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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications

The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013-14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.

Intimate partner violence screening in the dental setting: Results of a nationally representative survey

BACKGROUND

The dental setting is a potential venue for identifying patients experiencing intimate partner violence (IPV). The study objective was to assess dentists' current practices and attitudes about IPV screening.

METHODS

A nationally representative survey of US general dentists assessed dentists' use of health history forms that queried about IPV and their acceptance of IPV screening as part of their professional roles. Parsimonious Poisson regression models were used in multivariable analysis to estimate risk ratios for the 2 dependent variables.

RESULTS

Almost all dentists did not include a question to screen for IPV on their patient history forms. More than one-half of dentists also did not know of a referral place for patients experiencing IPV and did not believe that IPV screening should be part of their professional roles.

CONCLUSIONS

Uptake of IPV screening and favorable attitudes toward screening were low among dentists studied. However, prior IPV training and clinical knowledge plus awareness of IPV referral mechanisms were positively associated with greater screening uptake and attitudes.

PRACTICAL IMPLICATIONS

The inclusion of brief, focused IPV interventions in dental education and the establishment of collaborations between dentists and IPV agencies for referral mechanisms, in conjunction with an overall shift in dentists' attitudes about their professional responsibilities, may facilitate IPV screening uptake in the dental setting.

HIV testing in the dental setting: perspectives and practices of experienced dental professionals

The dental setting is a largely untapped venue to identify patients with undiagnosed HIV infection. Yet, uptake of rapid HIV testing within the dental community remains low. This study sought to better understand the experiences of dental professionals who have administered the test and how these experiences might inform efforts to promote greater uptake of rapid HIV testing in dental settings. Qualitative interviews were conducted with United States dentists (N = 37) and hygienists (N = 5) who offered rapid HIV testing in their practices. The data revealed both the impeding and facilitating factors they experienced in implementing testing in their setting, as well as the reactions of their staff, colleagues, and patients. Overall, participants viewed rapid HIV testing favorably, regarding it as a valuable public health service that is simple to administer, generally well accepted by patients and staff, and easily integrated into clinical practice. Many had experience with a reactive test result. Participants described facilitating factors, such as supportive follow-up resources. However, they also cited persistent barriers that limit acceptance by their dental colleagues, including insufficient reimbursement and perceived incompatibility with scope of practice. The widespread adoption of routine HIV testing amongst dental professionals will likely require an expanded notion of the proper scope of their professional role in overall patient health, along with greater support from national dental organizations, dental education, and dental insurance companies, especially in the form of sufficient reimbursement.

Non-buprenorphine opioid utilization among patients using buprenorphine

BACKGROUND AND AIMS

Buprenorphine is commonly used to treat opioid use disorder; however, non-buprenorphine prescription opioid use among these patients is not well defined. We sought to estimate the prevalence of non-buprenorphine opioid use among incident buprenorphine users and quantify levels of opioid use prior to, during and after the first treatment episode.

DESIGN

We used QuintilesIMS anonymized, individual-level, all-payer pharmacy claims to identify incident users of buprenorphine between January 2010 and July 2012 from a large cohort of approximately 50 million patients filling two or more prescriptions for any opioid during any calendar year between 2006 and 2013 in 11 states of interest.

SETTING

Eleven states within the United States.

PARTICIPANTS

Of the individuals who met our inclusion criteria (n = 38 096), 55% were female and half were aged between 29 and 54 years. Median length of the first treatment episode was 55 days [interquartile range (IQR) = 28-168 days].

MEASUREMENTS

We calculated four measures of non-buprenorphine opioid use: (1) number of prescriptions, (2) quantity dispensed, (3) days of supply and (4) total morphine milligram equivalents (MME) before, during and after the first treatment episode. Our primary outcome was the MME per opioid day supplied during each time period.

FINDINGS

Approximately two-fifths (43%) of buprenorphine recipients filled an opioid prescription during the treatment episode and two-thirds (67%) filled an opioid prescription following treatment. The mean total of MME per opioid day supplied 12 months prior to treatment declined from 57 mg/per day [95% confidence interval (CI) = 57, 58] to 54 mg/per day (95% CI = 54, 55) during the treatment episode, then remained constant at 55 mg/per day (95% CI = 54, 56) following the treatment episode.

