Adoption and diffusion of evidence-based addiction medications in substance abuse treatment

Supporting medication-assisted recovery in recovery residences: staff support, managing built environment threats, and building a supportive network

Background: While medications for opioid use disorder (MOUD) are effective in reducing overdoses, widespread adoption and implementation of MOUD remains inadequate. Innovative approaches to promote MOUD use and to support people in their medication-assisted recovery (MAR) are needed. Recovery residences that serve people taking MOUD are steadily growing in number, yet little is known about how MOUD and the MAR pathway is promoted within the recovery residence setting.Objectives: The purpose of this qualitative analysis was to describe how recovery residences facilitate MOUD initiation and support residents' MAR pathway.Methods: We conducted interviews with 93 residents (59.1% male; 38.7% female) living in recovery residences located in five Texas cities that served people taking medication for opioid use disorder.Results: We found that recovery residence staff addressed linkage to care gaps in their communities by connecting people who might benefit from MOUD to appropriate providers. Recovery residence staff also strengthened participants' community of MAR-supportive peers by hosting or connecting residents to Medication-Assisted Recovery Anonymous meetings. Additionally, recovery residences helped some residents overcome common logistical barriers (e.g. transportation issues, housing instability, distance to providers) that hinder MOUD access.Conclusion: Recovery residences that serve people taking MOUD are a well-positioned recovery support service to promote MOUD initiation and the MAR pathway.

Intention and preference to use long-acting injectable PrEP among MSM in the Netherlands: a diffusion of innovation approach

Long-acting injectable pre-exposure prophylaxis (LAI-PrEP) is efficacious in preventing HIV among men-who-have-sex-with-men (MSM) and will be soon available in Europe. This study investigated the intention and preference to use LAI-PrEP among MSM in the Netherlands by employing a diffusion of innovation approach. This study had a cross-sectional design nested within a cohort study established in 2017 to understand oral PrEP use among MSM. 309 MSM completed the survey on their awareness, interest, intention, and preference for LAI-PrEP in June 2022. Among them, 83% showed high/very-high interest in, and 63% showed high/very-high intention to use LAI-PrEP. A repeated innovator effect from the early adopters to LAI-PrEP was not observed. Early adopters did not show increased intention to use LAI-PrEP compared to other MSM subgroups, but neither did PrEP-naïve nor PrEP-discontinued MSM. However, among the 218 current oral PrEP users, suboptimal adherence was associated with preference for LAI-PrEP but not with intention to use it. In conclusion, our findings indicated that an effective, available, and affordable LAI-PrEP would be welcomed in the Netherlands, but that its introduction may not significantly expand PrEP coverage. However, the introduction of LAI-PrEP in the Netherlands could prove beneficial to MSM with suboptimal adherence to oral PrEP.

Diffusion of medications for opioid use disorder treatment in jail settings: a convergent mixed methods study of jail staff perspectives

BACKGROUND

Implementation of medications for opioid use disorder (MOUD) in jails varies by facility and across states. Organizational climate, including staff attitudes toward change and exposure to education, can influence perceptions of innovations like MOUD in jails. Using a mixed methods design, we aimed to understand the association between organizational climate and jail staff perceptions of MOUD.

METHODS

Jail staff (n = 111) who operate MOUD programs in 6 Massachusetts jails completed surveys that included the Organizational Readiness for Implementing Change (ORIC) survey. Random effects logistic regression models assessed associations between organizational climate and several outcomes of perceived MOUD efficacy, acceptability, and knowledge, while controlling for covariates. Jail staff (N = 61) participated in qualitative interviews and focus groups focused on organizational climate and knowledge diffusion, which we analyzed using inductive and deductive methods.

