy compared to only 61% of rural nurses. Similarly, 62% of urban nurses identified homeopathic medicines and treatments as pain management techniques compared to 52% of rural nurses. From the qualitative data, 32% of rural nurses stated that patients with pain management concerns only want pain medications compared to 14% of urban nurses. CONCLUSIONS Nurses have a critical position in and valuable perspective on the opioid epidemic. Rural communities are relatively disadvantaged in combatting the opioid epidemic. The finding that rural residents only want pain medication instead of alternative pain management options further challenges the country's rural health care workforce.
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Hartzell SYT, Keller MS, Albertson EM, Liu Y, Larson M, Friedman S. Variation in Nevada primary care clinicians' use of urine drug testing to mitigate opioid harm. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 145:208940. [PMID: 36880912 DOI: 10.1016/j.josat.2022.208940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 05/23/2023]
Abstract
INTRODUCTION The prescription opioid epidemic led to federal, state, and health system guidelines and policies aimed at mitigating opioid misuse, including presumptive urine drug testing (UDT). This study identifies whether a difference exists in UDT use among different primary care medical license types. METHODS The study used January 2017-April 2018 Nevada Medicaid pharmacy and professional claims data to examine presumptive UDTs. We examined correlations between UDTs and clinician characteristics (medical license type, urban/rural status, care setting) along with clinician-level measures of patient mix characteristics (proportions of patients with behavioral health diagnoses, early refills). Adjusted odds ratios (AORs) and predicted probabilities (PPs) from a logistic regression with a binomial distribution are reported. The analysis included 677 primary care clinicians (medical doctors [MD], physician assistants [PA], nurse practitioners [NP]). RESULTS Of those in the study, 85.1 % of clinicians did not order any presumptive UDTs. NPs had the highest proportion of UDT use (21.2 % of NPs), followed by PAs (20.0 % of PAs), and MDs (11.4 % of MDs). Adjusted analyses showed that being a PA or NP was associated with higher odds of UDT (PA: AOR: 3.6; 95 % CI: 3.1-4.1; NP: AOR: 2.5; 95 % CI: 2.2-2.8) compared to being an MD. PAs had the highest PP for ordering UDTs (2.1 %, 95 % CI: 0.5 %-8.4 %). Among clinicians who ordered UDTs, midlevel clinicians had higher mean and median UDT use (PA and NP mean: 24.3 % vs. MDs: 19.4 %; PA and NP median: 17.7 % vs. MDs: 12.5 %). CONCLUSION In Nevada Medicaid, UDTs are concentrated among 15 % of primary care clinicians who are frequently non-MDs. More research should include PAs and NPs when examining clinician variation in mitigating opioid misuse.
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Affiliation(s)
- Sarah Y T Hartzell
- School of Public Health, University of Nevada, Reno, 1664 N. Virginia St., Reno, NV 89557, United States.
