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Christine PJ, Chahine RA, Kimmel SD, Mack N, Douglas C, Stopka TJ, Calver K, Fanucchi LC, Slavova S, Lofwall M, Feaster DJ, Lyons M, Ezell J, Larochelle MR. Buprenorphine Prescribing Characteristics Following Relaxation of X-Waiver Training Requirements. JAMA Netw Open 2024; 7:e2425999. [PMID: 39102264 DOI: 10.1001/jamanetworkopen.2024.25999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/06/2024] Open
Abstract
Importance Local-level data are needed to understand whether the relaxation of X-waiver training requirements for prescribing buprenorphine in April 2021 translated to increased buprenorphine treatment. Objective To assess whether relaxation of X-waiver training requirements was associated with changes in the number of clinicians waivered to and who prescribe buprenorphine for opioid use disorder and the number of patients receiving treatment. Design, Setting, and Participants This serial cross-sectional study uses an interrupted time series analysis of 2020-2022 data from the HEALing Communities Study (HCS), a cluster-randomized, wait-list-controlled trial. Urban and rural communities in 4 states (Kentucky, Massachusetts, New York, and Ohio) with a high burden of opioid overdoses that had not yet received the HCS intervention were included. Exposure Relaxation of X-waiver training requirements (ie, allowing training-exempt X-waivers) on April 28, 2021. Main Outcomes and Measures The monthly number of X-waivered clinicians, X-waivered buprenorphine prescribers, and patients receiving buprenorphine were each summed across communities within a state. Segmented linear regression models to estimate pre- and post-policy change by state were used. Results The number of individuals in 33 participating HCS communities included 347 863 in Massachusetts, 815 794 in Kentucky, 971 490 in New York, and 1 623 958 in Ohio. The distribution of age (18-35 years: range, 29.4%-32.4%; 35-54 years: range, 29.9%-32.5%; ≥55 years: range, 35.7%-39.3%) and sex (female: range, 51.1%-52.6%) was similar across communities. There was a temporal increase in the number of X-waivered clinicians in the pre-policy change period in all states, which further increased in the post-policy change period in each state except Ohio, ranging from 5.2% (95% CI, 3.1%-7.3%) in Massachusetts communities to 8.4% (95% CI, 6.5%-10.3%) in Kentucky communities. Only communities in Kentucky showed an increase in the number of X-waivered clinicians prescribing buprenorphine associated with the policy change (relative increase, 3.2%; 95% CI, 1.5%-4.9%), while communities in other states showed no change or a decrease. Similarly, only communities in Massachusetts experienced an increase in patients receiving buprenorphine associated with the policy change (relative increase, 1.7%; 95% CI, 0.8%-2.6%), while communities in other states showed no change. Conclusions and Relevance In this serial cross-sectional study, relaxation of X-waiver training requirements was associated with an increase in the number of X-waivered clinicians but was not consistently associated with an increase in the number of buprenorphine prescribers or patients receiving buprenorphine. These findings suggest that training requirements may not be the primary barrier to expanding buprenorphine treatment.
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Affiliation(s)
- Paul J Christine
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
- Department of General Internal Medicine, Denver Health and Hospital Authority, Denver, Colorado
| | - Rouba A Chahine
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Simeon D Kimmel
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
- Section of Infectious Diseases, Department of Medicine, Boston Medical Center and Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
| | - Nicole Mack
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Christian Douglas
- Social, Statistical, and Environmental Sciences, Research Triangle Institute, Research Triangle Park, North Carolina
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, Massachusetts
| | - Katherine Calver
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Laura C Fanucchi
- Division of Infectious Diseases, College of Medicine, University of Kentucky, Lexington
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
| | - Svetla Slavova
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington
- Kentucky Injury Prevention Research Center, University of Kentucky, Lexington
| | - Michelle Lofwall
- Center on Drug and Alcohol Research, University of Kentucky, Lexington
- Department of Behavioral Science and Psychiatry, University of Kentucky, Lexington
| | - Daniel J Feaster
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Michael Lyons
- Department of Emergency Medicine, College of Medicine, The Ohio State University, Columbus
| | - Jerel Ezell
- Division of Community Health Sciences, School of Public Health, University of California, Berkeley
| | - Marc R Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Chobanian & Avedisian School of Medicine, Boston University, Boston, Massachusetts
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Kruger DJ, Kirk HM, Leonard KE, Lynch JJ, Nielsen N, Collins RL, Ditre JW, Fletcher-Blake D, Green SA, Hogue A, Hunter JK, Marraffa JM, Clemency BM. Assessing experts' perspectives on challenges in substance misuse prevention, harm reduction, and treatment to shape funding priorities in New York State. Harm Reduct J 2024; 21:134. [PMID: 39004729 PMCID: PMC11247824 DOI: 10.1186/s12954-024-01045-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 06/26/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Drug overdose is a leading cause of death and opioid-related deaths increased by more than 300% from 2010 to 2020 in New York State. Experts holding a range of senior leadership positions from across New York State were asked to identify the greatest challenges in substance misuse prevention, harm reduction, and treatment continuum of care. Expert input was used to shape funding priorities. METHOD Individual semi-structured interviews of sixteen experts were conducted in April and May 2023. Experts included academics, medical directors, leaders of substance misuse service agencies, administrators of a state agency, a county mental health commissioner, the president of a pharmacy chain, and a senior vice president of an addiction-related national non-profit. Zoom interviews were conducted individually by an experienced qualitative interviewer and were recorded, transcribed, and coded for content. An initial report, with the results of the interviews organized by thematic content, was reviewed by the research team and emailed to the expert interviewees for feedback. RESULTS The research team identified five major themes: 1. Siloed and fragmented care delivery systems; 2. Need for a skilled workforce; 3. Attitudes towards addiction (stigma); 4. Limitations in treatment access; and 5. Social and drug related environmental factors. Most experts identified challenges in each major theme; over three-quarters identified issues related to siloed and fragmented systems and the need for a skilled workforce. Each expert mentioned more than one theme, three experts mentioned all five themes and six experts mentioned four themes. CONCLUSIONS Research, educational, and programmatic agendas should focus on identified topics as a means of improving the lives of patients at risk for or suffering from substance use-related disorders. The results of this project informed funding of pilot interventions designed to address the identified care challenges.
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Affiliation(s)
- Daniel J Kruger
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, University at Buffalo Gateway Building, Suite 420, 77 Goodell St., Buffalo, NY, 14203, USA.
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, 3435 Main Street, Buffalo, NY, 14214, USA.
- Clinical and Research Institute On Addictions, University at Buffalo, 1021 Main St, Buffalo, NY, 14203, USA.
| | - Hilary M Kirk
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, University at Buffalo Gateway Building, Suite 420, 77 Goodell St., Buffalo, NY, 14203, USA
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, 3435 Main Street, Buffalo, NY, 14214, USA
| | - Kenneth E Leonard
- Clinical and Research Institute On Addictions, University at Buffalo, 1021 Main St, Buffalo, NY, 14203, USA
| | - Joshua J Lynch
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, University at Buffalo Gateway Building, Suite 420, 77 Goodell St., Buffalo, NY, 14203, USA
- Clinical and Research Institute On Addictions, University at Buffalo, 1021 Main St, Buffalo, NY, 14203, USA
| | - Nancy Nielsen
- Clinical and Research Institute On Addictions, University at Buffalo, 1021 Main St, Buffalo, NY, 14203, USA
| | - R Lorraine Collins
- Department of Community Health and Health Behavior, School of Public Health and Health Professions, University at Buffalo, 3435 Main Street, Buffalo, NY, 14214, USA
| | - Joseph W Ditre
- Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244, USA
| | | | - Susan A Green
- School of Social Work, University at Buffalo, 85 Baldy Hall, Buffalo, NY, 14260, USA
| | - Aaron Hogue
- Partnership to End Addiction, 711 Third Avenue, 5Th Floor, Suite 500, New York, NY, 10017, USA
| | - Julia K Hunter
- United Health Services Hospitals, Inc., 10-42 Mitchell Ave, Binghamton, NY, 13903, USA
| | - John M Marraffa
- Kinney Drugs, 6333 Route 298, Suite 305, Syracuse, NY, 13057, USA
| | - Brian M Clemency
- Department of Emergency Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, University at Buffalo Gateway Building, Suite 420, 77 Goodell St., Buffalo, NY, 14203, USA
- Clinical and Research Institute On Addictions, University at Buffalo, 1021 Main St, Buffalo, NY, 14203, USA
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Belden C, Kopak A, Coules C, Friesen T, Hall J, Shukla S. Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 162:209364. [PMID: 38626851 DOI: 10.1016/j.josat.2024.209364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 03/19/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Despite sustained efforts to reduce opioid-related overdose fatalities, rates have continued to rise. In many areas, overdose response involves emergency medical service (EMS) personnel administering naloxone and transporting patients to the emergency department (ED). However, a substantial number of patients decline transport, and many EDs do not provide medication for opioid use disorder (MOUD). One approach to filling this gap involves delivering MOUD to overdose patients in the field with trained post-overdose EMS teams who can initiate buprenorphine. In this MOUD field initiation pilot program, a trained EMS Community Paramedicine team initiates buprenorphine in the field and links patients to care. The program includes three pathways to treatment with the first designed for EMS to initiate buprenorphine after overdose reversal when the patient is in withdrawal from naloxone; a second pathway initiates buprenorphine after overdose when the patient is not in withdrawal; and a third enables self-referral via a connection to the community EMS team not necessarily related to a recent overdose. METHODS We conducted a retrospective cohort study of the MOUD field initiation pilot program. Data are from 28 patients who entered care immediately post-overdose initiation of buprenorphine, 21 patients who initiated on buprenorphine while not in naloxone withdrawal, and 37 patients who self-referred to treatment following outreach efforts by paramedicine and peer support professionals. RESULTS A total of 118 patients initiated buprenorphine during the 12-month study period and 104 (83 %) visited the clinic for their first appointment. Over two thirds (68 %, n = 80) remained engaged in care after 30 days. Retained patients tended to be male, white, uninsured, food insecure, have unstable housing, lack reliable transportation, and report prior involvement with the criminal legal system. CONCLUSION The initial 12-month period of the pilot program demonstrated the feasibility of initiating buprenorphine at the site of overdose without requiring transport to the ED and offer self-referral pathways for people experiencing barriers to treatment. Specialized EMS can play a critical role in expanding access to MOUD treatment by bridging the gap between overdose and comprehensive community-based care.
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Affiliation(s)
- Charles Belden
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Albert Kopak
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Courtney Coules
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Tessa Friesen
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Justin Hall
- Buncombe County Emergency Medical Services, 164 Erwin Hills Rd, Asheville, NC 28806, USA.
| | - Shuchin Shukla
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA
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Callister C, Porter S, Vatterott P, Keniston A, McBeth L, Mann S, Calcaterra SL, Limes J. The Impact of Completing X-Waiver Training and Clinical Addiction Exposure on Internal Medicine Residents Treating Patients With Opioid Use Disorder. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:356-366. [PMID: 38258815 DOI: 10.1177/29767342231221004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
BACKGROUND Treating opioid use disorder (OUD) with buprenorphine or methadone significantly reduces overdose and all-cause mortality. Prior studies demonstrate that clinicians and residents reported a lack of preparedness to diagnose or treat OUD. Little is known about how clinical exposure or buprenorphine X-waiver training impacts OUD care delivery by resident physicians. OBJECTIVE Distinguish the effects of X-waiver training and clinical exposure with OUD on resident's knowledge, attitudes, feelings of preparedness, and practices related to OUD treatment provision. METHODS From August 2021 to April 2022, we distributed a cross-sectional survey to internal medicine residents at a large academic training program. We analyzed associations between self-reported clinical exposure and X-waiver training across 4 domains: knowledge about best practices for OUD treatment, attitudes about patients with OUD, preparedness to treat OUD, and clinical experience with OUD. RESULTS Of the 188 residents surveyed, 91 responded (48%). A majority of respondents had not completed X-waiver training (60%, n = 55) while many had provided clinical care to patients with OUD (65%, n = 59). Most residents had favorable attitudes about OUD treatment (97%). Both residents with clinical exposure to treating OUD and X-waiver training, and residents with clinical exposure without X-waiver training, felt more prepared to treat OUD (P < .0008) compared to residents with neither clinical exposure or X-waiver training or only X-waiver training. CONCLUSIONS Residents with clinical exposure to treating OUD are more prepared to treat patients with OUD than those without clinical exposure. Greater efforts to incorporate clinical exposure to the treatment of OUD and education in internal medicine residency programs is imperative to address the opioid epidemic.
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Affiliation(s)
| | - Samuel Porter
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Phillip Vatterott
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Angela Keniston
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Lauren McBeth
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Sarah Mann
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Susan L Calcaterra
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
- Division of General Internal Medicine, University of Colorado, Aurora, CO, USA
| | - Julia Limes
- Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
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Savitz ST, Stevens MA, Nath B, D’Onofrio G, Melnick ER, Jeffery MM. Trends in the Prescribing of Buprenorphine for Opioid Use Disorder, 2019-2023. Mayo Clin Proc Innov Qual Outcomes 2024; 8:308-320. [PMID: 38841599 PMCID: PMC11152959 DOI: 10.1016/j.mayocpiqo.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2024] Open
Abstract
Objective To evaluate whether access to buprenorphine to treat opioid use disorder (OUD) was associated with the coronavirus disease pandemic, the relaxation of training requirements to obtain an X-Waiver to prescribe buprenorphine (April 2021), and the removal of the X-Waiver (December 2022). Patients and Methods The OptumLabs Data Warehouse, which includes claims from Commercial and Medicare Advantage enrollees, was used to evaluate trends in prescription fills from January 1, 2019, to June 30, 2023. We compared fill patterns of buprenorphine for OUD with acamprosate to treat alcohol use disorder and naltrexone to treat alcohol use disorder or OUD. We evaluated trends in the rate ratio (RR) of overall fills; RR by days supply; distribution of fills by daily dose; and distribution of fills by prescriber type. Results Coronavirus disease (RR, 1.06; 95% CI, 1.01-1.11) was associated with a slightly increased rate of fills for Commercial enrollees but not overall or for Medicare Advantage enrollees. There were also no significant increases (P>0.05) associated with the change in training requirements or removal of the X-Waiver. Over the study period, there was an increasing share of fills for 16+ mg for Commercial enrollees, and buprenorphine prescribers were more likely to be advanced practice nurses or physician assistants. Conclusion We did not find meaningful improvement in access in response to coronavirus disease or the changes in the X-Waiver. These findings suggest that interventions beyond removing the X-Waiver may be needed to improve buprenorphine access.
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Affiliation(s)
- Samuel T. Savitz
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Maria A. Stevens
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Gail D’Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
- Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
- Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Molly M. Jeffery
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN
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Bello JK, Dell NA, Laxton AM, Conte M, Chen L. Prevalence and predictors of medication for opioid use disorder among reproductive-aged women. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 11:100239. [PMID: 38711835 PMCID: PMC11070671 DOI: 10.1016/j.dadr.2024.100239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 04/17/2024] [Accepted: 04/25/2024] [Indexed: 05/08/2024]
Abstract
Background Women of reproductive age would benefit from treatment of opioid use disorder (OUD) prior to pregnancy to improve maternal and infant outcomes. In this study, we aimed to identify the prevalence of medication for OUD (MOUD) and characterize correlates of MOUD receipt among 12-49-year-old women with OUD seeking treatment in publicly funded substance use disorder treatment programs at the time of their first treatment episode. Methods This cross-sectional study explores the demographic and clinical characteristics of women of reproductive age with OUD receiving publicly funded substance use treatment services. We used data from the concatenated 2015-2021 Treatment Episode Data Set-Admissions (TEDS-A), which documents demographic and clinical characteristics of patient admissions to publicly funded substance use treatment services in the United States. Results In the sample of females aged 12-49 with no prior treatment admissions and primary OUD (n=325,512), 40.53% received MOUD (n=131,930), including 39.40% of non-pregnant women (n=115,315) and 52.79% of pregnant women (n=8423). Pregnant women had significantly higher odds of receiving MOUD (aOR = 2.42, 95%CI: 2.30, 2.54) compared to non-pregnant women. Non-white race, treatment setting, and treatment self-referral were also associated with higher levels of MOUD. Conclusions We identified a significant unmet need among both pregnant and non-pregnant women with OUD seeking care in publicly funded treatment clinics. While women who are pregnant are significantly more likely to receive evidence-based treatment with MOUD, still 47.21% of pregnant women did not receive MOUD. All reproductive-aged women with OUD should be offered evidence-based treatment options, including MOUD.
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Affiliation(s)
- Jennifer K. Bello
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | | | - Aaron M. Laxton
- School of Social Work, Saint Louis University, St. Louis, MO, USA
- Assisted Recovery Centers of America, St. Louis, MO, USA
| | - Mary Conte
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Lynn Chen
- Department of Family and Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
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Schuler MS, Dick AW, Gordon AJ, Saloner B, Kerber R, Stein BD. Growing importance of high-volume buprenorphine prescribers in OUD treatment: 2009-2018. Drug Alcohol Depend 2024; 259:111290. [PMID: 38678682 DOI: 10.1016/j.drugalcdep.2024.111290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 05/01/2024]
Abstract
BACKGROUND We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018. METHODS In this observational cohort study, IQVIA Real World retail pharmacy claims data were used to characterize trends in high-volume buprenorphine prescribers (clinicians with a mean of 30 or more active patients in every month that they were an active prescriber) during 2009-2018. Very high-volume prescribing (mean of 100+ patients per month) was also examined. RESULTS Overall, 94,491 clinicians prescribed buprenorphine dispensed during 2009-2018. The proportion of active prescribers meeting high-volume criteria increased from 7.4 % in 2009 to 16.7 % in 2018. High-volume prescribers accounted for 80 % of dispensed buprenorphine prescriptions during 2009-2018; very high-volume prescribers accounted for 26 %. Adult primary care physicians consistently comprised the majority of high-volume prescribers. Addiction specialists were much more likely to be high-volume prescribers compared to other specialties, including psychiatrists and pain specialists. By 2018, the proportion of prescriptions from high-volume prescribers paid by Medicaid had doubled to 40 %, accompanied by a decline in both self-pay and commercial insurance. High-volume prescribers were overwhelmingly concentrated in urban counties with the highest fatal overdose rates. In 2018, the highest density of high-volume prescribers was in New England and the mid-Atlantic region. CONCLUSIONS Growth in high-volume prescribers outpaced the overall growth in buprenorphine prescribers across 2009-2018. High-volume prescribers play an increasingly central role in providing medication for OUD in the U.S., yet results indicate key regional variation in the availability of high-volume buprenorphine prescribers.
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Affiliation(s)
- Megan S Schuler
- RAND Corporation, 1200 S Hayes St, Arlington, VA 22202, USA.
| | - Andrew W Dick
- RAND Corporation, 20 Park Plaza #920, Boston, MA 022, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Department of Internal Medicine, University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA
| | - Rose Kerber
- RAND Corporation, 20 Park Plaza #920, Boston, MA 022, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA 15213, USA
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Durpoix A, Rolling J, Coutelle R, Lalanne L. Psychotherapies in opioid use disorder: toward a step-care model. J Neural Transm (Vienna) 2024; 131:437-452. [PMID: 37987829 PMCID: PMC11055728 DOI: 10.1007/s00702-023-02720-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/01/2023] [Indexed: 11/22/2023]
Abstract
Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.
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Affiliation(s)
- Amaury Durpoix
- Addictology Department, Strasbourg University Hospital, 1, place de l'Hôpital, 67091, Strasbourg, France
- Strasbourg University, Faculty of Medicine, Strasbourg, France
| | - Julie Rolling
- Psychiatry, Mental Health and Addictology Department, Strasbourg University Hospital, Strasbourg, France
- Regional Center for Psychotrauma Great East, Strasbourg, France
- Centre National de la Recherche Scientifique Unité Propre de Recherche 3212 (CNRS UPR 3212), Institute for Cellular and Integrative Neurosciences (INCI), Strasbourg, France
| | - Romain Coutelle
- Psychiatry, Mental Health and Addictology Department, Strasbourg University Hospital, Strasbourg, France
- INSERM U1114, Cognitive Neuropsychology, and Pathophysiology of Schizophrenia, Strasbourg, France
| | - Laurence Lalanne
- Addictology Department, Strasbourg University Hospital, 1, place de l'Hôpital, 67091, Strasbourg, France.
- INSERM U1114, Cognitive Neuropsychology, and Pathophysiology of Schizophrenia, Strasbourg, France.
- Strasbourg University, Faculty of Medicine, Strasbourg, France.
- Fédération de Médecine translationnelle de Strasbourg, Strasbourg, France.
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Williams EC, Frost MC, Bounthavong M, Edmonds AT, Lau MK, Edelman EJ, Harvey MA, Christopher MLD. Implementation of Opioid Safety Efforts: Influence of Academic Detailing on Adverse Outcomes Among Patients in the Veterans Health Administration. SUBSTANCE USE & ADDICTION JOURNAL 2024:29767342241243309. [PMID: 38634339 DOI: 10.1177/29767342241243309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
BACKGROUND The Veterans Health Administration (VA) implemented academic detailing (AD) to support safer opioid prescribing and overdose prevention initiatives. METHODS Patient-level data were extracted monthly from VA's electronic health record to evaluate whether AD implementation was associated with changes in all-cause mortality, opioid poisoning inpatient admissions, and opioid poisoning emergency department (ED) visits in an observational cohort of patients with long-term opioid prescriptions (≥45-day supply of opioids 6 months prior to a given month with ≤15 days between prescriptions). A single-group interrupted time series analysis using segmented logistic regression for mortality and Poisson regression for counts of inpatient admissions and ED visits was used to identify whether the level and slope of these outcomes changed in response to AD implementation. RESULTS Among 955 376 unique patients (19 431 241 person-months), there were 53 369 deaths (29 025 pre-AD; 24 344 post-AD), 1927 opioid poisoning inpatient admissions (610 pre-AD; 1317 post-AD), and 408 opioid poisoning ED visits (207 pre-AD; 201 post-AD). Immediately after AD implementation, there was a 5.8% reduction in the odds of all-cause mortality (95% confidence interval [CI]: 0.897, 0.990). However, patients had a significantly increased incidence rate of inpatient admissions for opioid poisoning immediately after AD implementation (incidence rate ratio = 1.523; 95% CI: 1.118, 2.077). No significant differences in ED visits for opioid poisoning were observed. CONCLUSIONS AD was associated with decreased all-cause mortality but increased inpatient hospitalization for opioid poisoning among patients prescribed long-term opioids. Mechanisms via which AD's efforts influenced opioid-related outcomes should be explored.
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Affiliation(s)
- Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA, USA
| | - Mark Bounthavong
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
- VA Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA, USA
- UCSD Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, CA, USA
| | - Amy T Edmonds
- Department of Health Systems and Population Health, University of Washington School of Public Health, Seattle, WA, USA
- Mathematica, Seattle, WA, USA
| | - Marcos K Lau
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | | | - Michael A Harvey
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
| | - Melissa L D Christopher
- Academic Detailing Service, Pharmacy Benefits Management, Veterans Health Administration, Department of Veterans Affairs Central Office, Washington, DC, USA
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Rizk JG, Saini J, Kim K, Pathan U, Qato DM. County-level factors associated with a mismatch between opioid overdose mortality and availability of opioid treatment facilities. PLoS One 2024; 19:e0301863. [PMID: 38578818 PMCID: PMC10997118 DOI: 10.1371/journal.pone.0301863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/23/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Opioid overdose deaths in the United States remain a major public health crisis. Little is known about counties with high rates of opioid overdose mortality but low availability of opioid use disorder (OUD) treatment facilities. We sought to identify characteristics of United States (US) counties with high rates of opioid overdose mortality and low rates of opioid treatment facilities. METHODS Rates of overdose mortality from 3,130 US counties were compared with availability of opioid treatment facilities that prescribed or allowed medications for OUD (MOUD), from 2018-2019. The outcome variable, "risk-availability mismatch" county, was a binary indicator of a high rate (above national average) of opioid overdose mortality with a low (below national average) rate of opioid treatment facilities. Covariates of interest included county-level sociodemographics and rates of insurance, unemployment, educational attainment, poverty, urbanicity, opioid prescribing, depression, heart disease, Gini index, and Theil index. Multilevel logistic regression, accounting for the clustering of counties within states, was used to determine associations with being a "risk-availability mismatch" county. RESULTS Of 3,130 counties, 1,203 (38.4%) had high rates of opioid overdose mortality. A total of 1,098 counties (35.1%) lacked a publicly-available opioid treatment facility in 2019. In the adjusted model, counties with an additional 1% of: white residents (odds ratio, OR, 1.02; 95% CI, 1.01-1.03), unemployment (OR, 1.11; 95% CI, 1.05-1.19), and residents without insurance (OR, 1.04; 95% CI, 1.01-1.08) had increased odds of being a mismatch county. Counties that were metropolitan (versus non-metropolitan) had an increased odds of being a mismatch county (OR, 1.85; 95% CI, 1.45-2.38). CONCLUSION Assessing mismatch between treatment availability and need provides useful information to characterize counties that require greater public health investment. Interventions to reduce overdose mortality are unlikely to be effective if they do not take into account diverse upstream factors, including sociodemographics, disease burden, and geographic context of communities.
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Affiliation(s)
- John G. Rizk
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Jannat Saini
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Kyungha Kim
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Uzma Pathan
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
| | - Danya M. Qato
- Department of Practice, Sciences and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, United States of America
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Xu KY, Gertner AK, Greenfield SF, Williams AR, Grucza RA. Treatment setting and buprenorphine discontinuation: an analysis of multi-state insurance claims. Addict Sci Clin Pract 2024; 19:17. [PMID: 38493109 PMCID: PMC10943881 DOI: 10.1186/s13722-024-00450-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Accepted: 03/07/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine. METHODS In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression. RESULTS Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.03[1.01-1.06]) and PCPs (aHR = 1.07[1.05-1.10]). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.24[1.20-1.29] and aHR = 1.39[1.34-1.45] respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry). CONCLUSION Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.
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Affiliation(s)
- Kevin Y Xu
- Department of Psychiatry, Health and Behavior Research Center, Washington University School of Medicine, Renard Hospital 3007A, 4940 Children's Place, Saint Louis, MO, 63110, USA.
| | - Alex K Gertner
- University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Shelly F Greenfield
- Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, Belmont, MA, USA
- Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, NY, USA
| | - Richard A Grucza
- Advanced Health Data Institute, Department of Health and Outcomes Research, Department of Family/Community Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
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Rudy L, Lacroix E. Substance use disorders in hospice palliative care: A narrative review of challenges and a case for physician intervention. Palliat Support Care 2024:1-9. [PMID: 38420710 DOI: 10.1017/s1478951523001402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Substance use disorders (SUDs) are frequently encountered in hospice palliative care (HPC) and pose substantial quality-of-life issues for patients. However, most HPC physicians do not directly treat their patients' SUDs due to several institutional and personal barriers. This review will expand upon arguments for the integration of SUD treatment into HPC, will elucidate challenges for HPC providers, and will provide recommendations that address these challenges. METHODS A thorough review of the literature was conducted. Arguments for the treatment of SUDs and recommendations for physicians have been synthesized and expanded upon. RESULTS Treating SUD in HPC has the potential to improve adherence to care, access to social support, and outcomes for pain, mental health, and physical health. Barriers to SUD treatment in HPC include difficulties with accurate assessment, insufficient training, attitudes and stigma, and compromised pain management regimens. Recommendations for physicians and training environments to address these challenges include developing familiarity with standardized SUD assessment tools and pain management practice guidelines, creating and disseminating visual campaigns to combat stigma, including SUD assessment and intervention as fellowship competencies, and obtaining additional training in psychosocial interventions. SIGNIFICANCE OF RESULTS By following these recommendations, HPC physicians can improve their competence and confidence in working with individuals with SUDs, which will help meet the pressing needs of this population.
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Affiliation(s)
- Lauren Rudy
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
| | - Emilie Lacroix
- Department of Psychology, University of New Brunswick, Fredericton, NB, Canada
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13
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Nyaku AN, Zerbo EA, Chen C, Milano N, Johnston B, Chadwick R, Marcello S, Baston K, Haroz R, Crystal S. A survey of barriers and facilitators to the adoption of buprenorphine prescribing after implementation of a New Jersey-wide incentivized DATA-2000 waiver training program. BMC Health Serv Res 2024; 24:179. [PMID: 38331802 PMCID: PMC10851589 DOI: 10.1186/s12913-024-10648-2] [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: 11/03/2023] [Accepted: 01/28/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Opioid-involved overdose deaths continue to rise in the US, despite availability of highly effective treatments for opioid use disorder (OUD), in part due to the insufficient number of treatment providers. Barriers include the need for providers to gain expertise and confidence in providing MOUD to their patients who need these treatments. To mitigate this barrier, New Jersey sponsored a buprenorphine training program with financial incentives for participation, which met the then existing requirement for the DATA-2000 waiver. In a 2019 follow-up survey, participants reported on barriers and facilitators to subsequent buprenorphine prescribing. METHODS Participants in the training program completed a 10-min electronic survey distributed via email. The survey addressed demographics, practice characteristics, current buprenorphine prescribing, and barriers and facilitators to adoption and/or scale up of buprenorphine prescribing. RESULTS Of the 440 attendees with a valid email address, 91 individuals completed the survey for a response rate of 20.6%. Of the 91 respondents, 89 were eligible prescribers and included in the final analysis. Respondents were predominantly female (n = 55, 59.6%) and physicians (n = 55, 61.8%); representing a broad range of specialties and practice sites. 65 (73%) of respondents completed the training and DEA-registration, but only 31 (34.8%) were actively prescribing buprenorphine. The most frequently cited barriers to buprenorphine prescribing were lack of access to support services such as specialists in addiction, behavioral health services, and psychiatry. The most frequently reported potential facilitators were integrated systems with direct access to addiction specialists and psychosocial services, easier referral to behavioral health services, more institutional support, and improved guidance on clinical practice standards for OUD treatment. CONCLUSION More than half (52.3%) of those who completed incentivized training and DEA registration failed to actively prescribe buprenorphine. Results highlight provider perceptions of inadequate availability of support for the complex needs of patients with OUD and suggest that broader adoption of buprenorphine prescribing will require scaling up support to clinicians, including increased availability of specialized addiction and mental health services.
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Affiliation(s)
- Amesika N Nyaku
- Department of Medicine, Division of Infectious Diseases, Rutgers New Jersey Medical School, 185 South Orange Ave, MSB I689, Newark, NJ, 07103, USA.
| | - Erin A Zerbo
- Private Practice, Montclair, NJ, 07042, USA
- Department of Psychiatry, Rutgers New Jersey Medical School, 183 South Orange Ave, BHSB F-Level, Newark, NJ, 07103, USA
| | - Clement Chen
- Department of Psychiatry, Rutgers New Jersey Medical School, 183 South Orange Ave, BHSB F-Level, Newark, NJ, 07103, USA
| | - Nicole Milano
- Mental Health Association in New Jersey, 673 Morris Avenue, Suite 100, Springfield, NJ, 07781, USA
| | - Barbara Johnston
- Mental Health Association in New Jersey, 673 Morris Avenue, Suite 100, Springfield, NJ, 07781, USA
| | - Randall Chadwick
- Rutgers University Behavioral Health Care, 151 Centennial Avenue, Suite 1140, Piscataway, NJ, 08854, USA
| | - Stephanie Marcello
- Rutgers University Behavioral Health Care, 151 Centennial Avenue, Suite 1140, Piscataway, NJ, 08854, USA
| | - Kaitlan Baston
- Department of Internal Medicine, Cooper Medical School of Rowan University, Three Cooper Plaza, Camden, NJ, 08103, USA
| | - Rachel Haroz
- Department of Emergency Medicine, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St, 3rd Floor, New Brunswick, NJ, 08901, USA
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Borelli CM, Gao HT. Implementation of an education session on buprenorphine induction in the emergency department, a resident-led initiative. Harm Reduct J 2024; 21:22. [PMID: 38282077 PMCID: PMC10822147 DOI: 10.1186/s12954-023-00917-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/11/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Many physicians including emergency medicine physicians report insufficient training and education on prescribing buprenorphine for opioid use disorder. As emergency departments implement buprenorphine induction protocols, educational sessions can provide physicians with further familiarity with the treatment of opioid use disorder. This quality improvement project aimed to address the barrier of physician education in the implementation of buprenorphine initiation in the emergency department and presents a model for resident-led education sessions of emergency medicine physicians. METHODS The project was a resident-led educational quality improvement project on educating members of the Department of Emergency Medicine on buprenorphine induction. The thirty-minute educational session included a pre-test survey, lecture, practice case workshop, questions, post-test survey, and a discussion. The survey questions were designed for physicians including residents and faculty, but medical students were invited to complete the session. RESULTS Physicians including faculty and resident physicians responded positively to the educational survey, with an increase from 42.5 to 100% responding that they understood the risks and benefits of prescribing buprenorphine in the emergency department pre and post-survey respectively. Based on post-survey results, 88.5% of physicians responded that they planned to prescribe buprenorphine in the emergency department for patients meeting clinical criteria after completing the educational session. CONCLUSION The results suggest that a resident-led training session can encourage peer involvement in buprenorphine induction to treat opioid use disorder in the emergency department.
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15
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Treitler P, Enich M, Bowden C, Mahone A, Lloyd J, Crystal S. Implementation of an office-based addiction treatment model for Medicaid enrollees: A mixed methods study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 156:209212. [PMID: 37935350 PMCID: PMC10842178 DOI: 10.1016/j.josat.2023.209212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 05/31/2023] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD) are the most effective treatment for opioid use disorder (OUD) but remain underutilized. To reduce barriers to MOUD prescribing and increase treatment access, New Jersey's Medicaid program implemented the Office-Based Addiction Treatment (OBAT) Program in 2019, which increased reimbursement for office-based buprenorphine prescribing and established newly reimbursable patient navigation services in OBAT clinics. Using a mixed-methods design, this study aimed to describe stakeholder experiences with the OBAT program and to assess implementation and uptake of the program. METHODS This study used a concurrent, triangulated mixed-methods design, which integrated complementary qualitative (semi-structured interviews) and quantitative (Medicaid claims) data to gain an in-depth understanding of the implementation of the OBAT program. We elicited stakeholder perspectives through interviews with 22 NJ Medicaid MOUD providers and 8 policy key informants, and examined trends in OBAT program utilization using 2019-2020 NJ Medicaid claims for 5380 Medicaid enrollees who used OBAT services. We used cross-case analysis (provider interviews) and a case study approach (key informant interviews) in analyzing qualitative data, and calculated descriptive statistics and trends for quantitative data. RESULTS Provider enrollment and utilization of OBAT services increased steadily during the first two years of program implementation. Interviewees reported that enhanced reimbursements for office-based MOUD incentivized greater MOUD prescribing, while coverage of patient navigation services improved patient care. Despite increasing enrollment in the OBAT program, the proportion of primary care physicians in the state who enrolled in the program remained limited. Key barriers to enrollment included: requirements for a patient navigator; concerns about administrative burdens and reimbursement delays from Medicaid; lack of awareness of the program; and beliefs that patients with OUD were better served in comprehensive care settings. Patient navigation was highlighted as a critical and valuable element of the program, but navigator enrollment and reimbursement challenges may have prevented greater uptake of this service. CONCLUSIONS Implementation of an OBAT model that enhanced reimbursement and provided coverage for patient navigation likely expanded access to MOUD in NJ. Results support initiatives like the OBAT program in improving access to MOUD, but program adaptations, where feasible, could improve uptake and utilization.
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Affiliation(s)
- Peter Treitler
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; Boston University School of Social Work, 264 Bay State Rd., Boston, MA 02215, United States of America.
| | - Michael Enich
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America
| | - Cadence Bowden
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America
| | - Anais Mahone
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America
| | - James Lloyd
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901, United States of America; School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St., New Brunswick, NJ 08901, United States of America; School of Public Health, Rutgers, the State University of New Jersey, 683 Hoes Lane West, Piscataway, NJ 08854, United States of America
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Xu KY, Huang V, Williams AR, Martin CE, Bazazi AR, Grucza RA. Co-occurring psychiatric disorders and disparities in buprenorphine utilization in opioid use disorder: An analysis of insurance claims. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 9:100195. [PMID: 38023343 PMCID: PMC10630609 DOI: 10.1016/j.dadr.2023.100195] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023]
Abstract
Background As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation. Methods This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics. Results Buprenorphine initiation occurred in 29.3 % of those with co-occurring anxiety-and-related disorders, compared to 25.9 % and 17.5 % in people with mood and psychotic disorders. Mood (adjusted-risk-ratio[aRR] = 0.82[95 % CI = 0.82-0.83]) and psychotic disorders (aRR = 0.95[0.94-0.96]) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR = 1.06[1.05-1.06]). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratio[aHR] = 1.20[1.17-1.24]) and anxiety disorders (aHR = 1.12[1.09-1.14]), in contrast to no association between psychotic disorders and buprenorphine discontinuation. Conclusions We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.
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Affiliation(s)
- Kevin Y Xu
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Vivien Huang
- Health and Behavior Research Center, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Arthur Robin Williams
- Department of Psychiatry, College of Physicians and Surgeons of Columbia University, New York, New York, USA
- Division of Substance Use Disorders, New York State Psychiatric Institute, New York, New York, USA
| | - Caitlin E Martin
- Department of Obstetrics and Gynecology and the VCU Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Alexander R. Bazazi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA
| | - Richard A. Grucza
- Department of Family and Community Medicine, St. Louis University, St. Louis, Missouri, USA
- Department of Health and Clinical Outcomes Research, St. Louis University, St Louis, Missouri, USA
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Hodgkin D, Horgan CM, Jordan Brown S, Bart G, Stewart MT. Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment. THE JOURNAL OF MENTAL HEALTH POLICY AND ECONOMICS 2023; 26:149-158. [PMID: 38113385 PMCID: PMC10752219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/26/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care. AIMS To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability. METHODS We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far. RESULTS The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders. DISCUSSION A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends. IMPLICATIONS FOR HEALTH POLICY For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models. IMPLICATIONS FOR FURTHER RESEARCH For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.
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Affiliation(s)
- Dominic Hodgkin
- Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts 02453, United States
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Christine PJ, Larochelle MR, Lin L(A, McBride J, Tipirneni R. Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder. JAMA HEALTH FORUM 2023; 4:e233549. [PMID: 37862034 PMCID: PMC10589810 DOI: 10.1001/jamahealthforum.2023.3549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/17/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. Objective To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. Design, Setting, and Participants This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Exposures Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. Main Outcomes and Measures The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Results Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). Conclusions and Relevance In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.
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Affiliation(s)
- Paul J. Christine
- Section of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Marc R. Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Lewei (Allison) Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Addiction Center, Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Renuka Tipirneni
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Culp-Roche A, Vaughn J, Arms T, Roberto A, Hubbell S, Link T. Medications for opioid use disorder: An interactive educational program developed for the nurse practitioner curriculum. J Am Assoc Nurse Pract 2023; 35:638-641. [PMID: 37260253 DOI: 10.1097/jxx.0000000000000897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/25/2023] [Indexed: 06/02/2023]
Abstract
ABSTRACT Opioid overdose deaths remain a major public health concern in the United States and led to the recent changes in regulations that allow nurse practitioners (NPs) to prescribe buprenorphine without the previously required Drug Addiction Treatment Act waiver. Previously, waiver requirements included 24 hours of opioid use disorder (OUD) and medications for OUD (MOUD) training. Although this training is no longer required, NPs need education related to providing nonstigmatizing care to individuals with OUD and safe MOUD prescribing practices. A combination of online didactic modules, in-person simulation activities, and experiential learning was provided to psychiatric mental health NP (PMHNP) and family NP (FNP) students enrolled in a Doctor of Nursing Practice (DNP) program. OUD was presented through a chronic care lens to normalize treatment and decrease stigma, and harm reduction principles were included to increase safe prescribing of MOUD. Fifty-six students completed the didactic training, 51 students participated in the simulation, and 11 students completed shadowing experiences with an experienced MOUD provider. Psychiatric mental health NP and FNP graduates of this DNP program have the knowledge and skills to provide MOUD to individuals struggling with OUD, thus potentially increasing access to care and decreasing overdose deaths.
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Affiliation(s)
- Amanda Culp-Roche
- University of North Carolina Wilmington School of Nursing, Wilmington, North Carolina
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20
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Garcia CC, Bounthavong M, Gordon AJ, Gustavson AM, Kenny ME, Miller W, Esmaeili A, Ackland PE, Clothier BA, Bangerter A, Noorbaloochi S, Harris AHS, Hagedorn HJ. Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder. Implement Sci Commun 2023; 4:91. [PMID: 37563672 PMCID: PMC10413546 DOI: 10.1186/s43058-023-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/29/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.
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Affiliation(s)
- Carla C Garcia
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mark Bounthavong
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
- UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, San Diego, CA, 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, 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
| | - Allison M Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marie E Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Aryan Esmaeili
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Princess E Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Barbara A Clothier
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Ann Bangerter
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
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Lowenstein M, Perrone J, McFadden R, Xiong RA, Meisel ZF, O'Donnell N, Abdel-Rahman D, Moon J, Mitra N, Delgado MK. Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis. Ann Emerg Med 2023; 82:131-144. [PMID: 37318434 PMCID: PMC11019868 DOI: 10.1016/j.annemergmed.2023.03.033] [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] [Received: 11/18/2022] [Revised: 03/23/2023] [Accepted: 03/28/2023] [Indexed: 06/16/2023]
Abstract
STUDY OBJECTIVE Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs. METHODS We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls. RESULTS There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls. CONCLUSION An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.
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Affiliation(s)
- Margaret Lowenstein
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA.
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Rachel McFadden
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Ruiying Aria Xiong
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Zachary F Meisel
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nicole O'Donnell
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA
| | - Dina Abdel-Rahman
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
| | - Jeffrey Moon
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Mucio Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA; Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, PA
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Moses TEH, Waineo E, Levine D, Greenwald MK. Optimizing buprenorphine training during undergraduate medical education: Medical student feedback and attitudes. Am J Addict 2023; 32:376-384. [PMID: 36850044 PMCID: PMC10313763 DOI: 10.1111/ajad.13395] [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: 09/23/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Strong evidence supports efficacy of medications for opioid use disorder (MOUD), but stringent prescribing policies impair access. Many physicians report discomfort prescribing MOUD due to inadequate knowledge. Most medical students believe MOUD training should occur during undergraduate medical education (UME). As legislation surrounding buprenorphine prescribing shifts, it is timely to consider how best to incorporate MOUD training into UME. METHODS At the start of 3rd year, all students (n = 290) received a survey regarding experiences working with people with OUDs, and beliefs and knowledge regarding harm reduction and treatment. During orientation, students completed an 8-h online MOUD training. Afterwards, students completed another survey, including questions about training perceptions. RESULTS One-third of students (32.8%) completed MOUD training and both surveys. Before training, 60.0% had not heard of the waiver, but 82.1% endorsed interest in prescribing buprenorphine. Despite mixed feelings about training content and delivery, 79.1% believed future classes should receive it. Most thought it should be integrated longitudinally throughout the curriculum rather than as separate online training. CONCLUSION AND SCIENTIFIC SIGNIFICANCE Medical students want more MOUD education throughout their training; however, the 8-h online training may be less-than-optimal. As this training is no longer required to prescribe buprenorphine, there is an opportunity to modify the content presented. There is an urgent need for physicians with the knowledge and willingness to treat patients with OUD. Introducing integrated training about MOUD should help future physicians feel confident in their knowledge to treat patients and comfortable applying for the waiver.
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Affiliation(s)
- Tabitha E H Moses
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Eva Waineo
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Diane Levine
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Mark K Greenwald
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, Michigan, USA
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Heerema MR, Ventura AS, Blakemore SC, Montoya ID, Gobel DE, Kiang MV, LaBelle CT, Bazzi AR. Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce. Subst Abus 2023; 44:164-176. [PMID: 37287240 PMCID: PMC10688578 DOI: 10.1177/08897077231179601] [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: 06/09/2023]
Abstract
INTRODUCTION Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants. METHODS We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control. RESULTS Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points. CONCLUSIONS NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.
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Affiliation(s)
- Matthew R. Heerema
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Alicia S. Ventura
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Samantha C. Blakemore
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Ivan D. Montoya
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Danna E. Gobel
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
| | - Mathew V. Kiang
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, United States of America
| | - Colleen T. LaBelle
- General Internal Medicine, Boston Medical Center, Boston, MA, United States of America
- Grayken Center for Addiction Medicine, Boston Medical Center, Boston, MA, United States of America
- Boston University School of Medicine, Boston, MA, United States of America
| | - Angela R. Bazzi
- Boston University School of Public Health, Boston, MA, United States of America
- Herbert Wertheim School of Public Health, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, United States of America
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Kelley AT, Wilcox J, Baylis JD, Crossnohere NL, Magel J, Jones AL, Gordon AJ, Bridges JFP. Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives. J Gen Intern Med 2023; 38:2147-2155. [PMID: 36471194 PMCID: PMC10361924 DOI: 10.1007/s11606-022-07975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers. OBJECTIVE To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics. DESIGN We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources). PARTICIPANTS Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system. MAIN MEASURES B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance). KEY RESULTS Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist. CONCLUSIONS Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics.
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Affiliation(s)
- A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 50 North Medical Drive, 5R341, Salt Lake City, UT, 84132, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Jordynn Wilcox
- Office of the Director, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Norah L Crossnohere
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - John Magel
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Physical Therapy and Athletic Training, University of Utah College of Health, Salt Lake City, UT, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
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Shrestha S, Lindstrom MR, Harris D, Rock P, Srinivasan S, Pustz JC, Bayly R, Stopka TJ. Spatial access to buprenorphine-waivered prescribers in the HEALing communities study: Enhanced 2-step floating catchment area analyses in Massachusetts, Ohio, and Kentucky. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 150:209077. [PMID: 37211155 PMCID: PMC10330859 DOI: 10.1016/j.josat.2023.209077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 04/08/2023] [Accepted: 05/02/2023] [Indexed: 05/23/2023]
Abstract
INTRODUCTION The opioid overdose epidemic continues to impact a large swath of the population in the US. Medications for opioid use disorders (MOUD) are an effective resource to combat the epidemic; however, there is limited research on MOUD treatment access that accounts for both supply of and demand for services. We aimed to examine access to buprenorphine prescribers in the HEALing Communities Study (HCS) Wave 2 communities in Massachusetts, Ohio, and Kentucky during 2021, and the association between buprenorphine access and opioid-related incidents, specifically fatal overdoses and opioid-related responses by emergency medical services (EMS). METHODS We calculated Enhanced 2-Step Floating Catchment Area (E2SFCA) accessibility indices for each state, as well as Wave 2 communities in each state, based on the location of providers (buprenorphine-waivered clinicians from the US Drug Enforcement Agency Active Registrants database), population-weighted centroids at the census block group level, and catchment areas defined by the state or community's average commute time. In advance of intervention initiation, we quantified the opioid-related risk environment of communities. We assessed gaps in services by using bivariate Local Moran's I analysis, incorporating accessibility indices and opioid-related incident data. RESULTS Massachusetts Wave 2 HCS communities had the highest rates of buprenorphine prescribers per 1000 patients (median: 165.8) compared to Kentucky (38.8) and Ohio (40.1). While urban centers in all three states had higher E2SFCA index scores compared to rural communities, we observed that suburban communities often had limited access. Through bivariate Local Moran's I analysis, we identified numerous locations with low buprenorphine access surrounded by high opioid-related incidents, particularly in communities that surrounded Boston, Massachusetts; Columbus, Ohio; and Louisville, Kentucky. CONCLUSION Rural communities demonstrated a great need for additional access to buprenorphine prescribers. However, policymakers should also direct attention toward suburban communities that have experienced significant increases in opioid-related incidents.
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Affiliation(s)
- Shikhar Shrestha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111, United States of America
| | - Megan R Lindstrom
- Department of Geography, Ohio State University, 154 North Oval Mall, Columbus, OH 43210, United States of America
| | - Daniel Harris
- Department of Pharmacy Practice and Science, College of Pharmacy, Lee T. Todd Building, University of Kentucky, Lexington, KY 40506, United States of America; Institute of Pharmaceutical Outcomes and Policy, College of Pharmacy, Lee T. Todd Building, University of Kentucky, Lexington, KY 40506, United States of America
| | - Peter Rock
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY 40506, United States of America
| | - Sumeeta Srinivasan
- Department of Urban and Environmental Policy and Planning, Tufts University Graduate School of Arts and Sciences, 97 Talbot Ave., Medford, MA, United States of America
| | - Jennifer C Pustz
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111, United States of America
| | - Ric Bayly
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111, United States of America
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave., Boston, MA 02111, United States of America; Clinical and Translational Sciences Institute, Tufts University School of Medicine, 35 Kneeland St., Boston, MA 02111, United States of America; Department of Community Health, Tufts University, 574 Boston Ave, Medford, MA, United States of America; Department Urban and Environmental Policy and Planning, Tufts University, 97 Talbot Ave, Medford, MA, United States of America.
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Silwal A, Talbert J, Bohler RM, Kelsch J, Cook C, Blevins D, Gallivan M, Hunt T, Hatcher SM, Thomas CP, Williams S, Fanucchi L, Lofwall MR. State alignment with federal regulations in 2022 to relax buprenorphine 30-patient waiver requirements. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100164. [PMID: 37234704 PMCID: PMC10206439 DOI: 10.1016/j.dadr.2023.100164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
Background In 2021, the Department of Health and Human Services released guidelines allowing waiver-eligible providers seeking to treat up to 30 patients to be exempt from waiver training (WT) and the counseling and other ancillary services (CAS) attestation. This study evaluates if states and the District of Columbia had more restrictive policies preventing adoption of the 2021 federal guidelines. Methods First, the Westlaw database was searched for buprenorphine regulations. Second, state medical, osteopathic, physician assistant, nursing boards, and single state agencies (SSA) were surveyed to assess for the WT and CAS requirements and if they were discussing the 2021 guidelines. Results were recorded and compared by state and waiver-eligible provider types. Results The Westlaw search revealed seven states with regulations requiring the WT and ten states requiring CAS. Survey results showed ten state boards/SSAs required WT for at least one waiver-eligible practitioner type and eleven state boards/SSAs required CAS. In some states, the WT and CAS requirements only applied in special circumstances. Eleven states had discrepancies between the Westlaw and survey results among three waiver-eligible provider types. Conclusions Despite the 2021 federal change intended to increase access to buprenorphine, several states had regulations and/or provider boards and SSAs that were not supportive. Now, the Mainstreaming Addiction Treatment (MAT) Act of 2022 eliminated the federal x-waiver requirement to prescribe buprenorphine. However, these states may continue to have barriers to treatment access despite the MAT Act. Strategies to engage states with these restrictive policies are needed to improve buprenorphine treatment capacity.