RESULTS

The results indicate that organizational change readiness on the ORIC was associated with positive perceptions of MOUD, and educational resources facilitated MOUD implementation. Greater ORIC was associated with higher perception of methadone as highly acceptable for jail populations (Odds ratio [OR] 2.3, 95% Confidence Interval [CI] 1.2 to 4.4), and high knowledge of methadone (OR 2.3, 95% CI 1.1 to 4.9), with similar magnitude of effects for buprenorphine. High levels of training for jail staff on methadone and buprenorphine were also associated with higher knowledge of these medications (Methadone: OR 7.2, 95% CI 2.2 to 23.2; Buprenorphine: OR 3.4, 95% CI 1.2 to 9.5). Qualitative results point towards the importance of organizational climate and elucidate educational strategies to improve staff perceptions of MOUD.

CONCLUSION

Results underscore the importance of organizational climate for successful implementation of jail MOUD programs and provide support for medication-specific educational resources as a facilitator of successful MOUD implementation in jail settings. Findings highlight implementation strategies that may improve jail staff perceptions of MOUD.

Association between Prescribers’ Perceptions of the Utilization of Medication for Opioid Use Disorder and Opioid Dependence Treatability

Background: Medication for opioid use disorder (MOUD) has been proven to be effective, yet the perceptions or beliefs of prescribers of MOUD may have a substantial impact on their prescribing and dispensing of MOUD and their patients’ accessibility and utilization of MOUD services. We examined the associations of the perceptions of medical and pharmacy professionals regarding MOUD with sociodemographic characteristics, personal experiences with substance use disorders, and perceptions of opioid treatment. Method: Data were collected via telephone or online survey from March to August 2021, in Texas, to assess medical and pharmacy professionals’ perceptions of MOUD. Our sample included 542 participants who completed the survey. A multinomial logistic regression analysis was conducted to assess perceptions of MOUD, its use, and their correlates. Results: The participants had a mean age of 35 years (SD = 7.13) and had worked, on average, 6.90 years (SD = 5.37) in their current positions. The majority of the participants were males (50.93%) and medical professionals (82.01%). More than one third of the participants believed MOUD did not lead to abstinence or recovery (36.16%). Those who had personal experiences with a substance use disorder were more likely to believe that MOUD could be a replacement drug for previously misused substance(s) (RRR = 2.06, 95% CI = 1.19, 3.59) and that MOUD did not lead to abstinence or recovery (RRR = 2.34, 95% CI = 1.40, 3.91). However, the risk ratio values were lower for those who believed that a stigma against MOUD was a barrier for patients initiating and adhering to MOUD (MOUD is a replacement drug for previously misused substances (initiation RRR = 0.43, 95% CI = 0.19, 0.93 and adhering RRR = 0.30, 95% CI = 0.13, 0.71) or MOUD does not lead to abstinence or recovery (initiation RRR = 0.26, 95% CI = 0.13, 0.54 and adhering RRR = 0.36, 95% CI = 0.17, 0.78)). The various perceptions of the utilization of MOUD were not statistically different between medical and pharmacy professionals. Conclusion: Perceptions, experience with substance use disorder, and stigma against the utilization of MOUD influenced negative perceptions about MOUD. An innovative strategy is needed to improve medical and pharmacy professionals’ perceptions of MOUD, while efforts are being made to promote the use of MOUD for patients with opioid use disorders.

Support for COVID-19-Related Substance Use Services Policy Changes: a New York State-Wide Survey

This study aims to describe which substance use service (SUS) organizations and who within these organizations support the maintenance of policies targeted at improving substance use treatment services. An online survey assessing respondent, organizational and program demographics, and knowledge and support regarding policy changes was distributed to all certified SUS and harm reduction programs in NYS. Bivariate and latent class analyses were used to identify patterns and associations to policy choices. Across the 227 respondents, there was a support for maintaining expansion of insurance coverage, virtual behavioral health/counseling and medication initiation/maintenance visits, reductions in prior authorizations, and access to prevention/harm reduction services. Three classes of support for policies were derived: (1) high-supporters (n = 49; 21%), (2) low-supporters (n = 66; 29%), and (3) selective-supporters. Having knowledge of policy changes was associated with membership in the high-supporters class. Implications regarding the role of knowledge in behavioral health policies dissemination structures, decision-making, and long-term expansion of SUS are discussed.