| | - Michelle S Keller
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, 8700 Beverly Blvd #2900A, Los Angeles, CA 90040, United States; Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA 90095, United States
| | - Elaine Michelle Albertson
- Department of Health Policy and Management, UCLA Fielding School of Public Health, 650 Charles E Young Dr S, Los Angeles, CA 90095, United States
| | - Yan Liu
- School of Public Health, University of Nevada, Reno, 1664 N. Virginia St., Reno, NV 89557, United States
| | - Madalyn Larson
- School of Public Health, University of Nevada, Reno, 1664 N. Virginia St., Reno, NV 89557, United States
| | - Sarah Friedman
- School of Public Health, University of Nevada, Reno, 1664 N. Virginia St., Reno, NV 89557, United States
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16
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Sacarny A, Avilova T, Powell D, Williamson I, Merrick W, Jacobson M. A Randomized Trial Of Letters To Encourage Prescription Monitoring Program Use And Safe Opioid Prescribing. Health Aff (Millwood) 2023; 42:140-149. [PMID: 36623221 DOI: 10.1377/hlthaff.2022.00859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
To facilitate safer prescribing of opioids and other drugs, nearly all states operate prescription monitoring programs (PMPs), which collect and share data on controlled substance dispensing. Policy makers have sought to raise clinicians' engagement with these programs but lack evidence on effective interventions. Working with the Minnesota Prescription Monitoring Program, we conducted a randomized trial to assess whether letters to clinicians increased program use and decreased risky coprescribing of opioids with benzodiazepines or gabapentinoids. In March 2021 we randomly assigned 12,000 coprescribers to either a control arm or one of three study arms sent differing letters. The respective letters highlighted a new mandate to check the PMP before prescribing, provided information about coprescribing risks with a list of coprescribed patients, or contained both messages combined. Letters highlighting the mandate alone or along with coprescribing information increased PMP search rates by 4.5 and 4.0 percentage points, respectively, with no significant effect on coprescribing. These letters also increased PMP account-holding rates among clinicians. Effects persisted for at least eight months. The letter with only coprescribing information had no detected effects on key outcomes. Our results support the use of simple letter interventions as evidence-based tools to increase PMP engagement and potentially facilitate better-informed prescribing.
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Affiliation(s)
- Adam Sacarny
- Adam Sacarny , Columbia University, New York, New York
| | | | - David Powell
- David Powell, RAND Corporation, Arlington, Virginia
| | - Ian Williamson
- Ian Williamson, Minnesota Management and Budget Agency, Saint Paul, Minnesota
| | | | - Mireille Jacobson
- Mireille Jacobson, University of Southern California, Los Angeles, California
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17
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Amin-Esmaeili M, Gribble A, Johnson RM, Alinsky RH, Oyedele N, Parnham T, Byregowda H, Schneider KE, Park JN, Goddard L, Susukida R. Unsolicited reporting notifications (URNs) through Maryland's prescription drug monitoring program (PDMP): Characteristics of providers. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100111. [PMID: 36844159 PMCID: PMC9948924 DOI: 10.1016/j.dadr.2022.100111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
Objectives Unsolicited reporting is the activity of analyzing Prescription Drug Monitoring Program (PDMP) data and then sending unsolicited reporting notifications (URNs) to prescribers to notify them of their outlier prescribing behavior. We aimed to describe information about prescribers who were issued URNs. Methods A retrospective study of Maryland's PDMP data from Jan.2018-Apr.2021. All providers who were issued ≥ one URN were included in analyses. We summarized data on types of URNs issued by provider type and years in practice using basic descriptive measures. We also performed logistic regression analysis to provide odds ratio and estimated marginal probability of issuing ≥ one URN to providers in the Maryland health care workforce in comparison with physicians as reference group. Results A total of 4,446 URNs were issued to 2,750 unique providers. Odds ratio (OR) and the population estimated probability of issuing URNs were higher among nurse practitioners [OR: 1.42, 95% Confidence Interval (CI): 1.26-1.59] followed by physician assistants [OR: 1.87, 95% CI: 1.69-2.08], compared to physicians. Physicians and dentists with >10 years in practice comprised the majority of providers who were issued URNs (65.1% and 62.6%, respectively), while majority of nurse practitioners had been in practice for <10 years (75.8%). Conclusion Findings indicate a higher probability of issuing URN for Maryland's physician assistants and nurse practitioners, compared to physicians, and an overrepresentation of physicians and dentists with longer and nurse practitioners with shorter practice experience. The study suggests education programs on safer prescribing practices and management of opioids should target certain types of providers.
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Affiliation(s)
- Masoumeh Amin-Esmaeili
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University,Corresponding author at: Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, 624 N. Broadway Room 763, Baltimore, MD 21205, United States
| | - Anna Gribble
- Maryland Department of Health (MDH), Office of Provider Engagement and Regulation (OPER)
| | - Renee M. Johnson
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Rachel H Alinsky
- Division of Adolescent/Young Adult Medicine, Johns Hopkins University School of Medicine
| | - Natasha Oyedele
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Taylor Parnham
- Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University
| | - Himani Byregowda
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
| | - Kristin E. Schneider
- Department of Health Behavior and Society, Bloomberg School of Public Health, Johns Hopkins University
| | | | - Lindsey Goddard
- Maryland Department of Health (MDH), Office of Provider Engagement and Regulation (OPER)
| | - Ryoko Susukida
- Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University
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18
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Livingston CJ, Berenji M, Titus TM, Caplan LS, Freeman RJ, Sherin KM, Mohammad A, Salisbury-Afshar EM. American College of Preventive Medicine: Addressing the Opioid Epidemic Through a Prevention Framework. Am J Prev Med 2022; 63:454-465. [PMID: 35750550 DOI: 10.1016/j.amepre.2022.04.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 04/18/2022] [Accepted: 04/19/2022] [Indexed: 11/30/2022]
Abstract
The opioid epidemic has resulted in significant morbidity and mortality in the U.S. Health systems, policymakers, payers, and public health have enacted numerous strategies to reduce the harms of opioids, including opioid use disorder (OUD). Much of this implementation has occurred before the development of OUD‒related comparative effectiveness evidence, which would enable an understanding of the benefits and harms of different approaches. This article from the American College of Preventive Medicine (ACPM) uses a prevention framework to identify the current approaches and make recommendations for addressing the opioid epidemic, encompassing strategies across a primordial, primary, secondary, and tertiary prevention approach. Key primordial prevention strategies include addressing social determinants of health and reducing adverse childhood events. Key primary prevention strategies include supporting the implementation of evidence-based prescribing guidelines, expanding school-based prevention programs, and improving access to behavioral health supports. Key secondary prevention strategies include expanding access to evidence-based medications for opioid use disorder, especially for high-risk populations, including pregnant women, hospitalized patients, and people transitioning out of carceral settings. Key tertiary prevention strategies include the expansion of harm reduction services, including expanding naloxone availability and syringe exchange programs. The ACPM Opioid Workgroup also identifies opportunities for de-implementation, in which historical and current practices may be ineffective or causing harm. De-implementation strategies include reducing inappropriate opioid prescribing; avoiding mandatory one-size-fits-all policies; eliminating barriers to medications for OUD, debunking the myth of detoxification as a primary solo treatment for opioid use disorder; and destigmatizing care practices and policies to better treat people with OUD.
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Affiliation(s)
- Catherine J Livingston
- Department of Family Medicine, School of Medicine, Oregon Health & Science University, Portland, Oregon; Department of Health Management and Policy, School of Public Health, OHSU-Portland State University, Portland, Oregon.
| | - Manijeh Berenji
- Department of Occupational Health, VA Long Beach Healthcare System, Long Beach, California; Department of Occupational Medicine, UC Irvine School of Medicine, Irvine, California; Department of Environmental and Occupational Health, School of Public Health, University of California, Irvine, Irvine, California
| | - Tisha M Titus
- Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Lee S Caplan
- Department of Community Health & Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia
| | - Randall J Freeman
- Department of Occupational Medicine, Tripler Army Medical Center, Schofield Barracks, Hawaii
| | - Kevin M Sherin
- Department of Family Medicine and Rural Health Florida State University College of Medicine, Orlando, Florida; Department of Medicine University of Central Florida College of Medicine, Orlando, Florida
| | - Amir Mohammad
- Department of Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut; Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Elizabeth M Salisbury-Afshar
- Department of Family Medicine and Community Health, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