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Affiliation(s)
- Anita Silwal
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
- Department of Communication, College of Communication and Information, University of Kentucky, Lexington, KY, USA
| | - Jeffery Talbert
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Robert M. Bohler
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Jordan Kelsch
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Christopher Cook
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Derek Blevins
- Division of Substance Use Disorders, New York State Psychiatric Institute / Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Molly Gallivan
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Timothy Hunt
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | | | - Cindy Parks Thomas
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Soncere Williams
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | - Laura Fanucchi
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Division of Infectious Diseases, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Departments of Behavioral Science and Psychiatry, College of Medicine, University of Kentucky, Lexington, KY, USA
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Claypool AL, DiGennaro C, Russell WA, Yildirim MF, Zhang AF, Reid Z, Stringfellow EJ, Bearnot B, Schackman BR, Humphreys K, Jalali MS. Cost-effectiveness of Increasing Buprenorphine Treatment Initiation, Duration, and Capacity Among Individuals Who Use Opioids. JAMA HEALTH FORUM 2023; 4:e231080. [PMID: 37204803 PMCID: PMC10199347 DOI: 10.1001/jamahealthforum.2023.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/26/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity. Objective To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity. Design and Setting This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US. Interventions Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination. Main Outcomes and Measures Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective. Results Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously. Conclusion and Relevance This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.
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Affiliation(s)
- Anneke L. Claypool
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Catherine DiGennaro
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - W. Alton Russell
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Melike F. Yildirim
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Alan F. Zhang
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Zuri Reid
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Erin J. Stringfellow
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
| | - Mohammad S. Jalali
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- MIT Sloan School of Management, Cambridge, Massachusetts
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Jones KF, O'Reilly Jacob M, Spetz J, Hailer L, Tierney M. Eliminate the buprenorphine DEA X waiver: Justification using a policy analysis approach. J Nurs Scholarsh 2023; 55:655-664. [PMID: 36624606 PMCID: PMC10159879 DOI: 10.1111/jnu.12871] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/28/2022] [Accepted: 12/21/2022] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Drug overdoses have reached a historic milestone of over 100,000 deaths in a single year, 75,673 related to opioids. The acceleration in opioid-related deaths coupled with stark health inequities demands a close examination of opioid use disorder (OUD) treatment barriers and swift consideration of policy changes. DESIGN The aim of this buprenorphine policy analysis is to summarize existing buprenorphine barriers and present policy solutions to improve access and actualize the contributions of Advanced Practice Registered Nurses (APRNs). METHODS The policy analysis follows five sequential steps: (1) defining the problem, (2) identifying key stakeholders, (3) assessing the landscape of relevant policies, (4) describing viable policy options, and (5) making final recommendations. RESULTS Although there are laudable efforts to improve buprenorphine access, such as the new buprenorphine guidelines issued in April 2021, without larger-scale changes to federal, state, and scope of practice laws, overdose rates will continue to rise. We recommend a multipronged policy approach to improve buprenorphine treatment access, including eliminating the DEA X waiver, improving OUD education, and adopting full practice authority for APRNs in all states. CONCLUSION Incremental change is no longer sufficient to address opioid overdose deaths. Bolder and coordinated policy action is possible and necessary to empower the full clinical workforce to apply evidence-based life-saving treatments for OUD. The critical contributions of nurses in advancing equitable access to OUD care are emphasized in the National Academy of Medicine's Report, Future of Nursing: Charting a Path to Achieve Health Equity. Nurses are named as instrumental in improving buprenorphine access. Policy changes that acknowledge and build on evidence-based treatment expansion strategies are sorely needed. CLINICAL RELEVANCE One of the most robust tools to combat opioid overdose deaths is buprenorphine, a partial opioid agonist, and gold standard medication treatment for OUD, but only 5% of the prescribing workforce possess the required Drug Enforcement Agency (DEA) X waiver. A growing body of evidence demonstrates that Advanced Practice Registered Nurses are accelerating the growth in waiver update and buprenorphine use, despite the considerable barriers and limitations described in this policy analysis.
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Affiliation(s)
- Katie Fitzgerald Jones
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Mongan Institute for Aging and Serious Illness, Boston, Massachusetts, USA
- Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA
| | - Monica O'Reilly Jacob
- Boston College, William F. Connell School of Nursing, Chestnut Hill, Massachusetts, USA
| | - Joanne Spetz
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | | | - Matthew Tierney
- Office of Population Health, UCSF Health, University of California San Francisco, San Francisco, California, USA
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Elmore AL, Patrick SW, McNeer E, Fryer K, Reid CN, Sappenfield WM, Mehra S, Salemi JL, Marshall J. Treatment access for opioid use disorder among women with medicaid in Florida. Drug Alcohol Depend 2023; 246:109854. [PMID: 37001322 PMCID: PMC10121896 DOI: 10.1016/j.drugalcdep.2023.109854] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 03/15/2023] [Accepted: 03/19/2023] [Indexed: 04/23/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) remains prevalent. Medications for OUD (MOUD) are standard care for pregnant and non-pregnant women. Previous research has identified barriers to MOUD for women with Medicaid but did not account for the type of MOUD (methadone vs. buprenorphine) or pregnancy status. We examined access to MOUD by treatment type for pregnant and non-pregnant women with Medicaid in Florida. METHODS A secondary analysis of Florida "secret-shopper" data was conducted. Calls were made to clinicians from the 2018 Substance Abuse and Mental Health Services Administration provider list by women posing as either a pregnant or non-pregnant woman with OUD and Medicaid. We examined 546 calls to buprenorphine-waivered providers (BWP) and 139 to opioid treatment programs (OTP). Counts and percentages were used to describe caller success by type of treatment and pregnancy status. Chi-square tests were used to identify statistical differences. RESULTS Only 42 % of calls reached a treatment provider in Florida. Pregnant and non-pregnant women were less likely to obtain an appointment with Medicaid coverage by a BWP than an OTP (p < 0.01). Nearly 40 % of OTPs offered appointments to callers with Medicaid compared to only 17 % of BWPs. Both types of providers denied appointments more often for pregnant women. Thirty-eight percent of BWP's and 12 % of OTP's denied appointments to pregnant women using cash or Medicaid payment. CONCLUSIONS Our study demonstrates logistical and financial barriers to treatment for OUD among pregnant and non-pregnant women with Medicaid in Florida and highlights the need for improved systems of care.
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Affiliation(s)
- Amanda L Elmore
- College of Public Health, University of South Florida, Tampa, FL, United States.
| | - Stephen W Patrick
- Vanderbilt Center for Child Health Policy & Departments of Pediatrics and Health Policy, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Elizabeth McNeer
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kimberly Fryer
- Department of Obstetrics & Gynecology, University of South Florida, Tampa, FL, United States
| | - Chinyere N Reid
- College of Public Health, University of South Florida, Tampa, FL, United States
| | | | - Saloni Mehra
- College of Public Health, University of South Florida, Tampa, FL, United States
| | - Jason L Salemi
- College of Public Health, University of South Florida, Tampa, FL, United States
| | - Jennifer Marshall
- College of Public Health, University of South Florida, Tampa, FL, United States
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CERDÁ MAGDALENA, KRAWCZYK NOA, KEYES KATHERINE. The Future of the United States Overdose Crisis: Challenges and Opportunities. Milbank Q 2023; 101:478-506. [PMID: 36811204 PMCID: PMC10126987 DOI: 10.1111/1468-0009.12602] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.
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Affiliation(s)
- MAGDALENA CERDÁ
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
| | - NOA KRAWCZYK
- Center for Opioid Epidemiology and PolicyNYU Grossman School of Medicine
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Krupp J, Hung F, LaChapelle T, Yarrington ME, Link K, Choi Y, Chen H, Marais AD, Sachdeva N, Chakraborty H, McKellar MS. Impact of Policy Change on Access to Medication for Opioid Use Disorder in Primary Care. South Med J 2023; 116:333-340. [PMID: 37011580 PMCID: PMC10045971 DOI: 10.14423/smj.0000000000001544] [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] [Accepted: 11/17/2022] [Indexed: 04/05/2023]
Abstract
OBJECTIVES The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ2 test to evaluate the effect of the educational intervention on screening. RESULTS Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.
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Affiliation(s)
| | - Frances Hung
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine
| | | | - Michael E. Yarrington
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Katherine Link
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
| | - Yujung Choi
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Hillary Chen
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Andrea Des Marais
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Nidhi Sachdeva
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina
| | | | - Mehri S. McKellar
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine
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Winograd RP, Coffey B, Woolfolk C, Wood CA, Ilavarasan V, Liss D, Jain S, Stringfellow E. To Prescribe or Not to Prescribe?: Barriers and Motivators for Progressing Along Each Stage of the Buprenorphine Training and Prescribing Path. J Behav Health Serv Res 2023; 50:165-180. [PMID: 35060002 DOI: 10.1007/s11414-021-09783-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/24/2022]
Abstract
This study aimed to identify the strongest barriers and motivators associated with each step toward buprenorphine prescribing (1. obtaining a waiver, 2. beginning to prescribe, and 3. prescribing to more people) among a sample of Missouri-based medical professionals (N = 130). Item weights (number of endorsements times mean rank of the item's importance) were calculated based on their responses. Across groups, lack of access to psychosocial support services, need for higher levels of care, and clinical complexity were strong barriers. Among non-prescribers (n = 57, 46.3%), administrative burden, potential of becoming an addiction clinic, and concern about misuse and diversion were most heavily weighted. Among prescribers (n = 66, 53.7%), patients' inability to afford medications was a barrier across phases. Prominent motivators among all groups were the effectiveness of buprenorphine, improvement in other health outcomes, and a personal interest in treating addiction. Only prescribers reported the presence of institutional support and mentors as significant motivators.
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Affiliation(s)
- Rachel P Winograd
- St. Louis - Missouri Institute of Mental Health, University of Missouri, 43 Benton Court, St. Louis, MO, 63121, USA.
| | - Bridget Coffey
- St. Louis - Missouri Institute of Mental Health, University of Missouri, 43 Benton Court, St. Louis, MO, 63121, USA
| | - Candice Woolfolk
- St. Louis - Missouri Institute of Mental Health, University of Missouri, 43 Benton Court, St. Louis, MO, 63121, USA
| | - Claire A Wood
- St. Louis - Missouri Institute of Mental Health, University of Missouri, 43 Benton Court, St. Louis, MO, 63121, USA
| | - Vinith Ilavarasan
- St. Louis - Missouri Institute of Mental Health, University of Missouri, 43 Benton Court, St. Louis, MO, 63121, USA
| | - David Liss
- Department of Emergency Medicine, Washington University School of Medicine, 660 S Euclid Ave, St. Louis, MO, 63110, USA
| | - Subodh Jain
- Spectrum Health, Division of Psychiatry and Behavioral Medicine, 2750 E Beltline NE, Grand Rapids, MI, 49525, USA
| | - Erin Stringfellow
- Massachusetts General Hospital Institute for Technology Assessment & Harvard Medical School, Boston, MA, USA
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McKnight ER, Dong Q, Brook DL, Hepler SA, Kline DM, Bonny AE. A Descriptive Study on Opioid Misuse Prevalence and Office-Based Buprenorphine Access in Ohio Prior to the Removal of the Drug Addiction Treatment Act of 2000 Waiver. Cureus 2023; 15:e36903. [PMID: 37139287 PMCID: PMC10151104 DOI: 10.7759/cureus.36903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background Medications for the treatment of opioid use disorder (MOUD) are effective evidence-based strategies to reduce opioid overdose deaths. Strategies to optimize MOUD availability and uptake are needed. Objective We aim to describe the spatial relationship between the estimated prevalence of opioid misuse and office-based buprenorphine access in the state of Ohio prior to the removal of the Drug Addiction Treatment Act of 2000 (DATA 2000) waiver requirement. Methods We conducted a descriptive ecological study of county-level (N=88) opioid misuse prevalence and office-based buprenorphine prescribing access in Ohio in 2018. Counties were categorized into urban (with and without a major metropolitan area) and rural. The county-level prevalence estimates of opioid misuse per 100,000 were derived from integrated abundance modeling. Utilizing data from the Ohio Department of Mental Health and Addiction Services, as well as the state's Physician Drug Monitoring Program (PDMP), buprenorphine access per 100,000 was estimated by the number of patients in each county that could be served by office-based buprenorphine (prescribing capacity) and the number of patients served by office-based buprenorphine (prescribing frequency) for opioid use disorder. The ratios of opioid misuse prevalence to both prescribing capacity and frequency were calculated by county and mapped. Results Less than half of the 1,828 waivered providers in the state of Ohio in 2018 were prescribing buprenorphine, and 25% of counties had no buprenorphine access. The median estimated opioid misuse prevalence and buprenorphine prescribing capacity per 100,000 were highest in urban counties, particularly those with a major metropolitan area. Although the median estimated opioid misuse prevalence was lower in rural counties, all counties in the highest quartile of estimated misuse prevalence were rural. In addition, the median buprenorphine prescribing frequency was highest in rural counties. While the ratio of opioid misuse prevalence to buprenorphine prescribing capacity was lowest in urban counties, the ratio of opioid misuse prevalence to buprenorphine prescribing frequency was lowest in rural counties. Opioid misuse prevalence and buprenorphine prescribing frequency demonstrated similar spatial patterns, with highest levels in the southern and eastern portions of the state, while office-based buprenorphine prescribing capacity did not. Conclusion Urban counties had higher buprenorphine capacity relative to their burden of opioid misuse; however, access was limited by buprenorphine prescribing frequency. In contrast, in rural counties, a minimal gap was evident between prescribing capacity and frequency, suggesting that buprenorphine prescribing capacity was the major factor limiting access. While the recent deregulation of buprenorphine prescribing should help improve buprenorphine access, future research should investigate whether deregulation similarly impacts buprenorphine prescribing capacity and buprenorphine prescribing frequency.
