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Stopping Opioid Addiction At One Key Source: The Hospital

It may not be rocket science, but a group of surgeons at the University of Michigan’s Michigan Medicine have devised a strategy to curb the nation’s opioid epidemic — starting at their own hospital.

Their findings appeared online Wednesday in the journal JAMA Surgery.

Opioid addiction has been deemed a “national emergency.” It’s estimated to have claimed 64,000 lives in 2016 alone. And research shows that post-surgical patients are at an increased risk of addiction because of the medication they receive to help manage pain during recovery.

It’s a simple enough idea: Surgeons should give patients fewer pills after surgery — the time when many people are first introduced to what can be highly addictive painkillers. They should also talk to patients about the proper use of opioids and the associated risks.

That seemingly small intervention could lead to significant changes in how opioids are prescribed and make inroads against the current epidemic, said the researchers.

“The way we’ve been prescribing opioids until this point is we’ve basically been taking a guess at how much patients would need,” said Jay Lee, a research fellow and general surgery resident at the University of Michigan, and one of the paper’s authors. “We’re trying to prevent addiction and misuse by making sure patients themselves who are receiving opioids know how to use them more safely — that they are getting a more consistent amount and one that will reduce the risk of them getting addicted.”

The researchers identified 170 patients who underwent gallbladder surgery and surveyed them within a year of the operation — asking how many pills they actually used, what pain they experienced after surgery and whether they had used other painkillers, such as ibuprofen.

They used those findings to create new hospital guidelines that cut back the standard opioid prescription for gallbladder surgeries.

Then, they analyzed how patients fared under the new guidelines, tracking 200 new surgery patients who received substantially fewer pills — an average of 75 milligrams, compared with 250 mg previously. Despite getting less medication, patients didn’t report higher levels of pain, and they were no more likely than the previously studied patients to ask for prescription refills. They were also likely to actually use fewer pills.

The takeaway: After surgery, patients are getting prescribed more opioids than necessary and doctors can reduce the amount without experiencing negative side effects.

Within five months of the new guidelines taking effect at Michigan Medicine, surgeons reduced the volume of prescribed opioids by about 7,000 pills. It’s now been a year since the change took effect, and the researchers estimate they have curbed prescriptions by about 15,000 pills, said Ryan Howard, a general surgery resident and the paper’s lead author.

That has real implications. Studies have found that overprescribing opioids helps drive the epidemic. It can put patients at risk of addiction. And it endangers friends and family, who can easily acquire unused excess pills in, for instance, an unsecured medication cabinet. Reducing prescriptions altogether makes that less likely.

“This really shows in a very methodological way that we are dramatically overprescribing,” said Michael Botticelli, who spearheaded drug-control policy under the Obama White House, including the administration’s response to the opioid crisis.

“Not only do we have to reduce the supply to prevent future addiction, but we really have to minimize opportunities for diversion and misuse,” he said.

More hospitals are starting to turn in this direction, Botticelli said. He now runs the Grayken Center for Addiction at Boston Medical Center, which is also trying to systematically reduce opioid prescriptions after patients have surgery.

Meanwhile, 24 states have passed laws to limit how many pills a doctor can prescribe at once, according to the National Conference of State Legislatures.

“Those limits are just sort of generic limits across the board,” said Chad Brummett, an anesthesiology professor at the University of Michigan and another co-author of the paper. Their concept, he added, “is a step even further beyond what some of these policymakers are trying to do, and it’s one I think surgeons are more likely to adopt.”

The researchers also created a set of talking points for doctors and nurses to use with patients based on “fairly common sense” measures, Lee said. They include:

  • Encouraging patients to use lower-strength, non-addictive painkillers first;
  • Warning them about the risks of addiction; and
  • Reminding them that even a sufficient opioid prescription would leave them feeling some pain.

The talking points also offer tips for patients on safely storing and disposing of extra pills.

“So much of this problem can be addressed with solutions that are not complicated … like telling patients what to do with the medications when they’re finished using them,” said Julie Gaither, an instructor at Yale School of Medicine. Gaither has researched the opioid epidemic’s consequences, though she was not involved with this study.

The Michigan team is pushing its new prescribing guidelines online, in hopes of encouraging other hospitals to adopt similar practices. It also has started implementing the change in other hospitals around the state.

Still, this gets at only a small part of the problem, noted Jonathan Chen, an assistant professor of medicine at Stanford University, who has also researched opioid abuse and addiction. The bulk of opioid prescriptions are written by family doctors and general internists, he said.

“This won’t solve every problem — but nothing ever does,” said Chen, who was not involved with this study. “It’s one concrete area, and a natural place to start.”

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If Your Insurer Covers Few Therapists, Is That Really Mental Health Parity?

