The Supply of Physicians Waivered to Prescribe Buprenorphine for Opioid Use Disorders in the United States: A State-Level Analysis

Availability and Opportunities for Expansion of Buprenorphine for the Treatment of Opioid Use Disorder

There is an urgent need to expand access to treatment for persons with opioid use disorder (OUD). As neurologists may frequently encounter patients with chronic pain who have developed OUD, they are in a position to serve as advocates for treatment. Buprenorphine is the most scalable medication for OUD in the United States, yet expansion has plateaued in recent years despite growing treatment needs. Reluctance of providers to establish treatment with new patients, challenges with rural expansion, stigma related to buprenorphine-based care, and pharmacy pressures that incentivize low dispensing and inventories may have stalled expansion. This review introduces these challenges before outlining actionable and evidenced-based strategies that warrant investigation, including methods to improve patient access to care (remotely delivered care, mobile delivery programs, Bridge programs) and provider retention and confidence in prescribing (expert consults, Extension for Community Healthcare Outcomes, a telementoring model, hub-and-spoke services), as well as novel innovations (virtual reality, artificial intelligence, wearable technologies). Overall, fortifying existing delivery systems while developing new transformative models may be necessary to achieve more optimal levels of buprenorphine treatment expansion.

"They make it too hard and too many hoops to jump": system and organizational barriers to drug treatment during epidemic rates of opioid overdose

INTRODUCTION

The United States is currently facing an opioid overdose crisis. Research suggests that multiple interventions are needed to reduce overdose deaths including increasing access and retention to medications to treat opioid use disorders (MOUD, i.e., methadone, buprenorphine, and naltrexone) and increasing the distribution and use of naloxone, a medication that can reverse the respiratory depression that occurs during opioid overdoses. However, barriers to MOUD initiation and retention persist and discontinuations of MOUD carry a heightened risk of overdose. Many times, MOUD is not sought as a first line of treatment by people with opioid use disorder (OUD), many of whom seek treatment from medically managed withdrawal (detox) programs. Among those who do initiate MOUD, retention is generally low. The present study examines the treatment experiences of people who use opioids in three states, Connecticut, Kentucky, and Wisconsin.

METHODS

We conducted in-depth interviews with people who use opioids in a rural, urban, and suburban area of three states: Connecticut, Kentucky and Wisconsin. Data analysis was collaborative and key themes were identified through multiple readings, coding of transcripts and discussion with all research team members.

RESULTS

Results reveal a number of systemic issues that reduce the likelihood that people initiate and are retained on MOUD including the ubiquity of detox as a first step in drug treatment, abstinence requirements and requiring patients to attend group treatment. MOUD-related stigma was a significant factor in the kinds of treatment participants chose and their experiences in treatment.

CONCLUSIONS

Interventions to reduce MOUD stigma are needed to encourage MOUD as a first course of treatment. Eliminating abstinence-based rules for MOUD treatment may improve treatment retention and decrease overdose risk.

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

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.

Racial/ethnic disparities in timely receipt of buprenorphine among Medicare disability beneficiaries

BACKGROUND

Medicare disability beneficiaries (MDBs) have disproportionately high risk of opioid use disorder (OUD) and related harms given high rates of comorbidities and high-dose opioid prescribing. Despite this increased risk, little is known about timely receipt of medication for opioid use disorder (MOUD), including potential disparities by patient race/ethnicity or moderation by county-level characteristics.

METHODS

National Medicare claims for a sample of MDBs with incident OUD diagnosis between March 2016 and June 2019 were linked with county-level data. Multivariable mixed effects Cox proportional hazards models estimated time (in days) to buprenorphine receipt within 180 days of incident OUD diagnosis. Primary exposures included individual-level race/ethnicity and county-level buprenorphine prescriber availability, percent non-Hispanic white (NHW) residents, and Social Deprivation Index (SDI) score.

RESULTS

The sample (n=233,079) was predominantly White (72.3%), ≥45 years old (76.3%), and male (54.8%). Black (adjusted hazard ratio [aHR]=0.50; 95% CI, 0.47-0.54), Asian/Pacific Islander (aHR=0.54; 95% CI, 0.41-0.72), Hispanic/Latinx (aHR=0.81; 95% CI, 0.76-0.87), and Other racial/ethnic groups (aHR=0.75; 95% CI, 0.58-0.97) had a lower likelihood of timely buprenorphine than non-Hispanic white beneficiaries after adjusting for individual and county-level confounders. Timely buprenorphine receipt was positively associated with county-level buprenorphine prescriber availability (aHR=1.05; 95% CI, 1.04-1.07), percent non-Hispanic white residents (aHR=1.01; 95% CI, 1.00-1.01), and SDI (aHR=1.06; 95% CI, 1.01-1.10).

CONCLUSIONS

Racial/ethnic disparities highlight the need to improve access to care for underserved groups. Implementing equity-focused quality and performance measures and developing interventions to increase office-based buprenorphine prescribing in predominantly minority race/ethnicity counties may reduce disparities in timely access to medication for OUD.

A comparison of mortality rates for buprenorphine versus methadone treatments for opioid use disorder

OBJECTIVE

Mortality from opioid use disorder (OUD) can be reduced for patients who receive opioid agonist treatment (OAT). In the United States (US), OATs have different requirements including nearly daily visits to a dispensing facility for methadone but weekly to monthly prescriptions for buprenorphine. Our objective was to compare mortality rates for buprenorphine and methadone treatments among a large sample of US patients with OUD.

METHODS

We measured all-cause mortality, overdose mortality, and suicide mortality among US Department of Veterans Affairs patients with a diagnosis of OUD who received OAT from 2010 through 2019. We leveraged substantial and sustained regional variation in prescribing buprenorphine versus methadone as an instrumental variable (IV) and used inverse propensity of treatment weighting to balance relevant covariates across treatment groups. We compared mortality with true two-stage IV using both probit and linear probability models, as well as a reduced form IV model, adjusting for demographics and health status.

RESULTS

Our cohort consisted of 61,997 patients with OUD who received OAT, of whom 92.7% were male with a mean age of 47.9 (SD = 14.1) years. Patients were followed for a median of 2 (IQR = 1,4) calendar years. Across regional terciles, mean methadone prescribing was 4.8%, 19.5%, and 75.1% of OAT patients. All models identified significant reductions in all-cause and suicide mortality for buprenorphine relative to methadone. For example, predicted all-cause mortality from the probit model was 169.7 per 10,000 person years (95% CI, 157.8, 179.6) in the lowest tercile of methadone prescribing compared with 206.1 (95% CI, 196.0, 216.3) in the highest tercile. No difference was identified for overdose mortality.

CONCLUSION

We found significantly lower all-cause mortality and suicide mortality rates for buprenorphine compared with methadone. Our results support the less restrictive prescribing practices for buprenorphine as OAT in the US.

Patterns in Geographic Distribution of Substance Use Disorder Treatment Facilities in the US and Accepted Forms of Payment From 2010 to 2021

Importance

The drug overdose crisis is a continuing public health problem and is expected to grow substantially in older adults. Understanding the geographic accessibility to a substance use disorder (SUD) treatment facility that accepts Medicare can inform efforts to address this crisis in older adults.

Objective

To assess whether geographic accessibility of services was limited for older adults despite the increasing need for SUD and opioid use disorder treatments in this population.

Design, Setting, and Participants

This longitudinal cross-sectional study obtained data on all licensed SUD treatment facilities for all US counties and Census tracts listed in the National Directory of Drug and Alcohol Abuse Treatment Programs from 2010 to 2021.

Main Outcomes and Measures

Measures included the national proportion of treatment facilities accepting Medicare, Medicaid, private insurance, or cash as a form of payment; the proportion of counties with a treatment facility accepting each form of payment; and the proportion of the national population with Medicare, Medicaid, private insurance, or cash payment residing within a 15-, 30-, or 60-minute driving time from an SUD treatment facility accepting their form of payment in 2021.

Results

A total of 11 709 SUD treatment facilities operated across the US per year between 2010 and 2021 (140 507 facility-year observations). Cash was the most commonly accepted form of payment (increasing slightly from 91.0% in 2010 to 91.6% by 2021), followed by private insurance (increasing from 63.5% to 75.3%), Medicaid (increasing from 54.0% to 71.8%), and Medicare (increasing from 32.1% to 41.9%). The proportion of counties with a treatment facility that accepted Medicare as a form of payment also increased over the same study period from 41.2% to 53.8%, whereas the proportion of counties with a facility that accepted Medicaid as a form of payment increased from 53.5% to 67.1%. The proportion of Medicare beneficiaries with a treatment facility that accepted Medicare as a form of payment within a 15-minute driving time increased from 53.3% to 57.0%. The proportion of individuals with a treatment facility within a 15-minute driving time that accepted their respective form of payment was 73.2% for those with Medicaid, 69.8% for those with private insurance, and 71.4% for those with cash payment in 2021.

Conclusions and Relevance

Results of this study suggest that Medicare beneficiaries have less geographic accessibility to SUD treatment facilities given that acceptance of Medicare is low compared with other forms of payment. Policy makers need to consider increasing reimbursement rates and using additional incentives to encourage the acceptance of Medicare.

Variations in national availability of waivered buprenorphine prescribers by racial and ethnic composition of zip codes

BACKGROUND

Opioid overdose remains a public health crisis in diverse communities. Between 2019 and 2020, there was an almost 40% increase in drug fatalities primarily due to opioid analogues of both stimulants and opioids. Medications for opioid use disorder (MOUD; e.g., buprenorphine) are effective, evidence-based treatments that can be delivered in office-based primary care settings. We investigated disparities in the proportion of national prescribers who have obtained a waiver issued to prescribe MOUD by demographic characteristics.

METHODS

Data for the secondary data analyses were obtained from the Drug Enforcement Administration that maintains data on waivered MOUD prescribers across the US. Proportion of waivered prescribers were examined by ZIP code, race and ethnicity composition, socioeconomic status, insurance, and urban-rural designation using generalized linear mixed effects models.

RESULTS

Compared with predominantly Non-Hispanic White ZIP codes, other racially and ethnically diverse areas had a higher proportion of waivered buprenorphine prescribers. Differences in prescriber availability between predominant racial group was dependent on rurality based on the interaction found in our fitted model. In metropolitan areas, we found that predominantly Non-Hispanic White ZIP codes had a lower rate of waivered prescribers compared to predominantly Black/African American ZIP codes.

CONCLUSIONS

Our findings suggest that among AI/AN and Black/African American neighborhoods, availability of waivered prescribers may not be a primary barrier. However, availability of waivered prescribers and prescribing might potentially be an obstacle for Hispanic/Latinx and rural communities. Additional research to determine factors related to improving MOUD availability among diverse communities therefore remains vital to advancing health equity.

Barriers to care for perinatal patients with opioid use disorder: family physician perspectives

BACKGROUND

While barriers to care for pregnant patients with opioid use disorder (OUD) have been described, the experiences and challenges of the physicians providing care to these patients are poorly understood.

OBJECTIVES

To describe the experiences of family physicians providing comprehensive care to pregnant people with OUD and the challenges they face in providing such care.

METHODS

Qualitative thematic analysis of 17 semistructured interviews conducted from July 2019 to September 2020 with family physicians who possess a Drug Enforcement Administration "X" waiver and provide care to pregnant patients.

RESULTS

Seventeen family physicians practicing in the United States who care for pregnant people with OUD were interviewed. They described physician-, patient-, and systems-level barriers to providing and accessing care for this patient population. Of the 12 interrelated themes regarding challenges to delivering and accessing this care, 3 were particularly salient: the pervasive effects of social determinants of health, a lack of adequately trained providers, and social stigma associated with pregnant people with OUD.

CONCLUSION

A comprehensive, multilevel, and multidisciplinary approach is necessary to address these barriers and move towards health equity for this vulnerable patient population.

Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design

BACKGROUND

The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown.

METHODS

We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD.

RESULTS

Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone.

CONCLUSIONS

Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.

Evaluating buprenorphine prescribing and opioid-related health outcomes following the expansion the buprenorphine waiver program

AIMS

To evaluate associations between new types of buprenorphine waivers (nurse practitioner and physician assistant [NP/PA]; 275-patient limit [MD/DO-275]) and both buprenorphine prescribing and health outcomes.

METHODS

Using comprehensive county-level data from California 2010-2018, we modeled quarterly associations between numbers of NP/PA and MD/DO-275 waivers and rates of buprenorphine prescribing, opioid-related deaths, emergency department (ED) visits, and hospitalizations among all counties and separately among metropolitan and nonmetropolitan counties using Poisson regression models with county and quarter fixed effects and adjusting for time-varying covariates.

RESULTS

Each additional NP/PA and MD/DO-275 waiver was associated with a 2.6% (95%CI: 1.1-4.1%) and 5.8% (4.1-7.4%) increase in buprenorphine prescribing among nonmetropolitan counties, respectively. Each additional MD/DO-275 waiver was associated with a 2.8% (1.0%-4.6%) increase in buprenorphine among metropolitan counties. There were no statistically significant associations between NP/PA waivers and buprenorphine prescribing among metropolitan counties or among either waiver type and opioid-related health outcomes.

CONCLUSIONS

NP/PA waivers were associated with increased buprenorphine prescribing among nonmetropolitan counties and MD/DO-275 waivers were associated with increased buprenorphine prescribing among both metropolitan and nonmetropolitan counties.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station

BACKGROUND

New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable.

METHODS

A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings.

RESULTS

Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations.

