Association Between Cost-Sharing and Buprenorphine Prescription Abandonment.

BACKGROUND: Prior studies suggest cost-sharing decreases buprenorphine dispensing. However, these studies used databases that only report prescriptions filled by patients, not those that were "abandoned." Consequently, the studies could not calculate the probability of buprenorphine prescription abandonment or evaluate whether cost-sharing is associated with abandonment. OBJECTIVE: To evaluate the association between cost-sharing and buprenorphine prescription abandonment. DESIGN: Cross-sectional analysis of the IQVIA Formulary Impact Analyzer, a pharmacy transaction database representing 63% of U.S. retail pharmacies. The database includes transaction records ("claims") for prescriptions even if they are not filled. PARTICIPANTS: Buprenorphine claims in 2022 among commercially insured and Medicare patients. MAIN MEASURES: We evaluated the association between cost-sharing per 30-day supply and abandonment using logistic regression, controlling for patient characteristics, product type, and buprenorphine use in the prior 180 days. We assessed for effect modification by prior buprenorphine use. KEY RESULTS: Analyses included 2,346,994 and 1,242,596 buprenorphine prescription claims for commercially insured and Medicare patients, respectively. Among these claims, mean (SD) cost-sharing per 30-day supply was $28.1 (46.4) and $8.4 (20.2), and 1.5% and 1.2% were abandoned. Each $10 increase in cost-sharing per 30-day supply was associated with a 0.09 (95% CI: 0.09, 0.10) and 0.09 (95% CI: 0.08, 0.10) percentage-point increase in abandonment among commercially insured and Medicare patients. Among commercially insured and Medicare patients without prior buprenorphine use, respectively, a $10 increase in cost-sharing per 30-day supply was associated with a 0.12 (95% CI: 0.11, 0.14) and 0.13 (95% CI: 0.07, 0.18) percentage-point higher increase in the probability of abandonment compared with patients with > 90 days of prior buprenorphine use. CONCLUSIONS: Among commercially insured and Medicare patients, buprenorphine prescription abandonment is rare and only minimally associated with cost-sharing. Findings suggest elimination of buprenorphine cost-sharing should only be one component of a larger, multi-faceted campaign to increase buprenorphine dispensing.

Association Between Cost Sharing and Naloxone Prescription Dispensing.

Importance: Increasing access to naloxone (an opioid antagonist that can reverse overdose) could slow the US opioid epidemic. Prior studies suggest cost sharing may be a barrier to dispensing of naloxone prescriptions, but these studies were limited by their cross-sectional designs and use of databases that do not capture prescriptions that are not filled (abandoned). Objective: To evaluate the association between cost sharing and naloxone prescription abandonment (nondispensing of naloxone prescriptions). Design, Setting, and Participants: This cross-sectional, regression discontinuity analysis exploited the fact that deductibles typically reset at the beginning of the year in commercial and Medicare plans. The included data were derived from the 2020-2021 IQVIA Formulary Impact Analyzer (a pharmacy transactions database that represents 63% of prescriptions at US pharmacies). The analysis included claims for naloxone nasal spray among commercially insured patients and Medicare patients that occurred during the 60 days before January 1, 2021, through 59 days after January 1, 2021. Exposure: Cost sharing, which is defined as the amount patients would have to pay to fill prescriptions. Main Outcomes and Measures: Local linear regression models were used to assess for abrupt changes in cost sharing and the probability of prescription abandonment on January 1, 2021. To estimate the association between cost sharing and prescription abandonment, a fuzzy regression discontinuity analysis was conducted. Results: These analyses included naloxone claims for 71 306 commercially insured patients and 101 706 Medicare patients (40 019 [56.1%] and 61 410 [60.4%], respectively, were female). The commercially insured patients and Medicare patients accounted for 73 311 and 106 076 naloxone claims, respectively. On January 1, 2021, the mean cost sharing per claim increased by $15.0 (95% CI, $13.8-$16.2) for commercially insured patients and increased by $12.3 (95% CI, $10.9-$13.6) for Medicare patients and the probability of abandonment increased by 4.7 (95% CI, 3.2-6.2) percentage points and 2.8 (95% CI, 1.6-4.1) percentage points, respectively. The results from the fuzzy regression discontinuity analysis suggest a decision by commercial and Medicare plans to increase naloxone cost sharing by $10 would be associated with percentage-point increases of 3.1 (95% CI, 2.2-4.1) and 2.3 (95% CI, 1.4-3.2), respectively, in the probability of abandonment. Conclusions: The elimination of cost sharing might be associated with increased naloxone dispensing to commercially insured and Medicare patients.