It’s been nearly a decade since Congress passed the mental health parity act, with its promise to make mental health and substance abuse treatment just as easy to get as care for any other condition. Yet today, in the midst of the opioid epidemic and a spike in the rate of suicide, patients still struggle to access treatment.

That’s the conclusion of a report published Thursday by Milliman Inc., a national risk management and health care consulting company. The report was released by a coalition of mental health and addiction advocacy organizations.

Among the findings:

  • In 2015, behavioral care was four to six times more likely to be provided out-of-network than medical or surgical care.
  • Insurers pay primary care providers 20 percent more for the same types of care as they pay addiction and mental health care specialists, including psychiatrists.
  • State statistics vary widely. In New Jersey, 45 percent of office visits for behavioral health care were out-of-network. In Washington D.C., the figure was 63 percent.

The researchers at Milliman examined two large national databases containing medical claims records from major insurers for PPOs — preferred provider organizations — covering nearly 42 million Americans in all 50 states and the District of Columbia from 2013 to 2015.

“I was surprised it was this bad. As someone who has worked on parity for 10-plus years, I thought we would have done better,” said Henry Harbin, former CEO of Magellan Health, a managed behavioral health care company. “This is a wake-up call for employers, regulators and the plans themselves that whatever they’re doing, they’re making it difficult for consumers to get treatment for all these illnesses. They’re failing miserably.”

The high proportion of out-of-network behavioral care means mental health and substance-abuse patients were far more likely to face the high out-of-pocket costs that can make treatment unaffordable, even for those with insurance.

In a statement issued with the report, the coalition of mental health groups, including Mental Health America, the National Association on Mental Illness, and The Kennedy Forum, called on federal regulators, state agencies and employers to conduct random audits of insurers to make sure they are in compliance with the parity law.

Harbin, now a consultant on parity issues, said the report’s finding that mental health providers are paid less than primary care providers is a particular surprise. In nine states, including New Hampshire, Minnesota, Vermont, Maine and Massachusetts, payments were 50 percent higher for primary care providers when they provided mental health care.

Because of such low reimbursement rates, he said, mental health and substance abuse professionals are not willing to contract with insurers. The result is insurance plans with narrow behavioral health networks that do not include enough therapists and other caregivers to meet the demands of patients.

For years, insurers have maintained that they are making every effort to comply with the Mental Health Parity and Addiction Equity Act, which was intended to equalize coverage of mental health and other medical conditions. And previous research has found that they have gone a long way toward eliminating obvious discrepancies in coverage. Most insurers, for example, have dropped annual limits on the therapy visits that they will cover. Higher copayments and separate mental health deductibles have become less of a problem.

Still, discrepancies appear to continue in the more subtle ways that insurers deliver benefits, including the size of provider networks.

Kate Berry, a senior vice president at America’s Health Insurance Plans, the industry’s main trade group, said the real problem is the shortage of behavioral health clinicians.

“Health plans are working very hard to actively recruit providers” and offer telemedicine visits in shortage areas, said Berry. “But some behavioral health specialists opt not to participate in contracts with providers simply because they prefer to see patients who are able to pay out of their pocket and may not have the kind of severe needs that other patients have.”

“This is a challenge that no single stakeholder in the health care infrastructure can solve,” she added.

Carol McDaid, who runs the Parity Implementation Coalition, countered that insurers have been willing and able to solve provider shortages in other fields. When there was a shortage of gerontologists, for example, McDaid said, insurers simply increased the rates and more doctors joined the networks. “The plans have the capacity to do this; I just think the will hasn’t been there thus far,” she said.

The scarcity of therapists who accept insurance creates a care landscape that is difficult to navigate for some of the most vulnerable patients.

Ali Carlin, 28, said she used to see her therapist in Richmond, Va., every week, paying a copay of $25 per session. But in 2015, the therapist stopped accepting her insurance, and her rate jumped to $110 per session.

Carlin, who has both borderline personality disorder and addiction issues, said she called around to about 10 other providers, but she couldn’t find anyone who accepted her insurance and was taking new patients.

“It’s such a daunting experience for someone who has trouble maintaining their home and holding a job and friendships,” said Carlin. “It makes me feel like no one can help me, and I’m not good enough, and it’s not an attainable goal.”

In Virginia, the Milliman report found that 26 percent of behavioral health office visits were out-of-network — more than seven times more than for medical care.

With no alternative, Carlin stuck with her old therapist but must save up between sessions. She has just enough to cover a visit once every few months.

“I make $30,000 a year. I can’t afford an out-of-pocket therapist or psychiatrist,” said Carlin. “I just can’t afford it. I’m choosing groceries over a therapist.”

Angela Kimball, director of advocacy and public policy at the National Alliance on Mental Illness, said she worries many patients like Carlin simply forgo treatment entirely.

“One of the most common reasons people give of not getting mental health treatment is the cost. The other is not being able to find care,” she said. “It’s hurting people in every corner of this nation.”

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