Evidence-Based Medicine

What gets prescribed and why: Opioids v. obesity meds

By M2|2018-12-06T18:37:08+00:00December 6th, 2018|Chronic pain, Evidence-Based Medicine, Health Care Trends, Insurance, Uncategorized, What do we pay for and why|

What gets prescribed and why: Opioids v. obesity meds

The U.S. health care system doesn’t always make sense. Sometimes, even when there is some logic to it, the reasons underpinning what gets prescribed by practitioners and covered by insurers are disappointing. Two pieces I read recently provide examples.

In one study, we learn that while primary care physicians are prescribing opioids less often, other specialists and nurse practitioners are prescribing them more often. Ultimately, opioid prescribing remains at a high level, despite known issues with misuse and abuse, and the availability of alternative pain treatments.

At the same time, while 40% of U.S. adults are obese, fewer than 2% of obese patients are offered medications for obesity, and ultimately “only about 1% of eligible patients fill a prescription for a weight loss medication.” Even when weight loss medications are prescribed, it is usually for a specific (fairly short) period of time, explained Dr. Caroline M. Apovian, a Professor of Medicine and Pediatrics, Department of Medicine, Section of Endocrinology at Boston University School of Medicine and the Director of Nutrition and Weight Management, Department of Endocrinology, Diabetes, and Nutrition, at Boston Medical Center, in an opinion piece in Medscape.

This is an example of what we like to call at M2: “what do we pay for and why?” If 40% of the public has a disease, why aren’t treatments prescribed and covered? Several chronic obesity management medications have been approved by the U.S. Food and Drug Administration (FDA) in the past few years, and have proven of efficacy of 5%-10% weight loss, but Dr. Apovian argues that “public perception of obesity as a matter of will power rather than a disease” is a key barrier to lower treatment rates for obesity.

The U.S. health care system doesn’t necessarily pay for what works, or the treatments people need. As with all policy decisions, there is a judgment about who deserves what, and who should pay for it. In the case of treating obesity with a prescription, Dr. Apovian succinctly explains the current policy stance: “If obesity is considered a moral failing, why treat it with a pill or surgery?”

What’s the hold up? Why do physicians not turn more frequently to the known effective treatments for obesity? Well, sometimes it is lack of proper training (discussed in our in April). Physicians have a lot to stay up to date on, and obesity treatments are often not prioritized despite the prevalence of comorbidities. As we discussed in a back in February, improved insurance coverage for proven effective weight loss treatments could help avoid expensive complications from obesity down the road and may improve quality of life. We suggest this is a better way to choose what is covered the current approach.

Pain affects a large number of people in the U.S. as well – more than 100 million adults. Nearly 40 million adults experience the highest levels of pain (category 3 or category 4), and there are more than 25 million adults who report chronic (daily) pain. Further, the Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain is clear: “Opioids are not first-line or routine therapy for chronic pain.” Despite this clear recommendation, as the recent study confirms, opioids continue to be frequently prescribed for pain, even though there are less addictive alternatives available. These medications aren’t that expensive so are frequently covered by insurance.

The M2 blog, Coverage Drives Treatment: The Case of Pain explains how insurance companies seem to prefer to cover what is inexpensive, and perhaps less effective, at least when it comes to opioids for pain.

Confounding situations like this are when we understand why an overhaul of the health care system is appealing to some. It would be an incredible opportunity to step back and create a new system that approaches all situations – obesity, pain, everything – from the perspective of longer term effectiveness. Ultimately this would reduce health care system costs overall, as less time (and money) would be spent covering up symptoms of something that is likely to cause greater expense down the road.

But in order to do this, we’d have to face who we think deserves what kind of care. These decisions are baked in to the system we have and rarely discussed. 2019 is around the corner. Should we start this conversation in the new year?

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Right Care at the Right Time in the Right Way – The Case of Antibiotics

By M2|2018-07-26T19:36:55+00:00July 26th, 2018|Evidence-Based Medicine, Health Care Trends, Retail Health, Uncategorized|

Right Care at the Right Time in the Right Way – The Case of Antibiotics

One of the most difficult problems to address in the U.S. health care system is treatment recommendations that are out-of-date, inaccurate, or based on an incorrect diagnosis. We write about this topic frequently () and Dr. Atul Gawande (who was recently named as the CEO of the new company being formed by Amazon.com Inc., Berkshire Hathaway Inc. and JPMorgan Chase & Co.) highlighted it most recently in a conversation with reporter Judy Woodruff at the Aspen Ideas Festival. Gawande argued there are three sources of waste that require different work but the biggest bucket is misutilization, “meaning the wrong care, at the wrong time, in the wrong way.”

A perfect example is antibiotic use. According to the Centers for Disease Control and Prevention (CDC) about 30% of antibiotics prescribed in physician’s offices and other outpatient settings are unnecessary. Further, says the CDC, “even when antibiotics are needed, prescribers often favor drugs that may be less effective and carry more risk over more targeted first-line drugs recommended by national guidelines.” In other words, clinical recommendations are often out-of-date or simply not following guidelines.

In urgent care centers, an increasingly popular site of care, the problem is even worse. According to a brief published this month by The Pew Charitable Trusts, “46% of all urgent care visits for non-antibiotic recommended diagnoses resulted in an antibiotic prescription,” compared to 14% of the time in retail clinics, 25% of the time in emergency departments, and 17% in office-based clinics. Acute respiratory conditions, for example, asthma and allergy, bronchitis, flu, and pneumonia are common reasons for a visit to a physician’s office or clinic, but in urgent care centers, it is fairly likely an antibiotic will be prescribed for these conditions, when they shouldn’t be, as shown in the table from Pew below.

Considering urgent care usage has skyrocketed in recent years, increasing by 1,675% (that is not a typo!) in rural areas and 2,308% in urban areas between 2007 and 2016, the higher rate of inappropriate antibiotic use is an even bigger problem than just comparing prescribing rates across site of care might indicate.

Inappropriate antibiotic prescription use plus skyrocketing urgent care visits equals a perfect case of “wrong care, at the wrong time, in the wrong way.”

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Avoidable ED visits – what does “avoidable” mean and what can we do about this issue?

By M2|2018-07-10T18:48:57+00:00July 9th, 2018|Evidence-Based Medicine, Hospitals, Uncategorized, What do we pay for and why|

Avoidable ED visits – what does “avoidable” mean and what can we do about this issue?

An employer group in Massachusetts is coming together to reduce avoidable emergency department (ED) visits, in large part because they claim ED visits are a key driver of health care costs in the Commonwealth. According to the coalition, “ED visits can be five times more expensive than primary care or urgent care visits.” Not only are ED visits expensive compared to other health care services, the coalition cites a Massachusetts Health Policy Commission estimate of $300-350 million in annual costs, in total, just for commercially insured people in Massachusetts.

While this seems laudable, it turns out there’s a big difference of opinion about the definition of “avoidable ED visit.” The coalition’s statement claims studies show more than 40% of ED visits are avoidable. Some of the most common conditions for avoidable ED visits, accordingly to this employer group, include acid reflux, allergies, back pain, bronchitis, sinusitis, stomach pain, and urinary tract infections. At first glance, these maladies don’t seem like they need to be treated in an emergent setting.

At issue is the definition of “avoidable.” According to the American College of Emergency Physicians (ACEP) only 3.3% of ED visits are avoidable. In a study based on data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for years 2005 to 2011, Renee Hsia, MD, MSc, of the Department of Emergency Medicine at the University of California, San Francisco, found many of the visits to EDs that are classified as “avoidable,” such as those listed above, also involve either mental health or dental issues.

Dr. Hsia argues, “This suggests a lack of access to health care rather than intentional inappropriate use is driving many of these ‘avoidable’ visits. These patients come to the ER because they need help and literally have no place else to go.”

So, are more than 40% of ED visits avoidable or is it less than 5%? This is a fairly big difference. In ACEP’s view, the entire concept of “avoidable ED visits” should be questioned. “Despite a relentless campaign by the insurance industry to mislead policymakers and the public into believing that many ER visits are avoidable, the facts say otherwise,” said Becky Parker, MD, FACEP, the president of the American College of Emergency Physicians (ACEP). “Most patients who are in the emergency department belong there and insurers should cover those visits. The myths about ‘unnecessary’ ER visits are just that – myths.”