First-line Medications for the Outpatient Treatment of Alcohol Use Disorder: A Systematic Review of Perceived Barriers

OBJECTIVES

Alcohol use disorder (AUD) is a common illness with significant health and economic consequences. Although three pharmacotherapeutic agents have been shown to decrease heavy drinking days among individuals with AUD, they are vastly underutilized in clinical practice. The objective of this review was to elucidate barriers that may prevent patients from obtaining medication for addiction treatment (MAT) for AUD in an outpatient or residential setting.

METHODS

Electronic searches of Medline and EMBASE were conducted, and reference lists were hand-searched. All study designs which discussed the use of MAT for AUD in an outpatient or residential setting were eligible for inclusion. Two reviewers independently screened the search output to identify potentially eligible articles, the full texts of which were retrieved and assessed for inclusion.

RESULTS

After eliminating duplicate citations and articles that did not meet eligibility criteria, 23 articles were included in the review. Perceived barriers to obtaining pharmacotherapy for the treatment of AUD in an outpatient or residential setting were grouped into 3 themes: lack of knowledge and concerns about efficacy and complexity of prescribing; treatment philosophy and stigma; medication accessibility including formulary restrictions, geographical and socioeconomic barriers.

CONCLUSIONS

Although evidence-based pharmacotherapeutics have been approved for the treatment of AUD, our findings suggest patients continue to experience barriers to the use of these medications. Efforts should be made to increase rates of prescribing by providers and the use of medications by patients. More research is needed to further elucidate perceived barriers to MAT use, along with strategies to overcome them.

Medicaid Expansion and Availability of Opioid Medications in the Specialty Substance Use Disorder Treatment System

OBJECTIVE

Research has examined the effect of Medicaid expansion on access to physicians with buprenorphine waivers, but less attention has been paid to Medicaid's impact on opioid use disorder medication availability within the specialty substance use disorder treatment system. To address this gap in the literature, this study examined the impact of Medicaid expansion on availability of opioid medications in specialty programs.

METHODS

This study used data from the National Survey of the Substance Abuse Treatment Services (2002-2017), containing all known substance use disorder treatment programs in the United States, to examine the effect of Medicaid expansion on the availability of opioid use disorder medications by treatment program ownership type (publicly owned, private for profit, and private nonprofit) among opioid treatment programs (OTPs) and non-OTPs.

RESULTS

The effects of Medicaid expansion were limited to nonprofit and for-profit OTPs. Medicaid expansion was associated with 135.1% and 57.5% increases in the number of nonprofit and for-profit OTPs offering injectable naltrexone, respectively, and with a 64.4% increase in the number of nonprofit OTPs offering buprenorphine. Nonprofit and for-profit OTPs compose <10% of the treatment system, indicating that improvements in opioid use disorder treatment associated with Medicaid expansion were limited to a small share of the specialty system.

CONCLUSIONS

The limited impact of Medicaid expansion on the specialty treatment system may perpetuate disparities in the accessibility and quality of opioid use disorder treatment for Medicaid enrollees and fail to alleviate high rates of opioid use disorder and opioid overdose deaths in this vulnerable population.

Adolescent-Serving Addiction Treatment Facilities in the United States and the Availability of Medications for Opioid Use Disorder

PURPOSE

Adolescents with opioid use disorder are less likely than adults to receive medications for opioid use disorder (MOUD), yet we know little about facilities that provide addiction treatment for adolescents. We sought to describe adolescent-serving addiction treatment facilities in the U.S. and examine associations between facility characteristics and offering MOUD, leading to informed recommendations to improve treatment access.

METHODS

This cross-sectional study used the 2017 National Survey of Substance Abuse Treatment Services. Facilities were classified by whether they offered a specialized adolescent program. Covariates included facility ownership, hospital affiliation, insurance/payments, government grants, accreditation/licensure, location, levels of care, and provision of MOUD. Descriptive statistics and logistic regression compared adolescent-serving versus adult-focused facilities and identified characteristics associated with offering maintenance MOUD.

