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Objective of this study was to generate policy, intervention, and research recommendations to improve access to care for these patients.Participants and Methods: We conducted a RAND/UCLA Modified Delphi, consisting of workshops, background videos and reading materials, and moderated web-based panel discussions held September 2020–January 2021. The panel consisted of 24 individuals from across Michigan, identified via expert nomination and snowball recruitment, including clinical providers, health science researchers, state-level policymakers and regulators, care coordination experts, patient advocates, payor representatives, and community and public health experts. The panel proposed intervention, policy, and research recommendations, scored the feasibility, impact, and importance of each on a 9-point scale, and ranked all recommendations by implementation priority.Results: The panel produced 11 final recommendations across three themes: reimbursement reform, provider education, and reducing racial inequities in care. The 3 reimbursement-focused recommendations were highest ranked (theme average = 4.2/11), including the two top-ranked recommendations: increasing reimbursement for time needed to treat complex chronic pain (ranked #1/11) and bundling payment for multimodal pain care (#2/11). Four provider education recommendations ranked slightly lower (theme average = 6.2/11) and included clarifying the spectrum of opioid dependence and training providers on multimodal treatments. Four recommendations addressed racial inequities (theme average = 7.2/11), such as standardizing pain management protocols to reduce treatment disparities.Conclusion: Panelists indicated reimbursement should incentivize traditionally lower-paying evidence-based pain care, but multiple strategies may be needed to meaningfully expand access. [ABSTRACT FROM AUTHOR]

Purpose: Patients on long-term opioid therapy (LTOT) for pain have difficulty accessing primary care clinicians who are willing to prescribe opioids or provide multimodal pain treatment. Recent treatment guidelines and statewide policies aimed at reducing inappropriate prescribing may exacerbate these access issues, but further research is needed on this issue. This study aimed to understand barriers to primary care access and multimodal treatment for chronic pain from the perspective of multiple stakeholders. Methods: Qualitative, semi-structured phone interviews were conducted with adult patients with chronic pain, primary care clinicians, and clinic office staff in Michigan. Interview questions covered stakeholder experiences with prescription opioids, opioid-related policies, and access to care for chronic pain. Interviews were coded using inductive and deductive methods for thematic analysis. Results: A total of 25 interviews were conducted (15 patients, 7 primary care clinicians, and 3 office staff). Barriers to treatment access were attributed to six themes: (1) reduced clinic willingness to manage prescribed opioids for new patients; (2) lack of time and reimbursement for quality opioid-related care; (3) paucity of multimodal care and coordination between providers; (4) fear of liability and use of new guidelines to justify not prescribing opioids; (5) delayed prescription receipt due to prior authorization and pharmacy issues; and (6) poor availability of effective non-opioid treatments. Conclusion: Issues of policy, logistics, and clinic-level resources converge to disrupt treatment access for patients with chronic pain, as many clinics both do not offer multimodal pain care and are unwilling to prescribe LTOT. The resulting conceptual model can inform the development of policy interventions to help mitigate these access barriers. [ABSTRACT FROM AUTHOR]

Objective: Among those on chronic opioids, to determine whether patients with Medicaid coverage have higher rates of high-risk opioid prescribing following surgery compared with patients on private insurance., Background: Following surgery, patients on chronic opioids experience gaps in transitions of care back to their usual opioid prescriber, but differences by payer type are not well understood. This study aimed to analyze how new high-risk opioid prescribing following surgery compares between Medicaid and private insurance., Methods: In this retrospective cohort study through the Michigan Surgical Quality Collaborative, perioperative data from 70 hospitals across Michigan were linked to prescription drug monitoring program data. Patients with either Medicaid or private insurance were compared. The outcome of interest was new high-risk prescribing, defined as a new occurrence of: overlapping opioids or benzodiazepines, multiple prescribers, high daily doses, or long-acting opioids. Data were analyzed using multivariable regressions and a Cox regression model for return to usual prescriber., Results: Among 1435 patients, 23.6% (95% CI: 20.3%-26.8%) with Medicaid and 22.7% (95% CI: 19.8%-25.6%) with private insurance experienced new, postoperative high-risk prescribing. New multiple prescribers was the greatest contributing factor for both payer types. Medicaid insurance was not associated with higher odds of high-risk prescribing (odds ratio: 1.067, 95% CI: 0.813-1.402)., Conclusions: Among patients on chronic opioids, new high-risk prescribing following surgery was high across payer types. This highlights the need for future policies to curb high-risk prescribing patterns, particularly in vulnerable populations that are at risk of greater morbidity and mortality., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To describe if patients with chronic opioid use with a consistent usual prescriber (UP) prior to surgery and if early return to that UP (<30 d) would be associated with fewer high risk prescribing events in the postoperative period., Summary Background Data: Over 10 million people each year are prescribed opioids for chronic pain. There is little evidence regarding coordination of opioid management and best practices for patients on long-term opioid therapy patients following surgery., Methods: The study design is a retrospective cohort study. We identified 5749 commercially insured patients aged 18 to 64 with chronic opioid use who underwent elective surgery between January 2008 and March 2015. The predictors were presence of a UP and early return (<30 d from surgery) to a UP. The primary outcome was new high-risk opioid prescribing in the 90-day postoperative period (multiple prescribers, overlapping opioid and/or benzodiazepine prescriptions, new long acting opioid prescriptions, or new dose escalations to > 100 mg OME)., Results: In this cohort, 73.8% of patients were exposed to high risk prescribing postoperatively. Overall, 10% of patients did not have a UP preoperatively, and were more likely to have prescriptions from multiple prescribers (OR 2.23 95% CI 1.75-2.83) and new long acting opioid prescriptions (OR 1.69, 95% CI 1.05-2.71). Among patients with a UP, earlier return was associated with decreased odds of receiving prescriptions from multiple prescribers (OR 0.80, 95% CI 0.68-0.95)., Conclusion: Patients without a UP prior to surgery are more likely to be exposed to high-risk opioid prescribing following surgery. Among patients who have a UP, early return visits may enhance care coordination with fewer prescribers.

Importance: Opioid-prescribing policies and guidelines aimed at reducing inappropriate opioid prescribing may lead physicians to stop prescribing opioids. Patients may thus encounter difficulties finding primary care practitioners willing to care for them if they take opioids., Objectives: To assess practitioner willingness to accept and continue prescribing opioids to new patients with pain and whether this willingness differs across payer types., Design, Setting, and Participants: This survey study used a simulated patient call audit method. A brief telephone survey was administered to all clinics followed by a call using a patient script simulating an adult patient with chronic pain who was taking long-term opioids. The patient had Medicaid or private insurance. Calls were made between June 22 and October 30, 2018, to 667 primary care clinics that served a general adult population in Michigan. Clinics that accepted both Medicaid and private insurance, took new patient appointments, and were successfully recontacted for the simulated call were eligible for the study., Main Outcomes and Measures: Prevalence of clinics' acceptance of new patients receiving prescription opioids overall and by clinic characteristics and insurance type., Results: Of the 194 eligible clinics, 94 (48.4%) were randomized according to insurance type to receive calls from research assistants posing as children of patients with Medicaid and 100 (51.5%) to receive calls from those with private insurance. Overall, 79 (40.7%) stated that their practitioners would not prescribe opioids to the simulated patient. Thirty-three clinics (17.0%) requested more information before making a decision. Compared with single-practitioner clinics, clinics with more than 3 practitioners were more likely (odds ratio [OR], 2.99; 95% CI, 1.48-6.04) to accept new patients currently taking opioids. No difference was found in access based on insurance status (OR, 0.92; 95% CI, 0.52-1.64) or whether the clinic offered medications for opioid use disorders (OR, 1.10; 95% CI, 0.45-2.69)., Conclusions and Relevance: The findings suggest that access to primary care may be reduced for patients taking prescription opioids, which could lead to unintended consequences, such as conversion to illicit substances or reduced management of other medical comorbidities.