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Bobb JF, Idu AE, Qiu H, Yu O, Boudreau DM, Wartko PD, Matthews AG, McCormack J, Lee AK, Campbell CI, Saxon AJ, Liu DS, Altschuler A, Samet JH, Northrup TF, Braciszewski JM, Murphy MT, Arnsten JH, Cunningham CO, Horigian VE, Szapocznik J, Glass JE, Caldeiro RM, Tsui JI, Burganowski RP, Weinstein ZM, Murphy SM, Hyun N, Bradley KA. Offering nurse care management for opioid use disorder in primary care: Impact on emergency and hospital utilization in a cluster-randomized implementation trial. Drug Alcohol Depend 2024; 261:111350. [PMID: 38875880 PMCID: PMC11281026 DOI: 10.1016/j.drugalcdep.2024.111350] [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: 12/13/2023] [Revised: 05/20/2024] [Accepted: 05/23/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Patients with opioid use disorder (OUD) have increased emergency and hospital utilization. The PROUD trial showed that implementation of office-based addiction treatment (OBAT) increased OUD medication treatment compared to usual care, but did not decrease acute care utilization in patients with OUD documented pre-randomization (clinicaltrials.gov/study/NCT03407638). This paper reports secondary emergency and hospital utilization outcomes in patients with documented OUD in the PROUD trial. METHODS This cluster-randomized implementation trial was conducted in 12 clinics from 6 diverse health systems (March 2015-February 2020). Patients who visited trial clinics and had an OUD diagnosis within 3 years pre-randomization were included in primary analyses; secondary analyses added patients with OUD who were new to the clinic or with newly-documented OUD post-randomization. Outcomes included days of emergency care and hospital utilization over 2 years post-randomization. Explanatory outcomes included measures of OUD treatment. Patient-level analyses used mixed-effect regression with clinic-specific random intercepts. RESULTS Among 1988 patients with documented OUD seen pre-randomization (mean age 49, 53 % female), days of emergency care or hospitalization did not differ between intervention and usual care; OUD treatment also did not differ. In secondary analyses among 1347 patients with OUD post-randomization, there remained no difference in emergency or hospital utilization despite intervention patients receiving 32.2 (95 % CI 4.7, 59.7) more days of OUD treatment relative to usual care. CONCLUSIONS Implementation of OBAT did not reduce emergency or hospital utilization among patients with OUD, even in the sample with OUD first documented post-randomization in whom the intervention increased treatment.
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Affiliation(s)
- Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA.
| | - Abisola E Idu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Hongxiang Qiu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Abigail G Matthews
- The Emmes Company, 401 N Washington St, Suite 700, Rockville, MD 20850, USA
| | - Jennifer McCormack
- The Emmes Company, 401 N Washington St, Suite 700, Rockville, MD 20850, USA
| | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108, USA
| | - David S Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, Three White Flint North, 11601 Landsdown Street, North Bethesda, MD 20852, USA
| | - Andrea Altschuler
- Kaiser Permanente Northern California Division of Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Jeffrey H Samet
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Crosstown Center, 801 Massachusetts Ave, Boston, MA 02119, USA
| | - Thomas F Northrup
- UTHealth Houston McGovern Medical School, Department of Family and Community Medicine, 6431 Fannin St, Houston, TX 77030, USA
| | - Jordan M Braciszewski
- Henry Ford Health, Center for Health Policy and Health Services Research, One Ford Place, Suite 5E, Detroit, MI 48202, USA
| | - Mark T Murphy
- MultiCare Health System, 315 Martin Luther King Jr. Way, Tacoma, WA 98415, USA
| | - Julia H Arnsten
- Montefiore Medical Center, 111 East 210 Street, Bronx, NY 10467, USA; Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, NY 10461, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, 1300 Morris Park Ave, The Bronx, NY 10461, USA
| | - Viviana E Horigian
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, 10th Floor, Miami, FL 33136, USA
| | - José Szapocznik
- Department of Public Health Sciences, University of Miami Miller School of Medicine, 1120 NW 14th Street, 10th Floor, Miami, FL 33136, USA
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Ryan M Caldeiro
- Mental Health and Wellness Department, Kaiser Permanente Washington, 1200 SW 27th St, Renton, WA 98057, USA
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
| | - Rachael P Burganowski
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Zoe M Weinstein
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Crosstown Center, 801 Massachusetts Ave, Boston, MA 02119, USA
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, 1300 York Avenue, New York, NY 10065, USA
| | - Noorie Hyun
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA
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Schweitzer EM, Urmanche A, Kong J, Hafezi S, Zhao J, Cooperman NA, Konova AB. The role of social connection in opioid use disorder treatment engagement. PSYCHOLOGY OF ADDICTIVE BEHAVIORS 2024; 38:222-230. [PMID: 37384450 PMCID: PMC10755080 DOI: 10.1037/adb0000934] [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] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Medications for opioid use disorder (OUD or MOUD) treatment combining pharmacotherapy with psychosocial support are effective for managing OUD. However, treatment engagement remains a challenge, with retention rates ∼30%-50%. Although social connection has been identified as important to recovery, it remains unclear whether and how social factors can bolster participation in treatment. METHOD Individuals receiving MOUD at three outpatient treatment programs (N = 82) and healthy community controls (N = 62) completed validated measures assessing social connection including (a) size, diversity, and embeddedness of social networks; (b) perceived social support and criticism within familial relationships; and (c) subjective social status. For those receiving MOUD, we also examined how aspects of social connection related to opioid (re)use and treatment engagement (medication adherence, group, and individual meeting attendance) assessed over ∼8 weeks/person. RESULTS Compared to controls, individuals receiving MOUD had smaller and less diverse and embedded social networks (Cohen's d > 0.4), and despite similar levels of perceived social support (d = 0.02), reported higher levels of social criticism (d = 0.6) and lower subjective social status (d = 0.5). Within the MOUD group, higher social network indices correlated specifically with higher therapeutic group attendance (Rs > 0.30), but not medication adherence, while higher levels of perceived criticism correlated with more frequent opioid use (R = 0.23). Results were mostly robust to control for sociodemographic variables, psychological distress/COVID-19, and treatment duration, but differed by MOUD type/program. CONCLUSIONS These findings highlight the potential importance of assessing an individual's social capital, promoting positive social connection, and continuing to assess the implementation and value of psychosocial support in MOUD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
| | - Adelya Urmanche
- University Behavioral Health Care & Brain Health Institute, Rutgers University-New Brunswick
| | - Julia Kong
- Department of Psychiatry, Rutgers University-New Brunswick
| | - Sahar Hafezi
- Department of Psychiatry, Rutgers University-New Brunswick
| | - Joshua Zhao
- Department of Psychiatry, Rutgers University-New Brunswick
| | | | - Anna B Konova
- Graduate Program in Neuroscience, Rutgers University-New Brunswick
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Gopaldas M, Wenzel K, Campbell ANC, Jalali A, Fishman M, Rotrosen J, Nunes EV, Murphy SM. Impact of Medication-Based Treatment on Health Care Utilization Among Individuals With Opioid Use Disorder. Psychiatr Serv 2023; 74:1227-1233. [PMID: 37337675 PMCID: PMC10730760 DOI: 10.1176/appi.ps.20220549] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVE This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health. METHODS This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics. RESULTS Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services. CONCLUSIONS These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.
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Affiliation(s)
- Manesh Gopaldas
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Kevin Wenzel
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Aimee N C Campbell
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Ali Jalali
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Marc Fishman
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - John Rotrosen
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Edward V Nunes
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
| | - Sean M Murphy
- New York State Psychiatric Institute and Columbia University Irving Medical Center, New York City (Gopaldas, Campbell, Nunes); Maryland Treatment Centers, Baltimore (Wenzel, Fishman); Department of Population Health Sciences, Weill Cornell Medical College, New York City (Jalali, Murphy); Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore (Fishman); Department of Psychiatry, New York University Grossman School of Medicine, New York City (Rotrosen)
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Becker TD, Eschliman EL, Thakrar AP, Yang LH. A conceptual framework for how structural changes in emerging acute substance use service models can reduce stigma of medications for opioid use disorder. Front Psychiatry 2023; 14:1184951. [PMID: 37829763 PMCID: PMC10565357 DOI: 10.3389/fpsyt.2023.1184951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023] Open
Abstract
Stigma toward people taking medication for opioid use disorder (MOUD) is prevalent, harmful to the health and well-being of this population, and impedes MOUD treatment resource provision, help-seeking, and engagement in care. In recent years, clinicians have implemented new models of MOUD-based treatment in parts of the United States that integrate buprenorphine initiation into emergency departments and other acute general medical settings, with post-discharge linkage to office-based treatment. These service models increase access to MOUD and they have potential to mitigate stigma toward opioid use and MOUD. However, the empirical literature connecting these emerging service delivery models to stigma outcomes remains underdeveloped. This paper aims to bridge the stigma and health service literatures via a conceptual model delineating how elements of emerging MOUD service models can reduce stigma and increase behavior in pursuit of life goals. Specifically, we outline how new approaches to three key processes can counter structural, public, and self-stigma for this population: (1) community outreach with peer-to-peer influence, (2) clinical evaluation and induction of MOUD in acute care settings, and (3) transition to outpatient maintenance care and early recovery. Emerging service models that target these three processes can, in turn, foster patient empowerment and pursuit of life goals. There is great potential to increase the well-being of people who use opioids by reducing stigma against MOUD via these structural changes.
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Affiliation(s)
- Timothy D. Becker
- Department of Psychiatry, New York-Presbyterian Hospital/Weill Cornell Medicine, New York, NY, United States
- Department of Psychiatry, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States
| | - Evan L. Eschliman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Ashish P. Thakrar
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Lawrence H. Yang
- Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York, NY, United States
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
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Jakubowski A, Singh-Tan S, Torres-Lockhart K, Nahvi S, Stein M, Fox AD, Lu T. Hospital-based clinicians lack knowledge and comfort in initiating medications for opioid use disorder: opportunities for training innovation. Addict Sci Clin Pract 2023; 18:31. [PMID: 37198707 PMCID: PMC10193697 DOI: 10.1186/s13722-023-00386-x] [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: 11/09/2022] [Accepted: 05/01/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Hospital-based clinicians infrequently initiate medications for opioid use disorder (MOUD) for hospitalized patients. Our objective was to understand hospital-based clinicians' knowledge, comfort, attitudes, and motivations regarding MOUD initiation to target quality improvement initiatives. METHODS General medicine attending physicians and physician assistants at an academic medical center completed questionnaires eliciting barriers to MOUD initiation, including knowledge, comfort, attitudes and motivations regarding MOUD. We explored whether clinicians who had initiated MOUD in the prior 12 months differed in knowledge, comfort, attitudes, and motivations from those who had not. RESULTS One-hundred forty-three clinicians completed the survey with 55% reporting having initiated MOUD for a hospitalized patient during the prior 12 months. Common barriers to MOUD initiation were: (1) Not enough experience (86%); (2) Not enough training (82%); (3) Need for more addiction specialist support (76%). Overall, knowledge of and comfort with MOUD was low, but motivation to address OUD was high. Compared to MOUD non-initiators, a greater proportion of MOUD initiators answered knowledge questions correctly, agreed or strongly agreed that they wanted to treat OUD (86% vs. 68%, p = 0.009), and agreed or strongly agreed that treatment of OUD with medication was more effective than without medication (90% vs. 75%, p = 0.022). CONCLUSIONS Hospital-based clinicians had favorable attitudes toward MOUD and are motivated to initiate MOUD, but they lacked knowledge of and comfort with MOUD initiation. To increase MOUD initiation for hospitalized patients, clinicians will need additional training and specialist support.
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Affiliation(s)
- Andrea Jakubowski
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Sumeet Singh-Tan
- Department of Medicine, Hospital Division, Albert Einstein College of Medicine/Montefiore Medical Center, 111 E. 210 St, Bronx, NY 10467 USA
| | - Kristine Torres-Lockhart
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Shadi Nahvi
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Melissa Stein
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Aaron D. Fox
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Tiffany Lu
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
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Mao W, Shalaby R, Agyapong VIO. Interventions to Reduce Repeat Presentations to Hospital Emergency Departments for Mental Health Concerns: A Scoping Review of the Literature. Healthcare (Basel) 2023; 11:healthcare11081161. [PMID: 37107995 PMCID: PMC10138571 DOI: 10.3390/healthcare11081161] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/13/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND The number of readmissions to the emergency department (ED) for mental health services each year is significant, which increases healthcare costs and negatively affects the morale and quality of life of patients and their families. OBJECT This scoping review aimed to establish a better understanding of interventions that have been implemented to reduce psychiatric patient readmission and ED use within the ED, to identify areas for improvement, and therefore to assist in the development of more effective actions in the future. METHOD The scoping review was conducted on several bibliographic databases to identify relevant studies. Two researchers independently screened and reviewed titles, abstracts, and full-text articles that met the inclusion criteria. Using Covidence software, 26 out of 6951 studies were eligible for inclusion in this scoping review based on the PRISMA checklist. Data were extracted, collated, summarized, presented, and discussed. RESULT This review identified 26 studies which examined interventions aimed to reduce ED visits, such as the High Alert Program (HAP), the Patient-Centered Medical Home (PCMH), the Primary Behavioral Health Care Integration (PBHCI), and the Collaborative Care (CC) Program, etc. Twenty-three of the studies were conducted in North America, while the rest were conducted in Europe and Australia. A total of 16 studies examined interventions directed to any mental health conditions, while the rest addressed specific health conditions, such as substance use disorders, schizophrenia, anxiety, depression. Interventions involved comprehensive and multidisciplinary services, incorporation of evidence-based behavioral and pharmacological strategies, and emphasized the case management that was found to be effective. Additionally, there was a marked consideration for diverse mental health groups, such as those with substance use disorder and of young age. Most interventions showed a positive effect on reducing psychiatric ED visits. CONCLUSION Various initiatives have been implemented worldwide to reduce the number of emergency department visits and the associated burden on healthcare systems. This review highlights the greater need for developing more accessible interventions, as well as setting up a comprehensive community health care system aiming to reduce frequent ED presentations.
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Affiliation(s)
- Wanying Mao
- Department of Psychiatry, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Reham Shalaby
- Department of Psychiatry, University of Alberta, Edmonton, AB T6G 1C9, Canada
| | - Vincent Israel Opoku Agyapong
- Department of Psychiatry, University of Alberta, Edmonton, AB T6G 1C9, Canada
- Department of Psychiatry, Faculty of Medicine, Dalhousie University, 5909 Veterans, Memorial Lane, 8th Floor Abbie J. Lane Memorial Building, QEII Health Sciences Centre, Halifax, NS B3H 2E2, Canada
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Grieb SM, Harris R, Rosecrans A, Zook K, Sherman SG, Greenbaum A, Lucas GM, Page KR. Awareness, perception and utilization of a mobile health clinic by people who use drugs. Ann Med 2022; 54:138-149. [PMID: 36799361 PMCID: PMC8741230 DOI: 10.1080/07853890.2021.2022188] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs. METHODS Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory. RESULTS Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients. DISCUSSION MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.
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Affiliation(s)
- Suzanne M Grieb
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert Harris
- Baltimore City Health Department, Baltimore, MD, USA
| | - Amanda Rosecrans
- Baltimore City Health Department, Baltimore, MD, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Zook
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Gregory M Lucas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen R Page
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dowd WN, Barch DH, Seibert JH, Mark TL. Development and validation of a claim-based provider-level measurement of use of medications to treat opioid use disorder. J Subst Abuse Treat 2022; 140:108824. [DOI: 10.1016/j.jsat.2022.108824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/28/2022] [Accepted: 06/07/2022] [Indexed: 11/25/2022]
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John WS, Mannelli P, Hoyle RH, Greenblatt L, Wu LT. Association of chronic non-cancer pain status and buprenorphine treatment retention among individuals with opioid use disorder: Results from electronic health record data. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100048. [PMID: 36845986 PMCID: PMC9948869 DOI: 10.1016/j.dadr.2022.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Although chronic non-cancer pain (CNCP) is common among individuals with opioid use disorder (OUD), its impact on buprenorphine treatment retention is unclear. The goal of this study was to use electronic health record (EHR) data to examine the association of CNCP status and 6-month buprenorphine retention among patients with OUD. METHODS We analyzed EHR data of patients with OUD who received buprenorphine treatment in an academic healthcare system between 2010 and 2020 (N = 676). We used Kaplan-Meier curves and Cox proportional hazards regression to estimate risk of buprenorphine treatment discontinuation (≥90 days between subsequent prescriptions). We used Poisson regression to estimate the association of CNCP and the number of buprenorphine prescriptions over 6 months. RESULTS Compared to those without CNCP, a higher proportion of patients with CNCP were of older age and had comorbid diagnoses for psychiatric and substance use disorders. There were no differences in the probability of buprenorphine treatment continuation over 6 months by CNCP status (p = 0.15). In the adjusted cox regression model, the presence of CNCP was not associated with time to buprenorphine treatment discontinuation (HR = 0.90, p = 0.28). CNCP status was associated with a higher number of prescriptions over 6 months (IRR = 1.20, p < 0.01). CONCLUSIONS These findings suggest that the presence of CNCP alone cannot be reliably associated with buprenorphine retention in patients with OUD. Nonetheless, providers should be aware of the association between CNCP and greater psychiatric comorbidity among patients with OUD when developing treatment plans. Research on the influence of additional characteristics of CNCP on treatment retention is needed.
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Affiliation(s)
- William S. John
- Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry, Duke University Medical Center, Durham, NC, United States
| | - Paolo Mannelli
- Department of Pyschiatry and Behavioral Sciences, Division of Adult Psychiatry and Psychology, Duke University Medical Center, Durham, NC, United States
| | - Rick H. Hoyle
- Department of Pyschiatry and Behavioral Sciences, Division of Adult Psychiatry and Psychology, Duke University Medical Center, Durham, NC, United States
| | - Lawrence Greenblatt
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
| | - Li-Tzy Wu
- Department of Psychiatry and Behavioral Sciences, Division of Social and Community Psychiatry, Duke University Medical Center, Durham, NC, United States
- Department of Psychology and Neuroscience, Duke University, Durham, NC, United States
- Department of Medicine, Division of General Internal Medicine, Duke University Medical Center, Durham, NC, United States
- Duke Institue for Brain Sciences, Duke University, Durham, NC, United States
- Center for Child and Family Policy, Sanford School of Public Policy, Duke University, Durham, NC, United States
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10
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Radic M, Parlier-Ahmad AB, Wills B, Martin CE. Social determinants of health and emergency department utilization among adults receiving buprenorphine for opioid use disorder. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 3:100062. [PMID: 35783992 PMCID: PMC9248991 DOI: 10.1016/j.dadr.2022.100062] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 05/09/2022] [Accepted: 05/09/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Individuals with opioid use disorder (OUD) use the emergency department (ED) at high rates. Medication treatment for OUD (MOUD) is associated with reduced ED utilization. However, individuals receiving MOUD still utilize ED services at higher rates than the general population. The objective of this study is to compare the psychosocial and clinical characteristics of those who do and do not utilize ED services based on the Healthy People 2030 framework regarding social determinants of health (SDoH) among a sample of individuals receiving MOUD. METHODS Participants receiving buprenorphine for OUD at an outpatient addiction clinic completed a cross-sectional survey between July and September 2019. A 6-month prospective medical record review was conducted. The primary outcome was ED visit (yes/no) during the 6-month study period. Demographic, psychosocial, and clinical characteristics were gathered from survey measures and chart abstraction. Chi square and T-tests tested differences by ED utilization. RESULTS Participants (n=142) were 54.9% female and 68.8% Black, with an average age of 43.2 years (SD=12.5). Of the participants, 38.7% visited the ED in the study period, primarily for infectious or musculoskeletal causes. Participants with an ED visit were more likely to be Black (p=.011), have less social support (p=.030), more medical comorbidities (p=.008) including chronic pain (p=.045), and more visits with an addiction provider in the study period (p=.009). CONCLUSIONS Factors associated with ED utilization among individuals receiving buprenorphine for OUD include low social support and medical comorbidities, including chronic pain. More research is needed on modifiable SDoH that influence ED utilization.
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Affiliation(s)
- Maja Radic
- Virginia Commonwealth University School of Medicine, 1201 E Marshall St, Richmond, VA 23298, USA
| | - Anna Beth Parlier-Ahmad
- Department of Psychology, Virginia Commonwealth University, 806 W. Franklin St., Richmond, VA 23284, USA
| | - Brandon Wills
- Department of Emergency Medicine, Virginia Commonwealth University, 1250 E. Marshall St., Richmond, VA 23298, USA
| | - Caitlin E. Martin
- Department of Obstetrics and Gynecology and Institute for Drug and Alcohol Studies, Virginia Commonwealth University School of Medicine, 1250 E. Marshall St., Richmond, VA 23298, USA
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11
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Petrakis I, Springer SA, Davis C, Ralevski E, Gu L, Lew R, Hermos J, Nuite M, Gordon AJ, Kosten TR, Nunes EV, Rosenheck R, Saxon AJ, Swift R, Goldberg A, Ringer R, Ferguson R. Rationale, design and methods of VA-BRAVE: a randomized comparative effectiveness trial of two formulations of buprenorphine for treatment of opioid use disorder in veterans. Addict Sci Clin Pract 2022; 17:6. [PMID: 35101115 PMCID: PMC8802273 DOI: 10.1186/s13722-022-00286-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background To address the US opioid epidemic, there is an urgent clinical need to provide persons with opioid use disorder (OUD) with effective medication treatments for OUD (MOUD). Formulations of sublingual buprenorphine/naloxone (SL-BUP/NLX) are considered the standard of care for OUD including within the Veterans Healthcare Administration (VHA). However, poor retention on MOUD undermines its effectiveness. Long-acting injectable monthly buprenorphine (INJ-BUP) (e.g., Sublocade®) has the potential to improve retention and therefore reduce opioid use and overdose. Designing and conducting studies for OUD pose unique challenges. The strategies and solutions to some of these considerations in designing Cooperative Studies Program (CSP) 2014, Buprenorphine for Treating Opioid Use Disorder in Veterans (VA-BRAVE), a randomized, 20-site, clinical effectiveness trial comparing INJ-BUP to SL-BUP/NLX conducted within the VHA may provide valuable guidance for others confronted with similar investigation challenges. Methods This 52-week, parallel group, open-label, randomized controlled trial (RCT) evaluates the comparative effectiveness of two current FDA-approved formulations of buprenorphine: (1) daily SL-BUP/NLX vs. (2) monthly (28-day) INJ-BUP for Veterans with moderate to severe OUD (n = 952). The primary outcomes are (1) retention in MOUD and (2) opioid abstinence. Secondary outcomes include measures of other drug use, psychiatric symptoms, medical outcomes including prevalence rates of HIV, hepatitis B and C as well as social outcomes (housing instability, criminal justice involvement), service utilization and cost-effectiveness. Special considerations in conducting a comparative effectiveness trial with this population and during COVID-19 pandemic were also included. Discussion The evaluation of the extended-release formulation of buprenorphine compared to the standard sublingual formulation in real-world VHA settings is of paramount importance in addressing the opioid epidemic. The extent to which this new treatment facilitates retention, decreases opioid use, and prevents severe sequelae of OUD has not been studied in any long-term trial to date. Positive findings in this trial could lead to widespread adoption of MOUD, and, if proven superior INJ-BUP, by clinicians throughout the VHA and beyond. This treatment has the potential to reduce opioid use among Veterans, improve medical, psychological, and social outcomes, and save lives at justifiable cost. Trial registration Registered at Clinicaltrials.gov NCT04375033
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Affiliation(s)
- Ismene Petrakis
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Sandra A Springer
- Section of Infectious Disease, Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia Davis
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lucy Gu
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
| | - John Hermos
- Section of General Internal Medicine, Department of Medicine, School of Medicine, Boston University, Boston, MA, USA.,Department of Internal Medicine, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA
| | | | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas R Kosten
- Department of Psychiatry, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Robert Rosenheck
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Robert Swift
- Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Alexa Goldberg
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Robert Ringer
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Ryan Ferguson
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
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12
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Treatment of Hepatitis C virus among people who inject drugs at a syringe service program during the COVID-19 response: The potential role of telehealth, medications for opioid use disorder and minimal demands on patients. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 101:103570. [PMID: 34954493 PMCID: PMC8685180 DOI: 10.1016/j.drugpo.2021.103570] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/19/2021] [Accepted: 12/08/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Healthcare delivery was disrupted during the COVID-19 pandemic, requiring minimized in-person contact between patients and clinicians. During the pandemic, people with opioid use disorder (OUD) were not only at elevated risk for COVID-19, but had markedly reduced access to treatment for OUD, Hepatitis C virus (HCV) and HIV due to recommended decreased in-person visits. METHODS From March 15-June 15, 2020 at the syringe services program (SSP) in New Haven, Connecticut, USA, a differentiated care model evolved with reduced clinical demands on people who inject drugs (PWID) to ensure screening and treatment for HCV, HIV and OUD, with a focus on HCV treatment. This model involved a single, bundled screening, evaluation, testing (SET) and monitoring strategy for all three conditions, minimal in-person visits, followed by tele-health communication between patients, outreach workers and clinicians. In-person visits occurred only during induction onto methadone and phlebotomy at baseline and phlebotomy 12 weeks post-treatment for HCV to measure sustained virological response (SVR). Patients received supportive texts/calls from outreach workers and clinicians. RESULTS Overall, 66 actively injecting PWID, all with OUD, underwent bundled laboratory screening; 35 had chronic HCV infection. Participants were 40 years (mean), mostly white (N = 18) men (N = 28) and 12 were unstably housed. Two were lost to-follow-up and 2 were incarcerated, leaving 31 who started pan-genotypic direct-acting antivirals (DAAs). The mean time from referral to initial phlebotomy and initiation of DAAs was 6.9 and 9.9 days, respectively. Fourteen additional patients were newly started on buprenorphine and 6 started on methadone; three and four, respectively, were on treatment at baseline. Overall, 29 (93.5%) PWID who initiated DAAs achieved SVR; among unstably housed persons the SVR was 83.3%. CONCLUSIONS In response to COVID-19, an innovative differentiated care model for PWID at an SSP evolved that included successful co-treatment for HCV, HIV and OUD using a client-centered approach that reduces treatment demands on patients yet supports ongoing access to evidence-based treatments.