RESULTS

Among 13,585 addiction treatment facilities in the U.S., 3,537 (26.0%) offered adolescent programs. Adolescent-serving facilities were half as likely to offer maintenance MOUD as adult-focused facilities (odds ratio, .53; 95% confidence interval, .49-.58), which was offered at 23.1% (816) of adolescent-serving versus 35.9% (3,612) of adult-focused facilities. Among adolescent-serving facilities, characteristics associated with increased unadjusted odds of offering maintenance MOUD were nonprofit status, hospital affiliation, accepting insurance (particularly, private insurance), accreditation, Northeastern location, or offering inpatient services.

CONCLUSIONS

The one-quarter of U.S. addiction treatment facilities that serve adolescents are half as likely to provide MOUD as adult-focused facilities, which may explain why adolescents are less likely than adults to receive MOUD. Strategies to increase adolescent access to MOUD may consider insurance reforms/incentives, facility accreditation, and geographically targeted funding.

A Scoping Review of Barriers and Facilitators to Implementation of Medications for Treatment of Opioid Use Disorder within the Criminal Justice System

BACKGROUND

Policies aimed at addressing the high rates of opioid overdose have prioritized increasing access to medications for treatment of opioid use disorder (MOUD). Numerous barriers exist to providing MOUD within the criminal justice system and/or to justice-involved populations. The aim of this study was to conduct a scoping review of the peer-reviewed literature on implementation of MOUD within criminal justice settings and with justice-involved populations.

METHODS

A systematic search process identified 53 papers that addressed issues pertaining to implementation barriers or facilitators of MOUD within correctional settings or with justice-involved populations; these were coded and qualitatively analyzed for common themes.

RESULTS

Over half of the papers were published outside of the U.S. (n = 28); the most common study designs were surveys or structured interviews (n = 20) and qualitative interviews/focus groups (n = 18) conducted with correctional or treatment staff and with incarcerated individuals. Four categories of barriers and facilitators were identified: institutional, programmatic, attitudinal, and systemic. Institutional barriers typically limited capacity to provide MOUD to justice-involved individuals, which led to programmatic practices in which MOUD was not implemented following clinical guidelines, often resulting in forcible withdrawal or inadequate treatment. These programmatic practices commonly led to aversive experiences among justice-involved individuals, who consequently espoused negative attitudes about MOUD and were reluctant to seek treatment with MOUD following their release to the community. Facilitators of MOUD implementation included increased knowledge and information from training interventions and favorable prior experiences with individuals being treated with MOUD among correctional and treatment staff. Few systemic facilitators to implementing MOUD with justice-involved individuals were evident in the literature.

CONCLUSION

Barriers to implementing MOUD in criminal justice settings and/or with justice-involved populations are pervasive, multi-leveled, and inter-dependent. More work is needed on facilitators of MOUD implementation.

Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.

Opioid agonist therapy during residential treatment of opioid use disorder: Cohort study on access and outcomes

OBJECTIVE

To determine access to opioid agonist therapy (OAT) for those entering residential treatment for opioid use disorder; to report on treatment outcomes for those taking OAT and those not taking OAT; and to determine the association between OAT use and residential treatment completion.

DESIGN

Retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

Patients with opioid use disorder admitted to publicly funded residential treatment programs in the province of Ontario between January 1, 2013, and December 31, 2016.

MAIN OUTCOME MEASURES

Access to OAT during residential treatment using descriptive statistics. Treatment outcomes (ie, completed the program, voluntarily left early, involuntary discharged, and other) for the entire cohort and for the OAT and non-OAT groups using descriptive statistics. Association between OAT use at admission and treatment completion (a binary outcome) using bivariate and multivariate models.

RESULTS

Among an identified cohort of 1910 patients with opioid use disorder, 52.8% entered programs that permitted access to OAT. Overall, 56.8% of patients completed treatment, 23.3% voluntarily left early (eg, were no-shows, dropped out), 17.0% were involuntarily discharged, and 2.9% were discharged early for other reasons. Those taking OAT were as likely to complete treatment as those not taking OAT (53.9% vs 57.5%, respectively; adjusted odds ratio of 1.07, 95% CI 0.77 to 1.38).