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19
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Nikpour J, Broome M, Silva S, Allen KD. Patient demographics and clinical characteristics influence opioid and nonopioid pain management prescriptions of primary care NPs, PAs, and physicians. J Am Assoc Nurse Pract 2022; 34:883-890. [PMID: 35544348 PMCID: PMC10201565 DOI: 10.1097/jxx.0000000000000728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/30/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Evidence exists on racial and gender disparities in chronic pain management among veterans. Most literature has described physicians' disparate opioid prescribing patterns, although it is unknown if prescribing disparities exist among nurse practitioners (NPs) and physician assistants (PAs) or among prescription of nonopioid analgesic strategies. PURPOSE To identify patient characteristics associated with opioid and nonopioid prescriptions among Veterans Affairs (VA) chronic pain patients by primary care physicians, NPs, and PAs. METHODOLOGY We used data from the VA's Survey of Health care Experience of Patients and Corporate Data Warehouse from October 2015 to September 2016. Outcomes included opioid and nonopioid analgesic prescriptions. Patient characteristics included race/ethnicity, gender, education level, age, and clinical characteristics (comorbidities, self-reported health, and self-reported mental health). Logistic regression was performed to test for associations of patient characteristics with outcomes. RESULTS Patients who were White, male, age 41-64 years, and with no postsecondary education had higher odds of receiving an opioid prescription (all p -values ≤ .01), whereas patients who were Black, female, and <65 years old had higher odds of a nonopioid prescription (all p -values < .01). Having 5+ comorbidities and fair/poor self-reported health increased the odds of opioid and nonopioid prescriptions (all p -values < .01). CONCLUSIONS Disparities in race, gender, and educational level significantly affect how primary care NPs, PAs, and physicians manage chronic pain. IMPLICATIONS NPs and other primary care providers should pursue training opportunities to identify and mitigate potential biases that may affect their practice. Future research should take an intersectional lens in examining the source of chronic pain disparities.
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Affiliation(s)
- Jacqueline Nikpour
- University of Pennsylvania School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Marion Broome
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Susan Silva
- Duke University School of Nursing, Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
| | - Kelli D. Allen
- Durham Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham Veterans Affairs Healthcare System, University of North Carolina-Chapel Hill
- School of Medicine, University of North Carolina-Chapel Hill
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20
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Abstract
This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY, 11367, United States.
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21
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Factors Associated with the Writing of Opioid Prescriptions. Int J Ment Health Addict 2022. [DOI: 10.1007/s11469-022-00823-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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22
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Schaffer S, Bayat D, Biffl WL, Smith J, Schaffer KB, Dandan TH, Wang J, Snyder D, Nalick C, Dandan IS, Tominaga GT, Castelo MR. Pain management on a trauma service: a crisis reveals opportunities. Trauma Surg Acute Care Open 2022; 7:e000862. [PMID: 35402732 PMCID: PMC8948384 DOI: 10.1136/tsaco-2021-000862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/08/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives The opioid crisis has forced an examination of opioid prescribing and usage patterns. Multimodal pain management and limited, procedure-specific prescribing guidelines have been proposed in general surgery but are less well studied in trauma, where multisystem injuries and multispecialty caregivers are the norm. We hypothesized that opioid requirements would differ by primary type of injury and by age, and we sought to identify factors affecting opioid prescribing at discharge (DC). Methods Retrospective analysis of pain management at a level II trauma center for January–November 2018. Consecutive patients with exploratory laparotomy (LAP); 3 or more rib fractures (fxs) (RIB); or pelvic (PEL), femoral (FEM), or tibial (TIB) fxs were included, and assigned to cohorts based on the predominant injury. Patients who died or had head Abbreviated Injury Scale >2 and Glasgow Coma Scale <15 were excluded. All pain medications were recorded daily; doses were converted to oral morphine equivalents (OMEs). The primary outcomes of interest were OMEs administered over the final 72 hours of hospitalization (OME72) and prescribed at DC (OMEDC). Multimodal pain therapy defined as 3 or more drugs used. Categorical variables and continuous variables were analyzed with appropriate statistical analyses. Results 208 patients were included: 17 LAP, 106 RIB, 31 PEL, 26 FEM, and 28 TIB. 74% were male and 8% were using opiates prior to admission. Injury cohorts varied by age but not Injury Severity Score (ISS) or length of stay (LOS). 64% of patients received multimodal pain therapy. There was an overall difference in OME72 between the five injury groups (p<0.0001) and OME72 was lower for RIB compared with all other cohorts. Compared with younger (age <65) patients, older (≥65 years) patients had similar ISS and LOS, but lower OME72 (45 vs 135*) and OMEDC. Median OME72 differed significantly between older and younger patients with PEL (p=0.02) and RIB (p=0.01) injuries. No relationship existed between OMEDC across injury groups, by sex or injury severity. Patients were discharged almost exclusively by trauma service advanced practice clinicians (APCs). There was no difference among APCs in number of pills or OMEs prescribed. 81% of patients received opioids at DC, of whom 69% were prescribed an opioid/acetaminophen combination drug; and only 13% were prescribed non-steroidal anti-inflammatory drugs, 19% acetaminophen, and 31% gabapentin. Conclusions Opioid usage varied among patients with different injury types. Opioid DC prescribing appears rote and does not correlate with actual opioid usage during the 72 hours prior to DC. Paradoxically, OMEDC tends to be higher among females, patients with ISS <16, and those with rib fxs, despite a tendency toward lower OME72 usage among these groups. There was apparent underutilization of non-opioid agents. These findings highlight opportunities for improvement and further study. Level of evidence IV.
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Affiliation(s)
- Sabina Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Dunya Bayat
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Walter L Biffl
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jeffrey Smith
- Orthopedic Trauma, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Kathryn B Schaffer
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Tala H Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Jiayan Wang
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Deb Snyder
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Chris Nalick
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Imad S Dandan
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Gail T Tominaga
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
| | - Matthew R Castelo
- Trauma Department, Scripps Memorial Hospital La Jolla, La Jolla, California, USA
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Nikpour J, Franklin M, Calhoun N, Broome M. Influence of provider type on chronic pain prescribing patterns A systematic review. J Am Assoc Nurse Pract 2022; 34:474-488. [PMID: 34935726 PMCID: PMC9562618 DOI: 10.1097/jxx.0000000000000673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 09/29/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chronic pain affects 100 million Americans and is most often treated in primary care, where the health care provider shortage remains a challenge. Nurse practitioners (NPs) represent a growing solution, yet their patterns of chronic pain management are understudied. Additionally, prescriptive authority limitations in many states limit NPs from prescribing opioids and often exist due to concerns of NP-driven opioid overprescribing. Little evidence on NP pain management prescribing patterns exists to address these issues. OBJECTIVE Systematic review, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, to examine opioid and nonopioid prescribing patterns of physicians, NPs, and physician assistants (PAs) in primary care. Eligible studies scored ≥60% on the Joanna Briggs Institute Critical Appraisal checklist. DATA SOURCES Searches within PubMed, Embase, CINAHL, and Web of Science. CONCLUSIONS Three themes were elucidated: 1) opioid prescribing in primary care, 2) similarities and differences in opioid prescribing by provider type, and 3) nonopioid pain management strategies. All provider groups had similar opioid prescribing patterns, although NPs and PAs may be slightly less likely to prescribe opioids than physicians. Although some studies suggested that NPs/PAs had higher opioid prescribing rates compared with physicians, methodological flaws may undermine these conclusions. Evidence is also lacking on nonopioid prescribing patterns across disciplines. IMPLICATIONS FOR PRACTICE Nurse practitioner/PA prescriptive authority limitations may not be as effective of a solution for addressing opioid overprescribing as transdisciplinary interventions targeting the highest subset of opioid prescribers. Future research should examine prescribing patterns of nonopioid, including nonpharmacologic, therapies.
