Opioid Prescribing Is Down, Yet Alternative Pain Treatments Remain Underused

https://www.practicalpainmanagement.com/news/opioid-prescribing-is-down-yet-alternative-pain-treatments-remain-underused

New study confirms reduction in opioid prescribing for cancer pain and non-cancer pain but, surprisingly, no matching increase in opioid alternatives. So how is chronic pain being treated?

New study confirms reduction in opioid prescribing for cancer pain and non-cancer pain but, surprisingly, no matching increase in opioid alternatives. So how is chronic pain being treated?

Since the CDC issued its practice guideline on prescribing opioids for chronic pain in 2016, professional organizations, payers, and many physicians have been moving away from opioids and looking toward other, often multidisciplinary, treatments to manage pain, including cancer-related pain.

According to a brand new study, opioid prescribing is indeed down – however, opioids do not seem to have been replaced with other therapies. The research, published August 10 in PLoS ONE, was led by Sachini Bandara, PhD, and Emma McGinty, PhD, of Johns Hopkins Bloomberg School of Health, and Mark Bicket, MD, PhD, of the University of Michigan.

When the CDC released its initial guidelines on opioid prescribing for chronic pain, the recommendations were largely in line with guidance from professional organizations calling for physicians to write fewer prescriptions for opioids and to instead use non-opioid drugs and non-pharmacological therapies as first-line treatments, explained Dr. Bandara, assistant professor and drug policy researcher at Johns Hopkins and first author on the study.

At the time, she noted, physicians as well as pain-advocacy communities warned that reduced opioid prescribing could have a negative impact on patients with chronic non-cancer pain if their pain was not properly managed with non-opioid therapies. The aim of the present study, wrote Dr. Bandara and team, was to find out whether opioid prescribing was actually decreasing and if non-opioid treatments were increasing correspondingly.

Previous reports have demonstrated a decrease in opioid prescribing overall between 2010 and 2020, but individuals with cancer and palliative, end-of-life-care were specifically excluded from the CDC recommendations on opioid use for pain. Dr. Bandara’s team looked at data from between 2012 and 2019, focused on opioid prescribing for pain in people with and without cancer, and found that the number of privately insured adults who were prescribed opioids for pain (both cancer pain and chronic non-cancer pain, or CNCP) declined during that period.¹

So while their report aligns with prior data, what is new is that opioid alternative use has not increased, begging the question: are individuals living with chronic pain getting the pain relief they need?

Using the IBM Marketscan Research Databases from 2012 to 2019, which include insurance claims and encounters for between 26 million and 53 million individuals covered by private insurance companies Bandara et al identified individuals who were diagnosed during that period with cancer pain or non-cancer pain, including low-back pain, neuropathic pain, headaches, and arthritis.

Their records analysis showed that the number of people who received an opioid prescription declined from 49.7% to 30.5% for those with chronic non-cancer pain and from 86% to 78.7% for those with cancer pain. In addition, of those who did receive opioid prescriptions, fewer received extremely high doses or more than one week’s supply of the medication.

Meanwhile, non-opioid prescriptions remained steady (from 66.7% to 66.4%) for people with non-cancer pain and increased slightly (from 74.4% to 78.8%) for those with cancer pain. “We see opioid prescribing going down, while non-opioid prescribing is not increasing to fill that gap,” said Dr. Bandara.

Non-pharmacological therapies (eg, interventional procedures, physical therapy and exercise, mental health care) do not appear to be filling the gap either. A secondary analysis of the data, which looked at a subset of the sample of patients with CNCP, found that substitution of non-pharmacological therapies in place of opioid therapy in patients with CNCP was 3.5% in 2019, essentially unchanged from 2013, when it was 3.4%.

Mark Bailey, DO, PhD, was not surprised by these findings. “We’ve known this for a long time,” he said, pointing out that the trend of prescribing fewer opioids has been underway since about 2012. Dr. Bailey, director of the neurology pain division at University of Alabama at Birmingham School of Medicine, said his perception is that people with cancer are not getting less pain medicine, but he does note that oncologists seem to be less willing to write prescriptions for pain. “I’ve definitely seen this, because they’re sending me their dying patients to take care of their opioids for them.”

Dr. Bailey also pointed out that, while there is an abundance of data showing that doctors are prescribing fewer opioids, overdose deaths are still rising dramatically, suggesting that people (whether they are under care or not) may be just “changing the drug of choice from prescription drugs to street fentanyl.”

