Availability of addiction medications in private health plans

Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017-21

Buprenorphine is a treatment medication that decreases mortality risks among people with opioid use disorder (OUD). Despite its efficacy, buprenorphine is underused in the US. Insurance restrictions are commonly cited as barriers to buprenorphine prescribing. Using Medicaid, Medicare Advantage, and commercial insurance formulary files, we examined insurance-imposed utilization restrictions for buprenorphine for OUD for each year from 2017 to 2021 by insurance type. Almost all plans covered immediate-release buprenorphine in 2021, with a general trend of decreasing prior authorization requirements and quantity limits since 2017. In contrast, two payers had relatively low coverage of extended-release buprenorphine, with only 46 percent of commercial plans and only 19 percent of Medicare Advantage plans covering this formulation. Even though most Medicaid plans covered extended-release buprenorphine in 2021, 37 percent required prior authorization. Policy makers and researchers concerned with buprenorphine insurance barriers should shift their attention to extended-release buprenorphine. State lawmakers could help address these barriers by mandating that insurers include extended-release buprenorphine on their preferred drug lists.

Developmental Considerations for the Use of Naltrexone in Children and Adolescents

Naltrexone (NTX) is a well-tolerated drug with a wide safety margin and mechanism of action that affords use across a wide variety of indications in adults and children. By antagonizing the opioid reward system, NTX can modulate behaviors that involve compulsivity or impulsivity, such as substance use, obesity, and eating disorders. Evidence regarding the disposition and efficacy of NTX is mainly derived from adult studies of substance use disorders and considerable variability exists. Developmental changes, plausible disease-specific alterations and genetic polymorphisms in NTX disposition, and pharmacodynamic pathways should be taken into consideration when optimizing the use of NTX in the pediatric population. This review highlights the current state of the evidence and gaps in knowledge regarding NTX to facilitate evidence-based pharmacotherapy of mental health conditions, for which few pharmacologic options exist.

Medication Utilization for Alcohol Use Disorder in a Commercially Insured Population

OBJECTIVE

Examine patterns of alcohol use disorder (AUD) medication use and identify factors associated with prescription fill among commercially insured individuals with an index AUD visit.

DESIGN

Using 2008-2018 claims data from a large national insurer, estimate days to first AUD medication using cause-specific hazards approach to account for competing risk of benefits loss.

PARTICIPANTS

Aged 17-64 with ≥ 1 AUD visit.

MAIN MEASURE

Days to AUD medication fill.

KEY RESULTS

A total of 13.3% of the 151,128 with an index visit filled an AUD prescription after that visit, while 69.8% lost benefits before filling and 17.0% remained enrolled but did not fill (median days observed = 305). Almost half (46.3%) of those who filled a prescription received substance use disorder (SUD) inpatient care within 7 days before the fill, and 63.4% received SUD outpatient care. Likelihood of medication use was higher for those aged 26-35, 36-45, and 46-55 years relative to 56-64 years (e.g., 26-35: hazard ratio = 1.29 [95% confidence interval 1.23-1.36]); those diagnosed with moderate/severe AUD (2.05 [1.98-2.12]), co-occurring opioid use disorder (OUD) (1.33 [1.26-1.39]), or severe mental illness (1.31 [1.27-1.35]); those with a chronic alcohol-related diagnosis (1.08 [1.04-1.12]); and those whose index visit was in an inpatient/emergency department (1.27 [1.23-1.31]) or intermediate care setting (1.13 [1.07-1.20]) relative to outpatient. Likelihood of use was higher in later years relative to 2008 (e.g., 2018:2.02 [1.89-2.15]) and higher for those who received the majority of AUD care in a practice with a psychiatrist/addiction medicine specialist (1.13 [1.10-1.16]). Likelihood of use was lower for those diagnosed with a SUD other than AUD or OUD (0.88 [0.85-0.92]), those with an acute alcohol-related condition (0.79 [0.75-0.84]), and males (0.71 [0.69-0.73]).

CONCLUSIONS

While AUD medication use increased and was more common among individuals with greater severity, few patients who could benefit from medications are using them. More efforts are needed to identify and treat individuals in non-acute care settings earlier in their course of AUD.

Prevention, screening, and treatment for heavy drinking and alcohol use disorder

Heavy drinking and alcohol use disorder are major public health problems. Practitioners not specialising in alcohol treatment are often unaware of the guidelines for preventing, identifying, and treating heavy drinking and alcohol use disorder. However, a consensus exists that clinically useful and valuable tools are available to address these issues. Here, we review existing information and developments from the past 5 years in these areas. We also include information on heavy drinking and alcohol use disorder among individuals with co-occurring psychiatric disorders, including drug use disorders. Areas covered include prevention; screening, brief intervention, and referral for treatment; evidence-based behavioural interventions; medication-assisted treatment; technology-based interventions (eHealth and mHealth); and population-level interventions. We also discuss the key topics for future research.

Price elasticity of demand for buprenorphine/naloxone prescriptions

Although there have been supply-side efforts in response to the opioid crisis (e.g., prescription drug monitoring programs), little information exists on demand-side approaches related to patient cost sharing that may affect utilization of and adherence to pharmacotherapy by individuals with opioid use disorder. Among individuals who had initiated pharmacotherapy, we estimated the price elasticity of demand of prescription fills of buprenorphine/naloxone, a common pharmacotherapy drug, overall and by patient characteristics. Using the IBM MarketScan® Commercial Claims and Encounters Database for individuals with employer-sponsored private health insurance coverage, we examined the relationship between cost sharing and the number of buprenorphine/naloxone prescription fills using enrollee-level longitudinal fixed effects models. Cost sharing was expressed as a price index for each employer-plan. By including enrollee-level fixed effects, the identification of the effect of interest comes from longitudinal variation in prices across multiple time points for each enrollee. Overall, the demand for buprenorphine/naloxone was price inelastic (p = 0.191). However, some subgroups were responsive to price. A doubling of price was associated with a decrease in fills by 3.0% for enrollees aged 45-64 years (p = 0.029); 5.7% for those in rural areas (p = 0.033); 5.8% for residents of the South (p ≤0.001); and 3.0% for those enrolled in an HMO (p = 0.004). Insurers should consider the effects on these groups before increasing beneficiary out-of-pocket costs for pharmacotherapy and efforts to increase adherence should consider that price may be a barrier for some subgroups with OUD.

Differences in Perceptions of and Practices Regarding Treatment of Alcohol Use Disorders Among VA Primary Care Providers in Urban and Rural Clinics

BACKGROUND

Effective behavioral and pharmacological treatments are available and recommended for patients with alcohol use disorders (AUD) but rarely received. Barriers to receipt and provision of evidence-based AUD treatments delivered by specialists may be greatest in rural areas.

METHODS

A targeted subanalysis of qualitative interview data collected from primary care providers at 5 Veterans Affairs clinics was conducted to identify differences in provider perceptions and practices regarding AUD treatment across urban and rural clinics. Key contacts were used to recruit 24 providers from 3 "urban" clinics at medical centers and 2 "rural" community-based outpatient clinics. Providers completed 30-minute semistructured interviews, which were recorded, transcribed, and analyzed using inductive content analysis.

RESULTS

Thirteen urban and 11 rural providers participated. Urban and rural providers differed regarding referral practices and in perceptions of availability and utility of specialty addictions treatment. Urban providers described referral to specialty treatment as standard practice, while rural providers reported substantial barriers to specialty care access and infrequent specialty care referral. Urban providers viewed specialty addictions treatment as accessible and comprehensive, and perceived addictions providers as "experts" and collaborators, whereas rural providers perceived inadequate support from the health care system for AUD treatment. Urban providers desired greater integration with specialty addictions care while rural providers wanted access to local addictions treatment resources.

CONCLUSIONS

Providers in rural settings view referral to specialty addictions treatment as impractical and resources inadequate to treat AUD. Additional work is needed to understand the unique needs of rural clinics and decrease barriers to AUD treatment.

Test of a workforce development intervention to expand opioid use disorder treatment pharmacotherapy prescribers: protocol for a cluster randomized trial

BACKGROUND

Overdoses due to non-medical use of prescription opioids and other opiates have become the leading cause of accidental deaths in the USA. Buprenorphine and extended-release naltrexone are key evidence-based pharmacotherapies available to addiction treatment providers to address opioid use disorder (OUD) and prevent overdose deaths. Treatment organizations' efforts to provide these pharmacotherapies have, however, been stymied by limited success in recruiting providers (physicians, nurse practitioners, and physician assistants) to prescribe these medications. Historically, the addiction treatment field has not attracted physicians, and many barriers to implementing OUD pharmacotherapy exist, ranging from lack of confidence in treating OUD patients to concerns regarding reimbursement. Throughout the USA, the prevalence of OUD far exceeds the capacity of the OUD pharmacotherapy treatment system. Poor access to OUD pharmacotherapy prescribers has become a workforce development need for the addiction treatment field and a significant health issue.

