Preventing Opioid Misuse with Prescription Drug Monitoring Programs: A Framework for Evaluating the Success of State Public Health Laws

The United States is in the midst of a prescription opioid overdose and misuse epidemic. Although many factors have contributed to the escalation of prescription painkiller misuse, it parallels increases in the supply and prescribing of opioids. Prominent state-level regulatory interventions, such as the establishment of prescription drug monitoring programs (“PDMPs”), recognize prescribers as opioid gatekeepers. Prescribers, who are uniquely situated to distinguish between appropriate use and misuse of opioids, are a natural target for regulation. PDMPs also target patients who seek to obtain high volumes of prescription opioids for illicit purposes. PDMP policies are widespread but heterogeneous, largely uninformed by robust evidence or a systematic assessment of best practices. Whether these programs successfully reduce opioid misuse and overdoses remains unclear. As well, PDMPs present a number of legal and ethical challenges that, along with intervention effectiveness, warrant careful policymaker consideration going forward. This Article articulates and synthesizes for the first time key criteria intended to assist state regulators in dynamically evaluating and justifying PDMPs and other public health laws. The criteria focus on the legality of the policy, approaches to measure its effectiveness, and normative considerations that should be factored into good laws. Such a framework is crucial for policymakers given the complexities and magnitude of this public health challenge, the rich arsenal of policy options from which to choose, and the slow and uncertain progress in combating prescription painkiller misuse. Concluding recommendations include implementing PDMPs with the following features: timely and complete data, strong incentives for prescriber participation, user guidelines and education, integration into clinical work flow, and robust confidentiality and privacy protections. Ongoing evaluation of programs to identify features appropriate for retention and replication is also crucial if PDMPs are to fulfill their potential to curb prescription opioid overdose and misuse

Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants

Abstract Background Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder (OUD). Buprenorphine and methadone have the strongest evidence base among MOUDs. Unlike methadone, buprenorphine may be prescribed in office-based settings in the U.S., including by nurse practitioners (NPs) and physician assistants (PAs) who have a federal waiver and adhere to federal patient limits. Buprenorphine is underutilized nationally, particularly in rural areas, and NPs/PAs could help address this gap. Therefore, we sought to identify perceptions of buprenorphine efficacy and perceptions of prescribing barriers among NPs/PAs. We also sought to compare perceived buprenorphine efficacy and perceived prescribing barriers between waivered and non-waivered NPs/PAs, as well as to compare perceived buprenorphine efficacy to perceived naltrexone and methadone efficacy. Methods We disseminated an online survey to a random national sample of NPs/PAs. We used Mann–Whitney U tests to compare between waivered and non-waivered respondents. We used non-parametric Friedman tests and post-hoc Wilcoxon signed-rank tests to compare perceptions of medication types. Results 240 respondents participated (6.5% response rate). Most respondents agreed buprenorphine is efficacious and believed counseling and peer support should complement buprenorphine. Buprenorphine was generally perceived as more efficacious than both naltrexone and methadone. Perceived buprenorphine efficacy and prescribing barriers differed by waiver status. Non-waivered practitioners were more likely than waivered practitioners to have concerns about buprenorphine affecting patient mix. Among waivered NPs/PAs, key buprenorphine prescribing barriers were insurance prior authorization and detoxification access. Conclusions Our results suggest that different policies should target perceived barriers affecting waivered versus non-waivered NPs/PAs. Concerns about patient mix suggest stigmatization of patients with OUD. NP/PA education is needed about comparative medication efficaciousness, particularly regarding methadone. Even though many buprenorphine treatment patients benefits from counseling and/or peer support groups, NPs/PAs should be informed that such psychosocial treatment methods are not necessary for all buprenorphine patients.http://deepblue.lib.umich.edu/bitstream/2027.42/173175/1/13722_2022_Article_321.pd

A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder

Abstract Background Evidence demonstrates that medications for treating opioid use disorder (MOUD) —namely buprenorphine, methadone, and extended-release naltrexone—are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications. Methods To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods. Results Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers—such as a lack of addiction treatment specialists—as additional barriers to prescribing medications to treat OUD. Conclusions Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.http://deepblue.lib.umich.edu/bitstream/2027.42/173830/1/13011_2020_Article_312.pd

Prevalence and Predictors of Driving after Prescription Opioid Use in an Adult ED Sample

Introduction: Prescription opioid use and driving is a public health concern given the risks associated with drugged driving, but the issue remains under-studied. We examined the prevalence and correlates of driving after taking prescription opioids (DAPO) among adults seeking emergency department (ED) treatment.Methods: Participants (aged 25-60) seeking ED care at a Level I trauma center completed a computerized survey. Validated instruments measured prescription opioid use, driving behaviors, and risky driving. Patients who reported past three-month prescription opioid use and drove at least twice weekly were administered an extended study survey measuring DAPO, depression, pain, and substance use.Results: Among participants completing the screening survey (n = 756; mean age = 42.8 [standard deviation {SD} =10.4]), 37.8% reported past three-month prescription opioid use (30.8% of whom used daily), and 14.7% reported past three-month DAPO. Of screened participants, 22.5% (n = 170) were eligible for the extended study survey. Unadjusted analyses demonstrated that participants reporting DAPO were more likely to use opioids daily (51.1% vs 15.9%) and had higher rates of opioid misuse (mean Current Opioid Misuse Measure score 3.4 [SD = 3.8] vs 1.1 [SD = 2.1]) chronic pain (80.7% vs 42.7%), and driving after marijuana or alcohol use (mean intoxicated driving score 2.1 [SD = 1.3] vs 0.3 [SD = 0.8]) compared to patients not reporting DAPO (all p<0.001). Adjusting for age, gender, employment, and insurance in a logistic regression model, participants reporting DAPO were more likely to report a chronic pain diagnosis (odds ratio [OR] = 3.77, 95% confidence interval [CI], 1.55-9.17), daily opioid use (OR = 3.81, 95% CI, 1.64-8.85), and higher levels of intoxicated driving (OR = 1.62, 95% CI, 1.07-2.45). Alcohol and marijuana use, depression, and opioid misuse were not associated with DAPO in adjusted analyses.Conclusion: Nearly one in six adult patients seeking ED care reported DAPO. The ED may be an important site for interventions addressing opioid-related drugged driving