Anna Oura (Tokyo Gakugei University International Secondary School) received Honorable Mention for her research paper on “A Comparative Study on Japanese and U.S. History Textbooks.”

Applications for the Spring 2019 session of Stanford e-Japan will be accepted online from January 10 to February 24, 2019.

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• Japan Day 2018: Recognizing future leaders in the U.S.–Japan relationship
• Winners announced for the Fall 2017 Stanford e-Japan Award

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 way that the economy has developed over the past generation is actually gone contrary to a lot of the existing economic models. The Simon Kuznetz phenomenon says it's not just globalization, it's economic growth. As the country is modernizing, as it's growing economically, it does lead to an increase in inequality. When you reach a  certain level of income, the inequality starts to decrease. That was the experience in Europe, in the 19th and 20th century, that was the case in the United States and so forth. That has not been the case of the countries that have been growing rapidly in recent years, where inequality has continued to increase," says CDDRL Mosbacher Director Francis Fukuyama. Watch here. 

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.” 

While Americans may be well acquainted with China’s quest for influence through the projection of power in the diplomatic, economic, and military spheres, they are less aware of the various ways in which Beijing has more recently been exerting cultural and informational influence. According to a new report, some of these ways challenge and even undermine our democratic processes, norms, and institutions.

With a growing realization that the ambition of Chinese influence operations requires far greater scrutiny than it has been getting, a group of American scholars and policy practitioners set out to document the extent of China’s influence-seeking activities in American society. The working group, co-chaired by Larry Diamond, senior fellow at the Freeman Spogli Institute for International Studies and at the Hoover Institution, and Orville Schell, Arthur Ross director of the Asia Society’s Center on U.S.-China Relations, just released its findings and recommendations in a report that has drawn much attention, “Chinese Influence and American Interests: Promoting Constructive Vigilance.” On December 4, Diamond and Schell discussed the report’s findings and implications at a special roundtable organized by Shorenstein APARC’s U.S.-Asia Security Initiative (USASI).

Diamond and Schell described the report’s detailing of a range of assertive and opaque “sharp power” activities that China has stepped up within the United States in multiple sectors, including Congress, state and local government, universities, think tanks, media, corporations, technology and research, and the Chinese American community. These activities, they argue, penetrate deeply the social and political fabric of our democratic society and exploit its openness. Unlike legitimate “soft power” efforts within the realm of normal public diplomacy, they constitute improper interference that demands greater awareness and a calibrated response.

“The report was born out of a recognition that things have changed,” said Schell. “Our engagement with China has either failed or is teetering on the brink of failure. The report aims to put the question of our interaction and exchange with China within the context of policy.”

Diamond noted that “The question at least has to be asked whether there is a threat to U.S. national interests.” He emphasized that the members of the working group that produced the report seek a productive relationship between China and the United States. The report therefore advocates for perspective and framework that are built on three principles regarding U.S.-China relations: transparency, institutional integrity, and reciprocity.

Diamond and Schell were joined at the panel by Hwang Ji-Jen, a Taiwanese scholar in the Institute for East Asian Studies at the University of California - Berkeley, who helped situate the forms and effects of Chinese “sharp power” in the United States in comparison to its practice in and toward Taiwan. Karl Eikenberry, director of USASI, chaired the discussion.

The event was co-sponsored by the US-Asia Security Initiative in the Asia-Pacific Research Center, and FSI’s Center on Democracy, Development, and the Rule of Law.

Audio from the event is available for download or streaming: