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Examining Medicare Prescribing of Painkillers

Examining Medicare Prescribing of Painkillers

According to published data, there has been a 10-fold increase in the misuse of opioid painkillers in the United States over the past 2 decades. Questions remain, however, about the causes that are driving this trend. “Some researchers and experts have suggested that small groups of high-volume prescribers working in so-called ‘pill mills’ are among the main reasons for the opioid overdose epidemic in the U.S.,” explains Anna Lembke, MD. “Despite this belief, opioid overprescribing is more than just a problem of a small group of high-volume prescribers,” adds Dr. Lembke.   Taking a Closer Look In a research letter published in JAMA Internal Medicine, Dr. Lembke and colleagues examined data from individual prescribers using the 2013 Medicare Part D claims data set created by CMS. Medicare data provide the opportunity to address the issue of opioid prescribing patterns across the nation. Medicare Part D covers about 68% of the roughly 50 million people on Medicare. For the more than 800,000 prescribers assessed in the study, data were examined on each drug prescribed, the total number of claims, and total costs. Data were available on both location and specialty of practice, and represented nearly 1.2 billion claims for approximately $81 billion. The analysis focused on schedule II opioid prescriptions containing hydrocodone, oxycodone, fentanyl, morphine, methadone, hydromorphone, oxymorphone, meperidine, codeine, opium, or levorphanol. The authors then calculated the cumulative claims for schedule II opioids from the top individual prescribers relative to the total claims for all prescribers. For comparisons, this exercise was repeated for prescription costs, for all drugs, and for each state.   Important Trends The study showed that the largest...
Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.   Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.   Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...
“Doctor Shopping” After Orthopedic Trauma

“Doctor Shopping” After Orthopedic Trauma

Recent reports have shown that the negative consequences of narcotic use are increasing, and diversion of these drugs for non-medical use is growing, with Americans consuming about 80% of the global opioid supply and 99% of the global hydrocodone supply. There has been an alarming rise in unintentional overdose deaths in the United States over the past decade due largely from increases in prescriptions of narcotics. It has been estimated that up to 20% of prescription drug abusers receive their narcotics from one physician prescriber, but a growing percentage obtain these medications by seeking multiple providers, a phenomenon dubbed “doctor shopping.” Few studies, however, have looked at narcotic use in patients who have experienced orthopedic trauma. While some investigations have focused their attention on positive toxicology screenings at the time of admission after orthopedic trauma, there is limited research exploring the impact of postoperative doctor shopping and the role of orthopedic surgeons in this phenomenon. “It has been suspected that many orthopedic trauma patients may be at a higher risk for pre-injury narcotic use and doctor shopping,” says Hassan R. Mir, MD, MBA, FACS. Exploring the Problem Dr. Mir, Brent J. Morris, MD, and colleagues sought to identify the prevalence of patients who have had orthopedic traumas and were seeking multiple providers for narcotics after surgery in a study published in the Journal of Bone and Joint Surgery. For the analysis, the researchers reviewed prescription records for 151 adults who were admitted to an orthopedic unit over a 1-year period and assessed data on narcotic prescriptions obtained 3 months before and within 6 months after each orthopedic procedure. Patients...
Managing Pain in Obese ED Patients

Managing Pain in Obese ED Patients

Weight-based dosing of opioids is a commonly used approach for managing patients who present to the ED with more severe pain. “Many patients who present to the ED with pain are obese or morbidly obese,” says Asad E. Patanwala, PharmD. “Heavier patients often receive larger total doses of opioids when compared with normal weight individuals. This can potentially increase the risk of serious adverse events.” He adds that morphine is one of the most commonly used opioids in EDs, but data on morphine dosing are limited among obese individuals. Studies are needed to evaluate the analgesic response to morphine, especially in patients with very high BMIs. Comparing Analgesic Responses In a study published in the Emergency Medicine Journal, Dr. Patanwala and colleagues retrospectively reviewed 300 consecutive patients who received intravenous morphine (4 mg) for pain. Patients were categorized into three groups based on their BMI: non-obese, obese, and morbidly obese. The authors then compared analgesic responses to morphine in the three groups. “Our primary goal was to see if patient weight really matters with regard to analgesic response to morphine,” Dr. Patanwala says. Using a scale of 0 being no pain and 10 being worst possible pain, the median baseline pain scores were 8.5, 8.0, and 8.5 in the non-obese, obese, and morbidly obese groups, respectively. The median analgesic response after morphine administration was 2.0, 3.0, and 2.0 in the non-obese, obese, and morbidly obese groups, respectively. In a linear regression analysis, BMI was not predictive of analgesic response. The analgesic response to a fixed dose of morphine did not appear to change as a function of BMI, says...

Drug Wars in the Exam Room

As physicians, we have all been faced with patients inappropriately looking for prescriptions for controlled substances. Some are looking to abuse them and some to divert them for profit. It is often hard to distinguish when a patient truly needs these medications or when they are just “drug-seeking.” More experienced doctors have a better sense of which patients are which. Drug-seeking patients often play on our emotions because they know we generally care about patients and may have difficulty turning down a request for opioids from someone in supposed pain. For years, patients have used many ruses to access these medications. Many of them “doctor shop,” use several pharmacies, or frequent various emergency rooms, making it difficult to track their prescriptions. And it’s much harder for a doctor to turn down a request from a new patient in acute pain than from one the doctor knows well and doubts. Having so many controlled substances available and sold on the streets has led to an increase in prescription drug dependency. These patients have a hard time breaking these addictions and often can only stop with help from special rehab programs. It has led to a further resurgence of IV heroin addiction and opioid deaths in many areas. As the states have tightened controlled substance prescriptions, they have become less available for diversion and are now a gateway drug to heroin—which is cheaper than prescribed medications. I am seeing teens in my practice addicted to IV heroin, a habit that started by raiding parents’ or relatives’ medicine cabinets. It has never been more imperative for doctors to step up and do...
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