CONCLUSION

This study demonstrates 2 large gaps in care for patients with opioid use disorder. First, these patients have poor access to OAT-the first-line treatment of opioid use disorder-while in publicly funded residential treatment programs; and second, many are involuntarily discharged from treatment. Additionally, this study indicates that patients taking OAT have similar likelihood of completing residential treatment as those not taking OAT do. Limitations of this study are that it is based on observational data for patients who self-selected before admission to use OAT or not, and it is likely not all confounders were accounted for.

Payer Policy Behavior Towards Opioid Pharmacotherapy Treatment in Ohio

Objective:

Few studies examine how payers address the need for improved access to pharmacotherapy for opioid use disorders and the influence of environmental variables on access to opioid agonist and antagonist medications.

Method:

The 52 Ohio Addiction Drug Abuse and Mental Health Services (ADAMHS) Boards that disburse funds for treatment services for the uninsured and underinsured were surveyed to assess coverage for opioid agonist and antagonist treatment medications. Analyses examined public health data on regional opioid addiction patterns, characteristics of the local health insurance market, and their associations with coverage for opioid addiction pharmacotherapy.

Results:

Most (70%) of the 44 participating ADAMHS Boards paid for opioid treatment medications. For payment policy, all Boards required behavioral therapy to be provided in conjunction with opioid agonist or opioid antagonist therapy, and 27% of the Boards limited length of a buprenorphine therapy regimen. Higher local opioid treatment admission rates were associated with higher rates of Board funding for opioid treatment pharmacotherapy. Environmental variables (eg, overdose fatality rates or the behaviors of private insurance payers) were not associated with ADAMHS support for opioid agonist or antagonist medication.

Conclusions:

The analysis highlights the policy preferences of these payers. Follow-up studies should examine the payer decision-making processes, preferences, and attitudes that affect support for pharmacotherapy for opioid dependence.

The payer's role in addressing the opioid epidemic: It's more than money

BACKGROUND AND OBJECTIVE

County, State, and Federal agencies are addressing the public health opioid crisis. Ohio's 51 county-based Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Boards finance and regulate opioid treatment services within their jurisdictions. This three-year comparative trial collaborated with ADAMHS Boards (n = 14) to test the Advancing Recovery Framework, a suite of organizational and system change strategies designed to promote use of buprenorphine for opioid agonist therapy.

METHODS

A multi-level intervention directed payers and treatment agencies to leverage their roles in increasing the use of buprenorphine. Half of the boards partnered with local substance use disorder treatment providers using the partnership strategies recommended by the Advancing Recovery (AR) framework. The comparison boards did not use the partnership strategies.

RESULTS AND CONCLUSION

A logistic regression analysis detected increases in the number of patients receiving buprenorphine in both conditions. Buprenorphine use, as a percentage of patients with an opioid use disorder diagnosis, was significantly greater among the boards using the Advancing Recovery strategies during the three-year experimental period (odds ratio (OR) 1.63, 95% CI, 1.50 to 1.76, p < .001) and a one-year maintenance period (OR 2.13, 95% CI, 1.85 to 2.46, p < .001). Boards in both groups provided similar levels of financial support to implement and maintain buprenorphine prescribing. Strategy differences between the study conditions existed in use of a committee that facilitated payer-provider partnering and the ADAMHS boards setting expectations for using buprenorphine. Payer-provider partnerships achieved greater improvements and maximized the effectiveness of funding in increasing access to buprenorphine.

State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder

OBJECTIVE

As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

METHODS

This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.

RESULTS

State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).

CONCLUSIONS

State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample

BACKGROUND

Opioid Agonist Treatment (OAT) is the standard of care for the treatment of opioid use disorders. However, most people in treatment do not receive OAT. This study evaluated whether there are racial and/or ethnic differences in OAT receipt among adults entering specialty treatment for opioid use disorders in publicly-funded treatment programs across the U.S.

