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Incze MA, Huebler S, Grant S, Gordon AJ. Using the Delphi Process to Prioritize an Agenda for Care Transition Research for Patients With Substance Use Disorders. Subst Use Addctn J 2024:29767342241246762. [PMID: 38622904 DOI: 10.1177/29767342241246762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Medical hospitalizations are increasingly recognized as important opportunities to engage individuals with substance use disorders (SUD) and offer treatment. While a growing number of hospitals have instituted interventions to support the provision of SUD care during medical admissions, post-hospitalization transitions of care remain a challenge for patients and clinicians and an understudied area of SUD care. Evidence is lacking on the most effective and feasible models of care to improve post-hospitalization care transitions for people with SUD. In the absence of strong empirical evidence to guide practice and policy, consensus-based research methods such as the Delphi process can play an important role in efficiently prioritizing existing models of care for future study and implementation. We conducted a Delphi study that convened a group of 25 national interdisciplinary experts with direct clinical experience facilitating post-hospitalization care transitions for people with SUD. Our panelists rated 10 existing care transition models according to anticipated effectiveness and facility of implementation based on the GRADE Evidence to Decision framework. Qualitative data on each care model were also gathered through comments and an online moderated discussion board. Our results help establish a hierarchy of SUD care transition models to inform future study and program development.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Program of 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
| | - Sophia Huebler
- Program of 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
| | | | - Adam J Gordon
- Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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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. Subst Use Addctn J 2024; 45:278-291. [PMID: 38288697 DOI: 10.1177/29767342231223721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [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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Cox N, Hohmeier KC, Cernasev A, Field C, Elliott S, LaFleur G, Barland KM, Green M, Gardner JW, Gordon AJ, Cochran G. Engaging community pharmacies in practice-based research: Lessons from opioid-focused research. Res Social Adm Pharm 2024; 20:457-462. [PMID: 38262889 PMCID: PMC10939711 DOI: 10.1016/j.sapharm.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/14/2023] [Accepted: 01/16/2024] [Indexed: 01/25/2024]
Abstract
There is an established need to translate evidence-based practices into real-world practice. Community pharmacists and their corresponding pharmacies are well-positioned to be effective partners as researchers seek to study and implement practice-based research. Challenges exist when partnering with community pharmacies which can vary based on the study type, the nature of the community pharmacy, and stakeholder groups (i.e., patients, staff, leadership, physicians). This commentary seeks to describe these challenges and provide recommendations that can help mitigate and/or overcome these challenges. Recommendations are provided for team structure, communication, research tools/technology, motivational factors, workflow, and sustainability. These recommendations are based on the authors' experience in partnering with community pharmacy for opioid-related research in a variety of study types, states, and pharmacy environments.
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Affiliation(s)
- Nicholas Cox
- University of Utah College of Pharmacy, United States.
| | | | - Alina Cernasev
- University of Tennessee Health Science Center, United States.
| | - Craig Field
- The University of Texas at El Paso, United States.
| | - Stacy Elliott
- University of Tennessee Health Science Center, United States.
| | - Grace LaFleur
- University of Utah College of Pharmacy, United States.
| | | | | | - John W Gardner
- Veterans Affairs Salt Lake City Health Care System, United States.
| | - Adam J Gordon
- University of Utah School of Medicine, United States.
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McCollister KE, Gordon AJ, Acevedo A, Voshtina D, Li JM, Tse B, Murphy SM. The 2023 Addiction Health Services Research Conference: Back in Person and Taking a Bite of the Big Apple. Subst Use Addctn J 2024; 45:163-167. [PMID: 38288727 DOI: 10.1177/29767342231225577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Abstract
The Addiction Health Services Research (AHSR) Conference has been held since 2002. This Conference brings together researchers, graduate students, policymakers, and treatment providers to focus improving the organization, distribution, and financing of healthcare resources for prevention/care of SUD. The AHSR 2023 Conference took place in New York City, October 18-20th, and was hosted by the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH; cherishresearch.org). Attended by more than 300 participants, the Conference comprised several themes relating to the latest research on addiction health services delivery, financing, and impact. The agenda also included pre-conference workshops, distinguished plenary speakers, a multitude of networking opportunities, and career support for early-stage and minority investigators. AHSR 2023 featured 3 plenary sessions, 120 oral presentations, and 143 poster presentations from academics throughout the world. Overall, AHSR 2023 provided numerous opportunities to advance the field of addiction health services research. The state-of-the-art techniques and insights gained by attending scholars will position them to be change-agents in the addiction field going forward.
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Affiliation(s)
- Kathryn E McCollister
- Division of Health Services Research and Policy, Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL, USA
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | - Dorela Voshtina
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Jazmine M Li
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Bonnie Tse
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Sean M Murphy
- Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH), Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
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Wyse JJ, Eckhardt A, Waller D, Gordon AJ, Shull S, Lovejoy TI, Mackey K, Morasco BJ. Patients' Perspectives on Discontinuing Buprenorphine for the Treatment of Opioid Use Disorder. J Addict Med 2024:01271255-990000000-00296. [PMID: 38498620 DOI: 10.1097/adm.0000000000001292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024]
Abstract
OBJECTIVES Buprenorphine and other medications for opioid use disorder (OUD) are recommended as standard of care in the treatment of OUD and are associated with positive health and addiction-related outcomes. Despite benefits, discontinuation is common, with half of patients discontinuing in the first year of treatment. Addressing OUD is a major clinical priority, yet little is known about the causes of medication discontinuation from the patient perspective. METHODS From March 2021 to April 2022, we conducted qualitative interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past 12 months. Eligible participants were selected from 2 Veterans Health Administration Health Care Systems in Oregon. Coding and analysis were guided by conventional qualitative content analysis. RESULTS Twenty participants completed an interview; 90% were White and 90% were male, and the mean age was 54.2 years. Before discontinuation, participants had received buprenorphine for 8.3 months on average (range, 1-40 months); 80% had received buprenorphine for less than 12 months. Qualitative analysis identified the following themes relating to discontinuation: health system barriers (eg, logistical hurdles, rules and policy violations), medication effects (adverse effects; attributed adverse effects, lack of efficacy in treating chronic pain) and desire for opioid use. Patient description of decisions to discontinue buprenorphine could be multicausal, reflecting provider or system-level barriers in interaction with patient complexity or medication ambivalence. CONCLUSIONS Study results identify several actionable ways OUD treatment could be modified to enhance patient retention.
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Affiliation(s)
- Jessica J Wyse
- From the Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR (JJW, AE, DW, SS, TIL, KM, BJM); School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR (JJW); Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT (AJG); 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 (AJG); Department of Psychiatry, Oregon Health & Science University, Portland, OR (TIL, BJM); and VA Office of Rural Health, Veterans Rural Health Resource Center, Portland, OR (TIL)
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Cochran G, Smid MC, Krans EE, Yu Z, Carlston K, White A, Abdulla W, Baylis J, Charron E, Okifugi A, Gordon AJ, Lundahl B, Silipigni J, Seliski N, Haaland B, Tarter R. Patient navigation for pregnant individuals with opioid use disorder: Results of a randomized multi-site pilot trial. Addiction 2024; 119:544-556. [PMID: 37859587 DOI: 10.1111/add.16364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 09/14/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND AND AIMS Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC). DESIGN This study was a pilot single-blinded multi-site randomized trial. SETTING Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated. PARTICIPANTS One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49). INTERVENTION PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2- and 6-month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management. MEASUREMENTS Feasibility assessments included consent, session delivery and assessment rates. Mixed-effect models for intent-to-treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non-prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum. FINDINGS We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non-prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = -10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = -0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = -21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%). CONCLUSIONS Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large-scale trial.
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Affiliation(s)
- Gerald Cochran
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Marcela C Smid
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC, Pittsburgh, PA, USA
| | - Ziji Yu
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kristi Carlston
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ashley White
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Walitta Abdulla
- Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC, Pittsburgh, PA, USA
| | - Jacob Baylis
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Charron
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Akiko Okifugi
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Brad Lundahl
- College of Social Work, University of Utah, Salt Lake City, UT, USA
| | - John Silipigni
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Utah Health, Salt Lake City, UT, USA
| | - Natasha Seliski
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ralph Tarter
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
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Grant S, Smart R, Gordon AJ, Pacula RL, Stein BD. Expert Views on State Policies to Improve Engagement and Retention in Treatment for Opioid Use Disorder: A Qualitative Analysis of an Online Modified Delphi Process. J Addict Med 2024; 18:129-137. [PMID: 38039084 PMCID: PMC10939945 DOI: 10.1097/adm.0000000000001253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2023]
Abstract
OBJECTIVES The aim of this study was to examine expert views on the effectiveness and implementability of state policies to improve engagement and retention in treatment for opioid use disorder (OUD). METHODS We conducted a 3-round modified Delphi process using the online ExpertLens platform. Participants included 66 experts on OUD treatment policies. Experts commented on 14 hypothetical state policies targeting treatment engagement and quality of care. Using the GRADE Evidence-to-Decision framework, we conducted reflexive thematic analysis to develop patterns of meaning from the dataset. RESULTS Only policies for providing continued access to evidence-based treatment for highly at-risk populations, settings, and periods were seen as effective in meaningfully reducing population-level opioid-related overdose mortality. Experts commented that, although the general public increasingly supports policies expanding medications for OUD and evidence-based care, ongoing stigma about OUD encourages public acceptance of punitive and paternalistic policies. Experts viewed all policies as at least moderately feasible given the current infrastructure and resources, with affordability reliant on long-term cost savings from reduced opioid-related harms. Equitability depended on whether experts perceived a policy as inherently equitable in its design as well as concerns about the potential for inequitable implementation due to structural oppression and interpersonal biases in criminal-legal, healthcare, and other systems. CONCLUSIONS Experts believe that supportive (rather than punitive) policies improve engagement and retention in OUD treatment. States could prioritize implementing supportive policies that are patient-centered and take a harm-reduction approach to enhance medications for OUD access and utilization. States could consider deimplementing punitive policies that are coercive, take an abstinence-only approach, and use punitive and restrictive measures.
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Affiliation(s)
| | | | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System
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Incze MA, Kelley AT, James H, Nolan S, Stofko A, Fordham C, Gordon AJ. Post-hospitalization Care Transition Strategies for Patients with Substance Use Disorders: A Narrative Review and Taxonomy. J Gen Intern Med 2024:10.1007/s11606-024-08670-5. [PMID: 38413539 DOI: 10.1007/s11606-024-08670-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 01/30/2024] [Indexed: 02/29/2024]
Abstract
Hospitalizations represent important opportunities to engage individuals with substance use disorders (SUD) in treatment. For those who engage with SUD treatment in the hospital setting, tailored supports during post-discharge transitions to longitudinal care settings may improve care linkages, retention, and treatment outcomes. We updated a recent systematic review search on post-hospitalization SUD care transitions through a structured review of published literature from January 2020 through June 2023. We then added novel sources including a gray literature search and key informant interviews to develop a taxonomy of post-hospitalization care transition models for patients with SUD. Our updated literature search generated 956 abstracts not included in the original systematic review. We selected and reviewed 89 full-text articles, which yielded six new references added to 26 relevant articles from the original review. Our search of five gray literature sources yielded four additional references. Using a thematic analysis approach, we extracted themes from semi-structured interviews with 10 key informants. From these results, we constructed a taxonomy consisting of 10 unique SUD care transition models in three overarching domains (inpatient-focused, transitional, outpatient-focused). These models include (1) training and protocol implementation; (2) screening, brief intervention, and referral to treatment; (3) hospital-based interdisciplinary consult team; (4) continuity-enhanced interdisciplinary consult team; (5) peer navigation; (6) transitional care management; (7) outpatient in-reach; (8) post-discharge outreach; (9) incentivizing follow-up; and (10) bridge clinic. For each model, we describe design, scope, approach, and implementation strategies. Our taxonomy highlights emerging models of post-hospitalization care transitions for patients with SUD. An established taxonomy provides a framework for future research, implementation efforts, and policy in this understudied, but critically important, aspect of SUD care.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Hannah James
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Seonaid Nolan
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Andrea Stofko
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Cole Fordham
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Greater Intermountain Node, National Institute on Drug Abuse Clinical Trial Network, Program of Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), , Salt Lake City, UT, USA
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Patient-Aligned Care Team, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Hawkins EJ, Malte CA, Hagedorn HJ, Gordon AJ, Williams EC, Trim RS, Blanchard BE, Lott A, Danner AN, Saxon AJ. Buprenorphine Receipt and Retention for Opioid Use Disorder following an Initiative to Increase Access in Primary Care. J Addict Med 2024:01271255-990000000-00278. [PMID: 38329814 DOI: 10.1097/adm.0000000000001275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVES Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative. METHODS Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post-index year and retention the proportion who received buprenorphine for 180 days or longer. RESULTS Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%-12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%-63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27-0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45-0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37-0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04-1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35-0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19-0.84) were less likely among non-Hispanic Black patients. CONCLUSIONS Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients.
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Affiliation(s)
- Eric J Hawkins
- From the Health Services Research & Development (HSR&D) Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, WA (EJH, CAM, ECW, AL, AND, AJS); Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, WA (EJH, CAM, HJH, AL, AND, AJS); HSR&D Center for Care Delivery & Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN (HJH); HSR&D Center of Innovation: Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT (AJG); Department of Health Services, University of Washington, Seattle, WA (ECW); Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA (EJH, BEB, AJS); Department of Psychiatry, University of Minnesota, Minneapolis, MN (HJH); Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (AJG); Center of Excellence in Substance Addiction Treatment and Education, Corporal Michael J. Crescenz Philadelphia VA Medical Center, Philadelphia, PA (RST)
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Richardson C, Daniels K, Confer A, Saxon AJ, Gordon AJ, Liberto J, Albanese AP, Renner J, Edens E, Kennedy AJ. Internal Medicine Resident Addiction Training at the Veteran's Health Administration: A Qualitative Evaluation of Site Directors' Response to the 2022 ACGME Requirements. J Gen Intern Med 2024:10.1007/s11606-024-08639-4. [PMID: 38302815 DOI: 10.1007/s11606-024-08639-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Substance use disorders (SUDs) are prevalent in the USA yet remain dramatically undertreated. To address this care gap, the Accreditation Council for Graduate Medical Education (ACGME) approved revisions to the Program Requirements for Graduate Medical Education (GME) in Internal Medicine, effective July 1, 2022, requiring addiction medicine training for all internal medicine (IM) residents. The Veterans Health Administration (VHA) is a clinical training site for many academic institutions that sponsor IM residencies. This focus group project evaluated VHA IM residency site directors' perspectives about providing addiction medical education within VHA IM training sites. OBJECTIVE To better understand the current state, barriers to, and facilitators of IM resident addiction medicine training at VHA sites. DESIGN This was a qualitative evaluation based on semi-structured video-based focus groups. PARTICIPANTS Participants were VHA IM site directors based at a VHA hospital or clinic throughout the USA. APPROACH Focus groups were conducted using a semi-structured group interview guide. Two investigators coded each focus group independently, then met to create a final adjudicated coding scheme. Thematic analysis was used to identify key themes. KEY RESULTS Forty-three participants from 38 VHA sites participated in four focus groups (average size: 11 participants). Six themes were identified within four pre-defined categories. Current state of training: most VHA sites offered no formal training in addiction medicine for IM residents. Barriers: addiction experts are often located outside of IM settings, and ACGME requirements were non-specific. Facilitators: clinical champions help support addiction training. Desired next steps: participants desired incentives to train or hire local champions and a pre-packaged didactic curriculum. CONCLUSIONS Developing competent clinical champions and leveraging VHA addiction specialists from non-IM settings would create more addiction training opportunities for IM trainees at VHA sites. These insights can likely be applied to IM training at non-VHA sites.
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Affiliation(s)
- Claire Richardson
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Karin Daniels
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrea Confer
- VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Andrew J Saxon
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, Salt Lake City Health Care System, Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Joseph Liberto
- Office of Mental Health and Suicide Prevention, Substance Use Disorders, Veterans Health Administration, Washington, DC, USA
| | - Anthony P Albanese
- VA Northern California Healthcare System, UC Davis, School of Medicine, Sacramento, CA, USA
| | - John Renner
- VA Boston Healthcare System, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Edens
- VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, USA
| | - Amy J Kennedy
- VA Puget Sound Healthcare System, University of Washington School of Medicine, Seattle, WA, USA.
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Nock NL, Stoutenberg M, Cook DB, Whitworth JW, Janke EA, Gordon AJ. Exercise as Medicine for People with a Substance Use Disorder: An ACSM Call to Action Statement. Curr Sports Med Rep 2024; 23:53-57. [PMID: 38315433 DOI: 10.1249/jsr.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
ABSTRACT Over 20 million Americans are living with a substance use disorder (SUD) and nearly 100,000 die annually from drug overdoses, with a majority involving an opioid. Many people with SUD have co-occurring chronic pain and/or a mental health disorder. Exercise is a frontline treatment for chronic pain and is an effective strategy for reducing depression and anxiety and improving overall mental health. Several studies have shown that exercise improves SUD-related outcomes including abstinence; however, there is limited large-scale randomized clinical trial evidence to inform integration of exercise into practice. In this Call to Action, we aim to raise awareness of the specific issues that should be addressed to advance exercise as medicine in people with SUD including the challenges of co-occurring chronic pain, mental illness, and cardiopulmonary health conditions. In addition, specialized training for exercise professionals and other support staff should be provided on these issues, as well as on the multiple dimensions of stigma that can impair engagement in treatment and overall recovery in people with SUD.
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Affiliation(s)
- Nora L Nock
- Department of Population and Quantitative Health Sciences, School of Medicine, Case Western Reserve University, Cleveland, OH
| | - Mark Stoutenberg
- Department of Kinesiology, College of Public Health, Temple University, Philadelphia, PA
| | | | | | - E Amy Janke
- Department of Health Sciences, School of Health Professions, Saint Joseph's University, Philadelphia, PA
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Goodman-Meza D, Goto M, Salimian A, Shoptaw S, Bui AAT, Gordon AJ, Goetz MB. Impact of Potential Case Misclassification by Administrative Diagnostic Codes on Outcome Assessment of Observational Study for People Who Inject Drugs. Open Forum Infect Dis 2024; 11:ofae030. [PMID: 38379573 PMCID: PMC10878055 DOI: 10.1093/ofid/ofae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/12/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Initiation of medications for opioid use disorder (MOUD) within the hospital setting may improve outcomes for people who inject drugs (PWID) hospitalized because of an infection. Many studies used International Classification of Diseases (ICD) codes to identify PWID, although these may be misclassified and thus, inaccurate. We hypothesized that bias from misclassification of PWID using ICD codes may impact analyses of MOUD outcomes. Methods We analyzed a cohort of 36 868 cases of patients diagnosed with Staphylococcus aureus bacteremia at 124 US Veterans Health Administration hospitals between 2003 and 2014. To identify PWID, we implemented an ICD code-based algorithm and a natural language processing (NLP) algorithm for classification of admission notes. We analyzed outcomes of prescribing MOUD as an inpatient using both approaches. Our primary outcome was 365-day all-cause mortality. We fit mixed-effects Cox regression models with receipt or not of MOUD during the index hospitalization as the primary predictor and 365-day mortality as the outcome. Results NLP identified 2389 cases as PWID, whereas ICD codes identified 6804 cases as PWID. In the cohort identified by NLP, receipt of inpatient MOUD was associated with a protective effect on 365-day survival (adjusted hazard ratio, 0.48; 95% confidence interval, .29-.81; P < .01) compared with those not receiving MOUD. There was no significant effect of MOUD receipt in the cohort identified by ICD codes (adjusted hazard ratio, 1.00; 95% confidence interval, .77-1.30; P = .99). Conclusions MOUD was protective of all-cause mortality when NLP was used to identify PWID, but not significant when ICD codes were used to identify the analytic subjects.
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Affiliation(s)
- David Goodman-Meza
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Greater Los Angeles Veterans Health Administration, Los Angeles, California, USA
| | - Michihiko Goto
- University of Iowa, Iowa City, Iowa, USA
- Iowa City VA Medical Center, Iowa City, Iowa, USA
| | - Anabel Salimian
- Division of Infectious Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Steven Shoptaw
- Department of Family Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Alex A T Bui
- Medical & Imaging Informatics (MII) Group, Department of Radiological Sciences, UCLA, Los Angeles, California, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Matthew B Goetz
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
- Greater Los Angeles Veterans Health Administration, Los Angeles, California, USA
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Andraka-Christou B, Golan O, Totaram R, Ohama M, Saloner B, Gordon AJ, Stein BD. Prior authorization restrictions on medications for opioid use disorder: trends in state laws from 2005 to 2019. Ann Med 2023; 55:514-520. [PMID: 36724766 PMCID: PMC9897778 DOI: 10.1080/07853890.2023.2171107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
RESEARCH OBJECTIVE Medications for opioid use disorder (MOUDs) - including methadone, buprenorphine, and naltrexone - are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions. METHODS We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis - a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time. RESULTS No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment. CONCLUSIONS The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD.KEY MESSAGESNo states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016.By 2019, fifteen states had an MOUD prior authorization prohibition law.States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.
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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 (Secondary Joint Appointment), University of Central Florida, Orlando, FL, USA
- CONTACT Barbara Andraka-Christou School of Global Health Management and Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, 32801FL, USA
| | - Olivia Golan
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Rachel Totaram
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Brendan Saloner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, 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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Andraka-Christou B, McAvoy E, Gordon AJ, Ohama M, Brach M, Taylor EA, Vaiana M, Saloner B, Stein BD. Urine drug testing in the context of opioid analgesic prescribing for chronic pain: a content analysis of U.S. state laws in 2022. Pain Med 2023; 24:1306-1317. [PMID: 37551941 PMCID: PMC10690857 DOI: 10.1093/pm/pnad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/07/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND In response to the opioid crisis, U.S. states have passed laws requiring urine drug testing (UDT) when opioid analgesics are prescribed for chronic pain. We sought to identify state law UDT requirements. METHODS We searched NexisUni legal database using terms related to UDT, chronic pain, and opioids. We included laws effective during spring 2022 that required UDT when opioids were prescribed for chronic pain. We performed deductive content analysis, coding laws for mandated UDT frequency, type of clinician and type of payer to whom the law applied, and circumstances under which UDT was mandated. RESULTS We found 32 laws across 13 states that met our inclusion criteria. UDT requirements varied substantially by state, including with regard to the type of clinician to whom the law applied, the mandated frequency of UDT (eg, at initiation/assessment, at least annually, more than once per year), and the circumstances in which UDT was mandated (eg, patient had substance use disorder; dosage/day threshold). DISCUSSION Relatively few states have UDT mandates associated with prescribing opioids as chronic pain treatment. When developing policy indicators for empirical studies, researchers evaluating how UDT policy affects health outcomes must consider the complexity and lack of uniformity of UDT requirements. In addition, even if states mandate UDT, it is unclear whether clinicians understand the best way to use the test results.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL 32801, United States
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL 32827, United States
| | - Elizabeth McAvoy
- O'Neill School of Public and Environmental Affairs, Indiana University, Bloomington, IN 47405, United States
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT 84108, 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 84108, United States
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL 32605, United States
| | | | - Erin A Taylor
- RAND Corporation, Santa Monica, CA 90401, United States
| | - Mary Vaiana
- RAND Corporation, Santa Monica, CA 90401, United States
| | - Brendan Saloner
- Department of Health Policy and Management, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, United States
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Huang LC, Bleicher J, Torre M, Johnson JE, Presson A, Millar MM, Gordon AJ, Brooke BS, Kaphingst KA, Harris AHS. Evaluating a health system-wide opioid disposal intervention distributing home-disposal bags. Health Serv Res 2023; 58:1256-1265. [PMID: 37700549 PMCID: PMC10622267 DOI: 10.1111/1475-6773.14227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023] Open
Abstract
OBJECTIVE To evaluate a health system-wide intervention distributing free home-disposal bags to surgery patients prescribed opioids. DATA SOURCES AND STUDY SETTING We collected patient surveys and electronic medical record data at an academic health system. STUDY DESIGN We conducted a prospective observational study. The bags were primarily distributed at pharmacies, though pharmacists delivered bags to some patients. The primary outcome was disposal of leftover opioids (effectiveness). Secondary outcomes were patient willingness to dispose and factors associated with disposal (effectiveness), recalling receipt of the bag (reach), and recalling receipt of bags and disposal over time (maintenance). We used a modified Poisson regression to evaluate the relative risk of disposal. Inverse probability of treatment weighting, based on propensity scores, was used to account for differences between survey responders and non-responders and reduce nonresponse bias. DATA COLLECTION/EXTRACTION METHODS From August 2020 to May 2021, we surveyed patients 2 weeks after discharge (allowing for home opioid use). Eligibility criteria were age ≥18, English being primary language, valid email address, hospitalization ≤30 days, discharge home, and an opioid prescription sent to a system pharmacy. PRINCIPAL FINDINGS We identified 5134 patients with 2174 completing the survey (response rate 42.3%). Among respondents, 1375 (63.8%) recalled receiving the disposal bag. Among 1075 respondents with leftover opioids, 284 (26.4%) disposed, 552 (51.3%) planned to dispose, 79 (7.4%) did not plan to dispose, 69 (6.4%) had undecided, and 91 (8.5%) had not considered disposal. Recalling receipt of the bag (incidence rate ratio [IRR] 1.25, 95% confidence interval [CI] 1.13-1.37) was positively associated with disposal. Patients who used opioids in the last year were less likely to dispose (IRR 0.82, 95% CI 0.73-0.93). Disposal rates remained stable over the study period while recalling receipt of bags trended up. CONCLUSIONS A pragmatic implementation of a disposal intervention resulted in lower disposal rates than prior trials.
