51
|
Snell-Rood C, Pollini RA, Willging C. Barriers to Integrated Medication-Assisted Treatment for Rural Patients With Co-occurring Disorders: The Gap in Managing Addiction. Psychiatr Serv 2021; 72:935-942. [PMID: 33530734 DOI: 10.1176/appi.ps.202000312] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Guidelines for treatment of opioid use disorder stipulate for mental health assessment and the option for treatment alongside medication for opioid use disorder (MOUD). Yet efforts to expand MOUD treatment capacity have focused on expanding the workforce of buprenorphine providers. This article aims to describe the processes facilitating and impeding integrated care for rural patients with co-occurring opioid use disorder and mental health conditions. METHODS Qualitative interviews were conducted with primary care and specialty providers (N=26) involved in integrated care through the state's hub-and-spoke system and with system-level stakeholders (N=16) responsible for expanding access to MOUD in rural California. RESULTS Rural primary care providers struggled to offer adequate mental health resources to patients with co-occurring conditions because of personnel shortages and inadequate availability of telehealth. Efforts to intensify care through referral to county mental health systems and private community providers were thwarted by access barriers. The bifurcated nature of treatment systems resulted in inadequate training in integrated care and the deprioritization of mental health in patient evaluations. CONCLUSIONS Significant system-level barriers undermine the implementation of integrated MOUD in rural areas, potentially increasing the suffering of residents with co-occurring conditions and intensifying burnout among providers.
Collapse
Affiliation(s)
- Claire Snell-Rood
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
| | - Robin A Pollini
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
| | - Cathleen Willging
- School of Public Health, University of California, Berkeley (Snell-Rood); School of Public Health, West Virginia University, Morgantown (Pollini); Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, Albuquerque, New Mexico (Willging)
| |
Collapse
|
52
|
Schottenfeld RS, Chawarski MC, Mazlan M. Behavioral counseling and abstinence-contingent take-home buprenorphine in general practitioners' offices in Malaysia: a randomized, open-label clinical trial. Addiction 2021; 116:2135-2149. [PMID: 33404150 DOI: 10.1111/add.15399] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 05/27/2020] [Accepted: 12/23/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM To address the widespread severe problems with opioid use disorder, buprenorphine-naloxone treatment provided by primary care physicians has greatly expanded treatment access; however, treatment is often provided with minimal or no behavioral interventions. Whether or which behavioral interventions are feasible to implement in various settings and improve treatment outcomes has not been established. This study aimed to evaluate two behavioral interventions to improve buprenorphine-naloxone treatment. DESIGN A 2 × 2 factorial, repeated-measures, open-label, randomized clinical trial. SETTINGS General medical practice offices in Muar, Malaysia. PARTICIPANTS Opioid-dependent individuals (n = 234). INTERVENTIONS Participants were randomly assigned to one of four treatment conditions and received study interventions for 24 weeks: (1) physician management with or without behavioral counseling and (2) physician management with or without abstinence-contingent buprenorphine-naloxone (ACB) take-home doses. MEASUREMENTS The primary outcomes were proportions of opioid-negative urine tests and HIV risk behaviors [assessed by audio computer-assisted AIDS risk inventory (ACASI-ARI)]. FINDINGS The rates of opioid-negative urine tests over 24 weeks of treatment were significantly higher with [68.2%, 95% confidence interval (CI) = 65-71] than without behavioral counseling (59.2%, 95% CI = 56-62, P < 0.001) and with (71.0%, 95% CI = 68-74) than without ACB (56.4%, 95% CI = 53-59, P < 0.001); interaction effects between and among behavioral interventions and time were not statistically significant. Scores on ACASI-ARI decreased significantly from baseline across all treatment groups (P < 0.001) and did not differ significantly with or without behavioral counseling (P = 0.099) or with or without ACB (P = 0.339). CONCLUSIONS Providing opioid-dependent patients in Muar, Malaysia with buprenorphine-naloxone and physician management plus behavioral counseling or abstinence-contingent buprenorphine-naloxone (ACB) resulted in greater reductions of opioid use compared with providing buprenorphine-naloxone and physician management without behavioral counseling or ACB.
Collapse
Affiliation(s)
- Richard S Schottenfeld
- Department of Psychiatry and Behavioral Sciences, Howard University College of Medicine, Washington, DC, USA
| | - Marek C Chawarski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | |
Collapse
|
53
|
Anderson JB, Martin SA, Gadomski A, Krupa N, Mullin D, Cahill A, Jenkins P. Project ECHO and primary care buprenorphine treatment for opioid use disorder: Implementation and clinical outcomes. Subst Abus 2021; 43:222-230. [PMID: 34086529 DOI: 10.1080/08897077.2021.1931633] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.
Collapse
Affiliation(s)
- James B Anderson
- Department of Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Stephen A Martin
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.,UMassMemorial Healthcare, Worcester, MA, USA
| | - Anne Gadomski
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - Nicole Krupa
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - Daniel Mullin
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA.,UMassMemorial Healthcare, Worcester, MA, USA
| | - Amber Cahill
- Family Medicine and Community Health, University of Massachusetts Medical School, Worcester, MA, USA
| | - Paul Jenkins
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| |
Collapse
|
54
|
Cos TA, Starbird LE, Lee H, Chun B, Gonnella K, Bird J, Livsey K, Bastos S, O'Brien M, Clark I, Jenkins D, Tavolaro-Ryley L. Expanding access to nurse-managed medication for opioid use disorder. Nurs Outlook 2021; 69:848-855. [PMID: 33992445 DOI: 10.1016/j.outlook.2021.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 02/21/2021] [Accepted: 03/11/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Advanced practice registered nurses (APRNs) are increasingly caring for individuals with opioid use disorder. Advances have been made to increase APRN education, outreach, and prescribing privileges, but as demand for medication for opioid use disorder (MOUD) grows, evidence suggests that policy and care barriers inhibit the ability of APRNs to support MOUD. PURPOSE This paper highlights the significant challenges of expanding access to buprenorphine prescribing by APRNs. RESULTS Barriers and recommendations were derived from the culmination of literature review, expert consensus discussions among a diverse stakeholder panel including patient representatives, and feedback from community webinars with care providers. DISCUSSION We provide an overview of existing care barriers, promising practices, and proposed recommendations to enhance the care of individuals and communities with opioid use disorder.
Collapse
Affiliation(s)
- Travis A Cos
- Public Health Management Corporation, Philadelphia, PA.
| | | | - Heeyoung Lee
- University of Pittsburgh, School of Nursing, Pittsburgh, PA
| | - Bianca Chun
- National Nurse-Led Care Consortium, Philadelphia, PA
| | | | - Jillian Bird
- National Nurse-Led Care Consortium, Philadelphia, PA
| | - Kae Livsey
- Western Carolina University, School of Nursing, Cullowhee, North Carolina
| | | | | | - Ivy Clark
- Member of the Patient Community, Philadelphia, PA
| | | | | |
Collapse
|
55
|
Logan AA, Jack HE, Darnton J, Klein JW. "It's that longitudinal relationship that pays off": A qualitative study of internal medicine residents' perspectives on learning to prescribe buprenorphine. Subst Abus 2021; 42:944-950. [PMID: 33797320 DOI: 10.1080/08897077.2021.1900990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND The opioid use disorder (OUD) epidemic is a national public health crisis. Access to effective treatment with buprenorphine is limited, in part because few physicians are trained to prescribe it. Little is known about how post-graduate trainees learn to prescribe buprenorphine or how to optimally train them to prescribe. We therefore aimed to explore the experiences and attitudes of residents learning to prescribe buprenorphine within two primary care-based opioid treatment models. Methods: We performed semi-structured interviews with second- and third-year internal medicine residents at an urban academic residency program. Participating residents practiced in clinics providing buprenorphine care using either a nurse care manager model or a provider-centric model. Subjects were sampled purposively to ensure that a diversity of perspectives were included. Interviews were conducted until theoretical saturation was reached and were analyzed using principles of thematic analysis. The research team developed a consensus code list. Each transcript was then independently coded by two researchers. The team then summarized each code and generated a set of themes that captured the main ideas emerging from the data. Results: We completed 14 interviews. Participants reported learning to prescribe buprenorphine through didactics, longitudinal outpatient prescribing, mentorship, and inpatient experiences. We characterized their attitudes toward patients with OUD, medication treatment of OUD, their own role in buprenorphine care, and future prescribing. Participants practicing in both clinical models viewed learning to prescribe buprenorphine as a normal part of their training and demonstrated positive attitudes toward buprenorphine prescribing. Conclusions: Longitudinal outpatient experiences with buprenorphine prescribing can prepare residents to prescribe buprenorphine and stimulate interest in prescribing after residency. Both nurse care manager and provider-centric clinical models can provide meaningful experiences for medical residents. Educators should attend to the volume of patients and inductions managed by each trainee, patient-provider continuity, and supporting trainees in the clinical encounter.
Collapse
Affiliation(s)
- Alexander A Logan
- Division of Hospital Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
| | - Helen E Jack
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - James Darnton
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - Jared W Klein
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, Washington, USA
| |
Collapse
|
56
|
Harris RA, Mandell DS, Kampman KM, Bao Y, Campbell K, Cidav Z, Coviello DM, French R, Livesey C, Lowenstein M, Lynch KG, McKay JR, Oslin DW, Wolk CB, Bogner HR. Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol. Contemp Clin Trials 2021; 103:106325. [PMID: 33631356 PMCID: PMC8117118 DOI: 10.1016/j.cct.2021.106325] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown. METHODS The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders. DISCUSSION The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis. CLINICAL TRIALS REGISTRATION www.clinicaltrials.gov registration: NCT04245423.
Collapse
Affiliation(s)
- Rebecca Arden Harris
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | - David S Mandell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kyle M Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY 10065, USA
| | - Kristen Campbell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Zuleyha Cidav
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Donna M Coviello
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Rachel French
- School of Nursing, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Cecilia Livesey
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Margaret Lowenstein
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Kevin G Lynch
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - James R McKay
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - David W Oslin
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA 19104, USA
| | - Courtney Benjamin Wolk
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA; Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Hillary R Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
57
|
Brunisholz KD, Knighton AJ, Sharma A, Nichols L, Reisig K, Burton J, Scovill D, Tometich C, Foote M, Read S, Whittle S. Trends in Abstinence and Retention Associated with a Medication-Assisted Treatment Program for People with Opioid Use Disorders. Prog Community Health Partnersh 2021; 14:43-54. [PMID: 32280122 DOI: 10.1353/cpr.2020.0007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Medication-assisted treatment (MAT) is an evidence-based program for patients with opioid use disorders. Yet, within the state of Utah, MAT had not been widely available, promoted, or adopted within the public sector. Recognizing the potential benefit, a collective impact approach was used to promote social change and increase the use of MAT in the community for treatment of opioid use disorders. OBJECTIVE Conduct a retrospective, observational case series study to measure the effect of a community-based, collective impact approach implementing the MAT program to improve the rate of abstinence and retention among individuals identified with an opioid use disorder in three Utah counties. METHODS The study was designed and implemented by the Utah Opioid Community Collaborative (OCC) using a collective impact approach, which included broad sector coordination (public-private collaboration), a common agenda, participation in mutually reinforcing activities, continuous communication, consistent measurement of results, and identification of a backbone organization. The MAT intervention program includes use of medications approved by the U.S. Food and Drug Administration in combination with counseling and behavioral therapies delivered within two community sites. Analysis was performed over time to describe the rate of abstinence and retention associated with participation in the MAT program during 2015 through 2017. RESULTS Of the 339 identified with risk of an opioid use disorders, 228 enrolled in the MAT Program. At MAT enrollment, average age was 32.6 ± 8.2 years old and 58.0% were female. At 365 days after MAT enrollment, 84% of participants were abstinent from opioid substances and 62% from all illicit substances. CONCLUSIONS Use of a collective impact approach provides a successful mobilization framework in Utah for increasing community engagement and expanding patient access to underresourced MAT programs while suggesting a high rate of abstinence from illicit substances at 12 months.
Collapse
|
58
|
Saunders EC, Moore SK, Walsh O, Metcalf SA, Budney AJ, Cavazos-Rehg P, Scherer E, Marsch LA. "It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder. Addict Sci Clin Pract 2021; 16:8. [PMID: 33499938 PMCID: PMC7839299 DOI: 10.1186/s13722-021-00213-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/06/2021] [Indexed: 01/17/2023] Open
Abstract
Background Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences. Methods This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed. Results While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma). Conclusions Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.
Collapse
Affiliation(s)
- Elizabeth C Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA.
| | - Sarah K Moore
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Olivia Walsh
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Stephen A Metcalf
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| |
Collapse
|
59
|
Rahman F, Evans N, Bernhardt J. Access to OUD Treatment and Maintenance of Sobriety amid the COVID-19 Pandemic. Subst Use Misuse 2021; 56:1005-1009. [PMID: 33754956 DOI: 10.1080/10826084.2021.1901935] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES The COVID-19 pandemic changed the way that healthcare is delivered, with non-urgent care becoming almost entirely virtual. Underserved communities already battling the opioid epidemic had new challenges in accessing medication assisted treatment (MAT). The investigators sought to determine if patients were retaining access to their opioid use disorder (OUD) treatment and maintaining sobriety during the pandemic, with the intention of using this information to improve subsequent patient care while the pandemic continues. METHODS In the assessment, seventy-five patient Epic EMR (electronic medical record) charts were reviewed to collect information on demographics, socioeconomic factors, healthcare access and sobriety during the pandemic period between March 1st, 2020 and June 15th, 2020. Patient charts were selected based on those receiving office-based opioid treatment (OBOT) for OUD at an urban healthcare center. RESULTS 98.7% of patients accessed the healthcare center in some form since March 1st, 2020. The most common form of communication was through telemedicine with 94.6% of calls over audio. Out of the 21 toxicology screens performed during the pandemic period, 16 (76%) patients were found to be adhering to their buprenorphine treatment. Only 78.7% had documented they had Narcan at their disposal. Among all patients, 11 (14.6%) reoccurrences in opioid use were documented during the pandemic period. Few patients (76%) were adhering to their prescribed buprenorphine treatment, revealing that patients may not be receiving needed MAT support amid the pandemic. CONCLUSION This assessment reveals short-comings of patient education in managing craving and the maintenance of support systems amid social-isolating conditions.
Collapse
Affiliation(s)
- Fatima Rahman
- University of Kansas School of Medicine-Wichita, Wichita, Kansas
| | | | | |
Collapse
|
60
|
Jakubowski A, Lu T, DiRenno F, Jadow B, Giovanniello A, Nahvi S, Cunningham C, Fox A. Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program. J Subst Abuse Treat 2020; 119:108140. [PMID: 33138925 PMCID: PMC7609975 DOI: 10.1016/j.jsat.2020.108140] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 07/14/2020] [Accepted: 09/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Buprenorphine is a safe and effective treatment for opioid use disorder (OUD), yet a small fraction of people with OUD receive it, and rates of retention in treatment are suboptimal. Dropout most commonly occurs within 30 days of treatment initiation. Therefore, research needs to investigate modifiable factors contributing to early dropout. Requiring multiple visits for evaluation prior to providing an initial buprenorphine prescription (delayed prescription) may lead to more early dropout when compared with prescribing at the first medical visit (same-day prescription). Our objective was to determine whether same-day (vs. delayed) buprenorphine prescription was associated with 30-day retention in treatment. METHODS We conducted a retrospective cohort study of 237 patients who initiated buprenorphine treatment at an urban federally qualified community health center (FQHC) between June 1, 2015, and December 31, 2017. We measured prescription delays by determining the time between patients' first request for buprenorphine treatment (by calling, presenting to the FQHC in-person, or requesting treatment during a visit) and when providers wrote buprenorphine prescriptions. We included only patients with prescription delays less than or equal to 30 days in the analysis. We defined same-day prescription as the patient experiencing no delays in starting treatment and receiving a prescription during the first medical visit. We examined whether patients who received same-day prescriptions had different sociodemographic and clinical characteristics than patients who received delayed prescriptions. We also evaluated whether there was an association between the initial provider who made the decision about same-day vs. delayed buprenorphine prescribing and same-day prescription. We built a multivariable logistic regression model to evaluate the independent association between same-day vs. delayed prescription receipt and odds of 30-day retention in treatment. RESULTS Of the 237 patients who initiated buprenorphine treatment from June 1, 2015, to December 31, 2017, 222 had delays less than or equal to 30 days and we included them in the analysis. Of the 222 patients, the mean age was 46 (SD 10.4), the majority were Hispanic (n = 160, 72%), male (n = 175, 79%), and publicly insured (n = 165, 74%). The majority of patients experienced delayed buprenorphine prescription receipt (n = 133, 60%). The median time to buprenorphine prescription was 5 days (IQR 0-11). Of those who experienced a delay (n = 133), the median delay time was 8 days (IQR 5-20). Compared to those with same-day prescription receipt, more patients with delayed prescription receipt were non-Hispanic white (11% vs. 2%, p = 0.01), had a history of alcohol use (43% vs. 21%, p < 0.01) or benzodiazepine use (22% vs. 9%, p = 0.01), and had the buprenorphine coordinator as their initial provider (57 vs. 13%, p < 0.01). Same-day prescription receipt was not significantly associated with 30-day treatment retention in the adjusted analysis (AOR 1.92, 95% CI 0.81-4.56). CONCLUSION Patients who received buprenorphine prescriptions on the same day as their initial evaluation differed from those who received delayed prescriptions. After adjustment for these differences, same-day prescription was not significantly associated with higher 30-day treatment retention. Providers may be delaying treatment when there is concern about alcohol and/or benzodiazepine use; however, providers could institute enhanced monitoring based on clinical concern for sedation or overdose risk without delaying buprenorphine prescription. Prospective studies of same-day vs. delayed buprenorphine receipt would elucidate the association between delays and retention more definitively.
Collapse
Affiliation(s)
- Andrea Jakubowski
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Internal Medicine, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, NY 10467, USA
| | - Tiffany Lu
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Internal Medicine, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, NY 10467, USA
| | - Frank DiRenno
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, USA
| | - Benjamin Jadow
- Albert Einstein College of Medicine, 1300 Morris Park Ave, Bronx, NY 10461, USA
| | - Angela Giovanniello
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Family and Social Medicine, 3544 Jerome Ave # B, The Bronx, NY 1046, Bronx, NY 10467, USA
| | - Shadi Nahvi
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Internal Medicine, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, NY 10467, USA
| | - Chinazo Cunningham
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Internal Medicine, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, NY 10467, USA
| | - Aaron Fox
- Albert Einstein College of Medicine/Montefiore Medical Center, Department of Internal Medicine, Division of General Internal Medicine, 3300 Kossuth Avenue, Bronx, NY 10467, USA.
| |
Collapse
|
61
|
Iqbal A, David Knaggs R, Anderson C, Toh LS. Role of pharmacists in optimising opioid therapy for chronic non-malignant pain; A systematic review. Res Social Adm Pharm 2020; 18:2352-2366. [PMID: 33309322 DOI: 10.1016/j.sapharm.2020.11.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 10/16/2020] [Accepted: 11/19/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND Opioid optimisation is a global issue in Chronic Non-malignant Pain (CNMP) management. OBJECTIVE This systematic review aims to assess the effectiveness of interventions delivered by pharmacists in outpatient clinical settings, community pharmacies and primary care services in optimising opioid therapy for people with CNMP and to explore stakeholders' opinions about role of pharmacists in optimising opioid therapy. METHODS We conducted searches in PubMed, CINAHL, Psych Info, EMBASE, ISI Web of Science and Conference Proceedings and International Pharmaceutical Abstracts. All studies where pharmacists in outpatient clinical settings, community pharmacies and patient care services helped in optimisation of opioids in the treatment of CNMP as individuals or part of a team were included. Authors followed the 27-item PRISMA guidelines and the review was registered in PROSPERO. All authors were involved in screening and selection of studies and included studies between January 1990-June 2020. Studies not published in English language and participants with cancer pain were excluded. All the included studies were descriptively synthesized. RESULTS Fourteen studies were included in the final data synthesis of this review and the total number of participants in all studies was 1175. Interventions by pharmacists were successful in decreasing opioid dose in 4 studies and improved patient opioid safety in 5 studies. Stakeholders considered that the role of pharmacists in optimisation of opioid therapy for people with CNMP can be promising and should be further developed. CONCLUSION This systematic review gives an overview of pharmacist intervention feasibility, stakeholders' opinions and possible benefits on opioid optimisation in people with CNMP in outpatient clinical settings, community pharmacies and primary care settings. However, further research is warranted, which can guide the development of new policies and guidelines for the utilisation of pharmacists to promote opioid safety in people using prescription opioids for CNMP management.
Collapse
Affiliation(s)
- Ayesha Iqbal
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, NG7 2RD, Nottingham, United Kingdom.
| | - Roger David Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, NG7 2RD, Nottingham, United Kingdom; Primary Integrated Community Solutions, Unit H4 Ash Tree Court, Nottingham Business Park, Nottingham NG8 6PY, United Kingdom.
| | - Claire Anderson
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, NG7 2RD, Nottingham, United Kingdom.
| | - Li Shean Toh
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, NG7 2RD, Nottingham, United Kingdom.
| |
Collapse
|
62
|
Fried JE, Basu S, Phillips RS, Landon BE. Financing Buprenorphine Treatment in Primary Care: A Microsimulation Model. Ann Fam Med 2020; 18:535-544. [PMID: 33168682 PMCID: PMC7708288 DOI: 10.1370/afm.2587] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/19/2020] [Accepted: 06/03/2020] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We sought to determine the financial impact to primary care practices of alternative strategies for offering buprenorphine-based treatment for opioid use disorder. METHODS We interviewed 20 practice managers and identified 4 approaches to delivering buprenorphine-based treatment via primary care practice that differed in physician and nurse responsibilities. We used a microsimulation model to estimate how practice variations in patient type, payer, revenue, and cost across primary care practices nationwide would affect cost and revenue implications for each approach for the following types of practices: federally qualified health centers (FQHCs), non-FQHCs in urban high-poverty areas, non-FQHCs in rural high-poverty areas, and practices outside of high-poverty areas. RESULTS The 4 approaches to buprenorphine-based treatment included physician-led visits with nurse-led logistical support; nurse-led visits with physician oversight; shared visits; and solo prescribing by physician alone. Net practice revenues would be expected to increase after introduction of any of the 4 approaches by $18,000 to $70,000 per full-time physician in the first year across practice type. Yet physician-led visits and shared medical appointments, both of which relied on nurse care managers, consistently produced the greatest net revenues ($29,000-$70,000 per physician in the first year). To ensure positive net revenues with any approach, providers would need to maintain at least 9 patients in treatment, with a no-show rate of <34%. CONCLUSIONS Using a simulation model, we estimate that many types of primary care practices could financially sustain buprenorphine-based treatment if demand and no-show rate requirements are met, but a nurse care manager-based approach might be the most sustainable.
Collapse
Affiliation(s)
- Jonathan E Fried
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts
| | - Sanjay Basu
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts .,Research and Population Health, Collective Health, San Francisco, California .,School of Public Health, Imperial College London, London, United Kingdom
| | - Russell S Phillips
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Bruce E Landon
- Center for Primary Care, Harvard Medical School, Boston, Massachusetts.,Division of General Internal Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
63
|
Blanco C, Ali MM, Beswick A, Drexler K, Hoffman C, Jones CM, Wiley TRA, Coukell A. The American Opioid Epidemic in Special Populations: Five Examples. NAM Perspect 2020; 2020:202010b. [PMID: 35291746 DOI: 10.31478/202010b] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
| | - Mir M Ali
- Office of the Assistant Secretary of Planning and Evaluation
| | - Aaron Beswick
- Health Resources and Services Administration, Federal Office of Rural Health Policy
| | | | - Cheri Hoffman
- Office of the Assistant Secretary for Planning and Evaluation
| | | | | | | | | |
Collapse
|
64
|
Coon SA, Hill LG, Hutchison RW, Arnold LM, Jarrett JB, Ottney AR, Oung AB, Painter NA, Smith MA, Stranges PM, Tran TH, McFee Winans AR, Bratberg JP. Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Scott A. Coon
- Department of Pharmacotherapeutics & Clinical Research University of South Florida, Taneja College of Pharmacy, Morsani College of Medicine Tampa Florida USA
| | - Lucas G. Hill
- Division of Pharmacy Practice The University of Texas at Austin College of Pharmacy Austin Texas USA
| | - Robert W. Hutchison
- Department of Pharmacy Practice Texas A&M Irma Lerma Rangel College of Pharmacy Round Rock Texas USA
| | - Lindsay M. Arnold
- Department of Pharmacy Services St. Elizabeth's Medical Center Brighton Massachusetts USA
| | - Jennie B. Jarrett
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Anne R. Ottney
- Department of Pharmacy Practice Ferris State University, College of Pharmacy Big Rapids Michigan USA
| | - Alvin B. Oung
- Department of Pharmacy Practice University of Wyoming School of Pharmacy Laramie Wyoming USA
| | - Nathan A. Painter
- Division of Clinical Pharmacy University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego California USA
| | - Michael A. Smith
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Paul M. Stranges
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Tran H. Tran
- Department of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove Illinois USA
| | - Amanda R. McFee Winans
- Section of Clinical Pharmacy, Department of Pharmaceutical Care Services Bassett Medical Center Cooperstown New York USA
| | - Jeffrey P. Bratberg
- Department of Pharmacy Practice University of Rhode Island College of Pharmacy Kingston Rhode Island USA
| |
Collapse
|
65
|
Cochran G, Bruneau J, Cox N, Gordon AJ. Medication treatment for opioid use disorder and community pharmacy: Expanding care during a national epidemic and global pandemic. Subst Abus 2020; 41:269-274. [PMID: 32697171 DOI: 10.1080/08897077.2020.1787300] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Medications for opioid use disorder (MOUD), such as methadone and buprenorphine, are effective strategies for treatment of opioid use disorder (OUD) and reducing overdose risk. MOUD treatment rates continue to be low across the US, and currently, some evidence suggests access to evidence-based treatment is becoming increasingly difficult for those with OUD as a result of the 2019 novel corona virus (COVID-19). A major underutilized source to address these serious challenges in the US is community pharmacy given the specialized training of pharmacists, high levels of consumer trust, and general availability for accessing these service settings. Canadian, Australian, and European pharmacists have made important contributions to the treatment and care of those with OUD over the past decades. Unfortunately, US pharmacists are not permitted to prescribe MOUD and are only currently allowed to dispense methadone for the treatment of pain, not OUD. US policymakers, regulators, and practitioners must work to facilitate this advancement of community pharmacy-based through research, education, practice, and industry. Advancing community pharmacy-based MOUD for leading clinical management of OUD and dispensation of treatment medications will afford the US a critical innovation for addressing the opioid epidemic, fallout from COVID-19, and getting individuals the care they need.
Collapse
Affiliation(s)
- Gerald Cochran
- Greater Intermountain Node, a NIH NIDA Clinical Trial Network node and Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Julie Bruneau
- Department of family medicine and emergency medicine, Université de Montréal, Montréal, Canada
| | - Nicholas Cox
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah, USA
| | - Adam J Gordon
- Greater Intermountain Node, a NIH NIDA Clinical Trial Network node and Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS Center), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| |
Collapse
|
66
|
Jones M, Bradshaw C, Jones J, John A, Snooks H, Watkins A. Primary Care Service Utilization Among People at High Risk of Fatal Opioid Overdose: A Short Communication on an Autopsy Study. J Prim Care Community Health 2020; 11:2150132720925957. [PMID: 32486998 PMCID: PMC7270930 DOI: 10.1177/2150132720925957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objectives: We sought to explore the sociodemographics and primary
care service utilization among people who died from opioid overdose and to
assess the possibility of using this information to identify those at high risk
of opioid overdose using routine linked data. Methods: Data related
to decedents of opioid overdose between January 1, 2012 and December 31, 2015
were linked with general practitioner (GP) records over a period of 36 months
prior to death. Results: Of n = 312 decedents of opioid overdose,
73% were male (n = 228). Average age at death was 40.72 (SD 11.92) years. A
total of 63.8% of the decedents were living in the 2 most deprived quintiles
according to the Welsh Index of Multiple Deprivation. Over 80% (n = 258) of the
decedents were recorded as having at least 1 GP episode during the 36-month
observation period prior to death. The median number of episodes per decedent
was 75 [38-118]. Overall, 31.8% (n = 82) of decedents with at least 1 GP episode
received a prescription for a proton pump inhibitor and 31% (n = 80) were
prescribed a broad-spectrum antibiotic. According to their GP records, less than
10% were referred to or receiving specialist drug treatment (n = 24, 9.3%); or
were known to be drug dependent (n = 21, 8.14%), or a drug user (n = 5, 1.94%).
In all, 81% were recorded as smokers (n = 209) and 10.5% as ex-smokers (n = 27).
Conclusions: The majority of decedents of opioid overdose were
in contact with GP services prior to death. GPs are either often unaware of
high-risk opioid use, or rarely record details of opioid use in patient notes.
It is possible that GP awareness of high-risk opioid use could be increased. For
example, awareness of the risks associated with opioid use, and the relationship
between the sociodemographic and clinical characteristics of opioid overdose
decedents could be raised using educational materials prominently displayed in
waiting areas. Clinicians in primary care may be in an excellent position to
intervene in problematic opioid use.
Collapse
Affiliation(s)
- Matthew Jones
- Swansea University, Swansea, UK
- Matthew Jones, Swansea University School of
Medicine, Singleton Park, Swansea, SA2 8PP, UK.
| | | | | | | | | | | |
Collapse
|
67
|
Robinson CA, Wilson JD. Management of Opioid Misuse and Opioid Use Disorders Among Youth. Pediatrics 2020; 145:S153-S164. [PMID: 32358206 PMCID: PMC7880138 DOI: 10.1542/peds.2019-2056c] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2020] [Indexed: 12/28/2022] Open
Abstract
In response to the growing impact of the current opioid public health crisis in the United States on adolescents and young adults, pediatricians have an expanding role in identifying opioid use early, preventing escalation of risky use, reducing opioid-related harms, and delivering effective therapies. Research and expert consensus suggest the use of brief interventions focused on reducing risks associated with ongoing opioid use and using motivational interviewing strategies to engage youth in treatment. Because fatal opioid overdose remains a major cause of opioid-related mortality among youth, delivering overdose education as part of any visit in which a youth endorses opioid use is one evidence-based strategy to decrease the burden of opioid-related mortality. For youth that are injecting opioids, safe injection practices and linkage to needle or syringe exchanges should be considered to reduce complications from injection drug use. It is crucial that youth be offered treatment at the time of diagnosis of an opioid use disorder (OUD), including medications, behavioral interventions, and/or referral to mutual support groups. The 2 medications commonly used for office-based OUD treatment in adolescents are extended-release naltrexone (opioid antagonist) and buprenorphine (partial opioid agonist), although there is a significant treatment gap in prescribing these medications to youth, especially adolescents <18 years of age. Addiction is a pediatric disease that pediatricians and adolescent medicine physicians are uniquely poised to manage, given their expertise in longitudinal, preventive, and family- and patient-centered care. Growing evidence supports the need for integration of OUD treatment into primary care.
Collapse
Affiliation(s)
- Camille A. Robinson
- Division of General Pediatrics and Adolescent Medicine, Department of Pediatrics, School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - J. Deanna Wilson
- Divisions of General Internal Medicine and Adolescent and Young Adult Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
68
|
Donroe JH, Bhatraju EP, Tsui JI, Edelman EJ. Identification and Management of Opioid Use Disorder in Primary Care: an Update. Curr Psychiatry Rep 2020; 22:23. [PMID: 32285215 DOI: 10.1007/s11920-020-01149-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs. RECENT FINDINGS The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.
Collapse
Affiliation(s)
- Joseph H Donroe
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.
| | | | - Judith I Tsui
- University of Washington School of Medicine, Seattle, WA, USA
| | - E Jennifer Edelman
- Yale School of Medicine, 1450 Chapel Street, Office MOB211, New Haven, CT, 06511, USA.,Yale Schools of Medicine and Public Health, E.S. Harkness Memorial Hall, Building A, 367 Cedar Street, Ste Suite 401, New Haven, CT, 06510, USA
| |
Collapse
|
69
|
Bayoumi I, Schultz SE, Glazier RH. Primary care reform and funding equity for mental health disorders in Ontario: a retrospective observational population-based study. CMAJ Open 2020; 8:E455-E461. [PMID: 32561592 PMCID: PMC7850171 DOI: 10.9778/cmajo.20190153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Mental health disorders are associated with high morbidity and reduced life expectancy, and are largely managed in primary care. We sought to assess the equity of distribution of new alternative payment models and teams introduced under primary care reform in Ontario for patients with mental health disorders. METHODS We conducted a retrospective observational study using population-level administrative data for insured Ontario adults (age ≥ 18 yr) to identify all primary care payments to physicians that were allocated to individual patients in 2002/03 and 2011/12. We identified patients with mental health disorders using validated algorithms, and modelled the relations between per capita primary care costs and mental health disorders over time, stratified by type of mental health or substance use disorder and type of primary care payment. In an adjusted model, we adjusted for age, sex, rurality, neighbourhood income quintile, immigrant status, comorbidity and primary care model. For comparative purposes, we also examined the distribution of primary care payments for people with diabetes mellitus. RESULTS Total per capita primary care payments increased more slowly over the study period for patients with mental health disorders (62.0%) than for the general population (88.3%). Total payments for patients with substance use disorders increased by 142.7%, largely owing to urine drug testing in opioid substitution clinics. Adjusted total payments for those with versus without mental health disorders decreased by 10% between 2002/03 and 2011/12, driven by lower alternative payments. Similar decreases, also driven by lower alternative payments, were found for all mental health disorder subgroups except substance use and for diabetes. INTERPRETATION Payment and team reforms were associated with inequitable resource allocation to people with mental health disorders. The findings suggest the need for monitoring reforms for their impact on high-needs populations and making appropriate adjustments.
Collapse
Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; ICES (Bayoumi, Schultz, Glazier); Department of Family and Community Medicine (Glazier), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital, Toronto, Ont.
| | - Susan E Schultz
- Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; ICES (Bayoumi, Schultz, Glazier); Department of Family and Community Medicine (Glazier), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Richard H Glazier
- Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; ICES (Bayoumi, Schultz, Glazier); Department of Family and Community Medicine (Glazier), University of Toronto; Department of Family and Community Medicine (Glazier), St. Michael's Hospital, Toronto, Ont
| |
Collapse
|
70
|
Gadomski A, Anderson J, Chung YK, Krupa N, Jenkins P. Full agonist opioid prescribing by primary care clinicians after buprenorphine training. Subst Abus 2020; 43:69-75. [PMID: 32150525 DOI: 10.1080/08897077.2020.1736709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Background: While primary care clinicians are being trained to use buprenorphine for the treatment of Opioid Use Disorder (OUD) in order to increase access to addiction treatment, it is not known what impact such training and subsequent experience treating patients with OUD has on full agonist opioid prescribing. Methods: This retrospective cohort study compares the full agonist opioid prescribing patterns of Drug Addiction Treatment Act (DATA)-waivered ("X-waivered") primary care clinicians to non-trained, non-waivered clinicians in a rural health network. X-waivered clinicians also received Project ECHO training and telementoring support for one year. Using prescriber data generated by an electronic medical record system, opioid prescribing and morphine milligram equivalents (MME) per day per patient were calculated. A between-group analysis was used to compare the study groups six months pre-versus post-training. Results: Although the mean number of full agonist opioid prescriptions per clinician and per 100 patient encounters decreased among all clinicians, there was no change in full agonist opioid prescribing MME. As expected, buprenorphine prescribing by X-waivered, trained clinicians increased significantly post-training. Conclusions: X-waivers plus Project ECHO support for the treatment of OUD using buprenorphine had no effect on full agonist opioid prescribing by primary care clinicians.
Collapse
Affiliation(s)
- Anne Gadomski
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - James Anderson
- Department of Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Yelim K Chung
- College of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Nicole Krupa
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| | - Paul Jenkins
- Bassett Medical Center, Bassett Research Institute, Cooperstown, NY, USA
| |
Collapse
|
71
|
Boudreau DM, Lapham G, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Campbell CI, Rossom RC, Binswanger IA, Yarborough BJ, Arnsten JH, Cunningham CO, Glass JE, Murphy MT, Zare M, Hechter RC, Ahmedani B, Braciszewski JM, Horigian VE, Szapocznik J, Samet JH, Saxon AJ, Schwartz RP, Bradley KA. Documented opioid use disorder and its treatment in primary care patients across six U.S. health systems. J Subst Abuse Treat 2020; 112S:41-48. [PMID: 32220410 PMCID: PMC7107675 DOI: 10.1016/j.jsat.2020.02.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 02/05/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The United States is in the middle of an opioid overdose epidemic, and experts are calling for improved detection of opioid use disorders (OUDs) and treatment with buprenorphine or extended release (XR) injectable naltrexone, which can be prescribed in general medical settings. To better understand the magnitude of opportunities for treatment among primary care (PC) patients, we estimated the prevalence of documented OUD and medication treatment of OUD among PC patients. METHODS This cross-sectional study included patients with ≥2 visits to PC clinics across 6 healthcare delivery systems who were ≥16 years of age during the study period (fiscal years 2014-2016). Diagnoses, prescriptions, and healthcare utilization were ascertained from electronic health records and insurance claims (5 systems that also offer health insurance). Documented OUDs were defined as ≥1 International Classification of Diseases code for OUDs (active or remission), and OUD treatment was defined as ≥1 prescription(s) for buprenorphine formulations indicated for OUD or naltrexone XR, during the 3-year study period. The prevalence of documented OUD and treatment (95% confidence intervals) across health systems were estimated, and characteristics of patients by treatment status were compared. Prevalence of OUD and OUD treatment were adjusted for age, gender, and race/ethnicity. Combined results were also adjusted for site. RESULT Among 1,403,327 eligible PC patients, 54-62% were female and mean age ranged from 46 to 51 years across health systems. The 3-year prevalence of documented OUD ranged from 0.7-1.4% across the health systems. Among patients with documented OUD, the prevalence of medication treatment (primarily buprenorphine) varied across health systems: 3%, 12%, 16%, 20%, 22%, and 36%. CONCLUSION The prevalence of documented OUD and OUD treatment among PC patients varied widely across health systems. The majority of PC patients with OUD did not have evidence of treatment with buprenorphine or naltrexone XR, highlighting opportunities for improved identification and treatment in medical settings. These results can inform initiatives aimed at improving treatment of OUD in PC. Future research should focus on why there is such variation and how much of the variation can be addressed by improving access to medication treatment.
Collapse
Affiliation(s)
- Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, United States of America.
| | - Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Eric A Johnson
- Kaiser Permanente Washington Health Research Institute, United States of America
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, United States of America
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, United States of America
| | | | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research and Colorado Permanente Medical Group, United States of America
| | - Bobbi Jo Yarborough
- Kaiser Permanente Northwest Center for Health Research, United States of America
| | | | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, United States of America
| | | | - Mohammad Zare
- University of Texas at Houston, United States of America
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation, United States of America
| | | | | | | | | | - Jeffrey H Samet
- Boston Medical Center, Boston University School of Medicine, United States of America
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System, United States of America
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, United States of America
| |
Collapse
|
72
|
Morozova O, Crawford FW, Cohen T, Paltiel AD, Altice FL. Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis. Addiction 2020; 115:437-450. [PMID: 31478285 PMCID: PMC7015766 DOI: 10.1111/add.14797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/24/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment. DESIGN, SETTING AND PARTICIPANTS Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD. MEASUREMENTS Incremental cost per quality-adjusted life-year gained in the simulated population. FINDINGS An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand. CONCLUSIONS It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.
Collapse
Affiliation(s)
- Olga Morozova
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
- Department of Statistics and Data Science, Yale University, New Haven, CT, USA
- Yale School of Management, New Haven, CT, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - A David Paltiel
- Yale School of Management, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- University of Malaya, Kuala Lumpur, Malaysia
| |
Collapse
|
73
|
Lapham G, Boudreau DM, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Samet JH, Saxon AJ, Campbell CI, Glass JE, Rossom RC, Murphy MT, Binswanger IA, Yarborough BJH, Bradley KA, Ahmedani B, Amoroso PJ, Arnsten JH, Bart G, Braciszewski JM, Cunningham CO, Hechter RC, Horigian VE, Liebschutz JM, Loree AM, Matson TE, McNeely J, Merrill JO, Northrup TF, Schwartz RP, Stotts AL, Szapocznik J, Thakral M, Tsui JI, Zare M. Prevalence and treatment of opioid use disorders among primary care patients in six health systems. Drug Alcohol Depend 2020; 207:107732. [PMID: 31835068 PMCID: PMC7158756 DOI: 10.1016/j.drugalcdep.2019.107732] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. METHODS Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. RESULTS Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. CONCLUSIONS Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.
Collapse
Affiliation(s)
- Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States; University of Washington, Department of Health Services, United States.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Pharmacy
| | | | | | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network
| | - Jeffrey H Samet
- Boston University & Boston Medical Center Department of Medicine, Division of General Internal Medicine
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System Center of Excellence in Substance Abuse Treatment and Education.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Mark T Murphy
- Multicare Health System MultiCare Tacoma Central Family Medicine
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research.,Colorado Permanente Medical Group, Denver, Colorado
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Health Services.,University of Washington Department of Medicine
| | - Brian Ahmedani
- Henry Ford Health System Center for Health Policy & Health Services Research
| | - Paul J Amoroso
- Multicare Health System MultiCare Institute for Research and Innovation
| | - Julia H Arnsten
- Montefiore Medical Center Department of Medicine.,Montefiore Medical Center Division of General Internal Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | | | | | - Chinazo O Cunningham
- Montefiore Medical Center Department of Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation
| | - Viviana E Horigian
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Jane M Liebschutz
- University of Pittsburgh School of Medicine Division of General Internal Medicine, Center for Research on Health Care
| | - Amy M Loree
- Henry Ford Health System Center for Health Policy & Health Services Research
| | | | - Jennifer McNeely
- New York University School of Medicine, Department of Population Health and Department of Medicine, Division of General Internal Medicine and Clinical Innovation
| | | | - Thomas F Northrup
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | | | - Angela L Stotts
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | - José Szapocznik
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Manu Thakral
- University of Massachusetts Boston College of Nursing and Health Sciences, Boston, MA, USA
| | - Judith I Tsui
- University of Washington Division of General Internal Medicine
| | - Mohammad Zare
- McGovern Medical School at The University of Texas Health Science Center at Houston
| |
Collapse
|
74
|
Kesten JM, Thomas K, Scott LJ, Bache K, Hickman M, Campbell R, Pickering AE, Redwood S. Acceptability of a primary care-based opioid and pain review service: a mixed-methods evaluation in England. Br J Gen Pract 2020; 70:e120-e129. [PMID: 31594772 PMCID: PMC6783137 DOI: 10.3399/bjgp19x706097] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 05/22/2019] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Primary care opioid prescribing to treat chronic non-cancer pain (CNCP) has progressively increased despite a lack of evidence for long-term safety and effectiveness. Developing primary care interventions to reduce opioid dependence in patients with CNCP is a public health priority. AIM To report the acceptability of the South Gloucestershire pain and opioid review service for patients with CNCP, which aimed to help patients understand their relationship with prescribed opioids and support non-drug-based pain management strategies. DESIGN AND SETTING A mixed-methods evaluation was performed on the service, which was based in two GP practices in South Gloucestershire, England, and delivered by project workers. METHOD Descriptive data were collected on delivered-within-service and community-based interventions. Twenty-five semi-structured interviews (n = 18 patients, n = 7 service providers) explored experiences of the service. RESULTS The enrolment process, person-centred primary care-based delivery, and service content focused on psychological issues underlying CNCP were found to be acceptable to patients and service providers. Patients welcomed having time to discuss their pain, its management, and related psychological issues. Maintaining a long-term approach was desired as CNCP is a complex issue that takes time to address. GPs recommended that funding was needed to ensure they have dedicated time to support a similar service and to ensure that project workers received adequate clinical supervision. CONCLUSION This service model was acceptable and may be a useful means to manage patients with CNCP who develop opioid dependence after long-term use of opioids. A randomised controlled trial is needed to formally test the effectiveness of the service.
Collapse
Affiliation(s)
- Joanna M Kesten
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West, University Hospitals Bristol NHS Foundation Trust; NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol
| | - Kyla Thomas
- Population Health Sciences, Bristol Medical School, University of Bristol; South Gloucestershire Council, Bristol
| | - Lauren J Scott
- NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | | | - Matthew Hickman
- Population Health Sciences, Bristol Medical School; NIHR Health Protection Research Unit in Evaluation of Interventions, University of Bristol, Bristol
| | - Rona Campbell
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Anthony E Pickering
- Department of Anaesthesia, University Hospitals Bristol NHS Foundation Trust; School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol
| | - Sabi Redwood
- NIHR CLAHRC West, University Hospitals Bristol NHS Foundation Trust; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| |
Collapse
|
75
|
Evaluation of a primary care-based opioid and pain review service: a mixed-methods evaluation in two GP practices in England. Br J Gen Pract 2020; 70:e111-e119. [PMID: 31791939 PMCID: PMC6890470 DOI: 10.3399/bjgp19x707237] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 07/23/2019] [Indexed: 12/31/2022] Open
Abstract
Background Opioid prescribing to treat chronic non-cancer pain has rapidly increased, despite a lack of evidence for long-term safety and effectiveness. A pain review service was developed to work with patients taking opioids long-term to explore opioid use, encourage non-drug-based alternatives, and, where appropriate, support dose reduction. Aim To evaluate the service and its potential impact on opioid use, health and wellbeing outcomes, and quality of life (QoL). Design and setting Mixed-methods evaluation of a one-to-one service based in two GP practices in South Gloucestershire, England, which took place from September 2016 to December 2017. Method Quantitative data were collected on baseline demographics; data on opioid use, misuse, and dose, health, wellbeing, QoL, and pain and interference with life measures were collected at baseline and follow-up. Twenty-five semi-structured interviews (n = 18 service users, n = 7 service providers) explored experiences of the service including perceived impacts and benefits. Results Of 59 patients who were invited, 34 (57.6%) enrolled in the service. The median prescribed opioid dose reduced from 90 mg (average daily morphine equivalent; interquartile range [IQR] 60 to 240) at baseline to 72 mg (IQR 30 to 160) at follow-up (P<0.001); three service users stopped using opioids altogether. On average, service users showed improvement on most health, wellbeing, and QoL outcomes. Perceived benefits were related to wellbeing, for example, improved confidence and self-esteem, use of pain management strategies, changes in medication use, and reductions in dose. Conclusion The service was well received, and health and wellbeing outcomes suggest a potential benefit. Following further service development, a randomised controlled trial to test this type of care pathway is warranted.
Collapse
|
76
|
Thomas J, Slat S, Woods G, Cross K, Macleod C, Lagisetty P. Assessing Medical Student Interest in Training About Medications for Opioid Use Disorder: A Pilot Intervention. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2020; 7:2382120520923994. [PMID: 32537516 PMCID: PMC7268112 DOI: 10.1177/2382120520923994] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 04/05/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE Educating medical students about buprenorphine may lessen barriers to providing treatment for opioid use disorder (OUD) by addressing stigma, removing the need to complete training while practicing, and normalizing it as a pharmacological option. We conducted a needs assessment to measure student interest in buprenorphine waiver training and pilot tested an online course with an in-person discussion for feasibility and acceptability. METHODS All 2019 graduating students were surveyed to assess interest in completing buprenorphine waiver training and understand in which format they preferred to receive the training. Interested students received information about a free online buprenorphine waiver course and an optional in-person case discussion with a faculty member. Baseline and follow-up surveys were used to assess the intervention. RESULTS Out of 228 students contacted, 173 (75.9%) responded to at least 1 survey. Of the 228, 62 (27.2%) responded to the initial survey asking students about receiving buprenorphine waiver training. The 166 non-responding students were sent a second survey, and 111 (66.9%) students responded. Of those 111, 29 (26.1%) indicated they forgot to respond to the first survey, and 24 (21.6%) did not see the survey. Of the 62 interested students, 41 students (66.1%) wanted a combination of online and in-person training. Of the 62, 30 (48.4%) interested students completed the online course and 10 (16.1%) attended the case discussion. While not significantly different, a higher proportion of students (88.9%) indicated being likely to prescribe buprenorphine after attending the case discussion than after completing the online course only (69.2%). CONCLUSIONS This assessment suggested that most of the medical students are willing to complete a buprenorphine waiver course. Feedback indicated an in-person component could increase future prescribing more than an online-only curriculum, and additional advertising could result in higher participation.
Collapse
Affiliation(s)
- Jennifer Thomas
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephanie Slat
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gregory Woods
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristen Cross
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Colin Macleod
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Pooja Lagisetty
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
77
|
Reif S, Brolin MF, Stewart MT, Fuchs TJ, Speaker E, Mazel SB. The Washington State Hub and Spoke Model to increase access to medication treatment for opioid use disorders. J Subst Abuse Treat 2020; 108:33-39. [PMID: 31358328 PMCID: PMC6893117 DOI: 10.1016/j.jsat.2019.07.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 07/08/2019] [Accepted: 07/16/2019] [Indexed: 10/26/2022]
Abstract
INTRODUCTION The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model. METHODS Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team. RESULTS The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone. CONCLUSIONS The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring "no wrong door," engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.
Collapse
Affiliation(s)
- Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA.
| | - Mary F Brolin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
| | - Maureen T Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
| | - Thomas J Fuchs
- Division of Behavioral Health and Recovery, Washington State Health Care Authority, 626 8th Avenue SE, P.O. Box 45330, Olympia, WA 98504, USA
| | - Elizabeth Speaker
- Research and Data Analysis, Washington State Department of Social and Health Services, 1115 Washington Street, P.O. Box 4520, Olympia, WA 98504, USA
| | - Shayna B Mazel
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453, USA
| |
Collapse
|
78
|
Luli AJ, Bounthavong M, Watanabe JH. Pharmacists on the front-line of solving a public health crisis: Increasing access to medications for opioid use disorder. J Am Pharm Assoc (2003) 2019; 60:297-303. [PMID: 31889651 DOI: 10.1016/j.japh.2019.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/24/2019] [Accepted: 10/28/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To demonstrate the advantages of pharmacist involvement to increase the accessibility of medication treatment for opioid use disorder (OUD). SUMMARY OUD continues to be a mounting public health crisis in the United States. Medications for OUD treatment have been reported to be safe and effective. Yet, underutilization and poor accessibility remain critical challenges. As the most accessible health care provider, pharmacists have the capability to help overcome these barriers and positively affect patient care. Preliminary strategies have been documented in the United States and abroad that can serve as a blueprint for expanded pharmacist involvement. CONCLUSION Pharmacists must expand efforts to increase patient accessibility to medications for OUD and become a key part of the solution to this epidemic.
Collapse
|
79
|
Alho H, Dematteis M, Lembo D, Maremmani I, Roncero C, Somaini L. Opioid-related deaths in Europe: Strategies for a comprehensive approach to address a major public health concern. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 76:102616. [PMID: 31855706 DOI: 10.1016/j.drugpo.2019.102616] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 11/07/2019] [Accepted: 12/03/2019] [Indexed: 12/28/2022]
Abstract
Use of illicit opioids and misuse of prescription opioids are the main causes of drug-related deaths across the world, and the continuing rise in opioid-related mortality, especially affecting North America, Australia and Europe, is a public health challenge. Strategies that may help to decrease the high levels of opioid-related mortality and morbidity and improve care across Europe include risk assessment and interventions to improve the use of opioid analgesics, e.g. prescription drug-monitoring programmes, education on pain management to reduce opioid prescribing, and the implementation of evidence-based primary prevention programmes to reduce the demand for opioids. For patients who develop opioid use disorder (a chronic and relapsing problematic use of opioids that causes clinical impairment or distress), treatment combining opiate receptor full or partial agonist medications for opioid-use disorder (MOUD) with psychosocial interventions is essential. However, in Europe a substantial proportion of the 1.3 million high-risk opioid users (defined as injecting drug use or regular use of opioids, mainly heroin) remain outside of dedicated treatment programmes. More widespread and easier access to MOUD could reduce mortality levels; via approaches such as primary care-led treatment models, and efforts to improve patient retention and adherence to treatment programmes. Other harm-reduction strategies, such as the use of MOUD at optimal doses, the provision of take-home naloxone, the introduction of supervised drug-consumption facilities, and patient education to reduce the risk of overdose may also be beneficial.
Collapse
Affiliation(s)
- Hannu Alho
- Department of Public Health Solutions, The Alcohol, Drugs and Addictions Unit, National Institute of Health and Welfare, Mannerheimintie 166, Helsinki, Finland.
| | - Maurice Dematteis
- Department of Addiction Medicine, Grenoble Alpes University Hospital and Faculty of Medicine, Grenoble Alpes University, France.
| | | | - Icro Maremmani
- Vincent P. Dole Dual Disorder Unit, Santa Chiara University Hospital, University of Pisa, Italy.
| | - Carlos Roncero
- Psychiatric Service, University of Salamanca Health Care Complex and Psychiatric Department, University of Salamanca, Salamanca, Spain.
| | - Lorenzo Somaini
- Addiction Treatment Centre, Local Health Unit, Biella, Italy.
| |
Collapse
|
80
|
Attitudes of primary care physicians toward prescribing buprenorphine: a narrative review. BMC FAMILY PRACTICE 2019; 20:157. [PMID: 31729957 PMCID: PMC6857230 DOI: 10.1186/s12875-019-1047-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/04/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND The opioid epidemic is a major public health issue associated with significant overdose deaths. Effective treatments exist, such as the medication buprenorphine, but are not widely available. This narrative review examines the attitudes of primary care providers (PCPs) toward prescribing buprenorphine. METHODS Narrative review of 20 articles published after the year 2000, using the Consolidated Framework for Implementation Research (CFIR) to organize the findings. RESULTS Three of the five CFIR domains ("Intervention Characteristics," "Outer Setting," "Inner Setting") were strongly represented in our analysis. Providers were concerned about the clientele associated with buprenorphine, diversion, and their self-efficacy in prescribing the medication. Some believed that buprenorphine does not belong in the discipline of primary care. Other barriers included philosophical objections and stigma toward substance use disorders. Notably, two studies reported a shift in attitudes once physicians prescribed buprenorphine to actual patients. CONCLUSIONS Negative attitudes toward buprenorphine encompassed multi-layered concerns, ranging from skepticism about the medication itself, the behaviors of patients with opioid use disorders, and beliefs regarding substance use disorders more generally. We speculate, however, that negative attitudes may be improved by tailoring support strategies that address providers' self-efficacy and level of knowledge.
Collapse
|
81
|
The epidemiology of prescription fentanyl misuse in the United States. Addict Behav 2019; 96:89-93. [PMID: 31063940 DOI: 10.1016/j.addbeh.2019.04.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Revised: 03/30/2019] [Accepted: 04/21/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND US opioid overdose deaths continue to climb, with a 12.0% increase from 2016 to 2017. Fentanyl, a synthetic opioid, has been a major contributor to opioid-related overdose deaths. While fentanyl-related overdose is driven by illicit fentanyl, little is known about individuals who misuse prescription fentanyl, which is also linked to elevated overdose and mortality risk. This work aimed to fill that gap through analyses of prescription fentanyl misuse correlates. METHODS Data were from the 2015-16 National Survey on Drug Use and Health (N = 114,043), a nationally representative survey of the non-institutionalized US population. Respondents were (all past-year): those misusing prescription fentanyl (PF); those misusing other (non-fentanyl) prescription opioids (NFPO); and population controls. Respondent groups were compared using multinomial regression on sociodemographics, physical health, mental health and substance use. The PF and NFPO misuse groups were compared on opioid misuse characteristics, using logistic regression. RESULTS An estimated 4.4% misused NFPO, and 0.1% misused PF (past-year). Past-year heroin use was more common in those who misused PF (44.3%) than those who misused other NFPO (4.4%; relative risk ratio [RRR] = 7.1, 95%CI = 3.7-13.9) or population controls (0.1%, RRR = 35.1, 95%CI = 17.3-71.1). Non-alcohol substance use disorder (SUD) was similarly elevated in those who misused PF (78.7%) versus the other NFPO group (27.5%, RRR = 3.8, 95%CI = 1.8-8.2) or population controls (1.6%, RRR = 20.6, 95%CI = 9.4-45.5). CONCLUSIONS Respondents who misused prescription fentanyl were both more drug-involved generally and opioid-involved specifically; and likely need a combination of significant interventions and monitoring for their polysubstance use.
Collapse
|
82
|
Predictors of Medication-Assisted Treatment Initiation for Opioid Use Disorder in an Interdisciplinary Primary Care Model. J Am Board Fam Med 2019; 32:724-731. [PMID: 31506368 PMCID: PMC6754209 DOI: 10.3122/jabfm.2019.05.190012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/05/2019] [Accepted: 05/06/2019] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Medication-assisted treatment (MAT) for opioid use disorder (OUD) is underused in primary care. Little is known about patient demographics associated with MAT initiation, particularly among models with an interdisciplinary approach, including behavioral health integration. We hypothesize few disparities in MAT initiation by patient characteristics after implementing this model for OUD. METHODS Electronic health record data were used to identify adults with ≥1 primary care visit in 1 of 2 study clinics in a Pacific Northwest academic health system between September 1, 2015 and August 31, 2017 (n = 23,372). Rates of documented OUD diagnosis were calculated. Multivariate logistic regression estimated odds ratios of MAT initiation, defined as ≥1 electronic health record order for buprenorphine or naltrexone, by patient covariates. RESULTS Seven percent of the study sample had an OUD diagnosis. Of those patients, 32% had ≥1 MAT order. Patients with documented psychiatric diagnoses or tobacco use had higher odds of initiating MAT (odds ratio [OR] = 1.62, P = .0003; OR = 2.46, P < .0001, respectively). Uninsured, Medicaid, and Medicare patients had lower odds than those commercially insured (OR = 0.53, 0.38, and 0.31, respectively; P < .0001). Patients who were older, of a race/ethnicity other than non-Hispanic white, had documented diabetes, and had documented asthma or chronic obstructive pulmonary disease showed lower odds of initiation. DISCUSSION MAT initiation varied by patient characteristics, including disparities by insurance coverage and race/ethnicity. The addition of behavioral health did not eliminate disparities in care, but higher odds of initiation among those with a documented psychiatric diagnosis may suggest this model reaches some vulnerable populations. Additional research is needed to further examine these findings.
Collapse
|
83
|
Haffajee RL, Lin LA, Bohnert ASB, Goldstick JE. Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder. JAMA Netw Open 2019; 2:e196373. [PMID: 31251376 PMCID: PMC6604101 DOI: 10.1001/jamanetworkopen.2019.6373] [Citation(s) in RCA: 184] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Accepted: 05/11/2019] [Indexed: 02/04/2023] Open
Abstract
Importance Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment. Objective To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications. Design, Setting, and Participants In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019. Exposures Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics. Main Outcome and Measures The outcome variable, "opioid high-risk county," was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county. Results Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98). Conclusions and Relevance Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.
Collapse
Affiliation(s)
- Rebecca L. Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| | - Lewei Allison Lin
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Amy S. B. Bohnert
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor
- Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jason E. Goldstick
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor
| |
Collapse
|
84
|
|
85
|
Korownyk C, Perry D, Ton J, Kolber MR, Garrison S, Thomas B, Allan GM, Dugré N, Finley CR, Ting R, Yang PR, Vandermeer B, Lindblad AJ. Opioid use disorder in primary care: PEER umbrella systematic review of systematic reviews. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e194-e206. [PMID: 31088885 PMCID: PMC6516704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To summarize the best available evidence regarding various topics related to primary care management of opioid use disorder (OUD). DATA SOURCES MEDLINE, Cochrane Library, Google, and the references of included studies and relevant guidelines. STUDY SELECTION Published systematic reviews and newer randomized controlled trials from the past 5 to 10 years that investigated patient-oriented outcomes related to managing OUD in primary care, diagnosis, pharmacotherapies (including buprenorphine, methadone, and naltrexone), tapering strategies, psychosocial interventions, prescribing practices, and management of comorbidities. SYNTHESIS From 8626 articles, 39 systematic reviews and an additional 26 randomized controlled trials were included. New meta-analyses were performed where possible. One cohort study suggests 1 case-finding tool might be reasonable to assist with diagnosis (positive likelihood ratio of 10.3). Meta-analysis demonstrated that retention in treatment improves when buprenorphine or methadone are used (64% to 73% vs 22% to 39% for control), when OUD is treated in primary care (86% vs 67% in specialty care, risk ratio [RR] of 1.25, 95% CI 1.07 to 1.47), and when counseling is added to pharmacotherapy (74% vs 62% for controls, RR = 1.20, 95% CI 1.06 to 1.36). Retention was also improved with naltrexone (33% vs 25% for controls, RR = 1.35, 95% CI 1.11 to 1.64) and reduced with medication-related contingency management (eg, loss of take-home doses as a punitive measure; 68% vs 77% for no contingency, RR = 0.86, 95% CI 0.76 to 0.99). CONCLUSION There is reasonable evidence that patients with OUD should be managed in the primary care setting. Diagnostic criteria for OUD remain elusive, with 1 reasonable case-finding tool. Methadone and buprenorphine improve treatment retention, while medication-related contingency methods could worsen retention. Counseling is beneficial when added to pharmacotherapy.
Collapse
Affiliation(s)
- Christina Korownyk
- Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
| | - Danielle Perry
- Nurse and Clinical Evidence Expert at the Alberta College of Family Physicians in Edmonton
| | - Joey Ton
- Pharmacist and Clinical Evidence Expert at the College of Family Physicians of Canada in Mississauga, Ont
| | - Michael R Kolber
- Family physician and Professor in the Department of Family Medicine at the University of Alberta
| | - Scott Garrison
- Family physician and Associate Professor in the Department of Family Medicine at the University of Alberta
| | - Betsy Thomas
- Pharmacist; Project Manager, Education and Knowledge Translation at the Alberta College of Family Physicians; and Assistant Adjunct Professor in the Department of Family Medicine at the University of Alberta
| | - G Michael Allan
- Family physician, Director of Programs and Practice Support at the College of Family Physicians of Canada, and Professor in the Department of Family Medicine at the University of Alberta
| | - Nicolas Dugré
- Pharmacist at the CIUSSS du Nord-de-l'Ile-de-Montréal and Clinical Associate Professor in the Faculty of Pharmacy at the University of Montreal in Quebec
| | | | - Rhonda Ting
- Doctoral student in the Faculty of Pharmacy and Pharmaceutical Sciences at the University of Alberta
| | | | - Ben Vandermeer
- Research Associate at the Alberta Research Centre for Health Evidence
| | - Adrienne J Lindblad
- Pharmacist and Knowledge Translation and Evidence Coordinator at the Alberta College of Family Physicians and Associate Clinical Professor in the Department of Family Medicine at the University of Alberta
| |
Collapse
|
86
|
Lin LA, Knudsen HK. Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States. Ann Fam Med 2019; 17:212-220. [PMID: 31085525 PMCID: PMC6827617 DOI: 10.1370/afm.2384] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 12/24/2018] [Accepted: 01/31/2019] [Indexed: 12/23/2022] Open
Abstract
PURPOSE Although there is a tremendous need to increase the use of buprenorphine for the treatment of opioid use disorder in rural areas, little is known about current rural/urban differences in treatment practices. We aimed to examine physician characteristics, treatment practices, and concordance with treatment guidelines among buprenorphine prescribers across different locations of practice. METHODS A national random sample of buprenorphine physician prescribers was surveyed (n = 1,174, response rate = 33%) from July 2014 to January 2017. Analyses examined buprenorphine treatment across locations of practice (categorized as nonmetropolitan, small metropolitan, and large metropolitan). RESULTS Among buprenorphine prescribers surveyed, 11.2% (n = 132) practiced in nonmetropolitan/rural areas, 32.5% (n = 382) in small metropolitan areas, and 56.2% (n = 660) in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including induction, frequency of visits, dosing, and use of psychosocial treatment, which were generally consistent with buprenorphine treatment recommendations. CONCLUSIONS There are important differences in characteristics of buprenorphine prescribers in nonmetropolitan areas compared with more urban areas, including the fact that the majority of nonmetropolitan physicians are primary care physicians. Although treatment access in rural areas is an ongoing challenge, buprenorphine treatment practices are similar. Understanding buprenorphine prescribers and their treatment practices may help inform tailored strategies to address treatment needs in different locations.
Collapse
Affiliation(s)
- Lewei Allison Lin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, Michigan .,Center for Clinical Management Research (CCMR), Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Hannah K Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
87
|
Lombardi BM, Zerden LDS, Guan T, Prentice A. The role of social work in the opioid epidemic: office-based opioid treatment programs. SOCIAL WORK IN HEALTH CARE 2019; 58:339-344. [PMID: 30596348 DOI: 10.1080/00981389.2018.1564109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/01/2018] [Accepted: 12/22/2018] [Indexed: 06/09/2023]
Abstract
The opioid epidemic is a national emergency in the United States. To meet the needs of individuals diagnosed with Opioid Use Disorder (OUD) office-based opioid treatment programs (OBOT) are quickly expanding. However, social workers roles in OBOT programs are not clearly described. This paper will emphasize three roles social workers may fulfill in OBOT programs to combat the opioid crisis.
Collapse
Affiliation(s)
| | - Lisa de Saxe Zerden
- b School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , NC
| | - Ting Guan
- b School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , NC
| | - Amy Prentice
- c Family Medicine , UNC Health Care , Chapel Hill , NC
| |
Collapse
|
88
|
Reddon H, Marshall BDL, Milloy MJ. Elimination of HIV transmission through novel and established prevention strategies among people who inject drugs. Lancet HIV 2018; 6:e128-e136. [PMID: 30558843 DOI: 10.1016/s2352-3018(18)30292-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 10/01/2018] [Accepted: 10/12/2018] [Indexed: 11/16/2022]
Abstract
Despite the effectiveness of existing HIV prevention strategies for people who inject drugs (PWID), uncontrolled outbreaks of HIV among this group are common and occur around the world. In this Review, we summarise recent evidence for novel and established HIV prevention approaches to eliminate HIV transmission among PWID. Effective HIV prevention strategies include mobile needle and syringe programmes, pre-exposure prophylaxis, supervised injection facilities, and, to a lesser extent, some behavioural interventions. Studies have also shown the cost-effectiveness of long-standing HIV prevention strategies including needle and syringe programmes, opioid agonist therapy, and antiretroviral therapy for prevention. Although each individual intervention can reduce the risk of HIV acquisition among PWID, there is a consensus that a combination of approaches is required to achieve substantial and durable reductions in HIV transmission. Unfortunately, in many settings, the implementation of these interventions is often limited by public and political opposition that manifests as structural barriers to HIV prevention, such as the criminalisation of drug use. Given that there is ample evidence showing the effectiveness of several HIV prevention methods, social and political advocacy will be needed to overcome these barriers and integrate innovative HIV prevention approaches with addiction science to create effective drug policies.
Collapse
Affiliation(s)
- Hudson Reddon
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Canadian Institutes of Health Research, Canadian HIV Trials Network, Vancouver, BC, Canada
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - M-J Milloy
- British Columbia Centre on Substance Use, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, BC, Canada.
| |
Collapse
|
89
|
TIMKO CHRISTINE, CUCCIARE MICHAELA. Commentary on Socias et al. (2018): Clinical research perspectives on cannabis use in opioid agonist treatment. Addiction 2018; 113:2259-2260. [PMID: 30251284 PMCID: PMC6542466 DOI: 10.1111/add.14432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 08/29/2018] [Indexed: 01/24/2023]
Abstract
Research is needed to determine clinical criteria as to who should be using cannabis therapeutically, how to implement therapeutic use of cannabis in opioid agonist treatment (OAT) settings optimally, and other behavioral approaches to improving OAT retention and outcomes.
Collapse
Affiliation(s)
- CHRISTINE TIMKO
- Center for Innovation to Implementation, Veterans Affairs (VA) Health Care System, Menlo Park, CA, USA,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - MICHAEL A. CUCCIARE
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA,VA South Central (VISN 16) Mental Illness Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA,Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
90
|
Furlan AD, Carnide N, Irvin E, Van Eerd D, Munhall C, Kim J, Li CMF, Hamad A, Mahood Q, MacDonald S. A systematic review of strategies to improve appropriate use of opioids and to reduce opioid use disorder and deaths from prescription opioids. Can J Pain 2018; 2:218-235. [PMID: 35005381 PMCID: PMC8730669 DOI: 10.1080/24740527.2018.1479842] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background Abuse of prescription opioids is a serious problem in North America. Aims The aim of this study was to conduct a systematic review of peer-reviewed and grey literature to examine existing strategies aimed at improving the appropriate use of prescription opioids and/or reducing the misuse, abuse, and diversion of these drugs. Methods The following electronic databases were searched to September 2015 without language restrictions: MEDLINE, EMBASE, PsycINFO, and CINAHL; the grey literature was searched to May 2014. Reference lists of retrieved papers were also searched. Studies were eligible if a strategy was implemented and its impact on at least one of the primary outcomes of interest (appropriate prescription opioid use; misuse, abuse, opioid use disorder, diversion; overdose) was measured. Standardized, prepiloted forms were used for relevance screening, quality appraisal, and data extraction. Results A total of 65 studies that assessed 66 distinct strategies were identified. Due to the heterogeneity of the strategies, a qualitative synthesis was conducted. Many studies combined more than one type of strategy and measured various types of outcomes. The strategies with most promising results involved education, clinical practices, collaborations, prescription monitoring programs, public campaigns, opioid substitution programs, and naloxone distribution. We also found strategies that had some unintended consequences after implementation. Conclusions Our review identified successful strategies that have been implemented and evaluated in various jurisdictions. There is a need to replicate and disseminate these strategies where the problem of prescription opioid misuse and abuse has taken a toll on society.
Collapse
Affiliation(s)
- Andrea D Furlan
- Institute for Work & Health, Toronto, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada.,University Health Network, Toronto, Ontario, Canada
| | - Nancy Carnide
- Institute for Work & Health, Toronto, Ontario, Canada
| | - Emma Irvin
- Institute for Work & Health, Toronto, Ontario, Canada
| | | | | | - Jaemin Kim
- Institute for Work & Health, Toronto, Ontario, Canada
| | | | - Abdul Hamad
- University Health Network, Toronto, Ontario, Canada
| | - Quenby Mahood
- Institute for Work & Health, Toronto, Ontario, Canada
| | | |
Collapse
|
91
|
Abstract
Unhealthy substance use is common in primary care populations and is a major contributor to morbidity and mortality. Two key strategies to address unhealthy substance use in primary care are the process of screening, brief intervention, and referral to treatment (SBIRT), and integration of treatment for substance use disorders into primary care. Implementation of SBIRT requires buy-in from practice leaders, careful planning, and staff and primary care provider training. Primary care-based treatment of opioid and alcohol use disorders can be effective; more data are needed to better understand the benefits of these models and identify means of treating other substance use disorders in primary care.
Collapse
Affiliation(s)
- Christine A Pace
- Section of General Internal Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA.
| | - Lisa A Uebelacker
- Department of Psychiatry and Human Behavior, Warren Alpert School of Medicine, Brown University, Box G-BH, 700 Butler Drive, Providence, RI 02906, USA; Department of Family Medicine, Brown University, Memorial Hospital of RI, 111 Brewster Street, Pawtucket, RI 02860, USA; Psychosocial Research, Butler Hospital, 345 Blackstone Boulevard Providence, RI 02906, USA
| |
Collapse
|
92
|
Look KA, Kile M, Morgan K, Roberts A. Community pharmacies as access points for addiction treatment. Res Social Adm Pharm 2018; 15:404-409. [PMID: 29909934 DOI: 10.1016/j.sapharm.2018.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 05/17/2018] [Accepted: 06/11/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND There is growing interest in utilizing community pharmacies to support opioid abuse prevention and addiction treatment efforts. However, it is unknown whether the placement of community pharmacies is conducive to taking on such a role. OBJECTIVE To examine the distribution of community pharmacies in Wisconsin and its relationship with the location of addiction treatment facilities and opioid-related overdose events in rural and urban areas. METHODS The total number of opioid-related overdose deaths and crude death rates per 100,000 population were determined for each county in Wisconsin. Substance abuse treatment facilities were identified in each county to estimate access to formal addiction treatment. A list of pharmacies in the state was screened to identify community pharmacies in each county. Descriptive statistics and Pearson correlation coefficients were used to describe the distribution of and relationships between county-level opioid-related overdose death rates and the number of treatment facilities and community pharmacies in the state. RESULTS Wisconsin has 72 counties, of which 45 (62.5%) are classified as rural. Although the number of opioid-related overdose deaths was highly concentrated in urban areas, crude death rates per 100,000 population were similar in urban and rural areas. Rural counties were significantly less likely to have formal substance abuse treatment facilities (r = -.42, P = .00) or community pharmacies (r = -.44, P = .00) compared to urban counties. However, community pharmacies were more prevalent and more likely to be located in rural counties with higher rates of opioid-related overdose deaths than substance abuse treatment facilities. All but 1 of the 14 counties without a formal substance abuse treatment facility had access to 1 or more community pharmacies. CONCLUSIONS Community pharmacies are ideally located in areas that could be used to support medication-assisted addiction treatment efforts, particularly in rural areas lacking formal substance abuse treatment facilities.
Collapse
Affiliation(s)
- Kevin A Look
- Social and Administrative Sciences Division, University of Wisconsin-Madison School of Pharmacy, Madison, WI, United States.
| | - Mercedes Kile
- University of Wisconsin-Madison School of Pharmacy, Madison, WI, United States
| | - Katie Morgan
- University of Wisconsin-Madison School of Pharmacy, Madison, WI, United States
| | - Andrew Roberts
- Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City, KS, United States
| |
Collapse
|
93
|
Haffajee RL, Bohnert ASB, Lagisetty PA. Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment. Am J Prev Med 2018; 54:S230-S242. [PMID: 29779547 PMCID: PMC6330240 DOI: 10.1016/j.amepre.2017.12.022] [Citation(s) in RCA: 163] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 12/18/2017] [Accepted: 02/01/2018] [Indexed: 11/22/2022]
Abstract
At least 2.3 million people in the U.S. have an opioid use disorder, less than 40% of whom receive evidence-based treatment. Buprenorphine used as part of medication-assisted treatment has high potential to address this gap because of its approval for use in non-specialty outpatient settings, effectiveness at promoting abstinence, and cost effectiveness. However, less than 4% of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and approximately 47% of counties lack a buprenorphine-waivered physician. Existing policies contribute to workforce barriers to buprenorphine provision and access. Providers are reticent to prescribe buprenorphine because of workforce barriers, such as (1) insufficient training and education on opioid use disorder treatment, (2) lack of institutional and clinician peer support, (3) poor care coordination, (4) provider stigma, (5) inadequate reimbursement from private and public insurers, and (6) regulatory hurdles to obtain the waiver needed to prescribe buprenorphine in non-addiction specialty treatment settings. Policy pathways to addressing these provider workforce barriers going forward include providing free and easy-to-access education for providers about opioid use disorders and medication-assisted treatment, eliminating buprenorphine waiver requirements for those licensed to prescribe controlled substances, enforcing insurance parity requirements, requiring coverage of evidence-based medication-assisted treatment as essential health benefits, and providing financial incentives for care coordination across healthcare professional types-including behavioral health counselors and other non-physicians in specialty and non-specialty settings. SUPPLEMENT INFORMATION This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.
Collapse
Affiliation(s)
- Rebecca L Haffajee
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
| | - Amy S B Bohnert
- Department of Psychiatry, University of Michigan Medical School, Ann Arbor, Michigan; Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan
| | - Pooja A Lagisetty
- Center for Clinical Management Research, Department of Veterans Affairs, Ann Arbor, Michigan; Division of General Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| |
Collapse
|
94
|
McGovern M, Dent K, Kessler R. A Unified Model of Behavioral Health Integration in Primary Care. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2018; 42:265-268. [PMID: 29488173 DOI: 10.1007/s40596-018-0887-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 01/19/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Mark McGovern
- School of Medicine, Stanford University, Stanford, CA, USA.
| | - Kaitlin Dent
- School of Medicine, Stanford University, Stanford, CA, USA
| | - Rodger Kessler
- School of the Science of Health Care Delivery, Arizona State University, Phoenix, AZ, USA
| |
Collapse
|