He added, “I think the take-home message is that prescribing less medicine has not curbed the overdose death rate; it has skyrocketed. But it’s not the drugs that we prescribe anymore. All the hoops and laws and regulations and guidelines that we put on ourselves have not fixed the problem they were designed to fix.”

And those efforts have created other problems. Jeffrey Bettinger, PharmD, clinical pharmacist and specialist in pain management at Saratoga Hospital Medical Group, pointed out that he is now seeing patients with non-cancer chronic pain and palliative care needs as well as cancer-related pain who are no longer able to get the same pain relief they got with opioids.

In this special series, Dr. Bettinger and Reed J. Yaras, DO, analyze the CDC opioid prescribing guideline revisions, including patient populations with and without cancer, which are expected to be released later this year.

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My story of how state medical boards can end careers and the Ruan Court decision

https://youtu.be/yy2rj82fABU

Because I choose to treat pain refugees who were refused pain care by 10+ doctors, I came up as an overprescriber, which scared the North Carolina Medical Board. (see future youtube video on overprescribing). The only doctors send to prison or had their licenses taken are doctors treating pain, no others

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Extending the list to others in the field of pain advocacy and research

Professors and Doctors, and Medical Researchers (Please distribute this redacted version w/o names)

This is an email to my doctor who is wanting to taper me off all opioids because he thinks I have Opioid Induced Hyperalgesia, so sorry for the not introducing the topic part.  If you feel like sharing my sitation with another others or first want more data, I can provide what I have.  I agree one thing – I should not be having 9/10 pain on 50 ug/hr of fentanyl and 10 mg Percocets TID, but it is what it is.  The question is -what is the cause and thus the right treatment?  Would a spinal cord simulator at L4 or wherever the knee nerves emerge, solve all 4 root causes?  Or would opioid rotation be your first choice to hit all possibilities?  Share with anyone you like, for my life is on the line and I welcome all the help I can get.  I hereby for HIPAA purposes in good mind and faith submit this to anyone you like.

No luck with RF ablation.  I’m going out of my mind due to pain.  During periods of decent analgesia, I have found 4 possible reasons for my predicament, and I have no clue which is right and if any treatment modality would help 2 or more or what testing might narrow it down.

1. Opioid Induced Hyperalgesia – After long term opioid use, a person becomes more sensitive to less painful signals.  The problem with this is that my pain is specific to the very targeted area of my knee medial meniscus. Improves with dose reduction.
2. Opioid Tolerance – loss of analgesic efficacy over exposure to an opioid.  Apparently this can happen to any opioid at any dose, and improves with dose escalation.
3. Maladaptive neuroplasticity – the spinal cord “learns” a repeated pain signal sent over and over again.
4. Central sensitization – the spinal cord becomes amplified much like maladaptive neuroplasticity.

I don’t know much about neuroscience, far less than you do, but it so it aeems that treatment needs to first figure out the right answer to 1-4 above, because for example 1) and 2) both suggest different dose strategies, though apparently opioid rotation treats both.  I found one decent paper on hyperalgesia, but I have only scratched the surface. Do you know how to tell these apart?  Here is what I know about each.

In January 2022, when swapped out Oxycontin for Fentanyl, for months my pain scores fell from7-9 to less than half or around 4-5.  When my dose was increased for the trial of 4 percocets, the pain was a bit easier to manage, and at 3.5 its been a bit harder to manage, and at 3 even harder.  When I say harder to manage, I mean its harder to catch pain at a 7 from going to a 9.5 with less medicine.  While these changes are small as a percent of my dose, the though dose-equivalent MME switch from Oxycontin to Fentanyl both at 120 MME did give me a stronger opioid, and pain fell hard, just as you would expect with opioid tolerance.

OIH was new to me.  I’ve asked professors, and I get mixed feedback.  Some think it isn’t a real phenomena and said it was mostly due to intrathecal morphine pump users who when their doses were reduced, their pain improved.

Dr. C, the interventional pain guy who did my RF ablation, came up with number 3 on the list.  He said over time, the nervous system becomes highly efficient at transmitting a pain signal over and over, but the rotation to fentanyl, even this was true, fixed the problem.

The fourth one came from Dr. B, but I found it in the literature.  He said my specific type of spinal cord damage predisposed me to central sensitization, which he called “wind up phenomena” which I also found papers on.