CONCLUSIONS

The use of buprenorphine for the treatment of opioid use disorder has increased markedly in the United States. However, a substantial proportion of patients fill prescriptions for non-buprenorphine opioids during and following such treatment.

Thinking, Fast and Slow? Some Field Experiments to Reduce Crime and Dropout in Chicago

We present the results of three large-scale randomized controlled trials (RCTs) carried out in Chicago, testing interventions to reduce crime and dropout by changing the decision making of economically disadvantaged youth. We study a program called Becoming a Man (BAM), developed by the nonprofit Youth Guidance, in two RCTs implemented in 2009-2010 and 2013-2015. In the two studies participation in the program reduced total arrests during the intervention period by 28-35%, reduced violent-crime arrests by 45-50%, improved school engagement, and in the first study where we have follow-up data, increased graduation rates by 12-19%. The third RCT tested a program with partially overlapping components carried out in the Cook County Juvenile Temporary Detention Center (JTDC), which reduced readmission rates to the facility by 21%. These large behavioral responses combined with modest program costs imply benefit-cost ratios for these interventions from 5-to-1 up to 30-to-1 or more. Our data on mechanisms are not ideal, but we find no positive evidence that these effects are due to changes in emotional intelligence or social skills, self-control or "grit," or a generic mentoring effect. We find suggestive support for the hypothesis that the programs work by helping youth slow down and reflect on whether their automatic thoughts and behaviors are well suited to the situation they are in, or whether the situation could be construed differently. JEL Codes: C91, C93, D03, D1, I24, I3, I32, K42.

Lessons From Medicaid's Divergent Paths On Mental Health And Addiction Services

Over the past fifty years Medicaid has taken divergent paths in financing mental health and addiction treatment. In mental health, Medicaid became the dominant source of funding and had a profound impact on the organization and delivery of services. But it played a much more modest role in addiction treatment. This is poised to change, as the Affordable Care Act is expected to dramatically expand Medicaid's role in financing addiction services. In this article we consider the different paths these two treatment systems have taken since 1965 and identify strategic lessons that the addiction treatment system might take from mental health's experience under Medicaid. These lessons include leveraging optional coverage categories to tailor Medicaid to the unique needs of the addiction treatment system, providing incentives to addiction treatment programs to create and deliver high-quality alternatives to inpatient treatment, and using targeted Medicaid licensure standards to increase the quality of addiction services.

Making Health Care Truly Affordable after Health Care Reform

The Affordable Care Act (ACA) is an essential first step toward making health insurance more affordable for lower and moderate income Americans. It has accomplished historic reductions in the proportion of Americans who are uninsured. The number of Americans reporting delaying medical care for financial reasons has declined by approximately one-third since 2010. Medicaid expansions, in particular, have significantly reduced financial burdens and accompanying anxieties experienced by low-income Americans in states that have embraced this opportunity. ⁴ Consistent with these finding, one recent analysis of credit report data finds that Medicaid expansion was associated with between a $600 and $1000 decline in collection balances among individuals who gained coverage. Notwithstanding these gains, premiums and cost-sharing are still too high for many Americans. And cost-sharing has continued to edge higher for the majority of Americans who have coverage through employer-based plans. Measures to address these challenges must build on the ACA to provide greater protection to millions of Americans and to address continued dissatisfaction with our health care financing system among middle-income Americans.

Sources of guns to dangerous people: what we learn by asking them

Gun violence exacts a lethal toll on public health. This paper focuses on reducing access to firearms by dangerous offenders, contributing original empirical data on the gun transactions that arm offenders in Chicago. Conducted in the fall of 2013, analysis of an open-ended survey of 99 inmates of Cook County Jail focuses on a subset of violence-prone individuals with the goal of improving law enforcement actions. Among our principal findings: *Our respondents (adult offenders living in Chicago or nearby) obtain most of their guns from their social network of personal connections. Rarely is the proximate source either direct purchase from a gun store, or theft. *Only about 60% of guns in the possession of respondents were obtained by purchase or trade. Other common arrangements include sharing guns and holding guns for others. *About one in seven respondents report selling guns, but in only a few cases as a regular source of income. *Gangs continue to play some role in Chicago in organizing gun buys and in distributing guns to members as needed. *The Chicago Police Department has a considerable effect on the workings of the underground gun market through deterrence. Transactions with strangers and less-trusted associates are limited by concerns over arrest risk (if the buyer should happen to be an undercover officer or a snitch), and about being caught with a "dirty" gun (one that has been fired in a crime).