It seems essential to know more about why people are going to the ED for health issues that don’t fall into the category of: I was taken to the ED in an ambulance because I was unconscious, or my friend drove me after I sliced off my finger…The Massachusetts Health Policy Commission has been gathering all sorts of data the past few years, and below is the chart they have published on avoidable ED use.

As the chart shows, nearly 70% of “avoidable ED visits” happen between 8am and 8pm. This is probably not the typical idea that people have in their minds about when “avoidable ED” visits occur. So based on Massachusetts data showing the majority of avoidable ED visits happening during daytime hours, it seems more likely that the ACEP point of view is correct: Maybe these visits really do indicate access to care problems more than patient choice – which possibly could be changed simply by improved education.

The Health Commission chart is accompanied by some analysis from the 2014 Massachusetts Health Insurance Survey. In the survey, of the respondents who had been to the ED in the past year, “over half said they had done so because they could not get a timely appointment with their usual source of care.” Ideas to address this lack of access include encouraging patients to seek care at retail clinics or urgent care centers, encouraging providers to expand office hours, making hotlines and telehealth more available, and “granting Nurse Practitioners full practice authority.”

Reducing unnecessary health care costs is a common goal across individuals, families, employers, and governments. The Massachusetts Employer-Led Coalition to Reduce Health Care Costs zeroes in on “avoidable ED visits,” listing a focus on four levers for impact:

Employee engagement
Data and measurement
Multi-sector collaboration
Policy advocacy

We often focus on what works, and it seems notable that the Commonwealth has a range of data showing expanding access to a broader range of providers (by changing scope of practice laws and reimbursing more convenient types of care) seems highly likely to reduce “avoidable ED visits.” As more specificity is put forth by the coalition, time will tell whether their policy solutions match the problem.

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Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

By M2|2018-05-23T16:53:35+00:00May 23rd, 2018|Evidence-Based Medicine, Health Care Trends, Hospitals, Providers, Social Determinants of Health, Uncategorized, What do we pay for and why|

Proof Point: Addressing Social Determinants of Health Reduces ED and Hospital Visits, and Reduces Costs

Just a couple weeks ago, I about social determinants of health (SDH), so I was intrigued to come across this recent study in Health Affairs showing that improved access to care and a consideration of SDH can lower emergency room use and inpatient hospitalizations, and reduce costs.

A health clinic in Dallas, the Baylor Scott & White Health and Wellness Center (we’ve also highlighted before), partnered with the Dallas Parks and Recreation Department to create a primary care clinic in a rec center in an underserved Dallas community. The public-private partnership offers clinical services such as routine primary care, regardless of the person’s ability to pay. But it also offers access to other health-supporting interventions. For example, the partnership provides access to programs that help community members participate in physical activity and get healthy food.

Community health workers are also a component of the approach. Patients often need help navigating both the health care system and support programs, for example, free exercise classes at the rec center. Community health workers assist patients with that navigation in a culturally relevant way for the Dallas center. Local churches – more than 25 of them – provide an additional level of support by increasing awareness of the health clinic/rec center offerings and availability of community health workers.

The clinic “exemplifies the integration of social determinants of health within a population health strategy,” according to the study by David Wesson, President, Baylor Scott & White Health and Wellness Center, and his colleagues.

While increasing access to both clinical health care services and health-supporting programs, such as those offered by rec centers, is worthy goal on its own, to health policy wonks the added proof point of cost savings due to a population based approach that integrates SDH is just as exciting.

The study examined emergency department (ED) and inpatient care use for 12 months after initiation of the program. People who used the center’s services experienced a reduction in ED use of 21.4% and a reduction in inpatient care use of 36.7%, with an average cost decrease of 34.5% and 54.4%, respectively. All of these are notable proof points: “These data support the use of population health strategies to reduce the use of emergency services,” the authors conclude.