Impact of Perceived Access and Treatment Knowledge on Medication Preferences for Opioid Use Disorder.

BACKGROUND: Medications for opioid use disorders (MOUDs) are effective, but most people with opioid use disorder (OUD) do not receive treatment. Prior research has explored patients' structural barriers to access and perceptions of MOUD. Little research has considered treatment knowledge and perceptions outside of the patient population. Members of the public without OUD themselves (eg, family, friends) can significantly influence treatment decisions of persons with OUD. Considering these gaps, we conducted an original survey with a diverse sample of US adults to explore knowledge and preferences toward OUD treatments. METHODS: We conducted an online survey with 1505 White, Black, and Latino/a Americans including a small percentage (8.5%) with self-reported lifetime OUD. The survey used vignettes to describe hypothetical patients with OUD, provide basic treatment information (ie, methadone, buprenorphine, naltrexone, nonmedication treatment), and then assessed treatment preferences. Using multivariable logistic regression, we examined associations between covariates of interest (eg, perceived access, knowledge, demographics) and preference for MOUD versus nonmedication treatment. RESULTS: There were 523 White, 502 Black, and 480 Latino/a respondents. Across racial/ethnic subsamples, respondents had the greatest knowledge of nonmedication treatments, with Black (72.7%) and Latino/a (70.2%) respondents having significantly greater knowledge compared to White respondents (61.8%). However, after viewing the vignette, a greater proportion of respondents chose methadone (35.8%) or buprenorphine (34.8%) as their first-choice treatment for hypothetical patients. Multivariable logistic regression suggested that among Black respondents, those with knowledge of nonmedication treatment were more likely to choose MOUD than those without knowledge (odds ratio = 2.41, 95% confidence interval = 1.34-4.34). Perceived treatment access did not affect treatment choice. CONCLUSIONS: Across racial groups, knowledge and perceived access to nonmedication treatment was greater than for MOUD, but many still selected MOUD as a first-choice treatment. Significant findings emphasized the importance of treatment knowledge around decision-making, highlighting opportunities for tailored education efforts to improve uptake of evidence-based treatment.

Perceptions around medications for opioid use disorder among a diverse sample of U.S. adults.

