Controlled substance agreements may reduce primary care visits, amid a decades-old, growing opioid crisis

Controlled substance agreements (CSAs) for patients receiving long-term opioid therapy for chronic noncancer pain were associated with fewer primary care visits but increased use of radiologic services, a study found.

Researchers retrospectively evaluated health care utilization changes among 772 patients who were receiving long-term opioid therapy for chronic noncancer pain and enrolled in a CSA between July 1, 2015, and Dec. 31, 2015, at one of five primary care practice sites.

A CSA was defined as a patient-physician opioid care process model that begins with an agreement and includes patient screening, monitoring of pain and functional status, documentation of refills, evaluation of opioid use or diversion through prescription monitoring programs and urine drug testing, and reliable provision of opioids for pain control. The study compared 12 months before and after CSA enrollment, and decreased utilization was defined as a decrease of one or more hospitalizations or ED visits and three or more outpatient primary and subspecialty care visits. Results were published Sept. 20 by Mayo Clinic Proceedings.

CSA enrollment was associated with decreased outpatient primary care visits (odds ratio [OR], 0.16; 95% CI, 0.14 to 0.19) and increased use of diagnostic radiology services (OR, 1.22; 95% CI, 1.02 to 1.47). No significant changes were observed in ED visits, hospitalizations, or outpatient subspecialty visits. After CSA enrollment, patients with greater comorbidity (Charlson Comorbidity Index score >3) were more likely to have fewer hospitalizations (adjusted OR, 2.8; 95% CI, 1.3 to 6.0; P=0.008), fewer outpatient primary care visits (adjusted OR, 2.0; 95% CI, 1.2 to 3.2; P=0.005), and fewer subspecialty care visits (adjusted OR, 2.0; 95% CI, 1.2 to 3.3; P=0.006).

“Although opioid therapy is associated with higher rates of health care utilization and cost in some clinical settings, our data suggest that CSAs and the care process around them reduce health care utilization, especially among opioid users with greater comorbidity,” the authors wrote.

Another recent study tracked the “exponential growth curve” of drug overdose mortality since 1979.

While rates associated with individual drugs have varied, the overall mortality rate has had a “remarkably smooth trajectory … for at least 38 years,” according to a report published in the Sept. 21 Science. Researchers analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death.

“This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process,” the authors said. “This process may continue along this path for several more years into the future. Paradoxically, there has been substantial variability with which specific drugs have become dominant in varying populations and geographic locales. This variability all but negates the possibility of confident predictions about the future role of specific drugs. Indeed, it is possible that a future overdose epidemic may be driven by a new or obscure drug that is not among the leading causes of drug overdose death today.”

Additional recent research assessed the use of opioids among seniors, finding that nearly 125,000 hospitalizations among Americans 65 years and older involved opioid-related diagnoses in 2015. In addition, in 2015 and 2016, nearly 4 million seniors filled four or more opioid prescriptions, while nearly 10 million filled at least one opioid prescription, according to the Agency for Healthcare Research and Quality (AHRQ).

AHRQ's new report on hospital use for opioid use disorder and opioid-related adverse events reported that between 2010 and 2015, opioid-related hospitalizations of seniors increased more than 50% and opioid-related ED visits more than doubled. In 2015, 124,300 hospitalizations and 36,200 ED visits occurred due to complications resulting from opioid use.