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Lindenfeld Z, Franz B, Cronin C, Chang JE. Hospital adoption of harm reduction and risk education strategies to address substance use disorders. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2023; 49:206-215. [PMID: 36877147 DOI: 10.1080/00952990.2023.2169832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Background: Hospitals are well-positioned to integrate harm reduction into their workflow. However, the extent to which hospitals across the United States are adopting these strategies remains unknown.Objectives: To assess what factors are associated with hospital adoption of harm reduction/risk education strategies, and trends of adoption across time.Methods: We constructed a dataset marking implementation of harm reduction/risk education strategies for a 20% random sample of nonprofit hospitals in the U.S (n = 489) using 2019-2021 community health needs assessments (CHNAs) and implementation strategies obtained from hospital websites. We used two-level mixed effects logistic regression to test the association between adoption of these activities and organizational and community-level variables. We also compared the proportion of hospitals that adopted these strategies in the 2019-2021 CHNAs to an earlier cohort (2015-2018.)Results: In the 2019-2021 CHNAs, 44.7% (n = 219) of hospitals implemented harm reduction/risk education programs, compared with 34.1% (n = 156) in the 2015-2018 cycle. In our multivariate model, hospitals that implemented harm reduction/risk education programs had higher odds of having adopted three or more additional substance use disorder (SUD) programs (OR: 10.5: 95% CI: 5.35-20.62), writing the CHNA with a community organization (OR: 2.14; 95% CI: 1.15-3.97), and prioritizing SUD as a top three need in the CHNA (OR: 2.63; 95% CI: 1.54-4.47.)Conclusions: Our results suggest that hospitals with an existing SUD infrastructure and with connections to community are more likely to implement harm reduction/risk education programs. Policymakers should consider these findings when developing strategies to encourage hospital implementation of harm reduction activities.
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Affiliation(s)
- Zoe Lindenfeld
- Department of Public Health Policy and Management, School of Global Public Health, New York University, Broadway, NY, USA
| | - Berkeley Franz
- Heritage College of Osteopathic Medicine, Ohio University, Athens, OH, USA
| | - Cory Cronin
- College of Health Sciences and Professions, Ohio University, Athens, OH, USA
| | - Ji Eun Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, Broadway, NY, USA
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Rubel SK, Eisenstat M, Wolff J, Calevski M, Mital S. Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review. Subst Use Misuse 2023; 58:685-697. [PMID: 36803159 PMCID: PMC10961708 DOI: 10.1080/10826084.2023.2177972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
BACKGROUND Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access. METHODS To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S. RESULTS In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD. CONCLUSIONS Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.
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Affiliation(s)
- Stephanie K Rubel
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew Eisenstat
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jessica Wolff
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Calevski
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Sasha Mital
- National Center for Injury Prevention and Control, Division of Overdose Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Fujita AW, Ramakrishnan A, Mehta CC, Yusuf OB, Wilson T, Shoptaw S, Carrico AW, Adimora AA, Eaton E, Cohen MH, Cohen J, Adedimeji A, Plankey M, Jones D, Chandran A, Colasanti JA, Sheth AN. Substance Use Treatment Utilization Among Women With and Without Human Immunodeficiency Virus. Open Forum Infect Dis 2023; 10:ofac684. [PMID: 36655189 PMCID: PMC9835749 DOI: 10.1093/ofid/ofac684] [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] [Received: 10/27/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Background Substance use (SU) contributes to poor health outcomes, yet limited data exist to inform strategies to optimize SU treatment among persons with human immunodeficiency virus (HIV). We describe SU and SU treatment utilization among women with and without HIV in the Women's Interagency HIV Study (WIHS). Methods We included data from women enrolled in WIHS from 2013 to 2020. Current SU was self-reported, nonmedical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was self-reported use of a drug treatment program in the past year. Multivariable regression models were used to investigate associations between participant characteristics and SU treatment. Results Among 2559 women (1802 women living with HIV [WWH], 757 women without HIV), 14% reported current SU. Among those with current SU (n = 367), 71% reported crack/cocaine followed by 40% reporting opioids, and 42% reported any treatment in the past year. The most common treatments were methadone (64%), Narcotics Anonymous (29%), inpatient programs (28%), and outpatient programs (16%). Among women using opioids (n = 147), 67% reported methadone use in the past year compared to 5% using buprenorphine/naloxone. Multivariable analysis showed lower odds of treatment utilization among WWH with concurrent alcohol or marijuana use. Visiting a psychiatrist/counselor was associated with higher odds of treatment. Among WWH, SU treatment was not associated with HIV-related clinical outcomes. Conclusions Treatment utilization was high, especially for methadone use. Our results highlight opportunities for accessing SU treatment for WWH, such as the need to prioritize buprenorphine and comprehensive, wraparound services in HIV care settings.
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Affiliation(s)
- Ayako W Fujita
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aditi Ramakrishnan
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, St Louis, Missouri, USA
| | - C Christina Mehta
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Oyindamola B Yusuf
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tracey Wilson
- Department of Community Health Sciences, School of Public Health, State University of New York Downstate Health Sciences University, Brooklyn, New York, USA
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Adam W Carrico
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Adaora A Adimora
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Ellen Eaton
- Division of Infectious Diseases, Department of Medicine, University of Alabama School of Medicine, Birmingham, Alabama, USA
| | - Mardge H Cohen
- Department of Medicine, Stroger Hospital of Cook County, Chicago, Illinois, USA
| | - Jennifer Cohen
- Department of Medicine, Infectious Diseases, University of California, San Francisco, San Francisco, California, USA
| | - Adebola Adedimeji
- Division of Health Behavior Research and Implementation Science, Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Michael Plankey
- Division of General Internal Medicine, Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Deborah Jones
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Aruna Chandran
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Jonathan A Colasanti
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Infectious Disease Program, Grady Health System, Atlanta, Georgia, USA
| | - Anandi N Sheth
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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Dai Z, Limen GN, Abate MA, Kraner JC, Mock AR, Smith GS. Characterization of Unintentional Deaths Among Buprenorphine Users. J Stud Alcohol Drugs 2023; 84:171-179. [PMID: 36799687 PMCID: PMC9948141 DOI: 10.15288/jsad.22-00049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/22/2022] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Medications used to treat opioid use disorder (OUD) reduce drug overdose risk. Buprenorphine is often the preferred treatment for OUD because of its high safety profile. Given expanding buprenorphine use, this study sought to examine buprenorphine-involved deaths (BIDs) and compare them with other drug-related deaths. METHOD West Virginia drug-related deaths from 2005 to early 2020 were identified. Study data included decedent demographics, toxicology, autopsy findings, and medical and prescription histories. Characteristics of BIDs compared with other drug-related deaths were statistically analyzed. RESULTS Among 11,764 drug-related deaths, only 564 (4.8%) involved buprenorphine. Buprenorphine alone was present in 32 deaths, of which 20 were considered the direct cause of death (0.2% of all drug-related deaths). Significantly more BIDs involved five or more drugs (23%) compared with other opioid deaths (14.9%). Co-intoxicants found most frequently in BIDs were benzodiazepines (47.3%), methamphetamine (27.1%), and fentanyl (22.9%). Cardiovascular and pulmonary comorbidities were identified in 43% and 21% of BIDs, respectively. Of the 564 BIDs, a current buprenorphine prescription was present in 132 deaths (23.4%). CONCLUSIONS Despite increasing buprenorphine use, BIDs comprised less than 5% of overall West Virginia drug-related deaths. Seldom was it the only drug found, and most decedents did not have current prescriptions for buprenorphine. Although buprenorphine is effective, with a wide safety margin, clinicians and patients should be aware that buprenorphine can be involved in overdose deaths, especially when buprenorphine is taken in combination with drugs such as benzodiazepines, methamphetamine, or fentanyl, and in persons with underlying cardiovascular or pulmonary comorbidities.
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Affiliation(s)
- Zheng Dai
- West Virginia University Health Affairs Institute, Morgantown, West Virginia
| | - George N. Limen
- West Virginia University School of Pharmacy, Morgantown, West Virginia
| | - Marie A. Abate
- West Virginia University School of Pharmacy, Morgantown, West Virginia
| | - James C. Kraner
- West Virginia Office of the Chief Medical Examiner, Charleston, West Virginia
| | - Allen R. Mock
- West Virginia Office of the Chief Medical Examiner, Charleston, West Virginia
| | - Gordon S. Smith
- West Virginia University School of Public Health, Morgantown, West Virginia
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Smart R, Kim JY, Kennedy S, Tang L, Allen L, Crane D, Mack A, Mohamoud S, Pauly N, Perez R, Donohue J. Association of polysubstance use disorder with treatment quality among Medicaid beneficiaries with opioid use disorder. J Subst Abuse Treat 2023; 144:108921. [PMID: 36327615 PMCID: PMC10664516 DOI: 10.1016/j.jsat.2022.108921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 08/22/2022] [Accepted: 10/23/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION The opioid crisis is transitioning to a polydrug crisis, and individuals with co-occurring substance use disorder (SUDs) often have unique clinical characteristics and contextual barriers that influence treatment needs, engagement in treatment, complexity of treatment planning, and treatment retention. METHODS Using Medicaid data for 2017-2018 from four states participating in a distributed research network, this retrospective cohort study documents the prevalence of specific types of co-occurring SUD among Medicaid enrollees with an opioid use disorder (OUD) diagnosis, and assesses the extent to which different SUD presentations are associated with differential patterns of MOUD and psychosocial treatments. RESULTS We find that more than half of enrollees with OUD had a co-occurring SUD, and the most prevalent co-occurring SUD was for "other psychoactive substances", indicated among about one-quarter of enrollees with OUD in each state. We also find some substantial gaps in MOUD treatment receipt and engagement for individuals with OUD and a co-occurring SUD, a group representing more than half of individuals with OUD. In most states, enrollees with OUD and alcohol, cannabis, or amphetamine use disorder are significantly less likely to receive MOUD compared to enrollees with OUD only. In contrast, enrollees with OUD and other psychoactive SUD were significantly more likely to receive MOUD treatment. Conditional on MOUD receipt, enrollees with co-occurring SUDs had 10 % to 50 % lower odds of having a 180-day period of continuous MOUD treatment, an important predictor of better patient outcomes. Associations with concurrent receipt of MOUD and behavioral counseling were mixed across states and varied depending on co-occurring SUD type. CONCLUSIONS Overall, ongoing progress toward increasing access to and quality of evidence-based treatment for OUD requires further efforts to ensure that individuals with co-occurring SUDs are engaged and retained in effective treatment. As the opioid crisis evolves, continued changes in drug use patterns and populations experiencing harms may necessitate new policy approaches that more fully address the complex needs of a growing population of individuals with OUD and other types of SUD.
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Affiliation(s)
- Rosanna Smart
- Drug Policy Research Center, RAND Corporation, 1776 Main Street, PO Box 2138, Santa Monica, CA 90407-2138, United States of America.
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street, Crabtree Hall A635, Pittsburgh, PA 15261, United States of America.
| | - Susan Kennedy
- AcademyHealth, 1666 K Street NW, Suite 1100, Washington, DC 20006, United States of America.
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261, United States of America.
| | - Lindsay Allen
- Department of Emergency Medicine, Buehler Center for Health Policy & Economics, Northwestern University, 750 N. Lake Shore Drive, Evanston, IL 60611, United States of America.
| | - Dushka Crane
- Government Resource Center, The Ohio State University, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH 43210, United States of America.
| | - Aimee Mack
- Government Resource Center, The Ohio State University, 150 Pressey Hall, 1070 Carmack Road, Columbus, OH 43210, United States of America.
| | - Shamis Mohamoud
- The Hilltop Institute, University of Maryland Baltimore County, Sondheim Hall, Third Floor, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America.
| | - Nathan Pauly
- Manatt Health Strategies, 151 N Franklin Street, Suite 2600, Chicago, IL 60606, United States of America.
| | - Rosa Perez
- The Hilltop Institute, University of Maryland Baltimore County, Sondheim Hall, Third Floor, 1000 Hilltop Circle, Baltimore, MD 21250, United States of America.
| | - Julie Donohue
- Department of Health Policy and Management, University of Pittsburgh, 130 DeSoto Street, Crabtree Hall A635, Pittsburgh, PA 15261, United States of America.
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Lutgen C, Callen E, Robertson E, Clay T, Filippi MK. Implementation and Evaluation of Primary Care Team Participation in Opioid Use Disorder Learning Sessions. Subst Abus 2023; 44:51-61. [PMID: 37226899 DOI: 10.1177/08897077231174675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION Previous studies show that some primary care clinicians do not feel equipped to treat patients with opioid use disorder (OUD). This study addressed the gaps in confidence and knowledge of primary care physicians and other participants (i.e., participants who were not physicians) in diagnosing, treating, prescribing, and educating patients with OUD through interactive learning sessions. METHODS The American Academy of Family Physicians National Research Network held monthly OUD learning sessions from September 2021 to March 2022 with physicians and other participants (n = 31) from 7 practices. Participants took baseline (n = 31), post-session (n = 11-20), and post-intervention (n = 21) surveys. Questions focused on confidence, knowledge, among others. We used non-parametric tests to compare individual responses pre-versus-post participation as well as to compare responses between groups. RESULTS All participants experienced significant changes in confidence and knowledge for most topics covered in the series. When comparing physicians to other participants, physicians had greater increases in confidence in dosing and monitoring for diversion (P = .047), but other participants had greater increases in confidence in the majority of topic areas. Physicians also had greater increases in knowledge than other participants in dosing and monitoring for safety (P = .033) and dosing and monitoring for diversion (P = .024), whereas other participants had greater increases in knowledge in most remaining topics. Participants agreed that sessions provided practical knowledge, except for relevancy of the case study portion of the session to current practice (P = .023) and the session improved participant ability to care for patients (P = .044). CONCLUSION Through participating in interactive OUD learning sessions, knowledge and confidence increased among physicians and other participants. These changes may impact participants' decisions to diagnose, treat, prescribe, and educate patients with OUD.
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Affiliation(s)
- Cory Lutgen
- American Academy of Family Physicians, National Research Network, Leawood, KS, USA
| | - Elisabeth Callen
- American Academy of Family Physicians, National Research Network, Leawood, KS, USA
| | - Elise Robertson
- American Academy of Family Physicians, National Research Network, Leawood, KS, USA
| | - Tarin Clay
- American Academy of Family Physicians, National Research Network, Leawood, KS, USA
| | - Melissa K Filippi
- American Academy of Family Physicians, National Research Network, Leawood, KS, USA
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Serota DP, Tookes HE, Tomita-Barber J, Bartholomew TS, Forrest DW, St. Onge J, Ford H, Taldone S. Integrating Persons With Lived Experience in Opioid Use Disorder Education: A Small Group Exercise and Patient Panel. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2023; 10:23821205231180172. [PMID: 37342657 PMCID: PMC10278406 DOI: 10.1177/23821205231180172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 05/18/2023] [Indexed: 06/23/2023]
Abstract
OBJECTIVES Based on increasing drug overdose deaths and a shortage of healthcare professionals trained in the management of opioid use disorder (OUD), it is imperative to improve health professional education in addiction medicine. This small group learning exercise and patient panel was designed to provide first year medical students with insights into the lives of people with OUD-through a lens of harm reduction-and to connect biomedical knowledge to the core values and professional themes of their doctoring courses. METHODS Facilitators were assigned to each small group of 8 students for the harm reduction-centered Long and Winding Road small group case exercise. This was followed by a patient panel of 2 to 3 persons with OUD. The small group was conducted with first-year medical students as a virtual training session due to the COVID-19 pandemic. Students completed pre- and post-session surveys about agreement with statements pertaining to the learning objectives. RESULTS The small group and patient panel were delivered over 8 sessions and attended by all first-year medical students (N = 201). Survey response rate was 67%. Post-session, there was significantly greater agreement with knowledge on all learning objectives compared to pre-session. Two relevant multiple-choice questions on the medical student final exam were answered correctly by 79% and 98% of students. CONCLUSION Centering on people with lived experience, we completed small groups and patient panels to introduce concepts of OUD and harm reduction to first year medical students. Pre- and post-session surveys showed short-term achievement of the learning objectives.
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Affiliation(s)
- David P Serota
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hansel E Tookes
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jasmine Tomita-Barber
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tyler S Bartholomew
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - David W Forrest
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joan St. Onge
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Henri Ford
- Department of Surgery, University of Miami Miler School of Medicine, Miami, FL, USA
| | - Sabrina Taldone
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
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Cloutier RM, Cole ES, McDonough BL, Lomauro DA, Miller JP, Talbert AL, Bear TM, Bridges NC, Foulds AL, Taber R, Gordon AJ, Cochran GT, Kmiec J, Donohue JM, Kelley D, DiDomenico E, Adair D, Pringle JL. Strategies to recruit rural primary care providers to implement a medication for opioid use disorder (MOUD) focused integrated care model. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231152808. [PMID: 37091535 PMCID: PMC9978659 DOI: 10.1177/26334895231152808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background Access to providers and programs that provide medications for opioid use disorder (MOUD) remains a systemic barrier for patients with opioid use disorder (OUD), particularly if they live in rural areas. The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) addressed this problem with a multisystem partnership that recruited, trained, and supported rural primary care providers to provide MOUD and implement an integrated care model (ICM) for patients with OUD. Given the demonstrated efficacy of Project RAMP, this article summarizes our recruitment strategies, including feasibility concerns for further expansion into other regions. Methods The approach for recruiting implementation sites included two phases: partner outreach and site identification. Once recruited, the Systems Transformation Framework guided planning and implementation activities. Recruitment and implementation activities were assessed with implementation trackers and evaluated by providers via key informant interviews (KIIs). Results Project RAMP recruited 26 primary care practices from 13 counties, including nine health systems and two private practice groups—exceeding the original target of 24 sites. There was a median of 49 days from first contact to project onboarding. A total of 108 primary care practices spanning 22 health systems declined participation. Findings from the KIIs highlighted the value of engaging PCPs by connecting to a shared vision (i.e., improving the quality of patient care) as well as addressing perceived participation barriers (e.g., offering concierge technical assistance to address lack of training or resources). Conclusion Findings highlight how successful recruitment activities should leverage the support of health system leadership. Findings also emphasize that aiding recruitment and engagement efforts successfully addressed prescribers’ perceived barriers to providing MOUD as well as facilitating better communication among administrators, PCPs, behavioral health professionals, care managers, and patients. Plain Language Summary: Opioid use disorder (OUD) is one of the leading causes of preventable illness and death. The standard of care for OUD is the provision of medications for opioid use disorder (MOUD) and the application of an integrative integrated care model (ICM) where behavioral health is blended with specialized medical services. Unfortunately, access to providers and healthcare facilities that provide MOUD or apply an ICM remains a systemic barrier for patients with OUD, particularly if they live in rural areas. Although there is no one-size-fits-all approach to implementing MOUD in primary care, findings from Project The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) highlight strategies that may improve future MOUD and ICM implementation efforts in similar rural contexts. Specifically, future efforts to increase MOUD capacity by recruiting new providers should be prepared to leverage health system leadership, address provider barriers via training and expert consultation, and facilitate connections to local behavioral health providers. This approach may be helpful to others recruiting health systems and primary care practices to implement new care models to use MOUD in treating patients with OUD.
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Affiliation(s)
- Renee M. Cloutier
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Evan S. Cole
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Brianna L. McDonough
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Daniel A. Lomauro
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - John P. Miller
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Abigail L. Talbert
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Todd M. Bear
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Nora C. Bridges
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abigail L. Foulds
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Rachel Taber
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald T. Cochran
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Julie Kmiec
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie M. Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - David Kelley
- Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - Ellen DiDomenico
- Pennsylvania Department of Drug and Alcohol Programs, Harrisburg, PA, USA
| | - Dale Adair
- Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - Janice L. Pringle
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Choe K, Zinn E, Lu K, Hoang D, Yang LH. Impact of COVID-19 pandemic on chronic pain and opioid use in marginalized populations: A scoping review. Front Public Health 2023; 11:1046683. [PMID: 37139395 PMCID: PMC10150088 DOI: 10.3389/fpubh.2023.1046683] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction The COVID-19 pandemic has had a variable effect on vulnerable populations, including patients with chronic pain who rely on opioid treatment or have comorbid opioid use disorder. Limited access to care due to isolation measures may lead to increased pain severity, worse mental health symptoms, and adverse opioid-related outcomes. This scoping review aimed to understand the impact of the COVID-19 pandemic on the dual epidemics of chronic pain and opioids in marginalized communities worldwide. Methods Searches of primary databases including PubMed, Web of Science, Scopus, and PsycINFO were performed in March 2022, restricting the publication date to December 1, 2019. The search yielded 685 articles. After title and abstract screening, 526 records were screened by title and abstract, 87 through full-text review, of which 25 articles were included in the final analysis. Results Our findings illuminate the differential distribution of pain burden across marginalized groups and how it serves to heighten existing disparities. Service disruptions due to social distancing orders and infrastructural limitations prevented patients from receiving the care they needed, resulting in adverse psychological and physical health outcomes. Efforts to adapt to COVID-19 circumstances included modifications to opioid prescribing regulations and workflows and expanded telemedicine services. Conclusion Results have implications for the prevention and management of chronic pain and opioid use disorder, such as challenges in adopting telemedicine in low-resource settings and opportunities to strengthen public health and social care systems with a multidisciplinary and multidimensional approach.
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Affiliation(s)
- Karen Choe
- School of Global Public Health, New York University, New York, NY, United States
- *Correspondence: Karen Choe,
| | - Eleanor Zinn
- Teachers College Columbia University, New York, NY, United States
| | - Kevin Lu
- Teachers College Columbia University, New York, NY, United States
| | - Dung Hoang
- Teachers College Columbia University, New York, NY, United States
| | - Lawrence H. Yang
- School of Global Public Health, New York University, New York, NY, United States
- Mailman School of Public Health, Columbia University, New York, NY, United States
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Gilbert LR, Starks S, Gray J, Reitzel LR, Obasi EM. Exploring the provider and organization level barriers to medication for opioid use disorder treatment for Black Americans: A study protocol. PUBLIC HEALTH IN PRACTICE 2022; 4:100308. [PMID: 36570391 PMCID: PMC9773041 DOI: 10.1016/j.puhip.2022.100308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 12/27/2022] Open
Abstract
Objectives This study seeks to examine the provider and organizational factors that could be limiting the treatment of Opioid Use Disorder (OUD) for Black Americans in Texas. Formative research at the provider and organizational level will assist in understanding the current facilitators, potential barriers, and capacity for OUD treatment for Black Americans. Study design Using the exploration phase of the Explore, Preparation, Implementation, Sustainment (EPIS) framework, the project will be a formative assessment of local factors that influence Medication for OUD (MOUD) treatment availability for Black Americans to guide the design of a culturally and locally relevant multi-level intervention strategy. Methods and analysis: This project will utilize emergent mixed methods to identify and clarify the problems that are obstructing treatment for Black patients with OUD. First, the perspectives of individual providers in their openness and willingness to provide MOUD treatment to Black Americans diagnosed with OUD will be explored through in-depth interviews. The organizational capacity factors associated with increased availability to treatment for Black American OUD patients will be examined with the organizational leaders using an exploratory sequential mixed-methods design. Leader and program managers of organizations that provide MOUD will be invited to participate in an online survey, with the option to participate in a follow-up in-depth interview. All qualitative data from the provider and organization staff interviews will be analyzed with a thematic analysis approach. The analysis of the two different types of qualitative data will be analyzed together, as a form of triangulation. Conclusions This project will assess the understandings of individual providers as well as the organizational-level awareness of the cultural contexts of MOUD intervention for Black Americans. This formative research seeks to highlight the current status of the opioid crisis in the Black community, and what additional supports are needed.
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Affiliation(s)
- Lauren R Gilbert
- University of Houston, College of Medicine, USA.,Humana Integrated Health System Sciences Institute at the University of Houston, USA
| | | | | | - Lorraine R Reitzel
- HEALTH Center for Addictions Research & Cancer Prevention at the University of Houston, USA
| | - Ezemenari M Obasi
- HEALTH Center for Addictions Research & Cancer Prevention at the University of Houston, USA
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Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic. Healthcare (Basel) 2022; 10:healthcare10122393. [PMID: 36553917 PMCID: PMC9778275 DOI: 10.3390/healthcare10122393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/19/2022] [Accepted: 11/24/2022] [Indexed: 12/03/2022] Open
Abstract
In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.
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Solmeyer AR, Berger AT, Barton SL, Nguyen B, Bart GB, Grahan B, Bell HJ, DeVine KM, Merrick W. Association of Project ECHO Training With Buprenorphine Prescribing by Primary Care Clinicians in Minnesota for Treating Opioid Use Disorder. JAMA HEALTH FORUM 2022; 3:e224149. [PMID: 36399352 PMCID: PMC9675001 DOI: 10.1001/jamahealthforum.2022.4149] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Importance Buprenorphine is an approved medication for opioid use disorder (MOUD); however, prescribing buprenorphine is limited by a requirement to obtain a waiver to prescribe it (hereinafter, "DATA [Drug Abuse Treatment Act]-waiver") and a lack of knowledge of the best practices among clinicians. Objective To examine how Project ECHO (Extension for Community Healthcare Outcomes) telementoring is associated with changes in DATA-waiver attainment and buprenorphine prescribing among primary care clinicians in Minnesota. Design, Setting, and Participants In this retrospective matched-cohort study of 918 clinicians, ECHO-trained clinicians were enrolled on the date they first attended ECHO (January 3, 2018, to June 11, 2020); comparison clinicians were assigned an enrollment date from the distribution of the first ECHO sessions. The baseline period was 12 months preceding enrollment, with follow-up for 18 months or until June 30, 2020. The ECHO-trained clinicians were a population-based sample of primary care clinicians who treated Medicaid patients in Minnesota 12 months prior to the initiation of ECHO training. This analysis used propensity score matching to select comparison clinicians who were similar across demographic and clinical practice characteristics at baseline in a 2:1 ratio. Follow-up was available for 167 ECHO-trained clinicians (54.6%) and 330 comparison clinicians (53.9%) at 18 months. Exposures ECHO-trained clinicians attended at least 1 weekly, hour-long ECHO session. Comparison clinicians never participated in any ECHO sessions. Main Outcomes and Measures DATA-waiver attainment, any buprenorphine prescribing, and the percentage of patients with opioid use disorder (OUD) who were prescribed buprenorphine. Results The final sample included 918 clinicians (ECHO-trained [306]; comparison [612]), of whom 620 (67.5%) practiced outside the metropolitan Twin Cities (Minneapolis-St Paul) region. The mean (SD) age of the ECHO-trained clinicians was 46.0 (12.1) years and that of the comparison clinicians was 45.7 (12.3) years. Relative to the changes among the matched comparison clinicians, the ECHO-trained clinicians were more likely to obtain a DATA-waiver (difference-in-differences, 22.7 percentage points; 95% CI, 15.5-29.9 percentage points; P < .001) and prescribe any buprenorphine (16.5 percentage points; 95% CI, 10.4-22.5 percentage points; P < .001) after 6 quarters of follow-up. ECHO-trained clinicians prescribed buprenorphine to a greater share of patients with OUD (a difference of 7.6 percentage points per month; 95% CI, 4.6-10.6 percentage points per month; P < .001), relative to that prescribed by the comparison clinicians. Conclusions and Relevance According to the findings of this matched-cohort study, ECHO telementoring may be associated with greater prescribing of buprenorphine by primary care clinicians. These findings suggest that Project ECHO training could be a useful tool for expanding access to MOUD.
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Affiliation(s)
| | | | | | | | - Gavin B. Bart
- Addiction Medicine Division, Hennepin Healthcare, Minneapolis, Minneota
| | - Brian Grahan
- Addiction Medicine Division, Hennepin Healthcare, Minneapolis, Minneota
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Dunphy CC, Zhang K, Xu L, Guy GP. Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid. Am J Prev Med 2022; 63:717-725. [PMID: 35803789 PMCID: PMC9588682 DOI: 10.1016/j.amepre.2022.05.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Expanding access to medications for opioid use disorder is a cornerstone to addressing the opioid overdose epidemic. However, recent research suggests that the distribution of medications for opioid use disorder has been inequitable. This study analyzes the racial‒ethnic disparities in the receipt of medications for opioid use disorder among Medicaid patients diagnosed with opioid use disorder. METHODS Medicaid claims data from the Transformed Medicaid Statistical Information System for the years 2017-2019 were used for the analysis. Logistic regression models estimated the odds of receiving buprenorphine and Vivitrol within 180 days after initial opioid use disorder diagnosis on the basis of race‒ethnicity. Analysis was conducted in 2022. RESULTS Non-Hispanic Black people, non-Hispanic American Indian or Alaskan Native/Asian/Hawaiian/Pacific Islander people, and Hispanic people had 42%, 12%, and 22% lower odds of buprenorphine receipt and 47%, 12%, and 20% lower odds of Vivitrol receipt, respectively, than non-Hispanic White people, controlling for clinical and demographic patient variables. CONCLUSIONS This study suggests that there are racial‒ethnic disparities in the receipt of buprenorphine and Vivitrol among Medicaid patients diagnosed with opioid use disorder after adjusting for demographic, geographic, and clinical characteristics. The potential strategies to address these disparities include expanding the workforce of providers who can prescribe medications for opioid use disorder in low-income communities and communities of color and allocating resources to address the stigma in medications for opioid use disorder treatment.
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Affiliation(s)
- Christopher C Dunphy
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia.
| | - Kun Zhang
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Likang Xu
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gery P Guy
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
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Hoch AM, Schoenberger SF, Boyle TP, Hadland SE, Gai MJ, Bagley SM. Attitudes and training related to substance use in pediatric emergency departments. Addict Sci Clin Pract 2022; 17:59. [PMID: 36274146 PMCID: PMC9590142 DOI: 10.1186/s13722-022-00339-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/28/2022] [Indexed: 11/10/2022] Open
Abstract
Background In recent years, pediatric emergency departments (PED) have seen an increase in presentations related to substance use among their adolescent patient population. We aimed to examine pediatric emergency medicine (PEM) physicians’ knowledge, attitudes, and beliefs on caring for adolescents with substance use. Methods We conducted a cross-sectional online survey of PEM physicians through the American Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee (PEM-CRC) listserv. The 41-item survey contained the following domains: demographics, current protocols and education for managing adolescent substance use, and attitudes about treatment of substance use. We calculated descriptive statistics for each variable within the domains. Results Of 177 respondents (38.2% response rate), 55.4% were female, 45.2% aged ≥ 50 years, 78% worked in a children’s hospital, and 50.8% had > 15 years clinical practice. Overall, 77.8% reported caring for adolescents with a chief complaint related to non-opioid substance use and 26.0% opioid use at least once a month. Most (80.9%) reported feeling comfortable treating major medical complications of substance use, while less than half were comfortable treating withdrawal symptoms. 73% said that they were not interested in prescribing buprenorphine. Conclusions Among this national sample of PEM physicians, 3 of 4 physicians managed substance-related visits monthly, but 52% lacked comfort in managing withdrawal symptoms and 73.1% were not interested in prescribing buprenorphine. Almost all PEM physician identified substance use-related education is important but lacked access to faculty expertise or educational content. Expanded access to education and training for PEM physicians related to substance use is needed. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00339-w.
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Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100091. [PMID: 36844166 PMCID: PMC9949336 DOI: 10.1016/j.dadr.2022.100091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Background While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP. Methods Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use. Results More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001). Conclusion Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States,Corresponding author at: Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.
| | - Emily P. Thacker
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lyn Yuen Choo
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Laura R. Lander
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - Babak Tofighi
- Department of Population Health, New York University School of Medicine, United States
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Jawa R, Walley AY, Wilson DJ, Green TC, McKenzie M, Hoskinson R, Bratberg J, Ramsey S, Rich JD, Friedmann PD. Prescribe to Save Lives: Improving Buprenorphine Prescribing Among HIV Clinicians. J Acquir Immune Defic Syndr 2022; 90:546-552. [PMID: 35587832 PMCID: PMC9283214 DOI: 10.1097/qai.0000000000003001] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 04/07/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention. METHODS The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites. RESULTS Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well. CONCLUSIONS Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.
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Affiliation(s)
- Raagini Jawa
- Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Boston University School of Medicine, Boston, MA, USA
| | - Alexander Y. Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2 Floor, Boston, MA, 02118
- Boston University School of Medicine, Boston, MA, USA
| | - Donna J. Wilson
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
| | - Traci C. Green
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, 415 South Street, Waltham, MA 02453
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Michelle McKenzie
- The Center for Health + Justice Transformation, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Randall Hoskinson
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
| | - Jeffrey Bratberg
- University of Rhode Island College of Pharmacy, 7 Greenhouse Rd, Kingston, RI 02881
| | - Susan Ramsey
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Josiah D. Rich
- The Center for Health + Justice Transformation, The Miriam and Rhode Island Hospitals, 164 Summit Avenue, Providence, RI 02906
- The Warren Alpert Medical School of Brown University, Providence, RI
| | - Peter D. Friedmann
- University of Massachusetts Medical School- Baystate and Baystate Health, 3601 Main Street, 3 Floor, Springfield, MA
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Levin A, Nagib PB, Deiparine S, Gao T, Mitchell J, Davis AK. Inconsistencies between national drug policy and professional beliefs about psychoactive drugs among psychiatrists in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 108:103816. [PMID: 35964449 DOI: 10.1016/j.drugpo.2022.103816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 07/26/2022] [Accepted: 07/29/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Evidence points to an incongruence between international drug policy and expert opinion about safety, abuse potential, and therapeutic potential of specific drugs. However, no prior studies have directly explored psychiatrists' attitudes about the current drug schedule. Therefore, we examined whether American psychiatrists' perceptions of four psychoactive drugs differed from those indicated by their schedules. METHODS A quasi-experimental online survey of a convenience sample of psychiatrists in the United States (N=181; Mean age=48.7; Female=35%). Participants were randomized to receive 1-of-4 vignettes, each depicting a depressed patient reporting relief from symptoms after non-prescribed psychoactive drug use (i.e., psilocybin [Schedule I], methamphetamine [SchedII], ketamine [SchedIII], or alprazolam [SchedIV]). Participants responded to questions related to this clinical scenario and then rated the safety, therapeutic, and abuse potentials of these four drugs and alcohol. RESULTS There were significant differences by vignette condition in mean likelihood ratings of: warning against engaging in drug use again (p<.01), being concerned about developing a new psychiatric problem (p<.001), being concerned about increased suicide risk (p<.01) and being supportive of further use of this drug as part of the treatment plan (p<.001). Overall, non-prescribed use of methamphetamine and alprazolam was rated more concerning and less acceptable than non-prescribed use of psilocybin and ketamine. Compared to psilocybin and ketamine, participants rated methamphetamine and alprazolam as less safe (p<.001), having less therapeutic potential (p<.001), and having more abuse potential (p<.001). Mean ratings of safety and abuse/therapeutic potential of alprazolam and methamphetamine were equivalent to that of alcohol, and all three were rated more harmful than psilocybin and ketamine. CONCLUSION American psychiatrists' perceptions about safety and abuse/therapeutic potentials associated with certain psychoactive drugs were inconsistent with those indicated by their placement in drug schedules. These findings add to a growing consensus amongst experts that the current drug policy is not scientifically coherent.
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Affiliation(s)
- Adam Levin
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States; Center for Psychedelic Drug Research and Education, College of Social Work, The Ohio State University, Columbus, OH 43210, United States
| | - Paul B Nagib
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States; Center for Psychedelic Drug Research and Education, College of Social Work, The Ohio State University, Columbus, OH 43210, United States
| | - Selina Deiparine
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Thomas Gao
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Justin Mitchell
- College of Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - Alan K Davis
- Center for Psychedelic Drug Research and Education, College of Social Work, The Ohio State University, Columbus, OH 43210, United States; Center for Psychedelic and Consciousness Research, Johns Hopkins University, Baltimore, MD 21224, United States; College of Medicine, The Ohio State University, Columbus, OH 43210, United States.
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