ERCP performed through previously placed duodenal stents: a multicenter retrospective study of outcomes and adverse events.

BACKGROUND AND AIMS: ERCP performed through previously placed enteral stents is an uncommon procedure without a significant amount of supporting literature and with a wide reported range of technical success. The purpose of this study was to evaluate and better define the technical feasibility and safety of performing ERCP through enteral stents in patients with combined malignant biliary and gastric outlet obstruction. METHODS: We conducted a multicenter, retrospective study on 71 patients with combined gastric outlet and biliary obstruction who underwent ERCP through a previously placed enteral stent at 2 tertiary care centers. Outcomes included but were not limited to technical success, clinical success, need for repeat ERCP, adverse events, and survival time. RESULTS: Overall technical success was achieved in 60 of 71 patients (85%), with technical success of 40 of 46 (87%) in type I obstructions (gastric outlet obstruction above the ampulla), 16 of 21 (76%) in type II obstructions (gastric outlet obstruction at the level of the ampulla), and 4 of 4 (100%) in type III obstructions (gastric outlet obstruction distal to the ampulla). In general, patients who achieved technical success also achieved clinical success. Adverse events occurred in 3 patients (3/71): 2 patients with acute cholangitis and 1 patient with perforation. Average survival time after the procedure was 4.6 months overall. CONCLUSIONS: ERCP performed through enteral stents is safe, with a high technical and clinical success rate, but may be more technically challenging in the setting of type II obstructions. This procedure could be considered first line in the unique setting that a patient requires ERCP through a previously placed enteral stent for malignant gastric outlet and biliary obstruction.

Declines in Opioid Prescribing After a Private Insurer Policy Change - Massachusetts, 2011-2015.

Overdose deaths involving opioid pain medications are epidemic in the United States, in part because of high opioid prescribing rates and associated abuse of these drugs (1). In 2014, nearly 2 million U.S. residents either abused or were dependent on prescription opioids (2). In Massachusetts, unintentional opioid-related overdose deaths, including deaths involving heroin, increased 45% from 2012 to 2013.* In 2014, the rate of these deaths reached 20.0 per 100,000, nearly 2.5 times higher than the U.S. rate overall (3,4). On July 1, 2012, Blue Cross Blue Shield of Massachusetts (BCBSMA), the largest insurer in the state with approximately 2.8 million members,† implemented a comprehensive opioid utilization program after learning that many of its members were receiving new prescriptions with a >30-day supply of opioids. The 2016 CDC Guideline for Prescribing Opioids for Chronic Pain recommends avoiding opioids as a first-line therapy for chronic pain and limiting quantities when initiating opioids for acute pain (5). CDC analyzed BCBSMA prescription claims data for the period 2011-2015 to assess the effect of the new utilization program on opioid prescribing rates. During the first 3 years after policy implementation, the average monthly prescribing rate for opioids decreased almost 15%, from 34 per 1,000 members to 29. The percentage of BCBSMA members per month with current opioid prescriptions also declined. The temporal association between implementation of the program and statistically significant declines in both prescribing rates and proportion of members using opioids suggests that the BCBSMA initiative played a role in reducing the use of prescription opioids among its members. Public and private insurers in the United States could benefit from developing their own best practices for prescription opioid utilization that ensure accessible pain care, while reducing the risk for dependence and abuse associated with these drugs.