Screening for substance misuse in the dental care setting: findings from a nationally representative survey of dentists

AIMS

The dental setting is a potentially valuable venue for screening for substance misuse. Therefore, we assessed dentists' inquiry of substance misuse through their patient medical history forms and their agreement with the compatibility of screening as part of the dentists' professional role.

DESIGN

A nationally representative survey of general dentists using a sampling frame obtained from the American Dental Association Survey Center (November 2010-November 2011).

SETTING

United States of America.

PARTICIPANTS

A total of 1802 general dentists.

MEASUREMENTS

A 38-item survey instrument assessing the relationship between dentists' practice, knowledge, behaviors and attitudes with their query about substance misuse and their belief that such screening is part of their professional role.

FINDINGS

Dentists who accepted substance misuse screening as part of their professional role were more likely to query about misuse with their patients (85.8%) compared with those who did not accept such screening as part of their role (68.2%) (P < 0.001). Prior experience and knowledge about substance misuse were the strongest predictors of dentists' inquiry about patient substance use/misuse and acceptance of screening as part of their role in their clinical practice (P < 0.05).

CONCLUSION

While more than three-quarters of US dentists report that they ask their patients about substance misuse, two-thirds do not agree that such screening is compatible with their professional role.

Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform

The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment--the state governmental organizations charged with overseeing addiction treatment programs--are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA's promise to improve access to and quality of addiction treatment.

Applications of PET imaging with the proliferation marker [18F]-FLT

[18F]-3'-fluoro-3'-deoxythymidine (FLT) is a nucleoside-analog imaging agent for quantifying cellular proliferation that was first reported in 1998. It accumulates during the S-phase of the cell cycle through the action of cytosolic thymidine kinase, TK1. Since TK1 is primarily expressed in dividing cells, FLT uptake is essentially limited to dividing cells. Thus FLT is an effective measure of cell proliferation. FLT uptake has been shown to correlate with the more classic proliferation marker, the monoclonal antibody to Ki-67. Increased cellular proliferation is known to correlate with worse outcome in many cancers. However, the Ki-67 binding assay is performed on a sampled preparation, ex vivo, whereas FLT can be quantitatively measured in vivo using positron emission tomography (PET). FLT is an effective and quantitative marker of cell proliferation, and therefore a useful prognostic predictor in the setting of neoplastic disease. This review summarizes clinical studies from 2011 forward that used FLT-PET to assess tumor response to therapy. The paper focuses on our recommendations for a standardized clinical trial protocol and components of a report so multi center studies can be effectively conducted, and different studies can be compared. For example, since FLT is glucuronidated by the liver, and the metabolite is not transported into the cell, the plasma fraction of FLT can be significantly changed by treatment with particular drugs that deplete this enzyme, including some chemotherapy agents and pain medications. Therefore, the plasma level of metabolites should be measured to assure FLT uptake kinetics can be accurately calculated. This is important because the flux constant (KFLT) is a more accurate measure of proliferation and, by inference, a better discriminator of tumor recurrence than standardized uptake value (SUVFLT). This will allow FLT imaging to be a specific and clinically relevant prognostic predictor in the treatment of neoplastic disease.

Does tougher enforcement make drugs more expensive?

AIMS

To review empirical research that seeks to relate marginal increases in enforcement against the supply of illicit drugs to changes in drug prices at the level of the drug supply system being targeted.

METHOD

Review of empirical studies.

FINDINGS

Although the fact of prohibition itself raises prices far above those likely to pertain in legal markets, there is little evidence that raising the risk of arrest, incarceration or seizure at different levels of the distribution system will raise prices at the targeted level, let alone retail prices. The number of studies available is small; they use a great variety of outcome and input measures and they all face substantial conceptual and empirical problems.

