Impact of CDC Guidelines and Health Payer Pharmacy Coverage Changes on Opioid Prescription Trends and Pharmaceutical Opioid Marketing Spending

Abstract

Due to the opioid epidemic in the US, the Center for Disease Control and Prevention (CDC) in March 2016 published new guidelines for primary care providers on opioid prescribing for chronic pain. Pharmacy coverage changes were also implemented by some health payers to help modify opioid prescribing behavior. Whether these initiatives were associated with changes in opioid initiation patterns across different provider specialties is unknown. Hence, we evaluate 3 of the CDC guidelines and 2 payer pharmacy coverage changes by asking the following questions: 1a. Were fewer extended release (ER) opioids relative to immediate release (IR) opioids prescribed post-CDC guideline release and post-pharmacy coverage change when initiating opioid treatment across different provider specialties? 1b. Were fewer patients started at opioid doses of ≥50MME per day post-CDC guideline release and post-pharmacy coverage change when initiating opioid treatment across different provider specialties? 1c. Were fewer patients starting opioid prescription with benzodiazepine overlap post-CDC guideline release when initiating opioid treatment across different provider specialties? Although the CDC guidelines were recommended for primary care providers, providers often adopt evidence-based recommendations from outside of their own areas of practice, and specialist providers may also have adopted the CDC guidelines. There is a paucity of information on whether there are differences between responses to the CDC guidelines and payer policy changes on opioid initiation practices between primary care providers and specialists. Likewise, there is no documentation on rural urban differences and patient’s insurance types influence on the response to the CDC guidelines and payer policy changes. Hence, we also evaluate: - Primary care compared to specialist providers 2a. If response to the CDC guideline and payer pharmacy coverage change discouraging prescribing first-time opioids at doses ≥50MME per day differ between primary care providers and specialist providers? 2b. If response to the CDC guideline discouraging prescribing first-time opioid with benzodiazepine overlap differ between primary care providers and specialist providers? - Commercial compared to Medicare Advantage patients2c. If response to the CDC guidelines and payer pharmacy coverage change discouraging prescribing first-time opioid prescription at doses ≥50MME per day differ when prescribing to commercially insured and Medicare Advantage patients? 2d. If response to the CDC guideline on prescribing first-time opioid with benzodiazepine overlap differ when prescribing to commercially insured and Medicare Advantage patients? - Urban compared to rural primary care service areas (PCSAs)2e. If response to the CDC guidelines and payer pharmacy coverage change discouraging prescribing first-time opioid prescription at doses ≥50MME per day differ when prescribing in urban and rural PCSAs? 2f. If response to the CDC guideline discouraging prescribing first-time opioid with benzodiazepine overlap differ when prescribing in urban and rural PCSAs? Following the CDC guidelines release, the rate of opioid prescriptions decreased, and may have impacted opioid sales by pharmaceutical companies. Opioid marketing encounters with providers are one of the ways pharmaceutical companies boost the rate of prescription and sale of opioids. In response to the CDC guidelines, there is no documentation on whether pharmaceutical companies may have also made changes in their opioid marketing practices to help boost opioid prescriptions following the CDC guideline release. Hence, we also evaluate 3a) If the CDC guidelines are associated with changes in total monthly pharmaceutical opioid amount received per provider and if these changes differ when marketing to primary care compared to specialist providers, and also when marketing to urban PCSA compared to rural PCSA providers.3b) If the CDC guidelines are associated with changes in pharmaceutical opioid marketing encounters per provider per month and if these changes differ when marketing to primary care compared to specialist providers, and also when marketing to urban PCSA compared to rural PCSA providers. 3c) If the CDC guidelines are associated with changes in pharmaceutical opioid marketing spending per encounter and if these changes differ when marketing to primary care compared to specialist providers, and also when marketing to urban PCSA compared to rural PCSA providers. To answer the first two group of questions (1a-1c, 2a-2c), we used claims data from OptumLabs® Data Warehouse between January 2014 and December 2018. Subjects were continuously enrolled opioid naïve patients ≥18 years old who had at least one chronic pain condition diagnosis within 2 weeks before their first (first-time) opioid prescription. We used multiple treatment period segmented regression discontinuity analysis to answer first two group of questions. To answers the third group of questions (3a-3c), we used data from the open payment database from CMS between August 2013 and December 2017. We used single and multiple groups interrupted time series analysis to answers the third group of questions.We found the CDC guidelines were not associated with any change in the rate of first-time prescriptions of extended-release opioids. However, a January 2017 payer pharmacy coverage change requiring prior authorization and provider attestation before initiating long-acting opioids instead of immediate release opioids was associated with a reduction in the rate of first-time extended-release opioid prescription by 22 in every 100,000 prescriptions [CI -40.04 to -2.92, P=0.013]. The CDC guidelines were associated with an immediate decline in level of first-time opioid prescription at doses ≥50MME per day by 74 in every 10,000 prescriptions [CI -124.86 to -23.13, P=0.004], and an increased rate of decline by 14 in every 10,000 prescriptions [CI -17.07 to -10.21, P<0.001]. These associations varied across different provider types and specialties. The March 2018 payer coverage change was associated with an immediate reduction in level of first-time opioid prescriptions at doses ≥50MME per day across all specialties. The CDC guidelines were also associated with a reduction in the rate of first-time opioid prescription overlap with benzodiazepines among family medicine, internal medicine, surgeons, emergency medicine providers, and providers with unknown specialty by 6, 5, 3, 11, and 9 in every 10,000 prescriptions monthly respectively [CI -9.48 to 02.73, -9.86 to -0.35, -5.40 to -0.38, -17.26 to -5.61 and -11.96 to -6.25 respectively, P<0.001, P=0.035, P=0.024, P<0.001 and P<0.001]. We found a larger decline in the rate of prescribing first-time opioid dose ≥50MME per day and first-time opioid prescription with benzodiazepine overlap following the CDC guidelines release among specialist providers than primary care providers. Prescribing first-time opioid fills at doses ≥50MME per day declined following the CDC guidelines release and payer coverage change, and the decline was more significant among specialist providers than PC providers and in rural PCSAs than Urban PCSAs. Also, following the CDC guidelines release the decline was more significant among MA patients however following the payer coverage change the decline was more significant among commercially insured patients. Decline in first-time opioid fill with benzodiazepine overlap did not differ between provider and insurance types and rural and urban PCSAs. Following the CDC guideline release, the monthly number of marketing encounters per physician and total monthly amount received per physician decreased. However, the amount spent at each marketing encounter increased. The CDC guideline release was associated with an immediate increase in level of opioid marketing spending per encounter by $0.59 (CI, $0.51 to $0.68, P< 0.001) and an over-time increase in rate of spending per encounter of $0.04 per month (CI, $0.03 to $0.05, P< 0.001). Physicians who received higher amounts per encounter also received a higher frequency of encounters. Following the CDC guideline, the immediate increase in level was greater when marketing to specialists than primary care physicians by $32 (CI, $0.16 to $0. 48, P=0.031), while increase in rate of spending per encounter was less among specialists compared to primary care physicians by $0.02 per month (CI, -$0.04 to -$0.01). The immediate increase in level was greater when marketing in urban PCSAs than rural PCSAs by $0.26 (CI, $0.05 to $0.46, P<0.001), while increase in rate of spending per encounter was less in urban PCSAs compared to rural PCSAs by $0.02 per month (CI, -$0.04 to -$0.001). Conclusion and Relevance: Some specialist providers also adopted the CDC guidelines. The CDC guidelines were associated with a reduction in some high-risk first-time opioid prescriptions. Payer pharmacy coverage changes were associated with such reductions, both in situations where the CDC guidelines did and did not show any associated reductions. Responses to the CDC guideline and payer pharmacy coverage changes differ between primary care and specialist providers, providers in urban and rural PCSAs and prescribing to Medicare Advantage and commercially insured patients. Understanding factors that may influence guideline adoption, such as provider specialties, patient insurance types, and location in urban or rural PCSAs is important and can help inform future opioid guidelines. The CD guideline release were associated with changes in pharmaceutical opioid marketing practices. Following the CDC guidelines, pharmaceuticals reduced their total spending per physician and number of marketing encounters to physicians but increased the value of food and beverages served at each encounter subsequently. The associated increase in the amount spent per opioid marketing encounter was more significant to specialists than primary care physicians and in urban than rural PCSAs. It is important to continue ongoing education for physicians to increase their awareness of pharmaceutical opioid marketing practices.