Physicians' Decision-making When Implementing Buprenorphine With New Patients: Conjoint Analyses of Data From a Cohort of Current Prescribers

Impact of an intervention to implement provision of opioid use disorder medication among patients with and without co-occurring substance use disorders

INTRODUCTION

Co-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs.

METHODS

This study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018-8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs.

RESULTS

Among patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02-1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02-1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs.

CONCLUSIONS

The SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts.

Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India

OBJECTIVE

Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups.

METHODS

We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status.

RESULTS

Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome.

CONCLUSION

Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.

Prevalence of Buprenorphine Providers Requiring Cash Payment From Insured Women Seeking Opioid Use Disorder Treatment

CONTEXT

Medications for opioid use disorder (OUD) are known to be effective, especially in reducing the risk of overdose death. Yet, many individuals suffering from OUD are not receiving treatment. One potential barrier can be the patient's ability to access providers through their insurance plans.

DATA AND METHODS

We used an audit (simulated patient) study methodology to examine appointment-granting behavior by buprenorphine prescribers in 10 different US states. Trained callers posed as women with OUD and were randomly assigned Medicaid or private insurance status. Callers request an OUD treatment appointment and then asked whether they would be able to use their insurance to cover the cost of care, or alternatively, whether they would be required to pay fully out-of-pocket.

FINDINGS

We found that Medicaid and privately insured women were often asked to pay cash for OUD treatment--40% of the time over the full study sample. Such buprenorphine provider requests happened more than 60% of the time in some states. Areas with more providers or with more generous provider payments were not obviously more willing to accept the patient's insurance benefits for OUD treatment. Rural providers were less likely to require payment in cash in order for the woman to receive care.

CONCLUSIONS

State-to-state variation was the most striking pattern in our field experiment data. The wide variation suggests that women of reproductive age with OUD in certain states face even greater challenges to treatment access than perhaps previously thought; however, it also reveals that some states have found ways to curtail this problem. Our findings encourage greater attention to this public health challenge and possibly opportunities for shared learning across states.

Treating opioid use disorder in veterans with co-occurring substance use: a qualitative study with buprenorphine providers in primary care, mental health, and pain settings

BACKGROUND

Most people with opioid use disorder (OUD) have co-occurring substance use, which is associated with lower receipt of OUD medications (MOUD). Expanding MOUD provision and care linkage outside of substance use disorder (SUD) specialty settings is a key strategy to increase access. Therefore, it is important to understand how MOUD providers in these settings approach care for patients with co-occurring substance use. This qualitative study of Veterans Health Administration (VA) clinicians providing buprenorphine care in primary care, mental health, and pain settings aimed to understand (1) their approach to addressing OUD in patients with co-occurring substance use, (2) perspectives on barriers/facilitators to MOUD receipt for this population, and (3) support needed to increase MOUD receipt for this population.

METHODS

We interviewed a purposive sample of 27 clinicians (12 primary care, 7 mental health, 4 pain, 4 pharmacists) in the VA northwest network. The interview guide assessed domains of the Tailored Implementation for Chronic Diseases Checklist. Interviews were transcribed and qualitatively analyzed using inductive content analysis.

RESULTS

Participants reported varied approaches to identifying co-occurring substance use and addressing OUD in this patient population. Although they reported that this topic was not clearly addressed in clinical guidelines or training, participants generally felt that patients with co-occurring substance use should receive MOUD. Some viewed their primary role as providing this care, others as facilitating linkage to OUD care in SUD specialty settings. Participants reported multiple barriers and facilitators to providing buprenorphine care to patients with co-occurring substance use and linking them to SUD specialty care, including provider, patient, organizational, and external factors.

CONCLUSIONS

Efforts are needed to support clinicians outside of SUD specialty settings in providing buprenorphine care to patients with co-occurring substance use. These could include clearer guidelines and policies, more specific training, and increased care integration or cross-disciplinary collaboration. Simultaneously, efforts are needed to improve linkage to specialty SUD care for patients who would benefit from and are willing to receive this care, which could include increased service availability and improved referral/hand-off processes. These efforts may increase MOUD receipt and improve OUD care quality for patients with co-occurring substance use.