The Baylor Scott White/Dallas Recreation Center partnership is a great example of how improving access to health care and addressing the social determinants of health can have a positive impact on both health outcomes as well as costs, by reducing expensive types of care such as emergency and inpatient services. We are still building the evidence-base, but this study shows taking a holistic approach to patient care, including addressing the social determinants of health such as culture and language, can help achieve what everyone wants: improved health and lower costs.

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Want to Fix the Opioid Crisis? First, Think Structurally

By M2|2018-05-17T16:49:16+00:00May 17th, 2018|Chronic pain, Evidence-Based Medicine, Insurance, Public Health, Social Determinants of Health, Uncategorized, What do we pay for and why|

Want to Fix the Opioid Crisis? First, Think Structurally

I am often asked to come up with creative ways to address various health care problems. When I was asked by a client a few years ago to come up with some ideas to address the opioid crisis, I dove in to the latest academic literature, news reports, and books (if you haven’t read it yet, and are interested in the bigger picture of opioids, check out Dreamland by Sam Quinones). Thousands of pages later, I came to what seemed an obvious conclusion: opioid misuse and abuse is not a singular crisis, but the effect of a huge set of policy decisions that have occurred over years.

In a recent commentary in the American Journal of Public Health, author Nabarun Dasgupta of the University of North Carolina, Chapel Hill, and colleagues are blunt – “The structural and social determinants of health framework is widely understood to be critical in responding to public health challenges. Until we adopt this framework, we will continue to fail in our efforts to turn the tide of the opioid crisis.”

Using a structural framework to analyze causes of the opioid crisis generates “an alternate hypothesis…that an environment that increasingly promotes obesity coupled with widespread opioid use may be the underlying drivers of increasing White middle-class mortality,” the authors point out. “Complex interconnections between obesity, disability, chronic pain, depression, and substance use have not been adequately explored.” Also, suicides “may be undercounted among overdose deaths,” they say. “Under both frameworks, social distress is a likely upstream explanatory factor.”

In order to “turn the tide” on the opioid crisis, the authors urge a focus on patient suffering, tied to things like social disadvantage, isolation, and pain. However, one of the challenges is that the U.S. health care system is “unprepared to meet the demands elucidated by a structural factors analysis.”

Again, seems obvious, but still bears repeating: the health care delivery system is not built to deal with structural problems.

Addressing these types of factors requires “meaningful clinical attention that is difficult to deliver in high-throughput primary care.” Indeed, the current “institutional, legal, and insurance architecture have robbed clinicians of time and incentives to continue care for these patients,” the authors say.

Incorporating social determinants of health (SDH) into care plans also highlights the need to “integrate clinical care with efforts to improve patients’ structural environment,” the commentary says. While the commentary authors recommend, “Training health care providers in ‘structural competency’” as promising, as the system scales up “partnerships that begin to address upstream structural factors such as economic opportunity, social cohesion, racial disadvantage, and life satisfaction,” I’m not as inclined to think health provider training alone will suffice. When I was first taught the basic premises of SDH and structural thinking as a young graduate student, the discipline was already decades old.

Knowing the importance of SDH is not enough. Until the evidence base is deeper, it is difficult to get payers to reimburse such as activities. (See next week’s blog for a great example though!)

Thinking structurally is not so difficult to learn, but acting structurally is extremely difficult. Still, the opioid crisis – like so many health care conundrums – can’t be solved without it. Let’s get to it.

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Obesity: Survey Finds Primary Care Providers’ Knowledge “Inconsistent” with Evidence-Based Recommendations

By M2|2018-04-26T20:09:32+00:00April 26th, 2018|Evidence-Based Medicine, Hospitals, Providers, Uncategorized|

Obesity: Survey Finds Primary Care Providers’ Knowledge “Inconsistent” with Evidence-Based Recommendations

Despite the high prevalence of obesity in the US, a new study finds that providers’ knowledge of evidence-based recommendations for obesity is low.

