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Roy PJ, Suda K, Luo J, Lee M, Anderton J, Olejniczak D, Liebschutz JM. Buprenorphine dispensing before and after the April 2021 X-Waiver exemptions: An interrupted time series analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 126:104381. [PMID: 38457960 DOI: 10.1016/j.drugpo.2024.104381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 02/23/2024] [Accepted: 02/28/2024] [Indexed: 03/10/2024]
Abstract
BACKGROUND Until the end of 2022, a special registration, known as the X-waiver, was required to prescribe buprenorphine in the US. Before its removal, US federal regulations trialed an X-waiver exemption, initiated on April 28, 2021, which permitted buprenorphine prescribing for up to 30 patients without additional training. We aimed to understand if these regulatory changes impacted buprenorphine dispensing. METHODS We conducted an interrupted time series analysis to understand changes in buprenorphine dispensing during the 26 weeks after the X-waiver exemption compared to the expected baseline trend established in the 26 weeks before using the IQVIA Longitudinal Prescription claims database. The primary outcome was number of new buprenorphine prescribers nationwide (defined as no prior buprenorphine prescription dispensed in the last 26 weeks). Segmented regression estimated relative changes in buprenorphine dispensing at 1, 13, and 26 weeks post-X-waiver change. RESULTS A total of 15,517,525 prescriptions filled for 1,328,172 patients (43.4 % female) ordered by 62,312 providers were included for analysis. At 26 weeks post-X-waiver change, there was no change in the number of new prescribers compared to the expected baseline trend (-2.7 % [95 % CI:-8.3,2.9]). The number of new (15.2 % [4.6,25.8]) and existing (1.7 % [0.9,2.4]) patients and patients per prescriber (4.3 % [3,5.6]) increased. Buprenorphine prescriptions reimbursed by Medicaid increased (7.5 % [6.6,8.4]) while commercial fills decreased (-3.4 % [-5.3,-1.5]). CONCLUSIONS The number of new prescribers did not increase six months post-X-waiver exemption while new patients continued to enter treatment at higher-than-expected rates. These findings suggest that additional interventions beyond the recent X-waiver removal may be needed to increase access to buprenorphine.
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Affiliation(s)
- Payel Jhoom Roy
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States.
| | - Katie Suda
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States; Center for Pharmaceutical Policy and Prescribing, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States; Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Jing Luo
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - MyoungKeun Lee
- Department of Oral and Craniofacial Sciences, Center for Craniofacial and Dental Genetics, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, United States
| | - Joel Anderton
- Department of Oral and Craniofacial Sciences, Center for Craniofacial and Dental Genetics, University of Pittsburgh School of Dental Medicine, Pittsburgh, PA, United States
| | - Donna Olejniczak
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
| | - Jane M Liebschutz
- Division of General Internal Medicine, Center for Research on Healthcare, Department of Medicine, UPMC/University of Pittsburgh, Pittsburgh, PA, United States
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Andraka-Christou B, Golan OK, Williams M, Buksbaum S, Gordon AJ, Stein BD. A Systematic Review of State Office-Based Buprenorphine Treatment Laws Effective During 2022: Counseling, Dosage, and Visit Frequency Requirements. SUBSTANCE USE & ADDICTION JOURNAL 2024; 45:278-291. [PMID: 38288697 DOI: 10.1177/29767342231223721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
BACKGROUND Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient limits applicable to office-based buprenorphine treatment (OBBT), among other settings, some states may still have policies imposing requirements on OBBT providers not required by federal law. METHODS We collected statutes and regulations from 50 US states and the District of Columbia (ie, 51 jurisdictions) between August 11 and November 30, 2022 using the Nexis Uni legal database and search terms related to OBBT counseling, dosage, and/or frequency of visits. We then used template analysis, a mixed deductive-inductive qualitative method, to analyze legal content. RESULTS Ten jurisdictions (20%) in 2022 had an OBBT counseling, dosage, and/or visit frequency requirement. Four jurisdictions had at least one law in each OBBT policy category examined. One-fifth of jurisdictions have OBBT policies not required under federal law. Five of these jurisdictions are among those with the highest overdose death rates per capita, according to publicly available data from 2021. Some OBBT requirements could potentially limit clinician interest in offering buprenorphine treatment or result in inadequate care (eg, if dosage limitations are too low.). CONCLUSIONS Even though a federal waiver is no longer required for OBBT, our results suggests that at least some jurisdictions have other OBBT requirements, such as counseling, dosage, and/or frequency requirements. Given the severity of the ongoing opioid overdose crisis, policymakers should carefully consider the extent to which OBBT requirements are evidence based.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine, University of Central Florida, Orlando, FL, USA
| | | | - Michelle Williams
- Legal Studies Department, University of Central Florida, Orlando, FL, USA
| | - Scott Buksbaum
- Legal Studies Department, University of Central Florida, Orlando, FL, 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
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Golan OK, Sheng F, Dick AW, Sorbero M, Whitaker DJ, Andraka-Christou B, Pigott T, Gordon AJ, Stein BD. Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 9:100193. [PMID: 37876376 PMCID: PMC10590758 DOI: 10.1016/j.dadr.2023.100193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/09/2023] [Accepted: 10/09/2023] [Indexed: 10/26/2023]
Abstract
Background Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status. Methods This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion. Results The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29). Conclusions Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.
