Survey of Barriers and Facilitators to Prescribing Buprenorphine and Clinician Perceptions on the Drug Addiction Treatment Act of 2000 Waiver

Pharmacist-prescriber collaborative models of care for opioid use disorder: an overview of recent research

PURPOSE OF REVIEW

Collaborative models of care where pharmacists work alongside physicians have been developed for a range of physical health conditions, with benefits including improved patient outcomes and increased access to ongoing care. Opioid agonist treatment (methadone and buprenorphine) is a clinically effective and cost-effective treatment for opioid use disorder that is under-utilized in many countries due to a shortage of prescribers. In recent years, there has been increased interest in the development of collaborative models that utilize pharmacists to overcome barriers to treatment. In this article, we present a narrative review to synthesise recent work in this rapidly developing area.

RECENT FINDINGS

Two key aspects of opioid agonist treatment were identified: Collaborative models have utilized pharmacists to facilitate buprenorphine induction, and collaborative models provide increased capacity for delivering ongoing care in a variety of settings and patient groups where prescriber access is limited. Pharmacists have undertaken direct patient care responsibilities with varying degrees of autonomy, with benefits including a reduction in prescriber workload, and improvements in treatment retention and continuity of care.

SUMMARY

Collaborative models in which pharmacists are responsible for buprenorphine induction and ongoing management with methadone and buprenorphine have been shown to reduce demands on prescribers while improving or maintaining patient outcomes, and appear feasible and acceptable in a wide range of outpatient settings.

Buprenorphine prescribing and treatment accessibility in response to regulation changes due to the COVID-19 public health emergency

BACKGROUND

In 2021, over 80,000 fatal overdoses occurred in the United States. Since 2020, the federal government has enacted multiple regulatory changes around buprenorphine prescribing for opioid use disorder (OUD) to increase access to buprenorphine. This study aims to explore trends in buprenorphine treatment initiation pre- and post-public health emergency to evaluate changes in the context of X-waiver relaxations and telehealth allowances.

METHODS

In a cross-sectional study, all RI residents who filled a buprenorphine prescription at a pharmacy in Rhode Island (RI), Massachusetts, and Connecticut between January 2017 and December 2023 were obtained from the RI Prescription Drug Monitoring Program (PDMP). The study excluded buprenorphine products not approved for OUD treatment from the analysis. Identified individuals had initiated buprenorphine for OUD during the study period if they did not have a prior prescription or if they had >30 days without buprenorphine exposure between their prescriptions. Spearman's rank correlation tests were used to identify significant associations between outcomes and regulation changes.

RESULTS

The average number of patients dispensed buprenorphine did not significantly change over the study period, however the average number of initiates significantly decreased (ρ = -0.38255, p = .0003). The average number of providers prescribing CII-CV substances in RI has increased 3.4 % over the study period. The average percentage of prescribers in the PDMP prescribing buprenorphine for OUD doubled (ρ = 0.96075, p < .0001).

CONCLUSION

Though efforts have been made to increase buprenorphine initiation, buprenorphine initiates remain well below pre-PHE levels. Efforts must continue to eliminate existing barriers to treatment and improve access to individuals seeking treatment.

A qualitative exploration of health care workers' approaches to relational harm reduction in HIV primary care settings

BACKGROUND

Structural harm reduction is an approach to care for people who use drugs (PWUD) that incorporates services and resources (e.g., naloxone, sterile syringes). As conceptualized in our previous research, harm reduction is also "relational," encompassing a patient-provider relationship that is non-judgmental and respectful of patients' autonomy. Little is known about health care workers' (HCW) knowledge or attitudes towards harm reduction beyond structural strategies, whose availability and legality vary across geographical settings. To operationalize how relational harm reduction is both characterized and employed in HIV care settings, where nearly half of patients have a diagnosed substance use disorder, we qualitatively explored HCWs' knowledge of and use of harm reduction via individual in-depth interviews.

METHODS

Our study sample included three HIV clinics, one in Birmingham, Alabama (AL) and two in Pittsburgh, Pennsylvania (PA). We conducted individual interviews with n = 23 health care workers via Zoom, using a semi-structured interview guide to probe for questions around health care workers' attitudes towards and experiences with providing care to PWH who use drugs and their knowledge of and attitudes towards relational and structural harm reduction. Data was analyzed in Dedoose using thematic analysis.

RESULTS

Qualitative analyses revealed two primary themes, Continuum of Relational Harm Reduction in Practice and Limited Harm Reduction Training. Nearly all HCWs (n = 19, 83%) described a patient interaction or expressed a sentiment that corresponded with the principles of relational harm reduction. Yet, over half of participants (n = 14, 61%) used language to describe PWH who use drugs that was stigmatizing or described an interaction that was antithetical to the principles of relational harm reduction. Five HCWs, all from Birmingham, were unaware of the term 'harm reduction.' Few HCWs had any harm reduction training, with most learning about harm reduction from webinars/conferences or on the job.

CONCLUSION

Our findings suggest that relational harm reduction in HIV care settings is practiced along a continuum, and that a range of behaviors exist even within individual HCWs (e.g., used stigmatizing terms such as "addict" but also described patient interactions that reflected patients' autonomy). Given that harm reduction is typically described as a structural approach, a broader definition of harm reduction that is not dependent on policy-dependent resources is needed.

Leveraging Project ECHO to Implement a Suite of Substance Use Learning Communities for Statewide Impact

BACKGROUND

Overdoses and alcohol consumption rose during the pandemic. However, uptake of practices which reduce mortality (eg, medications for opioid use disorder, harm reduction practices) remains insufficient. Provider training and telementoring is needed to ensure sufficient capacity for treating substance use disorders (SUDs) with evidence-based practices. The Project ECHO (Extension for Community Healthcare Outcomes) model involves the use of web technologies to deliver didactic and case-based learning through a panel of experts to build such competency in a community of learners. Project ECHO was leveraged to implement a statewide telementoring center of addictions-focused ECHO programs, including programming in prescribing, harm reduction, recovery support services, collaborations with first responders, and systems-level challenges.

