Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment

Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic

In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.

Association of Project ECHO Training With Buprenorphine Prescribing by Primary Care Clinicians in Minnesota for Treating Opioid Use Disorder

Importance

Buprenorphine is an approved medication for opioid use disorder (MOUD); however, prescribing buprenorphine is limited by a requirement to obtain a waiver to prescribe it (hereinafter, "DATA [Drug Abuse Treatment Act]-waiver") and a lack of knowledge of the best practices among clinicians.

Objective

To examine how Project ECHO (Extension for Community Healthcare Outcomes) telementoring is associated with changes in DATA-waiver attainment and buprenorphine prescribing among primary care clinicians in Minnesota.

Design, Setting, and Participants

In this retrospective matched-cohort study of 918 clinicians, ECHO-trained clinicians were enrolled on the date they first attended ECHO (January 3, 2018, to June 11, 2020); comparison clinicians were assigned an enrollment date from the distribution of the first ECHO sessions. The baseline period was 12 months preceding enrollment, with follow-up for 18 months or until June 30, 2020. The ECHO-trained clinicians were a population-based sample of primary care clinicians who treated Medicaid patients in Minnesota 12 months prior to the initiation of ECHO training. This analysis used propensity score matching to select comparison clinicians who were similar across demographic and clinical practice characteristics at baseline in a 2:1 ratio. Follow-up was available for 167 ECHO-trained clinicians (54.6%) and 330 comparison clinicians (53.9%) at 18 months.

Exposures

ECHO-trained clinicians attended at least 1 weekly, hour-long ECHO session. Comparison clinicians never participated in any ECHO sessions.

Main Outcomes and Measures

DATA-waiver attainment, any buprenorphine prescribing, and the percentage of patients with opioid use disorder (OUD) who were prescribed buprenorphine.

Results

The final sample included 918 clinicians (ECHO-trained [306]; comparison [612]), of whom 620 (67.5%) practiced outside the metropolitan Twin Cities (Minneapolis-St Paul) region. The mean (SD) age of the ECHO-trained clinicians was 46.0 (12.1) years and that of the comparison clinicians was 45.7 (12.3) years. Relative to the changes among the matched comparison clinicians, the ECHO-trained clinicians were more likely to obtain a DATA-waiver (difference-in-differences, 22.7 percentage points; 95% CI, 15.5-29.9 percentage points; P < .001) and prescribe any buprenorphine (16.5 percentage points; 95% CI, 10.4-22.5 percentage points; P < .001) after 6 quarters of follow-up. ECHO-trained clinicians prescribed buprenorphine to a greater share of patients with OUD (a difference of 7.6 percentage points per month; 95% CI, 4.6-10.6 percentage points per month; P < .001), relative to that prescribed by the comparison clinicians.

Conclusions and Relevance

According to the findings of this matched-cohort study, ECHO telementoring may be associated with greater prescribing of buprenorphine by primary care clinicians. These findings suggest that Project ECHO training could be a useful tool for expanding access to MOUD.

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

INTRODUCTION

Expanding access to medications for opioid use disorder is a cornerstone to addressing the opioid overdose epidemic. However, recent research suggests that the distribution of medications for opioid use disorder has been inequitable. This study analyzes the racial‒ethnic disparities in the receipt of medications for opioid use disorder among Medicaid patients diagnosed with opioid use disorder.

METHODS

Medicaid claims data from the Transformed Medicaid Statistical Information System for the years 2017-2019 were used for the analysis. Logistic regression models estimated the odds of receiving buprenorphine and Vivitrol within 180 days after initial opioid use disorder diagnosis on the basis of race‒ethnicity. Analysis was conducted in 2022.

RESULTS

Non-Hispanic Black people, non-Hispanic American Indian or Alaskan Native/Asian/Hawaiian/Pacific Islander people, and Hispanic people had 42%, 12%, and 22% lower odds of buprenorphine receipt and 47%, 12%, and 20% lower odds of Vivitrol receipt, respectively, than non-Hispanic White people, controlling for clinical and demographic patient variables.

CONCLUSIONS

This study suggests that there are racial‒ethnic disparities in the receipt of buprenorphine and Vivitrol among Medicaid patients diagnosed with opioid use disorder after adjusting for demographic, geographic, and clinical characteristics. The potential strategies to address these disparities include expanding the workforce of providers who can prescribe medications for opioid use disorder in low-income communities and communities of color and allocating resources to address the stigma in medications for opioid use disorder treatment.

Attitudes and training related to substance use in pediatric emergency departments

BACKGROUND

In recent years, pediatric emergency departments (PED) have seen an increase in presentations related to substance use among their adolescent patient population. We aimed to examine pediatric emergency medicine (PEM) physicians' knowledge, attitudes, and beliefs on caring for adolescents with substance use.

METHODS

We conducted a cross-sectional online survey of PEM physicians through the American Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) listserv. The 41-item survey contained the following domains: demographics, current protocols and education for managing adolescent substance use, and attitudes about treatment of substance use. We calculated descriptive statistics for each variable within the domains.

RESULTS

Of 177 respondents (38.2% response rate), 55.4% were female, 45.2% aged ≥ 50 years, 78% worked in a children's hospital, and 50.8% had > 15 years clinical practice. Overall, 77.8% reported caring for adolescents with a chief complaint related to non-opioid substance use and 26.0% opioid use at least once a month. Most (80.9%) reported feeling comfortable treating major medical complications of substance use, while less than half were comfortable treating withdrawal symptoms. 73% said that they were not interested in prescribing buprenorphine.

CONCLUSIONS

Among this national sample of PEM physicians, 3 of 4 physicians managed substance-related visits monthly, but 52% lacked comfort in managing withdrawal symptoms and 73.1% were not interested in prescribing buprenorphine. Almost all PEM physician identified substance use-related education is important but lacked access to faculty expertise or educational content. Expanded access to education and training for PEM physicians related to substance use is needed.

Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use

Background

While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP.

Methods

Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use.

Results

More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001).

Conclusion

Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.

Prescribe to Save Lives: Improving Buprenorphine Prescribing Among HIV Clinicians

BACKGROUND

HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention.

METHODS

The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites.

RESULTS

Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well.

CONCLUSIONS

Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.

Inconsistencies between national drug policy and professional beliefs about psychoactive drugs among psychiatrists in the United States

BACKGROUND

Evidence points to an incongruence between international drug policy and expert opinion about safety, abuse potential, and therapeutic potential of specific drugs. However, no prior studies have directly explored psychiatrists' attitudes about the current drug schedule. Therefore, we examined whether American psychiatrists' perceptions of four psychoactive drugs differed from those indicated by their schedules.

METHODS

A quasi-experimental online survey of a convenience sample of psychiatrists in the United States (N=181; Mean age=48.7; Female=35%). Participants were randomized to receive 1-of-4 vignettes, each depicting a depressed patient reporting relief from symptoms after non-prescribed psychoactive drug use (i.e., psilocybin [Schedule I], methamphetamine [SchedII], ketamine [SchedIII], or alprazolam [SchedIV]). Participants responded to questions related to this clinical scenario and then rated the safety, therapeutic, and abuse potentials of these four drugs and alcohol.

RESULTS

There were significant differences by vignette condition in mean likelihood ratings of: warning against engaging in drug use again (p<.01), being concerned about developing a new psychiatric problem (p<.001), being concerned about increased suicide risk (p<.01) and being supportive of further use of this drug as part of the treatment plan (p<.001). Overall, non-prescribed use of methamphetamine and alprazolam was rated more concerning and less acceptable than non-prescribed use of psilocybin and ketamine. Compared to psilocybin and ketamine, participants rated methamphetamine and alprazolam as less safe (p<.001), having less therapeutic potential (p<.001), and having more abuse potential (p<.001). Mean ratings of safety and abuse/therapeutic potential of alprazolam and methamphetamine were equivalent to that of alcohol, and all three were rated more harmful than psilocybin and ketamine.

CONCLUSION

American psychiatrists' perceptions about safety and abuse/therapeutic potentials associated with certain psychoactive drugs were inconsistent with those indicated by their placement in drug schedules. These findings add to a growing consensus amongst experts that the current drug policy is not scientifically coherent.

Education as drug policy: A realist synthesis of continuing professional development for opioid agonist therapy

BACKGROUND

Continuing professional development (CPD) for opioid agonist therapy (OAT) has been identified as a key health policy strategy to improve care for people living with opioid use disorder (OUD) and to address rising opioid-related harms. To design and deliver effective CPD programs, there is a need to clarify how they work within complex health system and policy contexts. This review synthesizes the literature on OAT CPD programs and educational theory to clarify which interventions work, for whom, and in what contexts.

METHODS

A systematic review and realist synthesis of evaluations of CPD programs focused on OAT was conducted. This included record identification and screening, theory familiarization, data collection, analysis, expert consultation, and iterative context-intervention-mechanism-outcome (CIMO) configuration development.

RESULTS

Twenty-four reports comprising 21 evaluation studies from 5 countries for 3373 providers were reviewed. Through iterative testing of included studies with relevant theory, five CIMO configurations were developed. The programs were categorized by who drove the learning outcomes (i.e., system/policy, instructor, learner) and their spheres of influence (i.e., micro, meso, macro). There was a predominance of instructor-driven programs driving change at the micro level, with few policy-driven macro-influential programs, inconsistent with the promotion of CPD as a clear opioid crisis policy-level intervention.

CONCLUSION

OAT CPD is challenged by mismatches in program justifications, objectives, activities, and outcomes. Depending on how these program factors interact, OAT CPD can operate as a barrier or facilitator to OUD care. With more deliberate planning and consideration of program theory, programs more directly addressing diverse learner and system needs may be developed and delivered. OAT CPD as drug policy does not operate in isolation; programs may feed into each other and intercalate with other policy initiatives to have micro, meso, and macro impacts on educational and population health outcomes.

Barriers to Buprenorphine Prescribing for Opioid Use Disorder in Hospice and Palliative Care

CONTEXT

Hospice and palliative care (HPC) clinicians increasingly care for patients with concurrent painful serious illness and opioid use disorder (OUD) or opioid misuse; however, only a minority of HPC clinicians have an X-waiver license or actively use it to prescribe buprenorphine as medication treatment for OUD.

OBJECTIVES

To understand barriers for HPC clinicians to obtaining an X-waiver and prescribing buprenorphine as medication treatment for OUD.

METHODS

We performed content analysis on 100 survey responses from members of the national Buprenorphine Peer Support Network, a group of HPC clinicians interested in buprenorphine, on X-waiver status, barriers to obtaining an X-waiver, and barriers to active prescribing.

RESULTS

Of 100 HPC clinicians surveyed, only 26 of 57 HPC clinicians with X-waivers had ever prescribed. Prominent barriers included discomfort managing concurrent pain, buprenorphine, and OUD; concerns about impacts on practice; unsupportive practice culture; insufficient practice support; patient facing challenges; and cumbersome regulatory policies.

CONCLUSION

Despite HPC clinicians' interest in buprenorphine prescribing for OUD, several steps are needed to facilitate the practice, including clinician education tailored to pain and to clinical challenges faced by HPC clinicians, mentorship on buprenorphine use, and cultural and practice changes to dismantle systemic stigma towards addiction. We propose evidence-based steps derived from our survey findings that individual clinicians, HPC leaders, and national HPC organizations can take to improve care for patients with painful serious illness and OUD.

Buprenorphine implementation at syringe service programs following waiver of the Ryan Haight Act in the United States

INTRODUCTION

Among people with an opioid use disorder in the United States, only 10% receive buprenorphine treatment. The Ryan Haight Act is a federal law that has regulated buprenorphine delivery, requiring an in-person examination between a patient and provider before initiating treatment. At the beginning of the COVID-19 pandemic, federal agencies waived in-person examination requirements for buprenorphine treatment initiation. We examined whether Ryan Haight Act waiver improved implementation of telehealth buprenorphine within syringe service programs (SSPs) - organizations that serve people with historically low access to treatment.

METHODS

We surveyed all known SSPs operating in the US in 2021 (N = 421) of which 77% responded (n = 325). We calculated the prevalence and accompanying 95% confidence intervals (CI) for implementation of telehealth buprenorphine inductions at SSPs in 2020. Multivariable logistic regression was used to assess differences in implementing telehealth buprenorphine inductions by organizational characteristics.

