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Hayes CJ, Raciborski RA, Martin BC, Gordon AJ, Hudson TJ, Brown CC, Pro G, Cucciare MA. Are gaps in rates of retention on buprenorphine for treatment of opioid use disorder closing among veterans across different races and ethnicities? A retrospective cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 166:209461. [PMID: 39067770 DOI: 10.1016/j.josat.2024.209461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/05/2024] [Accepted: 07/11/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION The U.S. Veterans Health Administration has undertaken several initiatives to improve veterans' access to and retention on buprenorphine because it prevents overdose and reduces drug-related morbidity. We aimed to determine whether improvements in retention duration over time was equitable across veterans of different races and ethnicities. METHODS This retrospective cohort study was conducted among veterans who initiated buprenorphine from federal fiscal years (FY) 2006 to 2020 after diagnosis of opioid use disorder. Using an accelerated failure time model, we estimated the association between time to buprenorphine discontinuation and FY of initiation, race and ethnicity, and other control covariates. We followed veterans from buprenorphine initiation until they discontinued or had a censoring event. We then estimated the predicted median days retained on buprenorphine, the average marginal effect of initiating in a later FY, the same measure by race and ethnicity, the incremental effect of the various racial and ethnic identities in contrast to non-Hispanic White, and the total change in the size of the gap over the 15 years of the study between veterans with a minoritized racial or ethnic identity compared to non-Hispanic White veterans. RESULTS Most of the 31,797 veterans in the sample were non-Hispanic White (74.5 %), from urban areas (83.5 %), male (92.0 %), and had significant comorbidities, most frequently anxiety disorders (51.0 %) and depression (63.0 %). Overall, 49.8 % of veterans were retained at least 180 days. The average marginal effect of FY was 7.0 days [95%CI:5.3, 8.8] but was significantly smaller among veterans identifying as Black or African American [3.2 days; 95%CI:2.4, 4.1] or Asian [3.6 days; 95%CI:1.6, 5.7] compared to veterans who identify as non-Hispanic White [7.9 days; 95%CI:5.9, 9.9]. Additional measures of change were significant for veterans identifying as Hispanic White or with two or more races. CONCLUSION Although buprenorphine retention in OUD treatment improved for all veterans over the 15-year study period, veterans from most minoritized racial and ethnic groups fell further behind as gains in duration on therapy accrued primarily to non-Hispanic White veterans. Targeted interventions addressing specific challenges experienced by veterans with minoritized identities are needed to close gaps in retention on buprenorphine.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA.
| | - Rebecca A Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Bradley C Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA; Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Teresa J Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Clare C Brown
- Department of Health Policy and Management, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - George Pro
- Department of Health Behavior and Health Education, College of Public Health, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael A Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA; Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA; Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
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Kleinman MB, Anvari MS, Felton JW, Bradley VD, Belcher AM, Abidogun TM, Hines AC, Dean D, Greenblatt AD, Wagner M, Earnshaw VA, Magidson JF. Reduction in substance use stigma following a peer-recovery specialist behavioral activation intervention. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 130:104511. [PMID: 39003894 DOI: 10.1016/j.drugpo.2024.104511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 06/20/2024] [Accepted: 06/24/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Patients' perceptions and experiences of stigma related to substance use and methadone treatment are barriers to successful treatment of opioid use disorder, particularly among low-income and medically underserved populations. Interventions led by peer recovery specialists (PRSs) may shift stigma-related barriers. This study sought to evaluate shifts in substance use and methadone treatment stigma in the context of an evidence-based behavioral intervention adapted for PRS delivery to support methadone treatment outcomes. METHODS We recruited patients who had recently started methadone treatment or demonstrated difficulty with adherence from a community-based program (N = 37) for an open-label pilot study of a 12-session behavioral activation intervention led by a PRS interventionist. Participants completed substance use and methadone treatment stigma assessments and the SIP-R, a brief measure of problems related to substance use, at baseline, mid-point (approximately six weeks), and post-treatment (approximately 12 weeks). Generalized estimating equations assessed change in total stigma scores between baseline and post-treatment as well as change in stigma scores associated with change in SIP-R responses. RESULTS There was a statistically significant decrease in substance use stigma (b(SE)=-0.0304 (0.0149); p = 0.042) from baseline to post-treatment, but not methadone treatment stigma (b(SE)=-0.00531 (0.0131); p = 0.68). Decreases in both substance use stigma (b(SE)=0.5564 (0.0842); p < 0.001) and methadone treatment stigma (b(SE)=0.3744 (0.1098); p < 0.001) were associated with a decrease in SIP-R scores. CONCLUSIONS PRS-led interventions have potential to shift substance use stigma, which may be associated with decrease in problems related to substance use, and therefore merit further testing in the context of randomized controlled trials.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA.
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Julia W Felton
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, MI, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tolulope M Abidogun
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Abigail C Hines
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Michael Wagner
- Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland School of Medicine, College Park, MD, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA; Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland School of Medicine, College Park, MD, USA
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Hayes CJ, Bin Noor N, Raciborski RA, Martin B, Gordon A, Hoggatt K, Hudson T, Cucciare M. Development and validation of machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans treated with buprenorphine for opioid use disorder. J Addict Dis 2024:1-18. [PMID: 38946144 DOI: 10.1080/10550887.2024.2363035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Buprenorphine for opioid use disorder (B-MOUD) is essential to improving patient outcomes; however, retention is essential. OBJECTIVE To develop and validate machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans initiating B-MOUD. METHODS Veterans initiating B-MOUD from fiscal years 2006-2020 were identified. Veterans' B-MOUD episodes were randomly divided into training (80%;n = 45,238) and testing samples (20%;n = 11,309). Candidate algorithms [multiple logistic regression, least absolute shrinkage and selection operator regression, random forest (RF), gradient boosting machine (GBM), and deep neural network (DNN)] were used to build and validate classification models to predict six binary outcomes: 1) B-MOUD retention, 2) any overdose, 3) opioid-related overdose, 4) overdose death, 5) opioid overdose death, and 6) all-cause mortality. Model performance was assessed using standard classification statistics [e.g., area under the receiver operating characteristic curve (AUC-ROC)]. RESULTS Episodes in the training sample were 93.0% male, 78.0% White, 72.3% unemployed, and 48.3% had a concurrent drug use disorder. The GBM model slightly outperformed others in predicting B-MOUD retention (AUC-ROC = 0.72). RF models outperformed others in predicting any overdose (AUC-ROC = 0.77) and opioid overdose (AUC-ROC = 0.77). RF and GBM outperformed other models for overdose death (AUC-ROC = 0.74 for both), and RF and DNN outperformed other models for opioid overdose death (RF AUC-ROC = 0.79; DNN AUC-ROC = 0.78). RF and GBM also outperformed other models for all-cause mortality (AUC-ROC = 0.76 for both). No single predictor accounted for >3% of the model's variance. CONCLUSIONS Machine-learning algorithms can accurately predict OUD-related outcomes with moderate predictive performance; however, prediction of these outcomes is driven by many characteristics.
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Affiliation(s)
- Corey J Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Nahiyan Bin Noor
- Institute for Digital Health and Innovation, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Rebecca A Raciborski
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Behavioral Health Quality Enhancement Research Initiative, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Evidence, Policy, and Implementation Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
| | - Bradley Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Adam Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Katherine Hoggatt
- San Francisco VA Medical Center, San Francisco, CA, USA
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Teresa Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Department of Emergency Medicine, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
- Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
- Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR, USA
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Kong Y, Guerrero E, Frimpong J, Khachikian T, Wang S, D'Aunno T, Howard D. Identifying the Heterogeneity in the Association between Workforce Diversity and Retention in Opioid Treatment among Black clients. RESEARCH SQUARE 2024:rs.3.rs-3932153. [PMID: 38405811 PMCID: PMC10889050 DOI: 10.21203/rs.3.rs-3932153/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
Background This study investigates the impact of workforce diversity, specifically staff identified as Black/African American, on retention in opioid use disorder (OUD) treatment, aiming to enhance patient outcomes. Employing a novel machine learning technique known as 'causal forest,' we explore heterogeneous treatment effects on retention. Methods We relied on four waves of the National Drug Abuse Treatment System Survey (NDATSS), a nationally representative longitudinal dataset of treatment programs. We analyzed OUD program data from the years 2000, 2005, 2014 and 2017 (n = 627). Employing the 'causal forest' method, we analyzed the heterogeneity in the relationship between workforce diversity and retention in OUD treatment. Interviews with program directors and clinical supervisors provided the data for this study. Results The results reveal diversity-related variations in the association with retention across 61 out of 627 OUD treatment programs (less than 10%). These programs, associated with positive impacts of workforce diversity, were more likely private-for-profit, newer, had lower percentages of Black and Latino clients, lower staff-to-client ratios, higher proportions of staff with graduate degrees, and lower percentages of unemployed clients. Conclusions While workforce diversity is crucial, our findings underscore that it alone is insufficient for improving retention in addiction health services research. Programs with characteristics typically linked to positive outcomes are better positioned to maximize the benefits of a diverse workforce in client retention. This research has implications for policy and program design, guiding decisions on resource allocation and workforce diversity to enhance retention rates among Black clients with OUDs.
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Heavey SC, Beehler GP, Funderburk J. (RE-)AIMing for Rapid Uptake: Pilot Evaluation of a Modified Hub and Spoke Model of Medication for Opioid Use Disorder. Med Care 2024; 62:44-51. [PMID: 37800974 DOI: 10.1097/mlr.0000000000001934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
OBJECTIVE Medication for opioid use disorder (MOUD) is an effective, evidence-based treatment, but significant gaps in implementation remain. We evaluate one novel approach to address this gap: a Hub and Spoke model to increase buprenorphine access and management. METHODS This outcome evaluation was guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework using secondary data analysis of clinical and administrative data to characterize program outcomes for program Reach, Effectiveness, Adoption, and Maintenance. Implementation was assessed through a chart review of provider progress notes and through key informant interviews with program staff to understand why this site was able to introduce a novel approach to MOUD. RESULTS Nearly half of patients with opioid use disorder (45.48%, n=156) were reached by the program over 2 years. Of those, 91.67% had 1 or more program visits after an initial intake appointment, and 78.85% had a buprenorphine prescription. Patients in the program were 2.44 times more likely to have a buprenorphine prescription than those in comparator site that did not have a Hub and Spoke program (95% CI: 1.77-3.37; P <0.001). There was significantly greater program reach in year 1 than year 2, suggesting rapid initial uptake followed by modest program growth. Key informant interviews illustrated several themes regrading program implementation, including the importance of process champions, the beneficial impact of MOUD for patients, and addressing facility performance metrics. A supportive organizational culture and a receptive climate were also key factors for implementation. CONCLUSIONS This program led to rapid improvement in MOUD uptake across the facility. Future efforts should focus on improving program maintenance, including supporting the exchange of patients from the hub to appropriate spokes.
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Affiliation(s)
- Sarah Cercone Heavey
- Department of Community Health & Health Behavior, School of Public Health & Health Professions, State University of New York at Buffalo, NY
- VA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, NY
| | - Gregory P Beehler
- Department of Community Health & Health Behavior, School of Public Health & Health Professions, State University of New York at Buffalo, NY
- VA Center for Integrated Healthcare, VA Western New York Healthcare System, Buffalo, NY
| | - Jennifer Funderburk
- VA Center for Integrated Healthcare, Syracuse VA Medical Center, Syracuse, NY
- Department of Psychiatry, University of Rochester, Rochester, NY
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Carr MM, Wolkowicz NR, Cave S, Martino S, Masheb R, Midboe AM. Weight change in a national cohort of U.S. Military Veterans engaged in medication treatment for opioid use disorder. J Psychiatr Res 2023; 168:204-212. [PMID: 37918033 DOI: 10.1016/j.jpsychires.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/27/2023] [Accepted: 10/07/2023] [Indexed: 11/04/2023]
Abstract
Medication treatments for opioid use disorder (MOUD) save lives and improve outcomes for countless individuals. However, data suggest the potential for significant weight gain during methadone treatment and little is known about weight change during buprenorphine treatment. Using Veteran Health Administration administrative data from fiscal year 2017 to fiscal year 2019, two cohorts were created: 1) Veterans diagnosed with opioid use disorder (OUD) taking methadone (N = 1425); and 2) Veterans diagnosed with OUD taking buprenorphine (N = 3756). Linear mixed models were used to analyze weight change during the first MOUD treatment episode in the observation period. Random slopes and intercepts were included in the model to estimate variation in BMI across individuals and time. The data revealed a slight upward trend in BMI over the course of treatment. Specifically, a daily increase of 0.004 for Veterans in methadone treatment and 0.002 for Veterans in buprenorphine treatment was observed. This translates to a gain of about 10 pounds over the course of 1 year of methadone treatment and 5 pounds for 1 year of buprenorphine treatment for a Veteran of average height and weight. The amount of weight gain in methadone treatment is significantly less than other published findings, but nonetheless indicates that assessment and discussions between patients and providers related to weight may be warranted.
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Affiliation(s)
- Meagan M Carr
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA.
| | - Noah R Wolkowicz
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Shayna Cave
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA
| | - Steve Martino
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Robin Masheb
- U.S. Department of Veterans Affairs, VA Connecticut Healthcare System, 950 Campbell Ave., West Haven, CT, 06516, USA; Department of Psychiatry, Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06511, USA
| | - Amanda M Midboe
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Rd, Menlo Park, CA, 94025, USA; Division of Health Policy and Management, University of California Davis-School of Medicine, Davis, CA, USA
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Frost MC, Malte CA, Hawkins EJ, Glass JE, Hallgren KA, Williams EC. Impact of an intervention to implement provision of opioid use disorder medication among patients with and without co-occurring substance use disorders. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209175. [PMID: 37751798 DOI: 10.1016/j.josat.2023.209175] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 06/14/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
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.
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Affiliation(s)
- Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
| | - Carol A Malte
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America.
| | - Joseph E Glass
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, United States of America.
| | - Kevin A Hallgren
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, United States of America.
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, United States of America; Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, United States of America.
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Kleinman MB, Hines AC, Anvari MS, Bradley VD, Shields A, Dean D, Abidogun TM, Jack HE, Magidson JF. "You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 122:104234. [PMID: 37866292 PMCID: PMC10872983 DOI: 10.1016/j.drugpo.2023.104234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment. METHODS The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis. RESULTS Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment. CONCLUSION Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, MD, USA.
| | - Abigail C Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Alia Shields
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | - Helen E Jack
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA; Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland, College Park, MD, USA
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Joyce VR, Oliva EM, Garcia CC, Trafton J, Asch SM, Wagner TH, Humphreys K, Owens DK, Bounthavong M. Healthcare costs and use before and after opioid overdose in Veterans Health Administration patients with opioid use disorder. Addiction 2023; 118:2203-2214. [PMID: 37465971 DOI: 10.1111/add.16289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 06/09/2023] [Indexed: 07/20/2023]
Abstract
AIMS To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort). DESIGN This is a retrospective cohort study of administrative and clinical data. SETTING The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems. PARTICIPANTS We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100). MEASUREMENTS Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework. FINDINGS Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611-18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends. CONCLUSIONS The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose.
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Affiliation(s)
- Vilija R Joyce
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Elizabeth M Oliva
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Carla C Garcia
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
- VA Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Todd H Wagner
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Keith Humphreys
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- Stanford Health Policy, Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Mark Bounthavong
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
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10
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Gordon AJ, Saxon AJ, Kertesz S, Wyse JJ, Manhapra A, Lin LA, Chen W, Hansen J, Pinnell D, Huynh T, Baylis JD, Cunningham FE, Ghitza UE, Bart G, Yu H, Sauer BC. Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration. Drug Alcohol Depend 2023; 248:109902. [PMID: 37196572 PMCID: PMC10875624 DOI: 10.1016/j.drugalcdep.2023.109902] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system. METHODS We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves). RESULTS We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5). CONCLUSIONS Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.
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Affiliation(s)
- Adam J Gordon
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, USA
| | - Stefan Kertesz
- Birmingham Veterans Affairs Health Care System, Birmingham, AL, USA; Department of Medicine, Heersink UAB School of Medicine, Birmingham, AL, USA
| | - Jessica J Wyse
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health CareSystem, Portland, OR, USA; School of Public Health, Oregon Health & Science University-Portland State University,PortlandOR, USA
| | - Ajay Manhapra
- Section of Pain Medicine, Department of Physical Medicine & Rehabilitation Services, Hampton VA Medical Center, Hampton, VA, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Wei Chen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jared Hansen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Derek Pinnell
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Tina Huynh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | - Udi E Ghitza
- Center for the Clinical Trials Network (CCTN), National Institute on Drug Abuse (NIDA), Bethesda, MD, USA
| | - Gavin Bart
- Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Hong Yu
- Center for Biomedical and Health Research in Data Sciences and Miner School of Computer & Information Sciences, University of Massachusetts Lowell, Lowell, MA, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Brian C Sauer
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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11
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Kleinman MB, Anvari MS, Seitz-Brown CJ, Bradley VD, Tralka H, Felton JW, Belcher AM, Greenblatt AD, Magidson JF. Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 149:209046. [PMID: 37061189 PMCID: PMC10229107 DOI: 10.1016/j.josat.2023.209046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 11/27/2022] [Accepted: 04/11/2023] [Indexed: 04/17/2023]
Abstract
INTRODUCTION Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder. METHODS This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes. RESULTS Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health. CONCLUSIONS Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA.
| | - Morgan S Anvari
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA
| | - Hannah Tralka
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA
| | | | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland at College Park, College Park, MD, USA; Center for Substance Use, Addiction & Health Research (CESAR), University of Maryland, College Park, MD, USA
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12
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Frost MC, Hawkins EJ, Glass JE, Hallgren KA, Williams EC. Associations Between Distinct Co-occurring Substance Use Disorders and Receipt of Medications for Opioid Use Disorder in the Veterans Health Administration. J Addict Med 2023; 17:278-285. [PMID: 37267168 PMCID: PMC10110763 DOI: 10.1097/adm.0000000000001095] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Madeline C. Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108
| | - Eric J. Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108
- Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195
| | - Joseph E. Glass
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101
| | - Kevin A. Hallgren
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101
| | - Emily C. Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108
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13
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Kleinman MB, Anvari MS, Bradley VD, Felton JW, Belcher AM, Seitz-Brown CJ, Greenblatt AD, Dean D, Bennett M, Magidson JF. "Sometimes you have to take the person and show them how": adapting behavioral activation for peer recovery specialist-delivery to improve methadone treatment retention. Subst Abuse Treat Prev Policy 2023; 18:15. [PMID: 36879304 PMCID: PMC9990281 DOI: 10.1186/s13011-023-00524-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 02/22/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Despite efficacy of medication for opioid use disorder, low-income, ethno-racial minoritized populations often experience poor opioid use disorder treatment outcomes. Peer recovery specialists, individuals with lived experience of substance use and recovery, are well-positioned to engage hard-to-reach patients in treatment for opioid use disorder. Traditionally, peer recovery specialists have focused on bridging to care rather than delivering interventions. This study builds on research in other low-resource contexts that has explored peer delivery of evidence-based interventions, such as behavioral activation, to expand access to care. METHODS We sought feedback on the feasibility and acceptability of a peer recovery specialist-delivered behavioral activation intervention supporting retention in methadone treatment by increasing positive reinforcement. We recruited patients and staff at a community-based methadone treatment center and peer recovery specialist working across Baltimore City, Maryland, USA. Semi-structured interviews and focus groups inquired about the feasibility and acceptability of behavioral activation, recommendations for adaptation, and acceptability of working with a peer alongside methadone treatment. RESULTS Participants (N = 32) shared that peer recovery specialist-delivered behavioral activation could be feasible and acceptable with adaptations. They described common challenges associated with unstructured time, for which behavioral activation could be particularly relevant. Participants provided examples of how a peer-delivered intervention could fit well in the context of methadone treatment, emphasizing the importance of flexibility and specific peer qualities. CONCLUSIONS Improving medication for opioid use disorder outcomes is a national priority that must be met with cost-effective, sustainable strategies to support individuals in treatment. Findings will guide adaptation of a peer recovery specialist-delivered behavioral activation intervention to improve methadone treatment retention for underserved, ethno-racial minoritized individuals living with opioid use disorder.
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Affiliation(s)
- Mary B Kleinman
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA.
| | - Morgan S Anvari
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Julia W Felton
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Aaron D Greenblatt
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Dwayne Dean
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
| | - Melanie Bennett
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland at College Park, College Park, Maryland, USA
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14
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Adapting a Behavioral Activation Intervention for Opioid Use Disorder and Methadone Treatment Retention for Peer Delivery in a Low-Resource Setting: A Case Series. COGNITIVE AND BEHAVIORAL PRACTICE 2023. [DOI: 10.1016/j.cbpra.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
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15
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Glanz JM, Binswanger IA, Clarke CL, Nguyen AP, Ford MA, Ray GT, Xu S, Hechter RC, Yarborough BJH, Roblin DW, Ahmedani B, Boscarino JA, Andrade SE, Rosa CL, Campbell CI. The association between buprenorphine treatment duration and mortality: a multi-site cohort study of people who discontinued treatment. Addiction 2023; 118:97-107. [PMID: 35815386 PMCID: PMC9722535 DOI: 10.1111/add.15998] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 06/22/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Buprenorphine is an effective medication for opioid use disorder that reduces mortality; however, many patients are not retained in buprenorphine treatment, and an optimal length of treatment after which patients can safely discontinue treatment has not been identified. This study measured the association between buprenorphine treatment duration and all-cause mortality among patients who discontinued treatment. Secondary objectives were to measure the association between treatment duration and drug overdose and opioid-related overdoses. DESIGN Multi-site cohort study. SETTING Eight US health systems. PARTICIPANTS Patients who initiated and discontinued buprenorphine treatment between 1 January 2012 and 31 December 2018 (n = 6550). Outcomes occurring after patients discontinued buprenorphine treatment were compared between patients who initiated and discontinued treatment after 8-30, 31-90, 91-180, 181-365 and > 365 days. MEASUREMENTS Covariate data were obtained from electronic health records (EHRs). Mortality outcomes were derived from EHRs and state vital statistics. Non-fatal opioid and drug overdoses were obtained from diagnostic codes. Four sites provided cause-of-death data to identify fatal drug and opioid-related overdoses. Adjusted frailty regression was conducted on a propensity-weighted cohort to assess associations between duration of the final treatment episode and outcomes. FINDINGS The mortality rate after buprenorphine treatment was 1.82 per 100 person-years (n = 191 deaths). In regression analyses with > 365 days as the reference group, treatment duration was not associated with all-cause mortality and drug overdose (P > 0.05 for both). However, compared with > 365 days of treatment, 91-180 days of treatment was associated with increased opioid overdose risk (hazard ratio = 2.94, 95% confidence interval = 1.11-7.79). CONCLUSIONS Among patients who discontinue buprenorphine treatment, there appears to be no treatment duration period associated with a reduced risk for all-cause mortality. Patients who discontinue buprenorphine treatment after 91-180 days appear to be at heightened risk for opioid overdose compared with patients who discontinue after > 365 days of treatment.
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Affiliation(s)
- Jason M. Glanz
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Colorado School of Public Health, Aurora, CO
| | - Ingrid A. Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO,Colorado Permanente Medical Group, Aurora, CO,Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO,Department of Health System Sciences, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA
| | | | - Anh P. Nguyen
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - Morgan A. Ford
- Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO
| | - G. Thomas Ray
- Division of Research, Kaiser Permanente Northern California, Oakland, CA
| | - Stanley Xu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Rulin C. Hechter
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | | | - Douglas W. Roblin
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Brian Ahmedani
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI,Department of Behavioral Health Services, Henry Ford Health System, Detroit, MI
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Kelley AT, Incze MA, Baylis JD, Calder SG, Weiner SJ, Zickmund SL, Jones AL, Vanneman ME, Conroy MB, Gordon AJ, Bridges JF. Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice. Subst Abus 2022; 43:1286-1299. [PMID: 35849749 PMCID: PMC9703846 DOI: 10.1080/08897077.2022.2095082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.
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Affiliation(s)
- A. Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael A. Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Jacob D. Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Spencer G. Calder
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Saul J. Weiner
- Center of Innovation for Complex Chronic Healthcare, Jesse Brown VA Chicago Health Care System, Chicago, Illinois, USA
- Division of Academic Internal Medicine and Geriatrics, Department of Medicine, The University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Susan L. Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Megan E. Vanneman
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Health System Innovation and Research, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Molly B. Conroy
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - John F.P. Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, Ohio, USA
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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17
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Magidson JF, Kleinman MB, Bradley V, Anvari MS, Abidogun TM, Belcher AM, Greenblatt AD, Dean D, Hines A, Seitz-Brown CJ, Wagner M, Bennett M, Felton JW. Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 108:103813. [PMID: 35932644 PMCID: PMC9590100 DOI: 10.1016/j.drugpo.2022.103813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 07/13/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention. METHODS Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems. RESULTS Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040]. CONCLUSION Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.
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Affiliation(s)
- Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, MD, USA.
| | - Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Valerie Bradley
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, MD, USA
| | | | | | | | - Dwayne Dean
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Abigail Hines
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - C J Seitz-Brown
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Michael Wagner
- Department of Psychology, University of Maryland, College Park, MD, USA
| | - Melanie Bennett
- Department of Psychiatry, University of Maryland, Baltimore, MD, USA
| | - Julia W Felton
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI, USA
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18
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Harris RA, Campbell K, Calderbank T, Dooley P, Aspero H, Maginnis J, O’Donnell N, Coviello D, French R, Bao Y, Mandell DS, Bogner HR, Lowenstein M. Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model. HEALTHCARE (AMSTERDAM, NETHERLANDS) 2022; 10:100641. [PMID: 35785613 PMCID: PMC9933784 DOI: 10.1016/j.hjdsi.2022.100641] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 11/04/2022]
Abstract
Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.
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Affiliation(s)
- Rebecca Arden Harris
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA; Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Kristen Campbell
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Tara Calderbank
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Patrick Dooley
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Heather Aspero
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jessica Maginnis
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Nicole O’Donnell
- Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, USA
| | - Donna Coviello
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Rachel French
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,School of Nursing, University of Pennsylvania, Philadelphia, PA, 19104, USA,National Clinician Scholars Program, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, 10065, USA
| | - David S. Mandell
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Hillary R. Bogner
- Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, 19104, USA,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
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Wyse JJ, Herreid-O'Neill A, Dougherty J, Shull S, Mackey K, Priest KC, Englander H, Thoma J, Lovejoy TI. Perioperative Management of Buprenorphine/Naloxone in a Large, National Health Care System: a Retrospective Cohort Study. J Gen Intern Med 2022; 37:2998-3004. [PMID: 34545469 PMCID: PMC9485300 DOI: 10.1007/s11606-021-07118-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/25/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medication for opioid use disorder, including buprenorphine and methadone, is considered the gold standard treatment for opioid use disorder (OUD). As the number of patients receiving buprenorphine has grown, clinicians increasingly care for patients prescribed buprenorphine who present for surgery and require management of perioperative pain. OBJECTIVE To describe practice patterns of perioperative and post-surgical use of buprenorphine among patients prescribed buprenorphine for OUD who experience major surgery. DESIGN Retrospective cohort study utilizing data from the VA Corporate Data Warehouse (CDW), a national repository of patient-level data. Data not accessible in CDW, including clinical instructions to patients to modify buprenorphine dose, were accessed via chart review. PARTICIPANTS National sample of patients receiving care through the Veterans Health Administration. MAIN MEASURES We report descriptive statistics on the incidence of buprenorphine dose hold prior to, during, and immediately following surgery, as well as post-surgical outcomes. Multivariable logistic regression identified socio-demographic and clinical characteristics associated with perioperative hold. KEY RESULTS Our final sample comprised 183 patients, the majority of whom were white and male. Most patients (66%) experienced a perioperative buprenorphine dose hold: during the pre-operative, day of surgery, and post-operative periods, 40%, 62%, and 55% of patients had buprenorphine held. Buprenorphine dose hold was less likely for patients who had experienced homelessness/housing insecurity in the year prior to surgery (aOR = 0.25; 95% CI 0.10-0.61) as well as patients residing in rural areas (aOR=0.29; 0.12-0.68). Within the 12-month period following surgery, 122 patients (67%) were retained on buprenorphine, 10 patients (5.5%) had experienced an overdose, and 15 (8.2%) had died. CONCLUSIONS We identified high rates of perioperative buprenorphine dose holds. As holding buprenorphine perioperatively does not align with emerging clinical recommendations and carries significant risks, educational campaigns or other provider-targeted interventions may be needed to ensure patients with OUD receive recommended care.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA.
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | - Anders Herreid-O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Jacob Dougherty
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Katherine Mackey
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
| | - Kelsey C Priest
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Honora Englander
- Section of Addiction Medicine, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Jessica Thoma
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Canada
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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20
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Frost MC, Richards JE, Blosnich JR, Hawkins EJ, Tsui JI, Edelman EJ, Williams EC. Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder. Drug Alcohol Depend 2022; 237:109521. [PMID: 35716644 PMCID: PMC9546132 DOI: 10.1016/j.drugalcdep.2022.109521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/09/2022] [Accepted: 05/28/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or 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 VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics. RESULTS Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98). CONCLUSIONS Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.
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Affiliation(s)
- Madeline C Frost
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Julie E Richards
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA; Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Seattle, WA 98101, USA.
| | - John R Blosnich
- Suzanne Dworak-Peck School of Social Work, University of Southern California, 669W 34th St, Los Angeles, CA 90089, USA; Health Services Research & Development (HSR&D) Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240, USA.
| | - Eric J Hawkins
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Center of Excellence in Substance Addiction Treatment and Education, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA.
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, 333 Cedar St, New Haven, CT 06510, USA.
| | - Emily C Williams
- Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA; Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, Seattle, WA 98195, USA.
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21
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Anvari MS, Kleinman MB, Massey EC, Bradley VD, Felton JW, Belcher AM, Magidson JF. "In their mind, they always felt less than": The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention. J Subst Abuse Treat 2022; 138:108721. [PMID: 35067397 PMCID: PMC9167238 DOI: 10.1016/j.jsat.2022.108721] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 10/19/2022]
Abstract
INTRODUCTION A substantial, national need exists for culturally acceptable, accessible opioid use disorder (OUD) treatment. Medication for opioid use disorder (MOUD) is regarded as effective in treating OUD; however, retention in MOUD programs remains low nationally. One known barrier to MOUD retention is stigma, particularly within ethno-racial minority communities. Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention. METHODS This study used qualitative methods to solicit feedback on how patients receiving methadone treatment (MT) experience stigma (i.e., toward substance use [SU] and MT). Study staff also gathered information regarding how a PRS role may reduce stigma and improve retention in care, including barriers and facilitators to the PRS role shifting stigma. Study staff conducted semi-structured qualitative interviews and focus groups (N = 32) with staff and patients receiving MT at an opioid treatment program as well as PRSs in Baltimore. RESULTS Participants identified experiences of internalized, as well as enacted and anticipated, MT and SU stigma, and described these as barriers to treatment. Participants also identified opportunities for PRSs to shift stigma-related barriers for patients receiving MT through unique aspects of the PRS role, such as their shared lived experience. CONCLUSIONS Reducing stigma surrounding SUD and MT is critical for improving MOUD outcomes, and future research may consider how the PRS role can support this effort.
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Affiliation(s)
- Morgan S Anvari
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA.
| | - Mary B Kleinman
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Ebonie C Massey
- Center for Substance Abuse Research (CESAR), University of Maryland, College Park, College Park, MD, USA
| | - Valerie D Bradley
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Julia W Felton
- Center for Health Policy & Health Services Research, Henry Ford Health System, Detroit, MI, USA
| | - Annabelle M Belcher
- Department of Psychiatry, University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Jessica F Magidson
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
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22
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Reuter Q, Larkin G, Dubé M, Vellanki S, Dos Santos A, McKinnon J, Jouriles N, Seaberg D. Stage-of-change Assessment Predicts Short-term Treatment Engagement for Opioid Use Disorder Patients Initiated on Buprenorphine. West J Emerg Med 2022; 23:684-692. [PMID: 36205682 PMCID: PMC9541985 DOI: 10.5811/westjem.2022.3.53197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 03/30/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction The emergency department (ED) is an effective setting for initiating medication for opioid use disorder (MOUD); however, predicting who will remain in treatment remains a central challenge. We hypothesize that baseline stage-of-change (SOC) assessment is associated with short-term treatment retention outcomes. Methods This is a longitudinal cohort study of all patients enrolled in an ED MOUD program over 12 months. Eligible and willing patients were treated with buprenorphine at baseline and had addiction medicine specialist follow-up arranged. Treatment retention at 30 and 90 days was determined by review of the Prescription Drug Monitoring Program. We used uni- and multivariate logistic regression to evaluate associations between patient variables and treatment retention at 30 and 90 days. Results From June 2018–May 2019, 279 patients were enrolled in the ED MOUD program. Of those patients 151 (54.1%) and 120 (43.0%) remained engaged in MOUD treatment at 30 and 90 days, respectively. The odds of treatment adherence at 30 days were significantly higher for those with advanced SOC (preparation/action/maintenance) compared to those presenting with limited SOC (pre-contemplation/contemplation) (60.0% vs 40.8%; odds ratio 2.18; 95% confidence interval 1.15 to 4.1; P <0.05). At 30 days, multivariate logistic regression determined that advanced SOC, age >40, having medical insurance, and being employed were significant predictors of continued treatment adherence. At 90 days, advanced SOC, non-White race, age > 40, and having insurance were all significantly associated with higher likelihood of treatment engagement. Conclusion Greater stage-of-change was significantly associated with MOUD treatment retention at 30 and 90 days post index ED visit.
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Affiliation(s)
- Quentin Reuter
- Summa Health System, Department of Emergency Medicine, Akron, Ohio; US Acute Care Solutions, Canton, Ohio
| | - Gregory Larkin
- Summa Health System, Department of Emergency Medicine, Akron, Ohio
| | | | - Suman Vellanki
- Summa Health System, Department of Psychiatry, Akron, Ohio
| | - Amanda Dos Santos
- Summa Health System, Department of Emergency Medicine, Akron, Ohio; US Acute Care Solutions, Canton, Ohio
| | - Jamie McKinnon
- Summa Health System, Department of Psychiatry, Akron, Ohio
| | - Nicholas Jouriles
- Summa Health System, Department of Emergency Medicine, Akron, Ohio; US Acute Care Solutions, Canton, Ohio
| | - David Seaberg
- Summa Health System, Department of Emergency Medicine, Akron, Ohio; US Acute Care Solutions, Canton, Ohio
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23
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Vakkalanka JP, Lund BC, Ward MM, Arndt S, Field RW, Charlton M, Carnahan RM. Telehealth Utilization Is Associated with Lower Risk of Discontinuation of Buprenorphine: a Retrospective Cohort Study of US Veterans. J Gen Intern Med 2022; 37:1610-1618. [PMID: 34159547 PMCID: PMC8219175 DOI: 10.1007/s11606-021-06969-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Treatment for opioid use disorder (OUD) may include a combination of pharmacotherapies (such as buprenorphine) with counseling services if clinically indicated. Medication management or engagement with in-person counseling services may be hindered by logistical and financial barriers. Telehealth may provide an alternative mechanism for continued engagement. This study aimed to evaluate the association between telehealth encounters and time to discontinuation of buprenorphine treatment when compared to traditional in-person visits and to evaluate potential effect modification by rural-urban designation and in-person and telehealth combination treatment. METHODS A retrospective cohort study of Veterans diagnosed with OUD and treated with buprenorphine across all facilities within the Veterans Health Administration (VHA) between 2008 and 2017. Exposures were telehealth and in-person encounters for substance use disorder (SUD) and mental health, treated as time-varying covariates. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year. RESULTS Compared to in-person encounters, treatment discontinuation was lower for telehealth for SUD (aHR: 0.69; 95%CI: 0.60, 0.78) and mental health (aHR: 0.69; 95%CI: 0.62, 0.76). There was no evidence of effect modification by rural-urban designation. Risk of treatment discontinuation appeared to be lower among those with telehealth only compared to in-person only for both SUD (aHR: 0.48, 95%CI: 0.37, 0.62) and for mental health (aHR: 0.46; 95%CI: 0.33, 0.65). CONCLUSIONS As telehealth demonstrated improved treatment retention compared to in-person visits, it may be a suitable option for engagement for patients in OUD management. Efforts to expand services may improve treatment retention and health outcomes for VHA and other health care systems.
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Affiliation(s)
- J Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA. .,Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA.,Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, IA, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, IA, USA.,Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - R William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, IA, USA
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24
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Ameral V, Hocking E, Leviyah X, Newberger NG, Timko C, Livingston N. Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder. Drug Alcohol Depend 2022; 233:109379. [PMID: 35255353 DOI: 10.1016/j.drugalcdep.2022.109379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 02/16/2022] [Accepted: 02/24/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD. METHODS Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings. RESULTS Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components. CONCLUSIONS Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.
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Affiliation(s)
- Victoria Ameral
- VISN 1 Mental Illness Research, Education, and Clinical Center, VA Bedford Healthcare System, Bedford, MA, USA; Department of Psychiatry, University of Massachusetts Medical School, Worcester, MA, USA.
| | | | - Xenia Leviyah
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA
| | - Noam G Newberger
- National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA
| | - Christine Timko
- VA Palo Alto Health Care System, Palo Alto, CA, USA; Stanford University School of Medicine, Stanford, CA, USA
| | - Nicholas Livingston
- VA Boston Healthcare System, Boston, MA, USA; National Center for PTSD, Behavioral Science Division, VA Boston Healthcare System, Boston, MA, USA; Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
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25
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Wyse JJ, McGinnis KA, Edelman EJ, Gordon AJ, Manhapra A, Fiellin DA, Moore BA, Korthuis PT, Kennedy AJ, Oldfield BJ, Gaither JR, Gordon KS, Skanderson M, Barry DT, Bryant K, Crystal S, Justice AC, Kraemer KL. Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV. AIDS Behav 2022; 26:975-985. [PMID: 34495424 PMCID: PMC8840957 DOI: 10.1007/s10461-021-03452-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2021] [Indexed: 12/22/2022]
Abstract
Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.
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Affiliation(s)
- Jessica J Wyse
- VA Portland Health Care System, Portland, OR, USA.
- School of Public Health, Oregon Health & Science University, Portland, OR, USA.
| | | | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ajay Manhapra
- Integrative Pain Recovery Service, Hampton VA Medical Center, Hampton, VA, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - David A Fiellin
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Brent A Moore
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Amy J Kennedy
- Los Angeles County Department of Health Services, Los Angeles, CA, USA
| | - Benjamin J Oldfield
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Julie R Gaither
- Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Kirsha S Gordon
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Declan T Barry
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- APT Foundation, Pain Treatment Services, New Haven, CT, USA
| | - Kendall Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Rutgers University, New Brunswick, NJ, USA
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Kevin L Kraemer
- Center for Research on Health Care, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
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26
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Impact of High Deductible Health Plans on Continuous Buprenorphine Treatment for Opioid Use Disorder. J Gen Intern Med 2022; 37:769-776. [PMID: 34405345 PMCID: PMC8904661 DOI: 10.1007/s11606-021-07094-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Long-term, continuous treatment with medication like buprenorphine is the gold standard for opioid use disorder (OUD). As high deductible health plans (HDHPs) become more prevalent in the commercial insurance market, they may pose financial barriers to people with OUD. OBJECTIVE To estimate the impact of HDHPs on continuity of buprenorphine treatment, concurrent visits for counseling/psychotherapy and OUD-related evaluation and management, and out-of-pocket spending. DESIGN Difference-in-differences analysis comparing trends in outcomes among enrollees whose employers offer an HDHP (treatment group) to enrollees whose employers never offer an HDHP (comparison group). PARTICIPANTS Enrollees with OUD from a national sample of commercial health insurance plans during 2007-2017 who initiate buprenorphine treatment. MAIN MEASURES Number of days of continuous buprenorphine treatment; probabilities of continuous buprenorphine treatment ≥30, ≥90, ≥180, and ≥365 days; probability of concurrent (i.e., within the same month) behavioral therapy (i.e., counseling or psychotherapy); probability of concurrent OUD-related evaluation and management visits; proportions of buprenorphine treatment episodes with counseling/psychotherapy and evaluation and management visits; and out-of-pocket (OOP) spending on buprenorphine, behavioral therapy, and evaluation and management visits. KEY RESULTS HDHPs were associated with an average increase of $98 (95% CI: $48, $150) on OOP spending on buprenorphine per treatment episode but no change in the number of days of continuous buprenorphine treatment or concurrent use of related services. CONCLUSIONS HDHPs do not reduce continuity of buprenorphine treatment among commercially insured enrollees with OUD but may increase financial burden for this population.
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27
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Akyar S, Nyaku A, Lao K, Ruthberg S, Zerbo EA. Satisfaction with group-based appointments among patients with opioid use disorder in an urban buprenorphine clinic. Subst Abus 2022; 43:913-916. [DOI: 10.1080/08897077.2021.2010258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Serra Akyar
- Department of Psychiatry and Behavioral Health Sciences, Northwell Health at Staten Island University Hospital, Staten Island, New York, USA
| | - Amesika Nyaku
- Department of Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kristyn Lao
- Department of Psychiatry, NYU Grossman School of Medicine, New York, New York, USA
| | - Stephanie Ruthberg
- Department of Psychiatry, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Erin A. Zerbo
- Department of Psychiatry, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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28
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Lin LA, Fortney JC, Bohnert ASB, Coughlin LN, Zhang L, Piette JD. Comparing telemedicine to in-person buprenorphine treatment in U.S. veterans with opioid use disorder. J Subst Abuse Treat 2022; 133:108492. [PMID: 34175175 PMCID: PMC8627529 DOI: 10.1016/j.jsat.2021.108492] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 02/15/2021] [Accepted: 05/24/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Telemedicine-delivered buprenorphine (tele-buprenorphine) can potentially increase access to buprenorphine for patients with opioid use disorder (OUD), especially during the COVID-19 pandemic, but we know little about use in clinical care. METHODS This study was a retrospective national cohort study of veterans diagnosed with opioid use disorder (OUD) receiving buprenorphine treatment from the Veterans Health Administration (VHA) in fiscal years 2012-2019. The study examined trends in use of tele-buprenorphine and compared demographic and clinical characteristics in patients who received tele-buprenorphine versus those who received in-person treatment only. RESULTS Utilization of tele-buprenorphine increased from 2.29% of buprenorphine patients in FY2012 (n = 187) to 7.96% (n = 1352) in FY2019 in VHA veterans nationally. Compared to patients receiving only in-person care, tele-buprenorphine patients were less likely to be male (AOR = 0.85, 95% CI: 0.73-0.98) or Black (AOR = 0.54, 95% CI: 0.45-0.65). Tele-buprenorphine patients were more likely to be treated in community-based outpatient clinics rather than large medical centers (AOR = 2.91, 95% CI: 2.67-3.17) and to live in rural areas (AOR = 2.12, 95% CI:1.92-2.35). The median days supplied of buprenorphine treatment was 722 (interquartile range: 322-1459) among the tele-buprenorphine patients compared to 295 (interquartile range: 67-854) among patients who received treatment in-person. CONCLUSIONS Use of telemedicine to deliver buprenorphine treatment in VHA increased 3.5-fold between 2012 and 2019, though overall use remained low prior to COVID-19. Tele-buprenorphine is a promising modality especially when treatment access is limited. However, we must continue to understand how practitioners and patient are using telemedicine and how these patients' outcomes compare to those using in-person care.
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Affiliation(s)
- Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Injury Prevention Center, Ann Arbor, MI, USA; Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - John C Fortney
- Department of Psychiatry, School of Medicine, University of Washington, Seattle, WA, USA; Department of Veterans Affairs, Health Services Research and Development, Center of Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA, USA
| | - Amy S B Bohnert
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Lara N Coughlin
- Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Lan Zhang
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - John D Piette
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Health Behavior Health Education, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Petrakis I, Springer SA, Davis C, Ralevski E, Gu L, Lew R, Hermos J, Nuite M, Gordon AJ, Kosten TR, Nunes EV, Rosenheck R, Saxon AJ, Swift R, Goldberg A, Ringer R, Ferguson R. Rationale, design and methods of VA-BRAVE: a randomized comparative effectiveness trial of two formulations of buprenorphine for treatment of opioid use disorder in veterans. Addict Sci Clin Pract 2022; 17:6. [PMID: 35101115 PMCID: PMC8802273 DOI: 10.1186/s13722-022-00286-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 01/10/2022] [Indexed: 11/13/2022] Open
Abstract
Background To address the US opioid epidemic, there is an urgent clinical need to provide persons with opioid use disorder (OUD) with effective medication treatments for OUD (MOUD). Formulations of sublingual buprenorphine/naloxone (SL-BUP/NLX) are considered the standard of care for OUD including within the Veterans Healthcare Administration (VHA). However, poor retention on MOUD undermines its effectiveness. Long-acting injectable monthly buprenorphine (INJ-BUP) (e.g., Sublocade®) has the potential to improve retention and therefore reduce opioid use and overdose. Designing and conducting studies for OUD pose unique challenges. The strategies and solutions to some of these considerations in designing Cooperative Studies Program (CSP) 2014, Buprenorphine for Treating Opioid Use Disorder in Veterans (VA-BRAVE), a randomized, 20-site, clinical effectiveness trial comparing INJ-BUP to SL-BUP/NLX conducted within the VHA may provide valuable guidance for others confronted with similar investigation challenges. Methods This 52-week, parallel group, open-label, randomized controlled trial (RCT) evaluates the comparative effectiveness of two current FDA-approved formulations of buprenorphine: (1) daily SL-BUP/NLX vs. (2) monthly (28-day) INJ-BUP for Veterans with moderate to severe OUD (n = 952). The primary outcomes are (1) retention in MOUD and (2) opioid abstinence. Secondary outcomes include measures of other drug use, psychiatric symptoms, medical outcomes including prevalence rates of HIV, hepatitis B and C as well as social outcomes (housing instability, criminal justice involvement), service utilization and cost-effectiveness. Special considerations in conducting a comparative effectiveness trial with this population and during COVID-19 pandemic were also included. Discussion The evaluation of the extended-release formulation of buprenorphine compared to the standard sublingual formulation in real-world VHA settings is of paramount importance in addressing the opioid epidemic. The extent to which this new treatment facilitates retention, decreases opioid use, and prevents severe sequelae of OUD has not been studied in any long-term trial to date. Positive findings in this trial could lead to widespread adoption of MOUD, and, if proven superior INJ-BUP, by clinicians throughout the VHA and beyond. This treatment has the potential to reduce opioid use among Veterans, improve medical, psychological, and social outcomes, and save lives at justifiable cost. Trial registration Registered at Clinicaltrials.gov NCT04375033
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Affiliation(s)
- Ismene Petrakis
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA. .,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
| | - Sandra A Springer
- Section of Infectious Disease, Department of Internal Medicine, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia Davis
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Ralevski
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.,Section of Infectious Disease, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lucy Gu
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Robert Lew
- Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
| | - John Hermos
- Section of General Internal Medicine, Department of Medicine, School of Medicine, Boston University, Boston, MA, USA.,Department of Internal Medicine, VA Boston Healthcare System, Jamaica Plain, Boston, MA, USA
| | | | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Thomas R Kosten
- Department of Psychiatry, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Department of Psychiatry, Baylor College of Medicine, Houston, TX, USA
| | - Edward V Nunes
- Department of Psychiatry, Columbia University Medical Center, New York, NY, USA
| | - Robert Rosenheck
- Department of Psychiatry, Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA.,Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA, USA.,Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Robert Swift
- Providence Veterans Affairs Medical Center, Providence, RI, USA.,Department of Psychiatry and Human Behavior, Center for Alcohol and Addiction Studies, Brown University Warren Alpert Medical School, Providence, RI, USA
| | - Alexa Goldberg
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Robert Ringer
- US Department of Veteran Affairs, Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM, USA
| | - Ryan Ferguson
- US Department of Veteran Affairs, Cooperative Studies Program Coordinating Center (CSPCC), Boston, MA, USA.,Department of Public Health, Boston University, Boston, MA, USA
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30
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Priest KC, King CA, Englander H, Lovejoy TI, McCarty D. Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis. Subst Abus 2022; 43:1251-1259. [PMID: 35670778 PMCID: PMC10292919 DOI: 10.1080/08897077.2022.2074601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.
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Affiliation(s)
- Kelsey C. Priest
- MD/PhD Program, School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
- Department of Psychiatry, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, U.S.A
| | - Caroline A. King
- MD/PhD Program, School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Honora Englander
- Division of Hospital Medicine & Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon, U.S.A
| | - Travis I. Lovejoy
- Department of Psychiatry, Oregon Health & Science University, Portland, Oregon, U.S.A
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, U.S.A
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, U.S.A
| | - Dennis McCarty
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, Oregon, U.S.A
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31
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Hayes CJ, Cucciare MA, Martin BC, Hudson TJ, Bush K, Lo-Ciganic W, Yu H, Charron E, Gordon AJ. Using data science to improve outcomes for persons with opioid use disorder. Subst Abuse 2022; 43:956-963. [PMID: 35420927 PMCID: PMC9705076 DOI: 10.1080/08897077.2022.2060446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Medication treatment for opioid use disorder (MOUD) is an effective evidence-based therapy for decreasing opioid-related adverse outcomes. Effective strategies for retaining persons on MOUD, an essential step to improving outcomes, are needed as roughly half of all persons initiating MOUD discontinue within a year. Data science may be valuable and promising for improving MOUD retention by using "big data" (e.g., electronic health record data, claims data mobile/sensor data, social media data) and specific machine learning techniques (e.g., predictive modeling, natural language processing, reinforcement learning) to individualize patient care. Maximizing the utility of data science to improve MOUD retention requires a three-pronged approach: (1) increasing funding for data science research for OUD, (2) integrating data from multiple sources including treatment for OUD and general medical care as well as data not specific to medical care (e.g., mobile, sensor, and social media data), and (3) applying multiple data science approaches with integrated big data to provide insights and optimize advances in the OUD and overall addiction fields.
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Affiliation(s)
- Corey J. Hayes
- Department of Biomedical Informatics, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR,Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR,Corresponding Author: 4301 West Markham Street, Slot #755, Little Rock, AR 72205
| | - Michael A. Cucciare
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR,Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR,Veterans Affairs South Central Mental Illness Research, Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock, AR
| | - Bradley C. Martin
- Division of Pharmaceutical Evaluation and Policy, College of Pharmacy, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Teresa J. Hudson
- Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, North Little Rock, AR,Center for Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Keith Bush
- Brain Imaging Research Center, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Weihsuan Lo-Ciganic
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL,Center for Drug Evaluation and Safety (CoDES), College of Pharmacy, University of Florida, Gainesville, FL
| | - Hong Yu
- Department of Computer Science, Kennedy College of Sciences, University of Massachusetts Lowell, Lowell, MA,Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA
| | - Elizabeth Charron
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Medicine, School of Medicine, University of Utah,Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Healthcare System
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32
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Hochheimer M, Unick GJ. Systematic review and meta-analysis of retention in treatment using medications for opioid use disorder by medication, race/ethnicity, and gender in the United States. Addict Behav 2022; 124:107113. [PMID: 34543869 DOI: 10.1016/j.addbeh.2021.107113] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 08/27/2021] [Accepted: 09/02/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS There is mounting evidence that opioid use disorder is experienced differently by people of different genders and race/ethnicity groups. Similarly, in the US access to specific medications for opioid use is limited by gender and race/ethnicity. This study aims to evaluate if gender or race/ethnicity is associated with different rates of treatment retention in the US, for each of three medications used to treat opioid use disorder. METHODS A systematic search was conducted using PubMed, CINHAL, and PsychINFO, databases. All studies that provided a ratio of those retained in treatment at a specified time in terms of gender and/or race/ethnicity and medication were included. Variables were created to assess the effects of time in treatment, recruited sample, required attendance at concurrent psychosocial treatment, and adherence to strict rules of conduct for continuation in treatment on retention. Meta-analytical and meta-regression methods were used to compare studies on the ratio of those who completed a specific time in treatment by race/ethnicity group and by gender. RESULTS Nineteen articles that provided the outcome variable of interest were found (11 buprenorphine, six methadone, and two naltrexone). Meta-analyses found that treatment retention was similar for all gender and racial/ethnic groups for all three medications. Meta-regression found that those of the African American group who were recruited into buprenorphine treatment were retained significantly longer than African Americans in buprenorphine treatment who were studied retrospectively. Also, both genders had significantly lower retention in methadone treatment when there was the additional requirement of psychosocial therapy.
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33
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Vakkalanka JP, Lund BC, Arndt S, Field W, Charlton M, Ward MM, Carnahan RM. Therapeutic relationships between Veterans and buprenorphine providers and effects on treatment retention. Health Serv Res 2021; 57:392-402. [PMID: 34854083 DOI: 10.1111/1475-6773.13919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 10/27/2021] [Accepted: 11/19/2021] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To examine the extent to which there was any therapeutic relationship between Veterans and their initial buprenorphine provider and whether the presence of this relationship influenced treatment retention. DATA SOURCES National, secondary administrative data used from the Veterans Health Administration (VHA), 2008-2017. STUDY DESIGN Retrospective cohort study. The primary exposure was a therapeutic relationship between the Veteran and buprenorphine provider, defined as the presence of a previous visit or medication prescribed by the provider in the 2 years preceding buprenorphine treatment initiation. The primary outcome was treatment discontinuation, evaluated as 14 days of absence of medication from initiation through 1 year. DATA COLLECTION/EXTRACTION METHODS Adult Veterans (age ≥ 18 years) diagnosed with opioid use disorder and treated with buprenorphine or buprenorphine/naloxone within the VHA system were included in this study. We excluded those receiving buprenorphine patches, those with documentation of a metastatic tumor diagnosis within 2 years prior to buprenorphine initiation, and those without geographical information on rurality. PRINCIPAL FINDINGS A total of 28,791 Veterans were included in the study. Within the overall study sample, 56.3% (n = 16,206) of Veterans previously had at least one outpatient encounter with their initial buprenorphine provider, and 24.9% (n = 7174) of Veterans previously had at least one prescription from that provider in the 2 years preceding buprenorphine initiation. There was no significant or clinically meaningful association between therapeutic relationship history and treatment retention when defined as visit history (aHR: 0.99; 95% CI: 0.96, 1.02) or medication history (aHR: 1.03; 95% CI: 1.00, 1.07). CONCLUSIONS Veterans initiating buprenorphine frequently did not have a therapeutic history with their initial buprenorphine provider, but this relationship was not associated with treatment retention. Future work should investigate how the quality of Veteran-provider therapeutic relationships influences opioid use dependence management and whether eliminating training requirements for providers might affect access to buprenorphine, and subsequently, treatment initiation and retention.
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Affiliation(s)
- Jayamalathi Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA.,Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa, USA
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Hasan MM, Young GJ, Shi J, Mohite P, Young LD, Weiner SG, Noor-E-Alam M. A machine learning based two-stage clinical decision support system for predicting patients' discontinuation from opioid use disorder treatment: retrospective observational study. BMC Med Inform Decis Mak 2021; 21:331. [PMID: 34836524 PMCID: PMC8620531 DOI: 10.1186/s12911-021-01692-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/15/2021] [Indexed: 11/17/2022] Open
Abstract
Background Buprenorphine is a widely used treatment option for patients with opioid use disorder (OUD). Premature discontinuation from this treatment has many negative health and societal consequences. Objective To develop and evaluate a machine learning based two-stage clinical decision-making framework for predicting which patients will discontinue OUD treatment within less than a year. The proposed framework performs such prediction in two stages: (i) at the time of initiating the treatment, and (ii) after two/three months following treatment initiation. Methods For this retrospective observational analysis, we utilized Massachusetts All Payer Claims Data (MA APCD) from the year 2013 to 2015. Study sample included 5190 patients who were commercially insured, initiated buprenorphine treatment between January and December 2014, and did not have any buprenorphine prescription at least one year prior to the date of treatment initiation in 2014. Treatment discontinuation was defined as at least two consecutive months without a prescription for buprenorphine. Six machine learning models (i.e., logistic regression, decision tree, random forest, extreme-gradient boosting, support vector machine, and artificial neural network) were tested using a five-fold cross validation on the input data. The first-stage models used patients’ demographic information. The second-stage models included information on medication adherence during the early phase of treatment based on the proportion of days covered (PDC) measure. Results A substantial percentage of patients (48.7%) who started on buprenorphine discontinued the treatment within one year. The area under receiving operating characteristic curve (C-statistic) for the first stage models varied within a range of 0.55 to 0.59. The inclusion of knowledge regarding patients’ adherence at the early treatment phase in terms of two-months and three-months PDC resulted in a statistically significant increase in the models’ discriminative power (p-value < 0.001) based on the C-statistic. We also constructed interpretable decision classification rules using the decision tree model. Conclusion Machine learning models can predict which patients are most at-risk of premature treatment discontinuation with reasonable discriminative power. The proposed machine learning framework can be used as a tool to help inform a clinical decision support system following further validation. This can potentially help prescribers allocate limited healthcare resources optimally among different groups of patients based on their vulnerability to treatment discontinuation and design personalized support systems for improving patients’ long-term adherence to OUD treatment.
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Affiliation(s)
- Md Mahmudul Hasan
- Department of Mechanical and Industrial Engineering, College of Engineering, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA, 02135, USA
| | - Gary J Young
- D'Amore-McKim School of Business, Bouve College of Health Sciences, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA, 02135, USA
| | - Jiesheng Shi
- Department of Mechanical and Industrial Engineering, College of Engineering, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA, 02135, USA
| | - Prathamesh Mohite
- Department of Mechanical and Industrial Engineering, College of Engineering, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA, 02135, USA
| | - Leonard D Young
- Prescription Monitoring Program, Massachusetts Department of Public Health, Boston, MA, 02108, USA
| | - Scott G Weiner
- Department of Emergency Medicine, Division of Health Policy and Public Health, Brigham and Women's Hospital, 75 Francis Street, NH-226, Boston, MA, 02115, USA
| | - Md Noor-E-Alam
- Department of Mechanical and Industrial Engineering, College of Engineering, Center for Health Policy and Healthcare Research, Northeastern University, 360 Huntington Avenue, Boston, MA, 02135, USA.
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Frost MC, Lampert H, Tsui JI, Iles-Shih MD, Williams EC. The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review. Addict Sci Clin Pract 2021; 16:62. [PMID: 34635170 PMCID: PMC8504567 DOI: 10.1186/s13722-021-00266-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 09/10/2021] [Indexed: 01/01/2023] Open
Abstract
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.
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Affiliation(s)
- Madeline C Frost
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States. .,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States.
| | - Hannah Lampert
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Judith I Tsui
- Department of Medicine, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Matthew D Iles-Shih
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA, 98195, United States
| | - Emily C Williams
- Department of Health Systems and Population Health, University of Washington School of Public Health, 1959 NE Pacific St, WA, 98195, Seattle, United States.,Health Services Research & Development (HSR&D) Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA, 98108, United States
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Manhapra A, Stefanovics EA, Rhee TG, Rosenheck RA. Who Uses Veterans Mental Health Services?: A National Observational Study of Male Veteran and Nonveteran Mental Health Service Users. J Nerv Ment Dis 2021; 209:702-709. [PMID: 33993183 DOI: 10.1097/nmd.0000000000001369] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Mental health (MH) research among veterans receiving services from the Veterans Health Administration (VHA) is extensive and growing and informs many clinical practice guidelines. We used nationally representative survey data to examine the generalizability of this extensive body of research by comparing sociodemographic and clinical characteristics of male veteran veterans health service (VHS) users (n = 491) with veteran non-VHS users (n = 840) and nonveteran (n = 6300) MH service users. VHS users were older, more often reported Black race, and less likely to have private or Medicaid insurance, but had similar prevalence of psychiatric or substance use disorder diagnoses but with a greater prevalence of posttraumatic stress disorder (PTSD). VHS users reported higher rates of medical diagnoses, pain interference, and poorer physical and MH status. These results suggest that VHA MH research may be reasonably generalizable to US mental health service users with caveats regarding age, PTSD diagnosis, pain, and racial distribution.
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Vakkalanka P, Lund BC, Arndt S, Field W, Charlton M, Ward MM, Carnahan RM. Association Between Buprenorphine for Opioid Use Disorder and Mortality Risk. Am J Prev Med 2021; 61:418-427. [PMID: 34023160 PMCID: PMC8384722 DOI: 10.1016/j.amepre.2021.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 02/20/2021] [Accepted: 02/23/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Veterans with opioid use disorder have an increased risk of suicide and overdose compared with the general population. Buprenorphine, a U.S. Food and Drug Administration-approved medication to treat opioid use disorder, has shown benefits, including decreased risk of illicit drug use and overdose. This study assesses the mortality outcomes with buprenorphine pharmacotherapy among Veterans up to 5 years from treatment initiation. METHODS This was a retrospective cohort study of Veterans receiving buprenorphine (2008-2017) across any Veterans Health Administration facility. Buprenorphine pharmacotherapy was evaluated as a time-varying covariate. The primary outcome was death up to 5 years from treatment initiation by suicide and overdose combined; secondary outcomes included suicide, overdose, opioid-specific overdose, and all-cause death. Secondary analyses included evaluating the risk of mortality in recent discontinuation and effect modification by select characteristics. All analyses were conducted in 2020. RESULTS Veterans who were not receiving buprenorphine were 4.33 (adjusted hazard ratio; 95% CI=3.60, 5.21) times more likely to die by suicide/overdose than those receiving buprenorphine pharmacotherapy on any given day, with similar protective associations with treatment across secondary outcomes. The risk of suicide/overdose was highest 8-14 days from treatment discontinuation (adjusted hazard ratio=6.54, 95% CI=4.32, 9.91) than in currently receiving buprenorphine pharmacotherapy. There was no evidence of effect modification by the selected covariates. CONCLUSIONS Mortality risk was greater among Veterans who were not receiving buprenorphine pharmacotherapy than among those who were. Providers should consider whether buprenorphine pharmacotherapy, either intermittent or continuous, may provide health benefits for their patients and prevent mortality.
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Affiliation(s)
- Priyanka Vakkalanka
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Department of Emergency Medicine, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa.
| | - Brian C Lund
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa; Center for Comprehensive Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Stephan Arndt
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa; Department of Psychiatry, University of Iowa Carver College of Medicine, University of Iowa Health Care, Iowa City, Iowa
| | - William Field
- Department of Occupational and Environmental Health, University of Iowa College of Public Health, Iowa City, Iowa
| | - Mary Charlton
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa
| | - Ryan M Carnahan
- Department of Epidemiology, University of Iowa College of Public Health, Iowa City, Iowa
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Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US. Drug Alcohol Depend 2021; 226:108849. [PMID: 34198132 DOI: 10.1016/j.drugalcdep.2021.108849] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion. METHODS Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors. RESULTS After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776). CONCLUSIONS Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.
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Shirk SD, Ameral V, Kraus SW, Houchins J, Kelly M, Pugh K, Reilly E, Desai N. Buprenorphine Naloxone and Extended Release Injectable Naltrexone for the Treatment of Opioid Use Disorder Among a Veteran Patient Sample: A Retrospective Chart Review. J Dual Diagn 2021; 17:207-215. [PMID: 34176448 DOI: 10.1080/15504263.2021.1942380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Previous research has demonstrated the effectiveness of both extended-release injectable naltrexone (XR-NTX) and buprenorphine/naloxone (BUP-NX) in the treatment of opioid use disorder (OUD). However, studies using real-world samples with multiple medical and psychiatric comorbidities are lacking. The study's primary aims were to: (1) compare clinical presentations in an inclusive sample of OUD-diagnosed US military veterans receiving XR-NTX and BUP-NX, and (2) investigate differences in 90-day treatment outcomes between these two groups. Methods: The medical records of 79 patients receiving medications to treat OUD in a VA hospital's addiction outpatient treatment program were reviewed retrospectively. The analysis included all veterans who initiated medication treatment during the study period. Differences between medication groups on co-occurring diagnoses, treatment retention, and related outcomes were examined. Results: The two groups were similar in medical and psychiatric comorbidity, although the BUP-NX group were more likely to have a pain diagnosis. No statistically significant differences in retention or toxicology results were found between the two groups over the 90-day study period. The rate of positive urine screens for the BUP-NX group was 19.2% for opiates and 13.5% for other illicit substances, and 3.7% and 11.1% respectively for the XR- NTX group. Conclusion: There was no evidence that 90-days outcomes differed for veterans based on medication received, and there were more similarities than differences in clinical characteristics. Additional research is needed, including larger sample size and prospective randomized control trial to evaluate VA patients' treatment outcomes receiving BUP-NX or XR-NTX for OUD.
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Affiliation(s)
- Steven D Shirk
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA.,Department of Psychiatry and Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Victoria Ameral
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA
| | - Shane W Kraus
- Department of Psychology, University of Nevada, NV, USA
| | | | - Megan Kelly
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA.,Department of Psychiatry and Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| | - Kendra Pugh
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA
| | - Erin Reilly
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA
| | - Nitigna Desai
- VISN 1 New England MIRECC, Bedford VA Healthcare System, Bedford, MA, USA.,Department of Psychiatry and Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA.,Department of Psychiatry, Boston University School of Medicine, Boston, MA, USA
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40
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Bailey SR, Lucas JA, Angier H, Cantone RE, Fleishman J, Garvey B, Cohen DJ, Rdesinski RE, Gordon L. Associations of retention on buprenorphine for opioid use disorder with patient characteristics and models of care in the primary care setting. J Subst Abuse Treat 2021; 131:108548. [PMID: 34244013 DOI: 10.1016/j.jsat.2021.108548] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 06/11/2021] [Accepted: 06/20/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Buprenorphine, a medication for opioid use disorder (OUD), can be administered within primary care; however, little is known about characteristics associated with retention on buprenorphine in these settings. This study examines patient correlates of buprenorphine retention and whether an integrated, interdisciplinary treatment model (buprenorphine and behavioral health) is associated with higher odds of buprenorphine retention than a primarily medication-only treatment model. METHODS Electronic health record data from adult patients with an OUD, ≥1 buprenorphine order and ≥1 visit to either of two primary care clinics between 9/2/2014-6/27/2018 were extracted (N = 494 patients). Two research team members reviewed the medication start and stop dates for each buprenorphine order and classified as retained (≥6 months of orders) or not retained (<6 months of orders). Logistic regressions estimated the odds of retention on buprenorphine by 1) patient characteristics and 2) timing of patient's engagement in buprenorphine treatment (pre- or post-implementation of an integrated treatment model). RESULTS Of the study sample, 53% had ≥6 months of buprenorphine orders. Almost two times higher odds of retention were found among patients with ≥1 psychiatric comorbidity (versus none) and among those with buprenorphine orders in the post- versus pre-period. CONCLUSIONS An integrated, interdisciplinary model of OUD treatment was associated with ≥6 months of buprenorphine orders among our study population. Continued research is needed in real-world primary care settings to understand the impact of OUD treatment models on patient outcomes. A more nuanced examination of the associations between psychiatric diagnoses and buprenorphine treatment retention is warranted.
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Affiliation(s)
- Steffani R Bailey
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America.
| | - Jennifer A Lucas
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Heather Angier
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Rebecca E Cantone
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Joan Fleishman
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Brian Garvey
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Rebecca E Rdesinski
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
| | - Leah Gordon
- Department of Family Medicine, Oregon Health & Science University (OHSU), United States of America
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Schuler MS, Dick AW, Stein BD. Growing racial/ethnic disparities in buprenorphine distribution in the United States, 2007-2017. Drug Alcohol Depend 2021; 223:108710. [PMID: 33873027 PMCID: PMC8204632 DOI: 10.1016/j.drugalcdep.2021.108710] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether per capita buprenorphine distribution varies by regional racial/ethnic composition, Medicaid expansion status, and time period. METHODS Our unit of analysis -- three-digit ZIP codes ("ZIP3s") -- was classified into quintiles based on percentage of White residents. A weighted linear regression model of buprenorphine distribution -- including White resident quintile, waivered prescriber rate, overdose rate, sociodemographic factors, and year fixed effects -- was estimated using national buprenorphine distribution data from 2007 to 2017. We report predictive margins of the buprenorphine distribution rate by quintile, as well as average marginal effects of waivered prescriber rate on buprenorphine distribution rate for each quintile. Analyses were stratified by Medicaid expansion status and time period (2007-2010, 2011-2014, 2015-2017). RESULTS Buprenorphine distribution increased nationally during 2007-2017, yet growth was disproportionately greater for ZIP3s with higher percentages of White residents. Medicaid expansion states exhibited significant differences in buprenorphine distribution across ZIP3 quintiles during 2007-2010, the magnitude of which increased across time periods. Non-expansion states exhibited significant quintile differences during 2011-2014 and 2015-2017. The average marginal effect of increasing the waivered prescriber rate on the distribution rate was consistently smaller in ZIP3s with lower percentages of White residents, particularly in expansion states. CONCLUSIONS We find ecological evidence consistent with racial/ethnic disparities in buprenorphine distribution. Our finding that increasing the waivered prescriber rate had differential effects by ZIP3 racial/ethnic composition suggest that broad initiatives to increase the number of waivered prescribers are likely insufficient to achieve equitable buprenorphine access. Rather, targeted and tailored policy efforts are warranted.
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Affiliation(s)
- Megan S Schuler
- RAND Corporation, 20 Park Plaza #920, Boston, MA, 02216, USA.
| | - Andrew W Dick
- RAND Corporation, 20 Park Plaza #920, Boston, MA, 02216, USA
| | - Bradley D Stein
- RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
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The association of opioid use disorder and homelessness nationally in the veterans health administration. Drug Alcohol Depend 2021; 223:108714. [PMID: 33865213 DOI: 10.1016/j.drugalcdep.2021.108714] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Substance use disorder (SUD) is a major risk factor for homelessness, but the specific association of opioid use disorder (OUD) and homelessness in the context of their shared risk factors has not been the focus of prior studies. We used national data from the United States Veterans Health Administration (VHA) to examine the association of OUD and homelessness in the context of shared risk factors. METHODS In this cross-sectional analysis of veterans who received VHA care during Fiscal Year 2012 (N = 5,450,078), we compared the prevalence of OUD and other sociodemographic, and clinical factors among homeless and non-homeless veterans. We estimated the odds ratio for homelessness associated with OUD alone, and after adjusting for other factors through multivariate logistic regression. RESULTS Homeless veterans had substantially higher prevalence of OUD than other VHA patients (7.7 % Vs 0.6 %) and OUD was associated with 13 times higher unadjusted odds of homelessness (Odds Ratio [OR] 13.36, 95 % CI 13.09-13.62), which decreased with adjustment for sociodemographic factors (black race, mean income and age), other SUD, medical, and psychiatric diagnoses (final OR 1.57, 95 % CI 1.53-1.61). Other SUDs (alcohol, cannabis, cocaine, and hallucinogens) showed similar or slightly higher odds of homelessness as OUD in the final model. CONCLUSIONS OUD was strongly associated with homelessness among US veterans although this association was largely but not entirely attenuated by shared sociodemographic and co-morbid risk factors including several other SUDs. Treatment of homeless veterans with OUD should address socio-economic vulnerabilities and other co-morbidities in addition to treatments for OUD.
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Cole ES, Drake C, DiDomenico E, Sharbaugh M, Kim JY, Nagy D, Cochran G, Gordon AJ, Gellad WF, Pringle J, Warwick J, Chang CCH, Kmiec J, Kelley D, Donohue JM. Patterns of clinic switching and continuity of medication for opioid use disorder in a Medicaid-enrolled population. Drug Alcohol Depend 2021; 221:108633. [PMID: 33631544 PMCID: PMC8931627 DOI: 10.1016/j.drugalcdep.2021.108633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 01/14/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses. OBJECTIVE To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose. DESIGN Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data. MAIN MEASURES MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose. RESULTS Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24-1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13-1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01-1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10-1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95-0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36-1.44). We did not observe a relationship between opioid-related overdose and clinic switches. CONCLUSIONS Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.
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Affiliation(s)
- Evan S Cole
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States.
| | - Coleman Drake
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States
| | - Ellen DiDomenico
- Pennsylvania Department of Drug and Alcohol Programs 2601 N 3rd St, Harrisburg, PA, 17110, United States
| | - Michael Sharbaugh
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States
| | - Joo Yeon Kim
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States
| | - Dylan Nagy
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States
| | - Gerald Cochran
- University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, 295 Chipeta Way, Salt Lake City, UT, 84132, United States
| | - Adam J Gordon
- University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, 295 Chipeta Way, Salt Lake City, UT, 84132, United States
| | - Walid F Gellad
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States; University of Pittsburgh School of Medicine, Division of General Internal Medicine, UPMC Montefiore Hospital, Suite W933, Pittsburgh, PA, 15213, United States
| | - Janice Pringle
- University of Pittsburgh School of Pharmacy, Program Evaluation and Research Unit 5607 Baum Blvd, Pittsburgh, PA, 15206, United States
| | - Jack Warwick
- University of Pittsburgh School of Pharmacy, Program Evaluation and Research Unit 5607 Baum Blvd, Pittsburgh, PA, 15206, United States
| | - Chung-Chou H Chang
- University of Pittsburgh School of Medicine, Division of General Internal Medicine, UPMC Montefiore Hospital, Suite W933, Pittsburgh, PA, 15213, United States
| | - Julie Kmiec
- University of Pittsburgh, Department of Psychiatry, Thomas Detre Hall, 3811 O'Hara Street, Pittsburgh, PA, 15213, United States
| | - David Kelley
- Pennsylvania Department of Human Services, 625 Forster St, Harrisburg, PA, 17120, United States
| | - Julie M Donohue
- University of Pittsburgh Graduate School of Public Health, Department of Health Policy and Management, 130 DeSoto Street, Pittsburgh, PA, 15261, United States
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Manhapra A, Rosenheck R. Commentary on Lin et al.: Saving lives during the opioid crisis-widening the focus from opioid use disorder to polysubstance use disorder and to multimorbidity. Addiction 2021; 116:105-106. [PMID: 32918327 DOI: 10.1111/add.15229] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/19/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ajay Manhapra
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States.,New England Mental Illness Research Education Clinical Center, VA Connecticut Healthcare System, West Haven, CT, United States.,Hampton VA Medical Center, Hampton, VA, United States.,Departments of Physical Medicine and Rehabilitation and Psychiatry, Eastern Virginia Medical School, Norfolk, VA, United States
| | - Robert Rosenheck
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, United States.,New England Mental Illness Research Education Clinical Center, VA Connecticut Healthcare System, West Haven, CT, United States
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Fendrich M, Becker J, Ives M, Rodis E, Marín M. Treatment Retention in Opioid Dependent Clients Receiving Medication-Assisted Treatment: Six-Month Rate and Baseline Correlates. Subst Use Misuse 2021; 56:1018-1023. [PMID: 33843448 DOI: 10.1080/10826084.2021.1906276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
In the current opioid overdose epidemic, treatment retention among clients receiving medication-assisted treatment (MAT) for opioid dependence is a significant and growing concern among treatment providers, policymakers, and researchers. Methods: We examined a sample of clients enrolled in a federally funded MAT expansion program implemented in four sites in Connecticut. Program participants received MAT for their opioid use disorders (OUDs). All program sites utilized a person in recovery from OUD (a recovery support coach, RSC) as part of the treatment team. By performing bivariate analyses and multivariate logistic regression models, we evaluated the association of 6-month retention and program site, gender, age, race/ethnicity, and past month substance use. Results: At 6-month follow-up, 58.9% of participants were classified as "retained." Multivariate logistic regression analysis revealed that participants who were older, reported no past month cocaine/crack use, or reported any illegal drug use other than cocaine/crack, were significantly more likely to be retained in treatment at follow-up. Conclusions: Retention rates were relatively high in these Connecticut sites compared to those examined in previous literature. Findings suggest that efforts for enhancing retention and successful treatment outcomes need to consider and potentially address the unique needs, problems, and risks of younger clients and clients with crack/cocaine involvement. The importance of drug use screening for those entering MAT is underscored. Future research needs to explore how levels of client involvement in adjunctive therapies may impact their retention.
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Affiliation(s)
- Michael Fendrich
- University of Connecticut, School of Social Work, Hartford, Connecticut, USA
| | - Jessica Becker
- University of Connecticut, School of Social Work, Hartford, Connecticut, USA
| | - Melissa Ives
- University of Connecticut, School of Social Work, Hartford, Connecticut, USA.,Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut, USA
| | - Eleni Rodis
- University of Connecticut, School of Social Work, Hartford, Connecticut, USA.,Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut, USA
| | - Martha Marín
- University of Connecticut, School of Social Work, Hartford, Connecticut, USA.,Connecticut Department of Mental Health and Addiction Services, Hartford, Connecticut, USA
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46
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Lin LA, Bohnert ASB, Blow FC, Gordon AJ, Ignacio RV, Kim HM, Ilgen MA. Polysubstance use and association with opioid use disorder treatment in the US Veterans Health Administration. Addiction 2021; 116:96-104. [PMID: 32428386 DOI: 10.1111/add.15116] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 02/14/2020] [Accepted: 05/12/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Lewei A Lin
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Amy S B Bohnert
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
| | - Frederic C Blow
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.,Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Rosalinda V Ignacio
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - H Myra Kim
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Consulting for Statistics, Computing and Analytics Research (CSCAR), University of Michigan, Ann Arbor, MI, USA
| | - Mark A Ilgen
- Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.,Addiction Center, Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
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Ker S, Hsu J, Balani A, Mukherjee SS, Rush AJ, Khan M, Elchehabi S, Huffhines S, DeMoss D, Rentería ME, Sarkar J. Factors That Affect Patient Attrition in Buprenorphine Treatment for Opioid Use Disorder: A Retrospective Real-World Study Using Electronic Health Records. Neuropsychiatr Dis Treat 2021; 17:3229-3244. [PMID: 34737569 PMCID: PMC8560173 DOI: 10.2147/ndt.s331442] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 10/08/2021] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To describe attrition patterns of opioid use disorder (OUD) patients treated with buprenorphine (BUP) and to assess how clinical, sociodemographic, or BUP medication dosing features are associated with attrition. PATIENTS AND METHODS Electronic health records of adults (16+ year-olds) with OUD treated with BUP from 23 different substance use or mental health care programs across 11 US states were examined for one year following BUP initiation in inpatient (IP), intensive outpatient (IOP), or outpatient (OP) settings. Treatment attrition was declared at >37 days following the last recorded visit. Survival analyses and predictive modelling were used. RESULTS Retention was consistently 2-3 times higher following BUP initiation in OP (n = 2409) than in IP/IOP (n = 2749) settings after 2 (50% vs 25%), 6 (27% vs 9%) and 12 months (14% vs 4%). Retention was higher for females, whites (vs blacks), and those with less severe OUD, better global function, or not using non-psychotropic medications. Comorbid substance use, other psychiatric disorders, and the number of psychotropic medications were variously related to retention depending on the setting in which BUP was initiated. Predictive modelling revealed that a higher global assessment of functioning and a smaller OUD severity based on the Clinical Global Impression - Severity led to longer retentions, a higher initial BUP dose led to higher retention in a few cases, an OP setting of BUP initiation led to longer retentions, and a lower total number of psychotropic and non-psychotropic medications led to longer retentions. These were the most important parameters in the model, which identified 75.2% of patients who left BUP treatment within three months post-initiation, with a precision of 90.5%. CONCLUSION Of all the OUD patients who began BUP, 50-75% left treatment within three months, and most could be accurately identified. This could facilitate patient-centered management to better retain OUD patients in BUP treatment.
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Affiliation(s)
- Sheryl Ker
- Holmusk Technologies, Inc., New York, NY, USA
| | - Jennifer Hsu
- John Peter Smith Health Network, Fort Worth, TX, USA
| | | | | | - A John Rush
- Department of Psychiatry, Duke-National University of Singapore (NUS), Singapore.,Duke University School of Medicine, Durham, NC, USA.,Texas Tech Health Sciences Center, Odessa, TX, USA
| | - Mehreen Khan
- John Peter Smith Health Network, Fort Worth, TX, USA
| | | | | | - Dustin DeMoss
- John Peter Smith Health Network, Fort Worth, TX, USA.,University of North Texas Health Science Center/Texas Christian University, Fort Worth, TX, USA
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48
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Feder R. Ten Years of Experience With Buprenorphine in a Private Psychiatric Outpatient Practice. Am J Addict 2020; 29:508-514. [DOI: 10.1111/ajad.13060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/19/2020] [Accepted: 05/02/2020] [Indexed: 11/27/2022] Open
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Abstract
Understanding the molecular biology of opioid analgesia is essential for its proper implementation and mechanistic approach to its modulation in order to maximize analgesia and minimize undesired effects. By appreciating the molecular mechanisms intrinsic to opioid analgesia, one can manipulate a molecular target to augment or diminish a specific effect using adjuvant drugs, select an appropriate opioid for opioid rotation or define a molecular target for new opioid drug development. In this review, we present the cellular and molecular mechanisms of opioid analgesia and that of the associated phenomena of tolerance, dependence, and hyperalgesia. The specific mechanisms highlighted are those that presently can be clinically addressed.
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50
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Agbese E, Leslie DL, Manhapra A, Rosenheck R. Early Discontinuation of Buprenorphine Therapy for Opioid Use Disorder Among Privately Insured Adults. Psychiatr Serv 2020; 71:779-788. [PMID: 32264801 DOI: 10.1176/appi.ps.201900309] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined the temporal relationship between early discontinuation of buprenorphine treatment and health care expenditures before and after treatment initiation. METHODS MarketScan commercial claims for patients who initiated buprenorphine for opioid use disorder in 2013 and had continuous insurance for the subsequent 12 months (N=6,444) were used to examine the relationship between treatment retention and health care expenditures before and after buprenorphine initiation. Analysis of covariance and generalized linear models (with gamma distribution/log link) were used to compare expenditures across four buprenorphine-retention groups (0-3, 3-6, 6-12, and 12 or more months). RESULTS Average total health care expenditures in the 3 months prior to buprenorphine initiation ranged from a high of $7,588 among those with the shortest retention to $4,929 among those with the longest retention (p<0.001). In the 12 months after buprenorphine initiation, total health care expenditures averaged $26,332 per year, with $2,916 (11.1%) in out-of-pocket expenditures. Average annual expenditures for medication were highest among patients with the longest buprenorphine retention, and total health care expenditures were highest among those with the shortest retention. Expenditures for health care services other than medication were highest among those with early discontinuation both before the initiation of buprenorphine and during the initial period after initiation but not in subsequent quarters. CONCLUSIONS Poorer treatment retention among privately insured adults was associated with greater clinical and financial burdens that preceded and continued during the period shortly following treatment initiation, suggesting that cost burdens may contribute to poor retention among privately insured adults.
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Affiliation(s)
- Edeanya Agbese
- Department of Public Health Sciences and Center for Applied Studies in Health Economics, Penn State College of Medicine, Hershey, Pennsylvania (Agbese, Leslie); U.S. Department of Veterans Affairs (VA) VISN 1 New England Mental Illness Research and Education Center, West Haven, Connecticut, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Manhapra, Rosenheck); Hampton VA Medical Center, Hampton, Virginia (Manhapra)
| | - Douglas L Leslie
- Department of Public Health Sciences and Center for Applied Studies in Health Economics, Penn State College of Medicine, Hershey, Pennsylvania (Agbese, Leslie); U.S. Department of Veterans Affairs (VA) VISN 1 New England Mental Illness Research and Education Center, West Haven, Connecticut, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Manhapra, Rosenheck); Hampton VA Medical Center, Hampton, Virginia (Manhapra)
| | - Ajay Manhapra
- Department of Public Health Sciences and Center for Applied Studies in Health Economics, Penn State College of Medicine, Hershey, Pennsylvania (Agbese, Leslie); U.S. Department of Veterans Affairs (VA) VISN 1 New England Mental Illness Research and Education Center, West Haven, Connecticut, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Manhapra, Rosenheck); Hampton VA Medical Center, Hampton, Virginia (Manhapra)
| | - Robert Rosenheck
- Department of Public Health Sciences and Center for Applied Studies in Health Economics, Penn State College of Medicine, Hershey, Pennsylvania (Agbese, Leslie); U.S. Department of Veterans Affairs (VA) VISN 1 New England Mental Illness Research and Education Center, West Haven, Connecticut, and Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut (Manhapra, Rosenheck); Hampton VA Medical Center, Hampton, Virginia (Manhapra)
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