METHODS

This cluster randomized controlled trial (RCT) is designed to increase buprenorphine and extended-release naltrexone treatment capacity for OUD. The implementation intervention to be tested is a bundle of OUD pharmacotherapy capacity building practices called the Prescriber Recruitment Bundle (PRB), which was developed and piloted in a previous statewide buprenorphine implementation study. For this cluster RCT, organizational sites will be recruited and then randomized into one of two arms: (1) control, with treatment as usual and access to a website with PRB resources, or (2) intervention, with organizations implementing the PRB using the Network for the Improvement of Addiction Treatment organizational change model over a 24-month intervention period and a 10-month sustainability period. The primary treatment outcomes for each organizational site are self-reported monthly counts of buprenorphine slots, extended-release naltrexone capacity, number of buprenorphine patients, and number of extended-release naltrexone patients. This trial will be conducted in Florida, Ohio, and Wisconsin, resulting in 35 sites in each arm, for a total sample size of 70 organizations.

DISCUSSION

This study addresses three issues of substantial public health significance: (1) the pressing opioid misuse epidemic, (2) the low uptake of OUD treatment pharmacotherapies, and (3) the need to increase prescriber participation in the addiction treatment workforce.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02926482.

Overcoming Barriers to Initiating Medication-assisted Treatment for Heroin Use Disorder in a General Medical Hospital: A Case Report and Narrative Literature Review

Deaths due to heroin overdoses are increasing and are the leading cause of death among intravenous heroin users. Although medication-assisted treatment (MAT) improves morbidity and mortality in patients with opioid use disorders, it is underutilized. Most efforts to expand access to MAT have focused on outpatient settings. Although the inpatient medical setting presents a critical opportunity to initiate treatment, general hospitals are often unfamiliar with MAT, creating a number of barriers to its use. In this report, we describe the case of a woman with heroin use disorder who was initiated on buprenorphine maintenance treatment while hospitalized for cardiac disease related to her intravenous heroin use. Barriers to initiating buprenorphine in this case included patient, practitioner, and organizational factors, and, ultimately, shared misperceptions about the feasibility of administering buprenorphine in a general medical hospital. These barriers were addressed, buprenorphine was initiated, and the patient demonstrated reduced craving, improved postoperative pain control, improved overall well-being, increased engagement in discharge planning, and acceptance of referral for addiction specialty aftercare. Our experience with this patient suggests that it is feasible to initiate buprenorphine in acute medical settings and that such treatment can improve patient outcomes. Our review of the literature reveals emerging evidence supporting the value of this practice.

First-line medications for alcohol use disorders among public drug plan beneficiaries in Ontario

OBJECTIVE

To examine use of first-line alcohol use disorder (AUD) medications (naltrexone and acamprosate) among public drug plan beneficiaries in the year following an AUD diagnosis.

DESIGN

Retrospective population-based cohort study.

SETTING

Ontario.

PARTICIPANTS

Individuals eligible for public drug plan benefits who had an AUD diagnosis at a hospital visit between April 1, 2011, and March 31, 2012.

MAIN OUTCOME MEASURES

Number of AUD medications dispensed to public drug plan beneficiaries who had a recent hospital visit with an AUD diagnosis, and number of prescriptions dispensed per person.

RESULTS

A total of 10 394 Ontarians between 18 and 65 years of age were identified who had a hospital visit with an AUD diagnosis and were eligible for public drug plan benefits. The rate of AUD medications dispensed in the subsequent year was 3.56 per 1000 population (95% CI 2.51 to 4.91; n = 37). This rate did not differ significantly by sex (P = .83).

CONCLUSION

Very few public drug plan beneficiaries are dispensed first-line AUD medications in the year following an AUD diagnosis.

Access to Addiction Pharmacotherapy in Private Health Plans

BACKGROUND

An increasing number of medications are available to treat addictions. To understand access to addiction medications, it is essential to consider the role of private health plans. To contain medication expenditures, most U.S. health plans use cost-sharing and administrative controls, which may impact physicians' prescribing and patients' use of addiction medications. This study identified health plan approaches to manage access to and utilization of addiction medications (oral and injectable naltrexone, acamprosate, and buprenorphine).

