Effects of U.S. State Medical Cannabis Laws on Treatment of Chronic Noncancer Pain.

BACKGROUND: State medical cannabis laws may lead patients with chronic noncancer pain to substitute cannabis in place of prescription opioid or clinical guideline-concordant nonopioid prescription pain medications or procedures. OBJECTIVE: To assess effects of state medical cannabis laws on receipt of prescription opioids, nonopioid prescription pain medications, and procedures for chronic noncancer pain. DESIGN: Using data from 12 states that implemented medical cannabis laws and 17 comparison states, augmented synthetic control analyses estimated laws' effects on receipt of chronic noncancer pain treatment, relative to predicted treatment receipt in the absence of the law. SETTING: United States, 2010 to 2022. PARTICIPANTS: 583 820 commercially insured adults with chronic noncancer pain. MEASUREMENTS: Proportion of patients receiving any opioid prescription, nonopioid prescription pain medication, or procedure for chronic noncancer pain; volume of each treatment type; and mean days' supply and mean morphine milligram equivalents per day of prescribed opioids, per patient in a given month. RESULTS: In a given month during the first 3 years of law implementation, medical cannabis laws led to an average difference of 0.05 percentage points (95% CI, -0.12 to 0.21 percentage points), 0.05 percentage points (CI, -0.13 to 0.23 percentage points), and -0.17 percentage points (CI, -0.42 to 0.08 percentage points) in the proportion of patients receiving any opioid prescription, any nonopioid prescription pain medication, or any chronic pain procedure, respectively, relative to what we predict would have happened in that month had the law not been implemented. LIMITATIONS: This study used a strong nonexperimental design but relies on untestable assumptions involving parallel counterfactual trends. Statistical power is limited by the finite number of states. Results may not generalize to noncommercially insured populations. CONCLUSION: This study did not identify important effects of medical cannabis laws on receipt of opioid or nonopioid pain treatment among patients with chronic noncancer pain. PRIMARY FUNDING SOURCE: National Institute on Drug Abuse.

Impact of High Deductible Health Plans on U.S. Adults With Chronic Pain.

INTRODUCTION: Chronic pain affects an estimated 20% of U.S. adults. Because high-deductible health plans have captured a growing share of the commercial insurance market, it is unknown how high-deductible health plans impact care for chronic pain. METHODS: Using 2007-2017 claims data from a large national commercial insurer, statistical analyses conducted in 2022-2023 estimated changes in enrollee outcomes before and after their firm began offering a high-deductible health plan compared with changes in outcomes in a comparison group of enrollees at firms never offering a high-deductible health plan. The sample included 757,530 commercially insured adults aged 18-64 years with headache, low back pain, arthritis, neuropathic pain, or fibromyalgia. Outcomes, measured at the enrollee year level, included the probability of receiving any chronic pain treatment, nonpharmacologic pain treatment, and opioid and nonopioid prescriptions; the number of nonpharmacologic pain treatment days; number and days' supply of opioid and nonopioid prescriptions; and total annual spending and out-of-pocket spending. RESULTS: High-deductible health plan offer was associated with a 1.2 percentage point reduction (95% CI= -1.8, -0.5) in the probability of any chronic pain treatment and an $11 increase (95% CI=$6, $15) in annual out-of-pocket spending on chronic pain treatments among those with any use, representing a 16% increase in average annual out-of-pocket spending over the pre-high deductible health plan offer annual average. Results were driven by changes in nonpharmacologic treatment use. CONCLUSIONS: By reducing the use of nonpharmacologic chronic pain treatments and marginally increasing out-of-pocket costs among those using these services, high-deductible health plans may discourage more holistic, integrated approaches to caring for patients with chronic pain conditions.

Protocol: mixed-methods study of how implementation of US state medical cannabis laws affects treatment of chronic non-cancer pain and adverse opioid outcomes.