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13
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Huang CL, Tsai IJ, Lin WC, Ho IK, Wang RY, Lee CWS. Augmentation in Healthcare Utilization of Patients with Opioid Use Disorder After Methadone Maintenance Treatment: A Retrospective Nationwide Study. Adv Ther 2021; 38:2908-2919. [PMID: 33559050 DOI: 10.1007/s12325-021-01633-w] [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: 12/04/2020] [Accepted: 01/19/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION The health benefits of entering methadone maintenance treatment (MMT) for opioid-dependent persons may not be merely limited to therapy of opioid use disorder. We aimed to compare the healthcare utilization of MMT patients before and after MMT. METHODS A retrospective analysis was performed using the Taiwan Illicit Drug Issue Database and the National Health Insurance Research Database (NHIRD) between 2014 and 2016. We included 1255 newly enrolled MMT patients in 2015 and randomly selected 5020 patients from NHIRD matched by age and gender as the comparison group. Changes in healthcare utilization 1 year before and 1 year after the date of the index date (MMT initiation) were compared within and between MMT and comparison groups. RESULTS During the 1-year period following MMT, the hospitalization length was considerably decreased, while the number of outpatient visits, emergency department (ED) visits, and ED expenditure significantly increased in MMT patients. Multivariable linear regression with the difference-in-difference approach revealed that all the categories of healthcare utilization increased, except for a minor increase of outpatient expenditure and a slight decrease of hospitalization length for the MMT group relative to the comparison group. Increases in utilization of the departments of psychiatry and infectious diseases of the MMT patients were considerable. CONCLUSION MMT is associated with increased healthcare utilization, and departments of psychiatry and infectious diseases play substantial roles. Policy-makers should warrant access for all who need healthcare by ensuring the availability of the treatment for drug dependence.
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Affiliation(s)
- Chieh-Liang Huang
- School of Medicine, China Medical University, Taichung, Taiwan
- Ph.D. Program for Aging, College of Medicine, China Medical University, Taichung, Taiwan
- Tsaotun Psychiatric Center, Ministry of Health and Welfare, Nan-Tou County, Taiwan
| | - I-Ju Tsai
- Center for Drug Abuse and Addiction, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Wen-Chi Lin
- Center for Drug Abuse and Addiction, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Ing-Kang Ho
- Ph.D. Program for Aging, College of Medicine, China Medical University, Taichung, Taiwan
- Center for Drug Abuse and Addiction, China Medical University Hospital, China Medical University, Taichung, Taiwan
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Ruey-Yun Wang
- Department of Public Health, China Medical University, Taichung, Taiwan
| | - Cynthia Wei-Sheng Lee
- Center for Drug Abuse and Addiction, China Medical University Hospital, China Medical University, Taichung, Taiwan.
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan.
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14
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Facilitating rapid access to addiction treatment: a randomized controlled trial. Addict Sci Clin Pract 2021; 16:34. [PMID: 34034821 PMCID: PMC8152083 DOI: 10.1186/s13722-021-00240-y] [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: 10/28/2020] [Accepted: 05/08/2021] [Indexed: 11/10/2022] Open
Abstract
Background Obtaining timely access to addiction medicine treatment for patients with substance use disorders is challenging and patients often have to navigate complex referral pathways. This randomized controlled trial examines the effect of providing an expedited pathway to addiction medicine treatment on initial treatment engagement and health care utilization. Methods Individuals with possible alcohol or opioid use disorder were recruited from three residential withdrawal management services (WMS). Subjects randomized to the Delayed Intervention (DI) group were given contact information for a nearby addiction medicine clinic; those randomized to the Rapid Intervention (RI) group were given an appointment at the clinic within 2 days and were accompanied to their first appointment. Results Of the 174 individuals who were screened, 106 were randomized to either the DI or RI group. The two groups were similar in demographics, housing status, and substance use in the last 30 days. In the 6-month period following randomization, 85% of the RI group attended at least one clinic appointment, compared to only 29% in the DI group (p < 0.0001). The RI group had a mean of 6.39 ED visits per subject in the 12 months after randomization, while the DI group had a mean of 13.02 ED visits per subject in the same 12-month period (p = 0.0469). Other health utilization measures did not differ between the two groups. Conclusion Providing immediate facilitated access to an addiction medicine service resulted in greater initial engagement and reduced emergency department visits at 6 months. Trial registration This trial is registered at the National Institutes of Health (ClinicalTrials.gov) under identifier #NCT01934751. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-021-00240-y.
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15
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Ferries E, Racsa P, Bizzell B, Rhodes C, Suehs B. Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population. J Manag Care Spec Pharm 2021; 27:596-606. [PMID: 33908274 PMCID: PMC10390915 DOI: 10.18553/jmcp.2021.27.5.596] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: More than 30% of Medicare beneficiaries and 40% of patients dually eligible for Medicare and Medicaid use opioids. With an estimated 8%-12% of patients developing an opioid use disorder (OUD) after initiating opioids, opioid misuse is a significant public health challenge, especially among high-risk Medicare populations. Medication-assisted treatment (MAT) is the use of medications for the treatment of OUD and to prevent relapse to opioid use. MAT is the most effective treatment for OUD. There are a variety of barriers to MAT therapy that may delay access to treatment. OBJECTIVE: To study the impact of the removal of prior authorization requirements for MAT medications on MAT utilization, opioid utilization, and clinical outcomes, including emergency department visits, inpatient admission, relapse rates, behavioral health services, and nonopioid pain medication utilization, among opioid-using individuals with Medicare Advantage Prescription Drug (MAPD) coverage. METHODS: This retrospective, cross-sectional study used administrative medical, pharmacy, and enrollment data to identify chronic opioid users and a subset cohort initiating MAT use in 2017, when prior authorization requirements were in effect, and 2018 after removal of prior authorization requirements. Opioid and MAT utilization and clinical outcomes from emergency department visits were also examined before and after prior authorization requirements. A logistic regression analysis was conducted to examine the impact of the policy change on relapse rates, comparing relapse rates in 2017 and 2018, after controlling for potentially confounding demographic and clinical factors. RESULTS: This policy change was followed by a decrease in opioid utilization, an increase in MAT initiation, and a 4% decline in relapse rates. Patients initiating MAT after removal of prior authorizations had a 19% decrease in likelihood of relapse, and those with an OUD diagnosis were 47% less likely to relapse. The majority of MAT recipients were aged younger than 65 years, had a mental or behavioral health disorder diagnosis, and initially used relatively low doses (< 90 MME) of prescription opioids. There were no statistically significant differences in the use of behavioral health services or the use of nonopioid medications from 2017 to 2018. CONCLUSIONS: Utilization management policies should ensure appropriate MAT use, while minimizing impediments to access. Providing patients with evidence-based therapy effective for the treatment of OUD is essential to patient recovery and combating the consequences of the opioid epidemic. Further strides are needed to eliminate additional obstacles to OUD care. DISCLOSURES: No outside funding supported this study. All authors are or were employees of Humana, Inc., at the time of the study and have no other potential conflicts of interest to disclose.
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16
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Sullivan RW, Szczesniak LM, Wojcik SM. Bridge clinic buprenorphine program decreases emergency department visits. J Subst Abuse Treat 2021; 130:108410. [PMID: 34118702 DOI: 10.1016/j.jsat.2021.108410] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Opioid withdrawal due to opioid use disorder (OUD) is an increasing health emergency and complaint in emergency departments (EDs) across the United States. As a response to the increased need for OUD treatment, a low threshold buprenorphine program, or Bridge Clinic, was established within our hospital system. Patients are primarily connected to the Bridge Clinic through the ED, and are able to complete their consultation appointment reliably within 1-3 days of referral. This program also serves to connect patients to community resources for continued treatment of OUD. METHODS A retrospective chart review was performed to identify ED-based referrals to the Bridge Clinic in the period from January 1, 2017 - December 31, 2018. Outcomes of interest included: (1) ED utilization in the six months before and after consultation at the Bridge Clinic and (2) adherence to buprenorphine therapy at 2-year follow-up. RESULTS A total of 269 patients were included in the study, with 167 males (62%) and a mean age of 37.8 years. There were 654 total visits to the ED six months before referral to the Bridge Clinic and 381 visits in the six-month period after the initial appointment. There was a high adherence to buprenorphine treatment at 2 year follow up (56%). CONCLUSIONS These early results suggest that prompt referral to a buprenorphine treatment program significantly reduces ED utilization and connects patients to community resources for continued buprenorphine treatment for OUD.
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Affiliation(s)
- Ross W Sullivan
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA.
| | | | - Susan M Wojcik
- Department of Emergency Medicine, Upstate Medical University, Syracuse, NY, USA
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17
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Wiercigroch D, Hoyeck P, Sheikh H, Hulme J. A qualitative examination of the current management of opioid use disorder and barriers to prescribing buprenorphine in a Canadian emergency department. BMC Emerg Med 2021; 21:48. [PMID: 33858328 PMCID: PMC8051038 DOI: 10.1186/s12873-021-00443-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 03/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Emergency departments (EDs) across Canada are increasingly prescribing buprenorphine for opioid use disorder (OUD). The objective of this study was to identify the current knowledge, attitudes, and behaviours of ED physicians on the management of OUD in the ED, including barriers and facilitators to prescribing buprenorphine. Methods We purposefully selected emergency physicians from one ED in Toronto which had recently received education on OUD management and had a new addiction medicine follow-up clinic, to participate in semi-structured interviews. We used semi-structured interviews to explore experiences with patients with OUD, conceptions of role of the ED in addressing OUD, and specifically ask about perceptions and experience on using buprenorphine for opioid withdrawal. Our analysis was informed by constructivist grounded theory to help uncover contextualized social processes and focus on what people do and why they do it. Two researchers independently coded transcripts using an iterative constant comparative and interpretative approach. Results Results fell broadly into facilitators and barriers. Generally, management of OUD in the ED varied significantly. Physician-level facilitators to treating opioid withdrawal with buprenorphine included: knowledge about OUD an7d buprenorphine, positive experiences with substitution therapy in the past, and the presence of physician champions. Systems-level facilitators included timely access to follow-up care and pre-printed order sets. Barriers included provider inexperience, lack of feedback on treatment effectiveness, limited time to counsel patients, and pressure to discharge patients quickly. Additional barriers included concerns about precipitating withdrawal, prescribing a chronic medication in acute care, and patient attitudes. Conclusion This study describes barriers and facilitators to addressing OUD and prescribing buprenorphine in a Canadian ED. These findings suggest a role for additional provider education, involvement of allied health professionals in counseling, and mentorship by physician champions in the department. Supplementary Information The online version contains supplementary material available at 10.1186/s12873-021-00443-1.