CONCLUSION

Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Federally Qualified Health Centers Can Expand Rural Access to Buprenorphine for Opioid Use Disorder in Arizona

Medication for Opioid Use Disorder (MOUD) is recommended, but not always accessible to those who desire treatment. This study assessed the impact of expanding access to buprenorphine through federally qualified health centers (FQHCs) in Arizona. We calculated mean drive-times to Arizona opioid treatment (OTP) locations, office-based opioid treatment (OBOT) locations, and FQHCs clinics using January 2020 location data. FQHCs were designated as OBOT or non-OBOT clinics to explore opportunities to expand treatment access to non-OBOT clinics (potential OBOTs) to further reduce drive-times for rural and underserved populations. We found that OTPs had the largest mean drive times (16.4 minutes), followed by OBOTs (7.1 minutes) and potential OBOTs (6.1 minutes). Drive times were shortest in urban block groups for all treatment types and the largest differences existed between OTPs and OBOTs (50.6 minutes) in small rural and in isolated rural areas. OBOTs are essential points of care for opioid use disorder treatment. They reduce drive times by over 50% across all urban and rural areas. Expanding buprenorphine through rural potential OBOT sites may further reduce drive times to treatment and address a critical need among underserved populations.

Medicaid participation among practitioners authorized to prescribe buprenorphine

INTRODUCTION

This study examines Medicaid participation among buprenorphine waivered providers in Virginia in 2019, with a particular focus on the prescribing differences between different physician specialties, nurse practitioners and physicians assistants (NP and PA).

METHODS

Secondary data sources include the 2019 DEA list of buprenorphine waivered prescribers, Virginia Medicaid claims for buprenorphine, physician characteristics from the Virginia Department of Health Professions, SAMHSA Behavioral Treatment Services Locator, and area level characteristics. This cross-sectional study is based on a linkage of Medicaid claims data to a list of Virginia practitioners authorized to prescribe buprenorphine in 2019. Using a two-part logistic regression, we assess prescriber license type and local area factors that are associated with: (1) the probability of prescribing buprenorphine to any Medicaid patients in 2019; (2) the number of Medicaid patients treated by each prescriber in 2019.

RESULTS

Adjusted odds ratios show that nurse practitioners with buprenorphine waivers are more likely to treat any Medicaid patients compared to physicians (odds ratio (OR), 2.016; p = 0.000). Among prescribers who treated any Medicaid patients, the probability of treating a large number of Medicaid patients was higher among nurse practitioners relative to physicians (OR, 2.869, p = 0.002). Medicaid participation was much higher among prescribers with patient limits of 100 and 275 compared to prescribers with patient limits of 30 (OR, 6.66, p = 0.000 and 29.40, p = 0.000, respectively).

CONCLUSIONS

State Medicaid programs have been at the forefront of addressing their state's opioid epidemic, including expanding access to buprenorphine treatment. This study provides evidence that targeted outreach efforts should include NP license types as well as physicians, and is consistent with prior studies showing that NP are especially important in filling treatment gaps for underserved areas and populations.

Transforming Behavioral Health Care in Virginia

The behavioral health care transformation in Virginia resulted not from one policy change but from multiple changes prior to Medicaid expansion. These changes combined to shape a new behavioral health landscape, with more providers and more treated patients. Virginia's layered approach may inform other states seeking to strengthen their capacity to fight the substance use epidemic, even as new epidemics emerge. The recent policy changes to procedures, outreach, eligibility, coverage, the workforce, and payment have laid the foundation for additional steps in the transformation of behavioral health care, including incorporating improvement in social determinants and addressing disparities.

Association between availability of medications for opioid use disorder in specialty treatment and use of medications among patients: A state-level trends analysis

INTRODUCTION

Access to medication for opioid use disorder (MOUD) is a recognized public health challenge to improving the health of people with opioid use disorder (OUD) in many communities. Prior studies have shown that although MOUD availability has increased over time, particularly in some states, many substance use treatment facilities still do not offer medications. The relationship between greater availability of MOUD and use of MOUD among patients in treatment programs is not well understood.

METHODS

We used the National Survey of Substance Abuse Treatment Services to calculate the percent of specialty facilities per state providing MOUD from 2007 to 2018 and the Treatment Episode Data Set-Admissions (TEDS-A) to estimate the likelihood that a patient would have MOUD as part of their treatment plan during the same time period. We estimated models with patient-level TEDS-A data as the outcome and state-aggregated one-year lagged availability of MOUD in facilities as the main predictor, stratifying by treatment facility type (intensive outpatient, non-intensive outpatient, and residential).

RESULTS

We found that increasing MOUD availability at the facility level was associated with increased MOUD use in non-intensive and residential facilities at the patient level. Specifically, a 10 percentage point increase in MOUD availability was associated with a 4.5 percentage point increase in MOUD use among patients of non-intensive outpatient facilities (p-value = 0.03), and a 2.5 percentage points increase in residential facilities (p-value = 0.02). Non-Whites and patients in the Northeast had greater likelihoods of increased MOUD use in response to increased availability by facilities.

CONCLUSION

Increasing MOUD availability among specialty treatment facilities is likely to promote better access to MOUD for patients seeking treatment for OUD.

Facilitators and barriers to utilization of medications for opioid use disorder in primary care in South Carolina

OBJECTIVE

Utilization of medications for opioid use disorder (MOUD) has not been widely adopted by primary care providers. This study sought to identify interprofessional barriers and facilitators for use of MOUD (specifically naltrexone and buprenorphine) among current and future primary care providers in a southeastern academic center in South Carolina.

METHOD

Faculty, residents, and students within family medicine, internal medicine, and a physician assistant program participated in focus group interviews, and completed a brief survey. Survey data were analyzed quantitatively, and focus group transcripts were analyzed using a deductive qualitative content analysis, based upon the theory of planned behavior.

RESULTS

Seven groups (N = 46) completed focus group interviews and surveys. Survey results indicated that general attitudes towards MOUD were positive and did not differ significantly among groups. Subjective norms around prescribing and controllability (i.e., beliefs about whether prescribing was up to them) differed between specialties and between level of training groups. Focus group themes highlighted attitudes about MOUD (e.g., "opens the flood gates" to patients with addiction) and perceived facilitators and barriers of using MOUD in primary care settings. Participants felt that although MOUD in primary care would improve access and reduce stigma for patients, prescribing requires improved provider education and an integrated system of care.

CONCLUSIONS

The results of this study provide an argument for tailoring education to specifically address the barriers primary care prescribers perceive. Results promote the utilization of active, hands-on learning approaches, to ultimately promote uptake of MOUD prescribing in the primary care setting in South Carolina.

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

BACKGROUND

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

Disparities Between US Opioid Overdose Deaths and Treatment Capacity: A Geospatial and Descriptive Analysis

INTRODUCTION

With opioid-related deaths reaching epidemic levels, gaining a better understanding of access to treatment for opioid use disorder (OUD) is critical. Most studies have focused on 1 side of the equation-either provider capacity or patients' need for care, as measured by overdose deaths. This study examines the overlay between treatment program availability and opioid mortality, comparing accessibility by region.

METHODS

Geospatial and statistical analyses were used to model OUD treatment programs relative to population density and opioid overdose death incidence at the state and county level. We computed a ratio between program capacity and mortality called the programs-per-death (PPD) ratio.

RESULTS

There were 40 274 opioid deaths in 2016 and 12 572 treatment programs across the contiguous 48 states, yielding a ratio of 1 program for every 3.2 deaths. Texas had the lowest number of treatment programs per 100 000 persons (1.4) and Maine the highest (13.2). West Virginia ranked highest in opioid deaths (39.09 per 100 000). Ohio, the District of Columbia, and West Virginia had the greatest mismatch between providers and deaths, with an average of 1 program for every 8.5 deaths. Over 32% of US counties had no treatment programs and among those with >10 deaths, nearly 2.5% had no programs. Over 19% of all counties had a ratio ≤1 provider facility per 10 deaths.

