Discontinuation of Buprenorphine Treatment for Opioid Use Disorder During the Coronavirus Disease-2019 Pandemic: A Multilevel Framework.

BACKGROUND: The coronavirus disease-2019 pandemic has been associated with large increases in opioid-related mortality, yet it is unclear whether specific subpopulations were especially likely to discontinue buprenorphine treatment for opioid use disorder as the pandemic ensued. OBJECTIVE: The aim was to assess predictors of buprenorphine discontinuation in the early months of the coronavirus disease-2019 pandemic (April-July 2020) compared with a prepandemic period (April-July 2019). DESIGN: In each time period, we estimated a multilevel regression models to assess risk of discontinuation in April-July for people who started buprenorphine in January-February. Models included person-level, prescriber-level, and area-level covariates. SUBJECTS: Individuals age 18 years or older in the all-payer IQVIA Longitudinal Prescription Claims. MEASURES: The primary outcome was buprenorphine discontinuation (ie, no filled prescriptions during the follow-up periods). RESULTS: Overall, 13.98% of patients discontinued buprenorphine in April-July 2020, less than the 15.71% in 2019 (P<0.001). In 2020, patient-level factors associated with discontinuation included younger age, male sex, shorter baseline possession ratio, and payment by cash. Compared with patients with a primary care physician prescriber, specialties most associated with discontinuation were pain medicine and physician assistant/nurse practitioner. Compared with the South Atlantic region, discontinuation risk was lowest in New England and highest in the West South Central States. The association between patient, prescriber, and geographic variables to risk of discontinuation was very similar in 2019 and 2020. CONCLUSIONS: While clinical and policy interventions may have mitigated opioid use disorder treatment discontinuation following the pandemic, such discontinuation is nevertheless common and varies by identifiable patient, provider and geographic factors.

Effect of Direct-to-Consumer Advertising on Statin Use in the United States.

IMPORTANCE: The value of direct-to-consumer advertising (DTCA) of prescription drugs is widely debated, as is the effect of DTCA on prescription sales and health care utilization. OBJECTIVE: We examined the association between DTCA intensity for statin medications and prescription sales and cholesterol-related health care utilization. DESIGN, SETTING, AND PARTICIPANTS: We conducted an ecological study for 75 designated market areas from 2005 to 2009 in the United States using linked data regarding televised DTCA volume, non-DTCA marketing and promotion, retail, mail order and long-term care prescription drug sales, prescription drug and ambulatory care health care utilization, and contextual factors such as health care density and socioeconomic status. Main outcomes and measures were volume of sales, number of dispensed prescriptions, and high cholesterol-related outpatient visits. Analyses were conducted in 2016. RESULTS: The intensity of rosuvastatin and atorvastatin ad exposures per household varied substantially across designated market areas. After adjustment for socioeconomic, demographic, and clinical characteristics, each 100-unit increase in advertisement viewership was associated with a 2.22% [95% confidence interval (CI), 0.30%-4.19%] increase in statin sales. Similar patterns were observed between DTCA and statin dispensing among the commercially insured. DTCA was associated with increases in high cholesterol-related outpatient visits among adults 18-45 years of age (3.15% increase in visits per 100-unit increase in viewership, 95% CI, 0.98%-5.37%) but not among those 46-65 years of age (0.51%, 95% CI, -1.49% to 2.55%). CONCLUSION: DTCA for statins is associated with increases in statin utilization and hyperlipidemia-related outpatient visits, especially for young adults.

Impact of abuse-deterrent OxyContin on prescription opioid utilization.