METHODS

Data are from a nationally representative survey of private health plans in 2010 (n=385 plans, 935 products; response rate 89%), compared to the same survey in 2003. The study assessed formulary inclusion, prior authorization, step therapy, overall restrictiveness, and if and how health plans encourage pharmacotherapy.

RESULTS

Formulary exclusions were rare in 2010, with acamprosate excluded most often, by only 9% of products. Injectable naltrexone was covered by 96% of products. Prior authorization was common for injectable naltrexone (85%) and rare for acamprosate (3%). Step therapy policies were used only for injectable naltrexone (41%) and acamprosate (20%). Several medications were often on the most expensive tier. Changes since 2003 include fewer exclusions, yet increased use of other management approaches. Most health plans encourage use of addiction pharmacotherapy, and use a variety of methods to do so.

CONCLUSIONS

Management of addiction medications has increased over time but it is not ubiquitous. However, health plans now also include all medications on formularies and encourage providers to use them, indicating that they value addiction pharmacotherapy as an evidence-based practice.

Buprenorphine Maintenance for Opioid Dependence in Public Sector Healthcare: Benefits and Barriers

BACKGROUND

Since its U.S. FDA approval in 2002, buprenorphine has been available for maintenance treatment of opiate dependence in primary care physicians' offices. Though buprenorphine was intended to facilitate access to treatment, disparities in utilization have emerged; while buprenorphine treatment is widely used in private care setting, public healthcare integration of buprenorphine lags behind.

RESULTS

Through a review of the literature, we found that U.S. disparities are partly due to a shortage of certified prescribers, concern of patient diversion, as well as economic and institutional barriers. Disparity of buprenorphine treatment dissemination is concerning since buprenorphine treatment has specific characteristics that are especially suited for low-income patient population in public sector healthcare such as flexible dosing schedules, ease of concurrently treating co-morbidities such as HIV and hepatitis C, positive patient attitudes towards treatment, and the potential of reducing addiction treatment stigma.

CONCLUSION

As the gap between buprenorphine treatment in public sector settings and private sector settings persists in the U.S., current research suggests ways to facilitate its dissemination.

Implementing buprenorphine in addiction treatment: payer and provider perspectives in Ohio

Background

Buprenorphine is under-utilized in treating opioid addiction. Payers and providers both have substantial influence over the adoption and use of this medication to enhance recovery. Their views could provide insights into the barriers and facilitators in buprenorphine adoption.

Methods

We conducted individual interviews with 18 Ohio county Alcohol, Drug Addiction, and Mental Health Services (ADAMHS) Boards (payers) and 36 addiction treatment centers (providers) to examine barriers and facilitators to buprenorphine use. Transcripts were reviewed, coded, and qualitatively analyzed. First, we examined reasons that county boards supported buprenorphine use. A second analysis compared county boards and addiction treatment providers on perceived barriers and facilitators to buprenorphine use. The final analysis compared county boards with low and high use of buprenorphine to determine how facilitators and barriers differed between those settings.

Results

County boards (payers) promoted buprenorphine use to improve clinical care, reduce opioid overdose deaths, and prepare providers for participation in integrated models of health care delivery with primary care clinics and hospitals. Providers and payers shared many of the same perceptions of facilitators and barriers to buprenorphine use. Common facilitators identified were knowledge of buprenorphine benefits, funds allocated to purchase buprenorphine, and support from the criminal justice system. Common barriers were negative attitudes toward use of agonist pharmacotherapy, payment environment, and physician prescribing capacity. County boards with low buprenorphine use rates cited negative attitudes toward use of agonist medication as a primary barrier. County boards with high rates of buprenorphine use dedicated funds to purchase buprenorphine in spite of concerns about limited physician prescribing capacity.

Conclusions

This qualitative analysis found that attitudes toward use of medication and medication funding environment play important roles in an organization’s decision to begin buprenorphine use and that physician availability influences an organization’s ability to expand buprenorphine use over time.

Additional education, reimbursement support, and policy changes are needed to support buprenorphine adoption and use, along with a greater understanding of the roles payers, providers, and regulators play in the adoption of targeted practices.

Views about responsibility for alcohol addiction and negative evaluations of naltrexone

BACKGROUND

Moral philosophers have debated the extent to which persons are individually responsible for the onset of and recovery from addiction. Empirical investigators have begun to explore counselors' attitudes on these questions. Meanwhile, a separate literature has investigated counselors' negative attitudes towards naltrexone, an important element of medication-assisted treatment for alcohol addiction. The present study bridges the literature on counselor views about responsibility for addiction with the literature on attitudes towards naltrexone. It investigates the extent to which a counselor's views of individual responsibility for alcohol addiction are related to that counselor's views of naltrexone.

METHODS

Using a vignette-based survey of 117 addiction treatment professionals, the study analyzes the relationship between an addiction counselor's views about individual responsibility for alcohol addiction and using naltrexone to treat it.

RESULTS

We find a significant difference in counselors who assign greater responsibility to a person for the onset of alcohol addiction. They agreed more strongly with several objections to naltrexone, including worries about compliance, naltrexone's side effects outweighing its benefits, naltrexone treating symptoms but not underlying causes, and the idea that medication may undermine a person's motivation to recover. Combined views of greater responsibility for addiction's onset and recovery also significantly predicted stronger agreement with objections.

CONCLUSIONS

We conclude that there is a strong relationship between a counselor assigning higher individual responsibility for addiction and holding more negative views about naltrexone. The study also sheds light on one reason why the model of addiction as a brain disease has had limited impact on clinical practice.

Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial

IMPORTANCE

Prescription opioid dependence is increasing and creates a significant public health burden, but primary care physicians lack evidence-based guidelines to decide between tapering doses followed by discontinuation of buprenorphine hydrochloride and naloxone hydrochloride therapy (hereinafter referred to as buprenorphine therapy) or ongoing maintenance therapy.

OBJECTIVE

To determine the efficacy of buprenorphine taper vs ongoing maintenance therapy in primary care-based treatment for prescription opioid dependence.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a 14-week randomized clinical trial that enrolled 113 patients with prescription opioid dependence from February 17, 2009, through February 1, 2013, in a single primary care site.

INTERVENTIONS

Patients were randomized to buprenorphine taper (taper condition) or ongoing buprenorphine maintenance therapy (maintenance condition). The buprenorphine taper was initiated after 6 weeks of stabilization, lasted for 3 weeks, and included medications for opioid withdrawal, after which patients were offered naltrexone treatment. The maintenance group received ongoing buprenorphine therapy. All patients received physician and nurse support and drug counseling.

MAIN OUTCOMES AND MEASURES

Illicit opioid use via results of urinanalysis and patient report, treatment retention, and reinitiation of buprenorphine therapy (taper group only).

RESULTS

During the trial, the mean percentage of urine samples negative for opioids was lower for patients in the taper group (35.2% [95% CI, 26.2%-44.2%]) compared with those in the maintenance group (53.2% [95% CI, 44.3%-62.0%]). Patients in the taper group reported more days per week of illicit opioid use than those in the maintenance group once they were no longer receiving buprenorphine (mean use, 1.27 [95% CI, 0.60-1.94] vs 0.47 [95% CI, 0.19-0.74] days). Patients in the taper group had fewer maximum consecutive weeks of opioid abstinence compared with those in the maintenance group (mean abstinence, 2.70 [95% CI, 1.72-3.75] vs 5.20 [95% CI, 4.16-6.20] weeks). Patients in the taper group were less likely to complete the trial (6 of 57 [11%] vs 37 of 56 [66%]; P < .001). Sixteen patients in the taper group reinitiated buprenorphine treatment after the taper owing to relapse.

CONCLUSIONS AND RELEVANCE

Tapering is less efficacious than ongoing maintenance treatment in patients with prescription opioid dependence who receive buprenorphine therapy in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00555425.

Improving treatment for opioid dependence: a perspective from the Ohio Valley node of the NIDA Clinical Trials Network

PROBLEM

Rates of adoption of evidenced-based practices, including the use of medications, to treat opioid dependence are low and severely limit secondary prevention efforts to curtail the prescription drug epidemic.

PURPOSE

The goal of this article was to describe how involvement in a research clinical trials network (CTN) facilitated the adoption of medications to treat opioid dependence at two community-based treatment programs (CTPs) affiliated with the Ohio Valley Node (OVN) of the National Institute on Drug Abuse's (NIDA) CTN.

KEY POINTS

Participation in a CTN may facilitate adoption by providing the infrastructure for trialability and observability, but the most critical function may be the knowledge translation that occurs through the individual-level professional relationships that develop.

CONCLUSION

Community-based treatment providers' involvement in research networks may increase the rate of evidence-based practice (EBP) adoption and improve outcomes for patients with opioid dependence.

Reimbursement and practice policies among providers of buprenorphine-naloxone treatment

ABSTRACT Background: Physician acceptance of cash payment and low adherence to practice guidelines may contribute to buprenorphine-naloxone diversion. The purpose of this study was to investigate the clinical practice policies of physicians who provide office-based treatment for opioid dependence with buprenorphine-naloxone.

METHODS

Data were obtained from 31 of 71 practices surveyed (response rate 43.7%) that provided answers to at least some of the survey questions.

RESULTS

Of these practices, 28 (90.3%) accepted cash as payment and 6 (19.4%) accepted only cash for treatment services. Analysis of open-ended responses to questions about office policies revealed wide variation among practices and overall suboptimal adherence to recommended treatment guidelines.

CONCLUSIONS

These results underscore the need for continuing education for physicians who prescribe buprenorphine-naloxone.

A qualitative study of the adoption of buprenorphine for opioid addiction treatment

Qualified physicians may prescribe buprenorphine to treat opioid dependence, but medication use remains controversial. We examined adoption of buprenorphine in two not-for-profit integrated health plans, over time, completing 101 semi-structured interviews with clinicians and clinician-administrators from primary and specialty care. Transcripts were reviewed, coded, and analyzed. A strong leader championing the new treatment was critical for adoption in both health plans. Once clinicians began using buprenorphine, patients' and other clinicians' experiences affected decisions more than did the champion. With experience, protocols developed to manage unsuccessful patients and changed to support maintenance rather than detoxification. Diffusion outside addiction and mental health settings was nonexistent; primary care clinicians cited scope-of-practice issues and referred patients to specialty care. With greater diffusion came questions about long-term use and safety. Recognizing how implementation processes develop may suggest where, when, and how to best expend resources to increase adoption of such treatments.

Establishing the feasibility of measuring performance in use of addiction pharmacotherapy

This paper presents the rationale and feasibility of standardized performance measures for use of pharmacotherapy in the treatment of substance use disorders (SUD), an evidence-based practice and critical component of treatment that is often underused. These measures have been developed and specified by the Washington Circle, to measure treatment of alcohol and opioid dependence with FDA-approved prescription medications for use in office-based general health and addiction specialty care. Measures were pilot tested in private health plans, the Veterans Health Administration (VHA), and Medicaid. Testing revealed that use of standardized measures using administrative data for overall use and initiation of SUD pharmacotherapy is feasible and practical. Prevalence of diagnoses and use of pharmacotherapy vary widely across health systems. Pharmacotherapy is generally used in a limited portion of those for whom it might be indicated. An important methodological point is that results are sensitive to specifications, so that standardization is critical to measuring performance across systems.

Disparities in access to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States

OBJECTIVE

Prior research suggests that publicly funded substance use disorder (SUD) treatment programs lag behind privately funded programs in adoption of evidence-based practices, resulting in disparities in access to high-quality SUD treatment. These disparities highlight a critical public health concern because the majority of SUD patients in the United States are treated in the publicly funded treatment sector. This study uses recent data to examine disparities in access to physicians and availability of medications for the treatment of SUDs between publicly and privately funded SUD treatment programs.

METHOD

Data were collected from 595 specialty SUD treatment programs from 2007 to 2010 via face-to-face interviews, mailed surveys, and telephone interviews with treatment program administrators.

RESULTS

Publicly funded programs were less likely than privately funded programs to have a physician on staff, even after controlling for several organizational characteristics that were associated with access to physicians. The results of negative binomial regression indicated that, even after taking into account physician access and other organizational variables, publicly funded programs prescribed fewer SUD medications than privately funded SUD treatment programs.

CONCLUSIONS

Patients seeking treatment in publicly funded treatment programs continue to face disparities in access to high-quality SUD treatment that supports patients' choices among a range of medication options. However, implementation of the Affordable Care Act may facilitate greater access to physicians and use of medications in publicly funded SUD treatment programs.