Associations Between Distinct Co-occurring Substance Use Disorders and Receipt of Medications for Opioid Use Disorder in the Veterans Health Administration

OBJECTIVES

Among people with opioid use disorder (OUD), having a co-occurring substance use disorder (SUD) is associated with lower likelihood of receiving OUD treatment medications (MOUD). However, it is unclear how distinct co-occurring SUDs are associated with MOUD receipt. This study examined associations of distinct co-occurring SUDs with initiation and continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA).

METHODS

Electronic health record data were extracted for outpatients with OUD who received care August 1, 2016, to July 31, 2017. Analyses were conducted separately among patients without and with prior-year MOUD receipt to examine initiation and continuation, respectively. SUDs were measured using diagnostic codes; MOUD receipt was measured using prescription fills/clinic visits. Adjusted regression models estimated likelihood of following-year MOUD receipt for patients with each co-occurring SUD relative to those without.

RESULTS

Among 23,990 patients without prior-year MOUD receipt, 12% initiated in the following year. Alcohol use disorder (adjusted incidence rate ratio [aIRR], 0.80; 95% confidence interval [CI], 0.72-0.90) and cannabis use disorder (aIRR, 0.78; 95% CI, 0.70-0.87) were negatively associated with initiation. Among 11,854 patients with prior-year MOUD receipt, 83% continued in the following year. Alcohol use disorder (aIRR, 0.94; 95% CI, 0.91-0.97), amphetamine/other stimulant use disorder (aIRR, 0.94; 95% CI, 0.90-0.99), and cannabis use disorder (aIRR, 0.95; 95% CI, 0.93-0.98) were negatively associated with continuation.

CONCLUSIONS

In this study of national VA outpatients with OUD, those with certain co-occurring SUDs were less likely to initiate or continue MOUD. Further research is needed to identify barriers related to specific co-occurring SUDs.

Factors associated with clinician treatment recommendations for patients with a new diagnosis of opioid use disorder

BACKGROUND

This study examined factors associated with treatment recommendations for patients with a new diagnosis of opioid use disorder (OUD), comparing recommendations for patients with clear signs of OUD versus those with lower likelihood of OUD.

METHODS

The study conducted a retrospective medical chart review in a randomly selected national sample of 520 Veteran Health Administration patients with a new opioid-related electronic health record (EHR) diagnosis from 2012 to 2017. The study categorized patients as having "high likelihood" or "lower likelihood of OUD" based on the presence or absence of clinician documentation in medical records of specific qualifying criteria (e.g., clinician documentation of patient meeting diagnostic criteria for OUD, etc). Analyses examined the association between baseline demographic and clinical characteristics with recommendations for medication and other treatments for OUD.

RESULTS

Among patients with a new diagnosis of OUD, 28.7 % (n = 149) were recommended medication treatment, 52.5 % (n = 273) were recommended specialty substance use disorder (SUD) treatment, and 41.9 % (n = 218) were recommended treatment in non-SUD mental health settings. In adjusted models, high likelihood of OUD (AOR 8.31, 95 % CI 4.81-15.03) was strongly associated with the clinician recommending medications for OUD, while age 56-75 (compared to <35, AOR 0.36, 95 % CI 0.18-0.69), stimulant use disorder (AOR 0.28, 95 % CI 0.15-0.53), and rural residence (AOR 0.51, 95 % CI 0.30-0.85) were associated with lower likelihood of being recommended medication treatment.

CONCLUSIONS

Differentiating among patients with EHR diagnoses of OUD to identify the subset with higher likelihood of underlying OUD is important to accurately understand OUD treatment rates and disparities. However, even among patients with a clear diagnosis of OUD, medication treatment is still recommended less often than other treatments, suggesting interventions are needed to encourage clinicians to prioritize medication treatment as a first-line treatment, especially for older, rural patients and those with polysubstance use.