For example, only 15% were able to identify the “appropriate indication” for prescribing pharmacotherapy for patients: a BMI over 27 with an obesity-associated comorbid condition. Two-thirds said it is appropriate to continue long-term pharmacotherapy under conditions inconsistent with evidence-based guidelines. Providers were “most knowledgeable” regarding the physical activity guidelines, with 49% answering correctly.

In addition, “only 16% of respondents indicated that obesity counseling should be provided approximately twice monthly in an individual or group setting for at least 6 months,” in accordance with U.S. Preventive Services Task Force and CMS guidelines, according to the study by Monique Turner, George Washington University, Milken Institute of Public Health, et al., and published in the journal Obesity. (Shout out to my colleague at GWU, Dr. Monique!)

Overall, providers’ understanding of clinical care for obesity, which includes intensive behavioral therapy, physical activity, and pharmacotherapy, is “inconsistent with evidence-based recommendations” the study found – despite the fact that most health care providers believe they are responsible for ensuring patients are informed about obesity treatments.

Given the current obesity epidemic and the known costs associated with obesity, it seems obvious that primary care physicians should make it a priority to be up-to-date with current treatments and approaches to weight loss and optimal health. This would also help them advocate for better coverage of interventions.

In an accompanying commentary, Robert Kushner, Northwestern University, Feinberg School of Medicine, appears to agree:

“Knowledge of the guidelines is a reasonable objective but is not sufficient to change practice behavior,” Kushner says. Nonadherence to practice guidelines “may be due to other factors independent of knowledge,” including fragmentation of care, disagreement between guidelines, and “external practice barriers.”

He cites the need for effective dissemination and implementation approaches for practice guidelines. He also points out that other educational initiatives are under way “that will impact the practice of obesity in the primary care setting,” for example, through the Obesity Medicine Education Collaborative (OMEC), which is “currently finalizing a set of 32 obesity-specific competencies” as part of undergraduate, postgraduate, and fellowship training. “By taking a continual and comprehensive educational approach, we are on our way to get primary care ready to treat obesity,” he concludes.

Obesity is a growing problem in the U.S. in terms of both health outcomes and costs; in fact, as I’ve about recently, it is also linked to declining mortality improvements in the US compared to other wealthy countries. Unfortunately, despite the availability of a range of non-surgical interventions supported by evidence-based practice guidelines, primary care providers generally are not appropriately trained in this area, nor do they keep pace with new treatment findings on how to address this problem. If we want to tackle the obesity problem and improve health outcomes, life expectancy and costs, we must find ways to address barriers of this kind, and our reimbursement policies will need to incentivize providers to focus on this issue.

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An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

By M2|2018-04-10T19:27:24+00:00April 10th, 2018|Chronic pain, Evidence-Based Medicine, Health Disparities, Insurance, Social Determinants of Health, Uncategorized, What do we pay for and why|

An Alternative to Opioids? Other Interventions Show Significant Improvements in Pain and Physical Function For Disadvantaged Populations

Pain is a common, yet difficult to treat condition; it is one of the top reasons people go to the doctor. Opioids are commonly prescribed to treat pain; opioids are quite effective but addictive. The use of cognitive behavioral therapy (CBT) is known to be efficacious in addressing chronic pain; however, its benefit in disadvantaged populations is not well understood.

To help shed light on this question, a team led by Beverly Thorn, University of Alabama, conducted a study to evaluate the efficacy of literacy-adapted and simplified group CBT versus group pain education (EDU) versus usual care.

The randomized controlled trial enrolled 290 adults with chronic pain symptoms. Most had incomes at or below the poverty level, and about one-third read below a fifth grade level. Many participants were taking opioids at the beginning of the study.

Both the CBT and EDU were delivered in ten weekly 90-minute group sessions. Participants in all three groups reported their pain levels and physical functioning via questionnaires at baseline, ten weeks, and six months.

The study, funded by the Patient-Centered Outcomes Research Institute and published in the Annals of Internal Medicine, found that patients in the CBT and EDU groups had greater decreases in pain intensity scores between baseline and post-treatment than participants receiving usual care.

However, while treatment gains were still present in the EDU group at six-month follow-up, these gains were not maintained in the CBT group, Thorn, et al., say.

