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CE Information Activity Available Online: To access the article and evaluation online, go to https://www.highmarksce.com/mscare. Target Audience: The target audience for this activity is physicians, advanced practice clinicians, nursing professionals, pharmacists, and other health care providers involved in the management of patients with multiple sclerosis (MS). Learning Objectives: Recognize the frequency of utilization of non-DMT medications by MS patients and integrate questions about their use into patient history. Characterize and be mindful of the out-of-pocket cost burden of DMT and non-DMT medication use in patients with MS. Accreditation Statement: In support of improving patient care, this activity has been planned and implemented by The Consortium of Multiple Sclerosis Centers (CMSC) and Intellisphere, LLC. CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team. This activity was planned by and for the health care team, and learners will receive 0.5 Interprofessional Continuing Education (IPCE) credit for learning and change. For Physicians: The Consortium of Multiple Sclerosis Centers designates this journal-based activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. For Nurses: This activity is awarded 0.5 contact hours of nursing continuing professional development (NCPD) (0.5 of these credits are in the area of pharmacology). For Pharmacists: This knowledge-based activity (UAN JA4008165-9999-22-020-H01-P) qualifies for 0.5 contact hours (0.05 CEUs) of continuing pharmacy education credit. For Physician Assistants: The Consortium of Multiple Sclerosis Centers has been authorized by the American Academy of PAs (AAPA) to award AAPA Category 1 CME credit for activities planned in accordance with AAPA CME Criteria. This activity is designated for 0.5 AAPA Category 1 CME credits. Approval is valid until April 1, 2023. PAs should only claim credit commensurate with the extent of their participation. It is the policy of the Consortium of Multiple Sclerosis Centers to mitigate all relevant financial disclosures from planners, faculty, and other persons that can affect the content of this CE activity. For this activity, all relevant disclosures have been mitigated. Disclosures: Francois Bethoux, MD, editor in chief of the International Journal of MS Care (IJMSC), has served as Physician Planner for this activity. He has disclosed no relevant financial relationships. Alissa Mary Willis, MD, Associate Editor of IJMSC, has disclosed no relevant financial relationships. Daniel Hartung, PharmD, MPH, consults for the National Multiple Sclerosis Society and Sandoz Pharmaceuticals. Leorah Freeman, MD, PhD, has served as a consultant for Genentech, Celgene/Bristol Myers Squibb, EMD Serono, TG Therapeutics, and Novartis; and has received grant/program support from EMD Serono and Genentech. The staff at IJMSC, CMSC, and Intellisphere, LLC who are in a position to influence content have disclosed no relevant financial relationships. Laurie Scudder, DNP, NP, Continuing Education Director CMSC, has served as a planner and reviewer for this activity. She has disclosed no relevant financial relationships. Method of Participation: Release Date: April 1, 2022; Valid for Credit through: April 1, 2023 In order to receive CE credit, participants must: (1) Review the continuing education information, including learning objectives and author disclosures.(2) Study the educational content.(3) Complete the evaluation, which is available at https://www.highmarksce.com/mscare. Statements of Credit are awarded upon successful completion of the evaluation. There is no fee to participate in this activity. Disclosure of Unlabeled Use: This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. The CMSC and Intellisphere, LLC do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Intellisphere, LLC. Disclaimer: Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.

This cross-sectional study evaluates opioid prescribing patterns from 2009 to 2018 in a network of community health centers that frequently treat low-income patients in the US., Key Points Question Are there prescribing patterns for opioid medications in safety-net clinics? Findings In this cross-sectional study of 3 227 459 opioid prescriptions abstracted from electronic health records of patients treated at a network of community health centers between January 1, 2009, and December 31, 2018, the number of prescriptions per 100 primary care patients decreased 73.7% from 110.8 in 2009 to 29.1 in 2018. Other metrics of opioid use decreased to a similar degree. Meaning Opioid prescribing in a large network of community health centers decreased from January 1, 2009, to December 31, 2018, which likely reflects a mix of federal, state, and local policies and initiatives directed at reducing harms associated with increased opioid prescribing in the early 2000s., Importance Understanding opioid prescribing patterns in community health centers (CHCs) that disproportionately serve low-income patients may help to guide strategies to reduce opioid-related harms. Objective To assess opioid prescribing patterns between January 1, 2009, and December 31, 2018, in a network of safety-net clinics serving high-risk patients. Design, Setting, and Participants Cross-sectional study of 3 227 459 opioid prescriptions abstracted from the electronic health records of 2 129 097 unique primary care patients treated from 2009 through 2018 at a network of CHCs that included 449 clinic sites in 17 states. All age groups were included in the analysis. Main Outcomes and Measures The following measures were described at the population level for each study year: (1) percentage of patients with at least 1 prescription for an opioid by age and sex, (2) number of opioid prescriptions per 100 patients, (3) number of long-acting opioid prescriptions per 100 patients, (4) mean annual morphine milligram equivalents (MMEs) per patient, (5) mean MME per prescription, (6) number of chronic opioid users, and (7) mean of high-dose opioid users. Results The study population included 2 129 097 patients (1 158 413 women [54.4%]) with a mean (SD) age of 32.2 (21.1) years and a total of 3 227 459 opioid prescriptions. The percentage of patients receiving at least 1 opioid prescription in a calendar year declined 67.4% from 15.9% in 2009 to 5.2% in 2018. Over the 10-year study period, a greater percentage of women received a prescription (13.1%) compared with men (10.9%), and a greater percentage of non-Hispanic White patients (18.1%) received an opioid prescription compared with non-Hispanic Black patients (9.5%), non-Hispanic patients who self-identified as other races (8.0%), and Hispanic patients (6.9%). The number of opioid prescriptions for every 100 patients decreased 73.7% from 110.8 in 2009 to 29.1 in 2018. The number of long-acting opioids for every 100 patients decreased 85.5% during the same period, from 22.0 to 3.2. The MMEs per patient decreased from 1682.7 in 2009 to 243.1 in 2018, a decline of 85.6%. Conclusions and Relevance In this cross-sectional study, the opioid prescribing rate in 2009 in the CHC network was higher than national population estimates but began to decline earlier and more precipitously. This finding likely reflects harm mitigation policies and efforts at federal, state, and clinic levels and strong clinical quality improvement strategies within the CHCs.

RESEARCH OBJECTIVE: The impact of prescribing initiatives that encourage dose reductions is still largely unknown. Our objective was to determine whether the degree of opioid dose reduction among patients with high‐dose chronic opioid treatment (COT) associates with suicide, opioid overdose, other opioid‐related adverse events, or buprenorphine fills. STUDY DESIGN: In this retrospective cohort study, we identified patients with COT in 2014 or 2015 with 12 months of follow‐up to determine opioid dose trajectory and an additional 12 months of follow‐up to identify outcomes. We characterized dose trajectories in 12 months after a period of COT as abrupt discontinuation, dose reduction with discontinuation, dose reduction without discontinuation, and no dose reduction or discontinuation. We also characterized the effect of patient demographics (age, race, gender, rural vs. urban), prescription profile during COT, and diagnoses of alcohol abuse, depression, or any drug abuse. Multivariate logistic regression was used to examine the effect of dose trajectories on suicide (fatal or non‐fatal), opioid overdose (fatal or non‐fatal), other adverse events, and buprenorphine fills in the following year. Other adverse events included a diagnosis of adverse effects, opioid abuse, opioid dependence, or unspecified opioid use diagnosed in outpatient, inpatient (hospital), or emergency department settings. POPULATION STUDIED: We studied 17,990 continuously enrolled Medicaid recipients in Oregon with high‐dose COT. All analyses used the Oregon Medicaid claims data linked with the Oregon Prescription Drug Monitoring Program (PDMP) and vital statistics data sets covering calendar years 2014 to 2017. PRINCIPAL FINDINGS: In the 12 months after the high‐dose COT period, there were 1,328 (7.38%) individuals with an abrupt discontinuation, 2,953 (16.41%) with a dose reduction with discontinuation, 4,282 (23.8%) with a dose reduction without discontinuation, and 9,427 (52.40%) with no dose reduction or discontinuation. Patients who abruptly discontinued had the highest odds of fatal or nonfatal suicide (adjusted odds ratio (aOR) 12.1, 95% confidence interval (CI) 3.5, 41.6), fatal or nonfatal overdose (aOR 2.6, 95% CI 1.4, 4.7), or other adverse events (aOR 2.0, 95% CI 1.4, 2.7). Among those who had an opioid overdose, patients who discontinued opioid use after COT were more likely to overdose on heroin than those who did not discontinue opioid use (P

Access to providers of treatment for opioid use disorder is a critical challenge to confronting the opioid epidemic. In 2017, the Comprehensive Addiction and Recovery Act (CARA) expanded buprenorphine prescribing privileges to nurse practitioners (NP). This research examined the effect of this regulatory change on buprenorphine prescribing in the state of Oregon. We performed an interrupted time‐series (ITS) analysis to examine the effect of CARA implementation (February 2017) on buprenorphine prescribing for medications to treat opioid disorders (MOUD) from January 1, 2016 to December 31, 2018. Specifically, we characterized changes in the trend and patterns of buprenorphine prescribing overall, by prescriber type (NPs vs MD/DO), and geographic designation. Our ITS regression models estimated prepolicy trends, immediate changes after CARA implementation, and changes in trend following implementation. We used Oregon Prescription Drug Monitoring Program data linked to a provider and dispensing characteristic files. Our study sample post‐CARA included 179 NPs with a total of 440 525 buprenorphine prescriptions statewide written by all prescribers. Prior to CARA implementation, the trend in total buprenorphine dispensing was increasing by 149 prescriptions per month (P

Key Points Question What is the association of industry payments to physicians and prescriptions for repository corticotropin (H. P. Acthar Gel; Mallinckrodt Pharmaceuticals)? Findings In this cross-sectional study of 235 specialist physicians who frequently prescribe corticotropin to Medicare beneficiaries, 207 (88%) received a monetary payment from the drug’s maker, with more than 20% of frequent prescribers receiving more than $10 000. There was a significant association between higher dollar amounts paid to these prescribers and greater Medicare spending on their corticotropin prescriptions. Meaning Financial conflicts of interest among physicians may be driving corticotropin expenditures for the Medicare program., This study uses Medicare Part D and Open Payments data to characterize payments to physicians from the manufacturer of repository corticotropin gel (H. P. Acthar Gel, an ACTH analogue) and associations between those payments and the number of prescriptions and Medicare expenditures for the drug in 2015., Importance Despite great expense and little evidence supporting use over corticosteroids, prescriptions for repository corticotropin (H. P. Acthar Gel; Mallinckrodt Pharmaceuticals) have increased markedly. Aggressive sales tactics and payments from the manufacturer may influence prescribing behavior for this expensive medication. Objective To characterize industry payments to physician specialists who prescribe corticotropin in the Medicare program. Design, Setting, and Participants This study was a cross-sectional analysis of Centers for Medicare & Medicaid Services 2015 Part D prescribing data linked to 2015 Open Payments data. Nephrologists, neurologists, and rheumatologists with more than 10 corticotropin prescriptions (frequent prescribers) in 2015 were included. Exposures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt recorded in the Open Payments database. Main Outcomes and Measures Frequency, category, and magnitude of corticotropin-related payments from Mallinckrodt, as well as corticotropin prescriptions and expenditures for Medicare beneficiaries. Results Of the 235 included physicians, 65 were nephrologists; 59, neurologists; and 111, rheumatologists. A majority of frequent corticotropin prescribers (207 [88%]) received corticotropin-related payments from Mallinckrodt. The median (range) total payment for 2015 was $189 ($11-$138 321), with the highest payments ranging from $56 549 to $138 321 across the specialties. More than 20% of frequent prescribers received more than $10 000 and the top quartile of recipients received a median (range) of $33 190 ($9934-$138 321) in total payments per prescriber. Payments for compensation for services other than consulting contributed the most to the total amount. Mallinckrodt payments were positively associated with greater Medicare spending on corticotropin (β = 1.079; 95% CI, 1.044-1.115; P

Background Academic detailing is an interactive, convenient, and user-friendly approach to delivering non-commercial education to healthcare clinicians. While evidence suggests academic detailing is associated with improvements in prescribing behavior, uncertainty exists about generalizability and scalability in diverse settings. Our study evaluates different models of delivering academic detailing in a rural family medicine setting. Methods We conducted a pilot project to assess the feasibility, effectiveness, and satisfaction with academic detailing delivered face-to-face as compared to a modified approach using distance-learning technology. The recipients were four family medicine clinics within the Oregon Rural Practice-based Research Network (ORPRN). Two clinics were allocated to receive face-to-face detailing and two received outreach through video conferencing or asynchronous web-based outreach. Surveys at midpoint and completion were used to assess effectiveness and satisfaction. Results Each clinic received four outreach visits over an eight month period. Topics included treatment-resistant depression, management of atypical antipsychotics, drugs for insomnia, and benzodiazepine tapering. Overall, 90% of participating clinicians were satisfied with the program. Respondents who received in person detailing reported a higher likelihood of changing their behavior compared to respondents in the distance detailing group for five of seven content areas. While 90%-100% of respondents indicated they would continue to participate if the program were continued, the likelihood of participation declined if only distance approaches were offered. Conclusions We found strong support and satisfaction for the program among participating clinicians. Participants favored in-person approaches to distance interactions. Future efforts will be directed at quantitative methods for evaluating the economic and clinical effectiveness of detailing in rural family practice settings.