Misalignment of Stakeholder Incentives in the Opioid Crisis

Abstract

The current opioid epidemic has killed more than 446,000 Americans over the past two decades. Despite the magnitude of the crisis, little is known to what degree the misalignment of incentives among stakeholders due to competing interests has contributed to the current situation. In this study, we explore evidence in the literature for the working hypothesis that misalignment rooted in the cost, quality, or access to care can be a significant contributor to the opioid epidemic. The review identified several problems that can contribute to incentive misalignment by compromising the triple aims (cost, quality, and access) in this epidemic. Some of these issues include the inefficacy of conventional payment mechanisms in providing incentives for providers, practice guidelines in pain management that are not easily implementable across different medical specialties, barriers in adopting multi-modal pain management strategies, low capacity of providers/treatments to address opioid/substance use disorders, the complexity of addressing the co-occurrence of chronic pain and opioid use disorders, and patients’ non-adherence to opioid substitution treatments. In discussing these issues, we also shed light on factors that can facilitate the alignment of incentives among stakeholders to effectively address the current crisis.

High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder

“…[3][4][5][6] Yet, patients frequently face substantial barriers to obtaining buprenorphine in a timely manner after ED discharge because of a lack of ED clinicians with US Drug Enforcement Agency X-waivers permitting them to prescribe buprenorphine or other logistical issues in filling prescriptions associated with prior authorization requirements, transportation, and health insurance coverage gaps. [7][8][9][10][11] The timing and dose of buprenorphine during induction may be an opportunity to address the lack of timely follow-up care after ED discharge. Existing treatment guidelines published by the Department of Health and Human Services, [12][13][14] which were developed for office-based practice, limit the maximum sublingual (SL) buprenorphine induction dose during the first 24 hours to 8 to 12 mg.…”

“… 3 , 4 , 5 , 6 Yet, patients frequently face substantial barriers to obtaining buprenorphine in a timely manner after ED discharge because of a lack of ED clinicians with US Drug Enforcement Agency X-waivers permitting them to prescribe buprenorphine or other logistical issues in filling prescriptions associated with prior authorization requirements, transportation, and health insurance coverage gaps. 7 , 8 , 9 , 10 , 11 …”

“…With a total of 50 042 lives lost in 2019 because of opioid overdose deaths, projections of a 30% increase in 2020, and evidence that ED-initiated buprenorphine is both life-saving and cost-effective, the American College of Emergency Physicians, the US Surgeon General, the National Institute of Drug Abuse, and the Substance Abuse and Mental Health Services Administration have all called for ED access to initiation of buprenorphine for treatment of OUD . Yet, patients frequently face substantial barriers to obtaining buprenorphine in a timely manner after ED discharge because of a lack of ED clinicians with US Drug Enforcement Agency X-waivers permitting them to prescribe buprenorphine or other logistical issues in filling prescriptions associated with prior authorization requirements, transportation, and health insurance coverage gaps …”