Public Release: 

Daily medication more cost-effective than monthly injections for opioid use disorder

American College of Physicians

1. Daily medication more cost-effective than monthly injections for opioid use disorder

Abstract: http://annals.org/aim/article/doi/10.7326/M18-0227
Editorial: http://annals.org/aim/article/doi/10.7326/M18-3293 URLs go live when the embargo lifts

A daily dose of buprenorphine-naloxone is cost-effective compared to monthly injections of extended-release naltrexone for treating opioid use disorder. The two medications were similarly effective in terms of quality of life and time abstaining from opioids. Findings from a cost-effectiveness study are published in Annals of Internal Medicine.

Three medications have been approved by the U.S. Food and Drug Administration (FDA) for first-line treatment of opioid use disorder. Methadone is available only in strictly regulated clinics, but buprenorphine and naltrexone can be prescribed in an office setting. Buprenorphine, often combined with naloxone, is typically administered orally once daily and does not require patient detoxification. Naltrexone is frequently administered as an injection just once a month and requires the patient to be detoxified before treatment can begin. Cost-effectiveness data on these medications are limited.

Researchers from Weill Cornell Medicine evaluated the total cost associated with daily oral buprenorphine-naloxone versus monthly naltrexone injections. The cost-effectiveness analysis was conducted alongside a previously reported randomized clinical trial of 570 adults in 8 U.S. inpatient or residential treatment programs. Medication costs were valued at $1.20/4 mg or $2.17/8 mg for generic buprenorphine-naloxone tablets and $704 per extended release naltrexone injection, according to the Federal Supply Schedule. The researchers also assessed costs associated with the criminal justice system, reduced workplace productivity, and patient time. After comparing total costs for each medication, they found that extended release naltrexone was more costly overall than buprenorphine-naloxone. The primary factors driving the higher relative cost for extended release naltrexone were its higher unit price and the costs associated with the detoxification requirement. All other cost differences between the drugs were non-significant.

The researchers conclude that since the medications are similarly effective, buprenorphine-naloxone should be preferred as the first-line treatment when both options are clinically appropriate.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Sean M. Murphy, PhD, please contact Anna Sokol at ana2059@med.cornell.edu.

2. Data supports limiting blood transfusions for moderate anemia

Abstract: http://annals.org/aim/article/doi/10.7326/M17-3253
Editorial: http://annals.org/aim/article/doi/10.7326/M18-3145
URLs go live when the embargo lifts

Tolerating instead of treating moderate anemia did not seem to adversely affect long-term red blood cell (RBC) transfusion events, rehospitalization, or mortality. In addition, reductions in risk-adjusted mortality were similar in patients with anemia and those without it. Findings from a retrospective cohort study are published in Annals of Internal Medicine.

Traditionally, treatment of moderate anemia (defined as hemoglobin levels between 7 and 10 g/dL in this study) in hospitalized patients were treated with RBC transfusion. However, this approach can increase the risk for complications and recent randomized clinical trials support decreased RBC transfusion and short-term tolerance of in-hospital anemia. Long-term outcomes related to changes in transfusion practice have not been described.

Researchers from Kaiser Permanente Northern California Division of Research and the National Heart, Lung, and Blood Institute examined the incidence and prevalence of anemia for 445,371 patients in an integrated health care delivery system at and within 6 months of hospital discharge after implementation of patient blood management initiatives. The researchers found that the incidence and prevalence of moderate anemia at discharge and within 6 months of hospitalization increased over the study period and was concomitant with changes in RBC transfusion practice. However, no adverse effects on patient outcomes were detected.

The authors of an editorial from Stanford University question the study's conclusion. They suggest that transfusion rate is not a clinical outcome, and mortality and readmission, although important, may not provide an accurate or comprehensive snapshot of patient well-being. They say that missing is a wide spectrum of morbidity outcomes and issues related to diminished quality of life from anemia that do not research the severity level requiring admission but nonetheless detract from patients' health and well-being.

Media contact: For an embargoed PDF, please contact Lauren Evans at laevans@acponline.org. To interview the lead author, Nareg H. Roubinian, MD, MPHTM, please contact Brett Israel at brett.t.israel@kp.org. The author of the editorial can be reached through Aryeh Shander at ashan82293@mac.com.

3. Patients with low back pain or pain at multiple sites at highest risk for chronic opioid use

Recent efforts to reduce opioid use may be showing some success
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2261
URLs go live when the embargo lifts

Patients with low back pain or pain at multiple anatomical sites are at highest risk for chronic opioid use. However, recent efforts to reduce opioid use may have had some success. A brief research report published in Annals of Internal Medicine shows that the risk for chronic opioid use among patients with musculoskeletal pain decreased between 2008 and 2014.

Musculoskeletal pain, such as neck, shoulder, knee, or low back pain, is common. Patients that have it may transition to chronic opioid use, or opioid use that involves filling 10 or more prescriptions or having at least 120 days' supply for hydrocodone, hydromorphone, methadone, morphine, oxymorphone, and/or oxycodone between 3 months and 1 year after the initial diagnosis. However, the risk factors for chronic opioid use among patients with musculoskeletal pain is not fully understood.

Researchers from Stanford University School of Medicine used a large health care database to assess the risk and risk factors for chronic opioid use among more than 400,000 opioid-naïve patients recently diagnosed with musculoskeletal pain in the knee, neck, low back, or shoulder. They found that risk for chronic opioid use ranged from 0.3 percent for knee pain to 1.5 percent for multiple-site pan and decreased for some anatomical regions during the timeframe studied. Anatomical location (low back and multiple sites) was the biggest risk factor for chronic opioid. According to the authors, measures such as avoiding opioid use soon after diagnosis, can further reduce the risk, especially among patients at highest risk for chronic opioid use.

Media Contact: For an embargoed PDF or author contact information, please contact Lauren Evans at laevans@acponline.org.

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Also in this issue:
Nerve Agent Incidents and Public Health Preparedness
Arthur Chang, MD, MS; Jerry Thomas, MD; Rudolph Johnson, PhD; Susan E. Gorman, PharmD, MS; Josh Schier, MD, MPH; and Luke Yip, MD
Ideas and Opinions
Abstract: http://annals.org/aim/article/doi/10.7326/M18-2428

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