INTRODUCTION: Medications for opioid use disorder (MOUD) including methadone (MMT), buprenorphine (BUP), and naltrexone (NTX) are safe and effective. However, there are significant negative perceptions surrounding MOUD, creating barriers to uptake. While research on MOUD stigma has largely focused on provider and patient experiences, fewer studies have explored MOUD perceptions among the general public. Given that MOUD stigma expressed by social ties surrounding individuals with OUD can influence treatment choices, we assessed MOUD perceptions among U.S. adults to determine how beliefs impacted treatment preference. We further explored how MOUD perceptions may be amplified among racialized groups with histories of experiencing drug-related discrimination. METHODS: The study collected survey data from a diverse sample of U.S. adults (n = 1508) between October 2020 and January 2021. The survey measured knowledge of MOUD and non-medication treatments, relative agreement with common MOUD perceptions, and treatment preferences. Multinomial logistic regression analysis tested associations with treatment preference, stratified by race/ethnicity. RESULTS: Descriptive results indicated that across groups, many respondents (66.8 %) had knowledge of MOUD, but believed MOUD was a "substitute" for opioids and had some degree of concern about misuse. Multivariable results showed knowledge of non-medication treatments was positively associated with MOUD preference among White (MMT OR = 3.16, 95 % CI = 1.35-7.39; BUP OR = 2.69, CI = 1.11-6.47), Black (MMT OR = 3.91, CI = 1.58-9.69), and Latino/a (MMT OR = 5.12, CI = 1.99-13.2; BUP OR = 3.85, CI = 1.5-9.87; NTX OR = 4.51, CI = 1.44-14.06) respondents. Among White respondents, we identified positive associations between MOUD experience and buprenorphine preference (OR = 4.33, CI = 1.17-16.06); non-medication treatment experience and preference for buprenorphine (OR = 2.86, CI = 1.03-7.94) and naltrexone (OR = 3.17, CI = 1.08-9.28). Concerns around misuse of methadone were negatively associated with methadone preference among White (OR = 0.65, CI = 0.43-0.98) and Latino/a (OR = 0.49, CI = 0.34-0.7), and concerns around misuse of buprenorphine was negatively associated with preference for MOUD among White (MMT OR = 0.62, CI = 0.39-0.99; BUP OR = 0.48, CI = 0.3-0.77; NTX OR = 0.6, CI = 0.36-0.99) and Latino/a (BUP OR = 0.59, CI = 0.39-0.89) respondents. CONCLUSIONS: This analysis offers critical insights into treatment perceptions beyond the patient population, finding that negative beliefs around MOUD are common and negatively associated with preferences for medication-based treatment. These findings highlight implications for public support of evidence-based treatment and lay the groundwork for future interventions addressing public stigma toward MOUD.

The effect of a pilot brief educational intervention on preferences regarding treatments for opioid use disorder.

Purpose: Negative perceptions around medications for opioid use disorder (MOUD) amongst the public could deter patients with opioid use disorder (OUD) from engaging with MOUD. Thus, we evaluated whether a brief intervention could improve preferences for MOUD in people who may or may not use opioids. Methods: We employed a pre-post design to assess the effect of a brief educational intervention on preferences for methadone, buprenorphine, naltrexone, and non-medication treatment in an online sample of US adults stratified by race, who may or may not use opioids. Respondents ranked their preferences in OUD treatment before and after watching four one-minute educational videos about treatment options. Changes in treatment preferences were analyzed using Bhapkar's test and post hoc McNemar's tests. A binary logistic generalized estimating equation (GEE) assessed factors associated with preference between treatments. Results: The sample had 530 responses. 194 identified as White, 173 Black, 163 Latinx. Treatment preferences changed significantly towards MOUD (p<.001). This effect was driven by changes toward buprenorphine (OR=2.38; p<.001) and away from non-medication treatment (OR=0.20; p<.001). There was no significant difference in effect by race/ethnicity. People with lower opioid familiarity were significantly more likely to change their preferences towards MOUD following the intervention. Conclusion: Respondent preferences for MOUD increased following the intervention suggesting that brief educational interventions can change treatment preferences towards MOUD. These findings offer insights into perceptions of OUD treatment in a racially stratified sample and serve as a foundation for future educational materials that target MOUD preferences in the general public.

Improving Medical Student Knowledge and Reducing Stigmatizing Attitudes Toward Treating Patients With Opioid Use Disorder.

Objectives: Stigma and lack of knowledge are barriers to clinicians when caring for individuals with opioid use disorder (OUD). In 2018, only about 15 out of 180 American medical schools had comprehensive addiction programs. The AAMC reports that institutions are increasingly incorporating competencies to address the OUD and opioid epidemic. There have been few evaluated curriculums focused on reducing stigmatizing attitudes. This study evaluated whether a 4-hour case-based curriculum focused on improving stigmatizing attitudes toward patients with OUD could reduce medical student perceptions around viewing addiction as a punitive condition and other substitution-based misconceptions around opioid agonist-based medication. Methods: Medical students completed a 4-hour curricular workshop which included learning objectives focusing on barriers to healthcare/stigmatizing attitudes, effective behavioral therapy options, and appropriate use of opioid medications. We measured changes in knowledge and attitudes using validated scales on stigma. Non-parametric repeated measure tests determined statistically significant differences between pre and post assessments between OUD related perceptions and a control condition (diabetes). Results: Of 135 eligible participants, 99 (76%) students completed both pre- and post-surveys. Mean scores across knowledge questions improved (60%-81%, P < .001) and stigmatizing attitudes regarding perceived violence of people with OUD decreased (2.04-1.82, P = .016). There was significant improvement in mean scores for OUD-related opinions including desire to work with and effectively treat patients with OUD (3.58-3.88, P < .001) while no significant concurrent change was observed in mean opinion scores of a non-OUD comparator, diabetes (3.88-3.97, P = .201). Conclusions: Results indicate that the workshop was associated with measurable changes in knowledge and attitudinal forms of OUD stigma. With recent policy changes eliminating the X-waiver, healthcare institutions are eager to design curriculum around OUD management and treatment. This study provides a blueprint for an effective curriculum that improves clinician knowledge and reduces stigmatizing attitudes.