BACKGROUND: Thirty-three US states and Washington, D.C., have enacted medical cannabis laws allowing patients with chronic non-cancer pain to use cannabis, when recommended by a physician, to manage their condition. However, clinical guidelines do not recommend cannabis for treatment of chronic non-cancer pain due to limited and mixed evidence of effectiveness. How state medical cannabis laws affect delivery of evidence-based treatment for chronic non-cancer pain is unclear. These laws could lead to substitution of cannabis in place of clinical guideline-discordant opioid prescribing, reducing risk of opioid use disorder and overdose. Conversely, state medical cannabis laws could lead to substitution of cannabis in place of guideline-concordant treatments such as topical analgesics or physical therapy. This protocol describes a mixed-methods study examining the implementation and effects of state medical cannabis laws on treatment of chronic non-cancer pain. A key contribution of the study is the examination of how variation in state medical cannabis laws' policy implementation rules affects receipt of chronic non-cancer pain treatments. METHODS: The study uses a concurrent-embedded design. The primary quantitative component of the study employs a difference-in-differences design using a policy trial emulation approach. Quantitative analyses will evaluate state medical cannabis laws' effects on treatment for chronic non-cancer pain as well as on receipt of treatment for opioid use disorder, opioid overdose, cannabis use disorder, and cannabis poisoning among people with chronic non-cancer pain. Secondary qualitative and survey methods will be used to characterize implementation of state medical cannabis laws through interviews with state leaders and representative surveys of physicians who treat, and patients who experience, chronic non-cancer pain in states with medical cannabis laws. DISCUSSION: This study will examine the effects of medical cannabis laws on patients' receipt of guideline-concordant non-opioid, non-cannabis treatments for chronic non-cancer pain and generate new evidence on the effects of state medical cannabis laws on adverse opioid outcomes. Results will inform the dynamic policy environment in which numerous states consider, enact, and/or amend medical cannabis laws each year.

Coverage of Nonpharmacologic Treatments for Low Back Pain Among US Public and Private Insurers.

Importance: Despite epidemic rates of addiction and death from prescription opioids in the United States, suggesting the importance of providing alternatives to opioids in the treatment of pain, little is known regarding how payers' coverage policies may facilitate or impede access to such treatments. Objective: To examine coverage policies for 5 nonpharmacologic approaches commonly used to treat acute or chronic low back pain among commercial and Medicare Advantage insurance plans, plus an additional 6 treatments among Medicaid plans. Design, Setting, and Participants: Cross-sectional study of 15 commercial, 15 Medicaid, and 15 Medicare Advantage health plans for the 2017 calendar year in 16 states representing more than half of the US population. Interviews were conducted with 43 senior medical and pharmacy health plan executives from representative plans. Main Outcomes and Measures: Medical necessity and coverage status for the treatments examined, as well as the use of utilization management tools and cost-sharing magnitude and structure. Results: Commercial and Medicare insurers consistently regarded physical and occupational therapy as medically necessary, but policies varied for other therapies examined. Payers most commonly covered physical therapy (98% [44 of 45 plans]), occupational therapy (96% [43 of 45 plans]), and chiropractic care (89% [40 of 45 plans]), while transcutaneous electrical nerve stimulation (67% [10 of 15 plans]) and steroid injections (60% [9 of 15 plans]) were the most commonly covered among the therapies examined for Medicaid plans only. Despite evidence in the literature to support use of acupuncture and psychological interventions, these therapies were either not covered by plans examined (67% of all plans [30 of 45] did not cover acupuncture) or lacked information about coverage (80% of Medicaid plans [12 of 15] lacked information about coverage of psychological interventions). Utilization management tools, such as prior authorization, were common, but criteria varied greatly with respect to which conditions and what quantity and duration of services were covered. Interviewees represented 6 Medicaid managed care organizations, 2 Medicare Advantage or Part D plans, 9 commercial plans, and 3 trade organizations (eg, Blue Cross Blue Shield Association). Interviews with plan executives indicated a low level of integration between the coverage decision-making processes for pharmacologic and nonpharmacologic therapies for chronic pain. Conclusions and Relevance: Wide variation in coverage of nonpharmacologic treatments for low back pain may be driven by the absence of best practices, the administrative complexities of developing and revising coverage policies, and payers' economic incentives. Such variation suggests an important opportunity to improve the accessibility of services, reduce opioid use, and ultimately improve the quality of care for individuals with chronic, noncancer pain while alleviating the burden of opioid addiction and overdose.