Relationship between buprenorphine adherence and health service utilization and costs among opioid dependent patients

Incentivized collaborative care to disseminate and enhance contingency-management services

Contingency management is especially effective in supporting medication adherence and drug abstinence among people with opioid use disorder. However, the incorporation of contingency management into clinical practice has been slow. The present study was designed to evaluate the feasibility, acceptability, and usability of incentives for providers as a means of accelerating collaborative care with contingency management. Thirteen buprenorphine prescribers served as participants in a nonexperimental study. The prescribers who referred patients to a contingency-management service received monetary incentives for reviewing patient performance data and describing their use of these data in treatment decisions. The results show that this approach is feasible, acceptable, and easy to use for everyone involved. Self-reports indicate improved prescriber-patient relationships and more informed care. However, prescriber-focused incentives did not appear to greatly enhance access to contingency-management services for patients. Thus, provider incentives may be beneficial but further research is needed to advance adoption of contingency management.

An explainable machine learning framework for predicting the risk of buprenorphine treatment discontinuation for opioid use disorder among commercially insured individuals

OBJECTIVES

Buprenorphine is an effective evidence-based medication for opioid use disorder (OUD). Yet premature discontinuation undermines treatment effectiveness, increasing the risk of mortality and overdose. We developed and evaluated a machine learning (ML) framework for predicting buprenorphine care discontinuity within 12 months following treatment initiation.

METHODS

This retrospective study used United States (US) 2018-2021 MarketScan commercial claims data of insured individuals aged 18-64 who initiated buprenorphine between July 2018 and December 2020 with no buprenorphine prescriptions in the previous six months. We measured buprenorphine prescription discontinuation gaps of ≥30 days within 12 months of initiating treatment. We developed predictive models employing logistic regression, decision tree classifier, random forest, extreme gradient boosting, Adaboost, and random forest-extreme gradient boosting ensemble. We applied recursive feature elimination with cross-validation to reduce dimensionality and identify the most predictive features while maintaining model robustness. For model validation, we used several statistics to evaluate performance, such as C-statistics and precision-recall curves. We focused on two distinct treatment stages: at the time of treatment initiation and one and three months after treatment initiation. We employed SHapley Additive exPlanations (SHAP) analysis that helped us explain the contributions of different features in predicting buprenorphine discontinuation. We stratified patients into risk subgroups based on their predicted likelihood of treatment discontinuation, dividing them into decile subgroups. Additionally, we used a calibration plot to analyze the reliability of the models.

RESULTS

A total of 30,373 patients initiated buprenorphine and 14.98% (4551) discontinued treatment. C-statistic varied between 0.56 and 0.76 for the first-stage models including patient-level demographic and clinical variables. Inclusion of proportion of days covered (PDC) measured after one month and three months following treatment initiation significantly increased the models' discriminative power (C-statistics: 0.60 to 0.82). Random forest (C-statistics: 0.76, 0.79 and 0.82 with baseline predictors, one-month PDC and three-months PDC, respectively) outperformed other ML models in discriminative performance in all stages (C-statistics: 0.56 to 0.77). Most influential risk factors of discontinuation included early stage medication adherence, age, and initial days of supply.

CONCLUSION

ML algorithms demonstrated a good discriminative power in identifying patients at higher risk of buprenorphine care discontinuity. The proposed framework may help healthcare providers optimize treatment strategies and deliver targeted interventions to improve buprenorphine care continuity.

Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial

BACKGROUND/AIM

Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder.

METHODS

This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings.

RESULTS

Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05).

CONCLUSION

The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.

Assessing the Influence of Patient Empowerment Gained Through Mental Health Apps on Patient Trust in the Health Care Provider and Patient Compliance With the Recommended Treatment: Cross-sectional Study

BACKGROUND

In chronic mental illness, noncompliance with treatment significantly worsens the illness course and outcomes for patients. Considering that nearly 1 billion people worldwide experience mental health issues, including 1 of 5 Canadians in any given year, finding tools to lower noncompliance in these populations is critical for health care systems. A promising avenue is apps that make mental health services more accessible to patients. However, little is known regarding the impact of the empowerment gained from mental health apps on patient compliance with recommended treatment.

OBJECTIVE

This study aimed to investigate the impact of patient empowerment gained through mental health apps on patient trust in the health care provider and patient compliance with the recommended treatment.

METHODS

A cross-sectional web-based survey was conducted in Canada. Eligible participants were Canadian adults diagnosed with chronic mental health disorders who were using at least one of the following apps: Dialogue, MindBeacon, Deprexis, Ginger, Talkspace, BetterHelp, MindStrong, Mindshift, Bloom, Headspace, and Calm. A total of 347 valid questionnaires were collected and analyzed using partial least-squares structural equation modeling. Trust in the health care provider and patient compliance were measured with multiple-item scales adapted from existing scales. Patient empowerment was conceived and measured as a higher-order construct encompassing the following 2 dimensions: patient process and patient outcome. All the items contributing to the constructs in the model were measured with 7-point Likert scales. The reliability and validity of the measurement model were assessed, and the path coefficients of the structural model were estimated.

RESULTS

The results clearly show that patient empowerment gained through mental health apps positively influenced patient trust in the health care provider (β=.306; P<.001). Patient trust in the health care provider had a positive effect on patient compliance (β=.725; P<.001). The direct relationship between patient empowerment and patient compliance was not significant (β=.061, P=.23). Interestingly, the data highlight that the effect of patient empowerment on patient compliance was fully mediated by trust in the health care provider (β=.222; P<.001). The results show that patient empowerment gained through the mental health app involves 2 dimensions: a process and an outcome.

CONCLUSIONS

This study shows that for individuals living with mental health disorders, empowerment gained through mental health apps enhances trust in the health care provider. It reveals that patient empowerment impacts patient compliance but only through the full mediating effect of patient trust in the health care provider, indicating that patient trust is a critical variable to enhance patient compliance. Hence, our results confirm that health care systems could encourage the use of mental health apps to favor a climate that facilitates patients' trust in health care provider recommendations, possibly leading to better compliance with the recommended treatment.

Evaluation of opioid use disorder treatment outcomes in patients receiving split daily versus once daily dosing of buprenorphine-naloxone

INTRODUCTION

In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD.

METHODS

This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups.

RESULTS

The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82).

CONCLUSIONS

In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

Impact of Medication-Based Treatment on Health Care Utilization Among Individuals With Opioid Use Disorder

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.

Relationship between medication adherence for opioid use disorder and health care costs and health care events in a claims dataset

INTRODUCTION

Medication for opioid use disorder (MOUD) has well-documented benefits for treating OUD, though its efficacy depends on patient adherence. We know little about outcomes of MOUD nonadherence compared to treatment regimens without MOUD, and this article aims to address the gap. This analysis focused on office-based MOUD treatment (buprenorphine and naltrexone) to evaluate the long-term impact of adherence on subsequent health care costs and health care events.

METHODS

With claims data from 2017 to 2019, we used propensity score (PS) weighting to create three comparable cohorts of patients: 1) Adherent: filled MOUD prescription & ≧80 % of days covered by MOUD (N = 1045); 2) Nonadherent: filled MOUD & < 80 % of days covered (N = 1116), 3) did not fill MOUD (N = 16,784). The study defined three time intervals based on a patient's most recent MOUD episode: A 6-month baseline period before initiation of MOUD or random index date for those with MOUD; a 6-month treatment period, during which adherence or nonadherence was established; and a 12-month follow-up period to evaluate outcome measures. The study used generalized PS methodology to examine the effect of proportion of days covered (PDC) as a continuous measure of adherence.

RESULTS

Among patients who filled MOUD, adherence to MOUD was significantly predicted by having less severe OUD, being older, having fewer inpatient visits and lower outpatient costs before the start of treatment. Adherent patients displayed significantly lower health care costs in the follow-up period compared to nonadherent MOUD patients, and lower odds of experiencing health care events. The nonadherent MOUD group displayed significantly higher odds of health care events compared to patients who had no evidence of receiving MOUD in claims data (NO-MOUD). Among patients prescribed MOUD, each 10 % increase in PDC was associated with a significant decrease in inpatient/outpatient costs and in odds of health care events.

CONCLUSIONS

This analysis aligns with previous findings about the importance of maintaining long-term adherence to MOUD in supporting patient outcomes. The results also suggest a novel finding that despite confounder control via PS methods, nonadherent patients display poorer outcomes compared to similar NO-MOUD patients.

Buprenorphine deregulation as an opioid crisis policy response - A comparative analysis between France and the United States

BACKGROUND

In passing the Maintstreaming Addiction Treatment Act, the United States has abolished its federal X waiver, considered a major barrier to the wider buprenorphine prescribing needed to respond to opioid-related harms. Advocates for this policy have drawn on the French response of deregulating buprenorphine prescribing to address increasing overdose mortality around the turn of the millennium. So far, such policy advocacy has incompletely accounted for contextual and health system differences between the two countries.

METHODS

Using the health system dynamics framework, this analysis compares France from 1995 to 2003 (the relevant period of buprenorphine reform) to the US from 2018 until today (the comparison period to explore potential impacts of reform). We used it to guide examination of a) contextual issues relating to opioid use epidemiology and b) health system factors including prescriber supply, sector organization, and insurance coverage for primary care to draw relevant policy learning for the contemporary US.

RESULTS

We identified that the US had a 22.5-fold higher mortality rate and a 2.3-fold higher opioid use disorder (OUD) rate compared to France, despite having rates of prescribed buprenorphine per-capita higher than, and per-person with OUD comparable to, than that of France. These wide gulfs between the scales and nature of the problems between France and the US suggest that relaxing restrictions on buprenorphine prescribing through abolishing the X waiver will be insufficient for achieving hoped-for reductions in overdose mortality.

CONCLUSION

Health system strengthening with a focus on improvements in primary care prescriber supply, coverage, and coordination are likely higher yield policy complements to relaxing buprenorphine regulation. Such an approach would better prepare the US to adapt to ongoing dynamics and uncertainties in the opioid crisis and to optimize the already relatively high levels of buprenorphine prescribing.

Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder

BACKGROUND

The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program.

METHODS

We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data.

RESULTS

The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages.

CONCLUSIONS

Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.

Buprenorphine adherence and illicit opioid use among patients in treatment for opioid use disorder

Background: Buprenorphine is a partial mu opioid agonist medication that has been shown to decrease non-prescribed opioid use, cravings, and opioid related morbidity and mortality. There is an assumption that full adherence is needed to achieve ideal treatment outcomes, and that non-adherence is associated with ongoing opioid use. However, literature documenting the strength of that assertion is lacking.Objectives: Evaluate the association between daily buprenorphine adherence and illicit opioid use.Methods: Secondary analysis of a 12-week randomized controlled trial of adults with opioid use disorder who recently initiated buprenorphine. Weekly study visits included self-report of daily buprenorphine adherence over the past 7 days (Timeline Follow Back method) and urine drug tests (UDT). A log-linear regression model accounting for clustering by participant was used to assess the association between buprenorphine adherence and illicit opioid use. Buprenorphine adherence was measured as a continuous variable (0-7 days).Results: Among 78 participants (56 men, 20 women, 2 nonbinary) with 737 visits, full 7-day adherence was reported at 70% of visits. The predominant form of non-adherence was missed doses (92% of cases). Each additional day of adherence was associated with an 8% higher rate of negative UDT for illicit opioids (RR = 1.08; 95% CI:1.03-1.13, p = .0002).Conclusion: In this sample of participants starting buprenorphine, missed doses were not uncommon. Fewer missed days was significantly associated with a lower risk of illicit opioid use. These findings suggest that efforts to minimize the number of missed days of buprenorphine are beneficial for treatment outcomes.

Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration

BACKGROUND

Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system.

METHODS

We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves).

RESULTS

We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5).

CONCLUSIONS

Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.

Benzodiazepine Dose Intensity among Patients Concurrently Prescribed Buprenorphine in Rhode Island

Background: The concomitant use of buprenorphine and benzodiazepines has been linked to patient fatalities, with greater risk occurring with higher doses of benzodiazepines. We assessed benzodiazepine dose intensity among patients who were concurrently prescribed buprenorphine, as compared with patients prescribed benzodiazepines who were not receiving buprenorphine. Methods: We conducted a cross-sectional analysis of adult patients who received at least a 30-day supply of benzodiazepines during 2018, using data from the Rhode Island (RI) Prescription Drug Monitoring Program. Mean daily diazepam milligram equivalents (DME) were calculated overall and according to patient sex, age group, payment type, and RI county. Multivariable logistic regression analyses were conducted to assess the odds of higher-dose benzodiazepine utilization among patients with concurrent use of buprenorphine, as compared with patients not prescribed buprenorphine, adjusting for patient demographics. Results: Compared to patients prescribed benzodiazepines who were not receiving buprenorphine, those with concurrent buprenorphine utilization had a significantly higher mean DME/day (19.22, 95% CI: 18.70-19.74; vs 10.94, 95% CI: 10.93-10.95; p < 0.001). Patients who were prescribed benzodiazepines with concurrent utilization of buprenorphine also had a comparatively higher odds of a DME/day ≥15 (aOR: 2.86, 95% CI: 2.63-3.10), ≥20 DME/day (aOR: 2.98, 95% CI: 2.75-3.24), and ≥25 DME/day (aOR: 2.99, 95% CI: 2.65-3.18). Conclusion: Compared to patients prescribed benzodiazepines for at least 30 days who were not receiving buprenorphine, patients concurrently utilizing benzodiazepines and buprenorphine had more than twice the odds of higher dose benzodiazepine utilization. Future studies are needed to assess the relationship between benzodiazepine dose intensity, overdose outcomes, and treatment retention among patients receiving buprenorphine.

Use of a sequential multiple assignment randomized trial to test contingency management and an integrated behavioral economic and mindfulness intervention for buprenorphine-naloxone medication adherence for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment.

METHODS

The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization.

CONCLUSIONS

This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04080180.

Is use of opioid agonist treatment associated with broader primary healthcare use among men with recent injecting drug use histories following release from prison? A prospective cohort study

BACKGROUND

A precipitous decline in health status among people recently released from prison is common. In Victoria, Australia, opioid agonist treatment (OAT) in the community involves frequent contact with primary care, potentially facilitating broader use of primary healthcare services. Among a cohort of men who injected drugs regularly pre-imprisonment, we estimated differences in rates of primary healthcare use and medication dispensation between people who did and did not receive OAT post-release.

METHODS

Data came from the Prison and Transition Health Cohort Study. Three-month post-release follow-up interviews were linked with primary care and medication dispensation records. Generalised linear models were fit with one exposure (OAT: none/partial/complete) for 13 outcomes relating to primary healthcare use, pathology testing, and medication dispensation, adjusted for other covariates. Coefficients were reported as adjusted incidence rate ratios (AIRR).

RESULTS

Analyses included 255 participants. Compared to no OAT use, both partial and complete OAT use were associated with increased rates of standard (AIRR: 3.02, 95%CI: 1.88-4.86; AIRR: 3.66, 95%CI: 2.57-5.23), extended (AIRR: 2.56, 95%CI: 1.41-4.67; AIRR: 2.55, 95%CI: 1.60-4.07) and mental health-related (AIRR: 2.71, 95%CI: 1.42-5.20; AIRR: 2.27, 95%CI: 1.33-3.87) general practitioner (GP) consultations, total medication (AIRR: 1.88, 95%CI: 1.19-2.98; AIRR: 2.40, 95%CI: 1.71-3.37), benzodiazepine (AIRR: 4.99, 95%CI: 2.81-8.85; AIRR: 8.30, 95%CI: 5.28-13.04) and gabapentinoid (AIRR: 6.78, 95%CI: 3.34-13.77; AIRR: 4.34, 95%CI: 2.37-7.94) dispensations, respectively. Partial OAT use was also associated with increased after-hours GP consultations (AIRR: 4.61, 95%CI: 2.24-9.48) and complete OAT use? with increased pathology utilisation (e.g. haematological, chemical, microbiological or immunological tissue/sample testing; AIRR: 2.30, 95%CI: 1.52-3.48).

CONCLUSION

We observed higher rates of primary healthcare use and medication dispensation among people who reported partial and complete OAT use post-release. Findings suggest that access to OAT post-release may have a collateral benefit in supporting broader health service utilisation, underscoring the importance of retention in OAT after release from prison.

Duration of medication treatment for opioid-use disorder and risk of overdose among Medicaid enrollees in 11 states: a retrospective cohort study

BACKGROUND AND AIMS

Medication for opioid use disorder (MOUD) reduces harms associated with opioid use disorder (OUD), including risk of overdose. Understanding how variation in MOUD duration influences overdose risk is important as health-care payers increasingly remove barriers to treatment continuation (e.g. prior authorization). This study measured the association between MOUD continuation, relative to discontinuation, and opioid-related overdose among Medicaid beneficiaries.

DESIGN

Retrospective cohort study using landmark survival analysis. We estimated the association between treatment continuation and overdose risk at 5 points after the index, or first, MOUD claim. Censoring events included death and disenrollment.

SETTING AND PARTICIPANTS

Medicaid programs in 11 US states: Delaware, Kentucky, Maryland, Maine, Michigan, North Carolina, Ohio, Pennsylvania, Virginia, West Virginia and Wisconsin. A total of 293 180 Medicaid beneficiaries aged 18-64 years with a diagnosis of OUD and had a first MOUD claim between 2016 and 2017.

MEASUREMENTS

MOUD formulations included methadone, buprenorphine and naltrexone. We measured medically treated opioid-related overdose within claims within 12 months of the index MOUD claim.

FINDINGS

Results were consistent across states. In pooled results, 5.1% of beneficiaries had an overdose, and 67% discontinued MOUD before an overdose or censoring event within 12 months. Beneficiaries who continued MOUD beyond 60 days had a lower relative overdose hazard ratio (HR) compared with those who discontinued by day 60 [HR = 0.39; 95% confidence interval (CI) = 0.36-0.42; P < 0.0001]. MOUD continuation was associated with lower overdose risk at 120 days (HR = 0.34; 95% CI = 0.31-0.37; P < 0.0001), 180 days (HR = 0.31; 95% CI = 0.29-0.34; P < 0.0001), 240 days (HR = 0.29; 95% CI = 0.26-0.31; P < 0.0001) and 300 days (HR = 0.28; 95% CI = 0.24-0.32; P < 0.0001). The hazard of overdose was 10% lower with each additional 60 days of MOUD (95% CI = 0.88-0.92; P < 0.0001).