RESULTS

In 2020, the prevalence of implementing buprenorphine inductions via telehealth was 24% (95% CI:19-30%). Non-governmental SSPs had a higher odds of telehealth buprenorphine inductions (adjusted odds ratio (aOR)= 2.92; 95% CI:1.22-7.00; p = 0.016), compared to governmental SSPs. Furthermore, the larger the organization's annual budget, the higher the odds of telehealth buprenorphine implementation (aOR=2.00 per quartile (95% CI:1.33-2.99; p = 0.001). SSPs located in states with higher opioid overdose mortality rates did not have significantly higher likelihood of telehealth buprenorphine implementation.

CONCLUSION

A substantial number of SSPs implemented telehealth buprenorphine after waiver of the Ryan Haight Act. Permanent adoption of this waiver will be critical and providing financial resources to SSPs is vital to support implementation of new innovations.

Improving equity and access to buprenorphine treatment through telemedicine at syringe services programs

Background and aims

In the United States, access to buprenorphine remains low and disparities regarding who receives treatment have emerged. Federal laws have regulated buprenorphine delivery, ultimately limiting its implementation more broadly. At the onset of the COVID-19 pandemic, federal agencies acted quickly to remove a legal barrier, effectively allowing people with opioid used disorder (OUD) to initiate buprenorphine treatment via telemedicine. Leveraging this policy shift, a low barrier buprenorphine treatment initiative via telemedicine was started at syringe service programs in California. We assessed early findings from participants reached by this model of treatment.

Methods

In May 2020, buprenorphine treatment was offered through a virtual platform to SSP participants in California. SSP staff connected interested participants to virtual appointments with medical providers in a private location. During these visits, clinicians conducted clinical assessments for diagnosing participants with OUD and developed an unsupervised home induction plan for individuals who were eligible. Participants were prescribed a 7-day supply of up to 16 mg daily buprenorphine or 16 mg buprenorphine-2 mg naloxone and asked to return the following week if interested in continuing treatment.

Results

From May 2020 to March 2021, the SSP-buprenorphine virtual care initiative inducted 115 participants onto treatment with 87% of participants inducted on the same day as their referral. Of those inducted, 58% were between the ages of 30 and 49 and 28% were cisgender female. Regarding participants’ method of payment to reimburse buprenorphine costs, 92% of participants were covered by Medicare/Medicaid. Overall, 64% of participants returned for a second buprenorphine prescription refill.

Conclusions

These early findings suggest that this could be a promising approach to improve equity and access to buprenorphine treatment. We encourage policymakers to continue allowing buprenorphine delivery via telemedicine and researchers to study whether this approach improves equity and access to treatment throughout the United States.

Association of Medication-Assisted Therapy with New Onset of Cardiac Arrhythmia in Patients Diagnosed with Opioid Use Disorders

BACKGROUND

No data exist on comparative risk of cardiac arrhythmias among 3 Medication-Assisted Therapy (MAT) medications in patients with opioid use disorder. Understanding MAT medications with the least risk of arrhythmia can guide clinical decision-making.

METHOD

A multicenter retrospective cohort study was performed of patients 18 years or older diagnosed with opioid use disorder by the International Classification of Diseases, 10th revision, Clinical Modification without baseline arrhythmia in 2018-2019, using Clinformatics Data Mart Database (Optum, Eden Prairie, Minn). Everyone required 1 year of continuous enrollment prior to and after the diagnosis. Patients with MAT were propensity score-matched to those without MAT. Primary outcome was rate of arrhythmia across MAT (methadone, naltrexone, and buprenorphine). A multivariable logistic regression model was built to examine the outcome difference across 3 medications adjusted for patient's demographic and comorbidity.

RESULT

Only 14.1% of the 66,083 patients with opioid use disorder received MAT prescriptions in the 12 months after diagnosis. New-onset arrhythmia diagnoses occur more frequently among MAT vs non-MAT users (4.86% vs 3.92%), with 29% risk of incident arrhythmias among MAT users, even after adjusting relevant confounders (adjusted odds ratio [aOR] 1.29; 95% confidence interval [CI], 1.11-1.52). Incidence of arrhythmia varied by drugs: naltrexone (9.57%), methadone (5.71%), and buprenorphine (3.81%). Difference among the MAT drugs in incidence of arrhythmia remained significant even after adjusting covariates (aOR 2.44; 95% CI, 1.63-3.64 and buprenorphine aOR 0.77; 95% CI, 0.59-1.00, with methadone as reference).

CONCLUSION

MAT users had higher risk of cardiac arrhythmia than non-users. Naltrexone is associated with the highest risk of arrhythmia, suggesting caution with naltrexone use, especially in opioid use disorder patients with pre-existing heart conditions.

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Importance

Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment.

Objective

To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD.

Design, Setting, and Participants

For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds.

Main Outcomes and Measures

Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines.

Results

Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone.

Conclusions and Relevance

The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.

Comparing Two Databases to Identify Access to Buprenorphine Treatment for Opioid Use Disorder

OBJECTIVE

The objective of this study is to assess the differences in buprenorphine prescribers from a county level in the state of Texas by comparing the Substance Abuse and Mental Health Services Administration (SAMHSA) Buprenorphine Practitioner Locator to the Drug Enforcement Administration's (DEA) Controlled Substance Act (CSA) database.

METHODS

County-level counts of buprenorphine prescribers were calculated from both the publicly available SAMHSA buprenorphine practitioner locator list and the DEA CSA database. These were then used to estimate the number of providers per 100,000 residents in each county. Regional variation in access to buprenorphine was compared descriptively across the state using poverty data from the US Census and county-level demography from the Texas Demographic Center.

RESULTS

This study found 68.8% more X-waivered providers on the DEA CSA database (n = 2,622) with at least one provider reported in 125 of 144 counties in the state (49.2%) compared to the SAMHSA Buprenorphine Practitioner Locator (n = 1,553) with at least one provider reported in 103 counties (40.5%).

CONCLUSIONS

The lack of a complete public registry of buprenorphine prescribers can inhibit the ability of patients to identify a convenient treatment. More work is needed to quantify the gap between treatment capacity and treatment need.

Onge J, Forrest DW, Bartholomew TS, Serota DP. Opioid Use Disorder Curriculum: Medicine Clerkship Standardized Patient Case, Small-Group Activity, and Patient Panel

Introduction

The overdose crisis remains a critical public health problem, creating an urgent need to train physicians in the treatment and management of opioid use disorder (OUD). Our medicine clerkship module aimed to close this gap by training and assessing students' motivational interviewing skills, harm reduction knowledge, and use of nonstigmatizing language in the treatment of patients with OUD.

Methods

We evaluated the impact of a small-group, case-based activity and patient panel on the clinical documentation skills of students in a medicine clerkship. Clinical documentation was based on an observed structured clinical examination of a standardized patient with OUD and was evaluated using a grading rubric that followed the module learning objectives. Students also submitted reflections on the curriculum.

Results

Qualitative responses (n = 40) from students evaluating the small-group activity and patient panel exercise revealed overall student satisfaction with the patient panel and exposure to patients living with OUD. Three themes emerged from student reflections: (1) humanity, (2) different paths to recovery, and (3) using nonstigmatizing language. For the quantitative test, students' (n = 39) mean clinical documentation scores before and after the small-group activity and patient panel increased from 10.1 to 11.3 out of 13.5 possible points. There was a significant difference between mean pretest and posttest scores (p < .001).

Discussion

The medicine clerkship provided an acceptable and feasible opportunity for implementing a multifaceted educational experience for students with significant immediate impact on their evaluation of patients with OUD.

Survey of Barriers and Facilitators to Prescribing Buprenorphine and Clinician Perceptions on the Drug Addiction Treatment Act of 2000 Waiver

IMPORTANCE

As opioid-related deaths continue to climb, methods to reduce barriers to prescribing buprenorphine for individuals with opioid use disorder (OUD) are needed. Recent conversations by state and federal authorities targeting low-threshold buprenorphine aim to reduce some barriers to prescribing buprenorphine; however, what remains unclear is whether removal of the requirement to obtain a waiver for prescribing buprenorphine through the Drug Addiction Treatment Act of 2000 (an X-waiver) will be enough to increase access to buprenorphine.

OBJECTIVE

To assess barriers and facilitators of obtaining an X-waiver and prescribing buprenorphine.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-method survey study was conducted between September and December 2020; 607 office-based Texas clinicians were surveyed after they attended a buprenorphine X-waiver training course. All attendees between March 2, 2019, and February 28, 2020, were eligible to receive this survey; 126 responses were received (20% response rate: 81 physicians, 37 nurse practitioners, and 8 physician assistants). Data analysis was performed October 2021.

MAIN OUTCOMES AND MEASURES

Surveys measured the extent to which clinicians experienced 9 previously identified barriers during the waiver process and in prescribing buprenorphine. The survey included open-ended items assessing facilitating factors to obtaining a waiver and to prescribing buprenorphine for OUD. The barriers were analyzed using χ2 tests of homogeneity. Qualitative data were analyzed using a constant comparative method.

RESULTS

Among 126 clinicians who responded, 61 (48.4%) had received an X-waiver; of these waivered clinicians, 22 (36%) were prescribing buprenorphine and 39 (64%) were not. "Complexity of X-waiver process," "Perceived lack of professional support and referral network," and "Getting started" were significantly different barriers among waivered and nonwaivered clinicians. Significant differences in barriers experienced between prescribers and nonprescribers were "Getting started" and "Accessing reimbursement for treatment." The most frequently mentioned facilitators involved changes to the waiver training and the need for networks connecting experienced clinicians with those in the initial stages of readiness for prescribing buprenorphine for OUD.

CONCLUSIONS AND RELEVANCE

This survey study's results contribute new understanding of facilitators to obtaining the X-waiver and to prescribing buprenorphine. Furthermore, these findings suggest that to increase access to compassionate evidence-based treatment for OUD, clinicians need ongoing support and mentorship from experienced and knowledgeable clinicians. Interventions aimed at improving access to buprenorphine should focus on facilitating such networks to increase the number of clinicians who obtain an X-waiver and prescribe buprenorphine for OUD.

Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans

OBJECTIVE

Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment.

METHODS

A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

RESULTS

Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65).

CONCLUSIONS

As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.

Therapeutic relationships between Veterans and buprenorphine providers and effects on treatment retention

OBJECTIVE

To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention.

DATA SOURCES

National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017.

STUDY DESIGN

Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year.

DATA COLLECTION/EXTRACTION METHODS

Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality.

PRINCIPAL FINDINGS

A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07).

CONCLUSIONS

Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives

BACKGROUND

While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood.

OBJECTIVES

To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care.

METHODS

Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients.

RESULTS

Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD.

CONCLUSION

A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Northeast Postacute Medical Facilities Disproportionately Reject Referrals For Patients With Opioid Use Disorder

Referrals of hospitalized patients with opioid use disorder (OUD) to postacute medical care facilities are commonly rejected. We linked all electronic referrals from a Boston safety-net hospital in 2018 to clinical data and used multivariable logistic regression to examine the association between OUD diagnosis and rejection from postacute medical care. Hospitalized patients with OUD were referred to more facilities than patients without OUD (8.2 versus 6.6 per hospitalization), were rejected a greater proportion of the time (83.3 percent versus 65.5 percent), and in adjusted analyses had greater odds of rejection from postacute care (adjusted odds ratio, 2.2). In addition, people with OUD were referred disproportionately to a small subset of facilities with a higher likelihood of acceptance. Our findings document disparities in postacute care admissions for people with OUD. Efforts to ensure equitable access to medically necessary postacute medical care for people with OUD are needed.

The effect of Medicaid expansion on state-level utilization of buprenorphine for opioid use disorder in the United States

BACKGROUND

Research on the impact of Medicaid expansion on buprenorphine utilization has largely focused on the Medicaid program. Less is known about its associations with total buprenorphine utilization and non-Medicaid payers.

METHODS

Monthly prescription data (June 2013-May 2018) for proprietary and generic sublingual as well as buccal buprenorphine products were purchased from IQVIA®. Population-adjusted state-level utilization measures were constructed for Medicaid, commercial insurance, Medicare, cash, and total utilization. A difference-in-differences (DID) approach with population weights estimated the association between Medicaid expansion and buprenorphine utilization, while controlling for treatment capacity.

RESULTS

Monthly total buprenorphine prescriptions increased by 68% overall and increased 283% for Medicaid, 30% for commercial insurance, and 143% for Medicare. Cash prescriptions decreased by 10%. The DID estimate for Medicaid expansion was not statistically significant for total utilization (-19.780, 95% CI = -45.118, 5.558, p = .123). For Medicaid buprenorphine utilization, there was a significant increase of 27.120 prescriptions per 100,000 total state residents (95% CI = 9.458, 44.782, p = .003) in expansion states versus non-expansion states post-Medicaid expansion. Medicaid expansion had a negative effect on commercial insurance (DID estimate = -37.745, 95% CI = -62.946, -12.544, p = .004), cash utilization (DID estimate = -6.675, 95% CI = -12.627, -0.723, p = .029), and Medicare utilization (DID estimate = -1.855, 95% CI = -3.697, -0.013, p = .048).

DISCUSSION

The associations between Medicaid expansion and buprenorphine utilization varied across different types of payers, such that the overall impact of Medicaid expansion on buprenorphine utilization was not significant.

Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings

BACKGROUND

In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing.

METHODS

In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing.

RESULTS

Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support.

CONCLUSIONS

Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.

Flipping the script: The effects of opioid prescription monitoring on specialty-specific provider behavior

Mandatory access Prescription Drug Monitoring Programs (MA-PDMPs) aim to curb the epidemic at a common point of initiation of use, the prescription. However, there is recent concern about whether opioid policies have been too restrictive and reduced appropriate access to patients with the most need for opioid pharmaceuticals. We assess MA-PDMP's effect on specialty-specific opioid prescribing behavior of Medicare providers. Our findings suggest that requiring providers to query a PDMP differentially affects opioid prescribing across provider specialties. We find a three to four percent decrease in prescribing for Primary Care and Internal Medicine providers. This result is driven by healthcare providers at the lower end of the prescribing distribution. There is also suggestive evidence of an increase in opioid use disorder treatment drugs prescribed by these same providers. We also find no evidence for the hypothesis that MA-PDMPs restrict prescribing by providers who treat patients with potentially high levels of pain, few drug substitutes, or urgency for pain treatment (e.g., Oncology/Palliative care). This result is not dependent on whether a state provides exemptions for these providers. Our results indicate that MA-PDMPs may help close provider-patient informational gaps while retaining a provider's ability to supply these drugs to patients with a need for opioids.

Evaluating buprenorphine prescribing and opioid-related health outcomes following the expansion the buprenorphine waiver program

AIMS

To evaluate associations between new types of buprenorphine waivers (nurse practitioner and physician assistant [NP/PA]; 275-patient limit [MD/DO-275]) and both buprenorphine prescribing and health outcomes.

METHODS

Using comprehensive county-level data from California 2010-2018, we modeled quarterly associations between numbers of NP/PA and MD/DO-275 waivers and rates of buprenorphine prescribing, opioid-related deaths, emergency department (ED) visits, and hospitalizations among all counties and separately among metropolitan and nonmetropolitan counties using Poisson regression models with county and quarter fixed effects and adjusting for time-varying covariates.

RESULTS

Each additional NP/PA and MD/DO-275 waiver was associated with a 2.6% (95%CI: 1.1-4.1%) and 5.8% (4.1-7.4%) increase in buprenorphine prescribing among nonmetropolitan counties, respectively. Each additional MD/DO-275 waiver was associated with a 2.8% (1.0%-4.6%) increase in buprenorphine among metropolitan counties. There were no statistically significant associations between NP/PA waivers and buprenorphine prescribing among metropolitan counties or among either waiver type and opioid-related health outcomes.

CONCLUSIONS

NP/PA waivers were associated with increased buprenorphine prescribing among nonmetropolitan counties and MD/DO-275 waivers were associated with increased buprenorphine prescribing among both metropolitan and nonmetropolitan counties.

Opioid Agonist Treatment Recipients within Criminal Justice-Involved Populations

Background: In 2014, nearly 2.5 million Americans had a substance use disorder for opioids (e.g., prescription pain medication or heroin) with over half estimated to have had prior contact with the criminal justice system. Despite strong evidence that opioid agonist treatment (OAT) is effective in reducing overdose, increasing treatment retention, and improving physical health and well-being outcomes, the use of OAT among justice-involved individuals is relatively rare. Methods: The current study uses national data of publicly funded admissions to substance abuse treatment to assess the extent to which OAT is used for cases referred to treatment by the criminal justice system. We explore the relationship between demographics, substance use severity, and access to treatment and OAT receipt. Results: Findings indicate that fewer than 6% of criminal justice cases received OAT as part of the treatment plan. Those with daily substance use, comorbid psychiatric problems, prior treatment, females, Latinos, and those who were older and those who were living independently were more likely to receive OAT, as were those living in the Northeast and with government health insurance. Conclusions: Improving the integration of the criminal justice system with substance use treatment programs would improve access to care and potentially reduce multiple health disparities faced by those in the justice system. As criminal justice responses to substance use disorder move toward a public health approach, it is imperative that the criminal justice system consider mechanisms for improving access and referrals to OAT.

Buprenorphine Waiver Attitudes Among Primary Care Providers

BACKGROUND

Despite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change.

OBJECTIVE

The primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine.

METHODS

We conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states.

RESULTS

One hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists.

CONCLUSIONS

Results of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers' willingness to prescribe buprenorphine.

The Experience of Implementing a Low-Threshold Buprenorphine Treatment Program in a Non-Urban Medical Practice

BACKGROUND

To respond to the U.S. opioid crisis, new models of healthcare delivery for opioid use disorder treatment are essential. We used a qualitative approach to describe the implementation of a low-threshold buprenorphine treatment program in an independent, community-based medical practice in Ithaca, NY.

METHODS

We conducted 17 semi-structured interviews with program staff, leadership, and external stakeholders. Then we analyzed these data using content analysis. We used purposeful sampling aiming for variation in job title for program staff, and in organizational affiliation for external stakeholders.

RESULTS

We found that opening an independent medical practice allowed for low-threshold buprenorphine treatment with less regulatory oversight, but state-certification was ultimately required to ensure financial sustainability. Relying on health insurance reimbursement alone led to funding shortfalls and additional funding sources were also required. The practice's ability to build relationships with licensed substance use treatment programs, community organizations, the legal system, and government agencies in the region differed depending on how much these entities supported a harm reduction philosophy compared to abstinence-based treatment. Finally, expanding the practice to a second location in a different region, co-located with a syringe service program, required adapting to a new cultural and political environment.

