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Fourteen years ago, Stanford Health Policy’s Douglas K. Owens and colleagues published a cost-effectiveness analysis that would change the face of HIV prevention. Their landmark study in The New England Journal of Medicine showed that expanding HIV screening would increase life expectancy and curb transmission of the disease — and was cost effective in virtually all health-care settings.

Not long after their model-based results were published, their findings became key evidence in the decision to expand screening by the Centers for Disease Control and Prevention. Their work has been used in HIV screening guidelines from the U.S. Preventive Services Task Force — which Owens now chairs — the American College of Physicians and the Department of Veterans Affairs, among others.

Owens and his Stanford colleague Margaret Brandeau, professor of management science and engineering, have led this team of decision scientists who have been at the forefront of developing scientific models for the screening and prevention of HIV for two decades now. This modeling team — which also includes colleagues from UCSF and Yale — has published nearly 250 peer-reviewed studies and is one of the most experienced and respected in the world.

But today, the opioid epidemic is threatening the hard-fought gains in the prevention and control of HIV and hepatitis C virus (HCV). In support of their continued work to address the opioid epidemic, Owens received a highly prestigious MERIT award from the National Institute on Drug Abuse (NIDA),which provides up to 10 years of funding for the team.

“We are extremely grateful to NIDA for this support and to our colleague at NIDA, Dr. Peter Hartsock, who has worked with us for over 20 years to mitigate the harms from HIV and HCV,” said Owens.

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The team will now turn its sights on the complex interplay of the opioid epidemic, and HIV and hepatitis C virus (HCV) transmission. The transmission of HCV has been fueled by the opioid epidemic, and HCV now kills more Americans than all other infectious diseases combined.  

“The unfolding opioid epidemic is a defining challenge for the public health and medical systems in the United States,” Owens, the principal investigator of the team, and his colleagues wrote in their grant proposal. “The reversal of life expectancy growth in the demographic groups most affected by the opioid epidemic represents the aggregation of a complex web of harmful public health and population trends, including a rise in overdoses, suicides, mental health afflictions, economic disadvantages, and infectious disease outbreaks.”

Indeed, for the first time since the 1960s, the U.S. life expectancy has contracted for the second year in a row; drug overdoses have been the leading cause of death for Americans under age 50, with an estimated two-thirds of those deaths resulting from opioids.

Since the last renewal of their NIDA-funding grant in 2013, the team has watched the dramatic rise of opioid overuse, injection drug use, and overdose become a national public health crisis, with more than 60,000 drug overdose deaths in the United States reported by the CDC.

“The growing use of needle-based opioids increases the likelihood of accelerating HIV and HCV transmission,” said co-investigator Jeremy Goldhaber-Fiebert, an associate professor of medicine and core faculty at Stanford Health Policy. “Identifying the best combination of approaches to reduce HIV and HCV transmissions stemming from the opioid epidemic is of critical public health importance.”

The other co-investigators on the team of the project, “Making Better Decisions: Policy Modeling for AIDS and Drug Abuse,” are:

1. Eran Bendavid, an infectious diseases physician and associate professor of medicine at Stanford who is another a seasoned HIV modeler and outcomes expert;

2. Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford and a former senior policy advisor in the White House Office of National Drug Control Policy; 

3. David Paltiel, a Yale School of Public Health professor who pioneered policy options for mitigating the impact of HIV in the United States and abroad;

4. Gregg Gonsalves, an assistant professor of epidemiology at Yale and a 2018 MacArthur Foundation Fellow who will focus on developing new algorithms to detect and predict opioid-related outbreaks of HIV and HCV;

5. James Kahn of the Institute for Health Policy Studies at UCSF, professor of epidemiology and biostatistics and an expert on the individual and population impact of prevention and treatment for HIV, HCV and opioid use.

The End of AIDS? 

Toward 2012, a series of scientific advances led to calls for “the end of AIDS.” The two big factors were the cost of the “triple cocktail” of antiretrovirals plunging in developing countries and then huge donations from wealthy countries began pouring in to fight the disease.

Yet the researchers say successes have been too few and that the incidence of HIV remains far too high. About 40 million people were living with HIV around the world in 2017; an estimated 940,000 people died from AIDS-related illnesses that same year.

The year 2015 marked the first time in two decades that the number of HIV diagnoses tied to opioids increased.

"Although it was started by prescription opioid overprescribing, the epidemic has evolved to include significant injection opioid use which is now threatening to significantly increase the spread of infectious diseases like HIV and Hepatitis C,” said Humphreys.

The most visible example of an opioid-related HIV outbreak took place in Scott County, IN, in 2014-2015. A single infection introduced into the community resulted in nearly 200 new HIV cases within six months, largely related to oxymorphone injections. In 2017 and again in March 2018, two additional substantial outbreaks occurred in Scott County, likely linked to both risky sex and needle sharing. 

In addition, the CDC has identified 220 counties in 26 states that are uniquely vulnerable to HIV and HCV outbreaks related to opioid injections.

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“Developing models that forecast high-risk areas for HIV and HCV is essential for aligning surveillance and public health interventions with risk,” said Brandeau, a leader in designing models for the prevention of HIV and hepatitis, especially in drug abuse disorders.

There have also been striking increases in the injection of opioids and heroin that are closely linked to the spread of viral hepatitis. In the demographic areas most affected by opioids, the researchers found, diagnoses of acute hepatitis have more than quadrupled — reversing trends of the previous decade. And in the country as a whole, the number of new HCV cases has nearly tripled since 2010. 

“For any type of contact with an infected source such as a dirty needle, or even cocaine straws, HCV is by far the most rapidly transmissible of the blood-borne infections,” said Bendavid. “One of the challenging issues with hepatitis C is that its major health manifestations do not appear for many years after infection."

What’s the Plan? 

In the next five years, the team intends to evaluate how strategies to prevent and mitigate the harms of opioid use can decrease the spread of HIV and HCV and thereby reduce morbidity and mortality from opioid use. They have four specific goals: 

1. Model the effect of the opioid epidemic on transmission of HIV and HCV.

2. Model the epidemiological and population impacts of individual strategies to prevent and mitigate the harms of opioids and drug injection on HIV and HCV outcomes by evaluating prevention strategies;

3. Model the epidemiologic and population impact of portfoliosof strategies to mitigate the harms of opioid use and drug injection on HIV and HCV outcomes;

4. And model the impact of barriers to implementation of effective strategies to reduce the harms of opioid use on HIV and HCV.

“We will perform novel analyses assessing intervention impacts singly and in combination assessing outcomes for HIV, HCV and opioid use disorder,” the researchers wrote in their grant proposal.

Then, the researcher will model new methods for building complex multi-intervention and multi-disease models and developing adaptive testing algorithms for identifying outbreaks.

Finally, the team intends to assess the barriers and intervention approaches “that more realistically reflect implementation issues than current models and hence identify resource needs for system planning.”

Marcella Alsan and Marianne Wanamaker are recipients of this year’s prestigious Arrow Award from the International Health Economics Association for research that shows the health of African-American men was adversely impacted by the Tuskegee syphilis study of the early 20th century.

The annual award recognizes excellence in the field of health economics and is named after the late Kenneth J. Arrow, a Nobel Prize-winning economist and mathematician. He was a Stanford Health Policy fellow and senior fellow by courtesy at the Freeman Spogli Institute for International Studies (FSI). He was also a senior fellow, emeritus, at the Stanford Institute for Economic Policy Research (SIEPR).

The IHEA awarded the 27th annual Arrow Award to Alsan, a core faculty member at Stanford Health Policy, a senior fellow at FSI and SIEPR, and co-author Wanamaker of the University of Tennessee for their paper, “Tuskegee and the Health of Black Men” published in the Quarterly Journal of Economics.

The infamous Tuskegee study began in 1932 when the U.S. Public Health Service began following approximately 600 African-American men, some of whom had syphilis, for the stated purpose of understanding the natural history of the disease. The government willingly withheld treatment even after penicillin became an established magic bullet for treating the illness. 

The medical doctors and staff of the CDC followed the men for four decades, until ultimately the study was halted in 1972 when it was brought to the attention of the media by law student Peter Buxtun.

As noted in this story about the research, Alsan and Wanamaker found that the public disclosure of the study in 1972 was associated with an increase in medical mistrust and mortality among African-American men in the immediate aftermath of the revelation.

“The award is an immense honor for both Marianne and me. First, it sheds light on the importance of history for understanding health disparities. Second, it reaffirms the “expected behavior of the physician” that Professor Arrow eloquently described in his seminal 1963 paper on the distinctive features of the market for medical care and the externalities associated with deviating from those expectations.”

African-American men today have the worst health outcomes of all major ethnic, racial and demographic groups in the United States. Life expectancy for black men at age 45 is three years less than their white male peers, and five years less than for black women.

When their working paper was first published by the National Bureau of Economic Research, it became part of the national discussion about the lasting impact of the Tuskegee study.

“The story that Alsan and Wanamaker uncovered is even deeper than the direct effects of the Tuskegee Study,” wrote Vann R. Newkirk II in The Atlantic. “Their research helps validate the anecdotal experiences of physicians, historians, and public health workers in black communities and gives new power to them.”

The United States is the only country in the 35-member Organization for Economic Cooperation and Development that offers no paid leave to new mothers. The U.S. also has relatively poor infant health ratings, particularly for preterm births and infant mortality.

So why has the federal government been so reluctant to join other industrialized nations in paying new mothers to stay at home so they can nurture and nourish these new citizens?

“There’s opposition from business interests arguing that any type of mandate on employers imposes too large costs, especially for small businesses,” said Stanford Health Policy’s Maya Rossin-Slater. “There’s not much empirical evidence supporting this argument, but I think the strong political opposition from business supporters may be a central reason for a lack of action on the federal level.”

In a policy brief published March 28 in Health Affairs, Rossin-Slater, an assistant professor of health research and policy, lays out the evidence that suggests the introduction of paid family leave (PFL) for up to one year in duration may yield significant child and maternal health benefits, both in the short and long term. Her co-author on the brief is Lindsey Uniat, a predoctoral research fellow at the Stanford Institute for Economic Policy Research.

“Existing research suggests that when leave is paid, take-up rates are higher among low-income and disadvantaged families than when it is unpaid, which enables more families to benefit,” they wrote.

Some of the short- and long-term health benefits include decreased incidence of low birthweight and preterm births, increased breast-feeding, reduced rates of hospitalizations among infants and improved maternal health.

Family and Medical Leave Act

The federal Family and Medical Leave Act (FMLA) of 1993 provides 12 weeks of unpaid, job-protected leave with continued health insurance coverage to attend to a newborn or adopted child, a family member, or an employee’s own serious health condition. There are strict eligibility requirements for the FMLA, such as needing to have worked at least 1,250 hours for an employer with 50 or more employees during the 12 months before the start of the leave.

The most recent data, according to the authors, indicate that only about 60 percent of private-sector workers are eligible for FMLA, and 46 percent of those eligible report not being able to afford taking unpaid time off work.

Six states and the District of Columbia have passed paid family leave policies, and the issue has been receiving attention at both state and federal levels in recent years. California, Hawaii, New Jersey, New York and Rhode Island, as well as Puerto Rico, have State Disability Insurance (SDI), which provides partial wage-replaced leave for workers with temporary disabilities and for mothers preparing for and recovering from childbirth. These policies offer up to six weeks of leave postpartum for vaginal deliveries and eight weeks for C-section deliveries.

“The majority of existing research on the health effects of PFL focuses on children’s outcomes,” the authors write. Earlier work on the impacts of unpaid leave provided through the FMLA shows that it led to small increases in birthweight and large reductions in infant mortality rates.

However, these health benefits were apparent only for children of relatively advantaged mothers, the authors wrote, which is consistent with prior evidence that such mothers were most likely to be eligible for, and able to afford to use, unpaid leave.

“In contrast, mothers and children from less advantaged backgrounds particularly benefit from access to paid leave,” they said, noting that one study showed that the introduction of paid maternity leave through the SDI system in five states led to a reduction in the share of low birthweight and preterm births, especially for unmarried and black mothers.

Rossin-Slater and Uniat believe paid family leave may affect population health through multiple channels:

• Children of parents who take leave may receive more parental care, breast-feeding and immunizations if parents are able to stay home longer after birth;
• Child health may improve from the extra resources that parents get form PFL benefits, such as more nutritious food;
• Infant and long-term health outcomes may improve if PFL access lowers maternal stress during pregnancy, perhaps due to increased financial and job security;
• Taking time off from work without the financial strain may improve the parental bond with the infant — leading to long-term health benefits for the child.

The Labor Market

Finally, existing research indicates that paid family leave may benefit the labor market by leading to fewer high-school dropouts, thus an increase in children’s future wages.

“Several policy takeaways are evidence from the research to date,” the authors wrote. “Paid leave, in contrast to unpaid leave, increases leave usage and duration, especially among disadvantaged parents who are least able to afford unpaid time off.”

More research is needed, they said, to understand how paid family leave legislation could impact employers.

“We know little about how employers deal with work interruptions due to employees’ taking leave or whether employers respond to PFL mandates by changing their own benefits packages, hiring practices, or other aspects of jobs,” they said.

Most studies that look at whether democracy improves global health rely on measurements of life expectancy at birth and infant mortality rates. Yet those measures disproportionately reflect progress on infectious diseases — such as malaria, diarrheal illnesses and pneumonia — which relies heavily on foreign aid.

A new study led by Stanford Health Policy's Tara Templin and the Council on Foreign Relations suggests that a better way to measure the role of democracy in public health is to examine the causes of adult mortality, such as noncommunicable diseases, HIV, cardiovascular disease and transportation injuries. Little international assistance targets these noncommunicable diseases. 

When the researchers measured improvements in those particular areas of public health, the results proved dramatic.

“The results of this study suggest that elections and the health of the people are increasingly inseparable,” the authors wrote.

A paper describing the findings was published today in The Lancet. Templin, a graduate student in the Department of Health Research and Policy, shares lead authorship with Thomas Bollyky, JD, director of the Global Health Program at the Council on Foreign Relations.

“Democratic institutions and processes, and particularly free and fair elections, can be an important catalyst for improving population health, with the largest health gains possible for cardiovascular and other noncommunicable diseases,” the authors wrote.

Templin said the study brings new data to the question of how governance and health inform global health policy debates, particularly as global health funding stagnates.

“As more cases of cardiovascular diseases, diabetes and cancers occur in low- and middle-income countries, there will be a need for greater health-care infrastructure and resources to provide chronic care that weren’t as critical in providing childhood vaccines or acute care,” Templin said.

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Free and fair elections for better health

In 2016, the four mortality causes most ameliorated by democracy — cardiovascular disease, tuberculosis, transportation injuries and other noncommunicable diseases — were responsible for 25 percent of total death and disability in people younger than 70 in low- and middle-income countries. That same year, cardiovascular diseases accounted for 14 million deaths in those countries, 42 percent of which occurred in individuals younger than 70.

Over the past 20 years, the increase in democratic experience reduced mortality in these countries from cardiovascular disease, other noncommunicable diseases and tuberculosis between 8-10 percent, the authors wrote.

“Free and fair elections appear important for improving adult health and noncommunicable disease outcomes, most likely by increasing government accountability and responsiveness,” the study said.

The researchers used data from the Global Burden of Diseases, Injuries, and Risk Factors Study; V-Dem; and Financing Global Health databases. The data cover 170 countries from 1970 to 2015.

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Watch: Some of the authors of the study discuss the significant their findings: 

What Templin and her co-authors found was democracy was associated with better noncommunicable disease outcomes. They hypothesize that democracies may give higher priority to health-care investments.

HIV-free life expectancy at age 15, for example, improved significantly — on average by 3 percent every 10 years during the study period — after countries transitioned to democracy. Democratic experience also explains significant improvements in mortality from cardiovascular disease, tuberculosis, transportation injuries, cancers, cirrhosis and other noncommunicable diseases, the study said.

Foreign aid often misdirected

And yet, this connection between fair elections and global health is little understood.

“Democratic government has not been a driving force in global health,” the researchers wrote.  “Many of the countries that have had the greatest improvements in life expectancy and child mortality over the past 15 years are electoral autocracies that achieved their health successes with the heavy contribution of foreign aid.”

They note that Ethiopia, Myanmar, Rwanda and Uganda all extended their life expectancy by 10 years or more between 1996 and 2016. The governments of these countries were elected, however, in multiparty elections designed so the opposition could only lose, making them among the least democratic nations in the world.

Yet these nations were among the top two-dozen recipients of foreign assistance for health.

Only 2 percent of the total development assistance for health in 2016 was devoted to noncommunicable diseases, which was the cause of 58 percent of the death and disability in low-income and middle-income countries that same year, the researchers found.

“Although many bilateral aid agencies emphasize the importance of democratic governance in their policy statements,” the authors wrote, “most studies of development assistance have found no correlation between foreign aid and democratic governance and, in some instance, a negative correlation.”

Autocracies such as Cuba and China, known for providing good health care at low cost, have not always been as successful when their populations’ health needs shifted to treating and preventing noncommunicable diseases. A 2017 assessment, for example, found that true life expectancy in China was lower than its expected life expectancy at birth from 1980 to 2000 and has only improved over the past decade with increased government health spending. In Cuba, the degree to which its observed life expectancy has exceeded expectations has decreased, from four-to-seven years higher than expected in 1970 to three-to-five years higher than expected in 2016.

“There is good reason to believe that the role that democracy plays in child health and infectious diseases may not be generalizable to the diseases that disproportionately affect adults,” Bollyky said. Cardiovascular diseases, cancers and other noncommunicable diseases, according to Bollyky, are largely chronic, costlier to treat than most infectious diseases, and require more health care infrastructure and skilled medical personnel.  

The researchers hypothesize that democracy improves population health because:

1. When enforced through regular, free and fair elections, democracies should have a greater incentive than autocracies to provide health-promoting resources and services to a larger proportion of the population;
2. Democracies are more open to feedback from a broader range of interest groups, more protective of media freedom and might be more willing to use that feedback to improve their public health programs;
3. Autocracies reduce political competition and access to information, which might deter constituent feedback and responsive governance.

Various studies have concluded that democratic rule is better for population health, but almost all of them have focused on infant and child mortality or life expectancy at birth.

Over the past 20 years, the average country’s increase in democracy reduced mortality from cardiovascular disease by roughly 10 percent, the authors wrote. They estimate that more than 16 million cardiovascular deaths may have been averted due to an increase in democracy globally from 1995 to 2015. They also found improvements in other health burdens in the countries where democracy has taken hold: an 8.9 percent reduction in deaths from tuberculosis, a 9.5 percent drop in deaths from transportation injuries and a 9.1 percent mortality reduction in other noncommunicable disease, such as congenital heart disease and congenital birth defects.

“This study suggests that democratic governance and its promotion, along with other government accountability measures, might further enhance efforts to improve population health,” the study said. “Pretending otherwise is akin to believing that the solution to a nation’s crumbling roads and infrastructure is just a technical schematic and cheaper materials.”

The other researchers who contributed to the study are Matthew Cohen, Diana Schoder, Joseph Dieleman and Simon Wigley, from CFR, the University of Washington-Seattle and Bilkent University in Turkey, respectively.

Funding for the research came from Bloomberg Philanthropies and the Bill & Melinda Gates Foundation. Stanford’s Department of Health Research and Policy also supported the work.

Americans know that choosing a health insurance plan can tough. And once you’re retired and possibly on a limited or fixed income, it can become downright brutal.

Stanford Health Policy’s M. Kate Bundorf and Maria Polyakova and their colleagues set out to develop an online decision-support tool to test whether machine-based expert recommendations would influence choice among Medicare Part D enrollees — and make it easier.

“The use of technology seems like a natural way to address the challenges of choosing among plans,” they write in their study published in Health Affairs.

Medicare beneficiaries have been choosing among Medicare Advantage and Part D prescription drug plans for years, and more recently the Affordable Care Act established health insurance marketplaces for those who are younger than 65.

All that choice is supposed to create incentives for plans to offer a variety of low-cost, high-quality products that allow people to choose the plan that best meets their needs.

But sometimes too many good choices can lead to bad outcomes.

“Health insurance is a complex financial product with complicated cost-sharing rules, and the implications of different benefit designs for out-of-pocket spending and health care use vary across consumers depending on their needs,” wrote Bundorf, chief of the Department of Health Research and Policy and an associate professor of medicine at Stanford Medicine.

Another researcher in the study was Albert Chan, chief of digital patient experience and an investigator at Sutter Health, in Palo Alto, as well as an adjunct professor at the Stanford Center for Biomedical Informatics Research. Ming Tai-Seale, a professor of family medicine and public health at University of California San Diego, was also a principal investigator of the study.

Choosing Health Plan is Complicated

“Consistent with these challenges, researchers have documented that many consumers, both young and old, do not understand the characteristics of their plans,” they wrote in the March issue of Health Affairs, which is holding a public briefing on patients-as-consumers at the National Press Club on March 5th. Bundorf will present their research at the briefing in Washington, D.C., which will be streamed live and will be posted here once it has aired.

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“(Patients) often make decisions that may signal inaccurate evaluation of the costs and benefits of coverage — such as staying in their plan when better options are available, not enrolling in the plan that provides the best coverage for their drugs, or enrolling in plans that are objectively inferior to other available choices,” the authors wrote.

The Centers for Medicare and Medicaid Services (CMS) offers a tool to help beneficiaries choose among plans, but older adults — even those with high levels of formal education — find it difficult to use.

So, the research team developed a decision-support software tool called CHOICE to assist Medicare beneficiaries in choosing a Part D prescription plan. The software automatically imported the user’s list of current drugs from their electronic medical records (allowing users to adjust the list if desired); the algorithm would then crunch the numbers to come up with three recommended plans which were likely to be the least expensive for the user.

The team then conducted a randomized trial of this software tool among 1,185 patients of the Palo Alto Medical Foundation (PAMF), a large health-care provider in Northern California. Fifty-four percent of those patients were women, 65 percent were white, and 54 percent were married. Living in the Bay Area, their income and education levels were fairly high: They lived in areas in which the median income is $106,808 and 54 percent of the population has a college degree or more education.

While not representative of the general population of seniors in the United States, the researchers emphasized that it was important to conduct this study among these potential users, who are more likely to respond positively to an interaction with a computer. If these users didn’t find this software helpful or user friendly, it would not likely be a useful tool to roll out across the country as a whole.

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The study participants received access to one of two versions of the CHOICE tool: expert recommendations or individual analysis. Both versions automatically imported information on patients’ prescription drugs from their electronic health records and combined it with information on plan benefit design to provide individually customized information on users’ likely spending on both premiums and prescription drugs in each of the stand-alone Part D plans available in their area. The version of CHOICE that offered expert recommendations combined this information with an explicit recommendation on which plans were best for the user.

Willing and Able

The researchers found that providing an online tool not only increased older adults’ satisfaction with the process of choosing a prescription drug plan, but they also spent more time choosing that plan.

“The most significant finding of our trial is that individually customized information alone didn’t seem to be enough,” Bundorf, who is also a senior fellow at the Stanford Institute for Economic Policy Research (SIEPR), said in an interview. “The tool we developed was most effective when individually customized information paired with a clear-cut algorithmic expert recommendation that highlighted three plans that the computer thought were the best for the user based on total spending for prescription drugs.”

She said she was surprised to see that people spent more time choosing a plan and were more satisfied with the process when they had access to the CHOICE tool.

“Prior to our trial, I thought people might spend less time choosing a plan when they had access to expert recommendations because it would make the process easier,” Bundorf said. “But taken together, these results suggest that people are more engaged in decision-making when they have access to a patient-centered tool.”

Polyakova, who is also a faculty fellow at SIEPR, said a key takeaway from the trial is that people who are likely to use sophisticated tools are already more likely be more sophisticated shoppers of health care and prescription plans.

Opioids overdoses now kill more Americans than car accidents or guns, with more than 350,000 Americans having succumbed to the painkillers since 2000.

“The opioid misuse and overdose crisis touches everyone in the United States,” Health and Human Services Secretary Alex Azar said in this recent report. “The effects of the opioid crisis are cumulative and costly for our society — an estimated $504 billion a year in 2015 — placing burdens on families, workplaces, the health care system, states, and communities.”

Now, new research led by Stanford shows that not only have opioid-related deaths jumped fourfold in the last 20 years, but that those most affected by the epidemic, and where they live, has also shifted dramatically. In fact, the District of Columbia has had the fastest rate of increase in mortality from opioids, more than tripling every year since 2013.

“Although opioid-related mortality has been stereotyped as a rural, low-income phenomenon concentrated among Appalachian or midwestern states, it has spread rapidly, particularly among the eastern states,” writes Mathew V. Kiang, ScD, a research fellow at the Center for Population Health Sciences at the Stanford University School of Medicine, in an original investigation published in JAMA Network Open.

The study found the highest rates of opioid-related deaths and more rapid increases in mortality were observed in eight states: Connecticut, Illinois, Indiana, Massachusetts, Maryland, Maine, New Hampshire and Ohio. Two states, Florida and Pennsylvania, had opioid-related mortality rates that were doubling every two years — and tripling in Washington, D.C.

Kiang and his co-authors, including Stanford Health Policy’s Sanjay Basu, MD, PhD,an assistant professor of medicine at Stanford Medicine, used data from the National Center for Health Statistics and corresponding population estimates from the U.S. Census. The other authors are Jarvis Chen, ScD, at the Harvard T.H. Chan School of Public Health, and Monica Alexander, PhD, in the Department of Sociology at the University of Toronto.

“It seems there has been a vast increase in synthetic opioid deaths in the eastern states and especially in the District of Columbia because illicit drugs are often tainted with fentanyl or other synthetic opioids,” Kiang said in an interview.  “People aren’t aware their drugs are laced and more potent than they expected — putting them at higher risk of overdose.”

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Synthetic opioid deaths now outnumber heroin deaths in these eastern states, which suggests fentanyl has spread to other illegal drugs and is no longer limited to heroin.

“The identification and characterization of opioid `hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the authors write.

The research suggests the opioid epidemic has evolved as three intertwined, but distinct waves, based on the types of opioids associated with mortality:

1. The first wave of opioid-related deaths was associated with prescription painkillers from the 1990s until about 2010.
2. From 2010 until the present, the second wave was associated with a large increase in heroin-related deaths.
3. And in the third and current wave, which began around 2013, the rapid increase is associated with illicitly manufactured synthetic opioids, such as tramadol and fentanyl.

“The evolution has also seen a wider range of populations being affected, with the spread of the epidemic from rural to urban areas and considerable increases in opioid-related mortality observed in the black population,” they write.

The Centers for Disease Control and Prevention reports that African-Americans experienced the largest increase in opioid overdose deaths among any racial group from 2016 to 2017, with a 26 percent surge.

“The identification and characterization of opioid ‘hot spots’ — in terms of both high mortality rates and increasing trends in mortality — may allow for better-targeted policies that address the current state of the epidemic and the needs of the population,” the researchers write.

States are trying to combat the epidemic by enacting policies, such as restricting the supply of prescription drugs and expanding treatment and access to the overdose-reversing drug naloxone.

“Treating opioid use as a disorder should be our top priority to curb the problem,” said Kiang. “Similarly, we have the ability that counteract the effects of an overdose — these life-saving drugs should be easily accessible and widely available.”

To prescribe or not prescribe? In the realm of the nation’s opioid epidemic, it’s an important question.

Research has shown that inappropriate use of prescription opioids is part of the reason behind a dramatic rise in opioid-related deaths since 2000. By 2015, the amount of opioids prescribed in the U.S. had tripled — enough for every American to be medicated around the clock for three weeks, at 5 milligrams of hydrocodone every four hours. 

Now, new research by a trio of Stanford scholars shows how different insurance strategies affect the volume of opioid use and could help stem inappropriate prescribing behaviors. 

The study, released in a working paper by the National Bureau of Economic Research, was co-authored by Stanford Health Policy’s Laurence C. Baker, M. Kate Bundorf, and Daniel P. Kessler. Baker and Bundorf are professors in the Department of Health Research and Policy at the Medical School; Kessler is a professor in the Law School and Graduate School of Business, and a senior fellow at the Hoover Institution.  All are also senior fellows at the Stanford Institute for Economic Policy Research (SIEPR).

Their study — the first to investigate the effect of the form of Medicare drug coverage on opioid use — found that enrollment in Medicare Advantage, a combined medical and drug insurance plan, significantly reduces the likelihood of beneficiaries filling an opioid prescription, as compared to enrollment in a stand-alone drug plan.

Compared to beneficiaries enrolled in stand-alone plans, those enrolled in the integrated Medicare Advantage plan were 37 percent less likely to get an opioid prescription, according to their analysis of drug claims from 2014.

The researchers also found that enrollment in integrated insurance coverage under Medicare Advantage had a disproportionate effect on the likelihood of filling an opioid prescription from the nation’s highest opioid-prescribing doctors — the top 1 percent of prescribers in Medicare Part D. The lower likelihood of prescriptions from these high prescribers to Medicare Advantage enrollees accounted for more than half of the reduction, according to their findings.

To understand the scope of this health plan-related effect and what’s at stake, consider the backdrop laid out in the study:

Since its implementation in 2006, Medicare Part D has become the nation’s largest purchaser of prescription opioids. More than 42 million Americans are enrolled in Medicare Part D — either under the stand-alone drug plan or the integrated Medicare Advantage plan.

What’s more, opioid prescriptions are concentrated among a relatively small group of “high prescribers.” 

According to research published in the 2016 edition of JAMA Internal Medicine, more than one-third of opioid prescriptions under Medicare Part D were made by about 8,000 doctors, making up the top 1 percent of prescribers. And according to the Office of the Inspector General of the Department of Health and Human Services, “extreme use” and “questionable prescribing” have put almost 90,000 beneficiaries at serious risk for opioid misuse or overdose.

Because the researchers did not examine patient health outcomes, they could not definitively determine that enrollment in Medicare Advantage reduced only inappropriate opioid use. However, because the reduction in opioid use came disproportionately from high prescribers, and previous work has found that Medicare Advantage enrollees had higher prescription drug use overall, the reduction in use that the researchers found was targeted rather than a result of a broader effort to restrict access to treatment.  

The researchers’ results support the conclusions of previous work that integration of prescription drug coverage with the other benefits provided by Medicare Advantage plans

improves the quality of care. Further study will be needed to drill deeper into the reasons behind the impact of Medicare Advantage plans, and whether a similar effect occurs in non-elderly populations, the researchers said.

The national opioid epidemic has grown at such breakneck speed that public health experts have been left scrambling to keep up. Though they understand the reasons behind the abuse — the solutions are complicated and costly.

Yet there appears to be some success at reducing at least one area of opioid abuse.

In new research by Health Research and Policy’s Eric Sun, the risk for chronic opioid use among patients with musculoskeletal pain actually decreased slightly between 2008 and 2014. 

The Stanford Medicine assistant professor of anesthesiology and pain medicine found that measures such as avoiding opioid use soon after diagnosis can further reduce the risk of addiction, especially among patients at highest risk for chronic opioid use.

"We found that early opioid use after diagnosis is predictive of opioid use longer term, suggesting that it may be prudent to minimize opioid use where possible for patients with musculoskeletal pain,” said Sun, whose research was published earlier this week in the Annals of Internal Medicine.

His co-authors are Jasmin Moshfegh, who is working on her PhD in health policy, and Steven Z. George, director of musculoskeletal research at Duke University School of Medicine.

Patients with lower back or chronic neck, shoulder and knee pain are at the highest risk for opioid abuse since pain meds are typically prescribed to help ease their spasms. 

Patients who suffer musculoskeletal pain may unwittingly transition to chronic opioid use, which means filling 10 or more prescriptions or having a supply for at least 120 days. The prescription drugs include hydrocodone, hydromorphone, methadone, morphine, oxymorphone, and/or oxycodone. Those don’t include heroin and synthetic opioids such as fentanyl.

Sun and his fellow researchers at the 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 — those who have never been prescribed painkillers before — recently diagnosed with pain in the knee, neck, lower back or shoulder. 

The sample was restricted to privately insured patients, thereby excluding other policy-relevant populations, such as those who were prescribed pain medications under Medicare or Medicaid.

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. They discovered a relative decline of 25 to 50 percent across all pain types from 2008 to 2014.

Opioid Abuse

Opioid abuse has its roots in the late 1990s when pharmaceutical companies assured the medical community that patients would not become addicted to pain relievers. Clinicians began prescribing them at greater rates because they worked so well and seemed safe.

Today, more than 130 people die every day from opioid-related drug overdoses from prescription pain relievers, heroin and synthetic opioids such as fentanyl, according to the U.S. Department of Health and Human Services, From 2002 to 2017, there was more than a fourfold increase in opioid deaths, with some 49,000 people dying in 2017.

The Centers for Disease Control and Prevention estimates that the total economic burden of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.

“While our research found that only about 1 percent of patients with musculoskeletal pain progress to chronic opioid use, this is potentially concerning because it’s an extremely common diagnosis,” Sun said. “By pointing out the scope of the issue and identifying factors that place patients at risk, we hope this research will guide further efforts aimed at reducing opioid use among patients with musculoskeletal pain.” 

A national panel of medical experts is recommending for the first time that clinicians offer daily preventive medication to patients who are at high risk of acquiring HIV/AIDS.

The U.S. Preventive Services Task Force estimates that 1.1 million Americans are currently living with HIV. More than 700,000 people have died from AIDS in the United States since the first cases were reported in 1981 and some 40,000 Americans are diagnosed with the virus each year.

Though HIV is treatable, there is still no vaccine and it has significant health consequences.

But the Task Force said in a published draft recommendation on Tuesday that it found “convincing evidence” that taking a daily pre-exposure prophylaxis, known as PrEP, provides a substantial benefit in decreasing the risk of HIV infection in people at high risk. 

PrEP is a combination of two drugs, tenofovir disoproxil fumarate and emtricitabine, taken in one daily pill. The Centers for Disease Control and Prevention says that PrEP reduces the risk of getting HIV from sex by more than 90 percent and by 70 percent for intravenous drug users.

“Unfortunately, HIV is still a major problem in the United States,” said Stanford Health Policy’s Douglas K. Owens, vice-chairman of the Task Force, an independent, voluntary panel of experts in prevention and evidence-based medicine. “But the evidence on this daily treatment is that, if you take it properly, it’s very effective.”

The Task Force, whose recommendations are followed by primary care physicians and clinical practices across the country, gave the recommendation its highest grade, an A. But it noted that PrEP currently is not being used in many persons at high risk of HIV infection. 

“We hope our recommendation will bring attention to a very effective preventative service,” Owens said. “We want clinicians to be aware that for patients at high risk of HIV, PrEP is an important preventive strategy to discuss.”

The global AIDS epidemic has slowed in recent year. AIDS-related deaths have been reduced by more than 50 percent since the peak of the AIDS crisis in 2004. In 2017, 940,000 people died from AIDS-related illnesses worldwide, compared to 1.4 million in 2010 and 1.9 million in 2004.

But many people remain at risk, including sex workers and people who have been trafficked.

The Task Force recommendation is only for those Americans who remain at high risk for contracting the virus, including:

1. Sexually active men whose male partners are already living with HIV, or have a recent sexually transmitted infection (STI) such as syphilis, gonorrhea, or chlamydia;
2. Heterosexual women and men who are sexually active and have an STI or partner living with HIV or who are inconsistent in their use of condoms with a partner at high risk of HIV;
3. People who inject drugs and either share drug injection equipment.

The Task Force reaffirmed its 2013 recommendation that people ages 15 to 65 and all pregnant women also be screened for HIV in an additional draft recommendation. Both recommendations are open for public comment until December 26.

More children die from the indirect impact of armed conflict in Africa than those killed in the crossfire and on the battlefields, according to a new study by Stanford researchers. 

The study is the first comprehensive analysis of the large and lingering effects of armed conflicts — civil wars, rebellions and interstate conflicts — on the health of noncombatants.

The numbers are sobering: 3.1 to 3.5 million infants born within 30 miles of armed conflict died from indirect consequences of battle zones between 1995 and 2005. That number jumps to 5 million deaths of children under 5 in those same conflict zones.

“The indirect effects on children are so much greater than the direct deaths from conflict,” said Stanford Health Policy's Eran Bendavid, senior author of the study published today in The Lancet.

The authors also found evidence of increased mortality risk from armed conflict as far as 60 miles away and for eight years after conflicts. Being born in the same year as a nearby armed conflict is riskiest for young infants, the authors found, with the lingering effects raising the risk of death for infants by over 30 percent.

On the entire continent, the authors wrote, the number of infant deaths related to conflict from 1995 to 2015 were more than three times the number of direct deaths from armed conflict. Further, they demonstrated a strong and stable increase of 7.7 percent in the risk of dying before age 1 among babies born within 30 miles of an armed conflict.

The authors recognize it is not surprising that African children are vulnerable to nearby armed conflict. But they show that this burden is substantially higher than previously indicated. 

“We wanted to understands the effects of war and conflict, and discovered that this was surprisingly poorly understood,” said Bendavid, an associate professor of medicine at Stanford Medicine.  “The most authoritative source, the Global Burden of Disease, only counts the direct deaths from conflict, and those estimates suggest that conflicts are a minuscule cause of death.”

Paul Wise, a professor of pediatrics at Stanford Medicine and a senior fellow at the Freeman Spogli Institute for International Studies, has long argued that lack of health care, vaccines, food, water and shelter kills more civilians than combatants from bombs and bullets. 

This study has now put data behind the theory when it comes to children.

“We hope to redefine what conflict means for civilian populations by showing how enduring and how far-reaching the destructive effects of conflict have on child health,” said Bendavid, an infectious disease physician whose co-authors include Marshall Burke, PhD, an assistant professor of earth systems science and fellow at the Center on Food Security and the Environment.

“Lack of access to key health services or to adequate nutrition are the standard explanations for stubbornly high infant mortality rates in parts of Africa,” said Burke. “But our data suggest that conflict can itself be a key driver of these outcomes, affecting health services and nutritional outcomes hundreds of kilometers away and for nearly a decade after the conflict event”. 

The results suggest efforts to reduce conflict could lead to large health benefits for children.

The Data

The authors matched data on 15,441 armed-conflict events with data on 1.99 million births and subsequent child survival across 35 African countries. Their primary conflict data came from the Uppsala Conflict Data Program Georeferenced Events Dataset, which includes detailed information about the time, location, type and intensity of conflict events from 1946 to 2016. 

The researchers also used all available data from the Demographic and Health Surveys conducted in 35 African countries from 1995 to 2015 as the primary data sources on child mortality in their analysis.

The data, they said, shows that the indirect toll of armed conflict among children is three-to-five times greater than the estimated number of direct casualties in conflict. The indirect toll is likely even higher when considering the effects on women and other vulnerable populations.

Zachary Wagner, a health economist at RAND Corporation and first author of the study, said he knows few are surprised that conflict is bad for child health.

“However, this work shows that the relationship between conflict and child mortality is stronger than previously thought and children in conflict zones remain at risk for many years after the conflict ends.” 

He notes that nearly 7 percent of child deaths in Africa are related to conflict and reiterated the grim fact that child deaths greatly outnumber direct combatant deaths.

“We hope our findings lead to enhanced efforts to reach children in conflict zones with humanitarian interventions,” Wagner said. “But we need more research that studies the reasons for why children in conflict zones have worse outcomes in order to effectively intervene.” 

Another author, Sam Heft-Neal, PhD, is a research fellow at the Center for Food Security and the Environment and in the Department of Earth Systems Science. He, Burke and Bendavid have been working together to identify the impacts of extreme climate events on infant mortality in Africa.