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Mannelli P. Commentary on D'Agata Mount et al.: Higher dose buprenorphine to improve retention in opioid use disorder treatment, prevent relapse, and optimize integrated care interventions. Addiction 2024; 119:1973-1974. [PMID: 39313315 DOI: 10.1111/add.16672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2024] [Accepted: 08/20/2024] [Indexed: 09/25/2024]
Affiliation(s)
- Paolo Mannelli
- Duke University Medical Center, Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC, USA
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Johnson CE, Wehby GL, Chrischilles EA, Arndt S, Carnahan RM. Examining the effect of prescription drug monitoring program integration and mandatory use policies on the distribution of methadone and buprenorphine for opioid use disorder, United States, 2009-2021. Drug Alcohol Depend 2024; 264:112432. [PMID: 39241503 DOI: 10.1016/j.drugalcdep.2024.112432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Revised: 07/30/2024] [Accepted: 08/24/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND Prescription drug monitoring programs (PDMPs) have been shown to reduce opioid prescribing for pain, but it is not well understood whether PDMPs influence utilization of medications for opioid use disorder. PDMP integration and mandatory use policies are two approaches implemented by states to increase use of PDMPs by prescribers. This study examined the effect of these approaches on distribution of methadone and buprenorphine from 2009 to 2021 for 50 states and DC. METHODS The effect of PDMP integration and mandatory use policies on four outcomes (distribution of buprenorphine to opioid treatment programs, distribution of buprenorphine to pharmacies, distribution of methadone to opioid treatment programs, and the total combined distribution of methadone and buprenorphine) was estimated using a Callaway and Sant'Anna difference-in-differences model, controlling for co-occurring opioid-related state policies. RESULTS Distribution of buprenorphine to pharmacies decreased 8 % (95 % CI -14 %, -1 %) following implementation of mandatory use policies. Distribution of methadone to opioid treatment programs increased 17 % (95 % CI 4 %, 34 %) and the total combined distribution of methadone and buprenorphine increased 6 % (95 % CI -0 %, 14 %) following the joint implementation of both approaches. CONCLUSION Distribution of methadone and buprenorphine has increased since 2009, but less than a quarter of people with opioid use disorder currently receive these medications. We observed a small net benefit of PDMP integration and mandatory use policies on distribution of methadone and buprenorphine. Policymakers should continue to assess the impact of PDMPs on access to medications for opioid use disorder and consider additional approaches to increase access to treatment.
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Affiliation(s)
- Christian E Johnson
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA.
| | - George L Wehby
- Department of Health Management and Policy, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Elizabeth A Chrischilles
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Stephan Arndt
- Department of Psychiatry, Carver College of Medicine, University of Iowa, 200 Hawkins Drive, Iowa City, IA 52242, USA; Department of Biostatistics, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
| | - Ryan M Carnahan
- Department of Epidemiology, College of Public Health, University of Iowa, 145 N. Riverside Drive, Iowa City, IA 52242, USA
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Zoorob R, In Kim-Vences S, Hirth JM, Schaper K, Grigoryan L, Gonzalez S, Kowalchuk A. Asynchronous online training increased knowledge, confidence, and intent to screen and treat substance use disorders among primary care clinicians practicing in Texas. Prev Med 2024; 185:108038. [PMID: 38857769 DOI: 10.1016/j.ypmed.2024.108038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 06/06/2024] [Accepted: 06/07/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Despite increasing prevalence of substance use disorders (SUD), few patients are diagnosed and treated in primary care settings. This study evaluated changes in knowledge, confidence, and intention to implement screening and brief intervention (SBI) and SUD treatment after clinicians participated in an asynchronous online education course. METHODS A self-selected sample of primary care clinicians in Texas participated in online SBI and SUD education March 2021-July 2023. Baseline and post-training surveys evaluated changes in knowledge, confidence, and intent to implement SBI and SUD treatment. Changes were compared using paired t-tests. Multivariable linear regression examined factors potentially associated with confidence and intention to implement changes. Clinician feedback regarding the course was included. RESULTS Of 613 respondents, 50.9% were practicing family medicine clinicians. Knowledge of adolescent screening tools increased from 21.9% to 75.7% (p < 0.001). Knowledge about the number of drinks that define excessive drinking among non-pregnant women increased from 24.5% at baseline to 64.9% (p < 0.001). Clinicians reported lowest confidence in providing opioid use disorder pharmacotherapy, which improved after program participation. Intent to implement SBI and medication for alcohol, nicotine and opioid use disorders increased (p < 0.001) after training. No factors were associated with change in confidence or intention to implement in multivariable models (p > 0.05). Satisfaction was high and nearly 60% reported intention to change their clinical practice because of the program. CONCLUSION Knowledge, confidence, and intent to implement SBI and SUD treatment increased after completing the online course. Clinician satisfaction was high and demonstrated improved intention to implement SBI and SUD treatment.