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Affiliation(s)
- Lyen C. Huang
- Department of SurgeryUniversity of UtahSalt Lake CityUtahUSA
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
| | - Josh Bleicher
- Department of SurgeryUniversity of UtahSalt Lake CityUtahUSA
| | - Michael Torre
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | | | - Angela Presson
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Morgan M. Millar
- Department of Internal MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal MedicineUniversity of Utah School of MedicineSalt Lake CityUtahUSA
- Informatics, Decision‐Enhancement, and Analytic Sciences (IDEAS) CenterVA Salt Lake City Health Care SystemSalt Lake CityUtahUSA
| | | | - Kimberly A. Kaphingst
- Huntsman Cancer InstituteUniversity of UtahSalt Lake CityUtahUSA
- Department of CommunicationUniversity of UtahSalt Lake CityUtahUSA
| | - Alex H. S. Harris
- Department of SurgeryStanford UniversityStanfordCaliforniaUSA
- VA HSR&D Center for Innovation to ImplementationPalo Alto VA Health Care SystemPalo AltoCaliforniaUSA
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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 Alcohol Depend Rep 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] [What about the content of this article? (0)] [Affiliation(s)] [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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Bridges NC, Taber R, Foulds AL, Bear TM, Cloutier RM, McDonough BL, Gordon AJ, Cochran GT, Donohue JM, Adair D, DiDomenico E, Pringle JL, Gellad WF, Kelley D, Cole ES. Medications for opioid use disorder in rural primary care practices: Patient and provider experiences. J Subst Use Addict Treat 2023; 154:209133. [PMID: 37543217 DOI: 10.1016/j.josat.2023.209133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 08/07/2023]
Abstract
INTRODUCTION The opioid epidemic has exacted a significant toll in rural areas, yet adoption of medications for opioid use disorder (MOUD) lags. The Rural Access to Medication Assisted Treatment in Pennsylvania (RAMP) Project facilitated adoption of MOUD in rural primary care clinics. The purpose of this study was to gain a better understanding of the barriers and facilitators operating at multiple levels to access or provide MOUD in rural Pennsylvania. METHODS In total, the study conducted 35 semi-structured interviews with MOUD patients and MOUD providers participating in RAMP. Qualitative analysis incorporated both deductive and inductive approaches. The study team coded interviews and performed thematic analysis. Using a modified social-ecological framework, themes from the qualitative interviews are organized in five nested levels: individual, interpersonal, health care setting, community, and public policy. RESULTS Patients and providers agreed on many barriers (e.g., lack of providers, lack of transportation, insufficient rapport and trust in patient-provider relationship, and cost, etc.); however, their interpretation of the barrier, or indicated solution, diverged in meaningful ways. Patients described their experiences in broad terms pointing to the social determinants of health, as they highlighted their lives outside of the therapeutic encounter in the clinic. Providers focused on their professional roles, responsibilities, and operations within the primary care setting. CONCLUSIONS Providers may want to discuss barriers to treatment related to social determinants of health with patients, and pursue partnerships with organizations that seek to address those barriers. The findings from these interviews point to potential opportunities to enhance patient experience, increase access to and optimize processes for MOUD in rural areas, and reduce stigma against people with opioid use disorder (OUD) in the wider community.
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Affiliation(s)
- Nora C Bridges
- Department of Family Medicine, University of Pittsburgh; Schenley Place, Suite 520, 4420 Bayard Street, Pittsburgh, PA 15260, USA.
| | - Rachel Taber
- Department of Family Medicine, University of Pittsburgh; Schenley Place, Suite 520, 4420 Bayard Street, Pittsburgh, PA 15260, USA
| | - Abigail L Foulds
- Division of General Internal Medicine, University of Pittsburgh, 1218 Scaife Hall, 3550 Terrace Street, Pittsburgh, PA 15261, USA
| | - Todd M Bear
- Department of Family Medicine, University of Pittsburgh; Schenley Place, Suite 520, 4420 Bayard Street, Pittsburgh, PA 15260, USA
| | - Renee M Cloutier
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Medicine, 3501 Terrace St., Pittsburgh, PA 15261, USA
| | - Brianna L McDonough
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Medicine, 3501 Terrace St., Pittsburgh, PA 15261, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, UT, 84132, USA
| | - Gerald T Cochran
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, 30 N. 1900 E, Salt Lake City, UT, 84132, USA
| | - Julie M Donohue
- University of Pittsburgh School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, USA
| | - Dale Adair
- Pennsylvania Office of Mental Health and Substance Abuse Services, Harrisburg, PA 17105, USA
| | - Ellen DiDomenico
- Pennsylvania Department of Human Services, 625 Forster St., Harrisburg, PA, 17120, USA
| | - Janice L Pringle
- Program Evaluation and Research Unit (PERU), University of Pittsburgh School of Medicine, 3501 Terrace St., Pittsburgh, PA 15261, USA
| | - Walid F Gellad
- University of Pittsburgh School of Medicine, 3550 Terrace St., Pittsburgh, PA, 15213, USA
| | - David Kelley
- Pennsylvania Office of Mental Health and Substance Abuse Services, Harrisburg, PA 17105, USA
| | - Evan S Cole
- University of Pittsburgh School of Public Health, 130 De Soto St, Pittsburgh, PA, 15261, USA
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Bowman J, Lai M, Charles JE, Gordon AJ, Smid MC. Kratom Use Among Pregnant and Lactating Individuals With Substance Use Disorder. J Addict Med 2023; 17:722-724. [PMID: 37934544 DOI: 10.1097/adm.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
OBJECTIVE Kratom ( Mitragyna speciosa ) use in pregnancy is associated with maternal and neonatal opioid withdrawal syndrome. However, kratom use patterns in the population of peripartum and postpartum individuals with substance use disorder (SUD) are unknown. The aim of this study was to determine the proportion of pregnant and postpartum individuals with SUD who report using kratom in pregnancy or lactation and the reasons for their use. METHODS We conducted an anonymous survey of pregnant and postpartum individuals receiving care at a single center's multidisciplinary prenatal clinic for individuals with SUD. We collected participants' demographic and pregnancy characteristics. We assessed ever use of kratom, kratom use during pregnancy or lactation, and reasons for kratom use. Descriptive statistics were used to summarize the data. RESULTS From January 2021 to May 2021, a total of 80 surveys were collected (81% response rate of 98 eligible individuals). Most respondents were pregnant (n = 50 [62.5%]). The most frequent substance(s) of use were opioids (n = 50 [62.5%]) and methamphetamine (n = 39 [48.8%]). Many (n = 26 [32.5%]) reported ever use of kratom use. Of all respondents, 4 (5%) reported use during pregnancy, and 1 (1%) reported use during lactation. Kratom was primarily used to relieve opioid withdrawal symptoms and for relaxation, pain control, and stress relief. CONCLUSION In a survey of pregnant and postpartum individuals with SUD at a single high-risk pregnancy clinic, ever use of kratom was frequent, whereas peripartum use was rare.
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Affiliation(s)
- Justin Bowman
- From the University of Utah School of Medicine, Salt Lake City, UT (JB); Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of Utah Health, Salt Lake City, UT (JEC, MCS); Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT (ML, AJG); Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT (JEC, MCS); and Informatics, Decision-Enhancement, and Analytic Sciences Center, Salt Lake City VA Health Care System, Salt Lake City, UT (AJG)
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Percy A, Kelley AT, Valentino N, Butz A, Baylis JD, Suo Y, Gordon AJ, Jones AL. Care Practices of Mental Health Clinical Pharmacist Practitioners Within an Interdisciplinary Primary Care Model for Patients With Substance Use Disorders. Subst Abus 2023; 44:330-336. [PMID: 37840212 PMCID: PMC10773467 DOI: 10.1177/08897077231198679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023]
Abstract
BACKGROUND Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs' scope of practice varies substantially across clinics and settings. OBJECTIVES We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities. METHODS We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019. RESULTS CPPs provided care for 228 patients, including 766 in-clinic visits, 341 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state's prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients. CONCLUSION CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.
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Affiliation(s)
- Annette Percy
- Behavioral Health Interdisciplinary Program, Southern Oregon Rehabilitation Center and Clinics, White City, OR, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - A Taylor Kelley
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Natalie Valentino
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Amy Butz
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Ying Suo
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Audrey L Jones
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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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20
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Ackland PE, Kenny ME, Clothier BA, Salameh HA, Boening N, Gordon AJ, Noorbaloochi S, Gustavson AM, Miller W, Hagedorn HJ. What Contributes to Sustainability? Examining Access to Medications for Opioid Use Disorder in Low-Adopting VHA Facilities. J Gen Intern Med 2023; 38:2647-2654. [PMID: 37037986 PMCID: PMC10088728 DOI: 10.1007/s11606-023-08116-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Successful implementation can increase the availability of evidence-based treatments but continued patient access can be threatened if there is not deliberate focus on sustainment. Real-world examples are needed to elucidate contributors to sustainability. OBJECTIVE We examined sustainability of outcomes of a study which tested a 12-month external facilitation intervention. The study evaluated change in access to medications for opioid use disorder (MOUD) in Veterans Health Administration (VHA) facilities in the lowest quartile of MOUD prescribing. DESIGN Convergent mixed-methods design. PARTICIPANTS Thirty-nine providers and leaders from eight VHA facilities. APPROACH Thirty-minute post-implementation telephone interviews explored whether barriers identified pre-implementation were successfully addressed, the presence of any new challenges, helpfulness of external facilitation, and plans for sustaining MOUD access. Interviews were analyzed using a rapid turn-around approach. VHA administrative data were used to characterize the facilities and assess their ratio of patients with an OUD diagnosis receiving MOUD (MOUD/OUD ratio) at the end of a 9-month sustainability period. KEY RESULTS Commonly reported contributors to sustained MOUD access included national attention on the opioid epidemic, accountability created by study participation, culture shift in MOUD acceptability, leadership support, and plans to build on initial progress. Frequently reported barriers included staffing issues and lack of MOUD-devoted time; the need to overhaul existing policies, practices, and/or processes; and fear and anxiety about MOUD prescribing. All facilities either maintained MOUD/OUD ratio improvement (n = 2) or further improved (n = 6) at the end of sustainability. Facilities with the highest and lowest ratio at the end of sustainability used a team-based approach to MOUD delivery; however, organizational setting differences may have impacted overall MOUD access. CONCLUSIONS Ensuring stable and consistent staff, and sufficient time dedicated to MOUD are critical to sustaining access to evidence-based treatment in low-adopting facilities. This study highlights the importance of investing in local, system-level changes to improve and sustain access to effective treatments.
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Affiliation(s)
- Princess E Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA.
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Marie E Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Barbara A Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Hope A Salameh
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Natassia Boening
- ORD Strategic Initiative for Research and EHR Synergy (OSIRES), Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Allison M Gustavson
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Hildi J Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Centers of Excellence in Substance Addiction Treatment and Education, Puget Sound VAHCS/Philadelphia VAHCS, Seattle, WA, USA
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21
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Hammerslag L, Talbert J, Donohue JM, Sharbaugh M, Ahrens K, Allen L, Austin AE, Gordon AJ, Jarlenski M, Kim JY, Mohamoud S, Tang L, Burns M. Urine drug testing among Medicaid enrollees initiating buprenorphine treatment for opioid use disorder within 9 MODRN states. Drug Alcohol Depend 2023; 250:110875. [PMID: 37413960 PMCID: PMC10529442 DOI: 10.1016/j.drugalcdep.2023.110875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid. METHODS We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis. RESULTS The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state. CONCLUSIONS Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.
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Affiliation(s)
- Lindsey Hammerslag
- Division of Biomedical Informatics, College of Medicine, University of Kentucky, United States.
| | - Jeffery Talbert
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, United States
| | - Julie M Donohue
- Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Michael Sharbaugh
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Katherine Ahrens
- University of Southern Maine, Muskie School of Public Service, United States
| | - Lindsay Allen
- Feinberg School of Medicine, Northwestern University, United States
| | - Anna E Austin
- Gillings School of Global Public Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, United States
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy, Department of Internal Medicine, University of Utah School of Medicine and VA Salt Lake City Health Care System, United States
| | - Marian Jarlenski
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Joo Yeon Kim
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, United States
| | - Shamis Mohamoud
- The Hilltop Institute, University of Maryland Baltimore County, United States
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh School of Public Health, United States
| | - Marguerite Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, United States
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22
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Garcia CC, Bounthavong M, Gordon AJ, Gustavson AM, Kenny ME, Miller W, Esmaeili A, Ackland PE, Clothier BA, Bangerter A, Noorbaloochi S, Harris AHS, Hagedorn HJ. Costs of implementing a multi-site facilitation intervention to increase access to medication treatment for opioid use disorder. Implement Sci Commun 2023; 4:91. [PMID: 37563672 PMCID: PMC10413546 DOI: 10.1186/s43058-023-00482-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 07/29/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The United States has been grappling with the opioid epidemic, which has resulted in over 75,000 opioid-related deaths between April 2020 and 2021. Evidence-based pharmaceutical interventions (buprenorphine, methadone, and naltrexone) are available to reduce opioid-related overdoses and deaths. However, adoption of these medications for opioid use disorder has been stifled due to individual- and system-level barriers. External facilitation is an evidence-based implementation intervention that has been used to increase access to medication for opioid use disorder (MOUD), but the implementation costs of external facilitation have not been assessed. We sought to measure the facility-level direct costs of implementing an external facilitation intervention for MOUD to provide decision makers with estimates of the resources needed to implement this evidence-based program. METHODS We performed a cost analysis of the pre-implementation and implementation phases, including an itemization of external facilitation team and local site labor costs. We used labor estimates from the Bureau of Labor and Statistics, and sensitivity analyses were performed using labor estimates from the Veterans Health Administration (VHA) Financial Management System general ledger data. RESULTS The average total costs for implementing an external facilitation intervention for MOUD per site was $18,847 (SD 6717) and ranged between $11,320 and $31,592. This translates to approximately $48 per patient with OUD. Sites with more encounters and participants with higher salaries in attendance had higher costs. This was driven mostly by the labor involved in planning and implementation activities. The average total cost of the pre-implementation and implementation activities were $1031 and $17,816 per site, respectively. In the sensitivity analysis, costs for VHA were higher than BLS estimates likely due to higher wages. CONCLUSIONS Implementing external facilitation to increase MOUD prescribing may be affordable depending on the payer's budget constraints. Our study reported that there were variations in the time invested at each phase of implementation and the number and type of participants involved with implementing an external facilitation intervention. Participant composition played an important role in total implementation costs, and decision makers will need to identify the most efficient and optimal number of stakeholders to involve in their implementation plans.
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Affiliation(s)
- Carla C Garcia
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Mark Bounthavong
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA.
- UCSD Skaggs School of Pharmacy & Pharmaceutical Sciences, San Diego, CA, USA.
| | - Adam J Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative, Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS, Salt Lake City Veterans Affairs Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Allison M Gustavson
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marie E Kenny
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Wendy Miller
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Aryan Esmaeili
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Princess E Ackland
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Barbara A Clothier
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Ann Bangerter
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Alex H S Harris
- Center for Innovation to Implementation, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Surgery, School of Medicine, Stanford University, Stanford, CA, USA
| | - Hildi J Hagedorn
- Center for Care Delivery & Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, School of Medicine, University of Minnesota, Minneapolis, MN, USA
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23
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Jones AL, Chu K, Rose DE, Gelberg L, Kertesz SG, Gordon AJ, Wells KB, Leung L. Quality of Depression Care for Veterans Affairs Primary Care Patients with Experiences of Homelessness. J Gen Intern Med 2023; 38:2436-2444. [PMID: 36810631 PMCID: PMC10465405 DOI: 10.1007/s11606-023-08077-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 01/30/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND Persons who experience homelessness (PEH) have high rates of depression and incur challenges accessing high-quality health care. Some Veterans Affairs (VA) facilities offer homeless-tailored primary care clinics, although such tailoring is not required, within or outside VA. Whether services tailoring enhances care for depression is unstudied. OBJECTIVE To determine whether PEH in homeless-tailored primary care settings receive higher quality of depression care, compared to PEH in usual VA primary care. DESIGN Retrospective cohort study of depression treatment among a regional cohort of VA primary care patients (2016-2019). PARTICIPANTS PEH diagnosed or treated for a depressive disorder. MAIN MEASURES The quality measures were timely follow-up care (3 + completed visits with a primary care or mental health specialist provider, or 3 + psychotherapy sessions) within 84 days of a positive PHQ-2 screen result, timely follow-up care within 180 days, and minimally appropriate treatment (4 + mental health visits, 3 + psychotherapy visits, 60 + days antidepressant) within 365 days. We applied multivariable mixed-effect logistic regressions to model differences in care quality for PEH in homeless-tailored versus usual primary care settings. KEY RESULTS Thirteen percent of PEH with depressive disorders received homeless-tailored primary care (n = 374), compared to usual VA primary care (n = 2469). Tailored clinics served more PEH who were Black, who were non-married, and who had low income, serious mental illness, and substance use disorders. Among all PEH, 48% received timely follow-up care within 84 days of depression screening, 67% within 180 days, and 83% received minimally appropriate treatment. Quality metric attainment was higher for PEH in homeless-tailored clinics, compared to PEH in usual VA primary care: follow-up within 84 days (63% versus 46%; adjusted odds ratio [AOR] = 1.61, p = .001), follow-up within 180 days (78% versus 66%; AOR = 1.51, p = .003), and minimally appropriate treatment (89% versus 82%; AOR = 1.58, p = .004). CONCLUSIONS Homeless-tailored primary care approaches may improve depression care for PEH.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA.
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Karen Chu
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Danielle E Rose
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
| | - Lillian Gelberg
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
| | - Stefan G Kertesz
- Birmingham VA Health Care System, Birmingham, AL, USA
- Heersink University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center and Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT, 84148, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Kenneth B Wells
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
- UCLA Fielding School of Public Health, Los Angeles, CA, USA
- UCLA Center for Health Services and Society, Los Angeles, CA, USA
| | - Lucinda Leung
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP) and Veterans Assessment and Improvement Laboratory (VAIL), VA Greater Los Angeles Health Care System, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California-Los Angeles (UCLA), Los Angeles, CA, USA
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24
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Lott AM, Danner AN, Malte CA, Williams EC, Gordon AJ, Halvorson MA, Saxon AJ, Hagedorn HJ, Sayre GG, Hawkins EJ. Clinician Perspectives on Delivering Medication Treatment for Opioid Use Disorder during the COVID-19 Pandemic: A Qualitative Evaluation. J Addict Med 2023; 17:e262-e268. [PMID: 37579107 PMCID: PMC10417321 DOI: 10.1097/adm.0000000000001156] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 01/18/2023] [Indexed: 03/03/2023]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic necessitated changes in opioid use disorder care. Little is known about COVID-19's impact on general healthcare clinicians' experiences providing medication treatment for opioid use disorder (MOUD). This qualitative evaluation assessed clinicians' beliefs about and experiences delivering MOUD in general healthcare clinics during COVID-19. METHODS Individual semistructured interviews were conducted May through December 2020 with clinicians participating in a Department of Veterans Affairs initiative to implement MOUD in general healthcare clinics. Participants included 30 clinicians from 21 clinics (9 primary care, 10 pain, and 2 mental health). Interviews were analyzed using thematic analysis. RESULTS The following 4 themes were identified: overall impact of the pandemic on MOUD care and patient well-being, features of MOUD care impacted, MOUD care delivery, and continuance of telehealth for MOUD care. Clinicians reported a rapid shift to telehealth care, resulting in few changes to patient assessments, MOUD initiations, and access to and quality of care. Although technological challenges were noted, clinicians highlighted positive experiences, including treatment destigmatization, more timely visits, and insight into patients' environments. Such changes resulted in more relaxed clinical interactions and improved clinic efficiency. Clinicians reported a preference for in-person and telehealth hybrid care models. CONCLUSIONS After the quick shift to telehealth-based MOUD delivery, general healthcare clinicians reported few impacts on quality of care and highlighted several benefits that may address common barriers to MOUD care. Evaluations of in-person and telehealth hybrid care models, clinical outcomes, equity, and patient perspectives are needed to inform MOUD services moving forward.
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25
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Kelley AT, Wilcox J, Baylis JD, Crossnohere NL, Magel J, Jones AL, Gordon AJ, Bridges JFP. Increasing Access to Buprenorphine for Opioid Use Disorder in Primary Care: an Assessment of Provider Incentives. J Gen Intern Med 2023; 38:2147-2155. [PMID: 36471194 PMCID: PMC10361924 DOI: 10.1007/s11606-022-07975-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/17/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Primary care providers (PCPs) are essential to increasing access to office-based buprenorphine medication treatment for opioid use disorder (B-MOUD). Barriers to B-MOUD prescribing are well-documented, but there is little information regarding incentives to overcome these barriers. OBJECTIVE To identify optimal incentives for PCPs to promote B-MOUD prescribing and compare incentive preferences across provider and practice characteristics. DESIGN We surveyed PCPs using best-worst scaling (BWS) to prioritize seven potential incentives for B-MOUD prescribing (monetary compensation, paid vacation, protected time, professional development, reduced workload, service recognition, clinical resources). We then used a direct elicitation approach to determine preferred incentive levels (e.g., monetary thresholds) and types (e.g., specific clinical resources). PARTICIPANTS Primary care physicians and advanced practice providers (APPs) at a large Department of Veterans Affairs healthcare system. MAIN MEASURES B-MOUD prescribing incentive preferences and relative preference levels using descriptive statistics and conditional logistic regression with relative importance scale transformation (coefficients sum to 100, higher coefficient=greater importance). KEY RESULTS Fifty-three PCPs responded (73% response), including 47% APPs and 36% from community-based clinics. Reduced workload (relative importance score=26.8), protected time (18.7), and clinical resources (16.8) were significantly more preferred (Ps < 0.001) than professional development (10.5), paid vacation (10.3), or service recognition (1.5). Relative importance of monetary compensation varied between physicians (12.6) and APPs (17.5) and between PCPs located at a medical center (11.4) versus community clinic (22.3). APPs were more responsive than physicians to compensation increases of $5000 and $12,000 but less responsive to $25,000; trends were similar for medical center versus community clinic PCPs. The most frequently requested clinical resource was on-demand consult access to an addiction specialist. CONCLUSIONS Interventions promoting workload reductions, protected time, and clinical resources could increase access to B-MOUD in primary care. Monetary incentives may be additionally needed to improve B-MOUD prescribing among APPs and within community clinics.
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Affiliation(s)
- A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, 50 North Medical Drive, 5R341, Salt Lake City, UT, 84132, 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.
| | - Jordynn Wilcox
- Office of the Director, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), 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
| | - Norah L Crossnohere
- Division of General Internal Medicine, Department of Internal Medicine, The Ohio State University College of Medicine, Columbus, OH, USA
| | - John Magel
- 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
- Department of Physical Therapy and Athletic Training, University of Utah College of Health, Salt Lake City, UT, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), 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
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-aligned Care Team (VIP), 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
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John F P Bridges
- Department of Biomedical Informatics, The Ohio State University College of Medicine, Columbus, OH, USA
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Abstract
BACKGROUND Buprenorphine is a key medication to treat opioid use disorder (OUD). Since its approval in 2002, buprenorphine access has grown markedly, spurred by major federal and state policy changes. This study characterizes buprenorphine treatment episodes during 2007 to 2018 with respect to payer, provider specialty, and patient demographics. METHODS In this observational cohort study, IQVIA Real World pharmacy claims data were used to characterize trends in buprenorphine treatment episodes across four time periods: 2007-2009, 2010-2012, 2013-2015, and 2016-2018. RESULTS In total, we identified more than 4.1 million buprenorphine treatment episodes among 2 540 710 unique individuals. The number of episodes doubled from 652 994 in 2007-2009 to 1 331 980 in 2016-2018. Our findings indicate that the payer landscape changed dramatically, with the most pronounced growth observed for Medicaid (increased from 17% of episodes in 2007-2009 to 37% of episodes in 2016-2018), accompanied by relative declines for both commercial insurance (declined from 35 to 21%) and self-pay (declined from 27 to 11%). Adult primary care providers (PCPs) were the dominant prescribers throughout the study period. The number of episodes among adults older than 55 increased more than 3-fold from 2007-2009 to 2016-2018. In contrast, youth under age 18 experienced an absolute decline in buprenorphine treatment episodes. Buprenorphine episodes increased in length from 2007-2018, particularly among adults over age 45. CONCLUSIONS Our findings demonstrate that the U.S. experienced clear growth in buprenorphine treatment-particularly for older adults and Medicaid beneficiaries-reflecting some key health policy and implementation success stories. Yet, since the prevalence of OUD and fatal overdose rate have also approximately doubled during this period, the observed growth in buprenorphine treatment did not demonstrably impact the pronounced treatment gap. To date, only a minority of individuals with OUD currently receive treatment, indicating continued need for systemic efforts to equitably improve treatment uptake.
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Affiliation(s)
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care Knowledge and Advocacy (PARCKA) Department of Internal Medicine, University of Utah School of Medicine, and Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Incze MA, Chen D, Galyean P, Kimball E, Stolebarger L, Zickmund S, Gordon AJ. Examining the Primary Care Experience of Patients With Opioid Use Disorder: A Qualitative Study. J Addict Med 2023; 17:401-406. [PMID: 37579097 PMCID: PMC10411983 DOI: 10.1097/adm.0000000000001140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVES Despite substantial investment in expanding access to treatment for opioid use disorder (OUD), overdose deaths continue to increase. Primary care holds enormous potential to expand access to OUD treatment, but few patients receive medications for OUD (MOUD) in primary care. Understanding both patient and clinician experiences is critical to expanding access to patient-centered MOUD care, yet relatively little research has examined patient perspectives on primary care-based MOUD. We sought to examine the care experiences of patients with OUD receiving medication-based treatment in a primary care setting. METHODS We conducted semistructured interviews with patients receiving MOUD at a single primary care site at the University of Utah. Interviews were performed and transcribed by qualitative researchers, who used rapid qualitative analysis using a grounded theory-based approach to identify key themes pertaining to patient experiences receiving medication-based OUD treatment in primary care. RESULTS Twenty-one patients were screened, and 14 completed the interview. In general, participants had numerous medical and psychiatric comorbidities. The following key themes pertaining to primary care-based OUD treatment were identified: (1) overall health improvement, (2) team-based care, (3) comparing primary care to specialty addiction treatment, (4) access to medications for OUD, and (5) discrimination and stigma. CONCLUSIONS Patients reported many advantages to receiving primary care-based MOUD treatment. In particular, the flexibility and added support of team-based care along with the convenience of receiving addiction treatment alongside regular medical care were highly valued. These findings can be used to develop patient-centered initiatives aimed at expanding OUD treatment within primary care.
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Affiliation(s)
- Michael A. Incze
- Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - David Chen
- Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Patrick Galyean
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Elisabeth Kimball
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Laura Stolebarger
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Susan Zickmund
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA) University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT
- Vulnerable Veteran Innovative PACT (VIP) Initiative, VA Salt Lake City Health Care System, Salt Lake City, UT
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Griffin BA, Cabreros I, Saloner B, Gordon AJ, Kerber R, Stein BD. Exploring the Association of State Policies and the Trajectories of Buprenorphine Prescriber Patient Caseloads. Subst Abus 2023; 44:136-145. [PMID: 37401501 PMCID: PMC10680051 DOI: 10.1177/08897077231179824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Increasing buprenorphine access is critical to facilitating effective opioid use disorder treatment. Buprenorphine prescriber numbers have increased substantially, but most clinicians who start prescribing buprenorphine stop within a year, and most active prescribers treat very few individuals. Little research has examined state policies' association with the evolution of buprenorphine prescribing clinicians' patient caseloads. METHODS Our retrospective cohort study design derived from 2006 to 2018 national pharmacy claims identifying buprenorphine prescribers and the number of patients treated monthly. We defined persistent prescribers based on results from a k-clustering approach and were characterized by clinicians who did not quickly stop prescribing and had average monthly caseloads greater than 5 patients for much of the first 6 years after their first dispensed prescription. We examined the association between persistent prescribers (dependent variable) and Medicaid coverage of buprenorphine, prior authorization requirements, and mandated counseling policies (key predictors) that were active within the first 2 years after a prescriber's first observed dispensed buprenorphine prescription. We used multivariable logistic regression analyses and entropy balancing weights to ensure better comparability of prescribers in states that did and did not implement policies. RESULTS Medicaid coverage of buprenorphine was associated with a smaller percentage of new prescribers becoming persistent prescribers (OR = 0.72; 95% CI = 0.53, 0.97). There was no evidence that either mandatory counseling or prior authorization was associated with the odds of a clinician being a persistent prescriber with estimated ORs equal to 0.85 (95% CI = 0.63, 1.16) and 1.13 (95% CI = 0.83, 1.55), respectively. CONCLUSIONS Compared to states without coverage, states with Medicaid coverage for buprenorphine had a smaller percentage of new prescribers become persistent prescribers; there was no evidence that the other state policies were associated with changes in the rate of clinicians becoming persistent prescribers. Because buprenorphine treatment is highly concentrated among a small group of clinicians, it is imperative to increase the pool of clinicians providing care to larger numbers of patients for longer periods. Greater efforts are needed to identify and support factors associated with successful persistent prescribing.
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Affiliation(s)
| | | | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, 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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Gordon AJ, Saxon AJ, Kertesz S, Wyse JJ, Manhapra A, Lin LA, Chen W, Hansen J, Pinnell D, Huynh T, Baylis JD, Cunningham FE, Ghitza UE, Bart G, Yu H, Sauer BC. Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration. Drug Alcohol Depend 2023; 248:109902. [PMID: 37196572 PMCID: PMC10875624 DOI: 10.1016/j.drugalcdep.2023.109902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system. METHODS We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves). RESULTS We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5). CONCLUSIONS Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.
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Affiliation(s)
- Adam J Gordon
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
| | - Andrew J Saxon
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA; Center of Excellence in Substance Addiction Treatment and Education (CESATE), VA Puget Sound Health Care System, Seattle, WA, USA
| | - Stefan Kertesz
- Birmingham Veterans Affairs Health Care System, Birmingham, AL, USA; Department of Medicine, Heersink UAB School of Medicine, Birmingham, AL, USA
| | - Jessica J Wyse
- Center to Improve Veteran Involvement in Care (CIVIC), VA Portland Health CareSystem, Portland, OR, USA; School of Public Health, Oregon Health & Science University-Portland State University,PortlandOR, USA
| | - Ajay Manhapra
- Section of Pain Medicine, Department of Physical Medicine & Rehabilitation Services, Hampton VA Medical Center, Hampton, VA, USA
| | - Lewei A Lin
- VA Center for Clinical Management Research (CCMR), VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Wei Chen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jared Hansen
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Derek Pinnell
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Tina Huynh
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | | | - Udi E Ghitza
- Center for the Clinical Trials Network (CCTN), National Institute on Drug Abuse (NIDA), Bethesda, MD, USA
| | - Gavin Bart
- Hennepin Healthcare, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Hong Yu
- Center for Biomedical and Health Research in Data Sciences and Miner School of Computer & Information Sciences, University of Massachusetts Lowell, Lowell, MA, USA; Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, MA, USA
| | - Brian C Sauer
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Informatics, Decision Enhancement, and Analytics Science (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Saloner B, Andraka-Christou B, Stein BD, Gordon AJ. Will the End of the X-Waiver Expand Access to Buprenorphine Treatment? Achieving the Full Potential of the 2023 Consolidated Appropriations Act. Subst Abus 2023; 44:108-111. [PMID: 37675897 PMCID: PMC10719867 DOI: 10.1177/08897077231186212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
The 2023 Consolidated Appropriations Act repealed the special waiver for prescribing buprenorphine to patients with opioid use disorder, a bipartisan goal long sought by advocates. The change has symbolic importance in recognizing that buprenorphine is a mainstream medical treatment. We argue that the maximum potential of the law can be achieved by addressing three bottlenecks. First, it is important that new training requirements for all controlled substances prescribers be grounded in scientific principles of addiction treatment and are robustly evaluated to ensure they meet quality standards. Second, even with the elimination of the waiver, there are potential constraints from state law such as state-specific requirements that practitioners require counseling or obtain a separate credential, and many states also have limiting scope of practice regulations. We recommend that these requirements are eased wherever possible to improve treatment access. Third, it is critical to build onramps to treatment in settings such as primary care, hospitals, and correctional facilities. While we anticipate that buprenorphine prescribing will primarily occur in high-volume practices, there is the potential to activate a broader workforce to serve as entry points to care. We conclude that the stage is set for significant increases in lifesaving treatment but the difficult task ahead is ensuring that the resources and training are available to build strong capacity.
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Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | | | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Abstract
While there is limited research in the field regarding the various dimensions of co-use of alcohol and opioid medication, particularly related to co-use and levels of severity, our research has shown 20% to 30% of community pharmacy patients receiving opioid pain medications are engaged in co-use. Co-use of alcohol and opioid medications is a significant risk factor for opioid-related overdose. Community pharmacy is a valuable yet underutilized resource and setting for addressing the US opioid epidemic, with an untapped potential for identification of and intervention for risks associated with co-use of alcohol and opioids. This commentary describing the "Co-use of Opioid Medications and Alcohol Prevention Study (COAPS)" offers an innovative and promising approach to mitigating serious risks associated with co-use of alcohol (risk and non-risk use) and opioids in community pharmacy. COAPS aim 1involves adapting an existing opioid misuse intervention to target co-use of alcohol and opioid mediations. COAPS aim 2 involves testing the adapted intervention within a small-scale pilot randomized controlled trial (N = 40) to examine feasibility, acceptability and preliminary efficacy of the intervention versus standard care. COAPS aim 3 involves conducting key informant interviews related to future implementation of larger scale studies or service delivery in community pharmacy settings.
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Affiliation(s)
- Alina Cernasev
- University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Kenneth Hohmeier
- University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Craig Field
- Department of Psychology, University of Texas, El Paso, TX, USA
| | - Adam J Gordon
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Stacy Elliott
- University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Kristi Carlston
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Grace Broussard
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Gerald Cochran
- Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
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Austin AE, Tang L, Kim JY, Allen L, Barnes AJ, Chang CCH, Clark S, Cole ES, Durrance CP, Donohue JM, Gordon AJ, Huskamp HA, McDuffie MJ, Mehrotra A, Mohamoud S, Talbert J, Ahrens KA, Applegate M, Hammerslag LR, Lanier P, Tossone K, Zivin K, Burns ME. Trends in Use of Medication to Treat Opioid Use Disorder During the COVID-19 Pandemic in 10 State Medicaid Programs. JAMA Health Forum 2023; 4:e231422. [PMID: 37327009 PMCID: PMC10276306 DOI: 10.1001/jamahealthforum.2023.1422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/29/2023] [Indexed: 06/17/2023] Open
Abstract
Importance Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. Objectives To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). Design, Setting, and Participants This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Exposures Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Main Outcomes and Measures Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Results Among a total of 8 167 497 Medicaid enrollees before the PHE and 8 181 144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100 000 enrollees in March 2020 to 171.8 per 100 000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100 000 enrollees in March 2020 to 21.1 per 100 000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. Conclusions and Relevance In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.
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Affiliation(s)
- Anna E. Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, The University of North Carolina at Chapel Hill
- Injury Prevention Research Center, The University of North Carolina at Chapel Hill
| | - Lu Tang
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Joo Yeon Kim
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lindsay Allen
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Andrew J. Barnes
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond
| | - Chung-Chou H. Chang
- Department of Biostatistics, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Sarah Clark
- Department of Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor
| | - Evan S. Cole
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Julie M. Donohue
- Department of Health Policy and Management, School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Adam J. Gordon
- Department of Internal Medicine, University of Utah, Salt Lake City
| | - Haiden A. Huskamp
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Mary Joan McDuffie
- Center for Community Research and Service, Joseph R. Biden, Jr. School of Public Policy and Administration, University of Delaware, Newark
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Shamis Mohamoud
- The Hilltop Institute, University of Maryland, Baltimore County, Baltimore
| | - Jeffery Talbert
- Institute for Biomedical Informatics, University of Kentucky, Lexington
| | - Katherine A. Ahrens
- Public Health Program, Muskie School of Public Service, University of Southern Maine, Portland
| | | | | | - Paul Lanier
- School of Social Work, The University of North Carolina at Chapel Hill
| | - Krystel Tossone
- The Ohio Colleges of Medicine, Government Resource Center, College of Medicine, The Ohio State University, Columbus
| | - Kara Zivin
- Department of Psychiatry, Michigan Medicine, University of Michigan, Ann Arbor
| | - Marguerite E. Burns
- Population Health Sciences, School of Medicine and Public Health, University of Wisconsin-Madison
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Charron E, Yu Z, Lundahl B, Silipigni J, Okifuji A, Gordon AJ, Baylis JD, White A, Carlston K, Abdullah W, Haaland B, Krans EE, Smid MC, Cochran G. Cluster analysis to identify patient profiles and substance use patterns among pregnant persons with opioid use disorder. Addict Behav Rep 2023; 17:100484. [PMID: 36844693 PMCID: PMC9950438 DOI: 10.1016/j.abrep.2023.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/23/2023] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
The study objective was to identify distinct profiles of pregnant persons with opioid use disorder (PP-OUD) using cluster analysis and examine difference in substance use patterns between profiles. We examined data from 104 PP-OUD ≤ 32 weeks of gestation who were recruited into a behavioral health clinical trial at two academic medical centers. We used Partitioning Around Medoids analysis to identify clusters and explored patterns of substance use and substance use treatment between clusters using bivariate statistical tests and regression methods. We identified two distinct clusters of participants, including 'Group A' (n = 68; 65.4 %) and 'Group B' (n = 36; 34.6 %). Group A had fewer members who were not employed (38 % vs 58 %) and incarcerated (3 % vs 8 %) compared to Group B. Group A compared with Group B included more members with: a history of overdose (72 % vs 50 %); anxiety (85 % vs 25 %); ≥moderate pain (76 % vs 22 %); ≥moderate depression (75 % vs 36 %); ≥moderate drug use severity (94 % vs 78 %); and, more days of cannabis (mean: 6.2 vs 2.3 days), stimulant (mean: 4.5 vs 1.3 days), and injection heroin (mean: 1.3 vs 0 days) use in the past 30 days (P < 0.05 for all comparisons). Clusters of PP-OUD differed with respect to sociodemographic characteristics, mental health conditions, and substance use patterns. More research is needed to confirm identified profiles and assess treatment outcomes associated with cluster membership.
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Affiliation(s)
- Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma, Schusterman Center, Tulsa, OK, United States
- Program of 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
| | - Ziji Yu
- Program of 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
| | - Brad Lundahl
- College of Social Work, University of Utah, Salt Lake City, UT, United States
| | - John Silipigni
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Akiko Okifuji
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Adam J. Gordon
- Program of 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
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Jacob D. Baylis
- Program of 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
| | - Ashley White
- Program of 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
| | - Kristi Carlston
- Program of 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
| | - Walitta Abdullah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
| | - Benjamin Haaland
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Elizabeth E. Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, United States
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions (Magee CARES), Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Marcela C. Smid
- Program of 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
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, United States
| | - Gerald Cochran
- Program of 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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Wyse JJ, Shull S, Lindner S, Morasco BJ, Gordon AJ, Carlson KF, Korthuis PT, Ono SS, Liberto JG, Lovejoy TI. Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities. J Gen Intern Med 2023; 38:1871-1876. [PMID: 36690913 PMCID: PMC9870655 DOI: 10.1007/s11606-023-08027-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 12/30/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND For patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients. OBJECTIVE While Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How "Community Care," healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown. DESIGN Data for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015-2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time. PARTICIPANTS All 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinics MAIN MEASURES: The average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems. KEY RESULTS From 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems. CONCLUSIONS Strategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA.
- School of Public Health, Oregon Health & Science University, 840 SW Gaines St, Portland, OR, 97239, USA.
| | - Sarah Shull
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
| | - Stephan Lindner
- School of Public Health, Oregon Health & Science University, 840 SW Gaines St, Portland, OR, 97239, USA
- Department of Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
- Center for Health Systems Effectiveness, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, Oregon, 97239, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
- Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology & Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - Kathleen F Carlson
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
- School of Public Health, Oregon Health & Science University, 840 SW Gaines St, Portland, OR, 97239, USA
| | - P Todd Korthuis
- School of Public Health, Oregon Health & Science University, 840 SW Gaines St, Portland, OR, 97239, USA
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
- Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Sarah S Ono
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
- Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- VA Office of Rural Health, Veterans Rural Health Resource Center, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
| | - Joseph G Liberto
- Office of Mental Health and Suicide Prevention, VA Central Office (VACO), U.S. Department of Veterans Affairs, 1100 1st Street NE, Washington, D.C, 20002, USA
- Department of Psychiatry, University of Maryland School of Medicine, 655 W. Baltimore St, Baltimore, MD, 21201, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
- Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
- VA Office of Rural Health, Veterans Rural Health Resource Center, 3710 SW U.S. Veterans Hospital Rd, Portland, OR, 97239, USA
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Ahrens K, Sharbaugh M, Jarlenski MP, Tang L, Allen L, Austin AE, Barnes AJ, Burns ME, Clark S, Zivin K, Mack A, Liu G, Mohamoud S, McDuffie MJ, Hammerslag L, Gordon AJ, Donohue JM. Prevalence of Testing for Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Among Medicaid Enrollees Treated With Medications for Opioid Use Disorder in 11 States, 2016-2019. Clin Infect Dis 2023; 76:1793-1801. [PMID: 36594172 PMCID: PMC10209438 DOI: 10.1093/cid/ciac981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/21/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing. METHODS We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses. RESULTS From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states. CONCLUSIONS Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested.
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Affiliation(s)
- Katherine Ahrens
- Public Health Program, Muskie School of Public Service, University of Southern Maine, Portland, Maine, USA
| | - Michael Sharbaugh
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Marian P Jarlenski
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Lu Tang
- Department of Biostatistics, University of Pittsburgh, School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Lindsay Allen
- Health Policy, Management, and Leadership Department, School of Public Health, West Virginia University, Morgantown, West Virginia, USA
| | - Anna E Austin
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Andrew J Barnes
- Health Behavior and Policy Department, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Marguerite E Burns
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA
| | - Sarah Clark
- Department of Pediatrics, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kara Zivin
- Department of Psychiatry, School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Aimee Mack
- Government Resource Center, Ohio Colleges of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Gilbert Liu
- Government Resource Center, Ohio Colleges of Medicine, Ohio State University, Columbus, Ohio, USA
| | - Shamis Mohamoud
- Hilltop Institute, University of Maryland Baltimore County, Baltimore, Maryland, USA
| | - Mary Joan McDuffie
- Center for Community Research & Service, Biden School of Public Policy and Administration, University of Delaware, Newark, Delaware, USA
| | - Lindsey Hammerslag
- College of Medicine, Institute for Biomedical Informatics, University of Kentucky, Lexington, Kentucky, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Julie M Donohue
- Department of Health Policy and Management, University of Pittsburgh, School of Public Health, Pittsburgh, Pennsylvania, USA
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Saloner B, Whitley P, Dawson E, Passik S, Gordon AJ, Stein BD. Polydrug use among patients on methadone medication treatment: Evidence from urine drug testing to inform patient safety. Addiction 2023. [PMID: 37158468 DOI: 10.1111/add.16180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 02/16/2023] [Indexed: 05/10/2023]
Abstract
AIMS Patients in methadone medication treatment for opioid use disorder (M-MOUD) typically have a complex history of opioid use, often in combination with other drugs. It is unknown how frequently M-MOUD patients experience persistent substance or polysubstance use. We measured trends in illicit substance use in a large, multistate population of M-MOUD patients and persistence of substance use in the first year of treatment. DESIGN Retrospective cohort study of United States (US) M-MOUD patients from 2017 to 2021, focused on urine drug specimens provided for testing to Millennium Health, a third-party laboratory. Specimens were analyzed using liquid chromatography-tandem mass spectrometry (LC-MS/MS). Generalized estimating equations (GEE) were used to estimate the average trends in positivity during time in treatment. SETTING Specimens were obtained from clinics in 10 US states that provided at least 300 unique patients during the study period (Alaska, Arizona, Florida, Illinois, Kentucky, Minnesota, New Mexico, Ohio, Virginia and Washington). PARTICIPANTS Patients with opioid use disorder receiving M-MOUD (n = 16 386). MEASUREMENTS Positivity rates for heroin, fentanyl, methamphetamine and cocaine. FINDINGS From 2017 to 2021, yearly crude positivity rates for first collected specimens increased for fentanyl (13.1%-53.0%, P < 0.001), methamphetamine (10.6%-27.2%, P < 0.001) and cocaine (13.8%-19.5%, P < 0.001); for heroin positivity did not significantly change (6.9%-6.5%, P = 0.74). In regression models estimating patient trajectories from week 1 to week 52, marginal fentanyl positivity declined from 21.8% to 17.1% (incidence rate ratio [IRR] = 0.78, P < 0.001) and heroin positivity declined from 8.4% to 4.3% (IRR = 0.51, P < 0.001), but positivity for methamphetamine and cocaine did not significantly change, remaining at an average of 17.7% (IRR = 0.98, P = 0.53) and 9.2% (IRR = 0.96, P = 0.36), respectively. CONCLUSIONS Between 2017 and 2021, United States patients presenting to opioid treatment programs increasingly tested positive for fentanyl, methamphetamine and cocaine. Methadone medication treatment for opioid use disorder appears to remain an effective intervention for reducing illicit opioid use.
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Affiliation(s)
- Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Eric Dawson
- Millennium Health, San Diego, California, USA
| | | | - Adam J Gordon
- University of Utah and Veterans Health Administration, Salt Lake City, Utah, USA
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Stein BD, Saloner BK, Golan OK, Andraka-Christou B, Andrews CM, Dick AW, Davis CS, Sheng F, Gordon AJ. Association of Selected State Policies and Requirements for Buprenorphine Treatment With Per Capita Months of Treatment. JAMA Health Forum 2023; 4:e231102. [PMID: 37234015 DOI: 10.1001/jamahealthforum.2023.1102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Abstract
Importance Expanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing. Objective To examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents. Design, Setting, and Participants This cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder. Exposures State implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined. Main Outcomes and Measures The main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023. Results The mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents. Conclusions and Relevance In this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.
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Affiliation(s)
| | - Brendan K Saloner
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Olivia K Golan
- School of Public Health, Georgia State University, Atlanta
| | | | | | | | - Corey S Davis
- Network for Public Health Law, Los Angeles, California
| | | | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, Utah
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Charron E, White A, Carlston K, Abdullah W, Baylis JD, Pierce S, Businelle MS, Gordon AJ, Krans EE, Smid MC, Cochran G. Prospective acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder: A multisite qualitative study. Front Psychiatry 2023; 14:1137071. [PMID: 37139320 PMCID: PMC10149825 DOI: 10.3389/fpsyt.2023.1137071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Background While medications for opioid use disorder (MOUD) effectively treat OUD during pregnancy and the postpartum period, poor treatment retention is common. Digital phenotyping, or passive sensing data captured from personal mobile devices, namely smartphones, provides an opportunity to understand behaviors, psychological states, and social influences contributing to perinatal MOUD non-retention. Given this novel area of investigation, we conducted a qualitative study to determine the acceptability of digital phenotyping among pregnant and parenting people with opioid use disorder (PPP-OUD). Methods This study was guided by the Theoretical Framework of Acceptability (TFA). Within a clinical trial testing a behavioral health intervention for PPP-OUD, we used purposeful criterion sampling to recruit 11 participants who delivered a child in the past 12 months and received OUD treatment during pregnancy or the postpartum period. Data were collected through phone interviews using a structured interview guide based on four TFA constructs (affective attitude, burden, ethicality, self-efficacy). We used framework analysis to code, chart, and identify key patterns within the data. Results Participants generally expressed positive attitudes about digital phenotyping and high self-efficacy and low anticipated burden to participate in studies that collect smartphone-based passive sensing data. Nonetheless, concerns were noted related to data privacy/security and sharing location information. Differences in participant assessments of burden were related to length of time required and level of remuneration to participate in a study. Interviewees voiced broad support for participating in a digital phenotyping study with known/trusted individuals but expressed concerns about third-party data sharing and government monitoring. Conclusion Digital phenotyping methods were acceptable to PPP-OUD. Enhancements in acceptability include allowing participants to maintain control over which data are shared, limiting frequency of research contacts, aligning compensation with participant burden, and outlining data privacy/security protections on study materials.
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Affiliation(s)
- Elizabeth Charron
- Department of Health Promotion Sciences, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Tulsa, OK, United States
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Ashley White
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Kristi Carlston
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Walitta Abdullah
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
| | - Jacob D Baylis
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
| | - Stephanie Pierce
- Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Michael S Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Adam J Gordon
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, United States
| | - Elizabeth E Krans
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA, United States
- Center for Perinatal Addiction Research, Education and Evidence-based Solutions (Magee CARES), Magee-Womens Research Institute, Pittsburgh, PA, United States
| | - Marcela C Smid
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, UT, United States
| | - Gerald Cochran
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, United States
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Tan CJ, Shufelt T, Behan E, Jantara J, Koomsri C, Gordon AJ, Chaiyakunapruk N, Dhippayom T. Comparative effectiveness of psychosocial interventions in adults with harmful use of alcohol: A systematic review and network meta-analysis. Addiction 2023. [PMID: 36905310 DOI: 10.1111/add.16187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/23/2023] [Indexed: 03/12/2023]
Abstract
BACKGROUND AND AIMS Psychosocial approaches are the hallmark of treatment for harmful alcohol use. However, the most effective psychosocial intervention has not been identified. We aimed to compare the effectiveness of psychosocial therapy for harmful alcohol use using a network meta-analysis approach. METHODS We searched PubMed, Embase, CENTRAL, CINAHL and ProQuest Dissertations & Theses from inception to January 2022. Randomized controlled trials in adults age >18 years with harmful alcohol use were included. Psychosocial interventions were classified using the Theme, Intensity, and Provider/Platform (TIP) framework. The mean differences (MD) of the Alcohol Use Disorder Identification Test (AUDIT) score were estimated in the primary analysis using a random-effects model. Surface under the cumulative ranking curve (SUCRA) methods were used to rank different interventions. The certainty of evidence was evaluated using the Confidence in Network Meta-Analysis (CINeMA) approach. This review was registered with PROSPERO (CRD42022328972). RESULTS 4,225 records were retrieved from searching; 19 trials (n=7,149) met the inclusion criteria. The most common TIP combination was brief interventions delivered once via face-to-face sessions (6 studies) and 11 TIP features were included in the network meta-analysis. A significant difference in AUDIT score was evident among 16 out of 55 treatment comparisons, with the highest effect size observed when motivational interviewing plus cognitive behavioral therapy in multiple sessions via face-to-face (MI-CBT/Mult/F2F) was compared with usual care (MD: -4.98; 95% confidence interval [CI]: -7.04, -2.91). This finding was consistent with SUCRA, which suggested that MI-CBT/Mult/F2F is most likely to be better than other interventions (SUCRA=91.3). MI-CBT/Mult/F2F remained the highest-ranking intervention in our sensitivity analyses (SUCRA=64.9, 80.8). However, the certainty of evidence for most treatment comparisons was low. CONCLUSIONS Combined psychosocial intervention with more intensive approach may provide greater effect in reducing harmful alcohol consumption behavior.
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Affiliation(s)
- Chia Jie Tan
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Taylor Shufelt
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Emma Behan
- School of Pharmacy, University of Wisconsin-Madison, Madison, Wisconsin, USA
| | - Junpen Jantara
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Chanchanok Koomsri
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Department of Internal Medicine, Division of Epidemiology, School of Medicine, University of Utah, Salt Lake City, Utah, USA.,Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP); Informatics, Decision-Enhancement, and Analytic Science Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | - Teerapon Dhippayom
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Stein BD, Landis RK, Sheng F, Saloner B, Gordon AJ, Sorbero M, Dick AW. Buprenorphine Treatment Episodes During the First Year of COVID: a Retrospective Examination of Treatment Initiation and Retention. J Gen Intern Med 2023; 38:733-737. [PMID: 36474004 PMCID: PMC9734477 DOI: 10.1007/s11606-022-07891-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 10/26/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND During the COVID pandemic, overall buprenorphine treatment appeared to remain relatively stable, despite some studies suggesting a decrease in patients starting buprenorphine. There is a paucity of empirical information regarding patterns of buprenorphine treatment during the pandemic. OBJECTIVE To better understand the patterns of buprenorphine episodes during the pandemic and how those patterns compared to pre-pandemic patterns. DESIGN Pharmacy claims representing approximately 92% of all prescriptions filled at retail pharmacies in all 50 US states and the District of Columbia. PARTICIPANTS Individuals filling buprenorphine prescriptions indicated for treatment of opioid use disorder. MAIN MEASURES The number of active, starting, and ending buprenorphine treatment episodes March 13 to December 1, 2020, and the expected number of such episodes in 2020 based on the growth in treatment episodes from March 13 to December 1, 2019. KEY RESULTS The observed number of active buprenorphine episodes in December 2020 was comparable to the expected number, but new treatment episodes starting between March 13 and December 1, 2020, were 17.2% fewer than expected based on the 2019 experience. Similarly, the number of episodes that ended between March 13 and December 1, 2020, was 16.0% fewer than expected. Decreases from expected episode starts and ends occurred throughout the period but were greatest in the 2 months after the declaration of the public health emergency. CONCLUSIONS AND RELEVANCE Beneath the apparent stability of buprenorphine patient numbers during the pandemic, the flow of individuals receiving buprenorphine treatment changed substantially. Our findings shed light on how policy changes meant to support buprenorphine prescribing influenced prescribing dynamics during that period, suggesting that while policy efforts may have been successful in maintaining existing patients in treatment, that success did not extend to individuals not yet in treatment.
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Affiliation(s)
- Bradley D Stein
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA.
| | - Rachel K Landis
- George Washington University Trachtenberg School of Public Policy, Washington, DC, USA.,RAND Corporation, Arlington, VA, USA
| | | | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J Gordon
- VA Salt Lake City Health Care System and University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mark Sorbero
- RAND Corporation, 4570 Fifth Avenue, Suite 600, Pittsburgh, PA, 15213, USA
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Bershteyn A, Richard E, Zhou Q, Khan MR, Scheidell JD, Manandhar-Sasaki P, Ban K, Crystal S, Gordon AJ, Justice AC, Bryant KJ, Braithwaite RS. Potential health benefits of integrated screening strategies for alcohol, tobacco, other substance use, depression, anxiety, and chronic pain among people living with HIV in the USA: a mathematical modelling study. Lancet HIV 2023; 10:e118-e125. [PMID: 36731986 DOI: 10.1016/s2352-3018(22)00361-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Alcohol use, tobacco use, and other substance use often co-occur with depression, anxiety, and chronic pain, forming a constellation of alcohol, substance, and mood-related (CASM) conditions that disproportionately affects people with HIV in the USA. We used a microsimulation model to evaluate how alternative screening strategies accounting for CASM interdependence could affect life expectancy in people with HIV in the USA. METHODS We augmented a microsimulation model previously validated to predict US adult life expectancy, including in people with HIV. Using data from the Veterans Aging Cohort Study, we incorporated CASM co-occurrence, inferred causal relationships between CASM conditions, and assessed the effects of CASM on HIV treatment and preventive care. We simulated an in-care HIV cohort exposed to alternative CASM screening and diagnostic assessment strategies, ranging from currently recommended screenings (alcohol, tobacco, and depression, with diagnostic assessments for conditions screening positive) to a series of integrated strategies (screening for alcohol, tobacco, or depression with additional diagnostic assessments if any screened positive) to a maximal saturation strategy (diagnostic assessments for all CASM conditions). FINDINGS The saturation strategy increased life expectancy by 0·95 years (95% CI 0·93-0·98) compared with no screening. Recommended screenings provided much less benefit: 0·06 years (0·03-0·09) gained from alcohol screening, 0·08 years (0·06-0·11) from tobacco screening, 0·10 years (0·08-0·11) from depression screening, and 0·25 years (0·22-0·27) from all three screenings together. One integrated strategy (screening alcohol, tobacco, and depression with diagnostic assessment for all CASM conditions if any screened positive) produced near-maximal benefit (0·82 years [0·80-0·84]) without adding substantial screening burden, albeit requiring additional diagnostic assessments. INTERPRETATION Primary care providers for people with HIV should consider comprehensive diagnostic assessment of CASM conditions if one or more conditions screen positive. FUNDING US National Institute on Alcohol Abuse and Alcoholism.
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Affiliation(s)
- Anna Bershteyn
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Emma Richard
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Qinlian Zhou
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Maria R Khan
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Joy D Scheidell
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Prima Manandhar-Sasaki
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Kaoon Ban
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Stephen Crystal
- Center for Health Services Research, Rutgers University, New Brunswick, NJ, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA) and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Amy C Justice
- Veterans Aging Cohort Study Coordinating Center, VA Connecticut Healthcare System, West Haven, CT, USA; Schools of Medicine and Public Health, Yale University, New Haven, CT, USA
| | - Kendall J Bryant
- National Institute on Alcohol Abuse and Alcoholism, Bethesda, MD, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
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Bagley SM, Northup R, Wason K, Bratberg J, Gordon AJ, Oliva E. Examining Systems, Substance Use, and Disenfranchisement: Overview and Proceedings of the 2022 AMERSA Conference. Subst Abus 2023; 44:4-11. [PMID: 37226906 DOI: 10.1177/08897077231169569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Sarah M Bagley
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Division of General Pediatrics, Department of Pediatrics, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | | | - Kristin Wason
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, MA, USA
| | - Jeffrey Bratberg
- Department of Pharmacy Practice and Clinical Research, University of Rhode Island, Kingston, RI, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned-Care-Team, Informatics, Decision-Enhancement and Analytic Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Wyse JJ, Lovejoy TI, Gordon AJ, Mackey K, Herreid-O'Neill A, Morasco BJ. "I'm Clean and Sober, But Not Necessarily Free": Perceptions of Buprenorphine Among Patients in Long-Term Treatment. Subst Abus 2023; 44:41-50. [PMID: 37226910 DOI: 10.1177/08897077231165625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Patients receiving buprenorphine for the treatment of opioid use disorder (OUD) experience a roughly 50% reduction in mortality risk relative to those not receiving medication. Longer periods of treatment are also associated with improved clinical outcomes. Despite this, patients often express desires to discontinue treatment and some view taper as treatment success. Little is known about the beliefs and medication perspectives of patients engaged in long-term buprenorphine treatment that may underlie motivations to discontinue. METHODS This study was conducted at the VA Portland Health Care System (2019-2020). Qualitative interviews were conducted with participants prescribed buprenorphine for ≥2 years. Coding and analysis were guided by directed qualitative content analysis. RESULTS Fourteen patients engaged in office-based buprenorphine treatment completed interviews. While patients expressed strong enthusiasm for buprenorphine as a medication, the majority expressed the desire to discontinue, including patients actively tapering. Motivations to discontinue fell into 4 categories. First, patients were troubled by perceived side effects of the medication, including effects on sleep, emotion, and memory. Second, patients expressed unhappiness with being "dependent" on buprenorphine, framed in opposition to personal strength/independence. Third, patients expressed stigmatized beliefs about buprenorphine, describing it as "illicit," and associated with past drug use. Finally, patients expressed fears about buprenorphine unknowns, including potential long-term health effects and interactions with medications required for surgery. CONCLUSIONS Despite recognizing benefits, many patients engaged in long-term buprenorphine treatment express a desire to discontinue. Findings from this study may help clinicians anticipate patient concerns and can be used to inform shared decision-making conversations regarding buprenorphine treatment duration.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology & Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Katherine Mackey
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA
| | - Anders Herreid-O'Neill
- Oregon Rural Practice Network (ORPRN), Oregon Health & Science University, Portland, OR, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, OR, USA
- Department of Psychiatry, Oregon Health & Science University, Portland, OR, USA
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Scheidell JD, Townsend T, Ban KF, Caniglia EC, Charles D, Edelman EJ, Marshall BDL, Gordon AJ, Justice AC, Braithwaite RS, Khan MR. Cessation of self-reported opioid use and impacts on co-occurring health conditions. Drug Alcohol Depend 2023; 242:109712. [PMID: 36469994 PMCID: PMC10108375 DOI: 10.1016/j.drugalcdep.2022.109712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 10/31/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Among veterans in care reporting opioid use, we investigated the association between ceasing opioid use on subsequent reduction in report of other substance use and improvements in pain, anxiety, and depression. METHODS Using Veterans Aging Cohort Study survey data collected between 2003 and 2012, we emulated a hypothetical randomized trial (target trial) of ceasing self-reported use of prescription opioids and/or heroin, and outcomes including unhealthy alcohol use, smoking, cannabis use, cocaine use, pain, and anxiety and depressive symptoms. Among those with baseline opioid use, we compared participants who stopped reporting opioid use at the first follow-up (approximately 1 year after baseline) with those who did not. We fit logistic regression models to estimate associations with change in each outcome at the second follow-up (approximately 2 years after baseline) among participants with that condition at baseline. We examined two sets of adjusted models that varied temporality assumptions. RESULTS Among 2473 participants reporting opioid use, 872 did not report use, 606 reported use, and 995 were missing data on use at the first follow-up. Ceasing opioid use was associated with no longer reporting cannabis (adjusted odds ratio [AOR]=1.82, 95% confidence interval [CI] 1.10, 3.03) and cocaine use (AOR=1.93, 95% CI 1.16, 3.20), and improvements in pain (AOR=1.53, 95% CI 1.05, 2.24) and anxiety (AOR=1.56, 95% CI 1.01, 2.41) symptoms. CONCLUSION Cessation of opioid misuse may be associated with subsequent cessation of other substances and reduction in pain and anxiety symptoms, which supports efforts to screen and provide evidence-based intervention where appropriate.
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Affiliation(s)
- Joy D Scheidell
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA.
| | - Tarlise Townsend
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Kaoon Francois Ban
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Ellen C Caniglia
- University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics, Philadelphia, PA, USA
| | - Dyanna Charles
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - E Jennifer Edelman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Amy C Justice
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - R Scott Braithwaite
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
| | - Maria R Khan
- NYU Grossman School of Medicine, Department of Population Health, 227 E 30th Street, Sixth Floor, New York, NY 10016, USA
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Jones AL, Kelley AT, Suo Y, Baylis JD, Codell NK, West NA, Gordon AJ. Trends in Health Service Utilization After Enrollment in an Interdisciplinary Primary Care Clinic for Veterans with Addiction, Social Determinants of Health, or Other Vulnerabilities. J Gen Intern Med 2023; 38:12-20. [PMID: 35194740 PMCID: PMC8862702 DOI: 10.1007/s11606-022-07456-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/03/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND Models of interdisciplinary primary care (IPC) may improve upon traditional primary care approaches in addressing addiction and social determinants of health. OBJECTIVE To compare the trends in health care utilization in the year before and after enrollment in an IPC clinic model, and explore the variations in temporal patterns for patients with histories of high emergency department (ED) use, homelessness, and/or substance use disorders (SUDs). DESIGN AND PARTICIPANTS Interrupted time series study of utilization among IPC patients. MAIN MEASURES Quarterly ED, inpatient, primary care, and behavioral health visits were abstracted from administrative data before and after IPC enrollment. Negative binomial segmented regressions estimated changes in health care utilization over time. We used interactions to test for statistical differences in temporal patterns for IPC subgroups. RESULTS Among IPC patients (n=994), enrollment was associated with overall reductions in ED, inpatient, and behavioral health visits (p's<0.001) and increases in primary care (p's<0.001). Temporal patterns of ED visits, hospitalizations, and behavioral health differed across IPC subgroups (interaction p's<0.001). For those with histories of high ED use (n=265), ED, inpatient, and behavioral health visits decreased after enrollment (level change incidence rate ratios [IRRs]=0.57-0.69) and continued to decline over time (post-enrollment IRRs=0.80-0.88). Among other patients with homeless experiences (n=123), there were initial declines in hospitalizations (IRR=0.33) and overall declines in behavioral health visits (level change and post-enrollment IRRs=0.46-0.94). Other patients with SUDs had initial declines in hospitalizations (IRR=0.46), and post-enrollment declines in rates of specialty SUD visits (IRR=0.92). For all patients, primary care visits initially increased (level change IIRs=2.47-1.34) then gradually declined (post-enrollment IRRs=0.92-0.92). CONCLUSIONS An IPC model of care reduces acute care and behavioral health service use, particularly for patients with historically high ED use. IPC models may improve patient and system outcomes of vulnerable patient populations with social, clinical, and addiction morbidities.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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.
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - A Taylor Kelley
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob D Baylis
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Nodira K Codell
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Nancy A West
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Vulnerable Veteran Innovative Patient-Aligned Care Team (VIP), 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
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, University of Utah School of Medicine, Department of Internal Medicine, Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, UT, USA
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Cloutier RM, Cole ES, McDonough BL, Lomauro DA, Miller JP, Talbert AL, Bear TM, Bridges NC, Foulds AL, Taber R, Gordon AJ, Cochran GT, Kmiec J, Donohue JM, Kelley D, DiDomenico E, Adair D, Pringle JL. Strategies to recruit rural primary care providers to implement a medication for opioid use disorder (MOUD) focused integrated care model. Implementation Research and Practice 2023; 4:26334895231152808. [PMID: 37091535 PMCID: PMC9978659 DOI: 10.1177/26334895231152808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background Access to providers and programs that provide medications for opioid use disorder (MOUD) remains a systemic barrier for patients with opioid use disorder (OUD), particularly if they live in rural areas. The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) addressed this problem with a multisystem partnership that recruited, trained, and supported rural primary care providers to provide MOUD and implement an integrated care model (ICM) for patients with OUD. Given the demonstrated efficacy of Project RAMP, this article summarizes our recruitment strategies, including feasibility concerns for further expansion into other regions. Methods The approach for recruiting implementation sites included two phases: partner outreach and site identification. Once recruited, the Systems Transformation Framework guided planning and implementation activities. Recruitment and implementation activities were assessed with implementation trackers and evaluated by providers via key informant interviews (KIIs). Results Project RAMP recruited 26 primary care practices from 13 counties, including nine health systems and two private practice groups—exceeding the original target of 24 sites. There was a median of 49 days from first contact to project onboarding. A total of 108 primary care practices spanning 22 health systems declined participation. Findings from the KIIs highlighted the value of engaging PCPs by connecting to a shared vision (i.e., improving the quality of patient care) as well as addressing perceived participation barriers (e.g., offering concierge technical assistance to address lack of training or resources). Conclusion Findings highlight how successful recruitment activities should leverage the support of health system leadership. Findings also emphasize that aiding recruitment and engagement efforts successfully addressed prescribers’ perceived barriers to providing MOUD as well as facilitating better communication among administrators, PCPs, behavioral health professionals, care managers, and patients. Plain Language Summary: Opioid use disorder (OUD) is one of the leading causes of preventable illness and death. The standard of care for OUD is the provision of medications for opioid use disorder (MOUD) and the application of an integrative integrated care model (ICM) where behavioral health is blended with specialized medical services. Unfortunately, access to providers and healthcare facilities that provide MOUD or apply an ICM remains a systemic barrier for patients with OUD, particularly if they live in rural areas. Although there is no one-size-fits-all approach to implementing MOUD in primary care, findings from Project The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) highlight strategies that may improve future MOUD and ICM implementation efforts in similar rural contexts. Specifically, future efforts to increase MOUD capacity by recruiting new providers should be prepared to leverage health system leadership, address provider barriers via training and expert consultation, and facilitate connections to local behavioral health providers. This approach may be helpful to others recruiting health systems and primary care practices to implement new care models to use MOUD in treating patients with OUD.
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Affiliation(s)
- Renee M. Cloutier
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Evan S. Cole
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Brianna L. McDonough
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Daniel A. Lomauro
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - John P. Miller
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Abigail L. Talbert
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Todd M. Bear
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Nora C. Bridges
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Abigail L. Foulds
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Rachel Taber
- Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Adam J. Gordon
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald T. Cochran
- Program for Addiction Research, Clinical Care, Education, and Advocacy, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Julie Kmiec
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Julie M. Donohue
- Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - David Kelley
- Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - Ellen DiDomenico
- Pennsylvania Department of Drug and Alcohol Programs, Harrisburg, PA, USA
| | - Dale Adair
- Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg, PA, USA
| | - Janice L. Pringle
- Program Evaluation and Research Unit, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
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Hickey TR, Meeks T, Oxentine H, Park DC, Abelleira A, Edens E, Gordon AJ, Acampora G. Perioperative Management of Extended-Release Buprenorphine: A Narrative Review and Case Series. Subst Abus 2023; 44:96-103. [PMID: 37226900 DOI: 10.1177/08897077231167043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Perioperative management of formulations of buprenorphine used for the treatment of opioid use disorder and/or pain are common clinical challenges. Care strategies are increasingly recommending continuation of buprenorphine while administering multimodal analgesia including full agonist opioids. While this "simultaneous strategy" is relatively simple for the shorter-acting sublingual buprenorphine formulation, best practices are needed for the increasingly prescribed extended-release buprenorphine (ER-buprenorphine). To our knowledge there are no prospective data to guide perioperative management of patients on ER-buprenorphine. Herein we provide a narrative review, report on the perioperative experiences of a series of patients maintained on ER-buprenorphine, and propose recommendations for perioperative ER-buprenorphine management based on best evidence, clinical experience, and our judgments. CASES Here we present clinical data describing the perioperative experiences of patients maintained on extended-release buprenorphine who recently underwent a variety of surgeries ranging from outpatient inguinal hernia repair to multiple inpatient surgeries for source control in sepsis, at different medical centers throughout the United States. These patients were identified via an email solicitation to substance use disorder treatment providers throughout a nationwide healthcare system, requesting cases of patients maintained on extended-release buprenorphine who had recently undergone surgery. We report here on all of the cases received. DISCUSSION Extrapolating from these and recently published case reports, we describe an approach to perioperative management of extended-release buprenorphine.
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Affiliation(s)
- Thomas R Hickey
- VA Connecticut Healthcare System, Yale University School of Medicine, West Haven, CT, USA
| | - Thomas Meeks
- VA Portland Health Care System, Oregon Health & Science University, Vancouver, WA, USA
| | - Heather Oxentine
- Substance Abuse Treatment Program, Bay Pines VA Healthcare System, Bay Pines, FL, USA
| | - Dong Chan Park
- Bedford VA Healthcare System, Boston University Medical School, Bedford, MA, USA
| | | | - Ellen Edens
- Yale School of Medicine, Department of Psychiatry, VA Connecticut Healthcare System, West Haven, CT, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA. Sciences Center, VA Salt Lake City Health Care System, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytics Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Gregory Acampora
- MGH/Harvard Center for Addiction Medicine, Pain Management Center at MGH, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Magel J, Hartman P, Fritz JM, Koch NN, Dostal H, Vollmer N, Ferguson NL, Tapken J, Cohee K, Cochran G, Gordon AJ. Patients' Perceptions of Physical Therapists Addressing Opioid Misuse. Subst Abus 2023; 44:32-40. [PMID: 37226908 DOI: 10.1177/08897077231165072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
INTRODUCTION In the US, rising numbers of patients who misuse illicit or prescribed opioids provides opportunities for physical therapists (PTs) to be engaged in their care. Prior to this engagement, it is necessary to understand the perceptions of patients who access physical therapy services about their PTs playing such a role. This project examined patients' perceptions of PTs addressing opioid misuse. METHODS We surveyed patients, newly encountering outpatient physical therapy services in a large University-based healthcare setting, via anonymous, web-based survey. Within the survey, questions were rated on a Likert scale (1 = completely disagree to 7 = completely agree) and we evaluated responses of patients who were prescribed opioids versus those who were not. RESULTS Among 839 respondents, the highest mean score was 6.2 (SD = 1.5) for "It is OK for physical therapists to refer their patients with prescription opioid misuse to a specialist to address the opioid misuse." The lowest mean score was 5.6 (SD = 1.9) for "It is OK for physical therapists to ask their patient why they are misusing prescription opioids." Compared to those with no prescription opioid exposure while attending physical therapy, patients with prescription opioid exposure had lower agreement that it was OK for the physical therapist to refer their patients with opioid misuse to a specialist (β = -.33, 95% CI = -0.63 to -0.03). CONCLUSIONS Patients attending outpatient physical therapy seem to support PTs addressing opioid misuse and there are differences in support based on whether the patients had exposure to opioids.
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Affiliation(s)
- John Magel
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Paul Hartman
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Julie M Fritz
- Department of Physical Therapy and Athletic Training, University of Utah, Salt Lake City, UT, USA
| | - Nicholas N Koch
- University of Utah Health, University of Utah, Salt Lake City, UT, USA
| | - Hannah Dostal
- University of Utah Health, University of Utah, Salt Lake City, UT, USA
| | | | | | - Jennifer Tapken
- Direct Performance Physical Therapy, Virginia Beach, VA, USA
| | - Kim Cohee
- University of Utah Health, University of Utah, Salt Lake City, UT, USA
| | - Gerald Cochran
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA) and Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
| | - Adam J Gordon
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA) and Greater Intermountain Node (GIN) of the NIDA Clinical Trials Network, Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Informatics, Decision-Enhancement, and Analytic Sciences Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
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Miller WA, Gordon AJ, Clothier BA, Ackland PE, Bounthavong M, Garcia C, Kenny ME, Noorbaloochi S, Hagedorn HJ. Co-occurring implementation strategies: The effects of academic detailing for opioid use disorder campaign on the advancing pharmacological treatments for opioid use disorder (ADaPT-OUD) study. Implement Res Pract 2023; 4:26334895231199463. [PMID: 37790176 PMCID: PMC10504828 DOI: 10.1177/26334895231199463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023] Open
Abstract
Background Barriers at the system, clinician, and patient level limit access to medications for opioid use disorder (MOUD). The Advancing Pharmacological Treatments for Opioid Use Disorder (ADaPT-OUD) study implemented an external facilitation strategy within the Veterans Health Administration (VHA) aimed at facility-level barriers to improve uptake of MOUD. During ADaPT-OUD, an independent Academic Detailing Services Opioid Agonist Treatment of OUD Campaign was co-occurring and aimed to increase evidence-based practice for OUD at the clinician level. While both these initiatives aim to increase MOUD reach, they address different barriers and did not intentionally collaborate. Thus, understanding the interaction between these two independent implementation initiatives and their effect on MOUD reach will further inform and mold future implementation efforts of MOUD. Methods This was a secondary analysis of the ADaPT-OUD study that included 35 VHA facilities in the lowest quartile of MOUD reach; eight received the ADaPT-OUD external facilitation and 27 matched sites received implementation as usual. The number of academic detailing (AD) visits during ADaPT-OUD was used as a proxy for the intensity of Academic Detailing for OUD Campaign activity. The interaction between external facilitation status and AD intensity was evaluated by comparing the change in facility-level MOUD reach. Results There was a general increase in the number of AD visits, in both external facilitation and implementation as usual sites, over the course of ADaPT-OUD's implementation period. A non-statistically significant, positively sloped, linear relationship was observed between average number of AD visits per quarter and change in MOUD reach in facilities also receiving ADaPT-OUD external facilitation that was not observed in the implementation as usual sites. Conclusion Co-occurring initiatives focusing on different barriers to MOUD access have the potential to further increase MOUD in low-performing facilities, but further research into timing, quality, and collaboration between initiatives are warranted.
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Affiliation(s)
- Wendy A. Miller
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT Initiative, 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), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Barbara A. Clothier
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Princess E. Ackland
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Mark Bounthavong
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
- Skaggs School of Pharmacy & Pharmaceutical Sciences, University of California San Diego, San Diego, CA, USA
| | - Carla Garcia
- Health Economics Resource Center, Palo Alto Veterans Affairs HealthCare System, Palo Alto, CA, USA
| | - Marie E. Kenny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
| | - Siamak Noorbaloochi
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Hildi J. Hagedorn
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, Minneapolis, MN, USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN, USA
- Centers of Excellence in Substance Addiction Treatment and Education, Puget Sound VAHCS, Seattle, WA & Philadelphia VAHCS, Philadelphia, PA, USA
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Gustavson AM, Hagedorn HJ, Jesser LE, Kenny ME, Clothier BA, Bounthavong M, Ackland PE, Gordon AJ, Harris AHS. Healthcare quality measures in implementation research: advantages, risks and lessons learned. Health Res Policy Syst 2022; 20:131. [PMID: 36476309 PMCID: PMC9730563 DOI: 10.1186/s12961-022-00934-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 11/08/2022] [Indexed: 12/12/2022] Open
Abstract
Implementation studies evaluate strategies to move evidence-based practices into routine clinical practice. Often, implementation scientists use healthcare quality measures to evaluate the integration of an evidence-based clinical practice into real-world healthcare settings. Healthcare quality measures have standardized definitions and are a method to operationalize and monitor guideline-congruent care. Implementation scientists can access existing data on healthcare quality measures through various sources (e.g. operations-calculated), or they can calculate the measures directly from healthcare claims and administrative data (i.e. researcher-calculated). Implementation scientists need a better understanding of the advantages and disadvantages of these methods of obtaining healthcare quality data for designing, planning and executing an implementation study. The purpose of this paper is to describe the advantages, risks and lessons learned when using operations- versus researcher-calculated healthcare quality measures in site selection, implementation monitoring and implementation outcome evaluation. A key lesson learned was that relying solely on operations-calculated healthcare quality measures during an implementation study poses risks to site selection, accurate feedback on implementation progress to stakeholders, and the integrity of study results. A possible solution is using operations-calculated quality measures for monitoring of evidence-based practice uptake and researcher-calculated measures for site section and outcomes evaluation. This approach provides researchers greater control over the data and consistency of the measurement from site selection to outcomes evaluation while still retaining measures that are familiar and understood by key stakeholders whom implementation scientists need to engage in practice change efforts.
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Affiliation(s)
- Allison M. Gustavson
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Hildi J. Hagedorn
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Psychiatry, University of Minnesota School of Medicine, Minneapolis, MN 55455 USA
| | - Leah E. Jesser
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Marie E. Kenny
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Barbara A. Clothier
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
| | - Mark Bounthavong
- Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, CA 94025 USA
| | - Princess E. Ackland
- Veterans Affairs Health Services Research and Development Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Healthcare System, 1 Veterans Drive, Mail Code#152, Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, USA
| | - Adam J. Gordon
- Vulnerable Veteran Innovative PACT (VIP) Initiative; Informatics, Decision-Enhancement, and Analytic Sciences Center (IDEAS), Salt Lake City Veterans Healthcare System, 500 Foothill Drive, Salt Lake City, UT 84148 USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), University of Utah School of Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT 84148 USA
| | - Alex H. S. Harris
- Center for Innovation to Implementation, Palo Alto Veteran Affairs Healthcare System, Palo Alto, CA 94025 USA
- Department of Surgery, Stanford University School of Medicine, Stanford, CA 94305 USA
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