Nociplastic Pain and Pain-Motivated Drinking in Alcohol Use Disorder.

Heavy chronic alcohol use may produce pain amplification through neurochemical and neuroplastic changes at multiple levels of the nervous system. Similar changes are thought to underlie nociplastic pain. The American College of Rheumatology Fibromyalgia Survey has been used as a surrogate for nociplastic pain, including among individuals with alcohol use disorder (AUD). However, studies linking nociplastic pain to pain-motivated drinking are lacking. The present study aimed to determine if nociplastic pain is associated with pain-motivated drinking in AUD. To achieve this aim, a new scale-the Pain-Motivated Drinking Scale (PMDS)-was developed to measure how often participants were motivated by pain to drink alcohol. Measurement properties of this new scale were determined, including its factor structure, internal consistency reliability, and construct validity. In this cross-sectional observational study, participants with AUD (n = 138) were consecutively recruited from the patient pool at an academic addiction treatment facility. Seventy-two percent (95, 72.0%) reported they drank alcohol "to get relief from physical pain" at least some of the time, and over forty-two percent (56, 42.4%) reported pain relief motivated their drinking at least half of the time. PMDS had a single-factor structure, strong internal consistency reliability, and construct validity. A multiple hierarchical linear regression was run to determine if nociplastic pain was associated with pain-motivated drinking. Nociplastic pain was associated with PMDS even after controlling for potential confounders and pain severity. These findings suggest nociplastic pain is uniquely associated with pain-motivated drinking in AUD. PERSPECTIVE: Nociplastic pain is independently associated with pain-motivated drinking in alcohol use disorder (AUD). The Pain-Motivated Drinking Scale (PMDS) is a new scale to measure how often people drink to cope with pain. PMDS has promising psychometric properties. Nociplastic pain may be uniquely associated with pain-motivated drinking in AUD.

Harms Versus Harms: Rethinking Treatment for Patients on Long-Term Opioids.

In 2022, the CDC revised its and encourage clinicians to weight the risks versus harms of continued therapy and empathetically engage patients in patient-centered discussions around continued therapy while avoiding patient abandonment. This commentary discusses how the emphasis on "benefit" will almost always lead to discordance between the patient and provider since many clinicians find little benefit in opioid therapy for chronic pain with evidence questioning its efficacy for chronic pain. This disagreement between patients and providers has the potential to lead to unilateral tapers or patient abandonment and further increase patient harm. Considering this dilemma, we propose a revised framework that emphasizes weighing the harms of continuation of therapy against the harms of discontinuation of therapy when caring for patients on long-term opioid therapy. This revised harm-reductive decisional framework has the potential to retain patient-provider trust and increase opportunities for engagement in evidence-based multi-modal pain treatment, including non-opioid based treatment options.

Improving Access to Care for Patients Taking Opioids for Chronic Pain: Recommendations from a Modified Delphi Panel in Michigan.

Purpose: About 5-8 million US patients take long-term opioid therapy for chronic pain. In the context of policies and guidelines instituted to reduce inappropriate opioid prescribing, abrupt discontinuations in opioid prescriptions have increased and many primary care clinics will not prescribe opioids for new patients, reducing access to care. This may result in uncontrolled pain and other negative outcomes, such as transition to illicit opioids. The objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients. Participants and Methods: We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020-January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority. Results: The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities. Conclusion: Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access.

High-risk Prescribing Following Surgery Among Payer Types for Patients on Chronic Opioids.

OBJECTIVE: Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance. BACKGROUND: Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance. METHODS: In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber. RESULTS: Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402). CONCLUSIONS: Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality.

Feasibility and Acceptability of the Pain Profile, a Clinical Questionnaire Aimed at Improving Pain Care.

Purpose: Despite being one of the most common medical complaints, chronic pain is difficult to manage due to ineffective communication between providers and patients and time restraints during appointments. Patient-centered questionnaires have the potential to optimize communication by assessing a patient's pain history, prior treatments, and associated comorbidities to develop an effective treatment plan. This study aimed to analyze the feasibility and acceptability of a pre-visit clinical questionnaire aimed at improving communication and pain care. Patients and Methods: The "Pain Profile" questionnaire was piloted across two specialty pain clinics in a large academic medical center. Patient and provider surveys were conducted with patients who completed the Pain Profile questionnaire and providers who use it in practice. Surveys consisted of multiple-choice and open-ended questions regarding the helpfulness, usability, and implementation of the questionnaire. Descriptive analyses of patient and provider surveys were conducted. Qualitative data were analyzed using matrix framework-based coding. Results: A total of 171 patients and 32 clinical providers completed the feasibility and acceptability surveys. 77% of patients (N= 131) found the Pain Profile helpful in communicating their pain experiences and 69% of providers (N= 22) found it helpful in guiding clinical decisions. The section that assessed the impact of pain was rated most helpful by patients (4/5) while the open-ended section asking patients to describe their pain history was rated least helpful by patients and providers (3.7/5 and 4.1/5, respectively). Both patients and providers provided suggestions to future iterations of the Pain Profile, including the addition of opioid risk and mental health screening tools. Conclusion: The Pain Profile questionnaire was feasible and acceptable in a pilot study at a large academic site. Future testing in a large-scale, fully powered trial is needed to assess the effectiveness of the Pain Profile in optimizing communication and pain management.

Trends in Buprenorphine Initiation and Retention in the United States, 2016-2022.

This study uses data from an all-payer database of prescriptions dispensed in US retail pharmacies to assess trends in buprenorphine initiation and retention during 2016-2022.

Variation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis Codes.

BACKGROUND: Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. OBJECTIVE: (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. DESIGN: Longitudinal observational cohort study. PARTICIPANTS: National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. MAIN MEASURES: Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. KEY RESULTS: Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. CONCLUSIONS: Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population.

Factors associated with clinician treatment recommendations for patients with a new diagnosis of opioid use disorder.

BACKGROUND: This study examined factors associated with treatment recommendations for patients with a new diagnosis of opioid use disorder (OUD), comparing recommendations for patients with clear signs of OUD versus those with lower likelihood of OUD. METHODS: The study conducted a retrospective medical chart review in a randomly selected national sample of 520 Veteran Health Administration patients with a new opioid-related electronic health record (EHR) diagnosis from 2012 to 2017. The study categorized patients as having "high likelihood" or "lower likelihood of OUD" based on the presence or absence of clinician documentation in medical records of specific qualifying criteria (e.g., clinician documentation of patient meeting diagnostic criteria for OUD, etc). Analyses examined the association between baseline demographic and clinical characteristics with recommendations for medication and other treatments for OUD. RESULTS: Among patients with a new diagnosis of OUD, 28.7 % (n = 149) were recommended medication treatment, 52.5 % (n = 273) were recommended specialty substance use disorder (SUD) treatment, and 41.9 % (n = 218) were recommended treatment in non-SUD mental health settings. In adjusted models, high likelihood of OUD (AOR 8.31, 95 % CI 4.81-15.03) was strongly associated with the clinician recommending medications for OUD, while age 56-75 (compared to <35, AOR 0.36, 95 % CI 0.18-0.69), stimulant use disorder (AOR 0.28, 95 % CI 0.15-0.53), and rural residence (AOR 0.51, 95 % CI 0.30-0.85) were associated with lower likelihood of being recommended medication treatment. CONCLUSIONS: Differentiating among patients with EHR diagnoses of OUD to identify the subset with higher likelihood of underlying OUD is important to accurately understand OUD treatment rates and disparities. However, even among patients with a clear diagnosis of OUD, medication treatment is still recommended less often than other treatments, suggesting interventions are needed to encourage clinicians to prioritize medication treatment as a first-line treatment, especially for older, rural patients and those with polysubstance use.

Association of opioid exposure before surgery with opioid consumption after surgery.

OBJECTIVE: To determine the effect of prescription opioid use in the year before surgery on opioid consumption after surgery. BACKGROUND: Recently developed postoperative opioid prescribing guidelines rely on data from opioid-naïve patients. However, opioid use in the USA is common, and the impact of prior opioid exposure on the consumption of opioids after surgery is unclear. METHODS: Population-based cohort study of 26,001 adults 18 years of age and older who underwent one of nine elective general or gynecologic surgical procedures between January 1, 2017 and October 31, 2019, with prospectively collected patient-reported data from the Michigan Surgical Quality Collaborative (MSQC) linked to state prescription drug monitoring program at 70 MSQC-participating hospitals on 30-day patient-reported opioid consumption in oral morphine equivalents (OME) (primary outcome). RESULTS: Compared with opioid-naïve participants, opioid-exposed participants (26% of sample) consumed more prescription opioids after surgery (adjusted OME difference 12, 95% CI 10 to 14). Greater opioid exposure was associated with higher postoperative consumption in a dose-dependent manner, with chronic users reporting the greatest consumption (additional OMEs 32, 95% CI 21 to 42). However, for eight of nine procedures, 90% of opioid-exposed participants consumed ≤150 OMEs. Among those receiving perioperative prescriptions, opioid-exposed participants had higher likelihood of refill (adjusted OR 4.7, 95% CI 4.4 to 5.1), number of refills (adjusted incidence rate ratio 4.0, 95% CI 3.7 to 4.3), and average refill amount (adjusted OME difference 333, 95% CI 292 to 374)). CONCLUSIONS: Preoperative opioid use is associated with small increases in patient-reported opioid consumption after surgery for most patients, though greater differences exist for patients with chronic use. For most patients with preoperative opioid exposure, existing guidelines may meet their postoperative needs. However, guidelines may need tailoring for patients with chronic use, and providers should anticipate a higher likelihood of postoperative refills for all opioid-exposed patients.

Did prescribing laws disproportionately affect opioid dispensing to Black patients?

OBJECTIVE: To evaluate whether pain management clinic laws and prescription drug monitoring program (PDMP) prescriber check mandates, two state opioid policies with relatively rapid adoption across states, reduced opioid dispensing more or less in Black versus White patients. DATA SOURCES: Pharmacy claims data, US sample of commercially insured adults, 2007-2018. STUDY DESIGN: Stratifying by race, we used generalized estimating equations with an event-study specification to estimate time-varying effects of each policy on opioid dispensing, comparing to the four pre-policy quarters and states without the policy. Outcomes included high-dosage opioids, overlapping opioid prescriptions, concurrent opioid/benzodiazepines, opioids from >3 prescribers, opioids from >3 pharmacies. DATA EXTRACTION METHODS: We identified all prescription opioid dispensing to Black and White adults aged 18-64 without a palliative care or cancer diagnosis code. PRINCIPAL FINDINGS: Exactly 7,096,592 White and 1,167,310 Black individuals met inclusion criteria. Pain management clinic laws were associated with reductions in two outcomes; their association with high-dosage receipt was larger among White patients. In contrast, reductions due to PDMP mandates appeared limited to, or larger in, Black patients compared with White patients in four of five outcomes. For example, PDMP mandates reduced high-dosage receipt in Black patients by 0.7 percentage points (95% CI: 0.36-1.08 ppt.) over 4 years: an 8.4% decrease from baseline; there was no apparent effect in White patients. Similarly, while there was limited evidence that mandates reduced overlapping opioid receipt in White patients, they appeared to reduce overlapping opioid receipt in Black patients by 1.3 ppt. (95% CI: -1.66--1.01 ppt.) across post-policy years-a 14.4% decrease from baseline. CONCLUSIONS: PDMP prescriber check mandates but not pain management clinic laws appeared to reduce opioid dispensing more in Black patients than White patients. Future research should discern the mechanisms underlying these disparities and their consequences for pain management.

Patient Perspectives on Improving Patient-Provider Relationships and Provider Communication During Opioid Tapering.

BACKGROUND: Efforts to reduce opioid overdose fatalities have resulted in tapering (i.e., reducing or discontinuing) opioid prescriptions despite a limited understanding of patients' experiences. OBJECTIVE: To explore patients' perspectives on opioid taper experiences to ultimately improve taper processes and outcomes. DESIGN: Qualitative study. PARTICIPANTS: Patients on long-term opioid therapy for chronic pain who had undergone a reduction of opioid daily prescribed dosage of ≥50% in the past 2 years in two distinct medical systems and regions. APPROACH: From 2019 to 2020, we conducted semi-structured interviews that were audio-recorded, transcribed, systematically coded, and analyzed to summarize the content and identify key themes regarding taper experiences overall and with particular attention to patient-provider relationships and provider communication during tapers. KEY RESULTS: Participants (n=41) had lived with chronic pain for an average of 17.4 years (range, 3-36 years) and described generally adverse experiences with opioid tapers, the initiation of which was not always adequately justified or explained to them. Consequences of tapers ranged from minor to substantial and included withdrawal, mobility issues, emotional distress, exacerbated mental health symptoms, and feelings of social stigmatization for which adequate supports were typically unavailable. Narratives highlighted the consequential role of patient-provider relationships throughout taper experiences, with most participants describing significant interpersonal challenges including poor provider communication and limited patient engagement in decision making. A few participants identified qualities of providers, relationships, and communication that fostered more positive taper experiences and outcomes. CONCLUSIONS: From patients' perspectives, opioid tapers can produce significant physical, emotional, and social consequences, sometimes reducing trust and engagement in healthcare. Patient-provider relationships and communication influence patients' perceptions of the quality and outcomes of opioid tapers. To improve patients' experiences of opioid tapers, tapering plans should be based on individualized risk-benefit assessments and involve patient-centered approaches and improved provider communication.

Reasons for Preoperative Opioid Use Are Associated with Persistent Use following Surgery Among Patients Undergoing Total Knee and Hip Arthroplasty.

OBJECTIVE: Most studies on preoperative opioid use only describe whether or not patients use opioids without characterizing reasons for use. Knowing why patients use opioids can help inform perioperative opioid management. The objective of this study was to explore pain specific reasons for preoperative opioid use prior to total hip and knee arthroplasty (THA and TKA) and their association with persistent use. METHODS: This is a prospective study of 197 patients undergoing THA (n = 99) or TKA (n = 98) enrolled in the Analgesic Outcomes Study between December 2015 and November 2018. All participants reported preoperative opioid use. RESULTS: Reasons for preoperative opioid use were categorized as surgical site pain only (81 [41.1%]); pain in other body areas only (22 [11.2%]); and combined pain (94 [47.7%]). Compared to patients taking opioids for surgical site pain, those with combined reasons for use had 1.24 (P = .40) and 2.28 (P = .16) greater odds of persistent use at 3 and 6 months postoperatively, adjusting for relevant covariates. CONCLUSIONS: This study provides novel insights into the heterogeneity of reasons for presurgical opioid use in patients undergoing a THA or TKA. One key take away is that not all preoperative opioid use is the same and many patients are taking opioids preoperatively for more than just pain at the surgical site. Combined reasons for use was associated with long-term use, suggesting nonsurgical pain, in part, drives persistent opioid use after surgery. Future directions in perioperative care should focus on pain and non-pain reasons for presurgical opioid use to create tailored postoperative opioid weaning plans.