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Affiliation(s)
- David Wiercigroch
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Canada.
| | - Patricia Hoyeck
- Faculty of Medicine, University of Toronto, 1 King's College Circle, Toronto, Canada
| | - Hasan Sheikh
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,University Health Network Emergency Department, Toronto, Canada
| | - Jennifer Hulme
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada.,University Health Network Emergency Department, Toronto, Canada
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Kumar N, Mancino MJ, Thostenson JD, McGaugh J, Oliveto AH. Feasibility and Preliminary Efficacy of Isradipine During Outpatient Buprenorphine Stabilization and Detoxification: A Pilot Randomized, Placebo-Controlled Trial. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2020; 14:1178221820970926. [PMID: 33281447 PMCID: PMC7686602 DOI: 10.1177/1178221820970926] [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: 05/11/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022]
Abstract
Background: Given the immense burden of the widespread use of opioids around the world,
exploring treatments that improve drug use outcomes, and craving and
withdrawal measures in individuals with opioid use disorder is crucial. This
pilot study examined the feasibility and preliminary efficacy of the L-type
calcium-channel blocker isradipine (ISR) to improve drug use outcomes, and
craving and withdrawal measures during buprenorphine (BUP)/ISR stabilization
and subsequent taper in opioid-dependent individuals. Methods: Participants were stabilized on BUP sublingual tablets within the first 2
days of week 1, were then randomized and inducted on either ISR or placebo,
gradually increasing the dose over the next 2 weeks, followed by a 10-day
BUP taper during weeks 5-6, and ISR/placebo taper during weeks 7 to 8.
Assessments included thrice-weekly measures of craving and withdrawal, as
well as vital signs and urine drug screens. Medication compliance was
assessed by monitoring number of missed clinic visit days. Results: Baseline characteristics of participants (n = 25; 60% male, 96% Caucasian,
48% employed, mean age 32.8 years) did not differ significantly between
treatment groups (isradipine, n = 11; placebo, n = 14). During the
stabilization phase (n = 19), ISR participants had significantly lower rates
of illicit opioid-positive urines (treatment × visit:
t = -2.16, P = 0.03), as well as reduction
in craving intensity (t = –2.50,
P = 0.01), frequency (t = –3.43,
P < 0.01) and duration (t = –2.51,
P = 0.01). ISR was well tolerated with mild adverse
effects. Conclusions: This study was likely underpowered due to being a pilot trial. Although
preliminary results suggest ISR may improve BUP-assisted treatment outcomes,
concerns about high number of exclusions (n = 11 during taper phase) based
on cardiovascular measures as well as ISR-induced changes in vital signs
with the immediate release formulation may limit the feasibility of this
approach. Trial Registration: Clinicaltrials.gov identifier NCT01895270. Registered 10 July 2013, https://clinicaltrials.gov/ct2/show/NCT01895270?id=NCT01895270&draw=2&rank=1
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Affiliation(s)
- Nihit Kumar
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael J Mancino
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeff D Thostenson
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Janette McGaugh
- Ouachita Behavioral Health and Wellness, Hot Springs, AR, USA
| | - Alison H Oliveto
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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Panagiotoglou D, McCracken R, Lavergne MR, Strumpf EC, Gomes T, Fischer B, Brackett A, Johnson C, Kendall P. Evaluating the intended and unintended consequences of opioid-prescribing interventions on primary care in British Columbia, Canada: protocol for a retrospective population-based cohort study. BMJ Open 2020; 10:e038724. [PMID: 33154053 PMCID: PMC7646336 DOI: 10.1136/bmjopen-2020-038724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 08/08/2020] [Accepted: 10/01/2020] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Between 2015 and 2018, there were over 40 000 opioid-related overdose events and 4551 deaths among residents in British Columbia (BC). During this time the province mobilised a variety of policy levers to encourage physicians to expand access to opioid agonist treatment and the College of Physicians and Surgeons of British Columbia (CPSBC) released a practice standard establishing legally enforceable minimum thresholds of professional behaviour in the hopes of curtailing overdose events. Our goal is to conduct a comprehensive investigation of the intended and unintended consequences of these policy changes. Specifically, we aim to understand the effects of these measures on physician prescribing behaviours, identify physician characteristics associated with uptake of the new measures, and measure the effects of the policy changes on patients' access to quality primary care. METHODS AND ANALYSIS This is a population-level, retrospective cohort study of all BC primary care physicians who prescribed any opioid medication for opioid-use disorder or chronic non-cancer pain during the study period, and their patients. The study period is 1 January 2013-31 December 2018, with a 1-year wash-in period (1 January 2012-31 December 2012) to exclude patients who initiated long-term opioid treatment prior to our study period or whose pain type (ie, 'chronic non-cancer', 'acute', 'cancer or palliative', or 'other') cannot be confirmed. The project combines five administrative health datasets under the authority of the BC Ministry of Health, with the CPSBC's Physician Registry, BC Cancer Agency's Cancer Registry and Vital Statistics' Mortality data. We will create measures of prescribing concordance, access, continuity, and comprehensiveness to assess primary care delivery and quality at both the physician and patient level. We will use generalised estimating equations, interrupted time series, mixed effects models, and funnel plots to identify factors related to changes in prescribing and evaluate the impact of the changes to prescribing policies. Results will be reported using appropriate Enhancing the QUAlity and Transparency Of health Research guidelines (eg, STrengthening the Reporting of OBservational studies in Epidemiology). ETHICS AND DISSEMINATION This study has been approved by McGill University's Institutional Review Board (#A11-M55-19A), and the University of British Columbia's Research Ethics Board (#H19-03537). We will disseminate results via a combination of open access peer-reviewed journal publications, conferences, lay summaries and OpEds.
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Affiliation(s)
- Dimitra Panagiotoglou
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
| | - Rita McCracken
- Department of Family Practice, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - M Ruth Lavergne
- Centre for Applied Research in Mental Health and Addiction, Simon Fraser University, Burnaby, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Erin C Strumpf
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada
- Department of Economics, McGill University, Montreal, Québec, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Benedikt Fischer
- Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
- Institute for Mental Health Policy Research, Centre for Addiction and Mental, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | | | - Cheyenne Johnson
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- School of Nursing, University of British Columbia, Vancouver, British Columbia, Canada
| | - Perry Kendall
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
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Foster SD, Lee K, Edwards C, Pelullo AP, Khatri UG, Lowenstein M, Perrone J. Providing Incentive for Emergency Physician X-Waiver Training: An Evaluation of Program Success and Postintervention Buprenorphine Prescribing. Ann Emerg Med 2020; 76:206-214. [DOI: 10.1016/j.annemergmed.2020.02.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/06/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
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21
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Lewer D, Freer J, King E, Larney S, Degenhardt L, Tweed EJ, Hope VD, Harris M, Millar T, Hayward A, Ciccarone D, Morley KI. Frequency of health-care utilization by adults who use illicit drugs: a systematic review and meta-analysis. Addiction 2020; 115:1011-1023. [PMID: 31705770 PMCID: PMC7210080 DOI: 10.1111/add.14892] [Citation(s) in RCA: 84] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/04/2019] [Accepted: 11/04/2019] [Indexed: 11/26/2022]
Abstract
AIMS To summarize evidence on the frequency and predictors of health-care utilization among people who use illicit drugs. DESIGN Systematic search of MEDLINE, EMBASE and PsychINFO for observational studies reporting health-care utilization published between 1 January 2000 and 3 December 2018. We conducted narrative synthesis and meta-analysis following a registered protocol (identifier: CRD42017076525). SETTING AND PARTICIPANTS People who use heroin, powder cocaine, crack cocaine, methamphetamine, amphetamine, ecstasy/3,4-methylenedioxymethamphetamine (MDMA), cannabis, hallucinogens or novel psychoactive substances; have a diagnosis of 'substance use disorder'; or use drug treatment services. MEASUREMENTS Primary outcomes were the cumulative incidence (risk) and rate of care episodes in three settings: primary care, hospital admissions (in-patient) and emergency department (ED). FINDINGS Ninety-two studies were included, 84% from North America and Australia. Most studies focused on people using heroin, methamphetamine or crack cocaine, or who had a diagnosis of drug dependence. We were able to conduct a meta-analysis of rates across 25 studies reporting ED episodes and 25 reporting hospital admissions, finding pooled rates of 151 [95% confidence interval (CI) = 114-201] and 41 (95% CI = 30-57) per 100 person-years, respectively; on average 4.8 and 7.1 times more often than the general population. Heterogeneity was very high and was not explained by drugs used, country of study, recruitment setting or demographic characteristics. Predictors of health-care utilization were consistent across studies and included unstable housing, drug injection and mental health problems. Opioid substitution therapy was consistently associated with reduced ED presentation and hospital admission. There was minimal research on health-care utilization by people using ecstasy/MDMA, powder cocaine, hallucinogens or novel psychoactive substances. CONCLUSIONS People who use illicit drugs are admitted to emergency department or hospital several times more often than the general population.
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Affiliation(s)
- Dan Lewer
- UCL Collaborative Centre for Inclusion HealthInstitute of Epidemiology and Health Care UCLLondonUK
- National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - Joseph Freer
- Centre for Primary Care and Public HealthQueen Mary University of LondonLondonUK
| | - Emma King
- UCL Collaborative Centre for Inclusion HealthInstitute of Epidemiology and Health Care UCLLondonUK
| | - Sarah Larney
- National Drug and Alcohol Research Centre (NDARC)University of New South WalesRandwick,NSWAustralia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC)University of New South WalesRandwick,NSWAustralia
| | - Emily J. Tweed
- MRC/CSO Social and Public Health Sciences UnitUniversity of GlasgowGlasgowUK
| | - Vivian D. Hope
- Public Health InstituteLiverpool John Moores UniversityLiverpoolUK
| | - Magdalena Harris
- Department of Public Health, Environments and SocietyLondon School of Hygiene and Tropical Medicine, LondonUK
| | - Tim Millar
- Centre for Mental Health and SafetyThe University of ManchesterManchesterUK
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion HealthInstitute of Epidemiology and Health Care UCLLondonUK
| | - Dan Ciccarone
- Department of Family and Community MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Katherine I. Morley
- National Addictions Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
- Centre for Epidemiology and Biostatistics, Melbourne School of Global and Population HealthThe University of MelbourneMelbourneAustralia
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22
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Mark TL, Parish WJ, Zarkin GA. Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries. JAMA Netw Open 2020; 3:e203132. [PMID: 32310285 PMCID: PMC7171554 DOI: 10.1001/jamanetworkopen.2020.3132] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
IMPORTANCE Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes. OBJECTIVE To determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes. DESIGN, SETTING, AND PARTICIPANTS This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020. EXPOSURES Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone. MAIN OUTCOMES AND MEASURES Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures. RESULTS The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year). CONCLUSIONS AND RELEVANCE Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.
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Jones NR, Shanahan M, Dobbins T, Degenhardt L, Montebello M, Gisev N, Larney S. Reductions in emergency department presentations associated with opioid agonist treatment vary by geographic location: A retrospective study in New South Wales, Australia. Drug Alcohol Rev 2020; 38:690-698. [PMID: 31577058 DOI: 10.1111/dar.12976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS It is not known if the reduction in ED use during periods of OAT occurs across urgent and low acuity presentations. We aimed to compare the incidence and costs of urgent and low acuity ED presentations of people with opioid use disorder (OUD) in and out of opioid agonist treatment (OAT). DESIGN AND METHODS This was a retrospective cohort study (N=24,875), using linked administrative health data from New South Wales (NSW), Australia. Urgent and low acuity ED incidence and associated costs were calculated for periods in and out of OAT. GEE models estimated the adjusted incidence rate ratio (IRR) for ED presentations. Average costs per person-day were calculated with bootstrap confidence intervals. RESULTS Incidence of urgent presentations was lower in OAT compared to out of OAT [IRR (95%CI): 0.65 (0.61-0.69)]. In major cities, low acuity presentations were lower during OAT compared to timeout of OAT [IRR (95%CI): 0.82 (0.70-0.96)], in regional/remote areas, low acuity presentations were higher during OAT [IRR (95%CI): 2.65 (1.66-4.21)]. In major cities, average costs for low acuity presentations in OAT were 28% lower atA$0.50 (95%CI: A$0.48-A$0.52) and A$0.69 (95%CI: A$0.66-A$0.71) out of OAT, but 103% higher in regional/remote NSW, at A$2.12 (95%CI: A$1.91-A$2.34) in OAT and A$1.04 (95%CI: A$0.91-A$1.16) out of OAT. DISCUSSION AND CONCLUSIONS OAT was associated with reductions in urgent ED presentations and associated costs among people with OUD. Geographical variation was evident for low acuity ED presentations, highlighting the need to increase access to OAT in regional/remote areas.
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Affiliation(s)
- Nicola R Jones
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Marian Shanahan
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Timothy Dobbins
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Mark Montebello
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia.,Northern Sydney Local Health District, Sydney, Australia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
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24
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Lapham G, Boudreau DM, Johnson EA, Bobb JF, Matthews AG, McCormack J, Liu D, Samet JH, Saxon AJ, Campbell CI, Glass JE, Rossom RC, Murphy MT, Binswanger IA, Yarborough BJH, Bradley KA, Ahmedani B, Amoroso PJ, Arnsten JH, Bart G, Braciszewski JM, Cunningham CO, Hechter RC, Horigian VE, Liebschutz JM, Loree AM, Matson TE, McNeely J, Merrill JO, Northrup TF, Schwartz RP, Stotts AL, Szapocznik J, Thakral M, Tsui JI, Zare M. Prevalence and treatment of opioid use disorders among primary care patients in six health systems. Drug Alcohol Depend 2020; 207:107732. [PMID: 31835068 PMCID: PMC7158756 DOI: 10.1016/j.drugalcdep.2019.107732] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/25/2019] [Accepted: 11/11/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems. METHODS Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system. RESULTS Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations. CONCLUSIONS Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.
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Affiliation(s)
- Gwen Lapham
- Kaiser Permanente Washington Health Research Institute, United States; University of Washington, Department of Health Services, United States.
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Pharmacy
| | | | | | | | | | - David Liu
- National Institute on Drug Abuse Center for Clinical Trials Network
| | - Jeffrey H Samet
- Boston University & Boston Medical Center Department of Medicine, Division of General Internal Medicine
| | - Andrew J Saxon
- Veteran Affairs Puget Sound Health Care System Center of Excellence in Substance Abuse Treatment and Education.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Psychiatry and Behavioral Sciences
| | | | - Mark T Murphy
- Multicare Health System MultiCare Tacoma Central Family Medicine
| | - Ingrid A Binswanger
- Kaiser Permanente Colorado Institute for Health Research.,Colorado Permanente Medical Group, Denver, Colorado
| | | | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute.,University of Washington Department of Health Services.,University of Washington Department of Medicine
| | - Brian Ahmedani
- Henry Ford Health System Center for Health Policy & Health Services Research
| | - Paul J Amoroso
- Multicare Health System MultiCare Institute for Research and Innovation
| | - Julia H Arnsten
- Montefiore Medical Center Department of Medicine.,Montefiore Medical Center Division of General Internal Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | | | | | - Chinazo O Cunningham
- Montefiore Medical Center Department of Medicine.,Albert Einstein College of Medicine Department of Medicine, Division of General Internal Medicine
| | - Rulin C Hechter
- Kaiser Permanente Southern California Department of Research and Evaluation
| | - Viviana E Horigian
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Jane M Liebschutz
- University of Pittsburgh School of Medicine Division of General Internal Medicine, Center for Research on Health Care
| | - Amy M Loree
- Henry Ford Health System Center for Health Policy & Health Services Research
| | | | - Jennifer McNeely
- New York University School of Medicine, Department of Population Health and Department of Medicine, Division of General Internal Medicine and Clinical Innovation
| | | | - Thomas F Northrup
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | | | - Angela L Stotts
- McGovern Medical School at The University of Texas Health Science Center at Houston
| | - José Szapocznik
- University of Miami Miller School of Medicine, Department of Public Health Sciences
| | - Manu Thakral
- University of Massachusetts Boston College of Nursing and Health Sciences, Boston, MA, USA
| | - Judith I Tsui
- University of Washington Division of General Internal Medicine
| | - Mohammad Zare
- McGovern Medical School at The University of Texas Health Science Center at Houston
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Champagne-Langabeer T, Swank MW, Langabeer JR. Routes of non-traditional entry into buprenorphine treatment programs. Subst Abuse Treat Prev Policy 2020; 15:6. [PMID: 31959194 PMCID: PMC6972002 DOI: 10.1186/s13011-020-0252-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 01/09/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Excessive prescribing, increased potency of opioids, and increased availability of illicit heroin and synthetic analogs such as fentanyl has resulted in an increase of overdose fatalities. Medications for opioid use disorder (MOUD) significantly reduces the risk of overdose when compared with no treatment. Although the use of buprenorphine as an agonist treatment for opioid use disorder (OUD) is growing significantly, barriers remain which can prevent or delay treatment. In this study we examine non-traditional routes which could facilitate entry into buprenorphine treatment programs. METHODS Relevant, original research publications addressing entry into buprenorphine treatment published during the years 1989-2019 were identified through PubMed, PsychInfo, PsychArticles, and Medline databases. We operationalized key terms based on three non-traditional paths: persons that entered treatment via the criminal justice system, following emergencies, and through community outreach. RESULTS Of 462 screened articles, twenty studies met the inclusion criteria for full review. Most studies were from the last several years, and most (65%) were from the Northeastern region of the United States. Twelve (60%) were studies suggesting that the criminal justice system could be a potentially viable entry route, both pre-release or post-incarceration. The emergency department was also found to be a cost-effective and viable route for screening and identifying individuals with OUD and linking them to buprenorphine treatment. Fewer studies have documented community outreach initiatives involving buprenorphine. Most studies were small sample size (mean = < 200) and 40% were randomized trials. CONCLUSIONS Despite research suggesting that increasing the number of Drug Addiction Treatment Act (DATA) waived physicians who prescribe buprenorphine would help with the opioid treatment gap, little research has been conducted on routes to increase utilization of treatment. In this study, we found evidence that engaging individuals through criminal justice, emergency departments, and community outreach can serve as non-traditional treatment entry points for certain populations. Alternative routes could engage a greater number of people to initiate MOUD treatment.
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Affiliation(s)
| | - Michael W Swank
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA
| | - James R Langabeer
- School of Biomedical Informatics, University of Texas Health Science Center, Houston, TX, USA.
- McGovern Medical School, University of Texas Health Science Center, 7000 Fannin Street, Suite 600, Houston, TX, 77030, USA.
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Marotta PL, Stringer KL, Mandavia AD, Davis A, Beletsky L, Hunt T, Goddard-Eckrich D, Wu E, Gilbert L, El-Bassel N. Assessing factors associated with discharge from opioid agonist therapy due to incarceration in the United States. J Addict Dis 2020; 38:1-18. [PMID: 31821129 PMCID: PMC7224404 DOI: 10.1080/10550887.2019.1690365] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The following study investigates factors associated with discharge from OAT due to incarceration in a sample of 64,331 discharges in the United States. Multinomial regression investigated the association between demographic factors, prior arrest, referral source (i.e criminal justice agency) intravenous drug use, types of drug used, length of prior treatment and discharge due to incarceration compared to completing treatment or discharge due to other reasons. African Americans, Latinx, and Native Americans were at greater risk of discharge due to incarceration compared to whites. Referral to OAT from criminal justice agencies and self-referral was associated with increased risk of discharge from OAT due to incarceration compared to referral from a health care provider. Substance use of heroin, benzodiazepines, synthetic opioids, cocaine and non-prescription use of methadone were associated with discharge due to incarceration. Risk of discharge due to incarceration was higher for patients who reported intravenous drug use and who reported a co-morbid psychiatric problem. These findings enrich a nascent body of literature on mechanisms associated with attrition from OAT due to incarceration and emphasize the need for programs to divert people with OUD from incarceration to increase engagement and retention in OAT.
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Affiliation(s)
- Phillip L. Marotta
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
| | - Kristi L. Stringer
- School of Social Work, Columbia University, New York, NY, USA
- Social Intervention Group, New York, NY, USA
| | - Amar D. Mandavia
- Department of Counseling and Clinical Psychology, Teachers College of Columbia University, New York, NY, USA
- Center for the Study of Social Difference, Columbia University, New York, NY, USA
| | - Alissa Davis
- School of Social Work, Columbia University, New York, NY, USA
- Social Intervention Group, New York, NY, USA
| | - Leo Beletsky
- Center for the Study of Social Difference, Columbia University, New York, NY, USA
- School of Law, Northeastern University, Boston, MA, USA
- Bouve College of Health Sciences Northeastern University, Boston, MA, USA
| | - Tim Hunt
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
- School of Social Work, Columbia University, New York, NY, USA
| | - Dawn Goddard-Eckrich
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
- School of Social Work, Columbia University, New York, NY, USA
| | - Elwin Wu
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
- School of Social Work, Columbia University, New York, NY, USA
| | - Louisa Gilbert
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
- School of Social Work, Columbia University, New York, NY, USA
| | - Nabila El-Bassel
- Division of Prevention and Community Research, Department of Psychiatry, The Consultation Center, School of Medicine, Yale University, New Haven, CT, USA
- School of Social Work, Columbia University, New York, NY, USA
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Rege SV, Ngo DA, Ait-Daoud N, Holstege CP. Epidemiology of severe buprenorphine exposures reported to the U.S. Poison Centers. Drug Alcohol Depend 2019; 202:115-122. [PMID: 31344599 DOI: 10.1016/j.drugalcdep.2019.05.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aims to evaluate the trends and risk factors of severe buprenorphine outcomes (SBO) reported to the U.S. Poison Centers (PCs). METHODS We queried the National Poison Data System for exposures to buprenorphine from 2011 to 2016. SBO cases were defined as exposures that resulted in either a death or major clinical outcomes. Trends were tested using Poisson regression. Characteristics of the exposures were descriptively assessed. Logistic regression was used to evaluate the risk factors of SBO. RESULTS SBO cases (967) reported to the PCs increased by 66.6% during this period (114-190, p < 0.001). While adults between 20 and 39 years were more frequent in the SBO group (50.4%) compared to the non-SBO group (38.7%), cases under 6 years (29.6% vs 13.8%) were more common among the non-SBO group. Intentional abuse (20.1% vs 24.9%) and suspected suicides (13.7% vs 37.5%) were significantly higher among the SBO group. Multisubstance exposures were more frequent among the SBO cases (36.4% vs 71.4%). SBO risk increased with age, with cases above 60 years (AOR: 1.66, 95% CI: 1.14-2.42) demonstrating significantly increased odds. Suspected suicide (AOR: 1.87, 95% CI: 1.53-2.28) and abuse (AOR: 1.40, 95% CI: 1.13-1.73) cases were more likely to result in a SBO. Multisubstance exposures significantly increased the risk of a SBO. CONCLUSIONS This study reflected an increase in the cases of SBO paralleling the rise in the buprenorphine prescriptions. Age, reasons for exposure and multi-substance exposures significantly increased the risk of SBO.
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Affiliation(s)
- Saumitra V Rege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, 1222 Jefferson Park Avenue, Charlottesville, VA, 22903, USA.
| | - Duc Anh Ngo
- Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA
| | - Nassima Ait-Daoud
- Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA; Department of Psychiatry and Neurobehavioral Sciences, University of Virginia School of Medicine, 1300 Jefferson Park Avenue, Charlottesville, VA, 22903, USA
| | - Christopher P Holstege
- Division of Medical Toxicology, Department of Emergency Medicine, University of Virginia School of Medicine, 1222 Jefferson Park Avenue, Charlottesville, VA, 22903, USA; Department of Student Health, Division of Student Affairs, University of Virginia, 400 Brandon Ave, Charlottesville, VA 22903, USA
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Get Waivered: A Resident-Driven Campaign to Address the Opioid Overdose Crisis. Ann Emerg Med 2019; 74:691-696. [PMID: 31272821 DOI: 10.1016/j.annemergmed.2019.04.035] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Indexed: 11/22/2022]
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Blanco-Gandía MC, Rodríguez-Arias M. Pharmacological treatments for opiate and alcohol addiction: A historical perspective of the last 50 years. Eur J Pharmacol 2018; 836:89-101. [DOI: 10.1016/j.ejphar.2018.08.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/13/2018] [Accepted: 08/03/2018] [Indexed: 12/17/2022]
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Andrews CM, Westlake M, Wooten N. Availability of Outpatient Addiction Treatment and Use of Emergency Department Services Among Medicaid Enrollees. Psychiatr Serv 2018; 69:729-732. [PMID: 29695224 PMCID: PMC6511360 DOI: 10.1176/appi.ps.201700413] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The study examined whether the number of outpatient addiction programs accepting Medicaid in South Carolina counties is linked to repeat use of the emergency department for addiction-related conditions. METHODS The study included the population all adult Medicaid enrollees (N=2,401) in South Carolina with at least one addiction-related emergency service visit in 2012 or 2013. A random-effects logistic regression model was used to examine the association between outpatient addiction treatment availability and repeat use by Medicaid enrollees of emergency services for addiction-related conditions. RESULTS Enrollees in counties with two or more programs that accept Medicaid were less likely to have a repeat addiction-related emergency service visit than enrollees in counties with only one program that accepts Medicaid. CONCLUSIONS Availability of outpatient addiction treatment may reduce the need for addiction-related emergency services. Research is needed to explore potential causal mechanisms underlying this observed relationship.
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Affiliation(s)
- Christina M Andrews
- The authors are with the College of Social Work, University of South Carolina, Columbia
| | - Melissa Westlake
- The authors are with the College of Social Work, University of South Carolina, Columbia
| | - Nikki Wooten
- The authors are with the College of Social Work, University of South Carolina, Columbia
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Martin A, Mitchell A, Wakeman S, White B, Raja A. Emergency Department Treatment of Opioid Addiction: An Opportunity to Lead. Acad Emerg Med 2018; 25:601-604. [PMID: 29266577 DOI: 10.1111/acem.13367] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | | | - Sarah Wakeman
- Massachusetts General Hospital Substance Use Disorders Initiative
| | - Ben White
- Massachusetts General Hospital Emergency Department
| | - Ali Raja
- Massachusetts General Hospital Emergency Department
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Overcoming Barriers to Initiating Medication-assisted Treatment for Heroin Use Disorder in a General Medical Hospital: A Case Report and Narrative Literature Review. J Psychiatr Pract 2017; 23:221-229. [PMID: 28492461 DOI: 10.1097/pra.0000000000000231] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Deaths due to heroin overdoses are increasing and are the leading cause of death among intravenous heroin users. Although medication-assisted treatment (MAT) improves morbidity and mortality in patients with opioid use disorders, it is underutilized. Most efforts to expand access to MAT have focused on outpatient settings. Although the inpatient medical setting presents a critical opportunity to initiate treatment, general hospitals are often unfamiliar with MAT, creating a number of barriers to its use. In this report, we describe the case of a woman with heroin use disorder who was initiated on buprenorphine maintenance treatment while hospitalized for cardiac disease related to her intravenous heroin use. Barriers to initiating buprenorphine in this case included patient, practitioner, and organizational factors, and, ultimately, shared misperceptions about the feasibility of administering buprenorphine in a general medical hospital. These barriers were addressed, buprenorphine was initiated, and the patient demonstrated reduced craving, improved postoperative pain control, improved overall well-being, increased engagement in discharge planning, and acceptance of referral for addiction specialty aftercare. Our experience with this patient suggests that it is feasible to initiate buprenorphine in acute medical settings and that such treatment can improve patient outcomes. Our review of the literature reveals emerging evidence supporting the value of this practice.
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Campbell CI, Parthasarathy S, Young-Wolff KC, Satre DD. Buprenorphine Treatment and Patient Use of Health Services after the Affordable Care Act in an Integrated Health Care System. J Psychoactive Drugs 2017; 49:160-168. [PMID: 28426332 DOI: 10.1080/02791072.2017.1305519] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The Affordable Care Act (ACA) was expected to benefit patients with substance use disorders, including opioid use disorders (OUDs). This study examined buprenorphine use and health services utilization by patients with OUDs pre- and post-ACA in a large health care system. Using electronic health record data, we examined demographic and clinical characteristics (substance use, psychiatric and medical conditions) of two patient cohorts using buprenorphine: those newly enrolled in 2012 ("pre-ACA," N = 204) and in 2014 ("post-ACA," N = 258). Logistic and negative binomial regressions were used to model persistent buprenorphine use, and to examine whether persistent use was related to health services utilization. Buprenorphine patients were largely similar pre- and post-ACA, although more post-ACA patients had a marijuana use disorder (p < .01). Post-ACA patients were more likely to have high-deductible benefit plans (p < .01). Use of psychiatry services was lower post-ACA (IRR: 0.56, p < .01), and high-deductible plans were also related to lower use of psychiatry services (IRR: 0.30, p < .01). The relationship between marijuana use disorder and prescription opioid use is complex, and deserves further study, particularly with increasingly widespread marijuana legalization. Access to psychiatry services may be more challenging for buprenorphine patients post-ACA, especially for patients with deductible plans.
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Affiliation(s)
- Cynthia I Campbell
- a Research Scientist, Division of Research , Kaiser Permanente Northern California Region , Oakland , CA , USA
| | - Sujaya Parthasarathy
- b Economist, Division of Research , Kaiser Permanente Northern California Region , Oakland , CA , USA
| | - Kelly C Young-Wolff
- a Research Scientist, Division of Research , Kaiser Permanente Northern California Region , Oakland , CA , USA
| | - Derek D Satre
- c Associate Professor, Department of Psychiatry , UCSF Weill Institute for Neurosciences, University of California, San Francisco , San Francisco , CA , USA
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Evren C, Karabulut V, Can Y, Bozkurt M, Umut G, Evren B. Predictors of Outcome During a 6-Month Follow-Up Among Heroin Dependent Patients Receiving Buprenorphine/Naloxone Maintenance Treatment. ACTA ACUST UNITED AC 2016. [DOI: 10.5455/bcp.20140310072258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Cuneyt Evren
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Vahap Karabulut
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Yesim Can
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Muge Bozkurt
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Gokhan Umut
- Bakirkoy Training and Research Hospital for Psychiatry Neurology and Neurosurgery, Alcohol and Drug Research, Treatment and Training Center (AMATEM), Istanbul - Turkey
| | - Bilge Evren
- Baltalimani Training and Research Hospital for Muskuloskeletal Disorders, Department of Psychiatry, Istanbul - Turkey
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Marcovitz DE, McHugh RK, Volpe J, Votaw V, Connery HS. Predictors of early dropout in outpatient buprenorphine/naloxone treatment. Am J Addict 2016; 25:472-7. [PMID: 27442456 DOI: 10.1111/ajad.12414] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Revised: 07/08/2016] [Accepted: 07/09/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Identifying predictors of early drop out from outpatient treatment of opioid use disorder (OUD) with buprenorphine/naloxone (BN) may improve care for subgroups requiring more intensive engagement to achieve stabilization. However, previous research on predictors of dropout among this population has yielded mixed results. The aim of the present study was to elucidate these mixed findings by simultaneously evaluating a range of putative risk factors that may predict dropout in BN maintenance treatment. METHODS Outpatient medical records and weekly supervised urine toxicology results were retrospectively reviewed for patients at two community psychiatric clinics (n = 202): a private hospital clinic (n = 84) and a federally qualified health center (n = 118). A forward stepwise logistic regression was utilized to investigate the association between early dropout (i.e., discontinuing treatment or buprenorphine non-adherence within the first 3 months of clinic entry) and extracted sociodemographic, clinical, substance use, and treatment history variables. RESULTS Overall, 56 of 202 participants (27.7%) dropped out of treatment. The multivariable analysis indicated that age under 25 (B = 1.47, SEB = .52, p < .01) and opioid use in month 1 (B = 1.50, SEB = .41, p < .001) were significantly associated with early dropout; those with a history of suicide attempt were significantly less likely to drop out (B = -1.44, SEB = .67, p < .05). CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE Consistent with previous research, younger age and use of opioids during the first month of treatment predicted early dropout. Having a history of prior suicide attempt was associated with 3-month BN treatment retention, which has not been previously reported. (Am J Addict 2016;25:472-477).
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Affiliation(s)
- David E Marcovitz
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,Massachusetts General Hospital/McLean Adult Psychiatry Residency, Boston/Belmont, Massachusetts
| | - R Kathryn McHugh
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,McLean Hospital, Belmont, Massachusetts
| | - Julie Volpe
- Community Health Services, Hartford, Connecticut
| | | | - Hilary S Connery
- Harvard Medical School, Department of Psychiatry, Boston, Massachusetts.,McLean Hospital, Belmont, Massachusetts
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Abstract
As a result of the prescription opioid epidemic in the United States, there has been an increasing need for effective treatment interventions, both pharmacological and nonpharmacological. Buprenorphine has emerged as a critical component of the treatment of opioid use disorder, yet its adoption has not been without some concerns. This article first reviews the pharmacology, clinical use, and US legislative action related to buprenorphine, followed by a discussion of the misuse and diversion of buprenorphine in the United States as well as internationally. We then explore the impact of buprenorphine abuse as well as discussing strategies for its reduction, including changes in policy, prescription and pharmacy monitoring, and continuing medical education for guiding and improving clinical practice.
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Study protocol of the ESUB-MG cluster randomized trial: a pragmatic trial assessing the implementation of urine drug screening in general practice for buprenorphine maintained patients. BMC FAMILY PRACTICE 2016; 17:24. [PMID: 26931763 PMCID: PMC4774159 DOI: 10.1186/s12875-016-0413-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/22/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND In addiction care, urine drug screening tests are recommended to assess psychoactive substances use. While intrinsic diagnostic value of these tests is demonstrated, the consequences of carrying out these tests on opiate maintenance treatment (OMT) have not been established. The main objective will be to assess the impact of on-site urine drug screening tests (OS-UDS) in general practice compared to routine medical care on OMT retention at 6 months in opioid-dependent patients initiating buprenorphine. METHODS/DESIGN The ESUB-MG study uses a pragmatic, cluster randomized controlled trial design. General Practitioners (GPs) regularly managing patients treated with buprenorphine and consenting for participating will be invited to participate. GPs will be randomly assigned to one of two groups for 6 to 24 months: (a) control group (usual care: standard medical strategy for assessing drug use); (b) interventional group (including 1/ a training session on practice and interpretation of OS-UDS; 2/ the supply of OS-UDS at GPs' medical offices; 3/ performing an OS-UDS before the first prescription of buprénorphine). GPs will have to include 1 to 10 patients aged 18 years-old or more, consulting for starting treatment by buprenorphine, not opposed to participate. The primary outcome will be OMT retention at 6 months. DISCUSSION This randomized interventional trial should bring sufficient level of evidence to assess effectiveness of performing OS-UDS in general practice for patients treated by buprenorphine. Training GPs to drug tests and supplying them in their office should lead to an improvement of opioid-addicted patients' care through helping decision. TRIALS REGISTRATION NCT02345655 (first registration May 14, 2014).
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Affiliation(s)
- The ESUB-MG Study Group
- Département Universitaire de Médecine Générale, Université de Toulouse III, Faculté de Médecine, 133 route de Narbonne, 31062 Toulouse, France
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Walley AY. HIV prevention and treatment strategies can help address the overdose crisis. Prev Med 2015; 80:37-40. [PMID: 25895840 DOI: 10.1016/j.ypmed.2015.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Revised: 04/01/2015] [Accepted: 04/04/2015] [Indexed: 01/17/2023]
Abstract
Since the 1990s, effective HIV prevention and treatment strategies have been coordinated and implemented in the United States, resulting in substantial reductions in HIV-related death and HIV transmission among people who use injection drugs. During the same period, despite substantial long-term funding of War on Drugs policies, opioid addiction, driven by increased prescription opioid use and heroin accessibility, has made overdose the leading cause of accidental injury death in the United States. This commentary describes how the prevention and treatment successes among people who use drugs in the HIV/AIDS epidemic can be applied to address the opioid overdose crisis.
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Affiliation(s)
- Alexander Y Walley
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine/Boston Medical Center.
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Thakarar K, Morgan JR, Gaeta JM, Hohl C, Drainoni ML. Predictors of Frequent Emergency Room Visits among a Homeless Population. PLoS One 2015; 10:e0124552. [PMID: 25906394 PMCID: PMC4407893 DOI: 10.1371/journal.pone.0124552] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2014] [Accepted: 03/06/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Homelessness, HIV, and substance use are interwoven problems. Furthermore, homeless individuals are frequent users of emergency services. The main purpose of this study was to identify risk factors for frequent emergency room (ER) visits and to examine the effects of housing status and HIV serostatus on ER utilization. The second purpose was to identify risk factors for frequent ER visits in patients with a history of illicit drug use. METHODS A retrospective analysis was performed on 412 patients enrolled in a Boston-based health care for the homeless program (HCH). This study population was selected as a 2:1 HIV seronegative versus HIV seropositive match based on age, sex, and housing status. A subgroup analysis was performed on 287 patients with history of illicit drug use. Chart data were analyzed to compare demographics, health characteristics, and health service utilization. Results were stratified by housing status. Logistic models using generalized estimating equations were used to predict frequent ER visits. RESULTS In homeless patients, hepatitis C was the only predictor of frequent ER visits (OR 4.49, p<0.01). HIV seropositivity was not predictive of frequent ER visits. In patients with history of illicit drug use, mental health (OR 2.53, 95% CI 1.07-5.95) and hepatitis C (OR 2.85, 95% CI 1.37-5.93) were predictors of frequent ER use. HIV seropositivity did not predict ER use (OR 0.45, 95% CI 0.21 - 0.97). CONCLUSIONS In a HCH population, hepatitis C predicted frequent ER visits in homeless patients. HIV seropositivity did not predict frequent ER visits, likely because HIV seropositive HCH patients are engaged in care. In patients with history of illicit drug use, hepatitis C and mental health disorders predicted frequent ER visits. Supportive housing for patients with mental health disorders and hepatitis C may help prevent unnecessary ER visits in this population.
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Affiliation(s)
- Kinna Thakarar
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | - Jake R. Morgan
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Jessie M. Gaeta
- Boston Health Care for the Homeless Program, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Carole Hohl
- Boston Health Care for the Homeless Program, Boston, Massachusetts
- Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts
| | - Mari-Lynn Drainoni
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, ENRM Memorial VA Hospital, Bedford, Massachusetts
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Abstract
Release from short-term jail detention is highly destabilizing, associated with relapse to substance use, recidivism, and disrupted health care continuity. Little is known about emergency department (ED) use, potentially a surrogate for medical, psychiatric, or social instability, by people living with HIV/AIDS (PLWHA) leaving jails. All ED visits were reviewed from medical records for a cohort of 109 PLHWA in the year following release from county jail in Connecticut, between January 1, 2008 and December 31, 2010. Primary outcomes were frequency and timing of ED visits, modeled using multivariate negative binomial regression and Cox proportional hazards regression, respectively. Demographic, substance use, and psychiatric disorder severity factors were evaluated as potential covariates. Overall, 71 (65.1%) of the 109 participants made 300 unique ED visits (2.75 visits/person-year) in the year following jail-release. Frequency of ED use was positively associated with female sex (incidence rate ratios, IRR 2.40 [1.36-4.35]), homelessness (IRR 2.22 [1.15-4.41]), and recent substance use (IRR 2.47 [1.33-4.64]), and inversely associated with lifetime drug severity (IRR 0.01 [0-0.10]), and being retained in HIV primary care (IRR 0.80 [0.65-0.99]). Those in late or sustained HIV care used the ED sooner than those not retained in HIV primary care (median for late retention 16.3 days, median for sustained retention 24.9 days, median for no retention not reached at 12 months, p value 0.004). Using multivariate modeling, those who used the ED earliest upon release were more likely to be homeless (HR 1.98 [1.02-3.84]), to be retained in HIV care (HR 1.30 [1.04-1.61]), and to have recently used drugs (HR 2.51 [1.30-4.87]), yet had a low lifetime drug severity (HR 0.01 [0.00-0.14]). Among PLWHA released from jail, frequency of ED use is high, often soon after release, and is associated with social and drug-related destabilizing factors. Future interventions for this specific population should focus on addressing these resource gaps, ensuring housing, and establishing immediate linkage to HIV primary care after release from jail.
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Affiliation(s)
- Andrew T Boyd
- AIDS Program, Yale School of Medicine, New Haven, CT, USA,
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Haddad MS, Zelenev A, Altice FL. Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers. J Urban Health 2015; 92:193-213. [PMID: 25550126 PMCID: PMC4338126 DOI: 10.1007/s11524-014-9924-1] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut's largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80% (recommended) and ≥90% (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6%, respectively. Screening was highest for hypertension (91.0%), hepatitis C (80.1%), hepatitis B (76.3%), human immunodeficiency virus (71.4%), and hyperlipidemia (72.9%) and lower for syphilis (49.3%) and cervical (58.5%), breast (44.4%), and colorectal (48.7%) cancer. Achieving QHI-S ≥80% was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95% confidence interval (CI) = 1.18-4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95% CI = 1.78-6.37), and negatively with being female (AOR = 0.30; 95% CI = 0.16-0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.
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Affiliation(s)
- Marwan S Haddad
- Community Health Center, Inc., 635 Main Street, Middletown, CT, 06457, USA,
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Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BIOMED RESEARCH INTERNATIONAL 2015; 2015:137020. [PMID: 25629034 PMCID: PMC4299453 DOI: 10.1155/2015/137020] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 08/22/2014] [Accepted: 09/10/2014] [Indexed: 01/10/2023]
Abstract
Substance-related and addictive disorders are chronic relapsing conditions that substantially impact public health. Effective treatments for these disorders require addressing substance use/dependence comprehensively as well as other associated comorbidities. Comprehensive addressing of substance use in a medical setting involves screening for substance use, addressing substance use directly with the patient, and formulating an appropriate intervention. For alcohol dependence and opioid dependence, pharmacotherapies are available that are safe and effective when utilized in a comprehensive treatment paradigm, such as medication assisted treatment. In primary care, substance use disorders involving alcohol, illicit opioids, and prescription opioid abuse are common among patients who seek primary care services. Primary care providers report low levels of preparedness and confidence in identifying substance-related and addictive disorders and providing appropriate care and treatment. However, new models of service delivery in primary care for individuals with substance-related and addictive disorders are being developed to promote screening, care and treatment, and relapse prevention. The education and training of primary care providers utilizing approved medications for the treatment of alcohol use disorders and opioid dependence in a primary care setting would have important public health impact and reduce the burden of alcohol abuse and opioid dependence.
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Affiliation(s)
- Jinhee Lee
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Thomas F. Kresina
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Melinda Campopiano
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - Robert Lubran
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
- Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857, USA
| | - H. Westley Clark
- Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, Rockville, MD 20857, USA
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Li X, Shorter D, Kosten TR. Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies. Expert Opin Pharmacother 2014; 15:2263-75. [PMID: 25171726 DOI: 10.1517/14656566.2014.955469] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Buprenorphine follows the success of methadone as another milestone in the history of treatment for opioid addiction. Buprenorphine can be used in an office-based setting where it is clearly effective, highly accepted by patients and has a favorable safety profile and less abuse potential. However, the adoption of buprenorphine treatment has been slow in the USA. AREAS COVERED This article first reviews the history of medication-assisted opioid addiction treatment and the current epidemic opioid addiction, followed by a review of the efficacy, pharmacology and clinical prescription of buprenorphine in office-based care. We then explore the possible barriers in using buprenorphine and the ways to overcome these barriers, including new formulations, educational programs and policy regulations that strike a balance between accessibility and reducing diversion. EXPERT OPINION Buprenorphine can align addiction treatment with treatments for other chronic medical illnesses. However, preventing diversion will require graduate and continuing medical education and integrated care models for delivery of buprenorphine to those in need.
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Affiliation(s)
- Xiaofan Li
- Baylor College of Medicine, Menninger Department of Psychiatry and Behavioral Sciences , One Baylor Plaza, Houston, TX 77030 , USA
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44
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Gibson BA, Ghosh D, Morano JP, Altice FL. Accessibility and utilization patterns of a mobile medical clinic among vulnerable populations. Health Place 2014; 28:153-66. [PMID: 24853039 DOI: 10.1016/j.healthplace.2014.04.008] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 04/23/2014] [Accepted: 04/26/2014] [Indexed: 01/08/2023]
Abstract
We mapped mobile medical clinic (MMC) clients for spatial distribution of their self-reported locations and travel behaviors to better understand health-seeking and utilization patterns of medically vulnerable populations in Connecticut. Contrary to distance decay literature, we found that a small but significant proportion of clients was traveling substantial distances to receive repeat care at the MMC. Of 8404 total clients, 90.2% lived within 5 miles of a MMC site, yet mean utilization was highest (5.3 visits per client) among those living 11-20 miles of MMCs, primarily for those with substance use disorders. Of clients making >20 visits, 15.0% traveled >10 miles, suggesting that a significant minority of clients traveled to MMC sites because of their need-specific healthcare services, which are not only free but available at an acceptable and accommodating environment. The findings of this study contribute to the important research on healthcare utilization among vulnerable population by focusing on broader dimensions of accessibility in a setting where both mobile and fixed healthcare services coexist.
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Affiliation(s)
- Britton A Gibson
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA.
| | - Debarchana Ghosh
- University of Connecticut, Department of Geography, Storrs, CT, USA.
| | - Jamie P Morano
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA
| | - Frederick L Altice
- Yale University School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, USA; Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, CT, USA; University of Malaya, Centre of Excellence on Research in AIDS (CERiA), Kuala Lumpur, Malaysia
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Lavonas EJ, Severtson SG, Martinez EM, Bucher-Bartelson B, Le Lait MC, Green JL, Murrelle LE, Cicero TJ, Kurtz SP, Rosenblum A, Surratt HL, Dart RC. Abuse and diversion of buprenorphine sublingual tablets and film. J Subst Abuse Treat 2014; 47:27-34. [PMID: 24680219 DOI: 10.1016/j.jsat.2014.02.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 02/12/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
Abstract
Buprenorphine abuse is common worldwide. Rates of abuse and diversion of three sublingual buprenorphine formulations (single ingredient tablets; naloxone combination tablets and film) were compared. Data were obtained from the Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System Poison Center, Drug Diversion, Opioid Treatment (OTP), Survey of Key Informants' Patients (SKIP), and College Survey Programs through December 2012. To control for drug availability, event ratios (rates) were calculated quarterly, based on the number of patients filling prescriptions for each formulation ("unique recipients of a dispensed drug," URDD) and averaged and compared using negative binomial regression. Abuse rates in the OTP, SKIP, and College Survey Programs were greatest for single ingredient tablets, and abuse rates in the Poison Center Program and illicit diversion rates were greatest for the combination tablets. Combination film rates were significantly less than rates for either tablet formulation in all programs. No geographic pattern could be discerned.
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Affiliation(s)
- Eric J Lavonas
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - S Geoffrey Severtson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Erin M Martinez
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Becki Bucher-Bartelson
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Marie-Claire Le Lait
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Jody L Green
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
| | - Lenn E Murrelle
- Venebio Group, LLC, 7400 Beaufont Springs Drive, Suite 300, Richmond, VA 23225, USA.
| | - Theodore J Cicero
- Department of Psychiatry, Washington University in St. Louis, One Brookings Drive, Campus Box 8134, St. Louis, MO 63130 USA.
| | - Steven P Kurtz
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL 33137 USA.
| | - Andrew Rosenblum
- Institute for Treatment and Services Research, National Development and Research Institutes, 71 West 23rd Street, 4th floor, New York, NY 10010 USA.
| | - Hilary L Surratt
- Center for Applied Research on Substance Use and Health Disparities, Nova Southeastern University, 2 NE 40th Street, Suite 404, Miami, FL 33137 USA.
| | - Richard C Dart
- Rocky Mountain Poison and Drug Center, Denver Health and Hospital Authority, 777 Bannock Street, MC 0180, Denver, CO, 80204, USA.
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46
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Drainoni ML, Farrell C, Sorensen-Alawad A, Palmisano JN, Chaisson C, Walley AY. Patient perspectives of an integrated program of medical care and substance use treatment. AIDS Patient Care STDS 2014; 28:71-81. [PMID: 24428768 PMCID: PMC3926137 DOI: 10.1089/apc.2013.0179] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The benefits of integrating primary care and substance use disorder treatment are well known, yet true integration is difficult. We developed and evaluated a team-based model of integrated care within the primary care setting for HIV-infected substance users and substance users at risk for contracting HIV. Qualitative data were gathered via focus groups and satisfaction surveys to assess patients' views of the program, evaluate key elements for success, and provide recommendations for other programs. Key themes related to preferences for the convenience and efficiency of integrated care; support for a team-based model of care; a feeling that the program requirements offered needed structure; the importance of counseling and education; and how provision of concrete services improved overall well-being and quality of life. For patients who received buprenorphine/naloxone for opioid dependence, this was viewed as a major benefit. Our results support other studies that theorize integrated care could be of significant value for hard-to-reach populations and indicate that having a clinical team dedicated to providing substance use disorder treatment, HIV risk reduction, and case management services integrated into primary care clinics has the potential to greatly enhance the ability to serve a challenging population with unmet treatment needs.
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Affiliation(s)
- Mari-Lynn Drainoni
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
- Section of Infectious Diseases, Boston University School of Medicine, Boston, Massachusetts
- Center for Health Quality, Outcomes and Economic Research, ENRM Veterans Administration Hospital, Boston, Massachusetts
| | - Caitlin Farrell
- Department of Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
| | - Amy Sorensen-Alawad
- Department of Geriatrics, Boston University School of Medicine, Boston, Massachusetts
| | - Joseph N. Palmisano
- Department of Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
| | - Christine Chaisson
- Department of Data Coordinating Center, Boston University School of Public Health, Boston, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Alexander Y. Walley
- Department of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
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Jackson LA, McWilliam S, Martin F, Dingwell J, Dykeman M, Gahagan J, Karabanow J. Key challenges in providing services to people who use drugs: The perspectives of people working in emergency departments and shelters in Atlantic Canada. DRUGS-EDUCATION PREVENTION AND POLICY 2014; 21:244-253. [PMID: 24954982 PMCID: PMC4046876 DOI: 10.3109/09687637.2013.870534] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Aims Many people who use drugs (PWUD) have multiple health and social needs, and research suggests that this population is increasingly accessing emergency departments (EDs) and shelters for health care and housing. This qualitative study explored the practices of those working in EDs and shelters when providing services to PWUD, with a particular focus on key challenges in service provision. Methods EDs and shelters were conceptualized as ‘micro environments’ with various components (i.e. social, physical and resource). One-on-one interviews were conducted with 57 individuals working in EDs and shelters in Atlantic Canada. Findings The social, physical and resource environments within some EDs and shelters are key forces in shaping the challenges facing those providing services. For example, the social environments within these settings are focused on acute health care in the case of EDs, and housing in the case of shelters. These mandates do not encompass the complex needs of many PWUD. Resource issues within the wider community (e.g. limited drug treatment spaces) further contribute to the challenges. Conclusions Structural issues, internal and external to EDs and shelters need to be addressed to reduce the challenges facing many who work in these settings when providing services to PWUD.
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Affiliation(s)
- Lois A Jackson
- School of Health and Human Performance, Dalhousie University , Halifax, NS , Canada ; Atlantic Health Promotion Research Centre, Dalhousie University , Halifax, NS , Canada
| | - Susan McWilliam
- Atlantic Health Promotion Research Centre, Dalhousie University , Halifax, NS , Canada
| | - Fiona Martin
- Department of Sociology and Social Anthropology, Dalhousie University , Halifax, NS , Canada
| | | | - Margaret Dykeman
- Faculty of Nursing, University of New Brunswick , Fredericton, NB , Canada
| | - Jacqueline Gahagan
- School of Health and Human Performance, Dalhousie University , Halifax, NS , Canada ; Atlantic Health Promotion Research Centre, Dalhousie University , Halifax, NS , Canada
| | - Jeff Karabanow
- School of Social Work, Dalhousie University , Halifax, NS , Canada
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Bachireddy C, Soule MC, Izenberg JM, Dvoryak S, Dumchev K, Altice FL. Integration of health services improves multiple healthcare outcomes among HIV-infected people who inject drugs in Ukraine. Drug Alcohol Depend 2014; 134:106-114. [PMID: 24128379 PMCID: PMC3865106 DOI: 10.1016/j.drugalcdep.2013.09.020] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2013] [Revised: 09/16/2013] [Accepted: 09/17/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND People who inject drugs (PWID) experience poor outcomes and fuel HIV epidemics in middle-income countries in Eastern Europe and Central Asia. We assess integrated/co-located (ICL) healthcare for HIV-infected PWID, which despite international recommendations, is neither widely available nor empirically examined. METHODS A 2010 cross-sectional study randomly sampled 296 HIV-infected opioid-dependent PWID from two representative HIV-endemic regions in Ukraine where ICL, non-co-located (NCL) and harm reduction/outreach (HRO) settings are available. ICL settings provide onsite HIV, addiction, and tuberculosis services, NCLs only treat addiction, and HROs provide counseling, needles/syringes, and referrals, but no opioid substitution therapy (OST). The primary outcome was receipt of quality healthcare, measured using a quality healthcare indicator (QHI) composite score representing percentage of eight guidelines-based recommended indicators met for HIV, addiction and tuberculosis treatment. The secondary outcomes were individual QHIs and health-related quality-of-life (HRQoL). RESULTS On average, ICL-participants had significantly higher QHI composite scores compared to NCL- and HRO-participants (71.9% versus 54.8% versus 37.0%, p<0.001) even after controlling for potential confounders. Compared to NCL-participants, ICL-participants were significantly more likely to receive antiretroviral therapy (49.5% versus 19.2%, p<0.001), especially if CD4 ≤ 200 (93.8% versus 62.5% p<0.05); guideline-recommended OST dosage (57.3% versus 41.4%, p<0.05); and isoniazid preventive therapy (42.3% versus 11.2%, p<0.001). Subjects receiving OST had significantly higher HRQoL than those not receiving it (p<0.001); however, HRQoL did not differ significantly between ICL- and NCL-participants. CONCLUSIONS These findings suggest that OST alone improves quality-of-life, while receiving care in integrated settings collectively and individually improves healthcare quality indicators for PWID.
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Affiliation(s)
- Chethan Bachireddy
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Michael C. Soule
- Massachussetts General Hospital, Department of Psychiatry, Boston, USA
| | - Jacob M. Izenberg
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Frederick L. Altice
- Yale University School of Medicine, Department of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, USA,Yale University School of Public Health, Division of Epidemiology of Microbial Diseases, New Haven, USA
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Haddad MS, Zelenev A, Altice FL. Integrating buprenorphine maintenance therapy into federally qualified health centers: real-world substance abuse treatment outcomes. Drug Alcohol Depend 2013; 131:127-35. [PMID: 23332439 PMCID: PMC3674170 DOI: 10.1016/j.drugalcdep.2012.12.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Revised: 12/09/2012] [Accepted: 12/10/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few studies have examined real-world effectiveness of integrated buprenorphine maintenance treatment (BMT) programs in federally qualified health centers (FQHCs). METHODS Opioid dependent patients (N=266) inducted on buprenorphine between July 2007 and December 2008 were retrospectively assessed at Connecticut's largest FQHC network. Six-month BMT retention and opioid-free time were collected longitudinally from electronic health records; 136 (51.1%) of patients were followed for at least 12 months. RESULTS Participants had a mean age of 40.1 years, were primarily male (69.2%) and treated by family practitioners (70.3%). Co-morbidity included HCV infection (59.8%), mood disorders (71.8%) and concomitant cocaine use (59%). Retention on BMT was 56.8% at 6 months and 61.6% at 12 months for the subset observed over 1 year. Not being retained on BMT at 12 months was associated with cocaine use (AOR=2.18; 95% CI=1.35-3.50) while prescription of psychiatric medication (AOR=0.36; 95% CI 0.20-0.62) and receiving on-site substance abuse counseling (AOR=0.34; 95% CI 0.19, 0.59) improved retention. Two thirds of the participants experienced at least one BMT gap of 2 or more weeks with a mean gap length of 116.4 days. CONCLUSIONS Integrating BMT in this large FQHC network resulted in retention rates similarly reported in clinical trials and emphasizes the need for providing substance abuse counseling and screening for and treating psychiatric comorbidity.
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Affiliation(s)
| | | | - Frederick L. Altice
- Yale University School of Medicine, New Haven, CT, USA,Yale University School of Public Health, New Haven, CT, USA
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Meyer JP, Qiu J, Chen NE, Larkin GL, Altice FL. Frequent emergency department use among released prisoners with human immunodeficiency virus: characterization including a novel multimorbidity index. Acad Emerg Med 2013; 20:79-88. [PMID: 23570481 DOI: 10.1111/acem.12054] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 07/19/2012] [Accepted: 07/28/2012] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The objective was to characterize the medical, social, and psychiatric correlates of frequent emergency department (ED) use among released prisoners with human immunodeficiency virus (HIV). METHODS Data on all ED visits by 151 released prisoners with HIV on antiretroviral therapy (ART) were prospectively collected for 12 months. Correlates of frequent ED use, defined as having two or more ED visits postrelease, were described using univariate and multivariate models and generated medical, psychiatric, and social multimorbidity indices. RESULTS Forty-four (29%) of the 151 participants were defined as frequent ED users, accounting for 81% of the 227 ED visits. Frequent ED users were more likely than infrequent or nonusers to be female; have chronic medical illnesses that included seizures, asthma, and migraines; and have worse physical health-related quality of life (HRQoL). In multivariate Poisson regression models, frequent ED use was associated with lower physical HRQoL (odds ratio [OR] = 0.95, p = 0.02) and having not had prerelease discharge planning (OR = 3.16, p = 0.04). Frequent ED use was positively correlated with increasing psychiatric multimorbidity index values. CONCLUSIONS Among released prisoners with HIV, frequent ED use is driven primarily by extensive comorbid medical and psychiatric illness. Frequent ED users were also less likely to have received prerelease discharge planning, suggesting missed opportunities for seamless linkages to care.
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Affiliation(s)
- Jaimie P. Meyer
- Department of Medicine; Section of Infectious Diseases; AIDS Program; Yale University School of Medicine; New Haven CT
- Divisions of Chronic Disease Epidemiology; Yale University School of Public Health; New Haven CT
| | - Jingjun Qiu
- Department of Medicine; Section of Infectious Diseases; AIDS Program; Yale University School of Medicine; New Haven CT
| | - Nadine E. Chen
- Department of Medicine; Section of Infectious Diseases; AIDS Program; Yale University School of Medicine; New Haven CT
- Department of Medicine; Division of Global Public Health; University of California San Diego School of Medicine; University of California San Diego School of Medicine; San Diego CA
| | - Gregory L. Larkin
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
- Department of Surgery; Division of Emergency Medicine; University of Auckland School of Medicine; Auckland NZ
| | - Frederick L. Altice
- Department of Medicine; Section of Infectious Diseases; AIDS Program; Yale University School of Medicine; New Haven CT
- Division of Epidemiology of Microbial Diseases; Yale University School of Public Health; New Haven CT
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