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Affiliation(s)
- Olivia K. Golan
- NORC at the University of Chicago, Chicago, IL, United States
- School of Public Health, Georgia State University, Atlanta, Georgia
| | | | | | | | | | - Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, United States
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL, United States
| | - Therese Pigott
- School of Public Health, Georgia State University, Atlanta, Georgia
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
- 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, United States
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Silwal A, Talbert J, Bohler RM, Kelsch J, Cook C, Blevins D, Gallivan M, Hunt T, Hatcher SM, Thomas CP, Williams S, Fanucchi L, Lofwall MR. State alignment with federal regulations in 2022 to relax buprenorphine 30-patient waiver requirements. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 7:100164. [PMID: 37234704 PMCID: PMC10206439 DOI: 10.1016/j.dadr.2023.100164] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 04/28/2023] [Accepted: 05/01/2023] [Indexed: 05/28/2023]
Abstract
Background In 2021, the Department of Health and Human Services released guidelines allowing waiver-eligible providers seeking to treat up to 30 patients to be exempt from waiver training (WT) and the counseling and other ancillary services (CAS) attestation. This study evaluates if states and the District of Columbia had more restrictive policies preventing adoption of the 2021 federal guidelines. Methods First, the Westlaw database was searched for buprenorphine regulations. Second, state medical, osteopathic, physician assistant, nursing boards, and single state agencies (SSA) were surveyed to assess for the WT and CAS requirements and if they were discussing the 2021 guidelines. Results were recorded and compared by state and waiver-eligible provider types. Results The Westlaw search revealed seven states with regulations requiring the WT and ten states requiring CAS. Survey results showed ten state boards/SSAs required WT for at least one waiver-eligible practitioner type and eleven state boards/SSAs required CAS. In some states, the WT and CAS requirements only applied in special circumstances. Eleven states had discrepancies between the Westlaw and survey results among three waiver-eligible provider types. Conclusions Despite the 2021 federal change intended to increase access to buprenorphine, several states had regulations and/or provider boards and SSAs that were not supportive. Now, the Mainstreaming Addiction Treatment (MAT) Act of 2022 eliminated the federal x-waiver requirement to prescribe buprenorphine. However, these states may continue to have barriers to treatment access despite the MAT Act. Strategies to engage states with these restrictive policies are needed to improve buprenorphine treatment capacity.
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Affiliation(s)
- Anita Silwal
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
- Department of Communication, College of Communication and Information, University of Kentucky, Lexington, KY, USA
| | - Jeffery Talbert
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Robert M. Bohler
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Jordan Kelsch
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Christopher Cook
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Derek Blevins
- Division of Substance Use Disorders, New York State Psychiatric Institute / Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, USA
| | - Molly Gallivan
- Substance Use Priority Research Area (SUPRA), University of Kentucky, Lexington KY, USA
| | - Timothy Hunt
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | | | - Cindy Parks Thomas
- Heller School for Social Policy and Management at Brandeis University, Waltham, MA, USA
| | - Soncere Williams
- Social Intervention Group, School of Social Work, Columbia University, New York, NY, USA
| | - Laura Fanucchi
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Division of Infectious Diseases, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Michelle R. Lofwall
- Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, USA
- Departments of Behavioral Science and Psychiatry, College of Medicine, University of Kentucky, Lexington, KY, USA
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Treitler P, Nowels M, Samples H, Crystal S. Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access. JAMA Netw Open 2023; 6:e2312030. [PMID: 37145594 PMCID: PMC10163388 DOI: 10.1001/jamanetworkopen.2023.12030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/20/2023] [Indexed: 05/06/2023] Open
Abstract
Importance Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization. Objective To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access. Design, Setting, and Participants This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021. Exposure Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence. Main Outcomes and Measures Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty. Results Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation. Conclusions and Relevance In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.
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Affiliation(s)
- Peter Treitler
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
| | - Molly Nowels
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Hillary Samples
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
| | - Stephen Crystal
- Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- School of Social Work, Rutgers University, New Brunswick, New Jersey
- School of Public Health, Rutgers University, Piscataway, New Jersey
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Spetz J, Hailer L, Gay C, Tierney M, Schmidt LA, Phoenix B, Chapman SA. Buprenorphine Treatment: Advanced Practice Nurses Add Capacity. Health Aff (Millwood) 2022; 41:1231-1237. [PMID: 36067440 PMCID: PMC11062238 DOI: 10.1377/hlthaff.2022.00310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
During the COVID-19 pandemic, there was slower growth in the number of new waivers authorizing clinicians to provide buprenorphine treatment for opioid use disorder. However, treatment capacity grew at a stable rate as a result of already authorized clinicians obtaining waivers for larger patient panels. Advanced practice nurses accounted for the largest portion of capacity growth during the pandemic.
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Affiliation(s)
- Joanne Spetz
- Joanne Spetz , University of California San Francisco, San Francisco, California
| | | | - Caryl Gay
- Caryl Gay, University of California San Francisco
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