Impact of emergency department opioid use on future health resource utilization among patients with migraine

Treating the Uninsured and Underinsured with Migraine in the USA

PURPOSE OF REVIEW

To define, describe, and identify potential solutions for health disparities in the uninsured and underinsured with migraine in the USA.

RECENT FINDINGS

Uninsured and underinsured patients with migraine experience health disparities in diagnosis and treatment of migraine. Migraine patients have higher healthcare costs and higher employment disability, which contribute to a higher likelihood of uninsured or underinsured status. Uninsured or underinsured status, combined with factors such as race, socioeconomic status, geographic location, and care location, are correlated with delays in or decreased migraine diagnosis and treatment. Migraine prevalence is increased in the uninsured and underinsured. Potential solutions include advocacy for policy changes that improve access to care, increasing awareness and representation of underrepresented groups, providing resources to patients to reduce costs, and active patient engagement in migraine care. Continued efforts from all stakeholders have the potential to reduce health disparities in uninsured and underinsured patients with migraine, reducing disability and improving quality of life.

Rural disparities in emergency department utilization for migraine care

OBJECTIVE

To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences.

BACKGROUND

Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence.

METHODS

This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups.

RESULTS

One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001).

CONCLUSION

This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Burden of Episodic Migraine, Chronic Migraine, and Medication Overuse Headache in Alberta

OBJECTIVE

To describe demographic and clinical characteristics, healthcare resource use, costs, and treatment patterns in three migraine cohorts.

METHODS

This retrospective observational study using administrative data examined patients with episodic migraine (EM), chronic migraine (CM) (without medication overuse headache [MOH]), and medication overuse headache in Alberta, Canada. Migraine patients were identified between 2012 and 2018 based on ≥ 1 diagnostic codes or triptan prescription. Patients with CM were defined using parameter estimates of a logistic regression model, and MOH was defined as patients with an average of ≥ 15 supply days covered of acute medications. EM was defined as patients without CM or MOH. Study outcomes were summarized using descriptive statistics.

RESULTS

Patients with EM (n = 144,574), CM (n = 27,283), and MOH (n = 11,485) were included. Higher rates of healthcare use and costs were observed for CM (mean [SD] all-cause cost: ($12,693 [40,664]) and MOH ($16,611.5 [$38,748]) versus episodic migraine ($4,251 [$40,637]). Across all cohorts, opioids were the most dispensed acute medication (range across cohorts: 31.7%-89.8%), while antidepressants and anticonvulsants were the most dispensed preventive medication. Preventative medication classes were used by a minority of patients in each cohort, except anticonvulsants, where 50% of medication overuse patients had a dispensation.

CONCLUSIONS

Patients with CM and MOH have a greater burden of illness compared to patients with EM. The overutilization of acute medication, particularly opioids, and the underutilization of preventive medications highlight an unmet need to more effectively manage migraine.

Potentially Inappropriate Use of Opioids in the Management of Migraine in Colombia

RESEARCH OBJECTIVE

To identify the frequency of opioid use in a group of patients diagnosed with migraine in Colombia.

METHODS

Study of a retrospective cohort of patients with a diagnosis of migraine and a first prescription of antimigraine drugs from emergency services and a priority outpatient clinic. Sociodemographic, clinical, and pharmacological variables were identified; a 12-month follow-up was carried out to identify the use of a new opioid.

RESULTS

A total of 6309 patients with a diagnosis of migraine were identified, with a mean age of 35.5 ± 12.3 years, of which 81.3% were women. Nonsteroidal anti-inflammatory drugs (51.1%) were the most frequently prescribed medications, followed by ergotamine + caffeine (31.3%), acetaminophen (15.05%), and acetaminophen + codeine (14.4%). At the time of the index, 1300 (20.6%) patients received some opioid. During the follow-up, a total of 1437 (22.8%) patients received a new opioid, of which 31.8% belonged to the group that received an initial opioid and 20.4% to the group that did not receive one, which was statistically significant (OR:1.81; 95%CI:1.58-2.07; p < 0.001).

CONCLUSIONS

The frequent use of opioids in the management of migraines is potentially inappropriate and can lead to problems of tolerance, abuse and dependence. This combined with the low prescription of triptans, offers an opportunity for improvements in medical practice.

Disparities and Trends in Migraine Management in Pediatric Emergency Departments, 2009-19

OBJECTIVE

To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management.

METHODS

We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79).

CONCLUSIONS

Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.

Real-world opioid use among patients with migraine enrolled in US commercial insurance and risk factors associated with migraine progression

BACKGROUND: Migraineurs may be categorized as having episodic migraine (EM: < 15 headache days/month) or chronic migraine (CM: ≥ 15 days/month for > 3 months with ≥ 8 days/month having features of migraine). Opioid use has been linked to progression from EM to CM. OBJECTIVE: To describe the utilization of opioid prescriptions among patients with migraine, to determine the association between opioid use and migraine progression, and to explore demographic and clinical risk factors for migraine progression. METHODS: This retrospective cohort study used Optum's deidentified Clinformatics Data Mart Database from January 2015 to December 2018. Adult patients with a migraine diagnosis and continuous health plan enrollment were included. Opioid use was measured by average daily morphine equivalent dose, also known as morphine milligram equivalent (MME). Descriptive statistics were used to summarize the opioid use by patient demographic and clinical characteristics. A Cox proportional hazards model with stepwise selection was used to determine the risk factors of new-onset CM. RESULTS: Overall, 35% of patients with migraine (27,331 of 78,134) received prescription opioids (> 0 MME/day) during the 12-month follow-up period. Higher opioid dosage was found in patients who had CM and comorbidities of interest. Compared with patients with EM, patients with CM were twice as likely to receive at least 20 MME/day (CM 3.8% vs EM 1.9%) and had a higher median opioid day supply (CM 20 vs EM 10) during follow-up. About 7% of patients with CM with at least 1 opioid prescription had at least 50 MME/day in any 90-day period during follow-up. A significant association was found between MME level and the likelihood of new-onset CM. Additional significant risk factors of migraine progression included younger age, female sex, South and West regions, and having a diagnosis of medication overuse headache, depression, back pain, or fibromyalgia (all P < 0.05). CONCLUSIONS: Despite guidelines and the availability of more migraine-specific treatments, opioids are still commonly prescribed to patients with migraines in real-world practice, especially for those with CM. In this study population, a higher risk of new-onset CM was associated with receiving higher opioid doses.

Ahead of the pain: Where we stand after a decade of growth in United Council for Neurologic Subspecialties-certified headache subspecialists

OBJECTIVE

To characterize the geographic distribution of United States (US) headache subspecialists in 2021 compared to 2012 and analyze trends in distribution of and growth by geography.

INTRODUCTION

Headache disorders are the second-highest cause of disease burden worldwide. Historically, headache disorders have been treated by primary care and emergency physicians, often suboptimally. Our 2012 study identified further disparities in geographic distribution of United Council for Neurologic Subspecialties (UCNS)-certified headache subspecialists.

METHODS

This correlational population study explores the current geographic distribution of and changes in subspecialists by aggregating data from the UCNS, National Health Interview Survey, US Census, Bureau of Economic Analysis, and American Community Survey.

RESULTS

In 2021, there were 692 UCNS-certified headache subspecialists. There continued to be higher subspecialist density in the Northeast (1:34,678) and Midwest (1:55,005), with the highest density in Vermont (1:12,510) and Connecticut (1:20,419). The highest absolute subspecialist increases were in the South (99), California (35), and Texas (25). The highest relative subspecialist increases were in the West (105%), Vermont (500%), and Mississippi (500%). The univariable regressions showed significant associations between number of subspecialists and adult headache population (R²  = 0.797, p < 0.001), between subspecialist density and personal income (R²  = 0.935, p = 0.033), and between growth in subspecialists and poverty rate (R²  = 0.553, p = 0.022). However, the multivariable regressions showed that only the adult population was significantly associated with number of subspecialists (adjusted R²  = 0.806, p < 0.001).

CONCLUSION

Overall, there has been substantial growth in the number of UCNS-certified headache subspecialists in the US, especially relative to growth in adult headache population. Subspecialist density continues to be highest in the Northeast and is associated with higher per capita personal income. However, there has been encouraging growth in geographies that previously had little to no access. These findings represent positive progress, but there is more to be done to both increase access to optimal headache care by subspecialists nationally and decrease geographic disparities in access to care.