CONCLUSION

The results from this study provide insight about the challenges that independent medical practices might face in delivering low-threshold buprenorphine treatment. They support policy efforts to address the financial burdens associated with providing low-threshold buprenorphine therapy and inform the external relationships that other providers would need to consider when delivering novel treatment models.

Perspectives on extended-release naltrexone induction among patients living with HIV and opioid use disorder: a qualitative analysis

BACKGROUND

The CHOICES study randomized participants with HIV and opioid use disorder (OUD) to HIV clinic-based extended-release naltrexone (XR-NTX), which requires complete cessation of opioid use, versus treatment-as-usual (i.e., buprenorphine, methadone). Study participants randomized to XR-NTX were interviewed to assess their experiences with successful and unsuccessful XR-NTX induction.

METHODS

Semi-structured qualitative interviews were completed with a convenience sample of study participants with HIV and OUD (n = 37) randomized to XR-NTX in five HIV clinics between 2018 and 2019. All participants approached agreed to be interviewed. Interviews were digitally recorded, professionally transcribed, and analyzed using thematic analysis.

RESULTS

Participants included women (43%), African Americans (62%) and Hispanics (16%), between 27 to 69 years of age. Individuals who completed XR-NTX induction (n = 20) reported experiencing (1) readiness for change, (2) a supportive environment during withdrawal including comfort medications, and (3) caring interactions with staff. Four contrasting themes emerged among participants (n = 17) who did not complete induction: (1) concern and anxiety about withdrawal including past negative experiences, (2) ambivalence about or reluctance to stop opioids, (3) concerns about XR-NTX effects, and (4) preferences for other medications.

CONCLUSIONS

The results highlight opportunities to improve initiation of XR-NTX in high-need groups. Addressing expectations regarding induction may enhance XR-NTX initiation rates. Trial Registration ClinicalTrials.gov: NCT03275350. Registered September 7, 2017. https://clinicaltrials.gov/ct2/show/NCT03275350?term=extended+release+naltrexone&cond=Opioid+Use .

Buprenorphine prescriber monthly patient caseloads: An examination of 6-year trajectories

BACKGROUND

Many active buprenorphine prescribers treat few patients monthly, but little information is available regarding how prescribers' buprenorphine caseload fluctuates over time or how long it takes new prescribers to reach higher patient caseloads. We examine buprenorphine-prescribing clinicians' patient caseloads over time and explore prescriber characteristics associated with different caseload trajectories.

METHODS

Using 2006-2018 national buprenorphine pharmacy claims, we calculate monthly patient caseloads for buprenorphine prescribers for 6 years following a clinician's first filled buprenorphine prescription. We use K-means clustering to identify clusters of clinician caseload trajectories and bivariate analyses to examine prescriber and county characteristics associated with different trajectory classes.

RESULTS

We identified 42,067 buprenorphine prescribers with 3 trajectory classes. High-volume (1.4%;n = 571) whose mean monthly patient caseload increased to approximately 40 patients through the initial 20 months and stabilized at 40 or more patients; moderate-volume (9.2%;n = 3891) whose mean patient caseload increased during the initial 20 months, stabilizing at 15-20 patients; and low-volume (89.4%;n = 37,605), who typically had fewer than 5 patients monthly. Most low-volume prescribers (n = 31,470; 83.7% of all prescribers) initially treated 1-2 patients for several months, followed by no subsequent prescribing.

CONCLUSION

Almost three-quarters of buprenorphine prescribers treated no more than a few patients for several months before ceasing buprenorphine prescribing; only 10% of prescribers averaged more than 10 patients per month over the next 6 years. Efforts are needed to identify factors contributing to prescribers being willing to continue prescribing buprenorphine over time and to prescribe to more patients in order to increase access to buprenorphine treatment.

Assessment of State and Federal Health Policies for Opioid Use Disorder Treatment During the COVID-19 Pandemic and Beyond

IMPORTANCE

Federal and state governments implemented temporary strategies for providing access to opioid use disorder (OUD) treatment during the COVID-19 pandemic. Advocates hope many of these policies become permanent because of their potential to expand access to care.

OBJECTIVE

To consider the multitude of ways access to and utilization of treatment for individuals with OUD might have been expanded by state and federal policy so researchers can do a better job evaluating the effectiveness of specific policy approaches, which will depend on the interaction with other state policies.

EVIDENCE REVIEW

We summarize state-level policy data reported by government and nonprofit agencies that track health care regulations, specifically the Kaiser Family Foundation, Federation of State Medical Boards, American Association of Nurse Practitioners, American Academy of Physician Assistants, and the National Safety Council. Data were collected by these sources from September 2020 through January 2021. We examine heterogeneity in policy elements adopted across states during the COVID-19 pandemic in 4 key areas: telehealth, privacy, licensing, and medication for opioid use disorder. The analysis was conducted from March 2020 through January 2021.

FINDINGS

This cross-sectional study found that federal and state governments have taken important steps to ensure OUD treatment availability during the COVID-19 pandemic, but few states are comprehensive in their approach. Although all states and Washington, DC have adopted at least 1 telehealth policy, only 17 states have adopted telehealth policies that improve access to OUD treatment for new patients. Furthermore, only 9 states relaxed privacy laws, which influence the ability to use particular technology for telehealth visits. Similarly, all states have adopted at least 1 policy related to health care professional licensing permissions, but only 35 expanded the scope of practice laws for both physician assistants and nurse practitioners. Forty-four states expanded access to initiation and delivery of medication for OUD treatment. Together, no state has implemented all of these policies to comprehensively expand access to OUD treatment during the COVID-19 pandemic.

CONCLUSIONS AND RELEVANCE

With considerable policy changes potentially affecting access to treatment and treatment retention for patients with OUD during the pandemic, evaluations must account for the variation in state approaches in related policy areas because the interactions between policies may limit the potential effectiveness of any single policy approach.

A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration

Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

"I didn't feel like a number": The impact of nurse care managers on the provision of buprenorphine treatment in primary care settings

BACKGROUND AND OBJECTIVE

To promote increased access to and retention in buprenorphine treatment for opioid use disorder, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented the Buprenorphine Nurse Care Manager Initiative (BNCMI) in 2016, in which nurse care managers (NCMs) coordinate buprenorphine treatment in safety-net primary care clinics. To explore how patients experienced the care they received from NCMs, DOHMH staff conducted in-person, in-depth interviews with patients who had, or were currently receiving, buprenorphine treatment at BNCMI clinics. Participants were patients who were receiving, or had received, buprenorphine treatment through BNCMI at one of the participating safety-net primary care practices.

METHODS

The study team used a thematic analytic and framework analysis approach to capture concepts related to patient experiences of care received from NCMs, and to explore differences between those who were in treatment for at least six consecutive months and those who left treatment within the first six months.

RESULTS

Themes common to both groups were that NCMs showed care and concern for patients' overall well-being in a nonjudgmental manner. In addition, NCMs provided critical clinical and logistical support. Among out-of-treatment participants, interactions with the NCM were rarely the catalyst for disengaging with treatment. Moreover, in-treatment participants perceived the NCM as part of a larger clinical team that collectively offered support, and the care provided by NCMs was often a motivating factor for them to remain engaged in treatment.

CONCLUSION

Findings suggest that by providing emotional, clinical, and logistical support, as well as intensive engagement (e.g., frequent phone calls), the care that NCMs provide could encourage retention of patients in buprenorphine treatment.

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Clinical leaders and providers' perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs' facilities

BACKGROUND

Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers' perceptions about MOUD over the first year of implementation.

METHODS

Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach.

RESULTS

Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents' ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time.

CONCLUSIONS

Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers' and clinical leaders' perceptions of MOUD over time. Strategies that improve leaders' prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona

Medication for Opioid Use Disorder (MOUD) is recommended, but not always accessible to those who desire treatment. This study assessed the impact of expanding access to buprenorphine through federally qualified health centers (FQHCs) in Arizona. We calculated mean drive-times to Arizona opioid treatment (OTP) locations, office-based opioid treatment (OBOT) locations, and FQHCs clinics using January 2020 location data. FQHCs were designated as OBOT or non-OBOT clinics to explore opportunities to expand treatment access to non-OBOT clinics (potential OBOTs) to further reduce drive-times for rural and underserved populations. We found that OTPs had the largest mean drive times (16.4 minutes), followed by OBOTs (7.1 minutes) and potential OBOTs (6.1 minutes). Drive times were shortest in urban block groups for all treatment types and the largest differences existed between OTPs and OBOTs (50.6 minutes) in small rural and in isolated rural areas. OBOTs are essential points of care for opioid use disorder treatment. They reduce drive times by over 50% across all urban and rural areas. Expanding buprenorphine through rural potential OBOT sites may further reduce drive times to treatment and address a critical need among underserved populations.

Primary care physicians' preparedness to treat opioid use disorder in the United States: A cross-sectional survey

BACKGROUND

Efforts to increase opioid use disorder (OUD) treatment have focused on primary care. We assessed primary care physicians' preparedness to identify and treat individuals with OUD and barriers to increasing buprenorphine prescribing.

METHODS

We conducted a cross-sectional survey from January-August 2020 which assessed perceptions of the opioid epidemic; comfort screening, diagnosing, and treating individuals with OUD with medications; and barriers to obtaining a buprenorphine waiver and prescribing buprenorphine in their practice. Primary care physicians were sampled from the American Medical Association Physician Master File (n = 1000) and contacted up to 3 times, twice by mail and once by e-mail.

RESULTS

Overall, 173 physicians (adjusted response rate 27.3 %) responded. While most were somewhat or very comfortable screening (80.7 %) and diagnosing (79.3 %) OUD, fewer (36.9 %) were somewhat or very comfortable treating OUD with medications. One third of respondents were in a practice where they or a colleague were waivered and 10.7 % of respondents had a buprenorphine waiver. The most commonly cited barriers to both obtaining a waiver and prescribing buprenorphine included lack of access to addiction, behavioral health, or psychiatric co-management, lack of experience treating OUD, preference not to be inundated with requests for buprenorphine, and the buprenorphine training requirement.

CONCLUSIONS

While most primary care physicians reported comfort screening and diagnosing OUD, fewer were comfortable treating OUD with medications such as buprenorphine and even fewer were waivered to do so. Addressing provider self-efficacy and willingness, and identifying effective, coordinated, and comprehensive models of care may increase OUD treatment with buprenorphine.

Physician blame and vulnerability: novel predictors of physician willingness to work with patients who misuse opioids

Background

Successfully combating the opioid crisis requires patients who misuse opioids to have access to affirming and effective health care. However, there is a shortage of physicians who are willing to work with these patients. We investigated novel predictors of what might be contributing to physicians’ unwillingness to engage with this patient population to better identify and direct interventions to improve physician attitudes.

Methods

333 physicians who were board certified in the state of Ohio completed a survey about their willingness to work with patients who misuse opioids. The hypothesized relationships between the proposed predictors and willingness to work with this patient population were tested using multivariate regression, supplemented with qualitative analysis of open-text responses to questions about the causes of addiction.

Results

Perceptions of personal invulnerability to opioid misuse and addiction, opioid misuse and addiction controllability, and health care provider blame for the opioid crisis were negatively associated with physician willingness to work with patients who misuse opioids after controlling for known predictors of physician bias toward patients with substance use disorders. Physicians working in family and internal medicine, addiction medicine, and emergency medicine were also more willing to work with this patient population.

Conclusions

Distancing oneself and health care professionals from opioid misuse and placing blame on those who misuse are negatively associated with treatment willingness. Interventions to improve physician willingness to work with patients who misuse opioids can target these beliefs as a way to improve physician attitudes and provide patients with needed health care resources.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00242-w.

Association between discharges against medical advice and readmission in patients treated for drug injection-related skin and soft tissue infections

BACKGROUND

The prevalence of injection drug use (IDU)-related skin and soft tissue infections (SSTI) in Philadelphia has been steadily increasing since 2013. Patients seeking treatment for these infections are more likely to be discharged against medical advice (AMA), increasing the likelihood that they will end antibiotic treatment prematurely and require additional medical interventions.

