Opioid use disorder Cascade of care framework design: A roadmap

Medications for Alcohol Use Disorder: Rates and Predictors of Prescription Order and Fill in Outpatient Settings

BACKGROUND

Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it.

OBJECTIVES

To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings.

DESIGN

In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill.

PATIENTS

We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR.

KEY MEASURES

We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order.

KEY RESULTS

5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]).

CONCLUSIONS

The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.

Expert Panel Consensus on the Effectiveness and Implementation of Models to Support Posthospitalization Care Transitions for People With Substance Use Disorders

OBJECTIVES

Hospitals are increasingly offering treatment for substance use disorders (SUDs) during medical admissions. However, there is a lack of consensus on the best approach to facilitating a successful transition to long-term medical and SUD care after hospitalization. We aimed to establish a hierarchy of existing SUD care transition models in 2 categories-effectiveness and implementation-using an expert consensus approach.

METHODS

We conducted a modified online Delphi study that convened 25 interdisciplinary clinicians with experience facilitating posthospitalization care transitions for patients with SUD. Panelists rated 10 prespecified posthospitalization care transition models according to 6 criteria concerning each model's anticipated effectiveness (eg, linkage to care, treatment retention) and implementation (eg, feasibility, acceptability). Ratings were made on a 9-point bidirectional scale. Group consensus was determined using the interpercentile range adjusted for symmetry.

RESULTS

After 3 rounds of the Delphi process (96% retention across all 3 rounds), consensus was reached on all 60 rating criteria. Interdisciplinary addiction consult teams (ACTs) and in-reach from partnering outpatient clinics were rated highest for effectiveness. Interdisciplinary ACTs and bridge clinics were rated highest for implementation. Screening, brief intervention, and referral to treatment; protocol implementation; and postdischarge outreach received the lowest ratings overall. Feasibility of implementation was perceived as the largest challenge for all highly rated models.

CONCLUSIONS

An expert consensus approach including diverse clinician stakeholders found that interdisciplinary ACT, in-reach from partnering outpatient clinics, and bridge clinics had the greatest potential to enhance posthospitalization care transitions for patients with SUD when considering both perceived effectiveness and implementation.

Buprenorphine treatment and clinical outcomes under the opioid use disorder cascade of care

BACKGROUND

Challenges to engagement and retention on buprenorphine undermine treatment of individuals with opioid use disorder (OUD). Under the OUD Cascade of Care framework, we sought to identify patient characteristics and treatment response associated with superior clinical outcomes.

METHODS

A retrospective cohort study of specialty buprenorphine treatment patients entering treatment (n=19,487) based on EHR records from a large multi-state buprenorphine treatment network (2011-2019). Person-level care episodes were evaluated across treatment intake, engagement (i.e. 2+ visits in the month following intake), and retention at 6, 12, and 24 months. Time to achieving 90 days of continuous opioid abstinence was assessed using Cox proportional hazards regressions models and also assessed as a predictor of long-term retention.

RESULTS

Most patients engaged (82.4 %), but retention steadily declined over 6-month (38.7 %), 12-month (26.2 %), and 24-month (17.1 %) timepoints. Opioid-positive baseline tests were associated with lower hazards of achieving continuous abstinence for both buprenorphine-positive (aHR=0.33, p<.001) and buprenorphine-negative (aHR=0.49,p<.001) intakes. Opioid abstinence was associated with buprenorphine-positive baseline testing (aHR=1.59,p<.001), especially for those testing opioid-negative (aHR=1.82,p<.001). Patients who achieved and sustained abstinence at 6 months in care were 4.1 and 5.5 times as likely to achieve 12-month and 24-month retention, respectively, compared to patients with intermittent opioid use.

CONCLUSION

Treatment discontinuation was concentrated early in care and buprenorphine and opioid status at intake were prognostic of achieving and sustaining abstinence. Early abstinence was associated with higher likelihood of subsequent stage progression. Implementing interventions to support early clinical stability for high-risk patients is critical to improve clinical outcomes.

Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement: A Randomized Clinical Trial

Importance

Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment.

Objective

To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement.

Design, Setting, and Participants

This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization.

Interventions

Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor.

Main Outcomes and Measures

The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation.

Results

Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18).

Conclusions

This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment.

Trial Registration

ClinicalTrials.gov Identifier: NCT03611335.

Model-driven decision support: A community-based meta-implementation strategy to predict population impact

PURPOSE

Standard tools for public health decision making such as data dashboards, trial repositories, and intervention briefs may be necessary but insufficient for guiding community leaders in optimizing local public health strategy. Predictive modeling decision support tools may be the missing link that allows community level decision makers to confidently direct funding and other resources to interventions and implementation strategies that will improve upon the status quo.

METHODS

We describe a community-based model-driven decision support (MDDS) approach that requires community engagement, local data, and predictive modeling tools (agent-based modeling in our case studies) to improve decision-making on implementing strategies to address complex public health problems such as overdose deaths. We refer to our approach as a meta-implementation strategy as it provides guidance to a community on what intervention combinations and their required implementation strategies are needed to achieve desired outcomes. We use standard implementation measures including the Stages of Implementation Completion to assess adoption of this meta-implementation approach.

RESULTS

Using two case studies, we illustrate how MDDS can be used to support decision making related to HIV prevention and reductions in overdose deaths at the city and county level. Even when community acceptance seems high, data acquisition and diffuse responsibility for implementing specific strategies recommended by modeling are barriers to adoption.

CONCLUSIONS

MDDS has the capacity to improve community decision makers use of scientific knowledge by providing projections of the impact of intervention strategies under various scenarios. Further research is necessary to assess its effectiveness and the best strategies to implement it.

Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties

BACKGROUND

The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties.

METHODS

Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios.

RESULTS

Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county.

CONCLUSIONS

Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.

Opioid-induced hypogonadism in opioid use disorder, its role in negative reinforcement, and implications for treatment and retention

Hypogonadism is a highly prevalent complication of chronic opioid use associated with a constellation of affective, algesic, and cognitive symptoms as well as decreased quality of life. Given that the mainstays of pharmacologic opioid use disorder (OUD) treatment - methadone and buprenorphine - are themselves agonists or partial agonists at the mu opioid receptor, opioid-induced hypogonadism (OIH) remains an underappreciated clinical concern throughout the course of OUD treatment. Prominent theoretical frameworks for OUD emphasize the importance of negative reinforcement and hyperkatifeia, defined as the heightened salience of negative emotional and motivational states brought on by chronic opioid use. In this perspective article, we highlight the striking parallels between the symptom domains of hyperfakifeia and hypogonadism in males, who comprise the vast majority of existing clinical research on OIH. By extension we propose that future research and ultimately clinical care should focus on the identification and treatment of OIH in OUD patients to help address the longstanding paradox of poor treatment retention despite efficacious therapies, particularly in the setting of the current opioid overdose epidemic driven by high potency synthetic opioids such as fentanyl. We then review evidence from chronic pain patients that testosterone replacement provides clinically significant benefits to men with OIH. Finally, using this framework, we compare extant OUD therapeutics and discuss critical gaps in the clinical literature-including the relative dearth of data regarding hypothalamic-pituitary-gonadal function in females who use opioids-where future study should be focused.

Application of an opioid use disorder cascade of care in a large public health system

Background: Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time and can assist health systems in identifying areas of intervention to maximize the impact of evidence-based services. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using electronic health records.Objective: In this paper, we describe the process of operationalizing and applying the OUD Cascade in a large, urban, public hospital system.Methods: Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, lessons learned from compiling preliminary patient data and defining stages and outcome measures for the OUD Cascade of Care, and preliminary dataResults: We identified 33,616 (26.17% female) individuals with an OUD diagnosis. Almost half (48%) engaged with addiction services, while only 10.7% initiated medication-based treatment in an outpatient setting, 6.7% had timely follow-up, and 3.5% were retained for a minimum of 6 months.Conclusion: The current paper serves as a primer for other health systems seeking to implement data-informed approaches to guide more efficient care and improved substance use-related outcomes. An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design with an emphasis on early stages wherein drop-off is the greatest.

Racial and ethnic inequities in substance use treatment among women with opioid use disorder

Background: Research describes inequities in substance use treatment, but few studies focus specifically on racial and ethnic disparities in a range of aspects of substance use treatment among women with opioid use disorder (OUD).Objective: To examine whether substance use treatment (i.e. receipt, sources, barriers) differs by race and ethnicity among women with opioid use disorder (OUD) and to identify factors associated with treatment gap (i.e. needing treatment but not receiving it).Methods: We performed cross-sectional analyses using National Survey on Drug Use and Health 2015-2019 data, restricted to non-Hispanic Black, non-Hispanic White, and Hispanic women with past-year OUD (unweighted n = 1089). We estimated the prevalence of aspects of treatment among racial and ethnic groups, and used modified Poisson regression to estimate correlates of reported treatment gap.Results: Approximately 68% of White versus 87% of Black and 81% of Hispanic women with OUD had a treatment gap (p-value 0.0034). Commonly reported barriers to treatment included prioritization, affordability, and stigma. Older age was associated with lower prevalence of treatment gap among all women [prevalence ratio (PR) = 0.83, and 95% confidence interval (CI): 0.76, 0.92], while criminal legal involvement and healthcare coverage was associated with a lower prevalence of treatment gap among Hispanic and White women only (past year arrest: Hispanic women PR = 0.38, 95% CI: 0.17, 0.86; White women PR = 0.62, 95% CI: 0.47, 0.82).Conclusions: Receipt of treatment is low among women with OUD, especially Black and Hispanic women. Intersectional intervention approaches are needed to increase access and reduce inequities.

Strategies to support substance use disorder care transitions from acute-care to community-based settings: a scoping review and typology

BACKGROUND

Acute-care interventions that identify patients with substance use disorders (SUDs), initiate treatment, and link patients to community-based services, have proliferated in recent years. Yet, much is unknown about the specific strategies being used to support continuity of care from emergency department (ED) or inpatient hospital settings to community-based SUD treatment. In this scoping review, we synthesize the existing literature on patient transition interventions, and form an initial typology of reported strategies.

METHODS

We searched Pubmed, Embase, CINAHL and PsychINFO for peer-reviewed articles published between 2000 and 2021 that studied interventions linking patients with SUD from ED or inpatient hospital settings to community-based SUD services. Eligible articles measured at least one post-discharge treatment outcome and included a description of the strategy used to promote linkage to community care. Detailed information was extracted on the components of the transition strategies and a thematic coding process was used to categorize strategies into a typology based on shared characteristics. Facilitators and barriers to transitions of care were synthesized using the Consolidated Framework for Implementation Research.

RESULTS

Forty-five articles met inclusion criteria. 62% included ED interventions and 44% inpatient interventions. The majority focused on patients with opioid (71%) or alcohol (31%) use disorder. The transition strategies reported across studies were heterogeneous and often not well described. An initial typology of ten transition strategies, including five pre- and five post-discharge transition strategies is proposed. The most common strategy was scheduling an appointment with a community-based treatment provider prior to discharge. A range of facilitators and barriers were described, which can inform efforts to improve hospital-to-community transitions of care.

CONCLUSIONS

Strategies to support transitions from acute-care to community-based SUD services, although critical for ensuring continuity of care, vary greatly across interventions and are inconsistently measured and described. More research is needed to classify SUD care transition strategies, understand their components, and explore which lead to the best patient outcomes.

Application of an Opioid Use Disorder Cascade of Care in a Large Public Health System

Background

Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time, and can assist health systems in identifying areas of intervention to prevent overdose and maximize the impact of evidence-based services for patients with OUD. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using their systems' electronic medical records (EMR).

Objective

In this paper, we describe the process of operationalizing and implementing the OUD Cascade in one large, urban, public hospital system.

Methods

Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, and lessons learned from compiling patient data and defining stages and outcome measures for the OUD Cascade of Care. The current established framework and process will set the stage for subsequent research studies that quantify and evaluate patient progression through each stage of OUD treatment across the health system and identify target areas for quality improvement initiatives to better engage patients in care and improve health outcomes.

Results

The current paper can therefore serve as a primer for other health systems seeking to implement a data-informed approach to guide more efficient care and improved substance use-related outcomes.

Conclusion

An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design.

Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use

BACKGROUND

We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine.

METHODS

We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use.

RESULTS

The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use.

CONCLUSIONS

PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.

Commentary on Burns et al: MOUD saves lives, especially after 60 days, and the longer the better

Scaling interventions and treatment services to reduce mortality stemming from OUD is critical for turning back the opioid epidemic, yet empiric data are lacking regarding how risk changes over the course of care. Burns et al show substantial reductions in hazards of overdose accrue after 60 continuous days on medication.

Applications of technology in the assessment and treatment of cannabis use disorder

Cannabis use and Cannabis Use Disorder (CUD) have been increasing. There are no FDA approved medications and evidence-based psychotherapy is limited by insufficient providers, serving very few patients effectively. The lack of resources for prevention and treatment of CUD has resulted in a significant gap between the need for services and access to treatment. The creation of a scalable system to prevent, screen, refer and provide treatment for a chronic, relapsing diagnosis like CUD could be achieved through the application of technology. Many studies have utilized ecological momentary assessments (EMA) in treatment seeking and non-treatment seeking cannabis users. EMA allows for repeated, intensive, longitudinal data collection in vivo. EMA has been studied in cannabis use and its association with affect, craving, withdrawal, other substances, impulsivity, and interpersonal behaviors. EMA has the potential to serve as a valuable monitoring tool in prevention, screening, and treatment for CUD. Research has also focused on the development of internet and application-based treatments for CUD, including a currently available prescription digital therapeutic. Treatment options have expanded to more broadly incorporate telehealth as an option for CUD treatment with broad acceptance and change in regulation following the COVID-19 pandemic. While technology has limitations, including cost, privacy concerns, and issues with engagement, it will be a necessary medium to meet societal health needs as a consequence of an ever-changing cannabis regulatory landscape. Future work should focus on improving existing platforms while ethically incorporating other functions (e.g., sensors) to optimize a public and clinical health approach to CUD.