Opioid Prescribing

Evaluation of Interventions to Reduce Opioid Prescribing for Patients Discharged From the Emergency Department: A Systematic Review and Meta-analysis.

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Abstract

Importance: Limiting opioid overprescribing in the emergency department (ED) may be associated with decreases in diversion and misuse.

Objective: To review and analyze interventions designed to reduce the rate of opioid prescriptions or the quantity prescribed for pain in adults discharged from the ED.

Data Sources: MEDLINE, Embase, CINAHL, PsycINFO, and Cochrane Controlled Register of Trials databases and the gray literature were searched from inception to May 15, 2020, with an updated search performed March 6, 2021.

Study Selection: Intervention studies aimed at reducing opioid prescribing at ED discharge were first screened using titles and abstracts. The full text of the remaining citations was then evaluated against inclusion and exclusion criteria by 2 independent reviewers.

Data Extraction and Synthesis: Data were extracted independently by 2 reviewers who also assessed the risk of bias. Authors were contacted for missing data. The main meta-analysis was accompanied by intervention category subgroup analyses. All meta-analyses used random-effects models, and heterogeneity was quantified using I2 values.

Main Outcomes and Measures: The primary outcome was the variation in opioid prescription rate and/or prescribed quantity associated with the interventions. Effect sizes were computed separately for interrupted time series (ITS) studies.

Results: Sixty-three unique studies were included in the review, and 45 studies had sufficient data to be included in the meta-analysis. A statistically significant reduction in the opioid prescription rate was observed for both ITS (6-month step change, -22.61%; 95% CI, -30.70% to -14.52%) and other (odds ratio, 0.56; 95% CI, 0.45-0.70) study designs. No statistically significant reduction in prescribed opioid quantities was observed for ITS studies (6-month step change, -8.64%; 95% CI, -17.48% to 0.20%), but a small, statistically significant reduction was observed for other study designs (standardized mean difference, -0.30; 95% CI, -0.51 to -0.09). For ITS studies, education, policies, and guideline interventions (6-month step change, -33.31%; 95% CI, -39.67% to -26.94%) were better at reducing the opioid prescription rate compared with prescription drug monitoring programs and laws (6-month step change, -11.18%; 95% CI, -22.34% to -0.03%). Most intervention categories did not reduce prescribed opioid quantities. Insufficient data were available on patient-centered outcomes such as pain relief or patients’ satisfaction.

Conclusions and Relevance: This systematic review and meta-analysis found that most interventions reduced the opioid prescription rate but not the prescribed opioid quantity for ED-discharged patients. More studies on patient-centered outcomes and using novel approaches to reduce the opioid quantity per prescription are needed.

CMS Proposes Opioid Prescribing Limits for Medicare Enrollees

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Drug plans would implement ‘hard formulary levels’ at pharmacies

WASHINGTON — Pharmacies would have new limits on filling opioid prescriptions for Medicare beneficiaries under regulations proposed Thursday by the Centers for Medicare & Medicaid Services (CMS).

“We are proposing important new actions to reduce seniors’ risk of being addicted to or overdoing it on opioids while still having access to important treatment options,” said Demetrios Kouzoukas, CMS deputy administrator and director of the Center for Medicare, on a phone call with reporters. “We believe these actions will reduce the oversupply of opioids in our communities.”

Under the proposal, Part D plans would implement so-called “hard formulary levels” at pharmacies which would restrict the amount of opioids that beneficiaries could receive. “These are triggers … [that] can prompt conversations between physicians, patients, and plans about appropriate opioid use and prescribing,” Kouzoukas said. “The trigger can only be overridden by the plan sponsor after efforts to consult with the prescribing physician.” The safety level would be a 90 morphine-mg equivalent (MME) with a 7-day supply allowance.

The proposal also would limit the number of pills in an initial prescription for acute pain, “possibly with or without a daily dose maximum,” he said, adding that CMS is accepting comments on the proposals through March 5. In addition, CMS “expects sponsors to implement ‘soft’ safety edits” to flag a potential problem, although those could be overridden by the pharmacist.

CMS “is also enhancing [our] very successful opioid utilization monitoring system by adding flags for beneficiaries who use certain drugs in combination with prescription opioids,” said Kouzoukas. “And we’re considering a new measure on the concurrent use of opioids and benzodiazepines. We believe these measures are important to … safeguard the health and safety of our nation’s seniors.”

These actions are part of the agency’s effort “to end the scourge of the opioid epidemic” in response to a call to do so by President Trump, he said. CMS’s opioid utilization monitoring system “is already successful in reducing the risk of overprescribing of opioids in the Part D program.” The agency made other proposals last November, including one allowing plans to limit beneficiaries’ access to opioids by having them go through only a selected prescriber and selected pharmacies, Kouzoukas said.

CMS also announced several other proposals in its Medicare Advantage call letter Thursday, including a new star rating for statin use among patients with diabetes or cardiovascular disease, and the inclusion of certain additional supplemental health benefits for Medicare Advantage enrollees if the benefits would compensate for physical impairments or reduce emergency department utilization.