METHODS

Participants represented health and behavioral health disciplines practicing across the state of Texas in metropolitan and rural areas. Learners were administered: (1) an online registration form that inquired about basic demographics, (2) a post-session survey at the conclusion of each session capturing satisfaction and likelihood to implement, and (3) annual surveys measuring changes in knowledge and self-efficacy. Attendance and other learner data were stored and extracted from the partner relationship management database: iECHO.

RESULTS

Training programs were attended by 968 learners, with an average of 48 learners per session. Geographic reach included 47 Texas cities. Post-training survey results indicated high rates of learner satisfaction, with an average rating of 4.68 on a 5-point Likert-like scale. Annual surveys indicated improvements in provider knowledge and self-confidence across all programs.

CONCLUSIONS

Early results indicate robust uptake, wide geographic reach, high learner satisfaction, and provider knowledge and confidence gains. This preliminary evidence supports the use of the ECHO model as a potential tool for scaling comprehensive SUD telementoring centers to meet workforce development needs over large geographic areas.

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians

Importance

The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas.

Objective

To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas.

Design, Setting, and Participants

This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021.

Exposure

Prescribing of buprenorphine by NHSC clinicians.

Main Outcomes and Measures

The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics.

Results

During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation.

Conclusions and Relevance

These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.

Innovation in the Delivery of Behavioral Health Services

Several factors motivate the need for innovation to improve the delivery of behavioral health services, including increased rates of mental health and substance use disorders, limited access to services, inconsistent use of evidence-based practices, and persistent racial and ethnic disparities. This narrative review identifies promising innovations that address these challenges, assesses empirical evidence for the effectiveness of these innovations and the extent to which they have been adopted and implemented, and suggests next steps for research. We review five categories of innovations: organizational models, including a range of novel locations for providing services and new ways of organizing services within and across sites; information and communication technologies; workforce; treatment technologies; and policy and regulatory changes. We conclude by discussing the need to strengthen and accelerate the contributions of implementation science to close the gap between the launch of innovative behavioral health services and their widespread use.

Dialing for doctors: Secret shopper study of Arizona methadone and buprenorphine providers, 2022

INTRODUCTION

Methadone and buprenorphine are effective and safe treatments for opioid use disorder (OUD) and also reduce overdose and all-cause mortality. Identifying and reaching providers of medication for opioid use disorder (MOUD) has proven difficult for prospective patients and researchers.

OBJECTIVES

To assess the accuracy of government-maintained lists of Arizona (AZ) providers prescribing MOUD, and the extent to which these providers are accessible for treatment.

METHODS

A two-phase study used a listing of 2376 AZ MOUD providers obtained from the U.S. Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration. Phase 1 assessed the accuracy of the listing using internet confirmatory research from May-October 2022. Phase 2 used the resulting list of 838 providers to assess provider availability, type of MOUD treatment provided, and accepted payment through secret shopper calls between November 16 and 30, 2022.

RESULTS

Just over half (52.2 %, n = 1240) of providers were removed from the original listing during Phase 1. One quarter (25.9 %) were no longer in practice. Among the 833 eligible for the secret shopper Phase 2 study, 36.6 % (n = 307) were reached and identified as providing MOUD. A vast majority (88.1 %) of MOUD providers indicating treatment type were accepting new patients, however methadone was identified far more frequently than was likely permitted or provided for OUD. Providers were 5.5 times more likely to accept new patients if they accepted cash payment for services, and 4.9 times more likely if they accepted Medicaid. Rural areas remained underserved.

CONCLUSIONS

The active population of MOUD providers is far smaller than surmised. DEA and SAMHSA provider listings are not sufficiently accurate for survey research sampling. Other means of representative sampling will need to be devised, and trusted lists of providers for prospective patients should be promoted, publicly available, and regularly maintained for accuracy. Providers that offer treatment should assure that public-facing staff have basic information about the practice, the treatment offered, and conditions for taking new patients. Concerted efforts must assure rural access at the most local levels to reduce patient travel burden.

Buprenorphine dispensing before and after the April 2021 X-Waiver exemptions: An interrupted time series analysis

BACKGROUND

Until the end of 2022, a special registration, known as the X-waiver, was required to prescribe buprenorphine in the US. Before its removal, US federal regulations trialed an X-waiver exemption, initiated on April 28, 2021, which permitted buprenorphine prescribing for up to 30 patients without additional training. We aimed to understand if these regulatory changes impacted buprenorphine dispensing.

METHODS

We conducted an interrupted time series analysis to understand changes in buprenorphine dispensing during the 26 weeks after the X-waiver exemption compared to the expected baseline trend established in the 26 weeks before using the IQVIA Longitudinal Prescription claims database. The primary outcome was number of new buprenorphine prescribers nationwide (defined as no prior buprenorphine prescription dispensed in the last 26 weeks). Segmented regression estimated relative changes in buprenorphine dispensing at 1, 13, and 26 weeks post-X-waiver change.

RESULTS

A total of 15,517,525 prescriptions filled for 1,328,172 patients (43.4 % female) ordered by 62,312 providers were included for analysis. At 26 weeks post-X-waiver change, there was no change in the number of new prescribers compared to the expected baseline trend (-2.7 % [95 % CI:-8.3,2.9]). The number of new (15.2 % [4.6,25.8]) and existing (1.7 % [0.9,2.4]) patients and patients per prescriber (4.3 % [3,5.6]) increased. Buprenorphine prescriptions reimbursed by Medicaid increased (7.5 % [6.6,8.4]) while commercial fills decreased (-3.4 % [-5.3,-1.5]).