CONCLUSION

Assessing the overlay between treatment capacity and need demonstrated that regional imbalances exist. These data can aid in strategic planning to correct the mismatch and potentially reduce mortality in the most challenged geographic regions.

Geographic proximity to buprenorphine treatment providers in the U.S

OBJECTIVE

To combat the growing opioid epidemic, people who use drugs need access to medications for opioid use disorder (MOUD) as part of comprehensive treatment. Despite progress, treatment gaps remain. Our objective was to use a geospatial buffering model to estimate treatment access for buprenorphine providers nationally.

METHODS

Using buprenorphine provider location data from the Substance Abuse and Mental Health Services Administration (SAMHSA) and population estimates from the U.S. Census, we use geospatial distance buffering analyses to estimate the percent of the population who are within reasonable (10, 30, 50 mile) driving distances from a buprenorphine provider across the contiguous states. Pearson correlation coefficients were used to analyze relationships between variables.

RESULTS

There were 47,000 buprenorphine practitioners across the contiguous states, or 14.3 per every 100,000 persons. Approximately 28 million citizens, or 9.2 % of the population, were outside of a 10-mile distance from the nearest buprenorphine provider and 2.65 million outside of a 30-mile range. There was a positive correlation between state's percentage rurality and percentage outside distance buffers (r = .491, p < .000) and access is lower in areas of higher need Texas had the absolute highest number of people outside the 10-mile distance buffer (3.7 million), although South Dakota had 46 % of its overall population outside that access point.

CONCLUSIONS

Wide variability in treatment access to buprenorphine providers exists across all states. Improving geospatial proximity to buprenorphine providers is an important goal, but more work needs to be done to improve treatment access especially in certain states.

Buprenorphine waiver uptake among nurse practitioners and physician assistants: The role of existing waivered prescriber supply

BACKGROUND

Buprenorphine is an effective pharmacotherapy for the treatment of opioid use disorder (OUD), but recent increases in the rate of OUD in the U.S. have outpaced the supply of clinicians waivered to prescribe buprenorphine. To increase the supply of buprenorphine prescribers, the Comprehensive Addiction and Recovery Act expanded buprenorphine prescribing waiver eligibility beyond physicians to nurse practitioners (NP) and physician assistants (PA) in 2017. Little is known about patterns of waiver uptake among NPs and PAs. This study examined associations between the existing supply of waivered prescribers and waiver uptake among NPs and PAs in U.S. states.

METHODS

NP and PA waiver uptake was evaluated as the number of NPs or PAs obtaining an initial buprenorphine prescribing waiver per 10,000 state residents from January 2017 to December 2018 using data from the Buprenorphine Waiver Notification System. NP and PA waiver uptake was estimated as a function of existing waivered prescriber supply, OUD treatment capacity, and other state characteristics using generalized least squares (GLS) regression.

RESULTS

28,010 NPs and PAs have become waivered to prescribe buprenorphine since January 2017. GLS regressions indicated that waivered prescriber supply was significantly, positively associated with both NP (b = 0.101 p < 0.001) and PA (b = 0.030, p < 0.001) waiver uptake. Results suggest an addition of ten waivered prescribers to existing supply was associated with an increase of one waivered NP, and an addition of thirty-three waivered prescribers to existing supply was associated with an increase of one waivered PA.

CONCLUSIONS

NP and PA waiver uptake is strongly associated with the existing supply of waivered prescribers in a state, suggesting NPs and PAs may be more likely to acquire waivers in states with a high existing supply of buprenorphine prescribers. Additional policy solutions are needed to scale up the supply of buprenorphine prescribers in underserved states.

Rise and regional disparities in buprenorphine utilization in the United States

PURPOSE

Buprenorphine is an opioid partial agonist used to treat opioid use disorder. While several policy changes have attempted to increase buprenorphine availability, access remains well below optimal levels. This study characterized how buprenorphine utilization in the United States has changed over time and whether there are regional disparities in distribution of the medication.

METHODS

The amount of buprenorphine distributed from 2007 to 2017 was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Ordering System. Data were expressed as the percent change and milligrams per person in each state. The formulations and cost for prescriptions covered by Medicaid (2008 to 2018) were also examined.

RESULTS

Buprenorphine distributed to pharmacies increased about 7-fold (476.8 to 3179.9 kg) while the quantities distributed to hospitals grew 5-fold (18.6 to 97.6 kg) nationally from 2007 to 2017. Buprenorphine distribution per person was almost 20-fold higher in Vermont (40.4 mg/person) relative to South Dakota (2.1 mg/person). There was a strong association between the number of physicians authorized to prescribe buprenorphine and distribution per state (r[49] = +0.94, P < .0005). The buprenorphine/naloxone sublingual film (Suboxone) was the predominant formulation (92.6% of 0.31 million Medicaid prescriptions) in 2008 but accounted for less than three-fifth (57.3% of 6.56 million prescriptions) in 2018.

CONCLUSIONS

Although buprenorphine availability has substantially increased over the last decade, distribution was very nonhomogeneous across the United States.

Substance Use Disorder Assessment, Diagnosis, and Management for Patients Hospitalized With Severe Infections Due to Injection Drug Use

OBJECTIVES

Persons with injection drug use (IDU) have high healthcare utilization. Consequently, healthcare providers have opportunities to identify and treat underlying substance use disorders (SUD) that drive these hospitalizations. The study purpose was to characterize current SUD evaluation and treatment practices by primary and consulting services during hospitalization for severe infections related to IDU.

METHODS

This study is a retrospective chart review of inpatient admissions to an academic medical center. The 2 inclusion criteria were documentation of IDU in clinical notes and the presence of an infection likely related to IDU. Demographic and clinical data were extracted from electronic medical records.

RESULTS

A total of 108 inpatient admissions met inclusion criteria and were included in the study. The most common infections related to IDU were endocarditis (n = 65, 60.2%) and osteomyelitis (n = 27, 25.0%). The primary team explicitly documented substance use in the H&P and progress notes in 103 (95.4%) hospitalizations and in 84 (77.8%) at discharge. Opioid use disorder was coded by International Classification of Diseases, Ninth Revision in 62 (57.4%). The most frequent intervention was screening, brief intervention, and referral to treatment in 99 (91.7%) episodes. The vast majority of patients did not have specific plans or recommendations for SUD treatment upon discharge.

CONCLUSIONS

Though more than half of the patients in this study had opioid use disorder, pharmacotherapy for opioid use disorder was typically not provided, and screening, brief intervention, and referral to treatment (SBIRT) was the most common intervention. There are significant gaps in the clinical assessment, diagnosis, and management of SUD in persons hospitalized with life-threatening complications of IDU, leaving many opportunities to improve care for this complex patient population.