PURPOSE: We quantified the degree to which the August 2010 reformulation of abuse-deterrent OxyContin affected its use, as well as the use of alternative extended-release and immediate-release opioids. METHODS: We used the IMS Health National Prescription Audit, a nationally representative source of prescription activity in the USA, to conduct a segmented time-series analysis of the use of OxyContin and other prescription opioids. Our primary time period of interest was 12 months prior to and following August 2010. We performed model checks and sensitivity analyses, such as adjusting for marketing and promotion, using alternative lag periods, and adding extra observation points. RESULTS: OxyContin sales were similar before and after the August 2010 reformulation, with approximately 550 000 monthly prescriptions. After adjusting for declines in the generic extended-release oxycodone market, the formulation change was associated with a reduction of approximately 18 000 OxyContin prescription sales per month (p = 0.02). This decline corresponded to a change in the annual growth rate of OxyContin use, from 4.9% prior to the reformulation to -23.8% during the year after the reformulation. There were no statistically significant changes associated with the sales of alternative extended-release (p = 0.42) or immediate-release (p = 0.70) opioids. Multiple sensitivity analyses supported these findings and their substantive interpretation. CONCLUSIONS: The market debut of abuse-deterrent OxyContin was associated with declines in its use after accounting for the simultaneous contraction of the generic extended-release oxycodone market. Further scrutiny into the effect of abuse-deterrent formulations on medication use and health outcomes is vital given their popularity in opioid drug development.

Development of a Social Risk Score in the Electronic Health Record to Identify Social Needs Among Underserved Populations: Retrospective Study.

BACKGROUND: Patients with unmet social needs and social determinants of health (SDOH) challenges continue to face a disproportionate risk of increased prevalence of disease, health care use, higher health care costs, and worse outcomes. Some existing predictive models have used the available data on social needs and SDOH challenges to predict health-related social needs or the need for various social service referrals. Despite these one-off efforts, the work to date suggests that many technical and organizational challenges must be surmounted before SDOH-integrated solutions can be implemented on an ongoing, wide-scale basis within most US-based health care organizations. OBJECTIVE: We aimed to retrieve available information in the electronic health record (EHR) relevant to the identification of persons with social needs and to develop a social risk score for use within clinical practice to better identify patients at risk of having future social needs. METHODS: We conducted a retrospective study using EHR data (2016-2021) and data from the US Census American Community Survey. We developed a prospective model using current year-1 risk factors to predict future year-2 outcomes within four 2-year cohorts. Predictors of interest included demographics, previous health care use, comorbidity, previously identified social needs, and neighborhood characteristics as reflected by the area deprivation index. The outcome variable was a binary indicator reflecting the likelihood of the presence of a patient with social needs. We applied a generalized estimating equation approach, adjusting for patient-level risk factors, the possible effect of geographically clustered data, and the effect of multiple visits for each patient. RESULTS: The study population of 1,852,228 patients included middle-aged (mean age range 53.76-55.95 years), White (range 324,279/510,770, 63.49% to 290,688/488,666, 64.79%), and female (range 314,741/510,770, 61.62% to 278,488/448,666, 62.07%) patients from neighborhoods with high socioeconomic status (mean area deprivation index percentile range 28.76-30.31). Between 8.28% (37,137/448,666) and 11.55% (52,037/450,426) of patients across the study cohorts had at least 1 social need documented in their EHR, with safety issues and economic challenges (ie, financial resource strain, employment, and food insecurity) being the most common documented social needs (87,152/1,852,228, 4.71% and 58,242/1,852,228, 3.14% of overall patients, respectively). The model had an area under the curve of 0.702 (95% CI 0.699-0.705) in predicting prospective social needs in the overall study population. Previous social needs (odds ratio 3.285, 95% CI 3.237-3.335) and emergency department visits (odds ratio 1.659, 95% CI 1.634-1.684) were the strongest predictors of future social needs. CONCLUSIONS: Our model provides an opportunity to make use of available EHR data to help identify patients with high social needs. Our proposed social risk score could help identify the subset of patients who would most benefit from further social needs screening and data collection to avoid potentially more burdensome primary data collection on all patients in a target population of interest.

Novel population-level proxy measures for suboptimal HIV preexposure prophylaxis initiation and persistence in the USA.

OBJECTIVE: In the United States (USA), HIV preexposure prophylaxis (PrEP) use is suboptimal. Population-level metrics on PrEP use are limited and focus on prescriptions issued rather than how much prescriptions are picked up. We introduce PrEP reversals, defined as when patients fail to pick up PrEP prescriptions at the pharmacy point-of-sale, as a proxy for PrEP initiation and persistence. DESIGN: We analysed PrEP pharmacy claims and HIV diagnoses from a Symphony Health Solutions dataset across all US states from 1 October 2015 to 30 September 2019. METHODS: We calculated the percentage of individuals who were newly prescribed PrEP and who reversed (i.e. patient did not pick up an insurance-approved prescription and pharmacy withdrew the claim), delayed (reversed and then picked up within 90 days), very delayed (reversed and then picked up between 90 and 365 days) or abandoned (not picked up within 365 days), and subsequent HIV diagnosis within 365 days. RESULTS: Of 59 219 individuals newly prescribed PrEP, 19% reversed their index prescription. Among those, 21% delayed initiation and 8% had very delayed initiation. Seventy-one percent of patients who reversed their initial prescription abandoned it, 6% of whom were diagnosed with HIV---three times higher than those who persisted on PrEP. CONCLUSION: Nearly one in five patients newlyprescribed PrEP reversed initial prescriptions, leading to delayed medication access, being lost to PrEP care, and dramatically higher HIV risk. Reversals could be used for real-time nationwide PrEP population-based initiation and persistence tracking, and for identifying patients that might otherwise be lost to care.

Ambulatory specialist use by nonhospitalized patients in us health plans: correlates and consequences.

Approximately 7 of 10 (and 95% of the elderly) people in US health plans see one or more specialists in a year. Controlling for extent of morbidity, discontinuity of primary care physician visits is associated with seeing more different specialists. Having a general internist as the primary care physician is associated with more different specialists seen. Controlling for differences in the degree of morbidity, receiving care from multiple specialists is associated with higher costs, more procedures, and more medications, independent of the number of visits and age of the patient.

Effect of Florida's Prescription Drug Monitoring Program and Pill Mill Laws on Opioid Prescribing and Use.

IMPORTANCE: Prescription Drug Monitoring Program (PDMP) and pill mill laws are among the principal means states use to reduce prescription drug abuse and diversion, yet little high-quality evidence exists regarding their effect. OBJECTIVE: To quantify the effect of Florida's PDMP and pill mill laws on overall and high-risk opioid prescribing and use. DESIGN, SETTING, AND PARTICIPANTS: We applied comparative interrupted time-series analyses to IMS Health LifeLink LRx data to characterize the effect of PDMP and pill mill law implementation on a closed cohort of prescribers, retail pharmacies, and patients from July 2010 through September 2012 in Florida (intervention state) compared with Georgia (control state). We conducted sensitivity analyses, including varying length of observation and modifying requirements for continuous observation of individuals throughout the study period. MAIN OUTCOMES AND MEASURES: Total opioid volume, mean morphine milligram equivalent (MME) per transaction, mean days' supply per transaction, and total number of opioid prescriptions dispensed. Analyses were conducted per prescriber and per patient, in aggregate and after stratifying by volume of baseline opioid prescribing for prescribers and use for patients. RESULTS: From July 2010 through September 2012, a cohort of 2.6 million patients, 431,890 prescribers, and 2829 pharmacies was associated with approximately 480 million prescriptions in Florida and Georgia, 7.7% of which were for opioids. Total monthly opioid volume, MME per transaction, days' supply, and prescriptions dispensed were higher in Florida than Georgia before implementation. Florida's laws were associated with statistically significant declines in opioid volume (2.5 kg/mo, P<.05; equivalent to approximately 500,000 5-mg tablets of hydrocodone bitartrate per month) and MME per transaction (0.45 mg/mo, P<.05), without any change in days' supply. Twelve months after implementation, the policies were associated with approximately a 1.4% decrease in opioid prescriptions, 2.5% decrease in opioid volume, and 5.6% decrease in MME per transaction. Reductions were limited to prescribers and patients with the highest baseline opioid prescribing and use. Sensitivity analyses, varying time windows, and enrollment criteria supported the main results. CONCLUSIONS AND RELEVANCE: Florida's PDMP and pill mill laws were associated with modest decreases in opioid prescribing and use. Decreases were greatest among prescribers and patients with the highest baseline opioid prescribing and use.