CHOICE Blog: Trump Administration’s Blueprint to Address Drug Prices

I wrote a piece about the Trump Administration's plans to address drug prices, which was published on The CHOICE Institute Blog, Incremental Thoughts, on 16 May 2018. I summarized the key points from the Trump Administration and highlighted an interview by The CHOICE Institute alumnus, Dr. Jonathan H. Watanabe, Associated Professor of Clinical Pharmacy at the UCSD Skagg School of Pharmacy and Pharmaceutical Sciences. Dr. Watanabe argued that Medicare is unable to negotiate for lower prices like the U.S. Department of Veterans Affairs.

Dr. Watanabe's interview with NBC7 can be viewed here.

You can read my piece here.


Veterans Health Administration reduces opioid use with Academic Detailing

Recently, there have been several articles and blogs that highlight the success of the U.S. Department of Veterans Affairs (VA) Veterans Health Administration (VHA) in addressing the rising opioid epidemic, especially among veterans. Lin and colleagues reported that the VHA's Opioid Safety Initiative (OSI) was associated with a 16.1% reduction in high-dose opioid use [defined as 100 morphine equivalence (MEQ) or greater] twelve months after implementation in October 2013. Moreover, the dangerous combination of an opioid prescribed with a benzodiazepine was reduced by 20.7% across a similar time period. 

These results were, in part, affected by academic detailing, which provides one-on-one, unbiased educational outreach to providers in order to align their prescribing behaviors with the most current evidence-based practice. The former Interim Under Secretary of Health mandated that the VHA implement the National Academic Detailing Service (ADS) to address veterans' mental health and pain management by 2015. Since then, the ADS has been associated with reductions in high-dose opioid use and average MEQ over time. I recently presented some of these findings at the VA's HSR&D/QUERI meeting in Washington, DC on July 18-20, 2017. There was a greater reduction in high-dose opioid users in providers who received academic detailing compared to providers who did not receive academic detailing (58% versus 34%, respectively). Similarly, there was a greater reduction in the average MEQ per patient among providers who received academic detailing compared to those who did not (59% versus 31%, respectively). 

In the news, the blog reported that "the VA health care system has implemented a comprehensive “Opioid Safety Initiative,” which uses provider-level ongoing feedback for high-risk opioid prescribing, academic detailing to improve use of opioids, a robust naloxone distribution program for at-risk veterans, and residential treatment programs for substance abuse." Similarly, reported that Matthew Gowan, a VA spokesman, stated that the OSI and ADS have been crucial in the reduction of opioid use in Tomah VA Medical Center since their implementation. 

Williams, Nunes, and Olfson argued that a "Cascade of Care" model is needed to address the opioid epidemic in the U.S. They stated that academic detailing along with motivational interviewing and family engagement are needed in order to assist providers to bridge any knowledge gaps and stigma associated with safe and proper opioid prescribing. In addition, wrote that academic detailing provides providers with critical updates on pain management and opioid prescribing. 

Finally, an article by Carla K. Johnson of the Associated Press provided a "boots on the ground" perspective of academic detailing from the eyes of an academic detailer in Pennsylvania. In it, she follows Melissa Jones, an academic detailer, and wrote that "Evidence from New York City’s public health department and the Veterans Health Administration suggests Jones and others like her can reduce opioid prescribing, adapting a tried-and-true tactic from the pharmaceutical industry called detailing." In short, academic detailing has an important part to play in the overall mission to address the opioid epidemic. 

Despite these improvements in the VA's mission to reduce harmful opioid prescribing, it is uncertain whether reducing opioids will lead to a substitution effect or worse. Future studies will need to investigate any potential negative (and positive) consequences of these campaigns. 

Illustrating Value, Prioritizing Evaluation, Saving Lives

I recently co-authored an article with Melissa LD Christopher that is now posted on the National Resource Center for Academic Detailing (NaRCAD). Although the goal was to highlight the importance of performing program evaluations, the article also reports some of our findings with the Veterans Health Administration National Academic Detailing Service's impact on naloxone distribution.

In a retrospective, repeated measures cohort study, we reported that providers who were exposed to academic detailing had a greater rate of naloxone distribution compared to providers who were unexposed to academic detailing. This difference-in-differences estimation was significant at the alpha level of 0.05. The remarkable feature of our report is that academic detailing had a significant association with naloxone distribution. However, due to selection bias, which was not taken into account in our preliminary analysis, these findings may be limited.

In order to address selection bias, I will use a regression discontinuity design, which can mitigate selection bias and yield a causal interpretation. An important element of regression discontinuity design is the selection of a running (treatment assignment) variable. If the running variable has a distinct discontinuity for treatment assignment at a certain cut-off, it is considered a "sharp" regression discontinuity. However, if the probability of treatment assignment is not distinct, then it is considered a "fuzzy" regression discontinuity.