Responses among substance abuse treatment providers to the opioid epidemic in the USA: Variations in buprenorphine and methadone treatment by geography, operational, and payment characteristics, 2007-16

Objective

To identify the geographic, organisational, and payment correlates of buprenorphine and methadone treatment among substance abuse treatment (SAT) providers.

Methods

Secondary analyses of the National Survey of Substance Abuse Treatment Services (NSSATS) from 2007–16 were conducted. We provide bivariate descriptive statistics regarding substance abuse treatment services which offered buprenorphine and methadone treatment from 2007–16. Using multiple logistic regression, we regressed geographic, organisational, and payment correlates on buprenorphine and methadone treatment.

Results

Buprenorphine is increasingly offered at SAT facilities though uptake remains comparatively low outside of the northeast. SAT facilities run by tribal governments or Indian Health Service which offer buprenorphine remain low compared to privately operated SAT facilities (AOR = 0.528). The odds of offering buprenorphine among facilities offering free or no charge treatment (AOR = 0.838) or a sliding fee scale (AOR = 0.464) was lower. SAT facilities accepting Medicaid payments showed higher odds of offering methadone treatment (AOR = 2.035).

Conclusions

Greater attention towards the disparities in provision of opioid agonist therapies is warranted, especially towards the reasons why uptake has been moderate among civilian providers. Additionally, the care needs of Native Americans facing opioid-related use disorders bears further scrutiny.

Strengths and weaknesses of existing data sources to support research to address the opioids crisis

Better opioid prescribing practices, promoting effective opioid use disorder treatment, improving naloxone access, and enhancing public health surveillance are strategies central to reducing opioid-related morbidity and mortality. Successfully advancing and evaluating these strategies requires leveraging and linking existing secondary data sources. We conducted a scoping study in Fall 2017 at RAND, including a literature search (updated in December 2018) complemented by semi-structured interviews with policymakers and researchers, to identify data sources and linking strategies commonly used in opioid studies, describe data source strengths and limitations, and highlight opportunities to use data to address high-priority public health research questions. We identified 306 articles, published between 2005 and 2018, that conducted secondary analyses of existing data to examine one or more public health strategies. Multiple secondary data sources, available at national, state, and local levels, support such research, with substantial breadth in data availability, data contents, and the data's ability to support multi-level analyses over time. Interviewees identified opportunities to expand existing capabilities through systematic enhancements, including greater support to states for creating and facilitating data use, as well as key data challenges, such as data availability lags and difficulties matching individual-level data over time or across datasets. Multiple secondary data sources exist that can be used to examine the impact of public health approaches to addressing the opioid crisis. Greater data access, improved usability for research purposes, and data element standardization can enhance their value, as can improved data availability timeliness and better data comparability across jurisdictions.

Differences in Availability and Use of Medications for Opioid Use Disorder in Residential Treatment Settings in the United States

Importance

While many individuals with opioid use disorder seek treatment at residential facilities to initiate long-term recovery, the availability and use of medications for opioid use disorder (MOUDs) in these facilities is unclear.

Objective

To examine differences in MOUD availability and use in residential facilities as a function of Medicaid policy, facility-level factors associated with MOUD availability, and admissions-level factors associated with MOUD use.

Design, Setting, and Participants

This cross-sectional study used deidentified facility-level and admissions-level data from 2863 residential treatment facilities and 232 414 admissions in the United States in 2017. Facility-level data were extracted from the 2017 National Survey of Substance Abuse Treatment Services, and admissions-level data were extracted from the 2017 Treatment Episode Data Set-Admissions. Statistical analyses were conducted from June to November 2019.

Exposures

Admissions for opioid use disorder at residential treatment facilities in the United States that identified opioids as the patient's primary drug of choice.

Main Outcomes and Measures

Availability and use of 3 MOUDs (ie, extended-release naltrexone, buprenorphine, and methadone).

Results

Of 232 414 admissions, 205 612 (88.5%) contained complete demographic data (166 213 [80.8%] aged 25-54 years; 136 854 [66.6%] men; 151 867 [73.9%] white). Among all admissions, MOUDs were used in only 34 058 of 192 336 (17.7%) in states that expanded Medicaid and 775 of 40 078 (1.9%) in states that did not expand Medicaid (P < .001). A relatively low percentage of the 2863 residential treatment facilities in this study offered extended-release naltrexone (854 [29.8%]), buprenorphine (953 [33.3%]), or methadone (60 [2.1%]). Compared with residential facilities that offered at least 1 MOUD, those that offered no MOUDs had lower odds of also offering psychiatric medications (odds ratio [OR], 0.06; 95% CI, 0.05-0.08; Wald χ21 = 542.09; P < .001), being licensed by a state or hospital authority (OR, 0.39; 95% CI, 0.27-0.57; Wald χ21 = 24.28; P < .001), or being accredited by a health organization (OR, 0.28; 95% CI, 0.23-0.33; Wald χ21 = 180.91; P < .001). Residential facilities that did not offer any MOUDs had higher odds of accepting cash-only payments than those that offered at least 1 MOUD (OR, 4.80; 95% CI, 3.47-6.64; Wald χ21 = 89.65; P < .001).

Conclusions and Relevance

In this cross-sectional study of residential addiction treatment facilities in the United States, MOUD availability and use were sparse. Public health and policy efforts to improve access to and use of MOUDs in residential treatment facilities could improve treatment outcomes for individuals with opioid use disorder who are initiating recovery.

Association between opioid analgesic therapy and initiation of buprenorphine management: An analysis of prescription drug monitoring program data

BACKGROUND

In the US, medication assisted treatment, particularly with office-based buprenorphine, has been an important component of opioid dependence treatment among patients with iatrogenic addiction to opioid analgesics. The predictors of initiating buprenorphine for addiction among opioid analgesic patients have not been well-described.

METHODS

We conducted a time-to-event analysis using data from the North Carolina (NC) Prescription Drug Monitoring Program (PDMP). Our outcome of interest was time-to-initiation of sublingual buprenorphine. Our study population was a prospective cohort of all state residents receiving a full-agonist opioid analgesic between 2011 and 2015. Predictors of initiation of sublingual buprenorphine examined included: age, gender, cumulative pharmacies and prescribers utilized, cumulative opioid intensity (defined as cumulative opioid exposure divided by duration of opioid exposure), and benzodiazepine dispensing.

FINDINGS

Of 4.3 million patients receiving opioid analgesics in NC between 2011 and 2015 (accumulated 8.30 million person-years of follow-up), and a total of 28,904 patients initiated buprenorphine formulations intended for addiction treatment (overall rate 3.48 per 1,000 person-years). In adjusted multivariate models, the utilization of 3 or more pharmacies (HR: 2.93; 95% CI: 2.82, 3.05) or 6 or more controlled substance prescribers (HR: 12.09; 95% CI: 10.76, 13.57) was associated with buprenorphine initiation. A dose-response relationship was observed for cumulative opioid intensity (HR in highest decile relative to lowest decile: 5.05; 95% CI: 4.70, 5.42). Benzodiazepine dispensing was negatively associated with buprenorphine initiation (HR: 0.63; 95% CI: 0.61, 0.65).

CONCLUSIONS

Opioid analgesic patients utilizing multiple prescribers or pharmacies are more likely to initiate sublingual buprenorphine. This finding suggests that patients with multiple healthcare interactions are more likely to be treated for high-risk opioid use, or may be more likely to be identified and treated for addiction. Future research should utilize prescription monitoring program data linked to electronic health records to include diagnosis information in analytic models.

Relationship of County Opioid Epidemic Severity to Changes in Access to Substance Use Disorder Treatment, 2009-2017

OBJECTIVE

The study measured the association between local opioid problem severity and changes in the availability of substance use disorder treatment programs, including the distance required for travel to treatment.

METHODS

A two-part, multivariable regression estimated the number of treatment facilities in the county (per 100,000 residents) and the number of miles to the nearest program (for all treatment programs, programs offering opioid use disorder medication, and programs accepting Medicaid) using data from the 2009-2017 National Directory of Drug and Alcohol Abuse Treatment Facilities. The unit of analysis was the county-year (N=28,270).

RESULTS

The probability of having at least one treatment program meeting the established criteria was greater in counties with a high-severity opioid problem than in counties with a low-severity problem, and the probability improved over time. In counties with a high-severity problem, the probability of having a treatment program offering buprenorphine, methadone, or both was 60.3% higher than in counties with low-severity problems. Between 2009 and 2017, the likelihood of having a treatment program that accepts Medicaid grew by 25.3%. For counties without treatment programs, the distance to the nearest program improved markedly over time, but there were no differences between distance to treatment in high-, moderate-, and low-severity status counties.

CONCLUSIONS

The treatment system has reduced structural barriers to treatment where it is most needed. However, these findings do not imply that the treatment system has sufficient capacity to address the present scope of the opioid crisis. Policy makers should leverage this responsiveness to incentivize additional improvements in access.

Availability of Buprenorphine Treatment in the 10 States With the Highest Drug Overdose Death Rates in the United States

OBJECTIVE

The objective of this study was to assess the accuracy of the Substance Abuse and Mental Health Services Administration (SAMHSA) database for patients who use it to seek buprenorphine treatment.

DESIGN AND MEASUREMENTS

Buprenorphine providers within a 25-mile radius of the county with the highest drug-related death rates within the 10 states with the highest drug-related death rates were identified and called to determine whether the provider worked there, prescribed buprenorphine, accepted insurance, had appointments, or charged for visits.

RESULTS

The number of providers listed in each county ranged from 1 to 166, with 5 counties having <10 providers. In 3 counties no appointments were obtained, and another 3 counties had ≤3 providers with availability. Of the 505 providers listed, 355 providers (70.3%) were reached, 310 (61.4%) of the 505 listings were correct numbers, and 195 (38.6%) of the 505 providers in the listings provided buprenorphine. Of the 173 clinics that provided buprenorphine and were asked about insurance, 131 (75.7%) accepted insurance. Of the 167 clinics that provided buprenorphine and were asked about Medicaid, 105 (62.9%) accepted it. Wait times for appointments ranged from 1 to 120 days, with an average of 16.8 days for those that had a waitlist. Among the 39 providers who reported out-of-pocket costs, the average cost was $231 (range: $90 to $600). One hundred forty of the 505 providers listed in the database had appointments available (27.7%). Three hundred sixty-five of the 505 providers did not have appointments available (72.3%) for various reasons, including the fact that 120 providers (32.9% of the 365 providers) could not be reached, and 137 of the numbers (37.5% of the 365 listed numbers) were wrong. Other reasons appointments could not be obtained included the fact that providers did not treat outpatients, were not accepting new patients, were out of office, or required a referral.

CONCLUSION

Although the SAMHSA buprenorphine practitioner locator is used by patients and providers to locate treatment options, only a small portion of clinicians in the database ultimately offered initial appointments, implying that the database is only marginally useful for patients.

Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment

This pilot study evaluated the feasibility of the Recovery Initiation and Management after Overdose (RIMO) intervention to link individuals to medication-assisted treatment (MAT) following an opioid overdose. The study team worked with the Chicago Fire Department to train Emergency Medical Service (EMS) teams to request permission from individuals after an opioid overdose reversal to release their contact information; individuals were subsequently contacted by the study team for participation. A mixed-methods study design comprised: (1) an experimental pilot study that examined participation at each stage of the intervention and compared the odds of treatment received for individuals who were randomly assigned to either the RIMO intervention (n = 16) or a passive referral control (n = 17); and (2) a focus group that was subsequently conducted with participants in the RIMO group to obtain their feedback on the intervention components. Quantitative data was collected on participant characteristics at study intake and treatment received was based on self-report at a 30-day follow-up. The RIMO group had higher odds of receiving any treatment for opioid use (OR = 7.94) and any MAT (OR = 20.2), and received significantly more days of opioid treatment (Ms=15.2 vs. 3.4) and more days of MAT in the 30 days post-randomization (Ms=11.2 vs. 0.76), relative to the control group (all p < .05). Qualitative data illustrated that participants valued the assertive outreach, engagement, and persistent follow-up components of RIMO, which differed from their prior experiences. The pilot study suggests that the RIMO intervention is able to address the challenges of linking and engaging individuals into MAT after an opioid overdose.

A systematic review of rural-specific barriers to medication treatment for opioid use disorder in the United States

BACKGROUND

Opioid-related deaths have risen dramatically in rural communities. Prior studies highlight few medication treatment providers for opioid use disorder in rural communities, though literature has yet to examine rural-specific treatment barriers.

OBJECTIVES

We conducted a systematic review to highlight the state of knowledge around rural medication treatment for opioid use disorder, identify consumer- and provider-focused treatment barriers, and discuss rural-specific implications.

METHODS

We systematically reviewed the literature using PsycINFO, Web of Science, and PubMed databases (January 2018). Articles meeting inclusion criteria involved rural samples or urban/rural comparisons targeting outpatient medication treatment for opioid use disorder, and were conducted in the U.S. to minimize healthcare differences. Our analysis categorized consumer- and/or provider-focused barriers, and coded barriers as related to treatment availability, accessibility, and/or acceptability.

RESULTS

Eighteen articles met inclusion, 15 which addressed consumer-focused barriers, while seven articles reported provider-focused barriers. Availability barriers were most commonly reported across consumer (n = 10) and provider (n = 5) studies, and included the lack of clinics/providers, backup, and resources. Acceptability barriers, described in three consumer and five provider studies, identified negative provider attitudes about addiction treatment, and providers' perceptions of treatment as unsatisfactory for rural patients. Finally, accessibility barriers related to travel and cost were detailed in four consumer-focused studies whereas two provider-focused studies identified time constraints.

CONCLUSIONS

Our findings consistently identified a lack of medication providers and rural-specific implementation challenges. This review highlights a lack of rural-focused studies involving consumer participants, treatment outcomes, or barriers impacting underserved populations. There is a need for innovative treatment delivery for opioid use disorder in rural communities and interventions targeting provider attitudes.

The Opioid Epidemic and Psychiatry: The Time for Action Is Now

The number of people with opioid use disorder and the number of overdose deaths in the United States have increased dramatically over the past 20 years. U.S. Congress passed the SUPPORT for Patients and Communities Act, which was signed into law in 2018, authorizing almost $8 billion to address the crisis. As experts in the treatment of central nervous systems disorders, psychiatrists can play a leading role in expanding treatment for people with opioid use disorder and in advocating for policy changes to support community treatment for this group.

Predictors of availability of long-acting medication for opioid use disorder

BACKGROUND

The U.S. Food and Drug Administration has approved three long-acting medications for opioid use disorder (MOUD): extended-release naltrexone (XR-NTX) in 2010, a subdermal buprenorphine implant in 2016, and a depot buprenorphine injection in 2017. Long-acting MOUD options may improve adherence while reducing diversion, but their availability compared to daily-dosing MOUD has not been well-characterized. The objective of this analysis was to characterize the availability of long-acting MOUD in substance use disorder treatment settings in the United States.

METHODS

Using the 2017 National Survey on Substance Abuse Treatment Services (N-SSATS) and state-level opioid overdose mortality, we examined associations between state- and facility-level factors and offering long-acting MOUD, which included XR-NTX and the buprenorphine implant. We constructed multivariable mixed logistic regression models for both types of long-acting MOUD.

RESULTS

Nationwide, 38% (n = 5141) of substance use treatment facilities provided any kind of MOUD (daily or long-acting). Of these, 62% provided XR-NTX, whereas only 3% offered the buprenorphine implant. Facilities in the East North Central, East South Central, West North Central and Mountain regions had higher odds of offering XR-NTX, as did federally-funded facilities, and facilities in states with the highest opioid overdose mortality rates.

CONCLUSIONS

In 2017, XR-NTX was available at most of the minority of facilities offering MOUD, but the buprenorphine implant was not. Increasing the availability of MOUD, including long-acting options, is necessary to address unmet need for opioid use disorder treatment.

Using buprenorphine to treat patients with opioid use disorder

The US opioid epidemic is a complex problem that has resulted in legislative actions to make treatment more accessible to patients. Physician assistants (PAs) have taken an active role in expanding their scope of practice to keep up with treatment needs. This article describes opioid use disorder in the United States, treatment gaps, safe treatment with buprenorphine, and PA prescriptive authority.

Preliminary results of the evaluation of the California Hub and Spoke Program

In August 2017, California launched the Hub and Spoke Program to address the growing number of opioid overdose deaths in the state. The program connects opioid treatment programs ("hubs") with office based opioid treatment settings, like primary care clinics ("spokes") to build a network of treatment expertise and referral resources. A key objective of this program is to expand access to medications for opioid use disorders (MOUD), with a particular focus on getting more buprenorphine into spokes. This article describes the preliminary results of the evaluation of the California Hub and Spoke program. Using a mixed methods approach, this portion of the evaluation measures changes in numbers of MOUD patients and providers, and barriers and facilitators to implementation. Findings reveal that, in the first 15 months of the program, 3480 new patients started buprenorphine in 118 spokes, increasing treatment initiations by 94.7% over baseline. The number of waivered spoke providers also increased 52.4% to 268. Although these data demonstrate promising growth in the network, challenges to expanding treatment access remain. Provider activity was among the most notable. Despite growth in the number of spoke providers with waivers to prescribe buprenorphine, only 68.7% (n = 184) were actively prescribing to patients. A survey of providers found that those who were not yet using their waivers lacked the confidence and mentorship they needed to prescribe. Provider knowledge and attitudes toward MOUD, fear of legal consequences, and limited patient outreach were also contributing factors. Recommendations for strengthening Hub and Spoke program implementation include facilitating mentor linkage for prescribers, expanding the support offered to spoke providers, and offering additional training and technical assistance aimed at provider stigma. Efforts to address these recommendations are described in a companion paper (Miele et al., under review).

A randomized clinical trial on the effects of bupropion and buprenorphine on the reduction of methamphetamine craving

Background

The purpose of this study was to compare the effect of 300 mg of bupropion and 8 mg of buprenorphine per day on the treatment of methamphetamine withdrawal cravings over a 2-week treatment interval.

Method

Sixty-five methamphetamine-dependent men who met the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision) criteria for methamphetamine dependence and withdrawal were randomly divided into two groups. Subjects randomly received 300 mg of bupropion or 8 mg of buprenorphine per day in a psychiatric ward. Of the 65 subjects, 35 (53.8%) received buprenorphine and 30 (46.2%) received bupropion. The subjects were assessed by using methamphetamine craving score, interview, and negative urine drug test.

Findings

There were no statistically significant differences between the two groups in regard to age, education, duration of methamphetamine dependency, marital status, employment, and income. The mean ages were 32.8 years (standard deviation (SD) = 7.26, range = 22 to 59) for the buprenorphine group and 32.21 years (SD = 8.45, range = 17 to 51) for the bupropion group. All 65 patients completed the 2-week study. Both medications were effective in the reduction of methamphetamine cravings. Reduction of craving in the buprenorphine group was significantly more than the bupropion group (P = 0.011). Overall, a significant main effect of day (P <0.001) and group (P = 0.011) and a non-significant group-by-day interaction (P >0.05) were detected.

Conclusions

The results support the safety and effectiveness of buprenorphine and bupropion in the treatment of methamphetamine withdrawal craving. Administration of 8 mg of buprenorphine per day can be recommended for the treatment of methamphetamine withdrawal cravings. We should note that it is to be expected that craving decreases over time without any medication. So the conclusion may not be that bupropion and buprenorphine both lower the craving. As the buprenorphine is superior to bupropion, only buprenorphine does so for sure.

Trial registration

Iranian Registry of Clinical Trials (IRCT) registration number: IRCT2015010320540N1. Date registered: April 10, 2015.

The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs

BACKGROUND

Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes.

METHODS

We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation.

RESULTS

The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%).

CONCLUSION

Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.

Adoption of the 275-patient buprenorphine treatment waiver for treating opioid use disorder: A state-level longitudinal analysis

Background: Increasing access to buprenorphine treatment is a critical tool for addressing the opioid epidemic in the United States. In 2016, a federal policy change allowed physicians who meet specific requirements to treat up to 275 concurrent buprenorphine patients. This study examines state-level measures of buprenorphine treatment supply over 21 months since this policy change and estimates associations between the supply of 275-patient waivers and state characteristics. Methods: Monthly state-level measures of the number of physicians holding the 275-patient waiver per 100,000 residents were constructed from September 2016 to May 2018 using the Drug Enforcement Agency's Controlled Substance Act database. State characteristics were obtained from publicly available sources. Mixed-effects regression models were estimated to examine change over time. Results: During the 21-month period, the number of physicians waivered to treat 275 patients increased from 153 to 4009 physicians. The mean supply of 275-patient physicians per 100,000 state residents significantly increased from 0.07 (SD = 0.21) in September 2016 to 1.43 (SD = 1.08) in May 2018 (t = -9.84, df = 50, P < .001). The final mixed-effects regression model indicated that Census division and the preexisting supply of 100-patient waivered physicians were correlated with the rate of growth in 275-patient waivers over the study period. Conclusions: Although uptake of the 275-patient waiver has exceeded initial projections, growth is uneven across the United States. Unequal patterns of growth pose a challenge to efforts to increase treatment availability as a means of addressing the opioid epidemic.

Characteristics of US Counties With High Opioid Overdose Mortality and Low Capacity to Deliver Medications for Opioid Use Disorder

Importance

Opioid overdose deaths in the United States continue to increase, reflecting a growing need to treat those with opioid use disorder (OUD). Little is known about counties with high rates of opioid overdose mortality but low availability of OUD treatment.

Objective

To identify characteristics of US counties with persistently high rates of opioid overdose mortality and low capacity to deliver OUD medications.

Design, Setting, and Participants

In this cross-sectional study of data from 3142 US counties from January 1, 2015, to December 31, 2017, rates of opioid overdose mortality were compared with availability in 2017 of OUD medication providers (24 851 buprenorphine-waivered clinicians [physicians, nurse practitioners, and physician assistants], 1517 opioid treatment programs [providing methadone], and 5222 health care professionals who could prescribe extended-release naltrexone). Statistical analysis was performed from April 20, 2018, to May 8, 2019.

Exposures

Demographic, workforce, lack of insurance, road density, urbanicity, opioid prescribing, and regional division county-level characteristics.

Main Outcome and Measures

The outcome variable, "opioid high-risk county," was a binary indicator of a high (above national) rate of opioid overdose mortality with a low (below national) rate of provider availability to deliver OUD medication. Spatial logistic regression models were used to determine associations with being an opioid high-risk county.

Results

Of 3142 counties, 751 (23.9%) had high rates of opioid overdose mortality. A total of 1457 counties (46.4%), and 946 of 1328 rural counties (71.2%), lacked a publicly available OUD medication provider in 2017. In adjusted models, compared with the West North Central division, counties in the East North Central, Mountain, and South Atlantic divisions had increased odds of being opioid high-risk counties (East North Central: odds ratio [OR], 2.21; 95% CI, 1.19-4.12; Mountain: OR, 4.15; 95% CI, 1.34-12.89; and South Atlantic: OR, 2.99; 95% CI, 1.26-7.11). A 1% increase in unemployment was associated with increased odds (OR, 1.09; 95% CI, 1.03-1.15) of a county being an opioid high-risk county. Counties with an additional 10 primary care clinicians per 100 000 population had a reduced risk of being opioid high-risk counties (OR, 0.89; 95% CI, 0.85-0.93), as did counties that were micropolitan (vs metropolitan) (OR, 0.67; 95% CI, 0.50-0.90) and those that had an additional 1% of the population younger than 25 years (OR, 0.95; 95% CI, 0.92-0.98).

Conclusions and Relevance

Counties with low availability of OUD medication providers and high rates of opioid overdose mortality were less likely to be micropolitan and have lower primary care clinician density, but were more likely to be in the East North Central, South Atlantic, or Mountain division and have higher rates of unemployment. Strategies to increase medication treatment must account for these factors.

Management of opioid use disorder in the USA: present status and future directions

Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.

Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

Background

Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.

Methods

Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.

Results

Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.

Conclusions

Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.

Physicians as Mediators of Health Policy: Acceptance of Medicaid in the Context of Buprenorphine Treatment

Increasing numbers of individuals with opioid use disorder (OUD) are insured by Medicaid. Little is known about whether providers of buprenorphine, an evidence-based OUD pharmacotherapy, accept this type of payment. Data are scant regarding whether Medicaid acceptance varies by physician and state-level characteristics. To address these gaps, national survey data from 1174 buprenorphine-prescribing physicians (BPPs) and state characteristics were examined in a multi-level model of Medicaid acceptance. Only 52.0% of BPPs accepted Medicaid for buprenorphine-related office visits. Specialists in addiction and psychiatry were significantly less likely to accept Medicaid than other specialties, as were BPPs delivering buprenorphine in individual medical practice. Perceived adequacy of Medicaid reimbursement was positively associated with accepting Medicaid. Medicaid acceptance was not associated with states' implementation of the Medicaid expansion. Individuals who are covered by Medicaid may face barriers to accessing buprenorphine treatment, which has high public health significance given the ongoing opioid epidemic.

Concomitant use of buprenorphine for medication-assisted treatment of opioid use disorder and benzodiazepines: Using the prescription behavior surveillance system

BACKGROUND

Despite clinical guidelines discouraging the practice, it is well-documented that the concomitant use of benzodiazepines and opioid analgesics occurs regularly. Information on concomitant use of buprenorphine for medication-assisted treatment (MAT) of opioid use disorder (OUD) and benzodiazepines, however, is limited. Thus, we aimed to describe real-world drug dispensing patterns for the concomitant use of buprenorphine products approved for MAT and benzodiazepines.

METHODS

We examined concomitant use of buprenorphine for MAT and benzodiazepines using the 2013 Prescription Behavior Surveillance System data from eight states. For prescription-level analysis, we estimated the proportion of concomitant buprenorphine and benzodiazepine prescriptions and the proportions of concomitant prescriptions prescribed by the same provider (co-prescribing) and dispensed by the same pharmacy (co-dispensing) for each state. For patient-level analysis, we calculated the proportion of patients with ≥1 buprenorphine therapy episode overlapping with a benzodiazepine episode, i.e., concomitant users, and the proportion of concomitant users who experienced co-prescribing or co-dispensing.

RESULTS

In 2013, 1,925,072 prescriptions of buprenorphine products for MAT were dispensed to 190,907 patients in eight states. Approximately 1 in 8 buprenorphine prescriptions was used concomitantly with ≥1 benzodiazepine prescription(s). Co-prescribing proportions ranged from 22.2 to 64.6% across states, while co-dispensing proportions ranged from 54.7 to 91.0%. Approximately 17.7% of patients had >1 buprenorphine episode overlapping a benzodiazepine episode for ≥7 cumulative days' supply. Among these patients, 33.1-65.2% experienced co-prescribing, and 65.1-93.3% experienced co-dispensing.

CONCLUSIONS

The concomitant use of buprenorphine for MAT and benzodiazepines occurs frequently, with variations by state in co-prescribing and co-dispensing.

Buprenorphine Supply, Access, and Quality: Where We Have Come and the Path Forward

Buprenorphine is a form of opioid agonist treatment that has been demonstrated to be an effective medication for opioid addiction. It is available in different formulations and marketed under various trade names, including commonly as a buprenorphine/naloxone combination. This paper provides an overview of existing literature on the supply of buprenorphine treatment, the ability of people to access treatment with buprenorphine, and the quality of treatment received. We argue that better data for each of these aspects of treatment could inform policy to expand effective treatment with buprenorphine, and we suggest steps to obtain and act on such data.

Massachusetts Health Reform's Effect on Hospitalizations with Substance Use Disorder-Related Diagnoses

OBJECTIVE

To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals.

DATA/STUDY SETTING

2004-2010 MA inpatient discharge data.

DESIGN

Difference-in-differences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends.

DATA EXTRACTION METHODS

We identified 373,751 discharges where a SUD-related diagnosis was a primary or secondary discharge diagnosis.

FINDINGS

Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD-related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations.

CONCLUSIONS

Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage.