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Thompson R, Taddei T, Kaplan D, Rabiee A. Safety of naltrexone in patients with cirrhosis. JHEP Rep 2024; 6:101095. [PMID: 38961852 PMCID: PMC11220533 DOI: 10.1016/j.jhepr.2024.101095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 04/01/2024] [Accepted: 04/04/2024] [Indexed: 07/05/2024] Open
Abstract
Background & Aims Treatment of alcohol use disorder (AUD) improves survival in patients with alcohol-related cirrhosis. However, medications for alcohol use disorder (MAUD) are underutilized in this population, partially due to concerns regarding drug-induced liver injury (DILI). Our aim was to evaluate the safety of naltrexone in patients with cirrhosis. Methods This was a retrospective study of patients with cirrhosis who were prescribed naltrexone using the VOCAL (Veterans Outcomes and Costs Associated with Liver Disease) database. Patients with new initiation of naltrexone after diagnosis of cirrhosis who had liver enzymes checked within a 3-month time frame were included. A chart review was performed on patients who developed alanine aminotransferase or alkaline phosphatase elevations to more than 2× or 5× the upper limit of normal, respectively. The RUCAM (Roussel Uclaf causality assessment method) was used to determine if DILI occurred. Results A total of 3,285 patients with cirrhosis were initiated on naltrexone, of whom 2,940 had laboratory testing during the high-risk DILI period. Only 2% of patients had liver enzyme elevations, and among those, 30 (48%) were classified as "DILI excluded" and 32 (52%) were classified as "DILI unlikely". No patients were classified as possible, probable, or highly probable DILI. No deaths or new decompensations were attributed to naltrexone. Conclusions Naltrexone in patients with cirrhosis was not associated with development of DILI using RUCAM scoring. Naltrexone appears to be safe in patients with compensated and decompensated cirrhosis. Impact and Implications Naltrexone is an effective medication for treating alcohol use disorder but is underutilized in patients with underlying liver disease due to historical concerns regarding hepatotoxicity. This retrospective study shows no drug-induced liver injury in a large cohort of patients with cirrhosis with new initiation of naltrexone. This study may encourage providers to prescribe naltrexone to patients with existing liver disease with ongoing alcohol use disorder.
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Affiliation(s)
- Rachel Thompson
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Tamar Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, United States
- VA Connecticut Healthcare System, New Haven, CT, United States
| | - David Kaplan
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, United States
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Anahita Rabiee
- Section of Digestive Diseases, Yale School of Medicine, New Haven, CT, United States
- VA Connecticut Healthcare System, New Haven, CT, United States
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Richardson C, Daniels K, Confer A, Saxon AJ, Gordon AJ, Liberto J, Albanese AP, Renner J, Edens E, Kennedy AJ. Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements. J Gen Intern Med 2024; 39:1393-1399. [PMID: 38302815 PMCID: PMC11169109 DOI: 10.1007/s11606-024-08639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.
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Affiliation(s)
- Claire Richardson
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Karin Daniels
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea Confer
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew J Saxon
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake City Health Care System, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Substance Use Disorders, Veterans Health Administration, Washington, DC, USA
| | - Anthony P Albanese
- VA Northern California Healthcare System, UC Davis, School of Medicine, Sacramento, CA, USA
| | - John Renner
- VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Edens
- VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, USA
| | - Amy J Kennedy
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA.
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Wiggins M, Painter S, Burant C, Juratovac E, Alto K. Understanding Ohio X-Waivered Advanced Practice Registered Nurses' Rate of Naltrexone Prescription for Alcohol Use Disordered Patients. J Am Psychiatr Nurses Assoc 2024; 30:613-623. [PMID: 36694460 DOI: 10.1177/10783903221151062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Alcohol use disorder (AUD) is overrepresented within the United States. Naltrexone, a recommended treatment for AUD, is underutilized. However, the prescribing behaviors of advanced practice registered nurses (APRNs) regarding naltrexone for AUD patients have not been studied. The purpose of our study was to explore the prescriptive practices of a sample of APRNs. AIMS To describe and analyze survey responses of a sample of Ohio APRNs with training in medication for addiction treatment (MAT) for substance use disorders (as evidenced by DEA x-waiver receipt) regarding prescribing practices of naltrexone for AUD patients. METHOD Public information collected from the first author's Nursing Board (list of APRNs in Ohio) was checked against the public information of x-waivered providers nationally from the Substance Abuse and Mental Health Services Administration's (SAMHSA) website. This generated a potential sample size of 824 APRNs, all of whom were sent email solicitations to complete a Qualtrics survey. After 3 weeks, 55 surveys were completed, and the data were analyzed. Descriptive statistics were generated as well as a logistic regression with five potential predictor variables against the outcome variable (defined as use of naltrexone for AUD patients). RESULTS Years practicing as an APRN was found to negatively predict naltrexone prescribing behavior for AUD patients. Practice setting and work experience with an addiction specialist physician were not found to predict naltrexone prescribing behavior for AUD patients. CONCLUSION Implications for further study were discussed, with emphasis on regulatory variance between states.
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Affiliation(s)
- Morgan Wiggins
- Morgan Wiggins, MSN, APRN, PMHNP-BC, Case Western Reserve University, Cleveland, OH, USA; DNP, APRN, PMHNP-BC, The Ohio State University College of Nursing, Columbus, OH, USA
| | - Susan Painter
- Susan Painter, DNP, APRN, C-CNS, PMHCNS-BC, Case Western Reserve University, Cleveland, OH, USA
| | - Christopher Burant
- Christopher Burant, PhD, MACTM, FGSA, Case Western Reserve University, Cleveland, OH, USA
| | - Evanne Juratovac
- Evanne Juratovac, PhD, APRN, GCNS-BC, Case Western Reserve University, Cleveland, OH, USA
| | - Kathleen Alto
- Kathleen Alto, PhD, MetroHealth Medical Center Cleveland, OH, USA
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Shuey B, Suda KJ, Halbisen A, Wen H, Wharam JF, Rosland AM, Liebschutz JM. Anti-hypertensive Medication Use Among People with and without Substance Use Disorders. J Gen Intern Med 2024; 39:508-510. [PMID: 38010465 PMCID: PMC10897085 DOI: 10.1007/s11606-023-08543-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/16/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Bryant Shuey
- Center for Research On Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Katie J Suda
- Center for Research On Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Alyssa Halbisen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Hefei Wen
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - James Frank Wharam
- Department of Medicine, Duke University, Durham, NC, USA
- Duke-Margolis Center for Health Policy, Duke University, Durham, NC, USA
| | - Ann-Marie Rosland
- Center for Research On Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Jane M Liebschutz
- Center for Research On Health Care, Division of General Internal Medicine, University of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Wellensiek J, Specka M, Just J, Banger M, Bonnet U, Scherbaum N. Patient Perspectives on Pharmacotherapy of Alcohol Dependence. PHARMACOPSYCHIATRY 2024; 57:21-29. [PMID: 38052239 DOI: 10.1055/a-2190-4842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Pharmacotherapy with drugs like naltrexone or acamprosate is a well-evaluated element in the treatment of alcohol dependence (AD). However, in many countries, these medications are rarely administered. The objective of the present study was to identify from patients' perspective factors that prevent the initiation and compliance with pharmacological treatment of AD. METHODS Patients from inpatient alcohol withdrawal treatment underwent a standardized interview. Questions included socio-demographic data, history of AD, treatment history, knowledge and personal experience regarding pharmacotherapy of AD, and personal views about the causes of AD. RESULTS Three hundred patients (mean age 47.3 years, 27.7% female, mean duration of AD 8.9 years, 67% with a history of previous inpatient withdrawal treatment) were included. The majority of patients (58.7%) already knew drugs for the pharmacotherapy of AD. Thirty percent had ever used such medications, most often acamprosate. Except for disulfiram, pharmacotherapy of AD had lasted only a few weeks, on average. Medication usually had been applied without additional psychotherapy. No severe side effects were reported. Patients had often stopped pharmacotherapy on their own, when assuming they had reached stable abstinence. Openness to start pharmacotherapy for AD was currently stated by 67% of the total sample. In multiple logistic regression, openness was predicted by having a concept of AD as a medical disease and by a shorter duration of AD. DISCUSSION To improve the administration of pharmacotherapy for AD implementation strategies should be systematically developed and evaluated with a focus on the concept of AD as a medical disease.
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Affiliation(s)
- Julian Wellensiek
- LVR Hospital Bonn, Department of Addiction Disorders and Psychotherapy, Bonn, Germany
| | - Michael Specka
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
| | - Johannes Just
- Witten/Herdecke University, Faculty of Health, Department of Medicine, Witten, Germany
| | - Markus Banger
- LVR Hospital Bonn, Department of Addiction Disorders and Psychotherapy, Bonn, Germany
| | - Udo Bonnet
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
- Department of Psychiatry, Psychotherapy and Psychosomatic Medicine, Evangelisches Krankenhaus Castrop-Rauxel, Academic Teaching Hospital of the University of Duisburg/Essen, Castrop-Rauxel, Germany
| | - Norbert Scherbaum
- LVR-Hospital Essen, Department of Psychiatry and Psychotherapy, Faculty of Medicine, University of Duisburg-Essen, Essen, Germany
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Socias ME, Scheuermeyer FX, Cui Z, Mok WY, Crabtree A, Fairbairn N, Nolan S, Slaunwhite A, Ti L. Using a cascade of care framework to identify gaps in access to medications for alcohol use disorder in British Columbia, Canada. Addiction 2023; 118:2128-2138. [PMID: 37488683 DOI: 10.1111/add.16273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 05/22/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND AND AIMS Despite the significant burden of alcohol use disorder (AUD) and availability of safe and effective medications for AUD (MAUD), population-level estimates of access and engagement in AUD-related care are limited. The aims of this study were to generate a cascade of care for AUD in British Columbia (BC), Canada, and to estimate the impacts of MAUD on health outcomes. DESIGN This was a retrospective population-based cohort study using linked administrative health data. SETTING British Columbia, Canada, 2015-2019. PARTICIPANTS Using a 20% random sample of BC residents, we identified 7231 people with moderate-to-severe alcohol use disorder (PWAUD; overall prevalence = 0.7%). MEASUREMENTS We developed a six-stage AUD cascade (from diagnosis to ≥6 months retention in MAUD) among PWAUD. We evaluated trends over time and estimated the impacts of access to MAUD on AUD-related hospitalizations, emergency department visits and death. FINDINGS Between 2015 and 2019, linkage to AUD-related care decreased (from 80.4% to 46.5%). However, rates of MAUD initiation (11.4% to 24.1%) and retention for ≥1 (7.0% to 18.2%), ≥3 (1.2% to 4.3%) or ≥6 months (0.2% to 1.6%) increased significantly. In adjusted analyses, access to MAUD was associated with reduced odds of experiencing any AUD-related adverse outcomes, with longer retention in MAUD showing a trend to greater odds reduction: adjusted odds ratio (95% CI) ranging from 0.59 (0.48-0.71) for MAUD retention <1 month to 0.37 (0.21-0.67) for ≥6 months retention. CONCLUSIONS Access to medications for alcohol use disorder among people with moderate-to-severe alcohol use disorder in British Colombia, Canada increased between 2015 and 2019; however, initiation and retention remained low. There was a trend between longer retention in medications for alcohol use disorder and greater reductions in the odds of experiencing alcohol use disorder-related adverse outcomes.
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Affiliation(s)
- Maria Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Frank Xavier Scheuermeyer
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Zizhan Cui
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wing Yin Mok
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Alexis Crabtree
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Seonaid Nolan
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Amanda Slaunwhite
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- BC Centre for Disease Control, Vancouver, British Columbia, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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Gordon AJ, Saxon AJ, Kertesz S, Wyse JJ, Manhapra A, Lin LA, Chen W, Hansen J, Pinnell D, Huynh T, Baylis JD, Cunningham FE, Ghitza UE, Bart G, Yu H, Sauer BC. Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration. Drug Alcohol Depend 2023; 248:109902. [PMID: 37196572 PMCID: PMC10875624 DOI: 10.1016/j.drugalcdep.2023.109902] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system. METHODS We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves). RESULTS We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5). CONCLUSIONS Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.
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Affiliation(s)
- Adam J Gordon
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, USA
| | - Stefan Kertesz
- Birmingham Veterans Affairs Health Care System, Birmingham, AL, USA; Department of Medicine, Heersink UAB School of Medicine, Birmingham, AL, USA
| | - Jessica J Wyse
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health CareSystem, Portland, OR, USA; School of Public Health, Oregon Health & Science University-Portland State University,PortlandOR, USA
| | - Ajay Manhapra
- Section of Pain Medicine, Department of Physical Medicine & Rehabilitation Services, Hampton VA Medical Center, Hampton, VA, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Wei Chen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jared Hansen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Derek Pinnell
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Tina Huynh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | - Udi E Ghitza
- Center for the Clinical Trials Network (CCTN), National Institute on Drug Abuse (NIDA), Bethesda, MD, USA
| | - Gavin Bart
- Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Hong Yu
- Center for Biomedical and Health Research in Data Sciences and Miner School of Computer & Information Sciences, University of Massachusetts Lowell, Lowell, MA, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Brian C Sauer
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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El-Akkad SED, Nolan S, Hayashi K, Dong H, MJ-Milloy, Debeck K, Ti L. Factors associated with patient perceived suboptimal dosing of in-hospital opioid agonist therapy among people who use illicit drugs in Vancouver, Canada. J Addict Dis 2023; 41:204-212. [PMID: 35727118 PMCID: PMC9768102 DOI: 10.1080/10550887.2022.2088014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Optimal dosing of opioid agonist therapy (OAT) is essential for treatment success. However, initiation and maintenance of OAT in hospital settings can be challenging given differing levels of opioid tolerance, withdrawal, and intoxication among patients. The objective of this study was to characterize the prevalence and factors associated with in-hospital patient perceived suboptimal OAT dosing among people who use illicit drugs (PWUD) in Vancouver, Canada. Data were derived from three prospective cohorts of PWUD in Vancouver, Canada. Bivariable and multivariable logistic regression models were used to examine factors associated with patient perceived suboptimal in-hospital OAT dose. 273 study participants were prescribed OAT while in hospital: 83 (30.4%) participants perceived their OAT dose to be suboptimal. In a multivariable model, factors positively associated with a perceived suboptimal OAT dose included: homelessness (adjusted odds ratio [AOR] = 2.85; 95% CI: 1.53-5.28), daily stimulant use (AOR = 2.03; 95% CI: 1.14-3.63) and illicit drug use while in hospital (AOR = 2.33; 95% CI: 1.31-4.16). Almost one third of participants perceived receiving a suboptimal OAT dose while in hospital. These observed correlations indicate that a patient's perception of suboptimal OAT dosing in hospital may be more prevalent for patients who are homeless, report polysubstance use with stimulants and opioids and who obtain illicit drugs while hospitalized. While cautious prescribing of OAT in patients experiencing hospitalization is important, these findings demonstrate a high prevalence of and apparent risk factors for perceived suboptimal OAT dosing.
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Affiliation(s)
- Saif-El-Din El-Akkad
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
| | - Kanna Hayashi
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada, V5A 1S6
| | - Huiru Dong
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
| | - MJ-Milloy
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
| | - Kora Debeck
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- School of Public Policy, Simon Fraser University, 8888 University Drive, Burnaby, BC, Canada, V5A 1S6
| | - Lianping Ti
- Department of Medicine, University of British Columbia, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC, Canada, V6Z 1Y6
- British Columbia Centre on Substance Use (BCCSU), 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
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Andraka-Christou B, Simon KI, Bradford WD, Nguyen T. Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017-21. Health Aff (Millwood) 2023; 42:658-664. [PMID: 37126752 PMCID: PMC10275692 DOI: 10.1377/hlthaff.2022.01513] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Buprenorphine is a treatment medication that decreases mortality risks among people with opioid use disorder (OUD). Despite its efficacy, buprenorphine is underused in the US. Insurance restrictions are commonly cited as barriers to buprenorphine prescribing. Using Medicaid, Medicare Advantage, and commercial insurance formulary files, we examined insurance-imposed utilization restrictions for buprenorphine for OUD for each year from 2017 to 2021 by insurance type. Almost all plans covered immediate-release buprenorphine in 2021, with a general trend of decreasing prior authorization requirements and quantity limits since 2017. In contrast, two payers had relatively low coverage of extended-release buprenorphine, with only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans covering this formulation. Even though most Medicaid plans covered extended-release buprenorphine in 2021, 37 percent required prior authorization. Policy makers and researchers concerned with buprenorphine insurance barriers should shift their attention to extended-release buprenorphine. State lawmakers could help address these barriers by mandating that insurers include extended-release buprenorphine on their preferred drug lists.
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Affiliation(s)
| | - Kosali I Simon
- Kosali I. Simon, Indiana University, Bloomington, Indiana
| | | | - Thuy Nguyen
- Thuy Nguyen, University of Michigan, Ann Arbor, Michigan
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Rabiee A, Mahmud N, Falker C, Garcia-Tsao G, Taddei T, Kaplan DE. Medications for alcohol use disorder improve survival in patients with hazardous drinking and alcohol-associated cirrhosis. Hepatol Commun 2023; 7:e0093. [PMID: 36972386 PMCID: PMC10043587 DOI: 10.1097/hc9.0000000000000093] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/13/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Medications for alcohol use disorder (MAUD) are highly effective in achieving and maintaining abstinence in patients with alcohol use disorder (AUD). Our aim was to evaluate the effect of MAUD on all-cause mortality in patients with alcohol-associated cirrhosis and active alcohol use. METHODS This was a retrospective cohort study of patients with alcohol-associated cirrhosis and high-risk alcohol use disorder in the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) database. Propensity score matching for exposure to MAUD (acamprosate or naltrexone) within a year after cirrhosis diagnosis was performed to account for potential confounders, and the association between MAUD and all-cause mortality was subsequently evaluated using Cox regression analysis. RESULTS A total of 9131 patients were included, of whom 886 (9.7%) were exposed to MAUD (naltrexone: 520, acamprosate: 307, both medications: 59). The duration of MAUD exposure was >3 months in 345 patients (39%). The strongest positive predictor of MAUD prescription was an inpatient diagnosis code for AUD, followed by a concurrent diagnosis of depression; the strongest negative predictor was a history of cirrhosis decompensation. After propensity score matching (866 patients in each group) with excellent covariate balance (absolute standardized mean differences <0.1), MAUD exposure was associated with improved survival, with an HR of 0.80 relative to no MAUD exposure (95% CI: 0.67-0.97, p = 0.024). CONCLUSION MAUD are underutilized in patients with alcohol-associated cirrhosis with high-risk alcohol use behavior but are associated with improved survival after adjustment for confounders such as the severity of liver disease, age, and engagement in the healthcare system.
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Affiliation(s)
- Anahita Rabiee
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
| | - Caroline Falker
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
- Department of Internal Medicine & Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Guadalupe Garcia-Tsao
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
| | - Tamar Taddei
- Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA
- VA Connecticut Healthcare System, New Haven, Connecticut, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
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11
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Tarn DM, Shih KJ, Ober AJ, Hunter SB, Watkins KE, Martinez J, Montero A, McCreary M, Leamon I, Sheehe J, Bromley E. Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness. Community Ment Health J 2023; 59:345-356. [PMID: 35906435 PMCID: PMC9859922 DOI: 10.1007/s10597-022-01012-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 07/15/2022] [Indexed: 01/25/2023]
Abstract
Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.
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Affiliation(s)
- Derjung M Tarn
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, USA. .,Department of Family Medicine, David Geffen School of Medicine at UCLA, 10880 Wilshire Blvd., Suite 1800, Los Angeles, CA, 90024, USA.
| | - Kevin J Shih
- Department of Family Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | | | | | | | - Alanna Montero
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | - Michael McCreary
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - John Sheehe
- LA County Department of Mental Health, Los Angeles, USA
| | - Elizabeth Bromley
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, Los Angeles, CA, USA
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12
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Miller WA, Gordon AJ, Clothier BA, Ackland PE, Bounthavong M, Garcia C, Kenny ME, Noorbaloochi S, Hagedorn HJ. Co-occurring implementation strategies: The effects of academic detailing for opioid use disorder campaign on the advancing pharmacological treatments for opioid use disorder (ADaPT-OUD) study. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231199463. [PMID: 37790176 PMCID: PMC10504828 DOI: 10.1177/26334895231199463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD. Methods This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach. Results There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites. Conclusion Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted.
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Affiliation(s)
- Wendy A. Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Barbara A. Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mark Bounthavong
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA, USA
| | - Carla Garcia
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
| | - Marie E. Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Centers of Excellence in Substance Addiction Treatment and Education, Puget Sound VAHCS, Seattle, WA & Philadelphia VAHCS, Philadelphia, PA, USA
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13
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MacKillop J, Agabio R, Feldstein Ewing SW, Heilig M, Kelly JF, Leggio L, Lingford-Hughes A, Palmer AA, Parry CD, Ray L, Rehm J. Hazardous drinking and alcohol use disorders. Nat Rev Dis Primers 2022; 8:80. [PMID: 36550121 PMCID: PMC10284465 DOI: 10.1038/s41572-022-00406-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2022] [Indexed: 12/24/2022]
Abstract
Alcohol is one of the most widely consumed psychoactive drugs globally. Hazardous drinking, defined by quantity and frequency of consumption, is associated with acute and chronic morbidity. Alcohol use disorders (AUDs) are psychiatric syndromes characterized by impaired control over drinking and other symptoms. Contemporary aetiological perspectives on AUDs apply a biopsychosocial framework that emphasizes the interplay of genetics, neurobiology, psychology, and an individual's social and societal context. There is strong evidence that AUDs are genetically influenced, but with a complex polygenic architecture. Likewise, there is robust evidence for environmental influences, such as adverse childhood exposures and maladaptive developmental trajectories. Well-established biological and psychological determinants of AUDs include neuroadaptive changes following persistent use, differences in brain structure and function, and motivational determinants including overvaluation of alcohol reinforcement, acute effects of environmental triggers and stress, elevations in multiple facets of impulsivity, and lack of alternative reinforcers. Social factors include bidirectional roles of social networks and sociocultural influences, such as public health control strategies and social determinants of health. An array of evidence-based approaches for reducing alcohol harms are available, including screening, pharmacotherapies, psychological interventions and policy strategies, but are substantially underused. Priorities for the field include translating advances in basic biobehavioural research into novel clinical applications and, in turn, promoting widespread implementation of evidence-based clinical approaches in practice and health-care systems.
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Affiliation(s)
- James MacKillop
- Peter Boris Centre for Addictions Research, McMaster University & St. Joseph's Healthcare Hamilton, Hamilton, ON, Canada.
- Homewood Research Institute, Guelph, ON, Canada.
| | - Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Cagliari, Italy
- Neuroscience Institute, Section of Cagliari, National Research Council, Cagliari, Italy
| | - Sarah W Feldstein Ewing
- Department of Psychology, University of Rhode Island, Kingston, RI, USA
- Department of Psychology and Behavioural Sciences, Centre for Alcohol and Drug Research, Aarhus University, Aarhus, Denmark
| | - Markus Heilig
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - John F Kelly
- Recovery Research Institute and Department of Psychiatry, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA
| | - Lorenzo Leggio
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, National Institute on Alcohol Abuse and Alcoholism, National Institutes of Health, Bethesda, MD, USA
- Clinical Psychoneuroendocrinology and Neuropsychopharmacology Section, Translational Addiction Medicine Branch, National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, USA
| | - Anne Lingford-Hughes
- Division of Psychiatry, Imperial College London, London, UK
- Central North West London NHS Foundation Trust, London, UK
| | - Abraham A Palmer
- Department of Psychiatry & Institute for Genomic Medicine, University of California San Diego, La Jolla, CA, USA
| | - Charles D Parry
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| | - Lara Ray
- Departments of Psychology and Psychiatry, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jürgen Rehm
- Institute for Mental Health Policy Research, Campbell Family Mental Health Research Institute, PAHO/WHO Collaborating Centre, Centre for Addiction and Mental Health, Toronto, Canada
- Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation; & Department of Psychiatry, University of Toronto (UofT), Toronto, Canada
- WHO European Region Collaborating Centre at Public Health Institute of Catalonia, Barcelona, Spain
- Technische Universität Dresden, Klinische Psychologie & Psychotherapie, Dresden, Germany
- Department of International Health Projects, Institute for Leadership and Health Management, I.M. Sechenov First Moscow State Medical University, Moscow, Russian Federation
- Zentrum für Interdisziplinäre Suchtforschung der Universität Hamburg (ZIS), Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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14
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Carter J, Li Z, Chen H, Greiner M, Bush C, Bhattacharya D, Poley S, Sachdeva N, Crowder JC, Feigal J. Low barrier medication for opioid use disorder at a federally qualified health center: a retrospective cohort study. Addict Sci Clin Pract 2022; 17:60. [PMID: 36335381 PMCID: PMC9636799 DOI: 10.1186/s13722-022-00342-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 10/19/2022] [Indexed: 11/07/2022] Open
Abstract
Background Medication for opioid use disorder (MOUD) reduces mortality, but few patients access MOUD. At a Federally Qualified Health Center (FQHC), we implemented a low barrier model of MOUD, including same-day MOUD initiation and a harm reduction philosophy. Objective To investigate whether low barrier MOUD improved retention in care compared to traditional treatment. Design and participants Retrospective cohort study of patients with at least one visit seeking MOUD at the FQHC during a historical control period (3/1/2018—3/31/2019) and a low barrier intervention period (11/1/2019—7/31/2020). Main measures Primary outcomes were any MOUD prescription within 6 months of the index visit and 3- and 6-month retention in treatment without care gap, with care gap defined as 60 consecutive days without a visit or prescription. Secondary outcomes were all-cause hospitalization and emergency department visit within 6 months of the index visit. Key results Baseline characteristics were similar between the intervention (n = 113) and control (n = 90) groups, except the intervention group had higher rates of uninsured, public insurance and diabetes. Any MOUD prescription within 6 months of index visit was higher in the intervention group (97.3% vs 70%), with higher adjusted odds of MOUD prescription (OR = 4.01, 95% CI 2.08–7.71). Retention in care was similar between groups at 3 months (61.9% vs 60%, aOR = 1.06, 95% CI 0.78–1.44). At 6 months, a higher proportion of the intervention group was retained in care, but the difference was not statistically significant (53.1% vs 45.6%, aOR 1.27, 95% CI 0.93–1.73). There was no significant difference in adjusted odds of 6-month hospitalization or ED visit between groups. Conclusions Low barrier MOUD engaged a higher risk population and did not result in any statistically significant difference in retention in care compared with a historical control. Future research should determine what interventions improve retention of patients engaged through low barrier care. Primary care clinics can implement low barrier treatment to make MOUD accessible to a broader population. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00342-1.
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Affiliation(s)
- Jamie Carter
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC 27707, North Carolina, US. .,Department of Population Health Sciences, Duke University School of Medicine, Durham, US.
| | - Zhen Li
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Hillary Chen
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Melissa Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Christopher Bush
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Debanjan Bhattacharya
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Stephanie Poley
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Nidhi Sachdeva
- Department of Population Health Sciences, Duke University School of Medicine, Durham, US
| | - Jane Carolyn Crowder
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC 27707, North Carolina, US
| | - Jacob Feigal
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC 27707, North Carolina, US.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, US.,Department of Medicine, Duke University School of Medicine, Durham, US
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15
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Hagedorn HJ, Gustavson AM, Ackland PE, Bangerter A, Bounthavong M, Clothier B, Harris AHS, Kenny ME, Noorbaloochi S, Salameh HA, Gordon AJ. Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD): an Implementation Trial in Eight Veterans Health Administration Facilities. J Gen Intern Med 2022; 37:3594-3602. [PMID: 34981352 PMCID: PMC8722660 DOI: 10.1007/s11606-021-07274-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Identifying effective strategies to improve access to medication treatments for opioid use disorder (MOUD) is imperative. Within the Veterans Health Administration (VHA), provision of MOUD varies significantly, requiring development and testing of implementation strategies that target facilities with low provision of MOUD. OBJECTIVE Determine the effectiveness of external facilitation in increasing the provision of MOUD among VHA facilities with low baseline provision of MOUD compared to matched controls. DESIGN Pre-post, block randomized study designed to compare facility-level outcomes in a stratified sample of eligible facilities. Four blocks (two intervention facilities in each) were defined by median splits of both the ratio of patients with OUD receiving MOUD and number of patients with OUD not currently receiving MOUD (i.e., number of actionable patients). Intervention facilities participated in a 12-month implementation intervention. PARTICIPANTS VHA facilities in the lowest quartile of MOUD provision (35 facilities), eight of which were randomly assigned to participate in the intervention (two per block) with twenty-seven serving as matched controls by block. INTERVENTION External facilitation included assessment of local barriers/facilitators, formation of a local implementation team, a site visit for action planning and training/education, cross-facility quarterly calls, monthly coaching calls, and consultation. MAIN MEASURES Pre- to post-change in the facility-level ratio of patients with an OUD diagnosis receiving MOUD compared to control facilities. KEY RESULTS Intervention facilities significantly increased the ratio of patients with OUD receiving MOUD from an average of 18% at baseline to 30% 1 year later, with an absolute difference of 12% (95% confidence interval [CI]: 6.6%, 17.0%). The difference in differences between intervention and control facilities was 3.0% (95% CI: - 0.2%. 6.7%). The impact of the intervention varied by block, with smaller, less complex facilities more likely to outperform matched controls. CONCLUSIONS Intensive external facilitation improved the adoption of MOUD in most low-performing facilities and may enhance adoption beyond other interventions less tailored to individual facility contexts.
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Affiliation(s)
- Hildi J. Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Allison M. Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Princess E. Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Ann Bangerter
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Mark Bounthavong
- Health Economics Resource Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94025 USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA 92093 USA
| | - Barbara Clothier
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Alex H. S. Harris
- Center for Innovation To Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA 94025 USA
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA 94305 USA
| | - Marie E. Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN 55455 USA
| | - Hope A. Salameh
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mil Code #152, Minneapolis, MN 55417 USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS, Salt Lake City Veterans Affairs Health Care System, 500 Foothill Drive, Salt Lake City, UT 84148 USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84148 USA
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16
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Krendl AC, Perry BL. Addiction onset and offset characteristics and public stigma toward people with common substance dependencies: A large national survey experiment. Drug Alcohol Depend 2022; 237:109503. [PMID: 35644088 DOI: 10.1016/j.drugalcdep.2022.109503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 11/03/2022]
Abstract
Drug-related overdose deaths topped 100,000 between 2020 and 2021. Opioids and stimulants are implicated as the primary drivers of this public health crisis. Stigma remains one of the primary barriers to treatment and recovery from substance use disorders. However, little is known about how stigma varies across different substance types, whether individuals are actively using or in recovery, and medical versus recreational onset. We examined these questions using data from the 2021 Shatterproof Addiction Stigma Index, the only nationally representative data available on this topic. Respondents (N = 7051) completed a vignette-based survey experiment to assess public stigma (social distance, prejudice, competence, and causal attributions) toward people with alcohol, opioid (following a prescription pain or recreational use onset), heroin, or methamphetamine dependencies. Vignette characters were described as active users or in recovery. Adjusting for covariates (e.g., race, age, gender), prejudice and desire for social distance were highest toward heroin and methamphetamine, and lowest toward alcohol dependence. The perceived onset of the dependency affected stigma. Specifically, prescription opioids with a recreational onset were more stigmatized than those with a medical onset. Moreover, individuals depicted as being in recovery were less stigmatized than those depicted as active users. Recovery status had the largest impact on prejudice and social distance toward methamphetamine, relative to other conditions. The nature and magnitude of substance dependency stigma differs across substance types and onset and offset conditions. Reducing stigma will require tailored strategies that consider the multidimensional nature of stigma toward people with addiction.
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Affiliation(s)
- Anne C Krendl
- Department of Psychological and Brain Sciences, Indiana University, Bloomington, IN, USA.
| | - Brea L Perry
- Department of Sociology, Indiana University, Bloomington, IN, USA
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17
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Wyse JJ, Mackey K, Lovejoy TI, Kansagara D, Tuepker A, Gordon AJ, Todd Korthuis P, Herreid-O'Neill A, Williams B, Morasco BJ. Expanding access to medications for opioid use disorder through locally-initiated implementation. Addict Sci Clin Pract 2022; 17:32. [PMID: 35725648 PMCID: PMC9207874 DOI: 10.1186/s13722-022-00312-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/04/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted. METHODS Guided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies. RESULTS Interviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes-including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators' perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving. CONCLUSIONS This study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.
- School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA.
| | - Katherine Mackey
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
- School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA
- Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anders Herreid-O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Beth Williams
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
- Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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18
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Abraham AJ, Lawler EC, Harris SJ, Bagwell Adams G, Bradford WD. Spillover of Medicaid Expansion to Prescribing of Opioid Use Disorder Medications in Medicare Part D. Psychiatr Serv 2022; 73:418-424. [PMID: 34407628 DOI: 10.1176/appi.ps.202000824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The authors examined whether there were positive spillovers in opioid use disorder medication prescribing to Medicare Part D beneficiaries in Medicaid expansion states. Although prior studies have shown several positive benefits of Medicaid expansion for Americans with opioid use disorder, research has not examined potential spillovers to Medicare beneficiaries who have been hit hard by the opioid crisis. METHODS Prescribing data were taken from the Medicare Part D Prescription Public Use File (2010-2017). A difference-in-differences linear regression framework was used to identify spillovers in prescribing of buprenorphine and injectable naltrexone to Medicare Part D beneficiaries in Medicaid expansion states. Three sets of dependent variables measured medication prescribing at the county-year level (N=24,850). All models included county and year fixed effects, with standard errors clustered at the state level to address within-state serial correlation. RESULTS Medicaid expansion was associated with an increase in the probability of a county having an injectable naltrexone provider (p<0.01). After expansion, the number of buprenorphine providers in expansion states increased by 5.6% (p<0.05), and the number of injectable naltrexone providers increased by 3.3% (p<0.01), relative to nonexpansion states. Expansion was associated with a 23.1% (p<0.01) increase in the number of daily doses of injectable naltrexone, relative to nonexpansion states. CONCLUSIONS Medicaid expansion states may be better equipped to address the opioid crisis because of direct benefits to Medicaid beneficiaries and availability of opioid use disorder medications for Medicare Part D beneficiaries. However, additional efforts are likely needed to close the opioid use disorder treatment gap for Medicare beneficiaries.
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Affiliation(s)
- Amanda J Abraham
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Emily C Lawler
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Samantha J Harris
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - Grace Bagwell Adams
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
| | - W David Bradford
- School of Public and International Affairs (Abraham, Lawler, Bradford) and College of Public Health (Bagwell Adams), University of Georgia, Athens; Bloomberg School of Public Health, Johns Hopkins University, Baltimore (Harris)
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19
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Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative. J Addict Nurs 2022; 33:70-79. [PMID: 35640210 DOI: 10.1097/jan.0000000000000455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings. METHODS From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes. RESULTS Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care. CONCLUSIONS In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.
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20
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Gordon AJ, Kenny M, Dungan M, Gustavson AM, Taylor Kelley A, Jones AL, Hawkins E, Frank JW, Danner A, Liberto J, Hagedorn H. Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings. Am J Addict 2022; 31:152-158. [PMID: 35118756 DOI: 10.1111/ajad.13260] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/04/2022] [Accepted: 01/09/2022] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing. METHODS In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing. RESULTS Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support. CONCLUSIONS Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.
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Affiliation(s)
- Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Marie Kenny
- Center for Care Delivery & Outcomes Research Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Matthew Dungan
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Allison M Gustavson
- Center for Care Delivery & Outcomes Research Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - A Taylor Kelley
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Division of General Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eric Hawkins
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington, USA.,Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Joseph W Frank
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anissa Danner
- Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington, USA.,Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph Liberto
- Veterans Health Administration's Office of Mental Health and Suicide Prevention, Substance Use Disorders, Washington, District of Columbia, USA
| | - Hildi Hagedorn
- Center for Care Delivery & Outcomes Research Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
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21
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Sang J, Patton RA, Park I. Comparing Perceptions of Addiction Treatment between Professionals and Individuals in Recovery. Subst Use Misuse 2022; 57:983-994. [PMID: 35373710 DOI: 10.1080/10826084.2022.2058706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: The purpose of this qualitative study was to compare and contrast the differing perspectives of service users and professionals regarding the current substance use disorders (SUD) services provided in Summit County, Ohio. Seven focus groups were conducted with 44 participants (52.3% male, mean age 46 years), including 15 individuals in recovery, 16 direct service providers, and 13 executive directors. The participants were asked about three areas: (1) effective treatment for SUD, (2) challenges for persons with SUD, and (3) suggestions for improving SUD treatment outcomes. The data were analyzed and coded according to major themes. Results: While there were numerous emergent themes that were concordant between service use and professionals, several differing themes between the groups were also identified. First, participants disagreed on the effectiveness of medication-assisted treatment/Medications for Opioid Use Disorder. Second, professionals identified trauma, stigma, "one-size-fits-all" approach to treatment, and limitations set by managed care act as barriers to treatment, whereas individuals in recovery reported difficulty dealing with feelings, feeling of being rushed into recovery, and the lack of long-term recovery plans as the most significant barriers. Lastly, in order to improve treatment outcomes, professionals emphasized the importance of education unlike individuals in recovery who identified sober supports as the most important factor. Conclusion: This study identified challenges in SUD recovery and highlights essential areas for consideration when developing and implementing SUD treatment. The findings can be used as guidelines to provide better services to individuals with SUDs.Supplemental data for this article is available online at https://doi.org/10.1080/10826084.2022.2058706 .
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Affiliation(s)
- Jina Sang
- School of Social Work and Family Sciences, The University of Akron, Akron, OH, USA
| | - Rikki A Patton
- School of Social Work and Family Sciences, The University of Akron, Akron, OH, USA
| | - Insun Park
- Department of Criminal Justice, The University of Akron, Akron, OH, USA
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22
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Kennedy AJ, McGinnis KA, Merlin JS, Edelman EJ, Gordon AJ, Korthuis PT, Skanderson M, Williams EC, Wyse J, Oldfield B, Bryant K, Justice A, Fiellin DA, Kraemer KL. Impact of intensity of behavioral treatment, with or without medication treatment, for opioid use disorder on HIV outcomes in persons with HIV. J Subst Abuse Treat 2022; 132:108509. [PMID: 34130128 PMCID: PMC8628025 DOI: 10.1016/j.jsat.2021.108509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/18/2021] [Accepted: 05/19/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Persons with HIV (PWH) and opioid use disorder (OUD) can have poor health outcomes. We assessed whether intensity of behavioral treatment for OUD (BOUD) with and without medication for OUD (MOUD) is associated with improved HIV clinical outcomes. METHODS We used Veterans Aging Cohort Study (VACS) data from 2008 to 2017 to identify PWH and OUD with ≥1 BOUD episode. We assessed BOUD intensity and ≥6 months of MOUD (methadone or buprenorphine) receipt during the 12 months after BOUD initiation. Linear regression models assessed the association of BOUD intensity and MOUD receipt with pre-post changes in log viral load (VL), CD4 cell count, VACS Index 2.0, antiretroviral treatment (ART) initiation, and ART adherence. RESULTS Among 2419 PWH who initiated BOUD, we identified five distinct BOUD intensity trajectories: single visit (39% of sample); low-intensity, not sustained (37%); high-intensity, not sustained (9%); low-intensity, sustained (11%); and high-intensity, sustained (5%). MOUD receipt was low (17%). Among 709 PWH not on ART at the start of BOUD, ART initiation increased with increased BOUD intensity (p < 0.01). Among 1401 PWH on ART at the start of BOUD, ART adherence improved more in higher-intensity BOUD groups (p < 0.01). VL, CD4 count and VACS Index 2.0 did not differ by BOUD or ≥6 months of MOUD treatment. CONCLUSION Among PWH and OUD who initiated BOUD, higher intensity BOUD was associated with improved ART initiation and adherence, but neither BOUD alone nor BOUD plus ≥6 months MOUD was associated with improvements in VL, CD4 count or VACS Index 2.0.
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Affiliation(s)
- Amy J Kennedy
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Jessica S Merlin
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - P Todd Korthuis
- Division of General Internal Medicine, Section of Addiction Medicine, Oregon Health and Sciences University, Portland, OR, USA
| | | | - Emily C Williams
- Department of Health Services, University of Washington, VA Puget Sound Healthcare System, Seattle, WA, USA; Seattle-Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research & Development VA Puget Sound Healthcare System, Seattle, WA, USA
| | - Jessica Wyse
- VA Portland Healthcare System, Portland, OR, USA; School of Public Health, Oregon Health and Sciences University, Portland, OR, USA
| | - Benjamin Oldfield
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Amy Justice
- VA Connecticut Healthcare System, West Haven, CT, USA; Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Kevin L Kraemer
- Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA; VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
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23
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Filteau MR, Green B, Jones K. Barriers to Community Treatment for Opioid Use Disorders among Rural Veterans. JOURNAL OF VETERANS STUDIES 2021. [DOI: 10.21061/jvs.v7i3.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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24
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Tran AD, Chen R, Nielsen S, Zahra E, Degenhardt L, Santo T, Farrell M, Larance B. Economic analysis of out-of-pocket costs among people in opioid agonist treatment: A cross-sectional survey in three Australian jurisdictions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 99:103472. [PMID: 34649203 DOI: 10.1016/j.drugpo.2021.103472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/05/2021] [Accepted: 09/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Out-of-pocket costs for opioid agonist treatment (OAT) constitute a barrier to treatment entry and retention.This study examines OAT clients' total out-of-pocket costs (including dispensing fees, travel costs and OAT-related appointment costs) in different treatment settings (public clinics, community pharmacies, and private clinics). METHODS Cross-sectional survey of 402 people with opioid drug use (OUD) in New South Wales (NSW), Victoria (VIC), Tasmania (TAS), Australia; 266 clients (66%) currently receiving methadone, buprenorphine or buprenorphine-naloxone treatment were asked about dispensing fees, travel costs and OAT-related appointment costs in the past 28 days. A two-part regression model was used to deal with non-normal distributions of costing data (right skew and excess zeros). RESULTS Among clients currently receiving OAT, 87% paid out-of-pocket costs. Among those who paid out-of-pocket costs (N=194), travel costs accounted for more than half of total costs (52%), followed by dispensing fees (44%). The mean monthly total out-of-pocket costs were AU$135 (SD: AU$121) for public clinics, AU$161 (SD: AU$110) to AU$214 (SD: AU$166) for community pharmacies and AU$355 (SD: AU$159) for private clinics. Compared to participants in NSW private clinics, those at public clinics paid one third the total out-of-pocket costs (coefficient = 0.33; 95%CI = 0.23-0.48) and those at NSW, TAS, VIC pharmacies paid approximately half the costs (coefficient = 0.58; 95%CI = 0.42-0.79; coefficient = 0.51; 95%CI = 0.36-0.72; coefficient = 0.47; 95%CI = 0.34-0.66, respectively). People in OAT for more than a year paid half the total out-of-pocket costs, compared with those in OAT less than a year (coefficient = 0.49, 95%CI = 0.31-0.77). CONCLUSIONS Participants in the current study spent one-eighth of their income on out-of-pocket costs associated with OAT representing a substantial financial burden. Total out-of-pocket costs disproportionately affects those who are newer in treatment and receiving fewer unsupervised doses. Considering and addressing total out-of-pocket costs, especially travel costs and dispensing fees, to clients is critical to prevent cost from being a barrier from receiving effective care.
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Affiliation(s)
- Anh Dam Tran
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.
| | - Rory Chen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - Emma Zahra
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Thomas Santo
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Briony Larance
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia; School of Psychology, University of Wollongong, Wollongong, Australia; Illawarra Health and Medical Research Institute University of Wollongong, Wollongong, Australia
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25
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Gordon AJ, Drexler K, Hawkins EJ, Burden J, Codell NK, Mhatre-Owens A, Dungan MT, Hagedorn H. Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities. Subst Abus 2021; 41:275-282. [PMID: 32697170 DOI: 10.1080/08897077.2020.1787299] [Citation(s) in RCA: 83] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.
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Affiliation(s)
- Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA.,Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Karen Drexler
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Eric J Hawkins
- Veterans Affairs (VA) Puget Sound Health Care System, Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, Washington, USA.,VA Puget Sound Health Care System, Center of Excellence in Substance Addiction Treatment and Education, Seattle, Washington, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
| | - Jennifer Burden
- Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Nodira K Codell
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Amy Mhatre-Owens
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Matthew T Dungan
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Hildi Hagedorn
- Center for Care Delivery and Outcomes Research Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.,Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
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Abstract
BACKGROUND Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals' attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.
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Affiliation(s)
- Aaron R Brown
- Department of Social Work, College of Health & Human Sciences, Western Carolina University, Cullowhee, North Carolina, USA
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27
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Hawkins EJ, Danner AN, Malte CA, Blanchard BE, Williams EC, Hagedorn HJ, Gordon AJ, Drexler K, Burden JL, Knoeppel J, Lott A, Sayre GG, Midboe AM, Saxon AJ. Clinical leaders and providers' perspectives on delivering medications for the treatment of opioid use disorder in Veteran Affairs' facilities. Addict Sci Clin Pract 2021; 16:55. [PMID: 34488892 PMCID: PMC8419813 DOI: 10.1186/s13722-021-00263-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving access to medication treatment of opioid use disorder (MOUD) is a national priority, yet common modifiable barriers (e.g., limited provider knowledge, negative beliefs about MOUD) often challenge implementation of MOUD delivery. To address these barriers, the VA launched a multifaceted implementation intervention focused on planning and educational strategies to increase MOUD delivery in 18 medical facilities. The purpose of this investigation was to determine if a multifaceted intervention approach to increase MOUD delivery changed providers' perceptions about MOUD over the first year of implementation. METHODS Cross-disciplinary teams of clinic providers and leadership from primary care, pain, and mental health clinics at 18 VA medical facilities received invitations to complete an anonymous, electronic survey prior to intervention launch (baseline) and at 12- month follow-up. Responses were summarized using descriptive statistics, and changes over time were compared using regression models adjusted for gender and prescriber status, and clustered on facility. Responses to open-ended questions were thematically analyzed using a template analysis approach. RESULTS Survey response rates at baseline and follow-up were 57.1% (56/98) and 50.4% (61/121), respectively. At both time points, most respondents agreed that MOUD delivery is important (94.7 vs. 86.9%), lifesaving (92.8 vs. 88.5%) and evidence-based (85.2 vs. 89.5%). Over one-third (37.5%) viewed MOUD delivery as time-consuming, and only 53.7% affirmed that clinic providers wanted to prescribe MOUD at baseline; similar responses were seen at follow-up (34.5 and 52.4%, respectively). Respondents rated their knowledge about OUD, comfort discussing opioid use with patients, job satisfaction, ability to help patients with OUD, and support from colleagues favorably at both time points. Respondents' ratings of MOUD delivery filling a gap in care were high but declined significantly from baseline to follow-up (85.7 vs. 73.7%, p < 0.04). Open-ended responses identified implementation barriers including lack of support to diagnose and treat OUD and lack of time. CONCLUSIONS Although perceptions about MOUD generally were positive, targeted education and planning strategies did not improve providers' and clinical leaders' perceptions of MOUD over time. Strategies that improve leaders' prioritization and support of MOUD and address time constraints related to delivering MOUD may increase access to MOUD in non-substance use treatment clinics.
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Affiliation(s)
- Eric J Hawkins
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA.
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA, 98108, USA.
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA.
| | - Anissa N Danner
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Carol A Malte
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - Brittany E Blanchard
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Hildi J Hagedorn
- HSR&D Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota, Minneapolis, MN, USA
| | - Adam J Gordon
- HSR&D Center of Innovation: Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Karen Drexler
- School of Medicine, Emory University, Atlanta, GA, USA
| | - Jennifer L Burden
- VA Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Jennifer Knoeppel
- VA Office of Mental Health and Suicide Prevention, Veterans Health Administration, Washington, DC, USA
| | - Aline Lott
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA, 98108, USA
| | - George G Sayre
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Department of Health Services, University of Washington, Seattle, WA, USA
| | - Amanda M Midboe
- Center for Innovation To Implementation, VA Palo Alto Health Care System, Menlo Park, CA, USA
| | - Andrew J Saxon
- Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System Seattle Division (S116ATC), 1660 S. Columbian Way, Seattle, WA, 98108, USA
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
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Trends in the Use of Naltrexone for Addiction Treatment among Alcohol Use Disorder Admissions in U.S. Substance Use Treatment Facilities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18168884. [PMID: 34444639 PMCID: PMC8394149 DOI: 10.3390/ijerph18168884] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/19/2021] [Accepted: 08/20/2021] [Indexed: 01/12/2023]
Abstract
Background: Naltrexone, a medication for addiction treatment (MAT), is an FDA-approved medication recommended for the treatment of alcohol use disorder (AUD). Despite the high prevalence of AUD and efficacy of naltrexone, only a small percentage of individuals with AUD receive treatment. Objectives: To identify trends for the prescription of naltrexone in AUD admissions in substance use treatment centers across the U.S. Methods: Data from the 2000–2018 U.S. Treatment Episode Data Set: Admissions (TEDS-A) were used in temporal trend analysis of naltrexone prescription in admissions that only used alcohol. Data from the 2019 National Survey of Substance Abuse Treatment Services (N-SSATS) were also used to characterize medication use among AUD clients across different treatment service settings. Results: Treatment of AUD with naltrexone was 0.49% in 2000 and tripled from 0.53% in 2015 to 1.64% in 2018 in AUD admissions (p < 0.0001 for the Cochran–Armitage trend test). Women, middle-aged adults, and admissions for clients living in the Northeast U.S. were more likely to be prescribed naltrexone than their respective counterparts, as were admissions with prior treatment episodes and referrals through alcohol/drug use care providers, who paid for treatment primarily through private insurance, used alcohol daily in the month prior to admission, and waited 1–7 days to enter treatment. Naltrexone was more commonly prescribed by AUD admissions compared to acamprosate and disulfiram and was more frequently prescribed in residential and outpatient services as opposed to hospital inpatient services. Conclusions: Naltrexone remains underutilized for AUD, and factors that influence prescription of medication are multifaceted. This study may contribute to the creation of effective interventions aimed at reducing naltrexone disparities for AUD.
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Hodgkin D, Horgan C, Bart G. Financial sustainability of payment models for office-based opioid treatment in outpatient clinics. Addict Sci Clin Pract 2021; 16:45. [PMID: 34225785 PMCID: PMC8256208 DOI: 10.1186/s13722-021-00253-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/22/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Office-Based Opioid Treatment (OBOT) is a delivery model which seeks to make medications for opioid use disorder (MOUD), particularly buprenorphine, widely available in general medical clinics and offices. Despite evidence supporting its effectiveness and cost-effectiveness, uptake of the OBOT model has been relatively slow. One important barrier to faster diffusion of OBOT may be the financial challenges facing clinics that could adopt it. METHODS We review key features and variants of the OBOT model, then discuss different approaches that have been used to fund it, and the findings from previous economic analyses of OBOT's impact on organizational finances. We conclude by discussing the implications of these analyses for the financial sustainability of the OBOT delivery model. RESULTS Like other novel services, OBOT poses challenges for providers due to its reliance on services which are 'non-billable' in a fee-for-service environment. A variety of approaches exist for covering the non-billable costs, but which approaches are feasible depends on local payer policies. The scale of the challenges varies with clinic size, organizational affiliations and the policies of the state where the clinic operates. Small clinics in a purely fee-for-service environment may be particularly challenged in pursuing OBOT, given the need to fund a dedicated staff and extra administrative work. The current pandemic may pose both opportunities and challenges for the sustainability of OBOT, with expanded access to telemedicine, but also uncertainty about the durability of the expansion. CONCLUSION The reimbursement environment for OBOT delivery varies widely around the US, and is evolving as Medicare (and possibly other payers) introduce alternative payment approaches. Clinics considering adoption of OBOT are well advised to thoroughly investigate these issues as they make their decision. In addition, payers will need to rethink how they pay for OBOT to make it sustainable.
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Affiliation(s)
- Dominic Hodgkin
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, United States.
| | - Constance Horgan
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, United States
| | - Gavin Bart
- Department of Medicine, University of Minnesota Medical School and Division of Addiction Medicine, Hennepin Healthcare, Minneapolis, United States
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Disparities in Access to Medications for Opioid Use Disorder in the Veterans Health Administration. J Addict Med 2021; 15:143-149. [PMID: 32826617 DOI: 10.1097/adm.0000000000000719] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES A variety of patients - including women, older, racial/ethnic minority, rural, homeless, and justice-involved patients - are vulnerable to experiencing poor healthcare access and quality, such as lower quality substance use disorder treatment, than other populations. The current study examined receipt of medications for opioid use disorder by vulnerable populations within Veterans Health Administration (VHA) facilities to determine whether there are patient and facility factors that are associated with disparities in care. METHODS Using national VHA clinical/administrative data from Fiscal Year 2017, we calculated receipt of medications for opioid use disorder using the American Society for Addiction Medicine quality measure specifications. A mixed-effects logistic regression model tested whether patient vulnerability (ie, women, older age, racial/ethnic minority, rural residence, homeless, and justice-involved) and facility (eg, regional location, availability of a methadone clinic) characteristics were associated with medication receipt. RESULTS Among the 53,568 veterans at VHA facilities diagnosed with opioid use disorder in Fiscal Year 2017, vulnerable populations - including women, older, Black, rural, homeless, and justice-involved veterans - had lower odds of receiving medications for opioid use disorder than their nonvulnerable counterparts. Veterans had higher odds of receiving medications at facilities with a higher proportion of patients with opioid use disorder, but lower odds of receiving medications at facilities in the Southern region compared to the Northeast region of the United States. CONCLUSIONS Quality improvement efforts targeted at vulnerable populations are needed at the VHA to ensure these groups receive the same quality of substance use disorder treatment as other veterans.
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Addressing Unhealthy Alcohol Use and the HIV Pre-exposure Prophylaxis Care Continuum in Primary Care: A Scoping Review. AIDS Behav 2021; 25:1777-1789. [PMID: 33219492 DOI: 10.1007/s10461-020-03107-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 12/19/2022]
Abstract
Individuals with unhealthy alcohol use are at increased risk for HIV acquisition and may benefit from receiving HIV pre-exposure prophylaxis (PrEP) in primary care settings. To date, literature synthesizing what is known about the impact of unhealthy alcohol use on the PrEP care continuum with a focus on considerations for primary care is lacking. We searched OVID Medline and Web of Science from inception through March 19, 2020, to examine the extent, range, and nature of research on PrEP delivery among individuals with unhealthy alcohol use in primary care settings. We identified barriers and opportunities at each step along the PrEP care continuum, including for specific populations: adolescents, people who inject drugs, sex workers, and transgender persons. Future research should focus on identification of candidate patients, opportunities for patient engagement in novel settings, PrEP implementation strategies, and stigma reduction.
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Saloner B, Andraka Christou B, Gordon AJ, Stein BD. It will end in tiers: A strategy to include "dabblers" in the buprenorphine workforce after the X-waiver. Subst Abus 2021; 42:153-157. [PMID: 33798034 DOI: 10.1080/08897077.2021.1903659] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Buprenorphine is one of the gold standard medication treatments for opioid use disorder (OUD), with proven effectiveness in preventing overdose, increasing abstinence, and improving quality of life. In the United States, buprenorphine can be legally prescribed and administered in office-based settings from clinicians who are specially credentialed to provide that care under the X-waiver. We believe the X-waiver will ultimately be repealed, but there is a need for a variety of strategies to create a new treatment system after the X-waiver. Building a new tier of treatment capacity will require educational outreach, systems strategies, and enhanced payments.
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Affiliation(s)
- Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Barbara Andraka Christou
- Department of Health Management and Informatics, University of Central Florida, Orlando, FL, USA.,Department of Internal Medicine, University of Central Florida, Orlando, FL, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Morse E, Binswanger IA, Taylor E, Gray C, Stimmel M, Timko C, Harris AHS, Smelson D, Finlay AK. Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study. J Subst Abuse Treat 2021; 129:108353. [PMID: 34080564 DOI: 10.1016/j.jsat.2021.108353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/07/2020] [Accepted: 02/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.
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Affiliation(s)
- Erica Morse
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA; Colorado Permanente Medical Group, 1835 Franklin St, Denver, CO 80218, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO 80045, USA.
| | - Emmeline Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Clinical Psychology, University of Colorado, 1420 Austin Bluffs Pkwy, Colorado Springs, CO 80918, USA.
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Matthew Stimmel
- Veterans Justice Programs, U.S. Department of Veterans Affairs (MS), 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 1199 Welch Road, Stanford, CA 94304, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Always Building, Suite M121, 300 Pasteur Drive, Stanford, CA 94305-2200, USA.
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, 200 Springs Road, Bedford, MA 01730, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
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Wallhed Finn S, Hammarberg A, Andreasson S, Jirwe M. Treating alcohol use disorders in primary care - a qualitative evaluation of a new innovation: the 15-method. Scand J Prim Health Care 2021; 39:51-59. [PMID: 33586596 PMCID: PMC7971313 DOI: 10.1080/02813432.2021.1882079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 11/21/2020] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE This study aims to explore how the characteristics of an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived. METHODS/DESIGN/SETTING/SUBJECT General practitioners and heads of primary care units (n = 10) that delivered the 15-method in a randomized controlled trial participated in individual interviews at two occasions in Stockholm, Sweden. Data were analyzed with theoretical thematic analysis, using Diffusion of Innovation Theory. RESULTS The participants described that offering the 15-method met a need among their patients. Participants were positive towards the training and the manual for the method. They mentioned a previous lack of routines to work with alcohol use disorders. The 15-method was described as easy to use. It would however be more feasible to implement in a team of different professions, rather than among general practitioners only. Priorities made by regional health care managers were described as important for the implementation, as well as financial incentives. A barrier to implementation was that alcohol screening was perceived as difficult. While the 15-method was perceived as effective in reducing the patients' alcohol use and cost effective, participants expressed uncertainty about the long-term effects. CONCLUSIONS The 15-method provides structure for treatment of alcohol use disorders and is described by general practitioners and heads as a promising approach. Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.KEY POINTSLittle attention has been given to develop treatment models for alcohol use disorders that are adapted to primary care settings.This study describes how an innovation, the 15-method, a stepped care model for treatment of alcohol use disorders in primary care was perceived.The 15-method provides structure for treatment of alcohol use disorders in primary care and is described by general practitioners and heads as a promising approach.Being able to offer treatment for alcohol dependence may increase the uptake of alcohol interventions in primary care.
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Affiliation(s)
- Sara Wallhed Finn
- Department of Global Public Health, Karolinska Institutet, Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm, Sweden
| | - Anders Hammarberg
- Department of Clinical Neurosciences, Karolinska Institutet, Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm, Sweden
| | - Sven Andreasson
- Department of Global Public Health, Karolinska Institutet, Centre for Psychiatry Research, Stockholm Health Care Services, Stockholm, Sweden
| | - Maria Jirwe
- Department of Health Science, Red Cross University College, Stockholm, Sweden
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Gustavson AM, Wisdom JP, Kenny ME, Salameh HA, Ackland PE, Clothier B, Noorbaloochi S, Gordon AJ, Hagedorn HJ. Early impacts of a multi-faceted implementation strategy to increase use of medication treatments for opioid use disorder in the Veterans Health Administration. Implement Sci Commun 2021; 2:20. [PMID: 33588952 PMCID: PMC7885503 DOI: 10.1186/s43058-021-00119-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 01/28/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Despite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes. METHODS Guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes. RESULTS Across eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16. CONCLUSIONS Early impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.
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Affiliation(s)
- Allison M Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA.
| | | | - Marie E Kenny
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Hope A Salameh
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Princess E Ackland
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Barbara Clothier
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
| | - Siamak Noorbaloochi
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, Utah, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Hildi J Hagedorn
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive, Mail Code #152, Minneapolis, MN, 55417, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, 55455, USA
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Borda JP, Friedman H, Buitrago J, Isaza M, Herrera P, Krawczyk N, Tofighi B. Barriers to treatment for opioid use disorder in Colombia. JOURNAL OF SUBSTANCE USE 2021. [DOI: 10.1080/14659891.2021.1875070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Juan P. Borda
- Faculty of Medicine, Universidad Alexander Von Humboldt, Armenia, Colombia
| | - Hannah Friedman
- Department of Population Health, New York University School of Medicine, New York, USA
| | | | - Maritza Isaza
- Secretaría de Salud Pública, Cali, Armenia, Colombia
| | - Paula Herrera
- Grupo de Investigación “Psiquiatria, Neurociencia y Comunidad”, Universidad Tecnológica de Pereira, Pereira, Colombia
| | - Noa Krawczyk
- Faculty of Medicine, Universidad Alexander Von Humboldt, Armenia, Colombia
| | - Babak Tofighi
- Faculty of Medicine, Universidad Alexander Von Humboldt, Armenia, Colombia
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Agabio R, Balia S, Gessa GL, Pani PP. Use of Medications for the Treatment of Alcohol Dependence: A Retrospective Study Conducted in 2011-2012. Curr Drug Res Rev 2021; 13:154-164. [PMID: 33371866 DOI: 10.2174/2589977512666201228121820] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 05/19/2020] [Accepted: 11/04/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Pharmacotherapy for Alcohol Dependence (AD) is underutilized. Barriers preventing the use of AD medications include high prices, lack of access to prescribing physicians, and a limited number of available medications. OBJECTIVE The study evaluated the use of AD medications in a sample of Italian outpatients who received these medications free of charge, had access to physicians during office hours, and for whom substitution therapy [gamma-hydroxybutyrate (GHB)] was available. We also evaluated the rate of patients who received a combination of non-pharmacological and pharmacological treatments among participants who were still drinking. METHODS SCID for AD and questionnaire were filled by to AD outpatients during a face-to-face interview. RESULTS & DISCUSSION 345 AD outpatients were interviewed: 58.8% were currently receiving at least one AD medication (GHB: 34.3%, disulfiram: 29.6%, acamprosate: 5.9%; naltrexone: 2.5%; more than one medication: 16.7%). Less than 30% of participants who were still drinking, received a combination of non-pharmacological and pharmacological treatments. Nonetheless, we found higher use of AD medications compared to previous studies conducted in other countries. This higher use of AD medications may be due to access to free medications, prescribing physicians' style, and a larger number of available medications. CONCLUSION Our results confirm the underutilization of AD medications, as less than 60% of AD outpatients received medications, and less than 30% of those who were still drinking, received a combination of non-pharmacological and pharmacological treatments. These findings may be useful in improving our knowledge of the barriers that prevent the use of AD medications in clinical practice.
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Affiliation(s)
- Roberta Agabio
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Sardinia, Italy
| | - Silvia Balia
- Department of Economics and Business, University of Cagliari and CRENoS, Sardinia, Italy
| | - Gian Luigi Gessa
- Department of Biomedical Sciences, Section of Neuroscience and Clinical Pharmacology, University of Cagliari, Sardinia, Italy
| | - Pier Paolo Pani
- Health Social Services, Public Health Trust Sardinia, Cagliari, Italy
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Scorsone KL, Haozous EA, Hayes L, Cox KJ. Ending the Chase: Experiences of Rural Individuals with Opioid Use Disorder. Subst Use Misuse 2021; 56:1224-1231. [PMID: 33871309 DOI: 10.1080/10826084.2021.1914109] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The US remains in the midst of an opioid overdose epidemic. Given that rural populations have higher rates of opioid-related morbidity and mortality, it is important to understand the factors that perpetuate opioid use and facilitate recovery in rural communities. Purpose: To explore experiences of individuals living with opioid use disorder (OUD) and to analyze these experiences within a broader sociocultural context. Methods: Using a descriptive, qualitative design, we interviewed twenty purposefully sampled participants. We used thematic content analysis to identify themes and patterns. Results: As participants became dependent, the chase for opioids was to avoid the pain of withdrawal. Waking up sick became an everyday experience, leading to a lifestyle of hustling. The pursuit of opioids resulted in physical, social, emotional, and legal consequences that fed a cycle of stigmatization. In recovery, participants learned to embrace a new way of thinking, allowing them to make new choices. The strong influence of family and community in their lives was a key factor in their resiliency and opioid use experiences. Conclusions: Individuals with OUD are impacted by intersecting social, physical, economic and policy factors that reinforce the expansion of the opioid epidemic rurally. This study provided a voice to rural individuals with opioid use disorder, a group often underrepresented in the literature, providing an understanding of their struggles and the unique sociocultural dynamics that exist in rural northern New Mexico. The complex sociocultural relationships to family and community represent important adaptive factors that could support individual healing and community transformation.
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Affiliation(s)
- Krista L Scorsone
- Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Health Care System, Aurora, Colorado, USA.,Rueckert-Hartman College for Health Professions, Regis University, Denver, Colorado, USA.,The College of Nursing, University of New Mexico, Albuquerque, New Mexico, USA
| | - Emily A Haozous
- Pacific Institute for Research and Evaluation, Albuquerque, New Mexico, USA
| | - Leslie Hayes
- El Centro Family Health, Española, New Mexico, USA
| | - Kim J Cox
- The College of Nursing, University of New Mexico, Albuquerque, New Mexico, USA
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Becker WC, Krebs EE, Edmond SN, Lin LA, Sullivan MD, Weiss RD, Gordon AJ. A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference. J Gen Intern Med 2020; 35:978-982. [PMID: 33145681 PMCID: PMC7728950 DOI: 10.1007/s11606-020-06260-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 09/21/2020] [Indexed: 11/27/2022]
Abstract
US military Veterans have been disproportionately impacted by the US opioid overdose crisis. In the fall of 2019, the Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of opioid safety, including both use of opioid analgesics and managing opioid use disorder. We present the methods and consensus recommendations from the SOTA. A core group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: managing opioid use disorder, long-term opioid therapy for pain including consideration for opioid tapering, and treatment of co-occurring pain and substance use disorders. The SOTA participants divided into three workgroups and identified key questions and seminal studies related to those three areas of focus. The strongest recommendations included testing implementation strategies in the VHA for expanding access to medication treatment for opioid use disorder, testing collaborative tapering programs for patients prescribed long-term opioids, and larger trials of behavioral and exercise/movement interventions for pain among patients with substance use disorders.
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Affiliation(s)
- William C Becker
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA.
- Yale School of Medicine, New Haven, CT, USA.
| | - Erin E Krebs
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA
- University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sara N Edmond
- Pain Research, Informatics, Multimorbidities & Education Center of Innovation, VA Connecticut Healthcare System, West Haven, CT, USA
- Yale School of Medicine, New Haven, CT, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Mark D Sullivan
- University of Washington School of Medicine, Seattle, WA, USA
| | - Roger D Weiss
- Harvard Medical School, Boston, MA, USA
- McLean Hospital, Belmont, MA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient Aligned Care Team Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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40
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Iheanacho T, Bommersbach T, Fuehrlein B, Arnaout B, Dike C. Brief Training on Medication-Assisted Treatment Improves Community Mental Health Clinicians' Confidence and Readiness to Address Substance Use Disorders. Community Ment Health J 2020; 56:1429-1435. [PMID: 32062717 PMCID: PMC7429311 DOI: 10.1007/s10597-020-00586-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 02/12/2020] [Indexed: 11/25/2022]
Abstract
Despite the availability and effectiveness of medication-assisted treatment (MAT) for substance use disorders (SUDs), utilization of these medications remains suboptimal, especially in public sector settings. A key limitation is clinicians' reluctance to include MAT in their routine practice due, in part, to low confidence about managing SUDs and limited awareness of the disease model of addiction. This study evaluates the impact of a 1-day MAT training for community mental health clinicians using a 30-item pre- and post-training questionnaire. Of the 109 clinicians who attended the training, 107 completed the pre- and post-training questionnaires. Factor analysis of the questionnaire identified two domains: readiness to address SUDs among patients (factor 1) and understanding SUDs as diseases (factor 2). Post training, there was a significant change in both factor 1 (p = .00001) and factor 2 (p = .00003), indicating that a brief MAT training can increase clinicians' confidence and readiness to address SUDs and improve their understanding of the disease model of addiction.
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Affiliation(s)
- Theddeus Iheanacho
- Yale University School of Medicine, New Haven, CT, USA.
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Department of Psychiatry, Yale University School of Medicine, 300 George Street, New Haven, CT, 06511, USA.
| | | | - Brian Fuehrlein
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Bachaar Arnaout
- Yale University School of Medicine, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Charles Dike
- Yale University School of Medicine, New Haven, CT, USA
- Connecticut's Department of Mental Health and Addiction Services, Hartford, CT, USA
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41
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Ray V, Waite MR, Spexarth FC, Korman S, Berget S, Kodali S, Kress D, Guenther N, Murthy VS. Addiction Management in Hospitalized Patients With Intravenous Drug Use–Associated Infective Endocarditis. PSYCHOSOMATICS 2020; 61:678-687. [DOI: 10.1016/j.psym.2020.06.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 10/23/2022]
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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 PMCID: PMC8916817 DOI: 10.31478/202010b] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [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
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Haffajee RL, Andraka-Christou B, Attermann J, Cupito A, Buche J, Beck AJ. A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder. Subst Abuse Treat Prev Policy 2020; 15:69. [PMID: 32928272 PMCID: PMC7491096 DOI: 10.1186/s13011-020-00312-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications. METHODS To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods. RESULTS Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD. CONCLUSIONS Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.
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Affiliation(s)
- Rebecca L. Haffajee
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- RAND Corporation, Boston, MA USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MA USA
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI USA
| | - Barbara Andraka-Christou
- Department of Health Management & Informatics, University of Central Florida, Orlando, FL USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL USA
| | - Jeremy Attermann
- the National Council for Behavioral Health, Washington, D.C, USA
| | - Anna Cupito
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Jessica Buche
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Angela J. Beck
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
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44
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Finlay AK, Morse E, Stimmel M, Taylor E, Timko C, Harris AHS, Smelson D, Yu M, Blue-Howells J, Binswanger IA. Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study. J Gen Intern Med 2020; 35:2529-2536. [PMID: 32583337 PMCID: PMC7459011 DOI: 10.1007/s11606-020-05944-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans. OBJECTIVE The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system. DESIGN This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder. PARTICIPANTS Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12). APPROACH We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach. KEY RESULTS Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention. CONCLUSIONS Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.
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Affiliation(s)
- Andrea K Finlay
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA. .,Department of Veterans Affairs, National Center on Homelessness Among Veterans, 795 Willow Road, Menlo Park, 94025, USA.
| | - Erica Morse
- Institute for Health Research, Kaiser Permanente Colorado, Denver, USA
| | - Matthew Stimmel
- Veterans Justice Programs, U.S. Department of Veterans Affairs, , Menlo Park, USA
| | - Emmeline Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Clinical Psychology, University of Colorado, Colorado Springs, Colorado Springs, USA
| | - Christine Timko
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, USA
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA.,Department of Surgery, Stanford University School of Medicine, Stanford, USA
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, Bedford, USA
| | - Mengfei Yu
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Road (MPD-152), Menlo Park, Willow, CA, 94025, USA
| | - Jessica Blue-Howells
- Veterans Justice Programs, U.S. Department of Veterans Affairs, , Menlo Park, USA
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Denver, USA.,Colorado Permanente Medical Group, Denver, USA.,Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, USA
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Muvvala SB, O'Malley SS, Rosenheck R. Multiple Psychiatric Morbidity and Continued Use of Naltrexone for Alcohol Use Disorder. Am J Addict 2020; 30:55-64. [PMID: 32805083 DOI: 10.1111/ajad.13089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 06/28/2020] [Accepted: 07/28/2020] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Despite substantial evidence of the efficacy of naltrexone in treating alcohol use disorder (AUD), naltrexone is used infrequently and often for short durations. Understanding factors related to the initiation and continued use of naltrexone could identify targets for improving its use in clinical practice. METHODS We used the Fiscal year 2012 national data from the Veterans Health Administration to identify the proportion of veterans diagnosed with AUD who initiated and then continued to receive naltrexone for AUD over a 6-month period (N = 67,788). We further examined correlates of any use and continued use, and patterns of use in inpatient and outpatient mental health services and psychotropic prescription fills. Comparisons were made using bivariate analyses and multinomial logistic regression. RESULTS Among the veterans diagnosed with AUD, 2.02% initiated treatment with naltrexone. Naltrexone initiation was associated with recent homelessness, concurrent psychiatric disorders, receipt of psychiatric outpatient services, psychotropic prescription fills, residential treatment, and psychiatric and medical-surgical hospitalization. Of the 1,366 patients initiating naltrexone, 43.2% (590) received 2 to 5 prescriptions and 16.3% (223) received more than 5 prescriptions for naltrexone. Use of naltrexone beyond one prescription was associated with homelessness, major depressive disorder, schizophrenia, psychotropic medication use, and psychiatric hospitalization. CONCLUSION Veterans with AUD who used and continued naltrexone were primarily those with multimorbidity and extensive involvement in psychiatric treatment. SCIENTIFIC SIGNIFICANCE Prior studies examined the correlates of initiation of naltrexone but retention in treatment has received less attention. This study identified the frequency and important patient and service correlates of continued use of naltrexone. (Am J Addict 2021;30:55-64).
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Affiliation(s)
| | | | - Robert Rosenheck
- Yale University School of Medicine, New Haven, Connecticut.,VISN1 VA New England Mental Illness Research, Education and Clinical Center.,VA Connecticut Health Care System, West Haven, Connecticut
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Frost MC, Ioannou GN, Tsui JI, Edelman EJ, Weiner BJ, Fletcher OV, Williams EC. Practice facilitation to implement alcohol-related care in Veterans Health Administration liver clinics: a study protocol. Implement Sci Commun 2020; 1:68. [PMID: 32835226 PMCID: PMC7393339 DOI: 10.1186/s43058-020-00062-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 12/23/2022] Open
Abstract
Background Alcohol-related care, including screening, brief intervention, and provision of/referral to medication or behavioral treatments for alcohol use disorder, could be delivered in liver clinics to better reach patients with chronic liver conditions. However, the provision of alcohol-related care in liver clinics is currently suboptimal. Practice facilitation is an evidence-based implementation strategy that may address barriers, harness facilitators, and optimize the implementation of alcohol-related care in liver clinic settings using a clinic-centered approach. We report the protocol of a study to test a practice facilitation intervention to implement alcohol-related care in four Veterans Health Administration liver clinics. Methods This study will employ a Hybrid Type 3 effectiveness-implementation design, in which implementation outcomes are considered primary and clinical outcomes secondary. Intervention and evaluation design were informed by the Consolidated Framework for Implementation Research. Qualitative data collected from clinical stakeholders and patients were used to tailor the intervention. The intervention involves a 6-month period of external practice facilitation, including regular meetings to identify clinic goals, challenges, and solutions; engagement of clinic champions; provision of training and development of educational materials for clinic staff and patients; and performance monitoring and feedback. Ongoing formative evaluation involves the collection of quantitative facilitator tracking data and qualitative data from meeting notes and patient interviews to describe intervention acceptability, feasibility, and adoption, and adjust implementation as needed. In the summative evaluation, implementation outcomes (clinic rates of screening, brief intervention, and treatment referral/receipt) and clinical outcomes (unhealthy alcohol use, liver health) will be assessed among patients in participating clinics using secondary electronic health record data and interrupted time series analysis. Discussion This will be the first study to our knowledge to test practice facilitation to implement alcohol-related care in liver clinic settings. Results from formative and summative evaluation will inform a framework for the successful implementation of effective alcohol-related care through practice facilitation in liver clinics, which may ultimately lead to better health outcomes for patients with chronic liver disease.
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Affiliation(s)
- Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108 USA.,Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - George N Ioannou
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108 USA.,Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 325 9th Ave, Seattle, WA 98104 USA
| | - E Jennifer Edelman
- Yale Schools of Medicine and Public Health, 367 Cedar Street, ES Harkness, suite 401, New Haven, CT 06510 USA
| | - Bryan J Weiner
- Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195 USA.,Department of Global Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Olivia V Fletcher
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108 USA
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108 USA.,Department of Health Services, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195 USA
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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.
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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
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48
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Madras BK, Ahmad NJ, Wen J, Sharfstein JS. Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers within the Treatment System. NAM Perspect 2020; 2020:202004b. [PMID: 35291732 PMCID: PMC8916813 DOI: 10.31478/202004b] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Even though evidence-based treatment for opioid use disorders (OUD) is effective, almost four in five Americans with OUD do not receive any form of treatment. The gap in access to evidence-based care, including treatment with medications for OUD, stems in part from barriers to change within the health care system. This paper includes nine key barriers that prevent access to evidence-based care, including stigma; inadequate clinical training; a dearth of addiction specialists; lack of integration of MOUD provision in practice; regulatory, statutory, and data sharing restrictions; and financial barriers. Action from a number of actors is urgently needed to address this crisis.
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Affiliation(s)
| | - N Jia Ahmad
- Johns Hopkins Bloomberg School of Public Health
| | - Jenny Wen
- Johns Hopkins University School of Medicine
| | - Joshua Sharfstein Sharfstein
- Johns Hopkins Bloomberg School of Public Health; and the Prevention, Treatment, and Recovery Working Group of the Action Collaborative on Countering the U.S. Opioid Epidemic
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Abstract
: Medication treatment of opioid use disorder (OUD) is recognized as an effective evidence-based treatment. It has been underused, in part due to challenges in recruiting and retaining a provider workforce that is able to prescribe and manage patients treated with OUD medications. A national goal should be: anyone with an OUD must have adequate access to a range of medications for treatment and support, provided in high-quality settings, and all programs receiving public or private funding should be so equipped. To accomplish this, it is important to understand what recruitment efforts are most successful, and what implementation strategies and service models are most effective. Building an adequate OUD treatment workforce, however, will require a system with adequate program resources and incentives, clinician and patient education to reduce stigma, limited regulatory burden, and adequate reimbursement and support high-quality services.
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Andrilla CHA, Jones KC, Patterson DG. Prescribing Practices of Nurse Practitioners and Physician Assistants Waivered to Prescribe Buprenorphine and the Barriers They Experience Prescribing Buprenorphine. J Rural Health 2020; 36:187-195. [DOI: 10.1111/jrh.12404] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- C. Holly A. Andrilla
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
| | - Kendall C. Jones
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
| | - Davis G. Patterson
- WWAMI Rural Health Research CenterDepartment of Family MedicineUniversity of Washington School of Medicine Seattle Washington
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