The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review

Background

Methamphetamine/amphetamine use has sharply increased among people with opioid use disorder (OUD). It is therefore important to understand whether and how use of these substances may impact receipt of, and outcomes associated with, medications for OUD (MOUD). This systematic review identified studies that examined associations between methamphetamine/amphetamine use or use disorder and 3 classes of outcomes: (1) receipt of MOUD, (2) retention in MOUD, and (3) opioid abstinence during MOUD.

Methods

We searched 3 databases (PubMed/MEDLINE, PsycINFO, CINAHL Complete) from 1/1/2000 to 7/28/2020 using key words and subject headings, and hand-searched reference lists of included articles. English-language studies of people with documented OUD/opioid use that reported a quantitative association between methamphetamine/amphetamine use or use disorder and an outcome of interest were included. Study data were extracted using a standardized template, and risk of bias was assessed for each study. Screening, inclusion, data extraction and bias assessment were conducted independently by 2 authors. Study characteristics and findings were summarized for each class of outcomes.

Results

Thirty-nine studies met inclusion criteria. Studies generally found that methamphetamine/amphetamine use or use disorder was negatively associated with receiving methadone and buprenorphine; 2 studies suggested positive associations with receiving naltrexone. Studies generally found negative associations with retention; most studies finding no association had small samples, and these studies tended to examine shorter retention timeframes and describe provision of adjunctive services to address substance use. Studies generally found negative associations with opioid abstinence during treatment among patients receiving methadone or sustained-release naltrexone implants, though observed associations may have been confounded by other polysubstance use. Most studies examining opioid abstinence during other types of MOUD treatment had small samples.

Conclusions

Overall, existing research suggests people who use methamphetamine/amphetamines may have lower receipt of MOUD, retention in MOUD, and opioid abstinence during MOUD. Future research should examine how specific policies and treatment models impact MOUD outcomes for these patients, and seek to understand the perspectives of MOUD providers and people who use both opioids and methamphetamine/amphetamines. Efforts to improve MOUD care and overdose prevention strategies are needed for this population.

Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration

AIMS

To understand the role of comorbid substance use disorders (SUDs), or polysubstance use, in the treatment of opioid use disorder (OUD), this study compared patients with OUD only to those with additional SUDs and examined association with OUD treatment receipt.

DESIGN, SETTING AND PARTICIPANTS

Retrospective national cohort study of Veterans diagnosed with OUD (n = 65 741) receiving care from the US Veterans Health Administration (VHA) in fiscal year (FY) 2017.

MEASUREMENTS

Patient characteristics were compared among those diagnosed with OUD only versus those with one other SUD (OUD + 1 SUD) and with multiple SUDs (OUD + ≥ 2 SUDs). The study examined the relationship between comorbid SUDs and receipt of buprenorphine, methadone and SUD outpatient treatment during 1-year follow-up, adjusting for patient demographic characteristics and clinical conditions.

FINDINGS

Among the 65 741 Veterans with OUD in FY 2017, 41.2% had OUD only, 22.9% had OUD + 1 SUD and 35.9% had OUD + ≥ 2 SUDs. Common comorbid SUDs included alcohol use disorder (41.3%), cocaine/stimulant use disorder (30.0%) and cannabis use disorder (22.4%). Adjusting for patient characteristics, patients with OUD + 1 SUD [adjusted odds ratio (aOR) = 0.87, 95% confidence interval (CI) = 0.82-0.93] and patients with OUD +≥ 2 SUDs (aOR = 0.65, 95% CI = 0.61-0.69) had lower odds of receiving buprenorphine compared with OUD only patients. There were also lower odds of receiving methadone for patients with OUD + 1 SUD (aOR = 0.91, 95% CI = 0.86-0.97)and for those with OUD + ≥2 SUDs (aOR = 0.79, 95% CI = 0.74-0.84). Patients with OUD + 1 SUD (aOR = 1.85, 95% CI = 1.77-1.93) and patients with OUD + ≥2 SUDs (aOR = 3.25, 95% CI = 3.103.41) were much more likely to have a SUD clinic visit.