Regarding the secondary outcome of physical function, those in the CBT and EDU interventions had greater post-treatment improvement than patients who received usual care; this progress was maintained at six-month follow-up. Changes in depression, another secondary outcome, did not differ between either the CBT or EDU group and those receiving usual care, the researchers state.

This study highlights the fact that when done correctly, i.e., when materials are adjusted and tailored to a patient’s reading level, there are non-opioid interventions like behavioral therapy and education that work. While it is probably easier to prescribe opioids for pain, given the increasing severity of the opioid addiction epidemic, insurers really should consider these effective alternative treatments which positively impact pain. Why NOT prescribe effective, non-addictive treatment whenever possible?

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Both Patients and Hospitals Tend to Avoid Care that Costs More – One Health Plan in MA is Trying to Address This

By M2|2018-03-01T20:30:49+00:00March 1st, 2018|Evidence-Based Medicine, Health care spending, Health Plans, Hospitals, Insurance, Out-of-pocket spending, Uncategorized, What do we pay for and why|

Both Patients and Hospitals Tend to Avoid Care that Costs More – One Health Plan in MA is Trying to Address This

Despite evidence that cervical cancer is most effectively treated with brachytherapy (a form of radiation), Medicare reimbursement for a less effective treatment, external beam radiation, is higher, according to an article in Healthcare Finance News. Additionally, the delivery costs of brachytherapy in hospitals is greater than for external beam radiation.

The lower cost of delivery combined with higher Medicare reimbursement means external beam radiation is four times more profitable than brachytherapy for a hospital – despite being the less effective treatment.

The study by Kristine Bauer-Nilsen, University of Virginia School of Medicine, et al., published in Radiation Oncology, evaluated the delivery costs, using time-driven activity-based costing, and reimbursement for definitive radiation therapy for locally advanced cervical cancer.

Brachytherapy for locally advanced cervical cancer “ends up costing hospitals money because it takes 80-plus percent more physician personnel time to administer brachytherapy than it does to deliver the increasingly popular external beam radiation,” the article says. Even though it costs more for hospitals to provide brachytherapy than it does to provide external-beam radiation, the reimbursement doesn’t reflect the difference. Which in turn means, “the comparatively poor reimbursement rates may mean some hospitals simply don’t offer brachytherapy or commit physician time to it” as Jeff Lagasse, the author of the Healthcare Finance News piece succinctly concludes.

Businesses naturally do the things that pay them more. This study highlights how reimbursement has to change before health providers will change. “Value based care,” envisioned by policymakers mean the system as a whole only pays for health interventions that are valuable. But what is of value to the system is different than what is of value to a health care business, for example, a hospital or physician group.

Similarly, what a patient values, might be different from every other entity in the health care system. Just as financial incentives may drive hospitals’ choice of therapies, they also affect patients’ decision making when it comes to managing chronic conditions. Now, a health plan in Massachusetts is aiming to remove the financial incentives that lead patients to avoid needed care. In order to incentivize patients to “manage their conditions optimally and proactively,” Neighborhood Health Plan (NHP) is waiving out-of-pocket costs for chronic conditions.

The new comprehensive benefit design, called Care Complement, eliminates copays for 11 common prescription medications that treat conditions like high cholesterol, diabetes, high blood pressure, heart disease, and depression. The program also waives cost sharing associated with cardiac rehabilitation therapy and screenings to prevent diabetes complications, according to a recent AHIP (America’s Health Insurance Plans) blog.

“With certain chronic conditions, such as diabetes, there are often many recommended services to fully control the condition and reduce the risk of complications,” Dr. Anton Dodek, chief medical officer at NHP, says in the blog. “For diabetes, these recommendations include an annual routine eye exam, diabetic education, and nutritional counseling. Each of these office visits typically require a co-payment from the member, and can create a barrier to receiving care.”

The program also offers “affordable alternatives to opioids for chronic pain.” For example, it waives cost-sharing for medication-assisted therapies (MAT), as well as expenses for recovery coaches. And it gives physicians the resources needed to “help determine if their patients would benefit from alternative pain management treatments, such as physical therapy/occupational therapy sessions, chiropractic visits, and acupuncture visits.”

“By eliminating cost sharing, we hope that members will be encouraged to work with their doctors to manage their conditions optimally and proactively, which will result in healthier outcomes in the long run,” Dr. Dodek says.

Neighborhood Health Plan’s approach is exactly the kind of approach that we need more of; by adjusting financial incentives for patients to choose the most “valued” care for their chronic conditions, this plan is moving beyond looking at short-term costs, and instead is looking at the big picture. By helping patients with what they value – lower costs and higher quality – the health plan is likely to improve health outcomes in the long term.

Value based payment is harder than it looks. These examples shed light on what doesn’t work, and what does. Policymakers need to both copy success, and halt failure if they want to bend the cost curve.

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Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

By M2|2017-10-08T11:16:59+00:00September 28th, 2017|Chronic pain, Evidence-Based Medicine, Health Disparities, Uncategorized|

Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

Headaches are one of the main reasons patients seek health care advice, and racial and ethnic differences exist. For example, migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life versus non-Hispanic whites. Given these disparities, researchers at the University of Michigan set out to determine whether there are also racial differences in the quality of migraine treatment.

In a study published in Cephalalgia, researchers reported that approximately 40% of patients received no preventive medications – prophylactic treatments – though that is the recommended approach for most patients. Further, “among patients that receive a prophylactic agent, it is almost twice as likely that they will receive exclusively agents with low-quality evidence as it is that they will receive agents with only high-quality evidence.”

As for race or ethnic differences in prophylactic treatment, however, patients were treated similarly: 41.3% of African Americans (AA) received no prophylactic treatments from 2006 to 2013, compared to 40.8% of non-Hispanic whites (NHW), and 41.2% of Hispanic (HI) patients.

For patients who needed first-line treatment (also called “abortive treatment”), as with preventive medication, the University of Michigan researchers did not find relevant differences across ethnicities or races, but they did find nearly 40% of patients did not receive a first-line treatment when it was indicated. And similar to the prescribing pattern for preventive medications, when a first-line treatment was prescribed, it was more likely to be one with low-quality evidence.

“This shows an underuse of medications with high-quality evidence,” first author Larry Charleston IV, M.D., M.Sc., an assistant professor of neurology at the University of Michigan Medical School said. “Even for patients being prescribed an abortive medication, we found 27 percent of them were given at least one low-quality abortive medication. Better options do exist.”

The data “suggest that there are major opportunities to improve the quality of headache medication prescribing in the United States, as less than a quarter of migraine patients received all high-quality abortive or prophylactic medications.”

Perhaps most disturbingly, migraine patients “receive prescriptions for opioids about as commonly as they receive prescriptions for medications with high-quality evidence for migraine treatment,” the researchers found.

Looking at the use of opiates, 15.2% of all patients had a prescription for opiates, but there were no racial differences, Larry Charleston and James Burke, University of Michigan, say. In other words, the “investigation into racial disparities in migraine treatment came up empty, but instead it found a different concern that reaches across populations” – opioid overuse, as noted in an article in Lab Report.

The findings on opioid overuse come at a time when opiate-related mortality is “rapidly increasing in the United States,” the study authors note.

“The argument against opiate use for migraine is strengthened by the observation that it is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), greater need to see health care providers and high risk for medication overuse headache. Moreover, most evidence suggests that opiates are, if anything, less effective than non-opiate alternatives,” according to the researchers.

“Given the considerable risks of opiates and the lack of evidence of increased efficacy, opiates should be used rarely, if ever, for migraine,” they conclude. “Interventions to reduce opiate use in the migraine population are urgently needed.”

This overuse of opiates and underuse of less risky, more effective therapies is another example of practitioners ignoring evidence-based medicine. What’s different about this particular example is that it involves opioids, at a time when the opioid abuse crisis has become so critical that the President recently declared it a national emergency. This seems to be an area ripe for educating physicians or for health plans to provide appropriate parameters for prescribing of migraine therapies, to ensure opioids are prescribed only for patients who truly need them.

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Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

By M2|2017-10-08T11:26:51+00:00August 30th, 2017|Evidence-Based Medicine, Uncategorized|

Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

As some states have legalized marijuana in recent years, for medical use and/or recreational use, the use of marijuana during pregnancy has also increased; almost 4% of pregnant women said they had used marijuana in the past month in 2014, compared with 2.4% in 2002, according to a recent study published in the Journal of the American Medical Association.

The New York Times recently highlighted the stories of several women who had written in about their experiences taking the drug while they were pregnant; of the “hundreds” of readers who wrote in, “most had smoked, while a few vaped or ate marijuana-laced edibles,” the article says. “Roughly half said they had used pot for a medical reason,” such as nausea or back pain.

“Most felt marijuana use had not affected their children, or were not sure; just a handful worried the children might have suffered cognitive deficits.”

However, the acceptance of marijuana has “outstripped scientific understanding of its effects on human health…Often pregnant women presume that cannabis has no consequences for developing infants. But preliminary research suggests otherwise.”

Indeed, “cannabinoids readily cross the placenta, entering the fetal circulation and brain, and higher fetal levels are seen with chronic use,” Jennifer Gunter, MD, an ob/gyn, points out in a June 2017 commentary.

“Another concern is that doses of THC [tetrahydrocannabinol, the main psychoactive ingredient] in marijuana have increased dramatically, from 4% in 1995 to 12% in 2014, with labs in Colorado reporting THC concentrations in some strains as high as 30%,” Gunter says. “Women choosing to use marijuana in pregnancy will be exposed to significantly higher doses compared with 20 years ago.” Also, “many strains that claim to be high in CBD [cannabidiol, the ingredient that may help nausea and pain] in fact contain little, if any.”

As for the various ways in which marijuana may be taken, “while women may think that marijuana concentrates and edibles are healthier because they do not involve smoking, they can still have significant and potentially harmful solvent residue from processing with chemicals such as butane,” she says.

“The endocannabinoid system is complex and not fully understood,” Dr. Gunter points out. “Animal studies show that prenatal exposure to THC, even at low doses, causes long-lasting neurologic changes among exposed progeny.” And in a recent meta-analysis of 24 studies of sufficient quality, women who use cannabis during pregnancy were found to have an “increased risk for anemia.” That study also found that “fetal exposure reduces birth weight and increases the need for neonatal intensive care unit admission.”

The American College of Obstetricians and Gynecologists (ACOG) recommends asking all women about marijuana use, Gunter notes. “Given the unsubstantiated reports of safety that women may find online, prenatal providers should be prepared to provide clear information about the safety concerns in a nonjudgmental way. It’s important that women get this information from their health providers so that they have accurate data to inform their medical decision-making. Prenatal providers should encourage women to report nausea and vomiting early and not downplay symptoms, as lack of help from traditional medicine may be one reason that women turn to marijuana.”

Gunter notes that ACOG “specifically recommends against advising marijuana use for nausea and vomiting in pregnancy. ACOG also recommends that providers help women who are using marijuana for medical reasons to find alternatives with pregnancy safety data.”

“Discussions about marijuana can be hard as the ‘safety’ of the drug seems entrenched,” she notes. “But I’ve found that many patients are receptive when I explain to them the extremely high concentrations of THC in modern strains, the often low levels of CBD despite advertising to the contrary, and concerns about solvents.”

This discussion highlights the fact that while some patients may assume that marijuana is safe and effective, and the main ob/gyn association recommends its members point patients toward prescription alternatives, the truth is we simply don’t know whether marijuana is safe or effective for pregnant women to treat symptoms such as nausea and pain.

This is yet another example of where data is lacking. What should physicians do in any situation in which there is insufficient data to make a recommendation? The answer as I see it: Admit researchers don’t have the answer yet. Although I realize this may be uncomfortable for many docs, it’s ok to say, “I don’t know.”

What the evidence suggests so far is the potential for cannabinoids to affect the brain and circulatory system of the baby in the womb. Thus, pointing out the potential risks of marijuana use during pregnancy, as noted by Dr. Gunter above, while acknowledging the overall lack of conclusive data, would seem the appropriate approach.

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