Buprenorphine utilization among all Washington State residents' based upon prescription monitoring program data - Characteristics associated with two measures of retention and patterns of care over time

Opioid use disorder Cascade of care: defining a taxonomy for measurement

Background: The opioid use disorder Cascade of care (OUD Cascade) is a public health framework used by federal/state/other agencies and researchers to facilitate monitoring and evaluating responses to the opioid epidemic, including surveillance and performance evaluation. As the use of the framework proliferates, there is an urgent need to standardize stage definitions to accurately monitor and improve patient outcomes and to align interpretation of findings across settings.Objectives: Define a taxonomy to uniformly apply the OUD Cascade to improve delivery of OUD services and better compare patient outcomes across settings and populations.Methods: We conducted a narrative review and synthesis focused on research and guidelines defining and measuring four key OUD Cascade stages: OUD identification, service engagement, medication initiation, and retention. Included articles come from peer-reviewed literature and define and/or operationalize OUD Cascade stages and associated measures across six characteristics based on an adaptation of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist including: 1) settings, 2) specific population, 3) perspective, 4) time horizon, 5) assumptions, and 6) analytic method.Results: Our review (n = 27 articles) and synthesis provide an overview of how OUD Cascade definitions and framework designs have been variously applied. We found considerable heterogeneity in study approaches for all four OUD Cascade stages. We define a taxonomy to guide future research emphasizing standardized definitions to harmonize efforts across settings. In particular, we emphasize the need for clarity in defining criteria for sample construction (i.e. Identification), clear distinctions between receipt of care services generally (i.e. Engagement) from MOUD Initiation specifically, and Retention definitions that use a 30+ day gap in treatment to define discontinuation.Conclusion: Establishing a shared taxonomy for key terms specifying OUD Cascade stages will help the field advance, compare approaches and results across settings, and improve population-level patient outcomes.

Relationship of hub and treatment characteristics with client outcomes in the initial Washington State hub and spoke cohort

INTRODUCTION

Washington State's Hub and Spoke (HS) approach aims to improve availability of opioid use disorder (OUD) treatment. Washington initially funded six hubs with expertise in medications for opioid use disorder (MOUD) that built care networks with referral and treatment partners (spokes). We assessed outcomes for the initial HS cohort, considering the role of HS and treatment characteristics.

METHODS

We conducted a cohort-based observational study using 2017-2019 Medicaid claims data for 2841 HS participants aged 18-64, excluding those with past-month MOUD, in an intent-to-treat analysis. We describe treatment characteristics (MOUD type, treatment setting, and hub type at the initial HS visit, number of outpatient services in their first HS month), and six-month outcomes (MOUD continuity, emergency department (ED) utilization, hospitalization, and intensive SUD treatment). We used multivariable regressions to assess associations with six-month outcomes, adjusting for client characteristics.

RESULTS

Two-thirds (68 %) of participants received buprenorphine, 22 % methadone, 5 % naltrexone, and 5 % outpatient without MOUD for their initial visit. Within six months, 45 % had an ED visit, 14 % any hospitalization, and 18 % entered intensive SUD treatment. Only 24 % remained on MOUD for six months. Compared to buprenorphine, the methadone sample had higher odds of MOUD continuity (aOR = 2.81, 95%CI 2.21-3.55), and the naltrexone sample had lower odds (aOR = 0.36, 95%CI 0.19-0.66). FQHC/public health treatment settings had higher odds of MOUD continuity (aOR = 1.70, 95%CI 1.17-2.47) but hub type was not significant. MOUD continuity increased with 2+ outpatient services for the buprenorphine sample (aOR range 2.55-4.73). Odds of intensive SUD treatment were lower for the methadone sample, compared to buprenorphine (aOR = 0.16, 95%CI 0.11-0.23), all settings compared to SUD settings (aOR range 0.32-0.58), and SUD + MH and medical/hospital hubs compared to SUD only hubs (aOR range 0.28-0.41).

CONCLUSIONS

Most participants did not attain six-month MOUD continuity, despite the HS approach, with variations by MOUD type and treatment setting. The number of outpatient services in the first month for buprenorphine clients was associated with greater odds of MOUD continuity and reduced odds of intensive SUD treatment. More work is needed to improve MOUD continuity for people with OUD within the HS model.

Federal Impacts on Buprenorphine Prescribing in Washington State, 2012 to 2022

Objectives. To evaluate changes in monthly buprenorphine dispensation associated with federal prescribing policies in Washington State from 2012 to 2022. Methods. We conducted an interrupted time series analysis comparing monthly buprenorphine prescriptions dispensed per 1000 population after the Comprehensive Addiction and Recovery Act (CARA), Substance Use-Disorder Prevention That Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT), and new prescribing rules during the COVID-19 pandemic. Buprenorphine formulated for opioid use disorder was included from the Washington State Prescription Monitoring Program. A log-linear autoregressive model measured linear trend changes. Results. Physician prescribing increased by 1.63% (95% confidence interval [CI] = 1.41%, 1.85%) per month after CARA with sustained declines after SUPPORT. Nurse practitioner (NP) prescribing increased by 19.48% (95% CI = 18.8%, 20.16%) per month after CARA with physician assistants (PAs) showing similar trends. Following the implementation of SUPPORT, NP and PA trends continued to increase at a reduced growth rate of 3.96% (95% CI = 2.01%, 5.94%) and 1.87% (95% CI = 0.56%, 3.19%), respectively. No prescribers experienced increases during the COVID-19 pandemic. Conclusions. CARA nearly tripled the buprenorphine prescribing rate. The SUPPORT Act initiated sustained declines for physician prescribing, and the COVID-19 period reversed gains for PAs and NPs. The current opioid crisis requires expanded efforts in Washington State. (Am J Public Health. 2024;114(7):696-704. https://doi.org/10.2105/AJPH.2024.307649).

Application of an opioid use disorder cascade of care in a large public health system

Background: Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time and can assist health systems in identifying areas of intervention to maximize the impact of evidence-based services. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using electronic health records.Objective: In this paper, we describe the process of operationalizing and applying the OUD Cascade in a large, urban, public hospital system.Methods: Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, lessons learned from compiling preliminary patient data and defining stages and outcome measures for the OUD Cascade of Care, and preliminary dataResults: We identified 33,616 (26.17% female) individuals with an OUD diagnosis. Almost half (48%) engaged with addiction services, while only 10.7% initiated medication-based treatment in an outpatient setting, 6.7% had timely follow-up, and 3.5% were retained for a minimum of 6 months.Conclusion: The current paper serves as a primer for other health systems seeking to implement data-informed approaches to guide more efficient care and improved substance use-related outcomes. An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design with an emphasis on early stages wherein drop-off is the greatest.

Repeated measures analysis of opioid use disorder treatment on clinical opiate withdrawal scale in a randomized clinical trial: sex differences

PURPOSE

Sex differences may exist in opioid use disorder (OUD) treatment. This study examined the treatment effects of buprenorphine/naloxone (BUP/NX) and methadone (MET) on the Clinical Opiate Withdrawal Scale (COWS) score in individuals with OUD and tested whether the associations differ by sex.

METHOD

We performed a secondary analysis of the data from the National Drug Abuse Treatment Clinical Trials Network (CTN) protocol-0027. A total of 1269 participants (861 males and 408 females) being aged 18 or older with OUD were randomly assigned to receive BUP/NX (n = 740) or MET (n = 529). The paired t test was initially used to compare the COWS scores between pre-dose and post-dose for BUP/NX and MET treatments, separately. The linear mixed model was used to examine the changes in COWS score adjusted for baseline demographic, substance use, and mental health disorders. The interaction of sex and treatment was detected and stratified analysis by sex was conducted.

RESULTS

The paired t test showed that both BUP/NX and MET treatments significantly reduced the COWS scores (p values <0.0001). BUP/NX revealed higher COWS scores than MET (p = 0.0008) and females demonstrated significantly higher COWS scores than males (p = 0.0169). Stratified by sex, BUP/NX compared with MET revealed higher COWS scores only in males (p = 0.0043), whereas baseline amphetamines use disorder and major depressive disorder were significantly associated with COWS scores in females (p = 0.0158 and 0.0422, respectively).

CONCLUSIONS

Both BUP/NX and MET are effective in decreasing opioid withdrawal symptoms via COWS scores, however, treatment plans for OUD by clinical providers should consider sex differences.

Application of an Opioid Use Disorder Cascade of Care in a Large Public Health System

Background

Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time, and can assist health systems in identifying areas of intervention to prevent overdose and maximize the impact of evidence-based services for patients with OUD. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using their systems' electronic medical records (EMR).

Objective

In this paper, we describe the process of operationalizing and implementing the OUD Cascade in one large, urban, public hospital system.

Methods

Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, and lessons learned from compiling patient data and defining stages and outcome measures for the OUD Cascade of Care. The current established framework and process will set the stage for subsequent research studies that quantify and evaluate patient progression through each stage of OUD treatment across the health system and identify target areas for quality improvement initiatives to better engage patients in care and improve health outcomes.

Results

The current paper can therefore serve as a primer for other health systems seeking to implement a data-informed approach to guide more efficient care and improved substance use-related outcomes.

Conclusion

An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design.

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.