CONCLUSIONS

The majority of Veterans in the US Veterans Health Administration diagnosed with opioid use disorder appeared to have at least one comorbid substance use disorder and many have multiple substance use disorders. Despite the higher likelihood of a substance use disorder clinic visit, having a non-opioid substance use disorder is associated with lower likelihood of buprenorphine treatment, suggesting the importance of addressing polysubstance use within efforts to expand treatment for opioid use disorder.

Program development and implementation outcomes of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS)

BACKGROUND

As the opioid epidemic continues, there is a mounting sense of urgency to improve access to high-quality early identification and treatment services. However, the need is outpacing capacity in many states and effective solutions to support primary care and specialty prescribers to identify and treat more patients with opioid use disorders are still emerging. This paper describes one state's approach to increase access to medication for opioid use disorders (MOUD) through development and implementation of a statewide addiction consultation service: Maryland Addiction Consultation Service (MACS). Methods: Program components include a warmline, outreach and training, and resource and referral linkages for prescribers based on related consultation service models and documented barriers to prescribing MOUDs. Results: Initial implementation outcomes indicate service components are being adopted as intended and by the target audience; many prescribers who engaged with the service have their buprenorphine waiver (44%) but do not have any additional formal addiction training (57%). Also, statewide penetration is promising with prescriber engagement in 100% of counites, however only 33% of counties in engaged in all four types of MACS services. Most calls (61%) originated from urban counties. Conclusions: The MACS program increases access to specialty addiction medicine consultation and training through use of technology. MACS can serve as a model for other states looking to bridge the gap in access to addiction treatment.

US physicians' decision-making during buprenorphine-naloxone treatment: Conjoint analyses of dose and office visit adjustments based on patient progress

BACKGROUND

Research on how US physicians individualize buprenorphine-naloxone treatment is limited. The current study uses conjoint analysis to examine the importance of current dose, visit frequency, clinical indicators, and payment type on office visit and dose adjustments during buprenorphine-naloxone treatment.

METHODS

A national random sample of 776 US buprenorphine-prescribing physicians participated in a mailed survey between October 2015 and July 2018. The survey contained 16 patient vignettes describing: (1) current dose, (2) urine drug test (UDT) results and opioid blockade, (3) recent intravenous use, (4) visit attendance, (5) counseling adherence, (6) payment, and (7) visit schedule. Physicians rated how they would adjust office visits (0=definitely decrease to 5=no change to 10=definitely increase) and the dose (0=definitely decrease to 5=no change to 10=definitely increase). Descriptive statistics were calculated for the vignette responses. Conjoint analysis was used to estimate relative importance scores and part-worth utilities.

RESULTS

Across the vignettes, the mean response for adjusting office visits was 7.43 (SD = 1.69), indicating a tendency to increase the frequency of visits. UDT results/opioid blockade, intravenous use, and current visit schedule had the greatest importance scores for office visit adjustments. The mean response for adjusting the dose was 5.48 (SD = 1.69), corresponding with a tendency toward not changing dose. Current dose, UDT results/opioid blockade, and intravenous use had the largest importance scores for dose adjustment.

CONCLUSIONS

Physicians individualized buprenorphine-naloxone treatment in response to hypothetical patient attributes by changing visit frequency and, to a lesser extent, modifying maintenance dose, in a manner generally consistent with current practice guidelines.

Perceived need and availability of psychosocial interventions across buprenorphine prescriber specialties

INTRODUCTION

Psychosocial interventions are often recommended as part of buprenorphine treatment for patients with opioid use disorder, but little is known about prescriber perspectives on their use and how this varies across buprenorphine prescriber specialties.

METHODS

A large US sample of physicians actively prescribing buprenorphine (n = 1174) was surveyed from July 2014 to January 2017. Analyses examined prescriber characteristics and their perceptions and use of psychosocial interventions across three groups of physicians: primary care providers (PCPs), addiction physicians/psychiatrists, and other physicians.

RESULTS

Across all prescribers, 93.3% (n = 1061) report most patients would benefit from formal counseling during buprenorphine treatment while only 36.4% (n = 414) believe there are adequate number of counselors in their communities. Among addiction physicians/psychiatrists, 75.9% (n = 416) report their treatment settings have the resources to provide psychiatric services to patients with complex psychiatric problems compared to 29.1% (n = 130) of PCPs and 29.6% (n = 39, p < .001) of other physicians. Addiction physicians/psychiatrists report a higher percentage of patients receive counseling from clinicians in their practice while PCPs report a higher percentage of patients receive counseling from external providers.

CONCLUSIONS

The majority of prescribers believe patients receiving buprenorphine would benefit from psychosocial interventions and there is variation in how these services are delivered. However, many prescribers, especially those without addiction or psychiatry backgrounds, report their settings do not have adequate psychosocial treatment resources for patients with complex psychosocial needs. Future work developing novel models of psychosocial interventions may be helpful to support prescribers to effectively treat complex patients with opioid use disorders.

Comparing Buprenorphine-Prescribing Physicians Across Nonmetropolitan and Metropolitan Areas in the United States

PURPOSE

Although there is a tremendous need to increase the use of buprenorphine for the treatment of opioid use disorder in rural areas, little is known about current rural/urban differences in treatment practices. We aimed to examine physician characteristics, treatment practices, and concordance with treatment guidelines among buprenorphine prescribers across different locations of practice.

METHODS

A national random sample of buprenorphine physician prescribers was surveyed (n = 1,174, response rate = 33%) from July 2014 to January 2017. Analyses examined buprenorphine treatment across locations of practice (categorized as nonmetropolitan, small metropolitan, and large metropolitan).

RESULTS

Among buprenorphine prescribers surveyed, 11.2% (n = 132) practiced in nonmetropolitan/rural areas, 32.5% (n = 382) in small metropolitan areas, and 56.2% (n = 660) in large metropolitan areas. Buprenorphine prescribers in nonmetropolitan areas were much more likely to be primary care physicians, accept Medicaid, and less likely to work in an individual practice. Overall, buprenorphine prescribers across the rural/urban continuum were similar in many of their treatment practices, including induction, frequency of visits, dosing, and use of psychosocial treatment, which were generally consistent with buprenorphine treatment recommendations.

CONCLUSIONS

There are important differences in characteristics of buprenorphine prescribers in nonmetropolitan areas compared with more urban areas, including the fact that the majority of nonmetropolitan physicians are primary care physicians. Although treatment access in rural areas is an ongoing challenge, buprenorphine treatment practices are similar. Understanding buprenorphine prescribers and their treatment practices may help inform tailored strategies to address treatment needs in different locations.

Understanding the use of diverted buprenorphine

BACKGROUND

Buprenorphine is approved in many countries for the treatment of opioid use disorder (OUD), but problems with diversion and abuse exist. There is a need to understand how and why patients use diverted buprenorphine, and whether barriers to access contribute to illicit use.

METHODS

Adults >18 years with DSM-IV criteria for substance use disorder and primarily using an opioid completed the online Survey of Key Informants' Patients (SKIP) between August and September 2016. The survey included closed- and open-ended questions regarding reasons for buprenorphine use with and without a prescription, sources of buprenorphine, route of administration, and barriers to treatment.

RESULTS

Of 303 respondents, 175 (58%) reported a history of diverted buprenorphine use, 65 (37%) of whom reported never receiving a prescription. The most common reasons for illicit buprenorphine use were consistent with therapeutic use: to prevent withdrawal (79%), maintain abstinence (67%), or self-wean off drugs (53%). Approximately one-half (52%) reported using buprenorphine to get high or alter mood, but few (4%) indicated that it was their drug of choice. Among respondents who had used diverted buprenorphine, 33% reported that they had issues finding a doctor or obtaining buprenorphine on their own. Most (81%) of these participants indicated they would prefer using prescribed buprenorphine, if available.

CONCLUSIONS

Although 58% of survey respondents reported a history of using diverted buprenorphine, the most frequently cited reasons for non-prescription use were consistent with therapeutic use. Diversion was partially driven by barriers to access, and an unmet need for OUD treatment persists.