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Affiliation(s)
- Roger Zoorob
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Sung In Kim-Vences
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jacqueline M Hirth
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Kylie Schaper
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Larissa Grigoryan
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Sandra Gonzalez
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Alicia Kowalchuk
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
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Campopiano von Klimo M, Nolan L, Corbin M, Farinelli L, Pytell JD, Simon C, Weiss ST, Compton WM. Physician Reluctance to Intervene in Addiction: A Systematic Review. JAMA Netw Open 2024; 7:e2420837. [PMID: 39018077 PMCID: PMC11255913 DOI: 10.1001/jamanetworkopen.2024.20837] [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] [Received: 02/06/2024] [Accepted: 05/07/2024] [Indexed: 07/18/2024] Open
Abstract
Importance The overdose epidemic continues in the US, with 107 941 overdose deaths in 2022 and countless lives affected by the addiction crisis. Although widespread efforts to train and support physicians to implement medications and other evidence-based substance use disorder interventions have been ongoing, adoption of these evidence-based practices (EBPs) by physicians remains low. Objective To describe physician-reported reasons for reluctance to address substance use and addiction in their clinical practices using screening, treatment, harm reduction, or recovery support interventions. Data Sources A literature search of PubMed, Embase, Scopus, medRxiv, and SSRN Medical Research Network was conducted and returned articles published from January 1, 1960, through October 5, 2021. Study Selection Publications that included physicians, discussed substance use interventions, and presented data on reasons for reluctance to intervene in addiction were included. Data Extraction and Synthesis Two reviewers (L.N., M.C., L.F., J.P., C.S., and S.W.) independently reviewed each publication; a third reviewer resolved discordant votes (M.C. and W.C.). This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines and the theoretical domains framework was used to systematically extract reluctance reasons. Main Outcomes and Measures The primary outcome was reasons for physician reluctance to address substance use disorder. The association of reasons for reluctance with practice setting and drug type was also measured. Reasons and other variables were determined according to predefined criteria. Results A total of 183 of 9308 returned studies reporting data collected from 66 732 physicians were included. Most studies reported survey data. Alcohol, nicotine, and opioids were the most often studied substances; screening and treatment were the most often studied interventions. The most common reluctance reasons were lack of institutional support (173 of 213 articles [81.2%]), knowledge (174 of 242 articles [71.9%]), skill (170 of 230 articles [73.9%]), and cognitive capacity (136 of 185 articles [73.5%]). Reimbursement concerns were also noted. Bivariate analysis revealed associations between these reasons and physician specialty, intervention type, and drug. Conclusions and Relevance In this systematic review of reasons for physician reluctance to intervene in addiction, the most common reasons were lack of institutional support, knowledge, skill, and cognitive capacity. Targeting these reasons with education and training, policy development, and program implementation may improve adoption by physicians of EBPs for substance use and addiction care. Future studies of physician-reported reasons for reluctance to adopt EBPs may be improved through use of a theoretical framework and improved adherence to and reporting of survey development best practices; development of a validated survey instrument may further improve study results.
