Trends in Out-of-Pocket Costs for and Characteristics of Pharmacy-Dispensed Naloxone by Payer Type

This study examines mean yearly out-of-pocket cost for naloxone dispensed from retail pharmacies by payer between 2018 and 2022 and by prescription characteristics and payer in 2022.

Longitudinal dose patterns among patients newly initiated on long-term opioid therapy in the United States, 2018 to 2019: an observational cohort study and time-series cluster analysis

ABSTRACT

Opioid prescribing varies widely, and prescribed opioid dosages for an individual can fluctuate over time. Patterns in daily opioid dosage among patients prescribed long-term opioid therapy have not been previously examined. This study uses a novel application of time-series cluster analysis to characterize and visualize daily opioid dosage trajectories and associated demographic characteristics of patients newly initiated on long-term opioid therapy. We used 2018 to 2019 data from the IQVIA Longitudinal Prescription (LRx) all-payer pharmacy database, which covers 92% of retail pharmacy prescriptions dispensed in the United States. We identified a cohort of 277,967 patients newly initiated on long-term opioid therapy during 2018. Patients were stratified into 4 categories based on their mean daily dosage during a 90-day baseline period (<50, 50-89, 90-149, and ≥150 morphine milligram equivalent [MME]) and followed for a 270-day follow-up period. Time-series cluster analysis identified 2 clusters for each of the 3 baseline dosage categories <150 MME and 3 clusters for the baseline dosage category ≥150 MME. One cluster in each baseline dosage category comprised opioid dosage trajectories with decreases in dosage at the end of the follow-up period (80.7%, 98.7%, 98.7%, and 99.0%, respectively), discontinuation (58.5%, 80.0%, 79.3%, and 81.7%, respectively), and rapid tapering (50.8%, 85.8%, 87.5%, and 92.9%, respectively). These findings indicate multiple clusters of patients newly initiated on long-term opioid therapy who experience discontinuation and rapid tapering and highlight potential areas for clinician training to advance evidence-based guideline-concordant opioid prescribing, including strategies to minimize sudden dosage changes, discontinuation, or rapid tapering, and the importance of shared decision-making.

Chronic Pain Among Adults - United States, 2019-2021

Chronic pain (i.e., pain lasting ≥3 months) is a debilitating condition that affects daily work and life activities for many adults in the United States and has been linked with depression (1), Alzheimer disease and related dementias (2), higher suicide risk (3), and substance use and misuse (4). During 2016, an estimated 50 million adults in the United States experienced chronic pain, resulting in substantial health care costs and lost productivity (5,6). Addressing chronic pain and improving the lives of persons living with pain is a public health imperative. Population research objectives in the National Pain Strategy, which was released in 2016 by the Interagency Pain Research Coordinating Committee, call for more precise estimates of the prevalence of chronic pain and high-impact chronic pain (i.e., chronic pain that results in substantial restriction to daily activities) in the general population and within various population groups to guide efforts to reduce the impact of chronic pain (3). Further, a 2022 review of U.S. chronic pain surveillance systems identified the National Health Interview Survey (NHIS) as the best source for pain surveillance data (7). CDC analyzed data from the 2019-2021 NHIS to provide updated estimates of the prevalence of chronic pain and high-impact chronic pain among adults in the United States and within population groups defined by demographic, geographic, socioeconomic, and health status characteristics. During 2021, an estimated 20.9% of U.S. adults (51.6 million persons) experienced chronic pain, and 6.9% (17.1 million persons) experienced high-impact chronic pain. New findings from this analysis include that non-Hispanic American Indian or Alaska Native (AI/AN) adults, adults identifying as bisexual, and adults who are divorced or separated are among the populations experiencing a higher prevalence of chronic pain and high-impact chronic pain. Clinicians, practices, health systems, and payers should vigilantly attend to health inequities and ensure access to appropriate, affordable, diversified, coordinated, and effective pain management care for all persons (8).

Trends in Out-of-Pocket Costs for and Characteristics of Pharmacy-Dispensed Buprenorphine Medications for Opioid Use Disorder Treatment by Type of Payer, 2015 to 2020

IMPORTANCE

Buprenorphine has been approved for opioid use disorder treatment, yet remains underutilized. Cost may present a barrier; little is known about how out-of-pocket costs vary.

OBJECTIVE

To determine if out-of-pocket costs and prescription characteristics for buprenorphine varied by type of payer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used all-payer data on retail pharmacy-dispensed buprenorphine prescriptions from January 1, 2015, through December 31, 2020, for adults (aged ≥18 years) in the US, excluding formulations primarily used to treat pain. Data were analyzed from July 2021 to June 2022.

EXPOSURES

Type of payer (private and commercial, self-pay, Medicaid, Medicare, assistance, and unknown) for dispensed prescription.

MAIN OUTCOMES AND MEASURES

All outcomes are prescription-level. Mean and median daily out-of-pocket costs were calculated overall and by payer type. Prescription characteristics (days supplied, patient age and sex, generic vs name brand formulations, and prescriber's location) were examined by payer type.

RESULTS

Although mean daily out-of-pocket costs decreased overall from $4.79 (95% CI, $4.79-$4.80) in 2015 (7 375 508 prescriptions) to $1.91 (95% CI, $1.90-$1.91) in 2020 (13 486 822 prescriptions), out-of-pocket costs continued to vary by payer in 2020. Medicaid had the lowest mean daily out-of-pocket cost across all years-$0.18 (95% CI, $0.18-$0.18) in 2015, and $0.10 (95% CI, $0.10-$0.10) in 2020. Private and commercial paid prescriptions fell from $4.80 (95% CI, $4.79-$4.81) per day in 2015 to $1.82 (95% CI, $1.82-$1.83) in 2020. Self-pay and assistance categories had the highest mean daily out-of-pocket costs across study years ($9.76 [95% CI, $9.74-$9.78] and $8.72 [95% CI, $8.71-$8.73], respectively, in 2015; $8.44 [95% CI, $8.43-$8.46] and $6.31 [95% CI, $6.30-$6.31], respectively, in 2020). Medicaid paid prescriptions had a mean supply of 15.59 days (95% CI, 15.58-15.59 days) and the lowest percentage of generic prescriptions (57.88%; 95% CI, 57.84%-57.92%). Out-of-pocket cost varied by prescriber location and patient characteristics; mean costs were highest for prescriptions written in the South ($2.91; 95% CI, $2.90-$2.91), metropolitan counties ($1.93; 95% CI, $1.93-$1.93), and for individuals aged 35 to 44 years ($2.10; 95% CI, $2.09-$2.10).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found that mean daily out-of-pocket costs for buprenorphine were lower in 2020 than in 2015, but variation by payer existed in all study years. Financial barriers to accessing and maintaining buprenorphine for opioid use disorder treatment may exist and differ by type of prescription coverage. Future research could monitor costs and identify potential barriers that may impact access and retention in care.

Dose tapering, increases, and discontinuity among patients on long-term high-dose opioid therapy in the United States, 2017-2019

BACKGROUND

While reduced exposure to prescription opioids may decrease risks, including overdose and opioid use disorder, abrupt tapering or discontinuation may pose new risks.

OBJECTIVES

To examine potentially unsafe tapering and discontinuation among dosage changes in opioid prescriptions dispensed to US patients on high-dose long-term opioid therapy.

DESIGN

Longitudinal observational study of adults (≥18 years) on stable high-dose (≥50 oral morphine milligram equivalents [MME] daily dosage) long-term opioid therapy during a 180-day baseline and a 360-day follow-up using all-payer pharmaceutical claims data, 2017-2019.

MEASURES

Dosage tapering, increases, and/or stability during follow-up; sustained dosage stability, reductions, or discontinuation at the end of follow-up; and tapering rate. Patients could experience more than one outcome during follow-up.

RESULTS

Among 595,078 patients receiving high-dose long-term opioid therapy in the sample, 26.7% experienced sustained dosage reductions and 9.3% experienced discontinuation. Among patients experiencing tapering, 62.0% experienced maximum taper rates between > 10-40% reductions per month and 36.1% experienced monthly rates ≥ 40%. Among patients with mean baseline daily dosages ≥ 150 MME, 47.7% experienced a maximum taper rate ≥ 40% per month. Relative to baseline, 19.7% of patients experiencing tapering had long-term dosage reductions ≥ 40% per month at the end of follow-up.

IMPLICATIONS

Dosage changes for patients on high-dose long-term opioid therapy may warrant special attention, particularly over shorter intervals, to understand how potentially sudden tapering and discontinuation can be reduced while emphasizing patient safety and shared decision-making. Rapid discontinuation of opioids can increase risk of adverse outcomes including opioid withdrawal.

Congruence of opioid prescriptions and dispensing using electronic records and claims data

OBJECTIVE

To quantify discrepancies between opioid prescribing and dispensing via the percentage of patients with Electronic Medical Record (EMR) prescriptions who subsequently filled the prescription within 90 days, defined as congruence, and compared opioid congruence with related medications.

DATA SOURCES

Deidentified data from the IBM MarketScan Explorys Claims-EMR Dataset.

STUDY DESIGN

In this retrospective, observational study, we examined congruence for commonly prescribed controlled substances-opioids, stimulants, and benzodiazepines. Congruence was stratified by age group and sex.

DATA COLLECTION/EXTRACTION METHODS

Continuously enrolled adults aged 18-64 years with an EMR encounter (excluding inpatient settings) and ≥ 1 prescription for selected classes between 1/1/2016 and 10/2/2017.

PRINCIPAL FINDINGS

During the study period, 1,353,478 adults had ≥1 EMR encounter. Patients with stimulants prescriptions had the highest congruence (83%) corresponding to 7151 claims for 8,635 EMR prescriptions, followed by opioids (66%; 62,766/95,690) and benzodiazepines (64%; 30,181/47,408). Chi-square testing showed congruence differed by age group within opioids (P < .0001) and benzodiazepines (P < .0001) and was higher among females within benzodiazepines (P < .0001).

CONCLUSIONS

These findings demonstrate that relying on claims data alone for opioid prescribing measures might underestimate actual prescribing magnitude by as much as one-third in these data. Combined EMR and claims data can help future research better understand characteristics associated with congruence or incongruence between prescribing and dispensing.

Impact of Medicaid expansion and methadone coverage as a medication for opioid use disorder on foster care entries during the opioid crisis

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0-1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents' drug use, a risk factor for child abuse/neglect and subsequent home removal.

Effect of Elementary School-Based Health Centers in Georgia on the Use of Preventive Services

INTRODUCTION

This study measures effects on the receipt of preventive care among children enrolled in Georgia's Medicaid or Children's Health Insurance Program associated with the implementation of new elementary school-based health centers. The study sites differed by geographic environment and predominant race/ethnicity (rural white, non-Hispanic; black, small city; and suburban Hispanic).

METHODS

A quasi-experimental treatment/control cohort study used Medicaid/Children's Health Insurance Program claims/enrollment data for children in school years before implementation (2011-2012 and 2012-2013) versus after implementation (2013-2014 to 2016-2017) of school-based health centers to estimate effects on preventive care among children with (treatment) and without (control) access to a school-based health center. Data analysis was performed in 2017-2019. There were 1,531 unique children in the treatment group with an average of 4.18 school years observed and 1,737 in the control group with 4.32 school years observed. A total of 1,243 Medicaid/Children's Health Insurance Program-insured children in the treatment group used their school-based health centers.

RESULTS

Significant increases in well-child visits (5.9 percentage points, p<0.01) and influenza vaccination (6.9 percentage points, p<0.01) were found for children with versus without a new school-based health center. This represents a 15% increase from the pre-implementation percentage (38.8%) with a well-child visit and a 25% increase in influenza vaccinations. Increases were found only in the 2 school-based health centers with predominantly minority students. The 18.7 percentage point (p<0.01) increase in diet/counseling among obese/overweight Hispanic children represented a doubling from a 15.3% baseline.

CONCLUSIONS

Implementation of elementary school-based health centers increased the receipt of key preventive care among young, publicly insured children in urban areas of Georgia, with potential reductions in racial and ethnic disparities.

Postpartum Medicaid Coverage and Contraceptive Use Before and After Ohio's Medicaid Expansion Under the Affordable Care Act

BACKGROUND

Ensuring that women with Medicaid-covered births retain coverage beyond 60 days postpartum can help women to receive care that will improve their health outcomes. Little is known about the extent to which the Affordable Care Act (ACA) Medicaid expansion has allowed for longer postpartum coverage as more women entering Medicaid under a pregnancy eligibility category could now become income eligible. This study investigates whether Ohio's Medicaid expansion increased continuous enrollment and use of covered services postpartum, including postpartum visit attendance, receipt of contraceptive counseling, and use of contraceptive methods.

METHODS

We used Ohio's linked Medicaid claims and vital records data to derive a study cohort whose prepregnancy and 6-month postpartum period occurred fully in either before (January 2011 to June 2013) or after (November 2014 to December 2015) the ACA Medicaid expansion implementation period (N = 170,787 after exclusions). We categorized women in this cohort according to whether they were pregnancy eligible (the treatment group) or income eligible (the comparison group) as they entered Medicaid and used multivariate logistic regression to test for differences in the association of the ACA expansion with their postpartum enrollment in Medicaid and use of services.

RESULTS

Women who entered Ohio Medicaid in the pregnancy eligible category had a 7.7 percentage point increase in the probability of remaining continuously enrolled 6 months postpartum relative to those entering as income eligible. Income eligible women had approximately a 5.0 percentage point increased likelihood of both a postpartum visit and use of long-acting reversible contraceptives. Pregnancy-eligible women had a significant but smaller (approximately 2 percentage point) increase in the likelihood of long-acting reversible contraceptive use.

CONCLUSIONS

Ohio's ACA Medicaid expansion was associated with a significant increase in the probability of women's continuous enrollment in Medicaid and use of long-acting reversible contraceptives through 6 months postpartum. Together, these changes translate into decreased risks of unintended pregnancy and short interpregnancy intervals.

Neonatal Abstinence Syndrome Incidence and Health Care Costs in the United States, 2016

This cross-sectional study examines the national incidence rate of neonatal abstinence syndrome using data from the 2016 Healthcare Cost and Utilization Project Kids’ Inpatient Database.

Changing the conversation: applying a health equity framework to maternal mortality reviews

The risk of maternal death in the United States is higher than peer nations and is rising and varies dramatically by the race and place of residence of the woman. Critical efforts to reduce maternal mortality include patient risk stratification and system-level quality improvement efforts targeting specific aspects of clinical care. These efforts are important for addressing the causes of an individual's risk, but research to date suggests that individual risk factors alone do not adequately explain between-group disparities in pregnancy-related death by race, ethnicity, or geography. The holistic review and multidisciplinary makeup of maternal mortality review committees make them well positioned to fill knowledge gaps about the drivers of racial and geographic inequity in maternal death. However, committees may lack the conceptual framework, contextual data, and evidence base needed to identify community-based contributing factors to death and, when appropriate, to make recommendations for future action. By incorporating a multileveled, theory-grounded framework for causes of health inequity, along with indicators of the community vital signs, the social and community context in which women live, work, and seek health care, maternal mortality review committees may identify novel underlying factors at the community level that enhance understanding of racial and geographic inequity in maternal mortality. By considering evidence-informed community and regional resources and policies for addressing these factors, novel prevention recommendations, including recommendations that extend outside the realm of the formal health care system, may emerge.