METHODS

Using data from the national Treatment: Episode Data Base, odds of OAT receipt were compared among black, Hispanic and white clients. Mediation analyses were used to explore whether any racial/ethnic differences in OAT receipt were explained by variation in clinical need or by other treatment, sociodemographic, or geographic characteristics. Interaction terms were used to assess whether this association was modified by primary opioid type.

RESULTS

Only 28.7% of clients received OAT. Odds of OAT receipt were significantly higher odds among blacks (OR: 2.27(2.14-2.41)) and Hispanics (OR: 1.98(1.88-2.09)), compared to whites. Differences in clinical need accounted for a substantial portion of this difference (76.79% and 49.74%, respectively). Differences persisted after accounting for other potential explanatory variables (adjusted OR: 1.37 (1.24-1.52); 1.21(1.11-1.32)), but were only evident for primary heroin users (adjusted OR: 1.50 (1.34-1.69); 1.29 (1.17-1.42)) and not other opioid users.

CONCLUSIONS

OAT receipt in treatment programs is low overall and particularly lacking among white heroin users. Differences in OAT receipt cannot be fully explained by differences in clinical need. More research is needed to understand and address barriers that underpin these differences so more patients with opioid use disorder can access evidenced-based treatment.

Achieving digital health sustainability: Breaking Free and CGL

Purpose

Multiple challenges remain in achieving sustainability of digital health innovations, with many failing to realise their potential due to barriers to research, development and implementation. Finding an approach that overcomes these challenges is important if society is to derive benefit from these new approaches to healthcare. Having been commissioned by local authorities, NHS Trusts, prisons, charities, and third sector providers across the UK, Breaking Free Group, who in 2010 launched Breaking Free Online (BFO), a computer-assisted therapy programme for substance misuse, have overcome many of these challenges. This has been possible through close collaborative working with partner organisations, to overcome barriers to implementation and sustainability. The paper aims to discuss these issues.

Design/methodology/approach

This paper synthesises findings from a series of qualitative studies conducted by Breaking Free Group in collaboration with health and social care charity, Change, Grow, Live (CGL), which explore barriers and facilitators of implementation and sustainability of BFO at CGL. Data are analysed using thematic analyses with findings conceptualised using behavioural science theory.

Findings

This partnership has resulted in UK wide implementation of BFO at CGL, enhanced focus on digital technologies in substance misuse recovery, and a growing body of published collaborative research.

Originality/value

Valuable lessons have been learnt through the partnership between Breaking Free Group and CGL, which will be of interest to the wider digital health community. This paper outlines those lessons, in the hope that they will provide guidance to other digital health developers and their partners, to contribute to the continued evolution of a sustainable digital health sector.

National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment

OBJECTIVES

We estimated national and state trends in opioid agonist medication-assisted treatment (OA-MAT) need and capacity to identify gaps and inform policy decisions.

METHODS

We generated national and state rates of past-year opioid abuse or dependence, maximum potential buprenorphine treatment capacity, number of patients receiving methadone from opioid treatment programs (OTPs), and the percentage of OTPs operating at 80% capacity or more using Substance Abuse and Mental Health Services Administration data.

RESULTS

Nationally, in 2012, the rate of opioid abuse or dependence was 891.8 per 100 000 people aged 12 years or older compared with national rates of maximum potential buprenorphine treatment capacity and patients receiving methadone in OTPs of, respectively, 420.3 and 119.9. Among states and the District of Columbia, 96% had opioid abuse or dependence rates higher than their buprenorphine treatment capacity rates; 37% had a gap of at least 5 per 1000 people. Thirty-eight states (77.6%) reported at least 75% of their OTPs were operating at 80% capacity or more.

CONCLUSIONS

Significant gaps between treatment need and capacity exist at the state and national levels. Strategies to increase the number of OA-MAT providers are needed.

