Opioid Prescribing to Medicare Part D Enrollees, 2013-2017: Shifting Responsibility to Pain Management Providers.

OBJECTIVE: To examine opioid prescribing frequency and trends to Medicare Part D enrollees from 2013 to 2017 by medical specialty and provider type. METHODS: We conducted a retrospective, cross-sectional, specialty- and provider-level analysis of Medicare Part D prescriber data for opioid claims from 2013 to 2017. We analyzed opioid claims and prescribing trends for specialties accounting for ≥1% of all opioid claims. RESULTS: From 2013 to 2017, pain management providers increased Medicare Part D opioid claims by 27.3% to 1,140 mean claims per provider in 2017; physical medicine and rehabilitation providers increased opioid claims 16.9% to 511 mean claims per provider in 2017. Every other medical specialty decreased opioid claims over this period, with emergency medicine (-19.9%) and orthopedic surgery (-16.0%) dropping opioid claims more than any specialty. Physicians overall decreased opioid claims per provider by -5.2%. Meanwhile, opioid claims among both dentists (+5.6%) and nonphysician providers (+10.2%) increased during this period. CONCLUSIONS: From 2013 to 2017, pain management and PMR increased opioid claims to Medicare Part D enrollees, whereas physicians in every other specialty decreased opioid prescribing. Dentists and nonphysician providers also increased opioid prescribing. Overall, opioid claims to Medicare Part D enrollees decreased and continue to drop at faster rates.

Distal intramural urethral pathology in women.

PURPOSE: We reviewed the evaluation of distal intramural urethral pathology in women and its management using urethral dilation and general anesthesia. MATERIALS AND METHODS: After receiving institutional review board approval we reviewed consecutive charts of women who underwent urethral dilation under general anesthesia for distal intramural urethral pathology. The pathological condition was defined as bothersome lower urinary tract symptoms with distal urethral narrowing and proximal ballooning on lateral voiding cystourethrogram. Patients with extramural, intraluminal or nondistal urethral pathology or neurogenic bladder were excluded from study. Success was defined as complete or major lower urinary tract symptom improvement 6 months after 1 urethral dilation using general anesthesia and no need for a repeat or another procedure. RESULTS: Eight of 101 cases (8%) reviewed between 1998 and 2010 were lost to followup at less than 6 months. Of the remaining 93 patients with a mean ± SD age of 52 ± 16 years and a mean followup of 46 ± 37 months 47 (51%) were classified as success. The failure group had a mean age of 50 ± 16 years and a mean time to failure of 8 ± 12 months. A history of urethral dilation was more common in the failure group (17% vs 39% cases, p = 0.02). CONCLUSIONS: Urethral dilation using general anesthesia is effective in some women with distal intramural urethral pathology diagnosed after extensive evaluation, including imaging and urodynamics. Distal intramural urethral pathology is a rare entity and these results are not applicable to women with nonspecific lower urinary tract symptoms.