CONCLUSIONS

The number of new prescribers did not increase six months post-X-waiver exemption while new patients continued to enter treatment at higher-than-expected rates. These findings suggest that additional interventions beyond the recent X-waiver removal may be needed to increase access to buprenorphine.

A Qualitative Exploration of Providers' Approaches to Relational Harm Reduction in HIV Primary Care Settings

Background

Structural harm reduction is an approach to care for people who use drugs (PWUD) that incorporates services and resources (e.g., naloxone, sterile syringes). As conceptualized in our previous research, harm reduction is also "relational," encompassing a patient-provider relationship that is non-judgmental and respectful of patients' autonomy. Little is known about providers' knowledge or attitudes towards harm reduction beyond structural strategies, whose availability and legality vary across geographical settings. To operationalize how relational harm reduction is both characterized and employed in HIV care settings, where nearly half of patients have a diagnosed substance use disorder, we qualitatively explored providers' knowledge of and use of harm reduction via individual in-depth interviews.

Methods

Our study sample included three HIV clinics, one in Birmingham, Alabama (AL) and two in Pittsburgh, Pennsylvania (PA). We conducted individual interviews with n = 23 providers via Zoom, using a semi-structured interview guide to probe for questions around providers' attitudes towards and experiences with providing care to PWH who use drugs and their knowledge of and attitudes towards relational and structural harm reduction. Data was analyzed in Dedoose using thematic analysis.

Results

Qualitative analyses revealed three primary themes, including Relational Harm Reduction in Practice, Not Harm Reduction, No Knowledge of Harm Reduction, and Harm Reduction Training. Nearly all providers (n = 19, 83%) described a patient interaction or expressed a sentiment that corresponded with the principles of relational harm reduction. Yet, over half of participants (n = 14, 61%) used language to describe PWH who use drugs that was stigmatizing or described an interaction that was antithetical to the principles of relational harm reduction. Five providers, all from Birmingham, were unaware of the term 'harm reduction.' Few providers had any harm reduction training.

Conclusion

Our findings suggest that relational harm reduction in HIV care settings is practiced along a continuum, and that a range of behaviors exist even within individual providers (e.g., used stigmatizing terms such as "addict" but also described patient interactions that reflected patients' autonomy). Given that harm reduction is typically described as a structural approach, a broader definition of harm reduction that is not dependent on policy-dependent resources is needed.

A survey of barriers and facilitators to the adoption of buprenorphine prescribing after implementation of a New Jersey-wide incentivized DATA-2000 waiver training program

BACKGROUND

Opioid-involved overdose deaths continue to rise in the US, despite availability of highly effective treatments for opioid use disorder (OUD), in part due to the insufficient number of treatment providers. Barriers include the need for providers to gain expertise and confidence in providing MOUD to their patients who need these treatments. To mitigate this barrier, New Jersey sponsored a buprenorphine training program with financial incentives for participation, which met the then existing requirement for the DATA-2000 waiver. In a 2019 follow-up survey, participants reported on barriers and facilitators to subsequent buprenorphine prescribing.

METHODS

Participants in the training program completed a 10-min electronic survey distributed via email. The survey addressed demographics, practice characteristics, current buprenorphine prescribing, and barriers and facilitators to adoption and/or scale up of buprenorphine prescribing.

RESULTS

Of the 440 attendees with a valid email address, 91 individuals completed the survey for a response rate of 20.6%. Of the 91 respondents, 89 were eligible prescribers and included in the final analysis. Respondents were predominantly female (n = 55, 59.6%) and physicians (n = 55, 61.8%); representing a broad range of specialties and practice sites. 65 (73%) of respondents completed the training and DEA-registration, but only 31 (34.8%) were actively prescribing buprenorphine. The most frequently cited barriers to buprenorphine prescribing were lack of access to support services such as specialists in addiction, behavioral health services, and psychiatry. The most frequently reported potential facilitators were integrated systems with direct access to addiction specialists and psychosocial services, easier referral to behavioral health services, more institutional support, and improved guidance on clinical practice standards for OUD treatment.

CONCLUSION

More than half (52.3%) of those who completed incentivized training and DEA registration failed to actively prescribe buprenorphine. Results highlight provider perceptions of inadequate availability of support for the complex needs of patients with OUD and suggest that broader adoption of buprenorphine prescribing will require scaling up support to clinicians, including increased availability of specialized addiction and mental health services.

Impact of the Communities That HEAL Intervention on Buprenorphine-Waivered Practitioners and Buprenorphine Prescribing: A Prespecified Secondary Analysis of the HCS Randomized Clinical Trial

Importance

Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined.

Objective

To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing.

Design, Setting, and Participants

This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022.

Intervention

Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity.

Main Outcomes and Measures

The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100 000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 8 166 963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10).

Conclusions and Relevance

In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT04111939.

Buprenorphine misinformation and willingness to treat patients with opioid use disorder among primary care-aligned health care professionals

BACKGROUND

Buprenorphine is a highly effective medication for opioid use disorder that is underused by health care professionals (HCPs). Medications for opioid use disorder (MOUD) misinformation may be an important barrier to buprenorphine access, but most implementation strategies have aimed to reduce negative attitudes towards patients with opioid use disorder (OUD) rather than misinformation specific to buprenorphine use. In this study, we assessed the degree to which HCPs endorsed misinformation related to buprenorphine, and whether this is associated with willingness to provide care to patients with OUD.

METHODS

In September-December of 2022, we surveyed HCPs practicing in Ohio (n = 409). Our primary outcomes included a previously validated 5-item measure of HCP willingness to treat patients with OUD, and three other measures of willingness. Our key independent variable was a study-developed 5-item measure of endorsement of misinformation related to buprenorphine, which assessed beliefs in buprenorphine's efficacy in managing withdrawal symptoms and reducing overdose deaths as well as beliefs about the role of buprenorphine in achieving remission. We computed descriptive and bivariable statistics and fit regression models predicting each outcome of interest.

RESULTS

On average, HCPs scored 2.34 out of 5.00 (SD = 0.80) on the composite measure of buprenorphine misinformation. 48.41% of participants endorsed at least one piece of misinformation. The most endorsed items were that buprenorphine is ineffective at reducing overdose deaths (M = 2.75, SD =0 .98), and that its use substitutes one drug for another (M = 2.41, SD = 1.25). HCP endorsement of buprenorphine misinformation significantly and negatively predicted willingness to work with patients with OUD (b = - 0.34; 95% CI - 0.46, - 0.21); intentions to increase time spent with this patient population (b = - 0.36; 95% CI - 5.86, - 1.28); receipt of an X-waiver (OR = 0.54, 95% CI 0.38, 0.77); and intention to get an X-waiver (OR: 0.56; 95% CI: 0.33-0.94).

CONCLUSIONS

Misinformation is common among HCPs and associated with lower willingness to treat patients with OUD. Implementation strategies to increase MOUD use among HCPs should specifically counter misinformation related to buprenorphine.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, NCT05505227. Registered 17 August 2022, https://clinicaltrials.gov/ct2/show/NCT05505227.

Real-World Dispensing of Buprenorphine in California during Prepandemic and Pandemic Periods

INTRODUCTION

The opioid overdose crisis in the United States has become a significant national emergency. Buprenorphine, a primary medication for individuals coping with opioid use disorder (OUD), presents promising pharmacokinetic properties for use in primary care settings, and is often delivered as a take-home therapy. The COVID-19 pandemic exacerbated the scarcity of access to buprenorphine, leading to dire consequences for those with OUD. Most existing studies, primarily focused on the immediate aftermath of the COVID-19 outbreak, highlight the challenges in accessing medications for opioid use disorder (MOUDs), particularly buprenorphine. However, these studies only cover a relatively short timeframe.

METHODS

To bridge this research gap, in our study, we utilized 33 months of California's prescription drug monitoring program (PDMP) data to provide insights into real-world buprenorphine dispensing trends since the onset of the pandemic from 2018 to 2021, focusing on outcomes such as patient counts, prescription volumes, prescriber involvement, days' supply, and dosage. Statistical analysis employed interrupted time series analysis to measure changes in trends before and during the pandemic.

RESULTS

We found no significant impact on patient counts or prescription volumes during the pandemic, although it impeded the upward trajectory of prescriber numbers that was evident prior to the onset of the pandemic. An immediate increase in days' supply per prescription was observed post-pandemic.

CONCLUSION

Our findings differ in comparison to previous data regarding the raw monthly count of patients and prescriptions. The analysis encompassed uninsured patients, offering a comprehensive perspective on buprenorphine prescribing in California. Our study's insights contribute to understanding the impact of COVID-19 on buprenorphine access, emphasizing the need for policy adjustments.

Positive contact and empathy as predictors of primary care providers' willingness to prescribe medications for opioid use disorder

Introduction

Patients with opioid use disorder (OUD) have a heightened need for quality health care, including access to evidence-based medications to reduce cravings and prevent overdose. However, primary care providers (PCPs) are reluctant to work with patients with OUD and implement medication prescribing into primary care practice. Previous studies have sought to identify potential ways to overcome these barriers, but often utilize interventions that facilitate both positive contact with as well as empathy for patients with OUD. In this study, we jointly assess positive contact and empathy to determine their unique impact on treatment attitudes and behaviors among PCPs, after controlling for other known predictors.

Methods

We surveyed 409 PCPs currently practicing in Ohio in 2022. Our primary dependent variables were willingness to work with patients with OUD, receipt of an X-waiver to prescribe buprenorphine, and interest in receiving an X-waiver. Our primary independent variables were positive contact and empathy toward patients with OUD. We computed bivariate correlations and multivariable linear regression (for continuous dependent variables) and logistic regression (for binary dependent variables) to understand the relationship between positive contact, empathy, and our outcome variables while accounting for other known predictors and relevant participant demographics.

Results

Positive contact was positively correlated with willingness to work with patients with OUD, receipt of the X-waiver, an interest in receiving the X-waiver, more frequent checking with patients about the need for naloxone, and higher odds of naloxone prescribing. These relationships held after accounting for PCP demographics, explicit bias toward patients with OUD, and overall levels of contact with patients with OUD. Empathy, conversely, was not a significant predictor of any treatment outcomes in the fully adjusted models.

Conclusion

Interventions and medical education programs aimed at improving treatment outcomes for patients with OUD should facilitate positive contact between PCPs and patients with OUD.

Beliefs and Attitudes about Vermont's Buprenorphine Decriminalization Law among Clinicians Who Prescribe Buprenorphine

BACKGROUND

On June 1, 2021, Vermont repealed all criminal penalties for possessing 224 milligrams or less of buprenorphine. We examined the potential impact of decriminalization with a survey of Vermont clinicians who prescribed buprenorphine within the past year.

METHODS

All 638 Vermont clinicians with a waiver to prescribe buprenorphine were emailed the survey by Vermont Department of Health; 117 responded. We estimated the prevalence of the following four outcomes, for all responding clinicians and stratified by clinician demographics and practice characteristics: awareness of decriminalization, beliefs about the effects of decriminalization, support for decriminalization, and changes in practice resulting from decriminalization.

RESULTS

72 (62%) prescribers correctly stated that Vermont does not have criminal penalties for buprenorphine possession. 107 (91%) support decriminalization. 56 (48%) believe that, because buprenorphine is decriminalized, their patients are more likely to give, sell, or trade the buprenorphine that is prescribed to them to someone else. However, only 5 providers (4%) said they now prescribe to fewer patients.

CONCLUSION

The great majority of Vermont clinicians who prescribe buprenorphine support its decriminalization and have not changed their prescribing practices because of decriminalization.

The association between longitudinal trends in receipt of buprenorphine for opioid use disorder and buprenorphine-waivered providers in the United States

AIMS, DESIGN AND SETTING

We sought to describe longitudinal trends in buprenorphine receipt and buprenorphine-waivered providers in the United States from 2003 to 2021 and measure whether the relationship between the two differed after capacity-building strategies were enacted nationally in 2017. This was a retrospective study of two separate cohorts covering the years 2003-21, testing whether the association between two trends in these cohorts changed comparing 2003 to 2016 and from 2017 to 2021, among buprenorphine providers in the United States, regardless of treatment setting. Patients receiving dispensed buprenorphine at retail pharmacies.

PARTICIPANTS

All providers who have obtained a waiver to prescribe buprenorphine in the United States, and an estimate of the annual number of patients who had buprenorphine for opioid use disorder (OUD) dispensed to them at a retail pharmacy.

MEASUREMENTS

We synthesized and summarized data from multiple sources to assess the cumulative number of buprenorphine-waivered providers over time. We used national-level prescription data from IQVIA to estimate annual buprenorphine receipt for OUD.

FINDINGS

From 2003 to 2021, the number of buprenorphine-waivered providers in the United States increased from fewer than 5000 in the first 2 years of Food and Drug Administration (FDA) approval to more than 114 000 in 2021, while patients receiving buprenorphine products for OUD increased from approximately 19 000 to more than 1.4 million. The strength of association between waivered providers and patients is significantly different before and after 2017 (P < 0.001). From 2003 to 2016, for each additional provider, there was an average increase of 32.1 [95% confidence interval (CI) = 28.7-35.6] patients, but an increase of only 4.6 (95% CI= 3.5-5.7) patients for each additional provider, beginning in 2017.

CONCLUSIONS

In the United States, the relationship between the rates of growth in buprenorphine providers and patients became weaker after 2017. While efforts to increase buprenorphine-waivered providers were successful, there was less success in translating that into significant increases in buprenorphine receipt.

Association of MOUD ECHO Participation on Expansion of Buprenorphine Prescribing in Rural Primary Care

BACKGROUND

Lack of access to buprenorphine to treat Opioid Use Disorder is profound in rural areas where over half of small and remote rural counties have no buprenorphine prescriber. To increase prescribing, an online, Medication of Opioid Use Disorder (MOUD) Extensions for Community Healthcare Outcomes (ECHO) was developed that addressed known barriers to the startup and expansion of treatment. The objective of the present study was to determine the relationship between participating in MOUD ECHO sessions and prescribing of buprenorphine for OUD in rural primary care.

METHODS

Using non-random, rolling-recruitment from Feb 2018 to October of 2021, all rural primary care clinics in New Mexico were contacted via phone call and fax to recruit providers (Physicians, Nurse Practitioners, and Physician Assistants) who had no or limited buprenorphine experience to enroll in this study. Participation in the MOUD ECHO was tracked across the 12 week series. Start-up and expansion of buprenorphine treatment was measured every 3 months for up to 2 years using 5 implementation benchmarks spanning training completion, obtaining licensure, prescribing and adding patients. Using a dose-response intention to treat type analysis, associations between number of sessions and benchmark achievement were analyzed using logistic regression.

RESULTS

Eighty providers were enrolled, mostly female (66%) white (82%), non-Hispanic (82%), and mostly nurse practitioners (51%) or MDs (38%). Achievement of prescribing benchmarks at 6 months was significantly increased by attendance at MOUD ECHO sessions including obtaining training and licensure Odds Ratio (OR = 1.24; P = .001); starting to prescribe (OR = 1.31; P = .004), and adding patients (OR = 1.14; P = .025).

CONCLUSIONS

This study provides compelling evidence that MOUD ECHO participation may significantly increase the number of providers implementing this treatment and adding patients onto their panels. The dose-response approach helps address current gaps in ECHO research that call for more rigorous examination of the ECHO model's impact on provider practice improvements.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Mental health and substance use disorder comorbidities among Medicaid beneficiaries: Associations with opioid use disorder and prescription opioid misuse

Background

Medicaid presently insures about one-fourth of the US population and disproportionately insures about 38 % of non-elderly adults with an opioid use disorder (OUD). Owing to Medicaid's prominent role insuring persons with an OUD and that Medicaid coverage includes pharmaceutical benefits, there has been considerable interest in studying potential prescription opioid misuse among Medicaid beneficiaries and identifying subpopulations at higher risk for misuse and possible progression to an OUD.

Methods

The study goals were to explore the associations among prescription opioid misuse, OUD, and co-occurring mental health and other substance use disorders (SUD). We analyzed Illinois Medicaid 2018 claims data for 1102479 adult beneficiaries 18 to 64 years of age. Using algorithms based on previous studies, we first determined either the presence or absence of nine SUDS (including OUD), nine mental health disorders and likely prescription opioid misuse. Then, we subdivided the beneficiary sample into five groups: those who were prescribed opioids and evidenced either no, possible, or probable misuse; those evidencing an OUD; and those evidencing no opioid use or misuse.

Results

Bivariate analyses, upset plots, and multinomial logistic regressions were used to compare the five subgroups on the prevalence of co-occurring SUDS and mental health disorders. Those with an OUD or with probable prescription opioid misuse had the highest prevalence of most co-occurring conditions with beneficiaries with an OUD the most likely to evidence co-occurring SUDS, particularly tobacco use disorder, whereas those with probable misuse had elevated prevalence rates of co-occurring mental health disorders comparable to those with an OUD.

Conclusion

The medical complexity of persons with an OUD or misusing prescription opioids are considered in light of recent attempts to expand buprenorphine provision as a medication for OUD among Medicaid beneficiaries. Additionally, we consider the possibility of gender, co-occurring mental health disorders, and tobacco use disorder as important risk factors for progressing to prescription opioid misuse and an OUD.

Evaluation of the New England Office Based Addiction Treatment ECHO: A Tool for Strengthening the Addiction Workforce

INTRODUCTION

Reducing substance-related morbidity requires an educated and well-supported workforce. The New England Office Based Addiction Treatment Extension for Community Healthcare Outcomes (NE OBAT ECHO) began in 2019 to support community-based addiction care teams through virtual mentoring and case-based learning. We sought to characterize the program's impact on the knowledge and attitudes of NE OBAT ECHO participants.

METHODS

We conducted an 18-month prospective evaluation of the NE OBAT ECHO. Participants registered for 1 of 2 successive ECHO clinics. Each 5-month clinic included ten 1.5-hour sessions involving brief didactic lectures and de-identified patient case presentations. Participants completed surveys at Month-0, -6, -12, and -18 to assess attitudes about working with patients who use drugs and evidence based practices (EBPs), stigma toward people who use drugs, and addiction treatment knowledge. We compared outcomes using 2 approaches: (i) between-groups, which involved comparing the first intervention group to the delayed intervention (comparison) group, and (ii) within-groups, which involved comparing outcomes at different time points for all participants. In the within-group approach, each participant acted as their own control.

RESULTS

Seventy-six health professionals participated in the NE OBAT ECHO, representing various roles in addiction care teams. Approximately half (47% [36/76]) practiced primary care, internal, or family medicine. The first intervention group reported improved job satisfaction and openness toward EBPs compared to the delayed intervention group. Within-group analyses revealed that ECHO participation was associated with increased positive perceptions of role adequacy, support, legitimacy, and satisfaction 6 months following program completion. No changes were identified in willingness to adopt EBPs or treatment knowledge. Stigma toward people who use drugs was persistent in both groups across time points.

CONCLUSIONS

NE OBAT ECHO may have improved participants' confidence and satisfaction providing addiction care. ECHO is likely an effective educational tool for expanding the capacity of the addiction workforce.

Low dose IV buprenorphine inductions for patients with opioid use disorder and concurrent pain: a retrospective case series

BACKGROUND

Hospitalizations are a vital opportunity for the initiation of life-saving opioid agonist therapy (OAT) for patients with opioid use disorder. A novel approach to OAT initiation is the use of IV buprenorphine for low dose induction, which allows patients to immediately start buprenorphine at any point in a hospitalization without stopping full agonist opioids or experiencing significant withdrawal.

METHODS

This is a retrospective case series of 33 patients with opioid use disorder concurrently treated with full agonist opioids for pain who voluntarily underwent low dose induction at a tertiary academic medical center. Low dose induction is the process of initiating very low doses of buprenorphine at fixed intervals with gradual dose increases in patients who recently received or are simultaneously treated with full opioid agonists. Our study reports one primary outcome: successful completion of the low dose induction (i.e. transitioned from low dose IV buprenorphine to sublingual buprenorphine-naloxone) and three secondary outcomes: discharge from the hospital with buprenorphine-naloxone prescription, self-reported pain scores, and nursing-assessed clinical opiate withdrawal scale (COWS) scores over a 6-day period, using descriptive statistics. COWS and pain scores were obtained from day 0 (prior to starting the low dose induction) to day 5 to assess the effect on withdrawal symptoms and pain control.

RESULTS

Thirty patients completed the low dose induction (30/33, 90.9%). Thirty patients (30/33, 90.9%) were discharged with a buprenorphine prescription. Pain and COWS scores remained stable over the course of the study period. Mean COWS scores for all patients were 2.6 (SD 2.8) on day 0 and 1.6 (SD 2.6) on day 5. Mean pain scores for all patients were 4.4 (SD 2.1) on day 0 and 3.5 on day 5 (SD 2.1).

CONCLUSIONS

This study found that an IV buprenorphine low dose induction protocol was well-tolerated by a group of 33 hospitalized patients with opioid use disorder with co-occurring pain requiring full agonist opioid therapy. COWS and pain scores improved for the majority of patients. This is the first case series to report mean daily COWS and pain scores over an extended period throughout a low dose induction process.

A scoping review of barriers and facilitators to the integration of substance use treatment services into US mainstream health care

Background

Following the national implementation of the Affordable Care Act (ACA) in 2014, barriers still exist that limit the adoption of substance use treatment (SUT) services in mainstream health care (MHC) settings in the United States. This study provides an overview of current evidence on barriers and facilitators to integrating various SUT services into MHC.

Methods

A systematic search was conducted with the following databases: "PubMed including MEDLINE", "CINAHL", "Web of Science", "ABI/Inform", and "PsycINFO." We identified barriers and/or facilitators affecting patients, providers, and programs/systems.

Results

Of the 540 identified citations, 36 were included. Main barriers were identified for patients (socio-demographics, finances, confidentiality, legal impact, and disinterest), providers (limited training, lack of time, patient satisfaction concerns, legal implications, lack of access to resources or evidence-based information, and lack of legal/regulatory clarity), and programs/systems (lack of leadership support, lack of staff, limited financial resources, lack of referral networks, lack of space, and lack of state-level support). Also, we recognized key facilitators pertaining to patients (trust for providers, education, and shared decision making), providers (expert supervision, use of support team, training with programs like Extension for Community Health Outcomes (ECHO), and receptivity), and programs/systems (leadership support, collaboration with external agencies, and policies e.g., those expanding the addiction workforce, improving insurance access and treatment access).

Conclusions

This study identified several factors influencing the integration of SUT services in MHC. Strategies for improving SUT integration in MHC should address barriers and leverage facilitators related to patients, providers, and programs/systems.

Buprenorphine Utilization and Prescribing Among New Jersey Medicaid Beneficiaries After Adoption of Initiatives Designed to Improve Treatment Access

Importance

Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization.

Objective

To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access.

Design, Setting, and Participants

This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021.

Exposure

Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence.

Main Outcomes and Measures

Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty.

Results

Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation.

Conclusions and Relevance

In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.

Eliminate the buprenorphine DEA X waiver: Justification using a policy analysis approach

INTRODUCTION

Drug overdoses have reached a historic milestone of over 100,000 deaths in a single year, 75,673 related to opioids. The acceleration in opioid-related deaths coupled with stark health inequities demands a close examination of opioid use disorder (OUD) treatment barriers and swift consideration of policy changes.

DESIGN

The aim of this buprenorphine policy analysis is to summarize existing buprenorphine barriers and present policy solutions to improve access and actualize the contributions of Advanced Practice Registered Nurses (APRNs).

METHODS

The policy analysis follows five sequential steps: (1) defining the problem, (2) identifying key stakeholders, (3) assessing the landscape of relevant policies, (4) describing viable policy options, and (5) making final recommendations.

RESULTS

Although there are laudable efforts to improve buprenorphine access, such as the new buprenorphine guidelines issued in April 2021, without larger-scale changes to federal, state, and scope of practice laws, overdose rates will continue to rise. We recommend a multipronged policy approach to improve buprenorphine treatment access, including eliminating the DEA X waiver, improving OUD education, and adopting full practice authority for APRNs in all states.

CONCLUSION

Incremental change is no longer sufficient to address opioid overdose deaths. Bolder and coordinated policy action is possible and necessary to empower the full clinical workforce to apply evidence-based life-saving treatments for OUD. The critical contributions of nurses in advancing equitable access to OUD care are emphasized in the National Academy of Medicine's Report, Future of Nursing: Charting a Path to Achieve Health Equity. Nurses are named as instrumental in improving buprenorphine access. Policy changes that acknowledge and build on evidence-based treatment expansion strategies are sorely needed.

CLINICAL RELEVANCE

One of the most robust tools to combat opioid overdose deaths is buprenorphine, a partial opioid agonist, and gold standard medication treatment for OUD, but only 5% of the prescribing workforce possess the required Drug Enforcement Agency (DEA) X waiver. A growing body of evidence demonstrates that Advanced Practice Registered Nurses are accelerating the growth in waiver update and buprenorphine use, despite the considerable barriers and limitations described in this policy analysis.

Impact of Policy Change on Access to Medication for Opioid Use Disorder in Primary Care

OBJECTIVES

The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care.

METHODS

We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ2 test to evaluate the effect of the educational intervention on screening.

RESULTS

Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey.

CONCLUSIONS

Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.

Building a statewide network of MOUD expertise using tiered ECHO® mentoring opportunities

BACKGROUND

Expanding access to workforce training for opioid use disorder (OUD) treatment continues to be a priority. This study explored the use of tiered mentoring opportunities within an ECHO® model to expand treatment capacity and develop a statewide network of medications for OUD (MOUD) expertise. ECHO® engages participants in a virtual community to learn best practices through case-based learning and interactions with experts.

METHODS

We studied two incentivized Illinois MOUD ECHO® training programs by examining aggregate demographic and prescribing data across eight training cohorts (n = 199 participants). Participants (n = 51) in the last two cohorts were evaluated with expanded pre- and post-training surveys. Qualitative interviews were completed with a subset (n = 13) to examine effects observed in the survey data.

RESULTS

For the whole group, we found a geographic expansion of the participants' prescribing capacity that reached into rural and other underserved areas in Illinois. Participants in the last two cohorts reported both increased self-efficacy for OUD treatment and increased connectedness to the addiction treatment community in Illinois. Participants who progressed through the tiered mentorship roles were found to exhibit stepwise increases in reported self-efficacy and connectedness measures.

CONCLUSION

An incentivized ECHO® program yielded substantive outcomes in terms of increased prescribing capacity across the state. The use of tiered mentoring opportunities enabled participants to develop MOUD expertise and support novice providers in a growing statewide network. There is potential to train professionals to a high level of expertise when the ECHO® model is combined with a mentorship pathway.

A Prescription Digital Therapeutic to Support Unsupervised Buprenorphine Initiation for Patients With Opioid Use Disorder: Protocol for a Proof-of-Concept Study

BACKGROUND

Home-based (unsupervised) buprenorphine initiation is considered safe and effective, yet many patients report barriers to successful treatment initiation. Prescription digital therapeutics (PDTs) are software-based disease treatments regulated by the US Food and Drug Administration (FDA). The reSET-O PDT was authorized by the FDA in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder (OUD). A prototype PDT (PEAR-002b) designed for use with reSET-O was developed to assist in unsupervised buprenorphine initiation.

OBJECTIVE

The primary objective of this pilot study is to evaluate the acceptability of PEAR-002b in individuals with OUD who use it to support buprenorphine initiation, their unsupervised buprenorphine initiation success rate, and their medication adherence.

METHODS

Ten adults with OUD will be recruited for acceptability and feasibility testing. Outcomes will be assessed using week-1 visit attendance, participant interviews and satisfaction surveys, and urine drug screening (UDS). Three tools will be used in the study: PEAR-002b, reSET-O, and EmbracePlus. PEAR-002b includes a new set of features designed for use with reSET-O. The mechanism of action for the combined PEAR-002b and reSET-O treatment is a program of medication dosing support during week 1 of the initiation phase, cognitive behavioral therapy, and contingency management. During the medication initiation phase, participants are guided through a process to support proper medication use. PEAR-002b advises them when to take their buprenorphine based on provider inputs (eg, starting dose), self-reported substance use, and self-reported withdrawal symptoms. This study also administers the EmbracePlus device, a medical-grade smartwatch, to pilot methods for collecting physiologic data (eg, heart rate and skin conductance) and evaluate the device's potential for use along with PDTs that are designed to improve OUD treatment initiation. Home buprenorphine initiation success will be summarized as the proportion of participants attending the post-buprenorphine initiation visit (week 1) and the proportion of participants who experience buprenorphine initiation-related adverse events (eg, precipitated withdrawal). Acceptability of PEAR-002b will be evaluated based on individual participants' ratings of ease of use, satisfaction, perceived helpfulness, and likelihood of recommending PEAR-002b. Medication adherence will be evaluated by participant self-report data and confirmed by UDS. UDS data will be summarized as the mean of individual participants' proportion of total urine samples testing positive for buprenorphine or norbuprenorphine over the 4-week study.