Longitudinal Examination of Medical Staff Utilization in Substance Use Disorder Treatment Organizations

This study examined changes in utilization of medical staff within organizations specializing in treatment of patients with substance use disorder (SUD) at two points in time (2007 and 2010). Utilization was calculated as the number of hours paid weekly for psychiatrists, physicians, nurses, and other medical staff working as employees or on contract. Study data come from a longitudinal national sample of 274 substance use disorder treatment centers. Average utilization of medical staff by these SUD treatment organizations increased by 26% from 2007 to 2010. The results showed that growing SUD treatment centers that obtained more referrals from health care providers, used case managers to coordinate comprehensive approaches to patient care, provided medication assisted treatment (MAT), and that were connected more closely with hospitals made increased use of medical staff over the 2007-2010 period. In 2010, these organizations seem to have been moving in directions consistent with trends forecasted for the SUD treatment environment after implementation of the Affordable Care Act.

Exploring Diversification as A Management Strategy in Substance Use Disorder Treatment Organizations

Implementation of the Affordable Care Act (ACA) creates both environmental uncertainties and opportunities for substance use disorder (SUD) treatment providers. One managerial response to uncertainties and emergent opportunities is strategic diversification of various dimensions of organizational activity. This paper explored organizational outcomes related to diversification of funding sources, services offered, and referral sources in a national sample of 590 SUD treatment organizations. Funding diversification was related to higher average levels of census, organization size, and recent expansion of operations. Service diversification was related to higher average levels of use of medication-assisted treatment (MAT), organization size, and expansion. Referral source diversification was related only to greater average use of MAT. Overall, strategic diversification in the three areas explored was related to positive organizational outcomes. Considering alternative strategies of diversification may help position SUD treatment centers to deliver more innovative treatments such as MAT as well as enhance capacity to satisfy current unmet treatment needs of individuals with behavioral health coverage provided under the ACA.

Modeling the Innovation-Decision Process: Dissemination and Adoption of a Motivational Interviewing Preparatory Procedure In Addiction Outpatient Clinics

Widespread adoption of empirically-supported treatment innovations has the potential to improve effectiveness of treatment received by individuals with substance use disorders. However, the process of disseminating such innovations has been complex, slow, and difficult. We empirically describe the dissemination and adoption of a treatment innovation--an alcohol-treatment preparatory therapeutic procedure based on motivational interviewing (MI)--in the context of Rogers' (2003) five stages of innovation-decision process (knowledge, persuasion, decision, implementation and confirmation). To this end, 145 randomly-chosen outpatient addiction treatment clinics in New York State received an onsite visit from a project trainer delivering one of three randomly-assigned dissemination intensities: a 15-minute, a half-day or a full-day presentation. Across these clinics, 141 primary administrators and 837 clinicians completed questionnaires assessing aspects of five innovation-decision stages. At each clinic, questionnaire administration occurred immediately pre- and post-dissemination, as well as 1 and 6 months after dissemination. Consistent with Rogers' theory, earlier stages of the innovation-decision process predicted later stages. As hypothesized, dissemination intensity predicted clinicians' post-dissemination knowledge. Clinician baseline characteristics (including gender, pre-dissemination knowledge regarding the MI preparatory technique, education, case load, beliefs regarding the nature of alcohol problems, and beliefs and behavior with regard to therapeutic style) predicted knowledge and persuasion stage variables. One baseline clinic characteristic (i.e., clinic mean beliefs and behavior regarding an MI-consistent therapeutic style) predicted implementation stage variables. Findings suggest that dissemination strategies should accommodate clinician and clinic characteristics.

Implementing buprenorphine in addiction treatment: payer and provider perspectives in Ohio

Background

Buprenorphine is under-utilized in treating opioid addiction. Payers and providers both have substantial influence over the adoption and use of this medication to enhance recovery. Their views could provide insights into the barriers and facilitators in buprenorphine adoption.

Methods

We conducted individual interviews with 18 Ohio county Alcohol, Drug Addiction, and Mental Health Services (ADAMHS) Boards (payers) and 36 addiction treatment centers (providers) to examine barriers and facilitators to buprenorphine use. Transcripts were reviewed, coded, and qualitatively analyzed. First, we examined reasons that county boards supported buprenorphine use. A second analysis compared county boards and addiction treatment providers on perceived barriers and facilitators to buprenorphine use. The final analysis compared county boards with low and high use of buprenorphine to determine how facilitators and barriers differed between those settings.

Results

County boards (payers) promoted buprenorphine use to improve clinical care, reduce opioid overdose deaths, and prepare providers for participation in integrated models of health care delivery with primary care clinics and hospitals. Providers and payers shared many of the same perceptions of facilitators and barriers to buprenorphine use. Common facilitators identified were knowledge of buprenorphine benefits, funds allocated to purchase buprenorphine, and support from the criminal justice system. Common barriers were negative attitudes toward use of agonist pharmacotherapy, payment environment, and physician prescribing capacity. County boards with low buprenorphine use rates cited negative attitudes toward use of agonist medication as a primary barrier. County boards with high rates of buprenorphine use dedicated funds to purchase buprenorphine in spite of concerns about limited physician prescribing capacity.

Conclusions

This qualitative analysis found that attitudes toward use of medication and medication funding environment play important roles in an organization’s decision to begin buprenorphine use and that physician availability influences an organization’s ability to expand buprenorphine use over time.

Additional education, reimbursement support, and policy changes are needed to support buprenorphine adoption and use, along with a greater understanding of the roles payers, providers, and regulators play in the adoption of targeted practices.

Medication-assisted treatment of opioid use disorder: review of the evidence and future directions

Medication-assisted treatment of opioid use disorder with physiological dependence at least doubles rates of opioid-abstinence outcomes in randomized, controlled trials comparing psychosocial treatment of opioid use disorder with medication versus with placebo or no medication. This article reviews the current evidence for medication-assisted treatment of opioid use disorder and also presents clinical practice imperatives for preventing opioid overdose and the transmission of infectious disease. The evidence strongly supports the use of agonist therapies to reduce opioid use and to retain patients in treatment, with methadone maintenance remaining the gold standard of care. Combined buprenorphine/naloxone, however, also demonstrates significant efficacy and favorable safety and tolerability in multiple populations, including youth and prescription opioid-dependent individuals, as does buprenorphine monotherapy in pregnant women. The evidence for antagonist therapies is weak. Oral naltrexone demonstrates poor adherence and increased mortality rates, although the early evidence looks more favorable for extended-release naltrexone, which has the advantages that it is not subject to misuse or diversion and that it does not present a risk of overdose on its own. Two perspectives-individualized treatment and population management-are presented for selecting among the three available Food and Drug Administration-approved maintenance therapies for opioid use disorder. The currently unmet challenges in treating opioid use disorder are discussed, as are the directions for future research.

Adoption of injectable naltrexone in U.S. substance use disorder treatment programs

OBJECTIVE

Medication-assisted treatment for substance use disorders (SUDs) is not widely used in treatment programs. The aims of the current study were to document the prevalence of adoption and implementation of extended-release injectable naltrexone, the newest U.S. Food and Drug Administration-approved medication for alcohol use disorder (AUD), in U.S. treatment programs and to examine associations between organizational and patient characteristics and adoption.

METHOD

The study used interview data from a nationally representative sample of 307 U.S. SUD treatment programs to examine adoption and implementation of injectable naltrexone.

RESULTS

Thirteen percent of programs used injectable naltrexone for AUD, and 3% of programs used it for opioid use disorder. Every treatment program that offered injectable naltrexone to its patients used it in conjunction with psychosocial treatment, particularly cognitive behavioral therapy. Multivariate logistic regression results indicated that adoption was positively associated with the provision of wraparound services, the percentage of privately insured patients, and the presence of inpatient detoxification services. For-profit status and offering inpatient services were negatively associated with adoption. Within adopting programs, an average of 4.1% of AUD patients and 7.1% of patients with opioid use disorder were currently receiving the medication, despite clinical directors' reports of positive patient outcomes, particularly for relapsers and for those who had been noncompliant with other medications. Cost was a significant issue for the majority of adopting organizations.

CONCLUSIONS

The rate of adoption of injectable naltrexone in U.S. treatment programs remains limited. Researchers should continue to examine patient, organizational, and external characteristics associated with the adoption and implementation of injectable naltrexone over time.