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Affiliation(s)
| | - Laura Nolan
- JBS International, Inc, North Bethesda, Maryland
| | - Michelle Corbin
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Lisa Farinelli
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Jarratt D. Pytell
- Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Caty Simon
- National Survivors Union, Greensboro, North Carolina
- NC Survivors Union, Greensboro, North Carolina
- Whose Corner Is It Anyway, Holyoke, Massachusetts
| | - Stephanie T. Weiss
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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Dowell D, Brown S, Gyawali S, Hoenig J, Ko J, Mikosz C, Ussery E, Baldwin G, Jones CM, Olsen Y, Tomoyasu N, Han B, Compton WM, Volkow ND. Treatment for Opioid Use Disorder: Population Estimates - United States, 2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2024; 73:567-574. [PMID: 38935567 PMCID: PMC11254342 DOI: 10.15585/mmwr.mm7325a1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
In 2022, 81,806 opioid-involved overdose deaths were reported in the United States, more than in any previous year. Medications for opioid use disorder (OUD), particularly buprenorphine and methadone, substantially reduce overdose-related and overall mortality. However, only a small proportion of persons with OUD receive these medications. Data from the 2022 National Survey on Drug Use and Health were applied to a cascade of care framework to estimate and characterize U.S. adult populations who need OUD treatment, receive any OUD treatment, and receive medications for OUD. In 2022, 3.7% of U.S. adults aged ≥18 years needed OUD treatment. Among these, only 25.1% received medications for OUD. Most adults who needed OUD treatment either did not perceive that they needed it (42.7%) or received OUD treatment without medications for OUD (30.0%). Compared with non-Hispanic Black or African American and Hispanic or Latino adults, higher percentages of non-Hispanic White adults received any OUD treatment. Higher percentages of men and adults aged 35-49 years received medications for OUD than did women and younger or older adults. Expanded communication about the effectiveness of medications for OUD is needed. Increased efforts to engage persons with OUD in treatment that includes medications are essential. Clinicians and other treatment providers should offer or arrange evidence-based treatment, including medications, for patients with OUD. Pharmacists and payors can work to make these medications available without delays.
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Richardson C, Daniels K, Confer A, Saxon AJ, Gordon AJ, Liberto J, Albanese AP, Renner J, Edens E, Kennedy AJ. Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements. J Gen Intern Med 2024; 39:1393-1399. [PMID: 38302815 PMCID: PMC11169109 DOI: 10.1007/s11606-024-08639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.
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Affiliation(s)
- Claire Richardson
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Karin Daniels
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea Confer
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew J Saxon
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake City Health Care System, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Substance Use Disorders, Veterans Health Administration, Washington, DC, USA
| | - Anthony P Albanese
- VA Northern California Healthcare System, UC Davis, School of Medicine, Sacramento, CA, USA
| | - John Renner
- VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Edens
- VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, USA
| | - Amy J Kennedy
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA.
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Riser E, Kennedy AG, Holterman LA, Brooklyn J, Maruti S, Sobel HG. Preparing Medical Students to Care for Patients with Opioid Use Disorder: Buprenorphine Waiver Training in Undergraduate Medical Education. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2024:10.1007/s40596-024-01968-w. [PMID: 38684575 DOI: 10.1007/s40596-024-01968-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/04/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Elly Riser
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA.
| | - Amanda G Kennedy
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Leigh Ann Holterman
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - John Brooklyn
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Sanchit Maruti
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
| | - Halle G Sobel
- The Robert Larner, MD College of Medicine at the University of Vermont, Burlington, VT, USA
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Bali B, Tuan WJ, Scott A, Bollampally P, Groff D, Leong SL, King VL, Bone C. Assessing men with opioid use disorder for testosterone deficiency after the development of symptoms. J Addict Dis 2024:1-7. [PMID: 38619057 DOI: 10.1080/10550887.2024.2327751] [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: 04/16/2024]
Abstract
OBJECTIVE Individuals with opioid use disorder (OUD) have reduced life expectancy and inferior outcomes when treated for depression, diabetes, and fractures. Their elevated risk of testosterone deficiency may contribute to all of these relationships, however few individuals prescribed opioids are evaluated with testosterone assays. The purpose of this study is to determine whether patients with opioid use disorder are evaluated for testosterone deficiency after development of a symptom that may merit investigation, such as erectile dysfunction (ED). METHOD We conducted a retrospective longitudinal cohort study that utilized data from a national database called TriNetX. Patients were eligible for inclusion if they were 20 to 90 years of age, male, and diagnosed with erectile dysfunction. We utilized descriptive statistics and logistic regression to address study aims. RESULTS Testosterone testing was uncommon for all patients with ED. Among 20,658 patients, it was assessed in 11.2% with OUD and 15.1% without OUD. Among those screened, 40% individuals with OUD and ED had testosterone deficiency. Odds of screening those with OUD were lower than matched controls (RR 0.74). CONCLUSIONS Individuals with OUD are at increased risk of testosterone deficiency than the general population, but nearly 90% are not evaluated for this condition even after development symptoms. That 40% of individuals assessed were classified as testosterone deficient suggests endocrine disorders may be contributing to increased fracture risk, chronic pain, and severe depression commonly encountered in patients with OUD. Addressing this care gap may reduce morbidity and mortality associated with opioid use disorder.