RESULTS

This project was funded in September 2019. As of September 2022, participant enrollment is ongoing.

CONCLUSIONS

This is the first study to our knowledge to develop a PDT that assists with unsupervised buprenorphine initiation with the intent to better support patients and prescribers during this early phase of treatment. This pilot study will assess the acceptability and utility of a digital therapeutic to assist individuals with OUD with unsupervised buprenorphine initiation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05412966; https://clinicaltrials.gov/ct2/show/NCT05412966.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/43122.

Readiness of community pharmacies to implement an opioid safety intervention

BACKGROUND

We report on efforts to measure readiness to adopt opioid safety initiatives in community pharmacies within 2 large chains. Previous studies identified lack of knowledge, confidence, or enthusiasm in addressing harm reduction efforts. We implemented an intervention that provided training to improve opioid safety. The goal was to increase naloxone prescribing and nonprescription syringe sales, reduce stigma, and decrease opioid overdoses among patients and customers.

OBJECTIVES

To assess pharmacy readiness for intervention delivery, by characterizing pharmacy culture around opioid safety; describing current practices and challenges interacting with patients and customers on naloxone, nonprescription syringe sales, and buprenorphine; and determining pharmacy defined goals for implementing the intervention.

METHODS

The sample included pharmacy managers and staff pharmacists from 2 large chains who completed a brief phone interview. Interviews consisted of Likert-scale and open-ended, theoretically driven questions. Questions focused on workplace culture, patient engagement, naloxone and buprenorphine prescribing, nonprescription syringe sales, and intervention goals. Coding categories for the open-ended questions were derived using a thematic review of responses.

RESULTS

A total of 163 respondents described both workplace culture and how they encourage patient opioid safety as including public health awareness, patient engagement, and naloxone prescribing. Sale of nonprescription syringes exhibited high variability: no sales barriers (53.9%), sales with barriers (21.5%), and no sales (20.9%). Half of pharmacists (50.3%) interacted with buprenorphine prescribers outside of medication fills. Most respondents (68.7%) endorsed being ready to promote the intervention. Pharmacists named goals in adopting the intervention of wanting more knowledge and educational materials, talking points with patients, and best practices for offering naloxone.

CONCLUSION

Community pharmacists, before implementation, described awareness of and receptiveness to opioid safety initiatives, with substantial barriers around nonprescription syringe sales. Assessed knowledge level, culture, and identified barriers that emerged in the readiness assessments can be used to tailor future pharmacy-specific programming.

Buprenorphine-Naloxone in the Setting of Kratom Withdrawal, Opioid Use Disorder, and Stage IV Lung Adenocarcinoma

Management of cancer-associated pain warrants consideration of many factors, including characterization and etiology of the pain, socioeconomic factors, medication tolerance, and substance use history. Kratom (Mitragyna speciosa) is an herbal substance with stimulant and analgesic properties that is becoming a popular drug in the United States. In this report, we present a patient with a history of opioid use disorder (OUD) who had been using high doses of kratom to alleviate progressive chest pain and dyspnea secondary to newly diagnosed stage IV lung adenocarcinoma. He underwent kratom withdrawal shortly after his index admission and was reluctant to continue full opioid agonists given his history of OUD and complex living situation. His kratom withdrawal and cancer-associated symptoms were successfully managed with buprenorphine-naloxone. Providers should obtain a careful history of novel substance use such as kratom. Furthermore, buprenorphine-naloxone is a safe and effective option to simultaneously manage kratom withdrawal and cancer-associated pain.

Effect of Didactic Training on Barriers and Biases to Treatment of Opioid Use Disorder: Meeting the Ongoing Needs of Patients with Opioid Use Disorder in the Emergency Department during the COVID-19 Pandemic

In the wake of COVID-19, morbidity and mortality due to Opioid Use Disorder (OUD) is beginning to emerge as a second wave of deaths of despair. Medication assisted treatment (MAT) for opioid use disorder MAT delivered by Emergency Medicine (EM) providers can decrease mortality due to OUD; however, there are numerous cited barriers to MAT delivery. We examined the impact of MAT training on these barriers among EM residents in an urban, tertiary care facility with a large EM residency. Training included the scripted and standardized content from the Provider Clinical Support System curriculum. Residents completed pre- and post-training surveys on knowledge, barriers, and biases surrounding OUD. We performed Wilcoxon matched-pairs signed-ranks test to detect statistical differences. Of 74 residents, 49 (66%) completed the pre-training survey, and 34 (69%) of these completed the follow-up survey. Residents reported improved preparedness to treat aspects of OUD across all areas queried, reported decreased perception of barriers to providing MAT, and increased comfort prescribing naloxone, counseling patients, prescribing buprenorphine, and treating opioid withdrawal. A didactic training on MAT was associated with residents reporting improved comfort providing buprenorphine and naloxone. As the wake of morbidity and mortality from both COVID and OUD continue to increase, programs should offer dedicated training on MAT.

Buprenorphine Waiver Attitudes Among Primary Care Providers

BACKGROUND

Despite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change.

OBJECTIVE

The primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine.

METHODS

We conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states.

RESULTS

One hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists.

CONCLUSIONS

Results of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers' willingness to prescribe buprenorphine.