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Affiliation(s)
- Jacqueline Nikpour
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Durham, North Carolina
| | | | - Nicole Calhoun
- Duke University School of Nursing, Durham, North Carolina
| | - Marion Broome
- Ruby F. Wilson Professor of Nursing, Duke University School of Nursing, Durham, North Carolina
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Carpenter RE, Silberman D, Takemoto JK. Transforming Prescription Opioid Practices in Primary Care With Change Theory. Health Serv Insights 2021; 14:11786329211058283. [PMID: 34880625 PMCID: PMC8647232 DOI: 10.1177/11786329211058283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 10/14/2021] [Indexed: 01/30/2023] Open
Abstract
The opioid epidemic continues to be an ongoing public health crisis. Many primary health care providers aptly serve as the gatekeeper to opioid prescriptions. The opioid epidemic has challenged the primary care profession whilst many of these providers have opted out of opioid prescribing altogether. This unintended consequence affirms erosion to primary care that is vital to the ecosystem of opioid management. The purpose of this study was to understand strategies to deliver opioids safely and effectively. Results indicate primary care providers are uniquely positioned to make a positive opioid impact through focused change initiatives. Five common themes arose from the inductive analysis: (1) provide leadership support; (2) define standard of work; (3) conduct pre-visit reviews; (4) conduct post-visit reviews; and (5) measure progress. Then, each common theme was deductively analyzed through a view of Kotter’s change theory to support an effective proxy for implementing and sustaining chronic opioid therapy in a primary care context. These finding have potential to provide actionable implications for health care management professionals and primary care organizations such as hospitals and group practices.
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Affiliation(s)
| | - Dave Silberman
- The University of Texas at Tyler, Tyler, TX, USA.,Boston University, Boston, MA, USA
| | - Jody K Takemoto
- College of Osteopathic Medicine, California Health Sciences University, CA, USA
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Pittman G, Ralph J, Freeman M, Freeman L, Borawski S. Nurse Practitioner Opioid Prescribing and Safety Measure Utilization Patterns in Ontario: An Explanatory Sequential Mixed Methods Study. JOURNAL OF NURSING REGULATION 2021. [DOI: 10.1016/s2155-8256(21)00115-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Policy Points The increased use of nurse practitioners represents a viable policy option to address continuing access-to-care deficiencies across the United States, but state scope-of-practice laws limit the ability of nurse practitioners to deliver health care. Groups in favor of restrictive scope-of-practice laws have argued that relaxing these laws will lead to increases in opioid prescriptions during an already severe opioid crisis, implicating patient safety concerns. An examination of a data set of 1.5 billion opioid prescriptions demonstrates that relaxing nurse practitioner scope-of-practice laws generally reduces opioid prescriptions. This evidence supports eliminating restrictive scope-of-practice laws that currently govern nurse practitioners in many states. CONTEXT As many parts of the United States continue to face physician shortages, the increased use of nurse practitioners (NPs) can improve access to care. However, state scope-of-practice (SOP) laws limit the ability of NPs to provide care by restricting the services they can provide and often requiring physician supervision of their practices. One important justification for the continuation of these restrictive SOP laws is preventing the overprescription of certain medications, particularly opioids. METHODS This study examined a data set of approximately 1.5 billion individual opioid prescriptions between 2011 and 2018, which were aggregated to the individual provider-year level. A series of difference-in-differences regression models was estimated to examine the association between laws allowing NPs to practice independently and opioid prescribing patterns among physicians and NPs. Opioid prescriptions were measured in total annual morphine milligram equivalents (MMEs) prescribed by individual providers. FINDINGS Across all NPs and physicians, independent NP practice was associated with a statistically significant decline of 6%, 2%, 3%, 7%, and 5% in total annual MMEs prescribed to commercially insured, cash-paying, Medicare, government-assistance, and all patients, respectively. Medicaid patients saw no statistically significant change in annual MMEs. Across all payers, NPs generally increase and physicians generally decrease the number of opioids they prescribe following a grant of NP independence. These counterbalancing changes result in an overall net decline in MMEs. CONCLUSIONS No evidence supports the contention that allowing NPs to practice independently increases opioid prescriptions. The results support policy changes that allow NPs to practice independently.
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