I’m not being a whinny patient who wants more and more opioids.  Yes the 4 Perocet was a band aide over the real problem.  But which of the 4 reasons behind my severe knee pain escapes me, but I’m no MD.  Dr. B did warn me about central sensitization long ago, and Dr.C pointed to number 3 on the list.  In fact, since the swap to fentanyl worked for 3 if that is the culprit, opioid rotation should work for 1, 2 and 3.  I deeply regret getting into this mess, and wish I never asked about my knees, but even Dr. J didn’t want to do a knee replacement before November 2021, and that is when I went to the head of orthopedics, Dr. R, who did my hip replacement in 1998 and got me in the clinical trial for the ceramic/ceramic hip, reportedly one of the top joint docs worldwide, and he told me no to knee replacement, so to check on his opinion I went to another medical univerisy orthopedics, who told me the same thing.  They said I’d have just as much pain after surgery as before surgery, and that knees are not replaced due to pain, but due to mechanical issues like knees locking up or other such phenomena.

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This appears to another “bench trial – no jury “, in a FEDERAL COURT – where historically anyone taken to a federal court – 90+% are found guilty. It is also odd that they claim that Walgreens “shipped” 1 out of every 5 Oxycodone & Hydrocodone doses nationally and yet Walgreen has/had about 10,000 community pharmacies out of a total of abt 50,000 community pharmacies.  None of the filled opiate Rxs were illegal prescriptions.

I find it strange that they are going after Walgreen and does not appear to be going after even the FIRST PHARMACIST for filling any of these opiate Rxs. With 10,000 pharmacies, Walgreen could have some 30,000 pharmacists working for them.  Legally, it is the Pharmacist that has the final say if a Rx is legit and should – or should not – be filled.  I guess that it was going to be a very expensive going after all/some of those 30,000 Pharmacists for filling these opiate Rxs… with little financial rewards to the bureaucrats… So they went after the single entity with the deepest pockets.  They state in the article that Walgreen paid a 80 million dollar fine to the DEA almost 10 yrs ago…  So that didn’t cause any real visible financial harm to Walgreen with that large fine… so it would seem like the bureaucrats and our legal system appear to be treating the corporations involved in opiate manufacturing and distribution like ATM machines that they can come and “withdrawal” money every decade or so.  They don’t want to run them out of business, too many people would be harmed from employees of these corporations to pts that are be taken care of by these corporations and there is not enough reserve capacity available to absorb and take care of all the people who would basically be tossed to the curb.  Besides, that could possibly mean that is one last corporation they come after every decade or so .. to extract money from.

Walgreens ‘Helped Fuel’ Opioid Crisis in San Francisco, Says Judge

https://reason.com/2022/08/11/walgreens-helped-fuel-opioid-crisis-in-san-francisco-says-judge/

Is Walgreens an illicit drug dealer? That’s essentially what a federal court has ruled, suggesting the pharmacy should have stopped “suspicious orders” for opioids from being filled. In failing to do so, the retailer “substantially contributed” to the opioid epidemic in San Francisco, Judge Charles Breyer of the U.S. District Court for the Northern District of California ruled.

Walgreens was “responsible for shipping nearly 1 out of every 5 oxycodone and hydrocodone pills distributed nationwide during the height of the opioid crisis,” reports The Washington Post. And “more than 100 million prescription opioid pills were dispensed by Walgreens in [San Francisco] between 2006 and 2020,” notes the Los Angeles Times.

Walgreens isn’t accused of filling fake prescriptions; the opioid orders it filled were written by licensed doctors. But some of these doctors had “suspect prescribing patterns,” noted Breyer. And other orders were written by doctors who would go on to have their licenses revoked or face criminal punishment. The judge agreed with the city and county of San Francisco, which brought the suit, that Walgreens pharmacists were negligent in not realizing something was afoot and therefore illegally contributed to a public nuisance. A trial will be held to determine damages owed.

“The effects of the opioid epidemic on San Francisco have been catastrophic. The city has fought hard and continues to do so, but the opioid epidemic, which Walgreens helped fuel, continues to substantially interfere with public rights in San Francisco,” Breyer wrote.

This seems, frankly, insane. Walgreens fills prescriptions. It is not in the business of drug enforcement. If some of the prescriptions filled by Walgreens were written by dirty doctors or went to people who abused them, it is not on individual pharmacists to figure that out.

Expecting pharmacists to be drug cops, too, ensures that more pharmacies will be hesitant to fill legitimate prescriptions, leaving patients in the lurch. It also threatens to worsen America’s pharmacist shortage.

In a number of recent cases, pharmacies and pharmacists have been sued for not filling prescriptions. including opioid prescriptions. It seems we’ve put them in a classic damned if you do, damned if you don’t situation.

This isn’t the first time Walgreens has been found guilty of opioid crimes. Last fall, a federal court in Ohio found CVS, Walgreens, and Walmart guilty of ignoring “red flags” about opioid prescriptions and thereby contributing to a “public nuisance.”

In 2013, Walgreens had to pay $80 million in civil penalties after the Drug Enforcement Administration (DEA) said it was negligent in filling narcotic prescriptions.

Under the Controlled Substances Act, pharmacies are required to have systems in place to monitor for suspicious orders. And Walgreens did. But the DEA—and now Breyer—say Walgreens’ policies weren’t sufficient.

The case showcases yet another bananas aspect of America’s war on drugs.

To sum it up: Walgreens filled prescriptions for a legal substance, but because some people went on to distribute or use the drugs in ways the government has forbidden, the company has to pay the government huge sums of money. Meanwhile, the inability of people to get prescription painkillers has given way to reliance on much more dangerous substances, like fentanyl, from which many more people are dying of overdoses. People keep taking opioids, and the government keeps making it harder for them to do so safely.

“These cases, along with thousands of other lawsuits by state and local governments that blame legal drug suppliers for opioid-related addiction and deaths, ask courts to focus on one link in a long causal chain,” noted Reason’s Jacob Sullum last November. “That chain includes decisions by state and federal regulators as well as actions by manufacturers, distributors, doctors, pharmacists, patients, black-market dealers who sell diverted pills, and nonmedical users who consume them.”

“We never manufactured or marketed opioids, nor did we distribute them to the ‘pill mills’ and internet pharmacies that fueled this crisis,” said Walgreens spokesman Fraser Engerman in a statement yesterday. “The plaintiff’s attempt to resolve the opioid crisis with an unprecedented expansion of public nuisance law is misguided and unsustainable. We look forward to the opportunity to address these issues on appeal.”

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CVS/Aetna’s $9 billion in profits paid for a lavish party and stock buybacks. Not patients’ medical claims.

https://wendellpotter.substack.com/p/cvsaetnas-9-billion-in-profits-paid
CVS/Aetna’s spending included trips to Disney and a John Legend concert for employees.

A few days after executives of CVS/Aetna won a resounding thumbs up from Wall Street last week, they headed south (many undoubtedly on private jets) to Disney World for a lavish “leadership” party they threw themselves.

Thanks to videos posted on social media by some of the partiers, we know the company hired John Legend to entertain them.

John Legend doesn’t come cheap. Back in 2015, he reportedly was paid $300,000 to sing two songs at a Beverly Hills wedding. Luxury wedding planner Scarlet tells clients it will now cost them $1 million (plus travel and production costs) to snag Legend for their big events. We don’t know what his corporate rate is, but I doubt he would charge the country’s fourth largest corporation anything less than that.

Meanwhile, a few miles southwest of Orlando, friends of cancer patient Jasen Garrity are trying to raise $10,000 on GoFundMe to cover the out-of-pockets Aetna made Garrity pay before his treatment could begin. As the fundraiser’s organizer wrote:

Jay currently requires an insertion of a tracheotomy to allow him increased ability to breathe. It is difficult for him to sleep. Robin (his wife) is awake most nights worrying over Jay. To get the trach inserted Jay will need to be admitted to the hospital for 6 days and the hospital requires $2600.00 to even schedule the surgery because Aetna’s family deductible has reset.

Garrity’s story is by no means unique. While CVS CEO Karen Lynch and other executives were swag surfin’ in Florida, thousands of American patients have had to turn to GoFundMe because they can’t afford the deductibles, copays, and other out-of-pockets insurers demand they pay. In fact, 100 million Americans–most of them insured by Aetna and other big insurers–are mired in medical debt. As Kaiser Health News reported in June:

In the past five years, more than half of U.S. adults report they’ve gone into debt because of medical or dental bills…A quarter of adults with health care debt owe more than $5,000. And about 1 in 5 with any amount of debt said they don’t expect to pay it off…The burden is forcing families to cut spending on food and other essentials. Millions are being driven from their homes or into bankruptcy.

While Jasen Garrity and millions of other insured Americans with serious health issues were begging for money to stay alive last year, Lynch hauled in more than $20 million, 458 times the average pay of other CVS employees. Also know that Aetna is spending considerably less paying patients’ medical claims as a percentage of revenues this year than last year, despite the fact that CVS collected billions more from its customers during the first six months of this year than in the same period in 2021 ($157.5 billion and $141.7 billion respectively).

That enabled the company to report making $9.3 billion in profits during the first half of 2022, $200 million more than during the first half of 2021. This year is off to such a good start for CVS that Lynch and her fellow executives told investors last Wednesday that they believe profits will be higher this year than they previously had expected.

Wall Street loved that news. By the time the New York Stock Exchange closed Wednesday afternoon, investors had bid the company’s stock up 6%, according to CNBC. 

CVS execs gave no indication they’ll use any of the extra billions to help customers like Jasen Garrity stay out of bankruptcy. They did say a few months ago, however, that they will spend up to $10 billion this year buying back shares of CVS stock, a gimmick that will increase the value of the millions of shares of CVS stock that Lynch and other company executives own.

By the way, most of the company’s revenues are now coming from the pharmacy benefit manager (PBM) it owns, not from its health plans and retail stores. During the first half of 2022, its PBM revenues totaled $82.3 billion, far more than the $45.9 billion from Aetna’s health plans and the $51.7 billion from CVS stores.

As patient advocate Beth Joyner Waldron tweeted about the company’s leadership bash in Orlando:

Beth Joyner Waldron @BethWaldron

How ironic CVS threw this party using patient profits the very weekend Congress passed a drug bill which excluded addressing the PBM industry & kickbacks they receive from pharma. We will NEVER get to the root of drug price inflation until we also address PBMs & formularies.

Beth Joyner Waldron @BethWaldron

It’s time for patients & clinicians to speak up LOUDLY against corporate practices which reduce our access to needed care while they reap record profits & party on completely deaf to our needs. Greater government protections for patients are needed ASAP to ensure patient safety.

I encourage you to read Waldron’s thread, which along with the pics and videos she found of CVS’ partying leaders, went viral. (If you have time, you might also consider reading a piece I wrote several years ago about the lavish parties insurers throw every year–using customers’ money–to reward their top sales executives. And take a look at the thread I wrote in March about the role Karen Lynch and Cigna CEO David Cordani played in creating America’s growing out-of-pocket debt crisis.)

I also encourage John Legend to donate whatever CVS paid him to help cover the outrageously high out-of-pocket expenses millions of insured Americans are desperately trying to cover.

I doubt he knew the enormous pain and suffering Aetna’s high out-of-pocket requirements are causing for so many. And based on this Twitter thread from 2020, I believe his heart is in the right place:

John Legend @johnlegend

It’s a trap for progressives to try to talk about healthcare as some sort of free market like they’re talking about tvs or cell phones. Healthcare is a necessity and there’s very little choice when you’re actually sick. You need treatment and you need it to not bankrupt you

He went on to say:

John Legend @johnlegend

And the so-called “market” for healthcare is so opaque, there are few if any perfectly informed consumers. And no one can predict what healthcare they’ll need in the future.

John Legend, the work I do now is an attempt to make amends for the years I helped big insurers make Wall Street happy and for all the leadership junkets I attended. I call on you to make amends for your ill-advised private CVS concert by supporting the important work of the Lower Out of Pockets NOW Coalition. We won’t rest until we make Aetna and the rest of Big Insurance change so their customers can stay out of bankruptcy and away from GoFundMe.  You can make an enormous difference if you’ll join us.

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CDC: Few Insured Patients With Hepatitis C Get Timely Treatment

— Not even one-third received curative drugs within a year of diagnosis

https://www.medpagetoday.com/infectiousdisease/hepatitis/100158

Although hepatitis C infection is a highly curable disease, few insured patients diagnosed received direct-acting antiviral (DAA) treatment during 2019-2020, while disparities contributed to treatment delays, according to new CDC data appearing in an early edition of the Morbidity and Mortality Weekly Report.

Adjusted multivariable regression analysis showed Medicaid recipients were least likely to initiate DAA treatment within 360 days of testing positive for hepatitis C infection (23%). Medicare recipients fared somewhat better (28%), as did individuals with private insurance (35%).

Adjusted odds ratios relative to private insurance for receiving DAA therapy were:

• Medicaid: 0.54, 95% CI 0.51–0.57
• Medicare: 0.62, 95% CI 0.56–0.68

And among those treated at some point, more with private insurance received it within 180 days of initial diagnosis (84%) compared with those on Medicaid (75%) or Medicare (77%), reported Carolyn Wester, MD, MPH, director of the Division of Viral Hepatitis at the CDC, and colleagues.

Medicaid is the least likely insurer to cover DAA treatment, so it was no surprise that residents of states with Medicaid treatment restrictions were less likely to initiate treatment, versus those in states without them (aOR 0.77, 95% CI 0.74–0.81).

Hepatitis C viral infection impacts over 2 million Americans with incidence on the rise — especially among young individuals with injection drug use — and leads to 14,000 annual deaths nationally. Eight to 12 weeks of DAA treatment is recommended to effectively cure 95% or more hepatitis C cases. Despite this, only about 1.2 million individuals initiated DAA treatment from 2014 to 2020, which remains far below the national elimination goal as fewer seek treatment.

“Everyone with hepatitis C should have access to lifesaving treatment, regardless of race, ethnicity, age or insurance status,” said CDC Acting Principal Deputy Director Debra Houry, MD, MPH, in a press release. “What these data tell us is that at best, only one in three people are treated within a year of being diagnosed and we must reduce the barriers and get more people treated for hepatitis C in our country. This is critical to stop preventable deaths and prevent new infections.”

For this report, CDC researchers retrospectively examined Health Verity data on over 2 million patients with hepatitis C across all 50 states and the District of Columbia from Jan. 30, 2019, to Oct. 31, 2020. Those included were adults ages 18-69, who were continuously insured for at least 60 days before and at least 360 days after their diagnosis. The analysis adjusted for demographics, insurance payor, and Medicaid restrictions.

Younger people – ages 18-39 – on Medicaid or private insurance had the lowest rates of treatment initiation, versus those ages 50-59. Across all insurance plans, men had consistently lower odds of initiating treatment than did women.

Among Medicaid recipients, odds of treatment initiation were lower for Black individuals (aOR, 0.93, 95% CI 0.88–0.99) or those coded as “other” for race (aOR 0.73, 95% CI 0.62–0.88), versus whites.

To increase treatment access, researchers suggested removing eligibility restrictions/preauthorization requirements, providing treatment where patients already receive services in as few visits as possible, and expanding primary care providers who can treat hepatitis C.

“People shouldn’t have to jump over hurdles to access lifesaving, cost-effective treatment,” said Wester in the CDC’s press release. “Removing barriers to treatment is a critical step, as is increasing screening for hepatitis C. We estimate about 40% of people with hepatitis C in the U.S. are unaware of their infection — testing is the first step to accessing curative treatment.”

Wester and colleagues acknowledged that the findings may not be generalizable to all hepatitis C patients, since those incarcerated or uninsured were excluded. Treatment initiation rates could have been overestimated, while data on ethnicity were missing for 61% of people included in the analysis.

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https://www.eventbrite.com/e/advancing-syringe-services-in-the-us-the-untapped-role-of-the-ada-tickets-339958243257

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Here’s who Democrats’ drug pricing bill will actually help

https://www.statnews.com/2022/08/09/democrats-drug-pricing-bill-will-help-medicare-patients/

WASHINGTON — Millions of patients in the Medicare program could eventually see lower prescription drug costs if Democrats pass their latest drug pricing plan into law.

The plan, which cleared a major hurdle Sunday when the Senate very narrowly approved it, has four major policies — it would allow Medicare to negotiate prices for some costly drugs, penalize drugmakers for hiking prices faster than inflation, redesign Medicare’s prescription drug benefit and cap annual costs at $2,000, and cap Medicare patients’ insulin costs at $35 per month.

Those changes won’t take effect right away. Most wouldn’t take effect until 2024; negotiated drug prices won’t be in place till 2026. The cap on insulin costs comes a little sooner, in 2023. And drugmakers that hike their prices would face penalties starting in October.

Democrats’ drug pricing reforms also won’t help as many people as they had originally hoped, as two major provisions that would have affected people who get insurance through their jobs ran afoul of Senate rules.

That means most of the patients who will directly benefit from the policy are adults 65 and older who are in the Medicare program. STAT has compiled a list of the categories of patients who are most likely to see benefits at the pharmacy counter.

There’s one big variable to keep in mind — insurance premiums. At least for a little while, as Medicare’s benefits get more generous and more patients can afford drugs, spending may go up.

“The premium effect is really difficult to predict, almost more difficult than the effect on drug prices,” said Juliette Cubanski, the deputy director of Medicare at the Kaiser Family Foundation.

The legislation would cap premium increases at 6% per year through 2029 to help decrease the impact, but it’s possible in the short-term that some beneficiaries could pay more for premiums than they would save.

None of the policies in Democrats’ package would directly affect people who get insurance through their jobs, or through Affordable Care Act marketplaces. There’s a raging debate over whether the pharmaceutical industry will charge these patients more to make up for lost money, or whether cost controls in Medicare could set a precedent for other insurers to demand lower prices, as well.

It seems counterintuitive, but Medicaid programs could actually have higher costs too if drugmakers raise their prices more slowly, according to congressional budget analysts. If that trend continues, it will cause states to have to make choices to work around the financial hit.

Medicare patients who pay a lot for drugs

The most obvious benefit is in the part of Medicare that covers drugs sold in pharmacies, Part D, where the reform package would cap patients’ annual out-of-pocket costs at $2,000 and spread them throughout the year, starting in 2024.

There are differing estimates of how many people could benefit from the cap.

Kaiser Family Foundation analysts found that 1.4 million people with traditional Medicare benefits spent $2,000 or more in 2020. An estimate co-authored by Sean Dickson, director of health policy at the West Health Policy Center, found that if a $2,000 out-of-pocket cap had been instituted in 2021, at least 3.1 million patients would have seen savings.

While many older adults may not spend more than $2,000 per year on their drugs right now, the new annual cost protections ensure financial protections for the future, said Vanderbilt University associate professor of health policy Stacie Dusetzina.

“People should be really excited. Medicare Part D has been an incredibly beneficial program for older adults, [and it] does not work for people who need expensive drugs,” Dusetzina said.

It’s unclear whether patients who take drugs that Medicare ultimately negotiates starting in 2026 will save money simply because of the negotiation.

They’re likely to be expensive, so it’s possible folks will still hit that $2,000 cap anyway. But if not, patients would likely end up paying a percentage of the lower price, which could save them money on each prescription fill.

Low-income patients on Medicare

The package also includes a change to Medicare’s low-income benefits for pharmacy drugs — a provision that has flown a bit under the radar.

Right now, Medicare enrollees who make between 135% and 150% of the federal poverty level get some help from the federal government for their drug costs, but they still have to pay 15% of the prices of their drugs. For 2022, 150% of the federal poverty level is $20,385 for a single person.

Starting in 2024, Democrats’ plan would allow people making up to 150% of the federal poverty level to get full benefits. That means they would have a set, low cost for each prescription instead of paying a percentage of the full price.

Around 400,000 people fell into that category in 2020, per a Kaiser Family Foundation analysis, but Dusetzina said there may be more patients out there who are eligible, but not enrolled.

“This is a really big deal because by definition, these patients are near poor but still have high cost-sharing,” Dusetzina said.

Medicare patients who use insulin

Democrats’ drug pricing plan would also force all plans in Medicare to offer insulin at a maximum of $35 per month for patients starting next year.

Medicare beneficiaries already have options to buy a plan that caps insulin costs at $35 per month, but about a quarter of Medicare patients still paid more than that in 2021, per data compiled by the the life science analytics firm IQVIA.

It’s a quick turnaround, as plans have already submitted their premium estimates for next year, but insurers have factored in that this policy could become law, West Health’s Dickson said.

Medicare patients taking drugs on the market now

It wouldn’t necessarily lower drug prices, but Democrats’ proposal to penalize drugmakers that hike prices faster than inflation would provide more predictable prices for Medicare patients.

This policy is the first scheduled to go into effect. The penalties would start in October for pharmacy drugs, and in January for drugs that are administered in doctors’ offices.

It’s hard to predict the future of which drugs would have seen dramatic price spikes, but similar to the annual cost protections, it allows more predictability for Medicare patients. However, half of drugs covered by Medicare took price hikes steeper than inflation in 2020, according to a Kaiser Family Foundation analysis.

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Disney Epcot. LOTS of Disney photos floating around social. Reddit says some CVS ‘leadership experience’ attendees were given spending money for Epcot because it was a ‘team building exercise’. 🤔 pic.twitter.com/R5Iev9RIAp

— Beth Joyner Waldron (@BethWaldron) August 8, 2022

The most recent quarter CVS reported abt a 3 BILLION net profit (pretax)… the above apparently is from a recent “upper echelon management” is REWARDED for helping CVS generate all those $$ in profits…

from the twitter post  ” The private John Legend concert CVS Health hosted (despite restrictive formularies, non-medical switching & denying patients medication access due to cost) was just the icing on the cake CVS leaders enjoyed this week in Orlando. Let’s take a peek at good times on patient dime…“

https://twitter.com/i/status/1556442291480436736

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Pain Management in Breast Cancer Outpatients

https://www.uspharmacist.com/article/pain-management-in-breast-cancer-outpatients

Pain is reported by 25% to 89% of breast cancer (BC) patients during the disease process. This pain, which may be due to disease progression, surgery, or drug treatment, can range from mild to severe and can be of short or long duration. Little is known about how this pain is managed in the outpatient setting.

A retrospective, administrative claims data study utilizing information from the National Ambulatory Medical Care Survey (NAMCS), which is a national probability cross-sectional sample survey of office-based medical care services, was conducted to examine pain management practices and the factors associated with the prescription of pain medications, especially opioids, in women with BC. The study analyzed NAMCS data obtained between 2011 to 2016.

Women aged 18 and older years were included in the study if—based on either International Classification of Disease-9 (ICD-9) or ICD-10 codes—BC was their primary diagnosis. The medications were classified using the American Hospital Formulary Service (AHFS) classification and included opioids, nonopioids (e.g., nonsteroidal anti-inflammatory agents, acetaminophen, salicylates), and combinations of both drug classes. Adjuvant analgesics included the anticonvulsants (e.g., barbiturates), antidepressants (e.g., selective serotonin reuptake inhibitors, serotonin norepinephrine reuptake inhibitors, tricyclic antidepressants), and corticosteroids.

Between 2011 and 2016, 23.95 million office visits were made by women with a primary diagnosis of BC. Of this group, over one-half (50.81%) were aged 40 to 64 years. One-third (32.81%) of visits occurred in the Northeast region, with almost all (95.65%) occurring in metropolitan areas. The vast majority of patients (83.7%) were identified as White. Most of these patients (84.93%) were seen in general and family practice settings. Depression and diabetes were the most common comorbidities.

During these visits, over one-quarter (27.12%, or about 6.5 million women) received pain medications. Among the total study population, 15.16% received opioids, 17.13% were prescribed nonopioid analgesics, and 22.7% received adjuvant therapies. Over one-tenth (10.27%) of patients received combination analgesics. Tramadol and oxycodone were the most prescribed opioids (3.75% and 1.57%, respectively). Ibuprofen, followed by naproxen, were the most prescribed nonsteroidal anti-inflammatory agents (3.73% and 1.27%, respectively). Benzodiazepines, followed by glucocorticoids, were the frequently prescribed adjunctive therapies (7.61% and 6.98%, respectively).

Factors significantly associated with the decreased prescribing of analgesics included residing in the Northeast as opposed to the West (odds ratio [OR] = 0.31, 95% CI -0.10 to 0.99), being White as opposed to Black (OR = 0.5, 95% CI 0.3-0.85) and being seen by nonprimary care physicians rather than primary care physicians (OR = 0.37, 95% CI 0.15-0.94). Being on Medicaid or other state-based payment programs as opposed to having private insurance (OR = 2.38, 95% CI 1.15-4.93), being prescribed adjuvant medications versus not receiving these agents (OR = 4.74, 95% CI 3.10-7.24), and visiting general or family practice specialties compared with other specialties (OR = 3.18, 95% CI 1.22-8.29) were associated with increased prescribing of pain medications.

The only two factors that were significantly associated with opioid prescribing were geography and medical specialty. Women living in the Northeast, Midwest, and South were 94-fold (OR = 0.06, 95% CI 0.01-0.29), 85-fold (OR = 0.15, 95% CI -0.04 to 0.62) and 76-fold (OR = 0.24, 95% CI 0.06-0.92) less likely to receive opioids than those residing in the West. General and family practice clinicians were significantly more likely to prescribe opioids compared with other disciplines (OR = 6.76, 95% CI 1.71-26.70).

This study provided a clear picture of pain medication usage among women with BC and can assist pharmacists in targeting deprescribing efforts geared at both patients and providers.

The content contained in this article is for informational purposes only. The content is not intended to be a substitute for professional advice. Reliance on any information provided in this article is solely at your own risk.

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