GluN2A Enables Noradrenergic Control of Prefrontal Oscillations and Cognitive Flexibility.

Approximately 17% of Medicare beneficiaries live in rural areas and often face suboptimal access to health care, leading to disproportionate health outcomes amid public health emergencies like the opioid epidemic. Opioid overdose deaths are nearly 13% higher in rural counties than urban counties. Furthermore, 13% and 16% of Medicare beneficiaries living in rural and rural-adjacent areas, respectively, are under 65 with a disability entitlement, compared to 11% in urban areas. From 2012 to 2016, Medicare beneficiaries with disabilities contributed to over 80% of Medicare opioid overdose deaths. A rural-urban analysis of opioid prescribing among beneficiaries with disabilities may uncover mechanisms contributing to the disproportionate effects of the opioid epidemic. In 2017, 14 of the 15 counties with the highest opioid prescribing rates were rural counties. Opioid prescribing rates have since decreased in rural communities, but at a slower rate than urban and suburban communities. Higher opioid prescribing in rural relative to urban communities may stem from rural communities having a higher burden of chronic pain, lower socioeconomic status, fewer economic opportunities, and longer travel distance to pain management clinics and opioid use disorder treatment providers. These factors synergistically worsen pain and suffering and drive opioid use and misuse among rural versus urban communities. Greater reliance on opioids for pain management in rural communities may create opioid prescribing complications for the physicians and pharmacies serving them amid opioid limitation policies like the 2019 Medicare opioid policy. In January 2019, the Centers for Medicare and Medicaid Services (CMS) implemented a nationwide opioid restriction that required all Part D plans to integrate a 7-day safety edit and a 90-morphine milligram equivalence (MME) safety edit, in accordance with 2016 Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing. Major Medicare Advantage (MA) plans adopted these safety edits, but operationalized the 90-MME edit in different ways. Those in this study enforced a multiple-prescriber 90-MME edit. The 7-day safety edit, targeted at new-to-opioid Medicare beneficiaries, triggers an automatic alert at the point-of-sale (POS) when the days’ supply of an opioid fill exceeds 7 days, prohibiting pharmacies from dispensing a greater than 7 days’ supply opioid fill to any beneficiary who has not recently filled an opioid prescription. Clinicians could override the limit by attesting to the medical necessity of the extended duration. The multiple-prescriber 90-MME safety edit is not exclusive to new-to-opioid Medicare beneficiaries and similarly triggers an automatic alert at the POS, prohibiting pharmacists from dispensing opioid fills, when the multiple-prescriber cumulative daily dosage exceeds 90 MME, unless up-to-date clinical evidence for medical necessity has been provided. CMS incorporated a policy rollback for the multiple-prescriber 90-MME safety edit at the onset of the COVID-19 pandemic to alleviate potential disruptions to opioid access.