CONCLUSION

Given the high human and economic costs of stringent enforcement measures, particularly incarceration, the lack of evidence that tougher enforcement raises prices call into question the value, at the margin, of stringent supply-side enforcement policies in high-enforcement nations.

Dentists' self-perceived role in offering tobacco cessation services: results from a nationally representative survey, United States, 2010-2011

Introduction

Dental visits represent an opportunity to identify and help patients quit smoking, yet dental settings remain an untapped venue for treatment of tobacco dependence. The purpose of this analysis was to assess factors that may influence patterns of tobacco-use–related practice among a national sample of dental providers.

Methods

We surveyed a representative sample of general dentists practicing in the United States (N = 1,802). Multivariable analysis was used to assess correlates of adherence to tobacco use treatment guidelines and to analyze factors that influence providers’ willingness to offer tobacco cessation assistance if reimbursed for this service.

Results

More than 90% of dental providers reported that they routinely ask patients about tobacco use, 76% counsel patients, and 45% routinely offer cessation assistance, defined as referring patients for cessation counseling, providing a cessation prescription, or both. Results from multivariable analysis indicated that cessation assistance was associated with having a practice with 1 or more hygienists, having a chart system that includes a tobacco use question, having received training on treating tobacco dependence, and having positive attitudes toward treating tobacco use. Providers who did not offer assistance but who reported that they would change their practice patterns if sufficiently reimbursed were more likely to be in a group practice, treat patients insured through Medicaid, and have positive attitudes toward treating tobacco dependence.

Conclusion

Findings indicate the potential benefit of increasing training opportunities and promoting system changes to increase involvement of dental providers in conducting tobacco use treatment. Reimbursement models should be tested to assess the effect on dental provider practice patterns.

Evidence-based treatment for opioid disorders: a 23-year national study of methadone dose levels

Effective treatment for patients with opioid use problems is as critical as ever given the upsurge in heroin and prescription opioid abuse. Yet, results from prior studies show that the majority of methadone maintenance treatment (MMT) programs in the US have not provided dose levels that meet evidence-based standards. Thus, this paper examines the extent to which US MMT programs have made changes in the past 23 years to provide adequate methadone doses; we also identify factors associated with variation in program performance. Program directors and clinical supervisors of nationally-representative methadone treatment programs were surveyed in 1988 (n=172), 1990 (n=140), 1995 (n=116), 2000 (n=150), 2005 (n=146), and 2011 (n=140). Results show that the proportion of patients who received doses below 60 mg/day-the minimum recommended-declined from 79.5 to 22.8% in a 23-year span. Results from random effects models show that programs that serve a higher proportion of African-American or Hispanic patients were more likely to report low-dose care. Programs with Joint Commission accreditation were more likely to provide higher doses, as were a program that serves a higher proportion of unemployed and older patients. Efforts to improve methadone treatment practices have made substantial progress, but 23% of patients across the nation are still receiving doses that are too low to be effective.

Dentists' willingness to provide expanded HIV screening in oral health care settings: results from a nationally representative survey

OBJECTIVES

Using a nationally representative survey, we determined dentists' willingness to provide oral rapid HIV screening in the oral health care setting.

METHODS

From November 2010 through November 2011, a nationally representative survey of general dentists (sampling frame obtained from American Dental Association Survey Center) examined barriers and facilitators to offering oral HIV rapid testing (n = 1802; 70.7% response). Multiple logistic regression analysis examined dentists' willingness to conduct this screening and perceived compatibility with their professional role.

RESULTS

Agreement with the importance of annual testing for high-risk persons and familiarity with the Centers for Disease Control and Prevention's recommendations regarding routine HIV testing were positively associated with willingness to conduct such screening. Respondents' agreement with patients' acceptance of HIV testing and colleagues' improved perception of them were also positively associated with willingness.

CONCLUSIONS

Oral HIV rapid testing is potentially well suited to the dental setting. Although our analysis identified many predictors of dentists' willingness to offer screening, there are many barriers, including dentists' perceptions of patients' acceptance, that must be addressed before such screening is likely to be widely implemented.