CONCLUSIONS

Continuation of medication for opioid use disorder (MOUD) in US Medicaid beneficiaries was associated with a substantial reduction in overdose risk up to 12 months after the first claim for MOUD.

Design, Implementation, and Evolution of the Medicaid Outcomes Distributed Research Network (MODRN)

BACKGROUND

In the US, Medicaid covers over 80 million Americans. Comparing access, quality, and costs across Medicaid programs can provide policymakers with much-needed information. As each Medicaid agency collects its member data, multiple barriers prevent sharing Medicaid data between states. To address this gap, the Medicaid Outcomes Distributed Research Network (MODRN) developed a research network of states to conduct rapid multi-state analyses without sharing individual-level data across states.

OBJECTIVE

To describe goals, design, implementation, and evolution of MODRN to inform other research networks.

METHODS

MODRN implemented a distributed research network using a common data model, with each state analyzing its own data; developed standardized measure specifications and statistical software code to conduct analyses; and disseminated findings to state and federal Medicaid policymakers. Based on feedback on Medicaid agency priorities, MODRN first sought to inform Medicaid policy to improve opioid use disorder treatment, particularly medication treatment.

RESULTS

Since its 2017 inception, MODRN created 21 opioid use disorder quality measures in 13 states. MODRN modified its common data model over time to include additional elements. Initial barriers included harmonizing utilization data from Medicaid billing codes across states and adapting statistical methods to combine state-level results. The network demonstrated its utility and addressed barriers to conducting multi-state analyses of Medicaid administrative data.

CONCLUSIONS

MODRN created a new, scalable, successful model for conducting policy research while complying with federal and state regulations to protect beneficiary health information. Platforms like MODRN may prove useful for emerging health challenges to facilitate evidence-based policymaking in Medicaid programs.

Long-term patient outcomes following buprenorphine/naloxone treatment for opioid use disorder: a retrospective analysis in a commercially insured population

Background: While buprenorphine/naloxone (buprenorphine) has been demonstrated to be an effective medication for treating opioid use disorder (OUD), an important question exists about how long patients should remain in treatment.Objective: To examine the relationship between treatment duration and patient outcomes for individuals with OUD who have been prescribed buprenorphine.Methods: We conducted a retrospective, longitudinal study using the Massachusetts All Payer Claims Database, 2013 to 2017. The study comprised over 2,500 patients, approximately one-third of whom were female, who had been prescribed buprenorphine for OUD. The outcomes were hospitalizations and emergency room (ER) visits at 36 months following treatment initiation and 12 months following treatment discontinuation. Patients were classified into four groups based on treatment duration and medication adherence: poor adherence, duration <12 months; good adherence, duration <6 months; good adherence, duration 6 to 12 months, and good adherence, duration >12 months. We conducted analyses at the patient level of the relationship between duration and outcomes.Results: Better outcomes were observed for patients whose duration was greater than 12 months. Patients in the other groups had higher odds of hospitalization at 36 months following treatment initiation: poor adherence (2.71), <6 months (1.53), and 6 to 12 months (1.42). They also had higher odds of ER visits: poor adherence (1.69), <6 months (1.51), and 6 to 12 months (1.30). Similar results were observed following treatment discontinuation.Conclusions: OUD treatment with buprenorphine should be continued for at least 12 months to reduce hospitalizations and ED visits.

Roles and Perceptions of Nurses During Implementation of a Medication Treatment for Opioid Use Disorder National Initiative

BACKGROUND

In the United States, a national priority exists to improve access to medication treatment for opioid use disorder (MOUD). Nurses can be an essential component of that care. We examined the perceptions and evolving roles of nurses in a national Veterans Health Administration (VHA) initiative designed to improve MOUD access within general medical settings.

METHODS

From April 15, 2021, to June 16, 2021, we recruited nurses participating in VHA's Stepped Care for Opioid Use Disorder Train the Trainer Initiative-a national program intending to implement MOUD in general medical settings-to participate in an interview about their roles, perceptions, and experiences. The respondents answered our inquiries through an interview or responded to an email solicitation with written responses, which were then recorded, transcribed, and independently coded to identify themes.

RESULTS

Nurses from 10 VHA facilities participated in an interview (n = 7) or completed the questionnaire (n = 4). Inadequate staffing, high patient-to-provider ratios, and time constraints were identified as barriers to MOUD care. Mentorship activities, existing VHA informational resources, and patients' willingness to accept treatment were identified as facilitators of MOUD care. The Stepped Care for Opioid Use Disorder Train the Trainer Initiative processes were acknowledged to promote role confidence, which in turn increased job satisfaction and empowered nurses to become content experts. Respondents often identified nurses as local lead facilitators in MOUD care.

CONCLUSIONS

In a national initiative to implement MOUD within general medical settings, nurses identified several barriers and facilitators to MOUD implementation. Nurses play vital collaborative care roles in enhancing access to MOUD.

Predictors of Five-year Readmission to an Inpatient Service among Patients with Opioid Use Disorders

Background Opioid use disorder (OUD), a relapsing-remitting chronic medical disease, accounts for a sizable proportion of all-cause adult inpatient stays. We evaluated the incidence and predictors of any and multiple readmissions to inpatient care for OUD. Methods This retrospective, register-based cohort study assessed consecutive patients with OUD admitted to a federally-funded inpatient service of an addiction treatment center in North India between January 2007 and December 2014. Binary logistic regression was used to determine independent readmission predictors based on demographic, clinical, and treatment variables that significantly differed in bivariate analysis. Results Among 908 patients, 306 (33.7%) and 106 (11.7%) had any and multiple readmissions, respectively. Injection drug use (Odds ratio [OR] 2.92, 95% confidence interval [CI] 1.90-4.49), comorbid severe mental illness (OR 2.80, 95% CI 1.42-5.55) and common mental disorder (OR 3.4 95% CI 1.65-6.95), antagonist treatment (OR 1.6 95% CI 1.14-2.27), and urban residence (OR 1.38 95% CI 1.01-1.90) increased odds of readmission. 'Improved' discharge status (OR 0.48 95% CI 0.34-0.70) in first admissions reduced odds of any readmission. Similar risk factors also influenced multiple readmissions with higher odds ratios. Conclusions Identification and adequate treatment of risk factors may reduce the chances of readmission.

Are x-waiver trainings enough? Facilitators and barriers to buprenorphine prescribing after x-waiver trainings

BACKGROUND

In the United States, an x-waiver credential is necessary to prescribe buprenorphine medication treatment for opioid use disorder (B-MOUD). Historically, this process has required certified training, which could be a barrier to obtaining an x-waiver and subsequently prescribing. To address this barrier, the US recently removed the training requirement for some clinicians. We sought to determine if clinicians who attended x-waiver training went on to obtain an x-waiver and prescribe B-MOUD, and to examine what facilitated or impeded B-MOUD prescribing.

METHODS

In September 2020, we conducted a cross-sectional, electronic survey of attendees of 15 in-person x-waiver pieces of training from June 2018 to January 2020 within the Veterans Health Administration (VHA). Of the attendees (n = 321), we surveyed current VHA clinicians who recalled taking the training. The survey assessed whether clinicians obtained the x-waiver, had prescribed B-MOUD, and barriers or facilitators that influenced B-MOUD prescribing.

RESULTS

Of 251 eligible participants, 62 (24.7%) responded to the survey, including 27 (43.5%) physicians, 16 (25.8%) advanced practice clinicians, and 12 (19.4%) pharmacists. Of the 43 clinicians who could prescribe, 29 (67.4%) had obtained their x-waiver and 16 (37.2%) had reported prescribing B-MOUD. Prominent barriers to prescribing B-MOUD included a lack of supporting clinical staff and competing demands on time. The primary facilitator to prescribing was leadership support.

CONCLUSIONS

Nine months after x-waiver training, two-thirds of clinicians with prescribing credentials had obtained their x-waiver and one-third were prescribing B-MOUD. Removing the x-waiver training may not have the intended policy effect as other barriers to B-MOUD prescribing persist.

A machine learning based two-stage clinical decision support system for predicting patients' discontinuation from opioid use disorder treatment: retrospective observational study

Background

Buprenorphine is a widely used treatment option for patients with opioid use disorder (OUD). Premature discontinuation from this treatment has many negative health and societal consequences.

Objective

To develop and evaluate a machine learning based two-stage clinical decision-making framework for predicting which patients will discontinue OUD treatment within less than a year. The proposed framework performs such prediction in two stages: (i) at the time of initiating the treatment, and (ii) after two/three months following treatment initiation.

Methods

For this retrospective observational analysis, we utilized Massachusetts All Payer Claims Data (MA APCD) from the year 2013 to 2015. Study sample included 5190 patients who were commercially insured, initiated buprenorphine treatment between January and December 2014, and did not have any buprenorphine prescription at least one year prior to the date of treatment initiation in 2014. Treatment discontinuation was defined as at least two consecutive months without a prescription for buprenorphine. Six machine learning models (i.e., logistic regression, decision tree, random forest, extreme-gradient boosting, support vector machine, and artificial neural network) were tested using a five-fold cross validation on the input data. The first-stage models used patients’ demographic information. The second-stage models included information on medication adherence during the early phase of treatment based on the proportion of days covered (PDC) measure.

Results

A substantial percentage of patients (48.7%) who started on buprenorphine discontinued the treatment within one year. The area under receiving operating characteristic curve (C-statistic) for the first stage models varied within a range of 0.55 to 0.59. The inclusion of knowledge regarding patients’ adherence at the early treatment phase in terms of two-months and three-months PDC resulted in a statistically significant increase in the models’ discriminative power (p-value < 0.001) based on the C-statistic. We also constructed interpretable decision classification rules using the decision tree model.

Conclusion

Machine learning models can predict which patients are most at-risk of premature treatment discontinuation with reasonable discriminative power. The proposed machine learning framework can be used as a tool to help inform a clinical decision support system following further validation. This can potentially help prescribers allocate limited healthcare resources optimally among different groups of patients based on their vulnerability to treatment discontinuation and design personalized support systems for improving patients’ long-term adherence to OUD treatment.

Retention in care for persons with opioid use disorder transitioning from sublingual to injectable buprenorphine

INTRODUCTION

In the current overdose epidemic, effective treatments for opioid use disorders (OUD), including innovations in medication delivery such as extended-release formulations, have the potential to improve treatment access and reduce treatment discontinuation. This study assessed treatment retention in a primary care-based, extended-release buprenorphine program.

METHODS

The study recruited individuals (n = 92) who transitioned from sublingual buprenorphine to extended-release buprenorphine (BUP-XR) in 2018-2019. The study defined the primary outcome, treatment retention, as three or more consecutive, monthly BUP-XR injections following the transition to BUP-XR in this retrospective chart review.

RESULTS

Participants' mean age was 38 years old and 67% were male. The average duration of sublingual buprenorphine prior to transition was 17.1 (±28.1) months. Three months after transition, 48% of extended-release buprenorphine patients had discontinued BUP-XR treatment. Persons with chronic pain were more likely, and those who had used heroin in the past month less likely to continue BUP-XR. Mean months on sublingual buprenorphine prior to BUP-XR initiation was 24.3 (±32.5) months for people who received 3+ post-induction injections compared to only 8.9 (±19.5) months for those who did not (p = .009).

CONCLUSIONS

Extended-release buprenorphine discontinuation was high in a real-world setting. Retention continues to represent a major obstacle to treatment effectiveness, and programs need interventions with even newer MOUD formulations.

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Cost-Effectiveness Analysis of a Prescription Digital Therapeutic for the Treatment of Opioid Use Disorder

The lack of adequate treatment for many patients with opioid use disorder (OUD) has led to high medical costs ($90B in 2020). An analysis of the cost-effectiveness (cost-utility) of reSET-O, the first and only FDA-approved prescription digital therapeutic (PDT) for the treatment of OUD, is needed to inform value assessments and healthcare decision making. To evaluate the cost-utility of reSET-O in conjunction with treatment-as usual (TAU) compared to TAU alone. A third-party payer-perspective decision analytic model evaluated the cost-effectiveness of reSET-O + TAU relative to TAU (i.e., oral buprenorphine, face-to-face counseling, and contingency management [immediate rewards for negative drug tests logged]) alone over 12 weeks. Clinical effectiveness data (retention in therapy and health state utilities) were obtained from the peer-reviewed literature, while resource utilization and cost data were obtained from a published claims data analyses. Over 12 weeks, the addition of reSET-O to TAU resulted in a gain of 0.003 quality-adjusted life years (QALYs), and $1,014 lower costs, resulting in economic dominance vs. TAU. reSET-O + TAU's was economically dominant (less costly, more effective) vs. TAU alone over 12 weeks, a result that was driven by a reduction in medical costs after initiation of reSET-O observed in a recent real-world claims analysis.

Changes In Health Services Use After Receipt Of Medications For Opioid Use Disorder In A Statewide Correctional System

To decrease opioid overdose mortality, prisons and jails in the US are increasingly offering medications for opioid use disorder (OUD) to incarcerated people. It is unknown how receipt of these medications in a correctional setting affects health services use after release. In this article we analyze changes in postrelease health care use after the implementation of a statewide medications for OUD program in the unified jail and prison system of the Rhode Island Department of Corrections. Using Medicaid claims data, we examined individual health care use in the community before and after receipt of medications for OUD while incarcerated. We found that inpatient admissions did not change, emergency department visits decreased, and both nonacute outpatient services and pharmacy claims increased after people received medications for OUD while incarcerated. There was no change in total health care costs paid by Medicaid. Our findings provide evidence that people's use of health care services paid for by Medicaid did not increase after they started medications for OUD in correctional settings. Given the frequent interaction of people with OUD with the criminal justice system, offering evidence-based treatment of OUD in correctional settings is an important opportunity to initiate addiction treatment.

Characterizing the Clinical use of a Novel Video-assisted Dosing Protocol With Secure Medication Dispensers to Reduce Barriers to Opioid Treatment

OBJECTIVES

Distance and travel costs to opioid treatment programs (OTPs), especially in rural communities, are barriers to treatment for opioid use disorder. Retention rates at 12 months in our OTP are 55% (range 53%-61%). We piloted a novel treatment platform utilizing a video directly observed therapy (VDOT) smartphone app and a secure medication dispenser to support adherence with take-home doses of methadone or buprenorphine while enabling patients to maintain prosocial activities, reduce time and cost of travel, and increase retention.

METHODS

Participants (n = 58) were adults in a Vermont OTP. Inclusion criteria included travel hardship, access to Wi-Fi or cellular network, and having an iPhone 4S or Android 4.0 or greater. Patients received a dispenser, VDOT app, clinic dispensed medication, counseling, and urine drug testing. Chart reviews assessed VDOT compliance, engagement in prosocial activities, travel costs and time savings, and treatment disposition/retention. Project-associated costs were examined.

RESULTS

Of the 15,831 expected videos, 15,581 (98.4%) were received and only 10 (0.063%) showed signs of medication noncompliance with 1 (0.0064%) showing an overt attempt at diversion. About 93% of participants engaged in prosocial activities, travel time and costs were reduced 86%, median cost saved $72 weekly, median travel time saved 5.5 hours weekly and 98% of participants were in treatment 12 months later.

CONCLUSIONS

VDOT participants using dispensers showed high levels of medication ingestion integrity, had favorable clinical stability, and lower travel time and costs. These findings suggest that using VDOT with dispensers may hold promise as an innovative platform for supporting medication adherence.

Buprenorphine utilization among all Washington State residents' based upon prescription monitoring program data - Characteristics associated with two measures of retention and patterns of care over time

BACKGROUND

Opioid use disorder is a serious health condition for which buprenorphine is proven effective, yet providers substantially underutilize buprenorphine. We present two approaches to measuring treatment duration, factors associated with retention, and patterns of care.

METHODS

The study determined incident buprenorphine prescribing for all Washingtonians utilizing prescription monitoring program data from 2012 to 2019. The study calculated episode of care and cumulative time in care. Generalized linear models estimated associations among the length of the first episode of care and cumulative time in care with sex, age, and rurality. Cox proportional hazards models estimated the time to discontinuing buprenorphine for the first four episodes of care and time to discontinuing the last episode of care.

RESULTS

Mean and median duration of the first episode were 320 and 84 days, respectively, and for cumulative time in care 308 and 195 days. A minority of peoples' first episodes exceeded 180 days (37%). Being female and older were significantly associated with longer first episodes and cumulative time in care. Survival analyses indicated that the proportion of those still in care at 6, 12, and 24 months into their first episode of care declined for those with more than one episode of care; conversely the study found much smaller differences in retention for the last episode of care, indicating that many people were eventually able to be retained in care for longer periods of time.

CONCLUSION

Episodes of care and cumulative time on buprenorphine were both short compared to minimum quality recommendations of 180 days. Median cumulative time in care was double that of the first episode, highlighting that many people engage in subsequent episodes of substantial length. Episode of care and cumulative care analyses should inform states, payers, health care systems and providers in measuring and setting treatment duration goals.

Removal of prior authorization for medication-assisted treatment: impact on opioid use and policy implications in a Medicare Advantage population

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.

Impact of a pharmacist-led substance use disorder transitions of care clinic on postdischarge medication treatment retention

BACKGROUND

The Veterans Health Administration (VHA) has made significant improvements in increasing prescribing of medication treatment for opioid use disorder (MOUD) and medication treatment for alcohol use disorder (MAUD); however, several barriers to treatment retention remain. In an effort to improve MOUD/MAUD retention, a Veterans Affairs (VA) facility established a pharmacist-led substance use disorder (SUD) transitions of care telephone clinic for patients discharged from an inpatient hospitalization on MOUD/MAUD, including buprenorphine/naloxone (BUP/NAL) and extended-release (ER) naltrexone injections. Pharmacists within the clinic assess aspects of treatment retention such as medication tolerability, perceived barriers to continuing treatment, status of current prescriptions, and appointment coordination.

OBJECTIVES

The primary objective of this study was to evaluate the impact of a pharmacist-led SUD transitions of care telephone clinic on MOUD/MAUD retention following inpatient initiation in patients with opioid use disorder (OUD) and/or alcohol use disorder (AUD). Secondary objectives included subanalyses of clinic impact on MOUD/MAUD retention based on study medication or diagnoses, health care utilization, and characterization of pharmacist interventions.

METHODS

The study identified patients for inclusion from inpatient units at a VA hospital. The study included patients if they were >18 years of age, had a diagnosis of AUD and/or OUD, and were initiated on ER naltrexone or BUP/NAL during admission and continued at discharge from August 1, 2018, to December 31, 2019. The study excluded patients if they declined clinic involvement, transferred facilities, moved beyond the VA catchment area, or were unable to be reached for initial contact after 3 telephone attempts. The intervention group included patients enrolled in the pharmacist-led SUD transitions of care telephone clinic, while the control group included patients initiated on MOUD/MAUD during admission who were eligible but not referred for clinic enrollment.

RESULTS/CONCLUSIONS

The study identified a total of 150 patients for inclusion (n = 54 intervention group; n = 96 control group). The study observed a statistically significant difference for the primary endpoint of combined 1- and 3-month MOUD/MAUD retention rates as measured by a continuous, multiple-interval measure of medication acquisition (CMA) of ER naltrexone and BUP/NAL for the intervention group vs. control group (1-month: 77.3% vs. 56.8%, p = 0.004; 3-month: 71.4% vs. 48%, p = 0.0002). When analyzed by study medication, we also observed a statistically significant improvement in continuous use of ER naltrexone for those enrolled in the clinic (1-month: 71.4% vs. 45.9%, p = 0.01; 3-month: 66.7% vs. 34.4%, p = 0.0003). The study did not observe any statistically significant improvements for BUP/NAL (1-month: 87.1% vs. 75.8%, p = 0.13; 3-month: 79.4% vs. 68.5%, p = 0.24) or establishment with a BUP/NAL clinic (90.5% vs. 80% patients established, p = 0.46). Likewise, the study did not observe any statistically significant differences for combined emergency department (ED) visits (1-month: 24.1% vs.17.1% patients with ED visit, p = 0.40; 3-month: 31.5% vs. 29.2% patients with ED visit, p = 0.85) or hospitalizations (1-month: 9.3% vs. 14.6% re-hospitalization, p = 0.45; 3-month: 14.8% vs. 26% re-hospitalization, p = 0.15) for those in the intervention group vs. the control group. Overall, the study observed statistically and clinically significant improvements in MOUD/MAUD retention rates for patients enrolled in a pharmacist-led SUD transitions of care telephone clinic.

Patterns of patient discontinuation from buprenorphine/naloxone treatment for opioid use disorder: A study of a commercially insured population in Massachusetts

BACKGROUND

Research has shown buprenorphine/naloxone to be an effective medication for treating individuals with opioid use disorder. At the same time, treatment discontinuation rates are reportedly high though much of the extant evidence comes from studies of the Medicaid population.

OBJECTIVES

To examine the pattern and determinants of buprenorphine/naloxone treatment discontinuation in a population of commercially insured individuals.

RESEARCH DESIGN

We performed a retrospective observational analysis of Massachusetts All Payer Claims Data (MA APCD) covering years 2013 through 2017. We defined treatment discontinuation as a gap of 60 consecutive days without a prescription for buprenorphine/naloxone within a time frame of 24 months from the initiation of treatment. A mixed-effect Cox proportional hazard model examined the associated risk of discontinuing treatment with baseline predictors.

SUBJECTS

A total of 5134 individuals who were commercially insured during the study period.

MEASURES

Buprenorphine/naloxone treatment discontinuation.

RESULTS

Overall 75% of individuals had discontinued treatment within two years of initiating treatment, and median time to discontinuation was 300 days. Patients aged between 18 and 24 years (HR = 1.436, 95%, CI = 1.240-1.663) and receiving treatment from prescribers with high panel-size (HR = 1.278, 95% CI = 1.112-1.468) had higher risk of discontinuing treatment. On the contrary, patients receiving treatment from multiple prescribers had lower associated risk of treatment discontinuation.

CONCLUSIONS

A substantial percentage of patients discontinue treatment well before they can typically meet criteria for sustained remission. Further investigations should assess the clinical outcomes following premature discontinuation and identify strategies for retaining patients in treatment.

Evaluation of the cost-utility of a prescription digital therapeutic for the treatment of opioid use disorder

Background: The opioid epidemic continues to generate a significant mental and physical health burden on patients, and claims the life of almost 150 Americans daily. Making matters worse, an increase in relapses and/or opioid-related deaths has been reported in more than 40 U.S. states since the start of the COVID-19 pandemic. Opioid use disorder (OUD) is one of the single most expensive disorders in the United States, generating average medical costs of $60B from just 2 million Americans diagnosed with the disorder. In commercial use since 2019, reSET-O is a non-drug, prescription digital therapeutic (PDT) that delivers evidence-based neurobehavioral treatment for OUD and helps overcome the barriers associated with access to care, stigma, and social distancing. Although shown to be cost effective and efficacious in clinical trials and real-world evidence studies, respectively, information on its value for money from a health utilities and cost per quality-adjusted life-year is needed to inform policy discussions.Objectives: To evaluate the impact of reSET-O on health utilities and assess its overall cost per quality-adjusted life year (QALY) gained vs. treatment-as-usual (TAU).Methods: Decision analytic model comparing reSET-O plus TAU to TAU alone (i.e. buprenorphine, face-to-face counseling, and contingency management) over 12 weeks. Clinical effectiveness data (abstinence and health utility) were obtained from a clinical trial, and resource utilization and cost data were adapted from a recent claims data analysis to reflect less frequent face-to-face counseling with the therapeutic.Results: The addition of reSET-O to TAU decreases total health care costs by -$131 and resulted in post-treatment utility values within population norms, with a corresponding gain of 0.003 QALYs. reSET-O when used adjunctively to TAU was economically dominant (less costly, more effective) vs. TAU alone.Conclusion: reSET-O is an economically-dominant adjunctive treatment for OUD and is associated with an overall reduction in total incremental cost vs TAU.

Economic modeling of reSET-O, a prescription digital therapeutic for patients with opioid use disorder

AIMS

reSET-O is a Food and Drug Administration-cleared prescription digital therapeutic (PDT) indicated to improve outpatient-treatment retention of patients with opioid use disorder (OUD). This study examined the cost-effectiveness and budget impact of reSET-O in conjunction with treatment as usual (reSET-O + TAU) relative to TAU.

MATERIALS AND METHODS

Adult patients with ≥1 OUD diagnosis, treated with buprenorphine from 1 January 2015 to 30 March 2018, were identified from Truven Health MarketScan Commercial and Medicare Supplemental Research Databases. Twelve-week healthcare resource utilization (HCRU) costs for patients categorized as adherent and nonadherent to buprenorphine treatment were estimated. Total 12-week costs included OUD treatment and other HCRU costs. The cost-effectiveness of reSET-O + TAU was modeled in accordance with prior clinical trial outcomes. The 12-week budget impact of reSET-O was modeled for a 1 million-member healthcare plan.

RESULTS

Higher buprenorphine adherence was associated with lower HCRU costs in claims data. Twelve-week per-patient total costs were $305 more for those receiving reSET-O + TAU than those receiving TAU. The incremental cost-effectiveness ratio was $18.70 per 1 percentage-point increase in the treatment retention rate. The probability that reSET-O + TAU would be considered cost-effective was over 92% for willingness-to-pay thresholds of $6,000 or more. The 12-week budget impact of reSET-O was $8,908, translating to $0.003 per member per month.

LIMITATIONS

The findings of the cost-effectiveness and budget impact modeling are limited by the assumptions of the models due to uncertainty around some inputs. While no model is free of bias, the inputs for this model were carefully selected to reflect contemporary treatment patterns.

CONCLUSIONS

Depending on the payer's willingness to pay, reSET-O may be cost-effective in increasing buprenorphine treatment retention rates. reSET-O results in an approximate budget impact of $0.003 per member per month, depending on market share and the prevalence of the population receiving treatment for OUD.

Risk of discharge against medical advice among hospital inpatients with a history of opioid agonist therapy in New South Wales, Australia: A cohort study and nested crossover-cohort analysis

BACKGROUND

People who use illicit opioids have high rates of hospital admission. We aimed to measure the risk of discharge against medical advice among inpatients with a history of opioid agonist therapy (OAT), and test whether OAT is associated with lower risk of discharge against medical advice.

METHODS

We conducted a cohort study of patients admitted to hospital in an emergency between 1 August 2001 and 30 April 2018 in New South Wales, Australia. All patients had a previous episode of OAT in the community. The main outcome was discharge against medical advice, and the main exposure was whether patients had an active OAT permit at the time of admission.

RESULTS

14,035/116,957 admissions (12 %) ended in discharge against medical advice. Admissions during periods of OAT had 0.79 (0.76-0.83; p < 0.001) times the risk of discharge against medical advice, corresponding to an absolute risk reduction of 3.0 percentage points. Risk of discharge against medical advice was higher among patients who were younger, male, identified as Aboriginal and/or Torres Strait Islander, and those admitted for accidents, drug-related reasons, or injecting-related injuries (such as cutaneous abscesses). In a subsample of 7793 patients included in a crossover-cohort analysis, OAT was associated with 0.84 (95 % CI 0.76-0.93; p < 0.001) times the risk of discharge against medical advice.

CONCLUSIONS

Among patients with a history of OAT, one in eight emergency hospital admissions ends in discharge against medical advice. OAT enrolment at the time of admission is associated with a reduction of this risk.

Adherence to buprenorphine: An analysis of prescription drug monitoring program data

BACKGROUND

Although buprenorphine is an evidence-based treatment for opioid use disorder (OUD), many individuals discontinue treatment soon after starting. This study assesses predictors of buprenorphine adherence using Prescription Drug Monitoring Program (PDMP) data.

METHODS

PDMP data for Philadelphia, Pennsylvania were used to measure 180-day adherence to buprenorphine among new initiates. Adherence was classified using percent days covered (PDC), and new initiates with PDC ≥ 0.80 were classified as adherent. Multivariable logistic regression was conducted to determine factors associated with buprenorphine adherence.

RESULTS

Between January 2017 and December 2018, 10,669 Philadelphia residents initiated buprenorphine and 26.6 % remained adherent after 180 days. Demographic factors associated with greater odds of adherence included age category and female sex (aOR: 1.37; 95 % CI: 1.25-1.50). Those filling an opioid prescription, other than buprenorphine, during the follow-up period had lower odds of adherence than those who did not fill an opioid prescription (aOR: 0.62; 95 % CI: 0.50-0.77). Odds of adherence was greater for those on the film formulation (aOR: 1.37; 95 % CI: 1.25-1.50) than the tablet formulation. Those filling medium (aOR: 1.76; 95 % CI: 1.55-2.00) and high dose (aOR: 5.11; 95 % CI: 4.30-6.17) buprenorphine prescriptions had higher odds of adherence than those filling low dose prescriptions.

CONCLUSIONS

Individual demographics, receipt of an opioid prescription, buprenorphine formulation, and buprenorphine dose were all associated with adherence to buprenorphine. Ongoing strategies to address OUD need to prioritize increasing retention in long-term evidence-based buprenorphine treatment while also encouraging providers to regularly consult the PDMP to ensure patient compliance.

Early Discontinuation of Buprenorphine Therapy for Opioid Use Disorder Among Privately Insured Adults

OBJECTIVE

This study examined the temporal relationship between early discontinuation of buprenorphine treatment and health care expenditures before and after treatment initiation.

METHODS

MarketScan commercial claims for patients who initiated buprenorphine for opioid use disorder in 2013 and had continuous insurance for the subsequent 12 months (N=6,444) were used to examine the relationship between treatment retention and health care expenditures before and after buprenorphine initiation. Analysis of covariance and generalized linear models (with gamma distribution/log link) were used to compare expenditures across four buprenorphine-retention groups (0-3, 3-6, 6-12, and 12 or more months).

RESULTS

Average total health care expenditures in the 3 months prior to buprenorphine initiation ranged from a high of $7,588 among those with the shortest retention to $4,929 among those with the longest retention (p<0.001). In the 12 months after buprenorphine initiation, total health care expenditures averaged $26,332 per year, with $2,916 (11.1%) in out-of-pocket expenditures. Average annual expenditures for medication were highest among patients with the longest buprenorphine retention, and total health care expenditures were highest among those with the shortest retention. Expenditures for health care services other than medication were highest among those with early discontinuation both before the initiation of buprenorphine and during the initial period after initiation but not in subsequent quarters.

CONCLUSIONS

Poorer treatment retention among privately insured adults was associated with greater clinical and financial burdens that preceded and continued during the period shortly following treatment initiation, suggesting that cost burdens may contribute to poor retention among privately insured adults.

Medication treatment for opioid use disorder and community pharmacy: Expanding care during a national epidemic and global pandemic

Medications for opioid use disorder (MOUD), such as methadone and buprenorphine, are effective strategies for treatment of opioid use disorder (OUD) and reducing overdose risk. MOUD treatment rates continue to be low across the US, and currently, some evidence suggests access to evidence-based treatment is becoming increasingly difficult for those with OUD as a result of the 2019 novel corona virus (COVID-19). A major underutilized source to address these serious challenges in the US is community pharmacy given the specialized training of pharmacists, high levels of consumer trust, and general availability for accessing these service settings. Canadian, Australian, and European pharmacists have made important contributions to the treatment and care of those with OUD over the past decades. Unfortunately, US pharmacists are not permitted to prescribe MOUD and are only currently allowed to dispense methadone for the treatment of pain, not OUD. US policymakers, regulators, and practitioners must work to facilitate this advancement of community pharmacy-based through research, education, practice, and industry. Advancing community pharmacy-based MOUD for leading clinical management of OUD and dispensation of treatment medications will afford the US a critical innovation for addressing the opioid epidemic, fallout from COVID-19, and getting individuals the care they need.

Predictors for 30-Day and 90-Day Hospital Readmission Among Patients With Opioid Use Disorder

OBJECTIVES

To identify the incidence, characteristics, and predictors for 30 and 90-day readmission among acutely hospitalized patients with opioid use disorder (OUD).

METHODS

This retrospective, cohort study evaluated consecutive adults with OUD admitted to an academic medical center over a 5-year period (10/1/11 to 9/30/16). Multivariable logistic regression was used to determine independent predictors for 30 and 90-day readmissions based on pertinent admission, hospital, and discharge variables collected via chart review and found to be different (with a P < 0.10) on univariate analysis.

RESULTS

Among the 470 adults (mean age 43.1 ± 12.8 years, past heroin use 77.9%; admission opioid agonist therapy use [buprenorphine 22.6%; methadone 27.0%]; medical [vs surgical] admission 75.3%, floor [vs ICU] admission 93.0%, in-hospital mortality 0.9%), 85 (18.2%) and 151 (32.1%) were readmitted within 30 and 90 days, respectively. Among the 90-day readmitted patients, median time to first readmission was 26 days. Buprenorphine use (vs no use) at index hospital admission was independently associated with reduced 30-day (odds ratio [OR] 0.47, 95% confidence interval [CI] 0.24-0.93) and 90-day (OR 0.57, 95% CI 0.34-0.96) readmission; prior heroin (vs prescription opioid) use was associated with reduced 90-day readmission (OR 0.59, 95% CI 0.37-0.94) and length of hospital stay was associated with both greater 30-day (OR 1.02, 95% CI 1.01-1.05) and 90-day (OR 1.04, 95% CI 1.01-1.06) readmission rates.

CONCLUSIONS

Among patients with OUD taking buprenorphine at the time of hospital admission, 30-day and 90-day hospital readmission was reduced by 53% and 43%, respectively.

Prevalence and treatment of opioid use disorders among primary care patients in six health systems

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.

Opioid Use Disorder Treatment Decision Making And Care Navigation Upon Release From Prison: A Feasibility Study

PURPOSE

Opioid use disorder (OUD) is a medical condition that is effectively treated with medications. A major challenge in breaking the cycle of OUD and related illegal activity is seamlessly introducing medications for opioid use disorder (MOUD) as individuals leave jail or prison. We examined the feasibility of a pilot intervention to link participants to ongoing MOUD and psychosocial supports following release from custody.

METHODS

The study enrolled adults with a history of OUD released from Washington State prisons to Department of Corrections (DOC) community supervision. Participants were randomized to the study intervention or comparison group. The intervention consisted of education on OUD and available treatments, support with individualized treatment decision making, and continued care navigation for 6 months to facilitate linkage to chosen treatments. Participants randomized to the control condition received referral to services in the community from their community corrections officers. A care navigation activity log documented intervention participants' intervention engagement, service utilization, and needs. Follow-up interviews were conducted at 1 and 6 months to assess satisfaction with the intervention.

RESULTS

Fifteen participants were enrolled. All were male, most were white (86.6%) and the average age was 36.9 years. The majority (14 of 15 participants) were near-daily heroin users with severe OUD prior to incarceration. Of the seven intervention participants, two wished to start medications immediately. Three participants reported starting buprenorphine or methadone in the subsequent follow-up period, with or without social support and/or outpatient counseling, and three reported enrolling in social support and/or outpatient counseling without medications. Participants who received the intervention reported high satisfaction. We discuss barriers and facilitators to study implementation.

CONCLUSION

An intervention to link participants to ongoing MOUD and psychosocial supports following release from prison had broad acceptability among participants and was feasible to implement among those recruited; however, enrollment was much lower than anticipated and the study intervention did not demonstrate the intended effect to facilitate use of MOUD immediately post-release in this small sample of participants. Given recent research showing benefits of pre-release medication initiation, the potential added benefits of this two-part intervention should be studied in systems that initiate MOUD prior to release.

'Too little dose - too early discontinuation?'-Effect of buprenorphine dose on short term treatment adherence in opioid dependence

BACKGROUND

Opioid substitution therapy is an evidence-based treatment for opioid dependence syndrome. Retention in treatment is a crucial mediator of treatment success. Our study aims to examine factors associated with early treatment non-compliance among patients who are initiated on office-based Buprenorphine Maintenance Treatment (BMT).

METHOD

This is a prospective observational study conducted among 89 subjects who were initiated on BMT and were followed up to 6 weeks. At baseline, we evaluated subjects using: Mini International Neuropsychiatric Interview Plus, Addiction Severity Index-Lite, Multi-Dimensional Scale of Perceived Social Support, Heroin Craving Questionnaire, and urine toxicological analysis. Treatment adherence for six weeks was noted.

RESULTS

Among Eighty-nine subjects, 57 per cent of the sample reported addiction to pharmaceutical opioids. The mean dose of Buprenorphine was 6.7 mg (SD = 4.1). During follow up 67 per cent (n = 62) patients were adherent to treatment while 33 per cent (n = 27) non-adherent to treatment. The mean dose of buprenorphine in the non-adherent group was significantly lower than the adherent group (4.3 mg and 7.7 mg, respectively, t [87] = 3.8, p < 0.001). A comparison of groups based on the dose of Buprenorphine (6 mg or higher vs lower than 6 mg) revealed that odds of treatment non-adherence were three times higher in patients receiving 6 mg or lesser dose (Odds Ratio = 3.15 [95% CI = 2.0-8.6],χ² [1] = 4.75, p = 0.035).

CONCLUSION

Dose of Buprenorphine prescribed by the treating clinician influences early treatment compliance significantly.

Effect of Integrating Substance Use Disorder Treatment into Primary Care on Inpatient and Emergency Department Utilization

BACKGROUND

Components of substance use disorder (SUD) treatment have been shown to reduce inpatient and emergency department (ED) utilization. However, integrated treatment using pharmacotherapy and recovery coaches in primary care has not been studied.

OBJECTIVE

To determine whether integrated addiction treatment in primary care reduces inpatient and ED utilization and improves outpatient engagement.

DESIGN

A retrospective cohort study comparing patients in practices with and without integrated addiction treatment including pharmacotherapy and recovery coaching during a staggered roll-out period.

PARTICIPANTS

A propensity score matched sample of 2706 adult primary care patients (1353 matched pairs from intervention and control practices) with a SUD diagnosis code, excluding cannabis or tobacco only, matched on baseline utilization.

INTERVENTION

A multi-modal strategy that included forming interdisciplinary teams of local champions, access to addiction pharmacotherapy, counseling, and recovery coaching. Control practices could refer patients to an addiction treatment clinic offering pharmacotherapy and behavioral interventions.

MAIN MEASURES

The number of inpatient admissions, hospital bed days, ED visits, and primary care visits.

KEY RESULTS

During the follow-up period, there were fewer inpatient days among the intervention group (997 vs. 1096 days with a mean difference of 7.3 days per 100 patients, p = 0.03). The mean number of ED visits was lower for the intervention group (36.2 visits vs. 42.9 per 100 patients, p = 0.005). There was no difference in the mean number of hospitalizations. The mean number of primary care visits was higher for the intervention group (317 visits vs. 270 visits per 100 patients, p < 0.001). Intervention practices had a greater increase in buprenorphine and naltrexone prescribing.

CONCLUSIONS

In a non-randomized retrospective cohort study, integrated addiction pharmacotherapy and recovery coaching in primary care resulted in fewer hospital days and ED visits for patients with SUD compared to similarly matched patients receiving care in practices without these services.

A comparison of adherence, outcomes, and costs among opioid use disorder Medicaid patients treated with buprenorphine and methadone: A view from the payer perspective

Medication-assisted treatment (MAT) with methadone or buprenorphine has been shown to be more effective at reducing the use of illicit opioids, the risk of drug-related overdose, and overall healthcare costs, on average, compared to abstinence-based addiction treatments for individuals with an opioid use disorder (OUD). Individuals who are adherent to MAT are more likely to experience positive outcomes. We used physical and behavioral Medicaid claims data of individuals newly treated with methadone (n = 212) and buprenorphine (n = 972) to examine the overall predictors of adherence, differences in adherence to each medication, the relationship between adherence and ED nonfatal drug-related overdose, and differences in total cost of care between the two medications. We found that older individuals and women had significantly lower risk of non-adherence. At six months, only 3.6% of individuals who were adherent to either treatment experienced a nonfatal drug-related overdose in the ED, compared to 13.2% of individuals who were non-adherent. We found no significant difference between methadone and buprenorphine on nonfatal drug-related overdose. Non-adherence to methadone was associated with a significant increase in total cost of care. Implications for how these results could be used to improve the overall impact of MAT are discussed.

Technological Interventions for Medication Adherence in Adult Mental Health and Substance Use Disorders: A Systematic Review

BACKGROUND

Medication adherence is critical to the effectiveness of psychopharmacologic therapy. Psychiatric disorders present special adherence considerations, notably an altered capacity for decision making and the increased street value of controlled substances. A wide range of interventions designed to improve adherence in mental health and substance use disorders have been studied; recently, many have incorporated information technology (eg, mobile phone apps, electronic pill dispensers, and telehealth). Many intervention components have been studied across different disorders. Furthermore, many interventions incorporate multiple components, making it difficult to evaluate the effect of individual components in isolation.

OBJECTIVE

The aim of this study was to conduct a systematic scoping review to develop a literature-driven, transdiagnostic taxonomic framework of technology-based medication adherence intervention and measurement components used in mental health and substance use disorders.

METHODS

This review was conducted based on a published protocol (PROSPERO: CRD42018067902) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review guidelines. We searched 7 electronic databases: MEDLINE, EMBASE, PsycINFO, the Cochrane Central Register of Controlled Trials, Web of Science, Engineering Village, and ClinicalTrials.gov from January 2000 to September 2018. Overall, 2 reviewers independently conducted title and abstract screens, full-text screens, and data extraction. We included all studies that evaluate populations or individuals with a mental health or substance use disorder and contain at least 1 technology-delivered component (eg, website, mobile phone app, biosensor, or algorithm) designed to improve medication adherence or the measurement thereof. Given the wide variety of studied interventions, populations, and outcomes, we did not conduct a risk of bias assessment or quantitative meta-analysis. We developed a taxonomic framework for intervention classification and applied it to multicomponent interventions across mental health disorders.

RESULTS

The initial search identified 21,749 results; after screening, 127 included studies remained (Cohen kappa: 0.8, 95% CI 0.72-0.87). Major intervention component categories include reminders, support messages, social support engagement, care team contact capabilities, data feedback, psychoeducation, adherence-based psychotherapy, remote care delivery, secure medication storage, and contingency management. Adherence measurement components include self-reports, remote direct visualization, fully automated computer vision algorithms, biosensors, smart pill bottles, ingestible sensors, pill counts, and utilization measures. Intervention modalities include short messaging service, mobile phone apps, websites, and interactive voice response. We provide graphical representations of intervention component categories and an element-wise breakdown of multicomponent interventions.

CONCLUSIONS

Many technology-based medication adherence and monitoring interventions have been studied across psychiatric disease contexts. Interventions that are useful in one psychiatric disorder may be useful in other disorders, and further research is necessary to elucidate the specific effects of individual intervention components. Our framework is directly developed from the substance use disorder and mental health treatment literature and allows for transdiagnostic comparisons and an organized conceptual mapping of interventions.

Are the Patients Ready for the Change?: An Empirical Study to Evaluate the Impact of Change in Formulation of Buprenorphine-Naloxone on Prescription Pattern, Treatment Adherence, and Patient Satisfaction

BACKGROUND

Therapeutic adherence is one of the most important determinants of the outcome with OST. There are no published studies that have explored the impact of change in tablet formulation of buprenorphine-naloxone from one brand to another among patients receiving OST.

OBJECTIVES

The current study is aimed at evaluation of the impact of change in buprenorphine-naloxone formulation on prescription pattern, treatment adherence, and patient satisfaction with OST.

METHODS

Our study was a cross sectional study based on a cohort of patients who were receiving OST at the study setting. Changes in prescription pattern, reports of subjective opioid withdrawal symptoms, or observation of objective opioid withdrawal symptoms were noted from the case records. The satisfaction and concerns of the patients with buprenorphine-naloxone formulations were assessed using a semi-structured proforma.

RESULTS

An increase in dose of buprenorphine-naloxone was noted in 22 participants, since formulation change. Twenty participants reported that the color of the formulation was different from the previous one, the intensity of effect was reported to be different by 87% participants. Seventy-three percent participants endorsed that increase in dose can be a possible solution to address the perceived differences in the effects of two formulations. Changes in physical attributes of the formulation, perception among treatment seeking peers regarding such changes in treatment, and lack of sense of autonomy regarding one's treatment play a more important role in determining response of the patients to changes in formulation of buprenorphine-naloxone.

The Economic Burden of Abuse of Prescription Opioids: A Systematic Literature Review from 2012 to 2017

BACKGROUND

Abuse of prescription opioids [opioid use disorder (OUD), poisoning, and fatal and non-fatal overdose] is a public health and economic challenge that is associated with considerable morbidity and mortality in the USA and globally.

OBJECTIVE

To systematically review and summarize the health economics literature published over the last 5 years that describes the economic burden of abuse of prescription opioids.

METHODS

Findings from searches of databases including MEDLINE, Embase, and Cochrane CENTRAL as well as hand searches of multiple conference abstracts were screened against predefined inclusion criteria to identify studies reporting cost and healthcare resource utilization (HRU) data associated with abuse of prescription opioids.

RESULTS

A total of 49 unique studies were identified. Most of the studies examined direct costs and HRU, which were substantially higher for abusers of prescription opioids than non-abuser controls in several matched cohort analyses (US$20,343-US$28,718 vs US$9716-US$14,079 for mean direct combined annual healthcare costs reported in 6 studies). Although only a small number of studies reported indirect costs, these findings suggest a high societal burden related to productivity losses, absenteeism, morbidity, and mortality among those who abuse opioids. Studies of medication-assisted treatment demonstrated that factors such as adherence, dose, formulation (film or tablet), and relapse during treatment, were associated with direct costs and HRU among treated patients.

CONCLUSIONS

This systematic literature review shows that abuse of prescription opioids is characterized by substantial direct healthcare costs, medical utilization, and related societal costs. Future research should further investigate the indirect costs of opioid abuse.

The Economic Burden of Abuse of Prescription Opioids: A Systematic Literature Review from 2012 to 2017

BACKGROUND

Abuse of prescription opioids [opioid use disorder (OUD), poisoning, and fatal and non-fatal overdose] is a public health and economic challenge that is associated with considerable morbidity and mortality in the USA and globally.

OBJECTIVE

To systematically review and summarize the health economics literature published over the last 5 years that describes the economic burden of abuse of prescription opioids.

METHODS

Findings from searches of databases including MEDLINE, Embase, and Cochrane CENTRAL as well as hand searches of multiple conference abstracts were screened against predefined inclusion criteria to identify studies reporting cost and healthcare resource utilization (HRU) data associated with abuse of prescription opioids.

RESULTS

A total of 49 unique studies were identified. Most of the studies examined direct costs and HRU, which were substantially higher for abusers of prescription opioids than non-abuser controls in several matched cohort analyses (US$20,343-US$28,718 vs US$9716-US$14,079 for mean direct combined annual healthcare costs reported in 6 studies). Although only a small number of studies reported indirect costs, these findings suggest a high societal burden related to productivity losses, absenteeism, morbidity, and mortality among those who abuse opioids. Studies of medication-assisted treatment demonstrated that factors such as adherence, dose, formulation (film or tablet), and relapse during treatment, were associated with direct costs and HRU among treated patients.

CONCLUSIONS

This systematic literature review shows that abuse of prescription opioids is characterized by substantial direct healthcare costs, medical utilization, and related societal costs. Future research should further investigate the indirect costs of opioid abuse.

MySafeRx: a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing for enhancing buprenorphine/naloxone adherence during opioid use disorder treatment: a pilot study

Background

While buprenorphine/naloxone (B/N) is approved for opioid use disorder treatment, effective delivery of B/N comes with significant challenges. Most notably, many patients do not take medication daily as prescribed; this non-adherence worsens treatment outcomes, increases healthcare costs, and leads to persistent worries of diversion among providers and policymakers. The present study examines the feasibility, usability, and acceptability of MySafeRx—a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing designed to address the challenges of office-based opioid treatment (OBOT) with B/N.

Methods

The MySafeRx platform integrates electronic pill dispensers, text-messaging, and videoconferencing to provide supervised self-administration of medication and daily motivational coaching through an Android app interface. High-risk early adults (18–39 years old) who were enrolled in OBOT with B/N and had documented illicit opioid use in the past month during opioid agonist therapy (n = 12) participated in a 28-day single-arm observational study of the MySafeRx platform in addition to standard care.

Results

Two-thirds of participants who completed the study achieved an average of > 5 days per week of supervised B/N self-administration. Visual confirmation of medication adherence was demonstrated for an average of 72% of study days among all participants. All participants achieved platform technical proficiency within 60 min, reporting good levels of usability and acceptability. Illicit opioid abstinence rates confirmed by urine toxicology increased by 53% during MySafeRx but fell 43% within 3 weeks post-intervention.

Conclusion

The MySafeRx medication adherence and remote coaching mobile platform is acceptable and can be feasibly implemented in real-world opioid use disorder treatment settings during high-risk periods (i.e., initial stabilization, after illicit opioid lapse), resulting in reduced illicit opioid use; however, the effect did not last after intervention completion, suggesting longer duration or extended taper of program may be needed.

ClinicalTrials.Gov NCT02942199 10/24/16 https://clinicaltrials.gov/ct2/show/NCT02942199

Electronic supplementary material

The online version of this article (10.1186/s13722-018-0122-4) contains supplementary material, which is available to authorized users.

Relationship between buprenorphine adherence and relapse, health care utilization and costs in privately and publicly insured patients with opioid use disorder

Background

Treatment for opioid use disorder is important because of the negative health, societal and economic consequences of illicit opioid use, but treatment adherence can be a challenge. This study assessed the association between buprenorphine medication-assisted treatment (MAT) adherence and relapse, health care utilization and costs.

Patients and methods

Patients with opioid use disorder who were newly initiating a buprenorphine MAT regimen were identified in the 2008-2014 MarketScan^® Commercial and Medicaid Databases and followed for 12 months after their earliest outpatient pharmacy claim for buprenorphine. Adherence was categorized using proportion of days covered (PDC) with buprenorphine, and patients with PDC≥0.80 were classified as adherent. Descriptive and adjusted analyses compared relapse prevalence, utilization and costs, all measured in the 12 months following buprenorphine MAT initiation, of adherent patients to patients in non-adherent PDC categories (PDC<0.20, 0.20≤PDC<0.40, 0.40≤PDC<0.60, 0.60≤PDC<0.80).

Results

Adherent patients were 37.1% of the Commercial sample (N=16,085) and 41.3% of the Medicaid sample (N=5,688). In both samples, non-adherent patients were significantly more likely than adherent patients to relapse and to have hospitalizations and emergency department visits. As a result, as buprenorphine MAT adherence increased, pharmacy costs increased, but medical costs decreased. Total costs (pharmacy plus medical costs) in the 12 months following buprenorphine MAT initiation decreased with adherence in Commercial patients ($28,525 for PDC<0.20 to $17,844 for PDC≥0.80). A slight decrease in total costs in the 12 months following buprenorphine MAT initiation was also observed in Medicaid patients ($21,292 for PDC<0.20 to $18,621 for PDC≥0.80). After adjustment, total costs of adherent patients in the Commercial sample ($17,519) were significantly lower compared with those of non-adherent patients (range $20,294-$24,431). In the Medicaid sample, adjusted total costs were not significantly different between adherence groups.

Conclusion

Buprenorphine MAT adherence in the 12 months following treatment was associated with reduced odds of relapse and reduced unadjusted medical costs. For Commercial patients who were adherent to treatment, the adjusted total costs were predicted to be 30% lower than those for patients with PDC<0.20.

Pharmacokinetic and pharmaceutical properties of a novel buprenorphine/naloxone sublingual tablet for opioid substitution therapy versus conventional buprenorphine/naloxone sublingual tablet in healthy volunteers

PURPOSE

A novel sublingual buprenorphine/naloxone rapidly-dissolving tablet (BNX-RDT) for opioid substitution therapy has been developed for improved bioavailability, rapid disintegration and improved taste masking. We compared the bioavailability and pharmaceutical properties of BNX-RDT with conventional buprenorphine/naloxone sublingual tablets (BNX).

METHODS

Fasting, open-label, randomized, single-dose, two-cohort crossover study in healthy volunteers under naltrexone block. Cohort 1 (high-dose, N = 64) received BNX-RDT 11.4/2.9 mg and BNX 16/4 mg. Cohort 2 (low-dose, N = 61) received BNX-RDT 2.9/0.71 mg and BNX 4/1 mg. Plasma samples were collected over 72 h. Relative systemic exposures of buprenorphine and naloxone were assessed using standard statistical models for bioequivalence analysis. Pharmaceutical assessments included dissolve time, taste and mouthfeel assessments, and overall preference.

RESULTS

BNX-RDT 11.4/2.9 mg provided equivalent buprenorphine and naloxone exposure to BNX 16/4 mg. BNX-RDT 2.9/0.71 mg provided ~20% lower buprenorphine and 35% lower naloxone exposure compared with BNX 4/1 mg. The comparison of BNX-RDT 2.9/0.71 mg with BNX 4/1 mg did not fully meet equivalence criteria. BNX-RDT was associated with improved dose proportionality across strengths compared with BNX (post hoc analysis), resulting in lower exposure from BNX-RDT relative to BNX at the lower strength. Median perceived dissolve times were significantly shorter for BNX-RDT than BNX at high (8.5 versus 16.2 min) and low (7.6 versus 9.1 min) doses. Taste and mouthfeel were rated significantly more pleasant than BNX, with ~78% of subjects preferring BNX-RDT.

CONCLUSION

BNX-RDT provided improved buprenorphine absorption compared to a conventional sublingual tablet, with shorter dissolve times and improved taste and mouthfeel, resulting in a high preference for the novel formulation.

Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data

Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.