METHODS

The research team performed a nested case-control study using the Pennsylvania Health Care Cost Containment Council database for Philadelphia residents hospitalized for SSTI and substance use-related diagnoses between 2013 and 2018. The primary outcome was readmission in the same or following quarter. The study examined the impact of discharge AMA on readmission along with clinical characteristics including diagnoses for anxiety, bipolar disorder, depression, schizophrenia, diabetes, and polydrug use.

RESULTS

There were 8265 hospitalizations for IDU-related SSTI and 316 (6%) were readmitted to the hospital at least once in the same or following quarter. In total, 23.4% of cases and 13% of controls left AMA. In the final multivariable regression model, AMA discharge (AOR 2.04, 95% CI 1.46-2.86), anxiety (AOR 1.44, 95% CI 1.01-2.05), diabetes (AOR 2.02, 95% CI 1.46-2.81), and polydrug use (AOR 2.11, 95% CI 1.52-2.92) were associated with higher odds of readmission.

CONCLUSIONS

Our study demonstrates that readmissions for IDU-related SSTI are associated with recent discharge AMA. As IDU-related SSTI and polydrug use continue to rise, premature antibiotic treatment completion will impact more people, leading to worse health outcomes and additional strain on the health care system.

Quality of Buprenorphine Care for Insured Adults With Opioid Use Disorder

AIM

The aim of this study was to characterize quality of buprenorphine care for opioid use disorder (OUD) by quantifying buprenorphine initiation, engagement, and maintenance for individuals in a large, diverse, real-world cohort in the United States.

DESIGN

This was a retrospective cohort analysis.

SETTING

OUD treatment in the outpatient setting.

PARTICIPANTS

A total of 45,210 commercially insured and Medicare Advantage (MA) enrollees 18 years or older in the OptumLabs Data Warehouse with an index diagnosis of OUD between January 1, 2018 and December 31, 2018.

INTERVENTIONS

Treatment with buprenorphine.

MEASUREMENTS

We calculated 6 measures of buprenorphine treatment quality. We conducted survival analyses to characterize treatment duration and logistic regressions to evaluate the association between clinical and sociodemographic characteristics and quality.

FINDINGS

Of 45,210 eligible individuals with OUD, ∼1 in 10 (n=4600, 10.2%) initiated buprenorphine within 365 days following diagnosis (Measure #1) and 2850 individuals (6.3%) initiated buprenorphine within 14 days of diagnosis (Measure #2). Of individuals initiating treatment within 14 days of diagnosis, 1769 (62.1%) had 2 or more buprenorphine claims within 34 days of initiation (Measure #3). Of the 4600 individuals who received buprenorphine, 2300 (50.0%) were maintained in care with 180 days or more of covered buprenorphine treatment during 365 days after diagnosis (Measure #4). Finally, of the 4600 individuals who received buprenorphine, 2543 (55.3%) did not fill any other concurrent opioid analgesic (Measure #5) and 2951 (64.2%) did not fill any concurrent benzodiazepine (Measure #6). Quality was generally lower for individuals with MA compared with commercial coverage and among Hispanic and Black adults compared with White adults.

CONCLUSION

Widespread gaps exist in quality of buprenorphine treatment initiation, engagement, and maintenance among commercially insured and MA enrollees with OUD.

Association between availability of medications for opioid use disorder in specialty treatment and use of medications among patients: A state-level trends analysis

INTRODUCTION

Access to medication for opioid use disorder (MOUD) is a recognized public health challenge to improving the health of people with opioid use disorder (OUD) in many communities. Prior studies have shown that although MOUD availability has increased over time, particularly in some states, many substance use treatment facilities still do not offer medications. The relationship between greater availability of MOUD and use of MOUD among patients in treatment programs is not well understood.

METHODS

We used the National Survey of Substance Abuse Treatment Services to calculate the percent of specialty facilities per state providing MOUD from 2007 to 2018 and the Treatment Episode Data Set-Admissions (TEDS-A) to estimate the likelihood that a patient would have MOUD as part of their treatment plan during the same time period. We estimated models with patient-level TEDS-A data as the outcome and state-aggregated one-year lagged availability of MOUD in facilities as the main predictor, stratifying by treatment facility type (intensive outpatient, non-intensive outpatient, and residential).

RESULTS

We found that increasing MOUD availability at the facility level was associated with increased MOUD use in non-intensive and residential facilities at the patient level. Specifically, a 10 percentage point increase in MOUD availability was associated with a 4.5 percentage point increase in MOUD use among patients of non-intensive outpatient facilities (p-value = 0.03), and a 2.5 percentage points increase in residential facilities (p-value = 0.02). Non-Whites and patients in the Northeast had greater likelihoods of increased MOUD use in response to increased availability by facilities.

CONCLUSION

Increasing MOUD availability among specialty treatment facilities is likely to promote better access to MOUD for patients seeking treatment for OUD.

Barriers and Challenges to Making Referrals for Treatment and Services for Opioid Misuse in Family Planning Settings

Background: In this opioid overdose epidemic, women are an overlooked group seeing increasing rates of overdose death. Implementation challenges have prevented evidence-based interventions from effectively reaching women who misuse opioids, with gaps in access to effective treatment and services. Family planning clinics could serve as important points of contact for referral to needed treatments and services. The study explores how family planning staff knowledge and attitudes related to opioid misuse serve as potential barriers and challenges in making referrals for evidence-based services and treatments. Methods: In 2018, we conducted a national online survey of family planning staff, assessing knowledge and attitudes of treatments and services for opioid misuse. Results: A total of 691 family planning staff completed the survey. Most respondents agreed that opioid misuse was a major problem in their community (86.0%) and identified challenges in responding to it, including a lack of treatment access (70.3%), the absence of in-house behavioral health staff (67.2%), and unfamiliarity with local treatment providers (54.1%). Respondents reported low levels of acceptability for syringe services programs (46.0%), medications such as methadone and buprenorphine (55.4%), and naloxone to reverse opioid overdose (60.1%). Controlling for other factors, race/ethnicity, urbanicity, workplace role, and substance use training were associated with differences in acceptability. Conclusions: Family planning settings could play a critical role in connecting women who misuse opioids to treatment and services. Strategies are needed to increase the acceptability of evidence-based interventions and the feasibility of having family planning staff play a linkage role.