The August 2023 issue of the American Journal of Health Economics will feature a cluster of articles that examine the opioid crisis. These articles consider such topics as access to treatment for opioid use, the impact of the Affordable Care Act on opioid-related emergency department visits, and the effectiveness of prescription drug monitoring programs.
In "Do Policies to Increase Access to Treatment for Opioid Use Disorder Work?" authors Leemore S. Dafny, Eric Barrette, and Karen Shen use longitudinal patient-level claims data to examine the impact of demand and supply-side policies on treatment rates among patients diagnosed with opioid use disorder (OUD) from 2009-2017.
The authors find that parity laws requiring insurance plans to provide equal coverage for substance use disorder treatment as for other medical conditions increase the use of residential treatment. However, this extension of parity decreases the use of agonist medications like methadone and buprenorphine that prevent opioid withdrawal symptoms, a treatment that comprises the current clinical standard of care. Direct interventions to increase access to medication may be more promising: increases in the number of county-level physicians able to prescribe agonists are associated with more medication-assisted treatment.
In "The Impact of the Affordable Care Act Insurance Expansions on Opioid-Related Emergency Department Visits," Sandra L. Decker, Michael S. Dworsky, Teresa B. Gibson, Rachel Mosher Henke, and Kimberly Walsh McDermott leverage ACA coverage expansions to study the impact of health insurance on opioid-related emergency department (ED) visits.
The authors use opioid-related ED visit rates as a marker of the extent of untreated OUD in local areas, taking into account within-state variation in pre-ACA uninsurance rates. With this model, the authors find that regardless of Medicaid expansion status, areas with higher uninsurance rates prior to the ACA saw larger reductions in opioid-related ED visits after the ACA took effect.
"We found that opioid-related ED visits plateaued for all states in 2016, corresponding with the publication of the CDC opioid prescribing guidelines," the authors note. They also observe that state efforts to address the opioid epidemic, notably prescription drug monitoring programs (PDMPs), appear to be associated with reductions in opioid-related ED visits, suggesting that these efforts may be worthwhile investments in addition to the expansion of insurance coverage.
Two other papers study the effectiveness of must-access PDMPs, through which providers are legally required to effect drug monitoring before dispensing controlled substances. In "Effects of Opioid-Related Policies on Opioid Utilization, Nature of Medical Care, and Duration of Disability," David Neumark and Bogdan Savych examine these monitoring programs alongside recent regulations that limit the duration of initial opioid prescriptions for patients with work-related injuries, focusing on opioid utilization and care related to pain management. The authors consider whether workers received any care that could be a substitute for opioid therapies, and whether opioid-related policies affected the duration of temporary disability benefits.
The study reveals must-access PDMPs contributed to declines in opioid utilization, while regulations limiting duration of initial opioid prescriptions had little effect on whether workers received opioids, but reduced opioid use among those with prescriptions. The authors find evidence that must-access PDMPs affected utilization of other medical care; for instance, in the case of patients with neurologic spine pain, significant due to this group's highest incidence of opioid prescriptions and highest morphine milligram equivalent amount, restricted access to opioid prescriptions led to greater use of non-opioid pain medication prescriptions and interventional pain management services. Additionally, the authors observe that must-access PDMPs and initial prescription limits had no significant impact on the duration of temporary disability benefits.
Finally, in "How do 'Must Access' Prescription Drug Monitoring Programs Address Opioid Misuse?" Benjamin Ukert and Daniel Polsky compare changes in prescribing rates for opioid-naïve individuals, who have not received opioids in the last six months, relative to patients who had recently received opioids. The authors' analysis, through this separation of individuals into those with and without a history of opioid use, suggests that broad "must access" PDMPs are especially effective at reducing opioid use among the non-opioid naïve.
The findings suggest that the "hassle cost" associated with the administration of PDMPs, a trend in which providers forego a treatment option due to the perceived effort it would require, explains most of the decline in initial prescribing. However, with respect to long-term outcomes, "information value," or the application of PDMPs with targeted consideration of a patient's opioid history, may be responsible for the greater part of prescription reductions. The authors posit that "must access" provisions cannot be seen as a universal policy instrument to reduce opioid prescribing, but that they seem to work in states when there is rampant opioid use. Ultimately, this finding "reinforces the value of policies targeting the non-opioid naïve to reduce opioid use among those with the highest risk of opioid misuse," and has powerful implications for policymakers and health systems seeking to limit the overall use of opioids.
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