Prescription drug abuse as a public health problem in Ohio: a case report

Prescription drug overdose is the leading cause of injury death in Ohio, as well as in 16 other states. Responding to the prescription drug epidemic is particularly challenging given the fragmentation of the health care system and that the consequences of addiction span across systems that have not historically collaborated. This case study reports on how Ohio is responding to the prescription drug epidemic by developing cross-system collaboration from local public health nurses to the Governor's office. In summary, legal and regulatory policies can be implemented relatively quickly whereas changing the substance abuse treatment infrastructure requires significant financial investments.

Barriers to use of pharmacotherapy for addiction disorders and how to overcome them

Substance use disorders are highly prevalent, debilitating conditions for which effective pharmacotherapies exist with a broad evidence base, yet pharmacotherapy for the treatment of addiction disorders is underutilized. The goals of this review are to describe the barriers that may contribute to poor adoption and utilization of pharmacotherapy for alcohol and opioid dependence at the system, provider, and patient level and to discuss ways to overcome those barriers. Multifaceted efforts directed at all three levels may be needed to speed pharmacotherapy adoption. More research is needed to help us better understand barriers from patients' perspectives. Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the practice, system, and individual patients. Pharmacotherapy is a valuable tool in the clinical armamentarium of addiction treatment; thus, overcoming barriers to implementation may improve clinical and social outcomes.

Adoption and implementation of medications in addiction treatment programs

OBJECTIVES

Little is known about the extent to which medications are being implemented as routine care in addiction treatment programs. This research describes medication adoption and implementation within the privately funded treatment sector.

METHODS

Face-to-face interviews were conducted with 345 administrators of a nationally representative sample of privately funded substance treatment organizations in the United States.

RESULTS

Rates of adoption of addiction treatment medications in private sector programs were lower than the adoption of psychiatric medications. Even when analyses were restricted to programs with access to physicians, adoption of each addiction treatment medication had occurred in less than 50% of programs. Within adopting programs, implementation was highly variable. While about 70% of patients with co-occurring psychiatric diagnoses received psychiatric medications, rates of implementation of medication-assisted treatment for opioid dependence and alcohol use disorders were just 34.4% and 24.0%, respectively.

CONCLUSIONS

Although previous research has documented higher rates of medication adoption in privately funded treatment programs, this study revealed that both adoption and implementation of pharmacotherapies to treat addiction remains modest. Future research should examine the different types of barriers to implementation, such as physician decision-making, patient preferences, and system-level barriers stemming from financing and public policy.

Comparing alternative specifications of quality measures: access to pharmacotherapy for alcohol use disorders

Availability and consideration of pharmacotherapy for the treatment of alcohol use disorders (AUD) are now consensus standards for evidence-based treatment. This study compares three competing specifications of the proportion of patients with AUD receiving approved medications. We examined how altering the numerator and denominator definitions affects observed rates of pharmacotherapy use and facilities' percentile ranks. Using pharmacy and administrative data from the Veterans Health Administration (VHA), three measures of pharmacotherapy receipt were calculated for 129 VHA facilities. Difference in measure specifications alters the overall estimates of pharmacotherapy receipt but unevenly across facilities, with some experiencing no change in percentile rank and others decreasing or increasing by over a quartile. The results demonstrate that the quality measures are not interchangeable, and the choice of which version to implement is of high consequence for some facilities.

A longitudinal examination of alcohol pharmacotherapy adoption in substance use disorder treatment programs: patterns of sustainability and discontinuation

OBJECTIVE

The objectives of this study were to (a) identify the patterns of disulfiram (Antabuse) and tablet naltrexone (Revia) adoption over a 48-month period in a nationally representative sample of privately funded programs that deliver substance use disorder treatment; (b) examine predictors of sustainability, later adoption, discontinuation, and nonadoption of disulfiram and tablet naltrexone; and (c) measure reasons for medication discontinuation.

METHOD

Two waves of data were collected via face-to-face structured interviews with 223 program administrators.

RESULTS

These data demonstrated that adoption of medications for alcohol use disorders (AUDs) was a dynamic process. Although nonadoption was the most common pattern, approximately 20% of programs sustained use of the AUD medications and 30% experienced organizational change in adoption over the study period. Bivariate multinomial logistic regression models revealed that organizational characteristics were associated with sustainability including location in a hospital setting, program size, accreditation, revenues from private insurance, referrals from the criminal justice system, number of medical staff, and use of selective serotonin reuptake inhibitors at baseline. Two patterns of discontinuation were found: Programs either discontinued use of all substance use disorder medications or replaced disulfiram/tablet naltrexone with a newer AUD medication.

CONCLUSIONS

These findings suggest that adoption of AUD medications may be positively affected by pressure from accreditation bodies, partnering with primary care physicians, medication-specific training for medical staff, greater availability of resources to cover the costs associated with prescribing AUD medications, and amending criminal justice contracts to include support for AUD medication use.

Policy implications of integrating buprenorphine/naloxone treatment and HIV care

Researchers, practitioners, and policymakers have long recognized the potential benefits of providing integrated substance abuse and medical care services, particularly for special populations such as people living with HIV/AIDS. Buprenorphine, an office-based pharmacological treatment for opioid dependence, offers new opportunities for integrating drug treatment into HIV care settings. However, the historical separation between the drug treatment and medical care systems has resulted in a host of policy barriers. The Buprenorphine and HIV Care Evaluation and Support initiative, a multisite demonstration project to assess the feasibility and effectiveness of integrating buprenorphine/naloxone into HIV care settings, provided an opportunity to evaluate if and how policy barriers affect efforts to integrate HIV care and addiction treatment. We found that financing issues, workforce and training issues, and the operational consequences of some conceptual differences between HIV care and addiction treatment are barriers to the full integration of buprenorphine into HIV care. We recommend changes to financing and reimbursement policies, programs to strengthen the addiction treatment skills of physicians, and cross training between the fields of addiction, medicine, drug treatment, and HIV medicine. By addressing some of the policy barriers to integration, this promising new treatment can help the thousands of people living with HIV/AIDS who are also opioid dependent.

Advancing performance measures for use of medications in substance abuse treatment

Performance measures have the potential to drive high-quality health care. However, technical and policy challenges exist in developing and implementing measures to assess substance use disorder (SUD) pharmacotherapy. Of critical importance in advancing performance measures for use of SUD pharmacotherapy is the recognition that different measurement approaches may be needed in the public and private sectors and will be determined by the availability of different data collection and monitoring systems. In 2009, the Washington Circle convened a panel of nationally recognized insurers, purchasers, providers, policy makers, and researchers to address this topic. The charge of the panel was to identify opportunities and challenges in advancing use of SUD pharmacotherapy performance measures across a range of systems. This article summarizes those findings by identifying a number of critical themes related to advancing SUD pharmacotherapy performance measures, highlighting examples from the field, and recommending actions for policy makers.

Alcohol and opioid dependence medications: prescription trends, overall and by physician specialty

Over the past decade, advances in addiction neurobiology have led to the approval of new medications to treat alcohol and opioid dependence. This study examined data from the IMS National Prescription Audit (NPA) Plus database of retail pharmacy transactions to evaluate trends in U.S. retail sales and prescriptions of FDA-approved medications to treat substance use disorders. Data reveal that prescriptions for alcoholism medications grew from 393,000 in 2003 ($30 million in sales) to an estimated 720,000 ($78 million in sales) in 2007. The growth was largely driven by the introduction of acamprosate in 2005, which soon became the market leader ($35 million in sales). Prescriptions for the two buprenorphine formulations increased from 48,000 prescriptions ($5 million in sales) in the year of their introduction (2003) to 1.9 million prescriptions ($327 million in sales) in 2007. While acamprosate and buprenorphine grew rapidly after market entry, overall substance abuse retail medication sales remain small relative to the size of the population that could benefit from treatment and relative to sales for other medications, such as antidepressants. The extent to which substance dependence medications will be adopted by physicians and patients, and marketed by industry, remains uncertain.

Addiction to prescription opioids: characteristics of the emerging epidemic and treatment with buprenorphine

Dependence on and abuse of prescription opioid drugs is now a major health problem, with initiation of prescription opioid abuse exceeding cocaine in young people. Coincident with the emergence of abuse and dependence on prescription opioids, there has been an increased emphasis on the treatment of pain. Pain is now the "5th vital sign" and physicians face disciplinary action for failure to adequately relieve pain. Thus, physicians are whipsawed between the imperative to treat pain with opioids and the fear of producing addiction in some patients. In this article, the authors characterize the emerging epidemic of prescription opioid abuse, discuss the utility of buprenorphine in the treatment of addiction to prescription opioids, and present illustrative case histories of successful treatment with buprenorphine.