Plus: How much has pandemic substance use hurt the labor market?
By Mark Mravic
Responses to the opioid crisis have taken on many forms. At the federal level, billions of dollars are being directed toward prevention, treatment and recovery. States, too, are determining how to allocate the large sums coming their way from settlements with drug manufacturers and distributors. But not all measures have to be of such vast scale. This week we highlight a pair of studies revealing small, easy-to-enact measures that could help get opioids under control.
Also, we look at an analysis suggesting that pandemic drug use has contributed to a persistent workforce shortage in the U.S.
From Jama Network:
A Computer Prompt Improves Opioid Prescribing
As electronic healthcare record (EHR) systems become more sophisticated, providers have been integrating a computer process called clinical decision support (CDS) to help educate doctors on best practices, improve outcomes and target specific goals such as safer prescribing habits. How effective are these computerized aids? Researchers from Kaiser Permanente Southern California (KPSC) wanted to find out whether adding safety-related prompts to its healthcare network’s CDS could improve opioid prescribing patterns.
On Jan. 1, 2019, California implemented Assembly Bill 2760, which mandates that high-risk patients who are prescribed opioids must also be offered a prescription for naloxone, the overdose-reversal drug. At the same time, KPSC added a series of prompts to its CDS that are triggered when the bill’s prescribing conditions are met. The prompts provide clinicians with safety alerts explaining the risks of opioid prescribing, reminding them to order naloxone in accordance with the new law and providing other recommendations that the clinician can either follow or override.
Examining the records of more than 500,000 patients over two years, the researchers found that upon the implementation of the new law and the prompts, prescribing rates for naloxone increased dramatically, from 2% in December 2018 to 27.1% in December 2019. In addition, overall opioid orders fell by 15.1% over the course of 2019, and total prescribed morphine milligram equivalents (MME) dropped by 7.1%.
The study found other unintended safety benefits, too—muscle-relaxant prescriptions, renewals of opioid orders and long-term high-dose prescriptions all declined, and while median MMEs per order increased slightly, the authors surmise that’s due to previously low-dose opioid patients being steered toward alternative pain treatments, another potential safer outcome. The researchers also note that opioid prescribing patterns improved even when patients didn’t meet the high-risk criteria specified by the new law. That suggests the CDS prompts helped guide clinicians toward safer prescribing measures. As the authors write, “Nudges, when incorporated into the EHR, can change clinician behaviors.”
From JAMA Network:
Making It Easier to Dispose of Unused Meds
Leftover pain medication is a cause for serious concern. Unused opioid pills that sit in a medicine cabinet or are tossed into the trash can lead to accidental consumption by a family member or be diverted for illicit use. So getting patients to properly dispose of their unused meds is an important step in preventing problem opioid use. Researchers at the University of Pennsylvania found that a simple measure—providing patients with mailed at-home kits—significantly increased the safe disposal of leftover opioids.
“I was pleased to see that such a simple ‘snail-mail’ approach could change behavior. … This could be extremely impactful at scale.”—Anish Agarwal, University of Pennsylvania
The study involved two groups that had been prescribed opioids after orthopedic or urologic procedures. One group followed usual care, receiving a texted link to nearby drug disposal locations. The other group was mailed a DisposeRX at-home kit—which sequesters the meds in a polymer gel, rendering them inactive and safe to discard. The study found that 60% of the latter group reported using the kits to dispose of their medications, compared to 43% in the control group that took their leftovers to a take-back location. Researchers estimated that an additional 480 pills were disposed of by the at-home kit group compared to the control.
That difference is significant enough, but the authors note that real-world disposal rates are just 20% to 30%, meaning the at-home method could double or triple disposal compliance—all at a cost of about $1.50 per patient. “I was pleased to see that such a simple, ‘snail mail’ approach could change behavior,” the study’s lead author, Anish Agarwal, MD, said in a release. “One could imagine that if scaled up to the thousands of surgeries that are done per year in our health system and millions done in the U.S., how this could be extremely impactful at scale.”
From the National Bureau of Economic Research:
Substance Use and the Labor Shortage
The COVID-19 pandemic caused a severe initial shock to the U.S. labor market, driving unemployment rates to levels not seen since the Great Depression. But even as the economy has bounced back in the ensuing two years, the workforce has still not fully recovered. A recent working paper from the National Bureau of Economic Research, a nonpartisan think-tank, analyzed the numbers and concluded that the rise in substance use during the pandemic has been a significant driver of the persistent COVID-era labor shortage.
The authors note that participation in the labor force among prime-age (25-54) people with opioid or methamphetamine use disorder has traditionally been about 15 percentage points lower than those without a substance use disorder (SUD). Crunching the data, they determined that the overall number of Americans misusing substances increased by 5.1 million during the pandemic. Given the lower workforce participation rates for people with SUD, the authors estimate that the rise in pandemic substance use accounts for between 9% and 25% of the labor market’s shortfall.
“It’s a bit of a puzzle right now why labor force participation rates are not recovered to pre-pandemic levels,” co-author Karen Kopecky, an economist at the Federal Reserve Bank of Atlanta, said. “This is one potential reason why. It’s definitely not the only reason.”