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Affiliation(s)
- Bhavna Bali
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Wen Jan Tuan
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Alyssa Scott
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | | | - Destin Groff
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Shou Ling Leong
- Penn State Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Van L King
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Curtis Bone
- University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
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Brown KG, Chen CY, Dong D, Lake KJ, Butelman ER. Impact of the COVID-19 Pandemic on Functions of Nursing Professionals in the Care of Opioid Use Disorder: Systematic Review. J Addict Nurs 2024; 35:107-113. [PMID: 38830000 DOI: 10.1097/jan.0000000000000573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
BACKGROUND Nursing professionals are vitally involved in the cascade of care for opioid use disorders (OUDs). The global spread of COVID-19 has had complex effects on public health aspects of major diseases, including OUDs. There are limited data on the major ways in which the COVID-19 pandemic has affected the functions of nursing professionals in the care of OUDs. METHOD This systematic review followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines and examined published data for trends in OUD care during the first 2 years of the COVID-19 pandemic, focusing on nursing functions. The National Library of Medicine PubMed database and the EMBASE database were examined for peer-reviewed studies with primary data published between January 1, 2020, and December 31, 2021. REVIEW FINDINGS AND CONCLUSIONS Rapid changes were observed in numerous aspects of OUDs during the early pandemic stage, as well as its care by nursing and other health professionals. These changes include increased overdoses (primarily from synthetic opioids such as fentanyl) and emergency department visits. These trends varied considerably across U.S. jurisdictions, underscoring the importance of region-specific examinations for public health policy and intervention. Out of necessity, healthcare systems and nursing professionals adapted to the challenges of OUD care in the pandemic. These adaptations included increases in telehealth services, increases in take-home doses of methadone or buprenorphine/naloxone, and expansion of layperson training in the use of naloxone for overdose reversal. It is likely that some of these adaptations will result in long-term changes in standards of care practices for OUDs by nursing professionals.
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Affiliation(s)
- Kate G Brown
- Kate G. Brown, NP, MS, Carina Y. Chen, BA, Deanna Dong, NP, MS, Kimberly J. Lake, NP, MS, and Eduardo R. Butelman, PhD, MS, Laboratory on the Biology of Addictive Diseases, The Rockefeller University, New York, New York
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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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Norton JD, Zeng C, Bayliss EA, Shetterly SM, Williams N, Reeve E, Wynia MK, Green AR, Drace ML, Gleason KS, Sheehan OC, Boyd CM. Ethical Aspects of Physician Decision-Making for Deprescribing Among Older Adults With Dementia. JAMA Netw Open 2023; 6:e2336728. [PMID: 37787993 PMCID: PMC10548310 DOI: 10.1001/jamanetworkopen.2023.36728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 08/27/2023] [Indexed: 10/04/2023] Open
Abstract
Importance Physicians endorse deprescribing of risky or unnecessary medications for older adults (aged ≥65 years) with dementia, but there is a lack of information on what influences decisions to deprescribe in this population. Objective To understand how physicians make decisions to deprescribe for older adults with moderate dementia and ethical and pragmatic concerns influencing those decisions. Design, Setting, and Participants A cross-sectional national mailed survey study of a random sample of 3000 primary care physicians from the American Medical Association Physician Masterfile who care for older adults was conducted from January 15 to December 31, 2021. Main Outcomes and Measures The study randomized participants to consider 2 clinical scenarios in which a physician may decide to deprescribe a medication for older adults with moderate dementia: 1 in which the medication could cause an adverse drug event if continued and the other in which there is no evidence of benefit. Participants ranked 9 factors related to possible ethical and pragmatic concerns through best-worst scaling methods (from greatest barrier to smallest barrier to deprescribing). Conditional logit regression quantified the relative importance for each factor as a barrier to deprescribing. Results A total of 890 physicians (35.0%) returned surveys; 511 (57.4%) were male, and the mean (SD) years since graduation was 26.0 (11.7). Most physicians had a primary specialty in family practice (50.4% [449 of 890]) and internal medicine (43.5% [387 of 890]). A total of 689 surveys were sufficiently complete to analyze. In both clinical scenarios, the 2 greatest barriers to deprescribing were (1) the patient or family reporting symptomatic benefit from the medication (beneficence and autonomy) and (2) the medication having been prescribed by another physician (autonomy and nonmaleficence). The least influential factor was ease of paying for the medication (justice). Conclusions and Relevance Findings from this national survey study of primary care physicians suggests that understanding ethical aspects of physician decision-making can inform clinician education about medication management and deprescribing decisions for older adults with moderate dementia.
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Affiliation(s)
| | - Chan Zeng
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Elizabeth A. Bayliss
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
- Department of Family Medicine, University of Colorado School of Medicine, Aurora
| | | | - Nicole Williams
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily Reeve
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Victoria, Australia
- Quality Use of Medicines and Pharmacy Research Centre, Clinical and Health Sciences, University of South Australia, Adelaide, South Australia
| | - Matthew K. Wynia
- University of Colorado Center for Bioethics and Humanities, Anschutz Medical Campus, Aurora
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora
- Department of Health Policy and Management, Colorado School of Public Health, Aurora
| | - Ariel R. Green
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie L. Drace
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | - Kathy S. Gleason
- Institute for Health Research, Kaiser Permanente Colorado, Aurora
| | | | - Cynthia M. Boyd
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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12
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Austin EJ, Chen J, Briggs ES, Ferro L, Barry P, Heald A, Merrill JO, Curran GM, Saxon AJ, Fortney JC, Ratzliff AD, Williams EC. Integrating Opioid Use Disorder Treatment Into Primary Care Settings. JAMA Netw Open 2023; 6:e2328627. [PMID: 37566414 PMCID: PMC10422185 DOI: 10.1001/jamanetworkopen.2023.28627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.
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Affiliation(s)
- Elizabeth J. Austin
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Elsa S. Briggs
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Paul Barry
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Joseph O. Merrill
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Geoffrey M. Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock
- Central Arkansas Veterans Health Care System
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - Anna D. Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Emily C. Williams
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound, Seattle, Washington
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13
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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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Adeniran E, Quinn M, Wallace R, Walden RR, Labisi T, Olaniyan A, Brooks B, Pack R. A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100152. [PMID: 37069961 PMCID: PMC10105485 DOI: 10.1016/j.dadr.2023.100152] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 04/19/2023]
Abstract
Background Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC. Methods A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems. Results Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access). Conclusions This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.
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Affiliation(s)
- Esther Adeniran
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
- Corresponding author at: Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, United States.
| | - Megan Quinn
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Richard Wallace
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Rachel R. Walden
- Quillen College of Medicine Library, East Tennessee State University, Johnson City, TN 37614, United States
| | - Titilola Labisi
- Department of Health Promotion, College of Public Health, University of Nebraska Medical Center, Omaha, NE 68198, United States
| | - Afolakemi Olaniyan
- Department of Health Promotion and Education, School of Human Sciences, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Billy Brooks
- Department of Biostatistics and Epidemiology, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
| | - Robert Pack
- Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN 37614, United States
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15
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Stein BD, Saloner BK, Golan OK, Andraka-Christou B, Andrews CM, Dick AW, Davis CS, Sheng F, Gordon AJ. Association of Selected State Policies and Requirements for Buprenorphine Treatment With Per Capita Months of Treatment. JAMA HEALTH FORUM 2023; 4:e231102. [PMID: 37234015 PMCID: PMC10220518 DOI: 10.1001/jamahealthforum.2023.1102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/24/2023] [Indexed: 05/27/2023] Open
Abstract
Importance Expanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing. Objective To examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents. Design, Setting, and Participants This cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder. Exposures State implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined. Main Outcomes and Measures The main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023. Results The mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents. Conclusions and Relevance In this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
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16
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Treitler P, Nowels M, Samples H, Crystal S. Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access. JAMA Netw Open 2023; 6:e2312030. [PMID: 37145594 PMCID: PMC10163388 DOI: 10.1001/jamanetworkopen.2023.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023] Open
Abstract
Importance Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization. Objective To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access. Design, Setting, and Participants This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021. Exposure Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence. Main Outcomes and Measures Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty. Results Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation. Conclusions and Relevance In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
| | - Molly Nowels
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Hillary Samples
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
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17
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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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Turi ER, McMenamin A, Wolk CB, Poghosyan L. Primary care provider confidence in addressing opioid use disorder: A concept analysis. Res Nurs Health 2023; 46:263-273. [PMID: 36611290 PMCID: PMC10033432 DOI: 10.1002/nur.22294] [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: 09/29/2022] [Revised: 12/08/2022] [Accepted: 12/14/2022] [Indexed: 01/09/2023]
Abstract
Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.
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Affiliation(s)
- Eleanor R Turi
- Columbia University School of Nursing, New York, New York, USA
| | - Amy McMenamin
- Columbia University School of Nursing, New York, New York, USA
| | | | - Lusine Poghosyan
- Columbia University School of Nursing, New York, New York, USA
- Columbia University Mailman School of Public Health, New York, New York, USA
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19
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Roy PJ, Callaway Kim K, Suda K, Luo J, Wang X, Olejniczak D, Liebschutz JM. Impact of COVID-19-related regulatory changes on nationwide access to buprenorphine: An interrupted time series design. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100135. [PMID: 36694665 PMCID: PMC9851915 DOI: 10.1016/j.dadr.2023.100135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/22/2023]
Abstract
Background The impact of COVID-19-related healthcare changes on access to buprenorphine (BUP) nationwide in the US is unknown. Methods We conducted an interrupted time series with the IQVIA LRx database. The study timeline included BUP prescriptions from 52 weeks before (2/23/19-2/21/20) to 52 weeks after (4/4/20-4/2/21) the initial pandemic period (2/22/20-4/3/20). Segmented regression estimated relative changes in total milligrams (MG) of BUP available per week nationwide at 1, 26, and 52 weeks post-initial-pandemic. We evaluated treatment disruptions in previously stable patients, defined as ≥6 months of BUP prescriptions. Results A total of 31 617 849 prescriptions were included. Total MG BUP dispensed increased at 1 and 26 weeks and then returned to baseline trends at 52 weeks post-initial pandemic period (4.1% [95% CI: 3.7,4.5], 2.1% [1.5,2.6], 0.1% [-0.6,0.9]). Stably-treated patients saw a decrease in 7-, 14-, and 28-day treatment disruptions at 52 weeks post-initial-pandemic period (-21.6% [-25.6,-17.7]; -10.8% [-16.3,-5.3]; -27.3% [-33.0,-21.6]). Men retained an increase in MG BUP compared to women at 52 weeks (0.7% [0.01,1.4] versus -0.6% [-1.5,0.2]). Younger age groups (18-29 years and 30-39 years) had a decrease in MG BUP at 52 weeks compared to expected baseline trend (-16.6 [-24.2, -9.0]; -1.6 [-3.0, -0.1). Patients with Medicaid demonstrated an increase in MG BUP at 52 weeks (8.3% [6.3,10.3]). MG BUP prescribed by APP prescribing increased by over 140 000 mg per week prior to the pandemic and continued to increase. Conclusions Regulatory changes around buprenorphine prescribing facilitated patient access to buprenorphine during the pandemic.
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Affiliation(s)
- Payel Jhoom Roy
- Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - Katherine Callaway Kim
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Katie Suda
- Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
- Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Jing Luo
- Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - Xiaoming Wang
- National Institute on Drug Abuse, Bethesda, MD, United States
| | - Donna Olejniczak
- Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - Jane M Liebschutz
- Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
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20
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Terranella A, Guy GP, Mikosz C. Buprenorphine Dispensing Among Youth Aged ≤19 Years in the United States: 2015-2020. Pediatrics 2023; 151:e2022058755. [PMID: 36691760 PMCID: PMC10142390 DOI: 10.1542/peds.2022-058755] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Opioid related overdose among adolescents and young adults in the United States is rising. Medications for opioid use disorder (MOUD), including buprenorphine can reduce the risk of overdose, however they are underutilized. A better understanding of buprenorphine prescribing to youth will help inform interventions to expand access to treatment. METHODS We used IQVIA data to examine buprenorphine dispensing trends among youth aged ≤19 years from 2015 to 2020. Dispensing was examined by prescriber specialty, age, and sex. Data were weighted to provide national estimates. RESULTS The rate of buprenorphine dispensed to youth decreased 25% over the study period, from 0.84 to 0.63 prescriptions per 1000 youth per year. The proportion of youth dispensed buprenorphine also decreased 45%, from 7.6 to 4.2 persons per 100 000 per year. Over the same time, the proportion of adults aged ≥20 years dispensed buprenorphine increased 47%, from 378 to 593 persons per 100 000. Differences in dispensing by sex and temporal trends were also noted. Pediatricians accounted for less-than 2% of all prescriptions dispensed. CONCLUSIONS Buprenorphine dispensing to youth is low and declining in recent years. Given rates of opioid use disorder among youth, these findings suggest that many youth who could benefit from MOUD are not receiving it. Pediatricians could play a role in expanding access to MOUD for this high-risk population. Efforts to expand access to MOUD for adolescents could include improving training in opioid use disorder treatment of pediatricians and encouraging all clinicians who care for adolescents and young adults to obtain waivers to prescribe buprenorphine for MOUD.
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21
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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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22
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Jain L, Morrisroe K, Modesto-Lowe V. To use or not to use buprenorphine for illegally manufactured fentanyl. Fam Pract 2022; 40:428-430. [PMID: 36048969 DOI: 10.1093/fampra/cmac098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Lakshit Jain
- General Psychiatry Department, Connecticut Valley Hospital, Middletown, CT, United States.,Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Kathleen Morrisroe
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
| | - Vania Modesto-Lowe
- Department of Psychiatry, University of Connecticut, Farmington, CT, United States
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23
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Three-year Retention Rates With Office-based Treatment of Buprenorphine for Opioid Use Disorder in a Private Family Medicine Practice. J Addict Med 2022; 16:716-721. [PMID: 35913992 DOI: 10.1097/adm.0000000000001009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Although primary care settings have benefits for implementing office-based opioid treatment (OBOT) programs with buprenorphine, few studies have examined the impact on patient retention beyond 12 months. The objective of this study is to assess long-term outcomes of buprenorphine treatment for opioid use disorder (OUD) integrated into comprehensive primary care treatment at a family medicine practice. METHODS A retrospective chart review of patients diagnosed with OUD who received treatment with buprenorphine between December 2006 and January 2018 was conducted at private family medicine practice in semirural Upstate New York. Patients were seen continuously by the same provider. The primary outcome was retention in OBOT at 3 years. RESULTS The primary outcome was met by 47.4% of included patients (N = 152). Mean retention in care for all patients was 24.3 months. More than three quarters of patients (77%) had a least one psychiatric comorbidity managed by the practice, most commonly depression (59.9%). Self-reported history of intravenous drug use at baseline was associated with a higher likelihood of patient dropout at year 1 (odds ratio, 2.99; 95% confidence interval, 1.39-6.44; P = 0.004) and year 2 (odds ratio, 2.46; 95% confidence interval, 1.15-5.28; P = 0.019), with no difference observed at year 3. CONCLUSIONS Office-based opioid treatment with buprenorphine in a family medicine practice setting resulted in high retention rates, emphasizing the importance of continuity of care and integration of primary care within the OUD treatment model. Further research is needed on barriers to implementation of OBOT among family medicine providers.
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