Shifting blame: Buprenorphine prescribers, addiction treatment, and prescription monitoring in middle-class America

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.

Buprenorphine for Chronic Pain Management: a Narrative Review

PURPOSE OF REVIEW

The aim of this review is to educate healthcare professionals regarding buprenorphine for the use of opioid use disorder (OUD) as well as for chronic pain management. This review provides physicians and practitioners with updated information regarding the distinct characteristics and intricacies of prescribing buprenorphine.

RECENT FINDINGS

Buprenorphine is approved by the US Food and Drug Administration (FDA) for acute pain, chronic pain, opioid use disorder (OUD), and opioid dependence. When compared to most other opioids, buprenorphine offers superior patient tolerability, an excellent half-life, and minimal respiratory depression. Buprenorphine does have notable side effects as well as pharmacokinetic properties that require special attention, especially if patients require future surgical interventions. Many physicians are not trained to initiate or manage patients on buprenorphine. However, buprenorphine offers a potentially safer alternative for medication management for patients who require chronic opioid therapy for pain or have OUD. This review provides updated information on buprenorphine for both chronic pain and OUD.

Hospital adoption of harm reduction and risk education strategies to address substance use disorders

Background: Hospitals are well-positioned to integrate harm reduction into their workflow. However, the extent to which hospitals across the United States are adopting these strategies remains unknown.Objectives: To assess what factors are associated with hospital adoption of harm reduction/risk education strategies, and trends of adoption across time.Methods: We constructed a dataset marking implementation of harm reduction/risk education strategies for a 20% random sample of nonprofit hospitals in the U.S (n = 489) using 2019-2021 community health needs assessments (CHNAs) and implementation strategies obtained from hospital websites. We used two-level mixed effects logistic regression to test the association between adoption of these activities and organizational and community-level variables. We also compared the proportion of hospitals that adopted these strategies in the 2019-2021 CHNAs to an earlier cohort (2015-2018.)Results: In the 2019-2021 CHNAs, 44.7% (n = 219) of hospitals implemented harm reduction/risk education programs, compared with 34.1% (n = 156) in the 2015-2018 cycle. In our multivariate model, hospitals that implemented harm reduction/risk education programs had higher odds of having adopted three or more additional substance use disorder (SUD) programs (OR: 10.5: 95% CI: 5.35-20.62), writing the CHNA with a community organization (OR: 2.14; 95% CI: 1.15-3.97), and prioritizing SUD as a top three need in the CHNA (OR: 2.63; 95% CI: 1.54-4.47.)Conclusions: Our results suggest that hospitals with an existing SUD infrastructure and with connections to community are more likely to implement harm reduction/risk education programs. Policymakers should consider these findings when developing strategies to encourage hospital implementation of harm reduction activities.

Barriers and facilitators to nurse practitioner buprenorphine prescribing for opioid use disorder in primary care settings

BACKGROUND

Increasing access to opioid use disorder (OUD) treatment is critical to curbing the opioid epidemic, particularly for rural residents who experience numerous health and health care disparities, including higher overdose death rates and limited OUD treatment access compared with urban dwellers. Buprenorphine-naloxone is an evidence-based treatment for OUD that is well suited for rural areas. However, providers must have a specialized federal waiver to prescribe the medication. Despite the acceleration of the opioid epidemic in rural areas and the recent liberalization of federal buprenorphine-naloxone prescribing laws, few providers hold buprenorphine-naloxone prescribing waivers and even fewer prescribe the medication.

PURPOSE

This study explores barriers and facilitators to buprenorphine-naloxone prescribing among nurse practitioners (NPs) working in primary care settings in eastern North Carolina.

METHODOLOGY

Individual interviews were conducted with 13 NPs working in primary care settings in eastern North Carolina. Qualitative thematic analysis was used to identify perceived barriers and facilitators to buprenorphine-naloxone prescribing.

RESULTS

Analysis found prescribing barriers related to OUD stigma, perceived knowledge, federal and state regulation, and prescribing resources and found facilitators related to adopting a person-centered approach, developing prescriber skills, and access to prescribing resources.

CONCLUSIONS

The barriers and facilitators that NPs experience related to buprenorphine prescribing for OUD are similar to those faced by physicians, although the barriers arguably more profound. Future research should consider how to mitigate these prescribing barriers to facilitate NP buprenorphine prescribing for OUD.

IMPLICATIONS

To our knowledge, this is the first qualitative study of NP buprenorphine-naloxone prescribing in rural areas. Given the prominence of OUD in rural regions and the key role NPs play in primary care provision, this study lays import groundwork for developing interventions to support buprenorphine-naloxone prescribing by NPs practicing in rural regions.

Bridging the Macro-micro Divide: A Qualitative Meta-synthesis on the Perspectives and Experiences of Health Care Providers on the Extramedical Use and Diversion of Buprenorphine

OBJECTIVES

Opioid agonist therapy using buprenorphine is one of the most effective treatments for opioid use disorder. However, concerns regarding its extramedical use and diversion, such as adverse patient outcomes and damage to the legitimacy of addictions practice, are persistent. The aim of this review is to synthesize the perspectives and experiences of health care providers around the extramedical use of buprenorphine.

METHODS

A qualitative meta-synthesis was conducted based on a systematic search of 8 databases. All primary qualitative and mixed-methods studies relating to the views of health care providers on the extramedical use of buprenorphine were included. A qualitative analysis informed by the constant comparative method was conducted, using NVivo for data management.

RESULTS

Sixteen studies were included in this review. Findings were organizedunder 2 key themes: (1) Harm-producing versus harm-reducing effects of extramedical buprenorphine use and (2) driving forces of and responses to extramedical buprenorphine use.

CONCLUSIONS

The studies included in our review identified a disconnect-health care providers noted that macro, health care system-level challenges drove extramedical use whereas the recommended solutions for prevention and management were primarily aimed at the micro, individual level. This study emphasizes the critical role that health care providers can play, in partnership with patients, in informing appropriate policies and health care system design to optimize the care for people with opioid use disorder.

Patient experiences of prescription drug monitoring programs: a qualitative analysis from an Australian pharmaceutical helpline

BACKGROUND

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, such as opioid analgesics and benzodiazepines. PDMP have been used widely throughout North America and have recently been implemented in Australia. Several unintended harms have been associated with PDMP in North America, including increased stigma, discrimination, and dismissal from care for patients prescribed these medications.

AIMS

This study aimed to better understand how people who use prescription medications extramedically and their loved ones give meaning to their consumption and their treatment experiences and concerns in the context of a newly implemented real-time PDMP in Victoria, Australia.

METHOD

Nineteen audio recordings of telephone calls made to the PDMP Pharmaceutical Helpline were transcribed and thematically analysed.

RESULTS

Patients and their families were hopeful that PDMP would stop the extra medical use of medications. However, many were deeply concerned about how they would cope with withdrawal or life stressors without the support these medications afforded. Patients reported experiences of stigma and strained therapeutic relationships associated with PDMP implementation.

CONCLUSION

PDMP have the potential to both assist and harm patients whose prescription medication use has been identified as 'risky' by the PDMP. The findings from this study suggest that clear and open communication, as well as reflection on unconscious bias and stigma may assist healthcare providers to facilitate better patient experiences and outcomes in the context of prescription medication dependence.

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

IMPORTANCE

As opioid-related deaths continue to climb, methods to reduce barriers to prescribing buprenorphine for individuals with opioid use disorder (OUD) are needed. Recent conversations by state and federal authorities targeting low-threshold buprenorphine aim to reduce some barriers to prescribing buprenorphine; however, what remains unclear is whether removal of the requirement to obtain a waiver for prescribing buprenorphine through the Drug Addiction Treatment Act of 2000 (an X-waiver) will be enough to increase access to buprenorphine.

OBJECTIVE

To assess barriers and facilitators of obtaining an X-waiver and prescribing buprenorphine.

DESIGN, SETTING, AND PARTICIPANTS

This mixed-method survey study was conducted between September and December 2020; 607 office-based Texas clinicians were surveyed after they attended a buprenorphine X-waiver training course. All attendees between March 2, 2019, and February 28, 2020, were eligible to receive this survey; 126 responses were received (20% response rate: 81 physicians, 37 nurse practitioners, and 8 physician assistants). Data analysis was performed October 2021.

MAIN OUTCOMES AND MEASURES

Surveys measured the extent to which clinicians experienced 9 previously identified barriers during the waiver process and in prescribing buprenorphine. The survey included open-ended items assessing facilitating factors to obtaining a waiver and to prescribing buprenorphine for OUD. The barriers were analyzed using χ2 tests of homogeneity. Qualitative data were analyzed using a constant comparative method.

RESULTS

Among 126 clinicians who responded, 61 (48.4%) had received an X-waiver; of these waivered clinicians, 22 (36%) were prescribing buprenorphine and 39 (64%) were not. "Complexity of X-waiver process," "Perceived lack of professional support and referral network," and "Getting started" were significantly different barriers among waivered and nonwaivered clinicians. Significant differences in barriers experienced between prescribers and nonprescribers were "Getting started" and "Accessing reimbursement for treatment." The most frequently mentioned facilitators involved changes to the waiver training and the need for networks connecting experienced clinicians with those in the initial stages of readiness for prescribing buprenorphine for OUD.

CONCLUSIONS AND RELEVANCE

This survey study's results contribute new understanding of facilitators to obtaining the X-waiver and to prescribing buprenorphine. Furthermore, these findings suggest that to increase access to compassionate evidence-based treatment for OUD, clinicians need ongoing support and mentorship from experienced and knowledgeable clinicians. Interventions aimed at improving access to buprenorphine should focus on facilitating such networks to increase the number of clinicians who obtain an X-waiver and prescribe buprenorphine for OUD.

Support for evidence-informed opioid policies and interventions: The role of racial attitudes, political affiliation, and opioid stigma

Political affiliation, racial attitudes, and opioid stigma influence public support for public health responses to address opioid use disorders (OUD). Prior studies suggest public perceptions of the opioid epidemic are less racialized and less politically polarized than were public perceptions of the crack cocaine epidemic. Analyzing a cross-sectional, nationally representative sample (n = 1161 U.S. adults) from the October 2020 AmeriSpeak survey, we explored how political affiliation, racial attitudes (as captured in the Color-Blind Racial Attitudes Scale [CoBRAS]), and OUD stigma were associated with respondents' expressed views regarding four critical domains. Respondents with unfavorable attitudes towards Black Americans were less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and distributing naloxone for overdose prevention. Democratic Party affiliation was associated with greater support for all three of the above measures, and increased support for mandatory treatment, which may be seen as a substitute for more punitive interventions. Black respondents were also less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and of distributing naloxone. Our finding suggest that negative attitudes towards African-Americans and political differences remain important factors of public opinion on responding to the OUD epidemic, even after controlling for opioid stigma. Our findings also suggest that culturally-competent dialogue within politically conservative and Black communities may be important to engage public support for evidence-informed treatment and prevention.

Assessing waivered and non-waivered physician barriers to treating patients with substance use disorders: a cross-sectional Kentucky pilot

INTRODUCTION

Opioid and other substance use disorders (OUD/SUDs) have been and continue to be significant public health issues. The standard of care for OUD is the use of medication for opioid use disorder (MOUD) in conjunction with counseling or behavioral therapies, yet research has indicated that barriers exist for patients accessing MOUD as well as for physicians prescribing MOUD due to requirements associated with the DATA 2000 waiver.

METHODS

A pilot cross-sectional survey was conducted among Kentucky physicians in order to reassess common barriers as well as to explore barriers that non-waivered providers face to becoming waivered. Barriers were compared by waiver status (waiver vs. non-waivered) as well as geographic location (rural vs. non-rural).

RESULTS

Compared to waivered physicians, non-waivered physicians were significantly less likely to report positive personal beliefs related to the use of MOUD for OUD and reported significantly more barriers to treating OUD patients in the areas of physicians' practice and culture, auditing, and institutional support and resources (p < .05). The majority (69%) of all physicians indicated they would benefit from a tool kit with evidence-based clinical guidelines.

CONCLUSIONS

The barriers and beliefs identified in this pilot study indicate the need for policy action at the federal level to reduce barriers and incentivize more physicians to obtain waivers to treat OUD. Further, the development of brief educational resources tailored to physicians to treat OUD patients including pregnant patients with OUD is recommended.

Thinking about Social Determinants of Health through the Relationality of Work and Drug Use

Public health often frames drug use and addiction as destructive and antithetical to productive citizenship, particularly formal employment. Anthropologists show how drug use emerges in specific institutional, social, and political economic contexts. This attention to context suggests that the relationship between drug use and work may not be as stable as epidemiology models it. There is a multiplicity to the relationality of work and drug use. These results are based on in-depth interviews conducted in 2018 and 2019 with 16 individuals undergoing addiction treatment at a residential facility in northern Arizona. In some cases, drug and alcohol use led to losing work. In other cases, drug and alcohol use made work more possible. The entanglements between work and drug use fluctuated through time. Social determinants of health are relationally brought into being, part of larger assemblages, and dynamic.

Evaluating buprenorphine prescribing and opioid-related health outcomes following the expansion the buprenorphine waiver program

AIMS

To evaluate associations between new types of buprenorphine waivers (nurse practitioner and physician assistant [NP/PA]; 275-patient limit [MD/DO-275]) and both buprenorphine prescribing and health outcomes.

METHODS

Using comprehensive county-level data from California 2010-2018, we modeled quarterly associations between numbers of NP/PA and MD/DO-275 waivers and rates of buprenorphine prescribing, opioid-related deaths, emergency department (ED) visits, and hospitalizations among all counties and separately among metropolitan and nonmetropolitan counties using Poisson regression models with county and quarter fixed effects and adjusting for time-varying covariates.

RESULTS

Each additional NP/PA and MD/DO-275 waiver was associated with a 2.6% (95%CI: 1.1-4.1%) and 5.8% (4.1-7.4%) increase in buprenorphine prescribing among nonmetropolitan counties, respectively. Each additional MD/DO-275 waiver was associated with a 2.8% (1.0%-4.6%) increase in buprenorphine among metropolitan counties. There were no statistically significant associations between NP/PA waivers and buprenorphine prescribing among metropolitan counties or among either waiver type and opioid-related health outcomes.

CONCLUSIONS

NP/PA waivers were associated with increased buprenorphine prescribing among nonmetropolitan counties and MD/DO-275 waivers were associated with increased buprenorphine prescribing among both metropolitan and nonmetropolitan counties.

Key considerations for the implementation of clinically focused Prescription Drug Monitoring Programs to avoid unintended consequences

Prescription Drug Monitoring Programs (PDMP) are electronic databases that are used to track and monitor the prescribing and dispensing of controlled substances, including opioid analgesics and benzodiazepines. PDMP have been widely implemented throughout North America and are currently being introduced in Australia and some parts of Europe. PDMP were originally developed by and for law enforcement, however many jurisdictions have now shifted use toward clinical care and harm reduction through early identification of prescription dependence and extra-medical use, and to ensure appropriate supply of controlled substances to the community through monitoring health care provider prescribing and dispensing patterns (Deloitte, 2018; Picco et al., 2021a; CDC, 2021a, U.S Department of Justice, 2018). Clinically-motivated PDMP highlight medication-related risk, based on the patient's prescribing and dispensing history. Health care professionals can use this information to aid or inform clinical decision-making and provide opportunities for intervention and treatment (Deloitte, 2018) . However, a number of harms have been associated with the use of PDMP, including increased stigma and discrimination, untreated pain and mental illness, and denial of appropriate health care for those identified as 'high risk'. In this article we examine these harms and potential mitigating factors. We conclude with some suggestions and future directions for research to address some of the current uncertainties regarding PDMP use. We highlight the need for mixed methods research to better understand the personal impacts of PDMP policy on the populations they were designed to aid.

Advancing Health Equity in Digital Mental Health: Lessons From Medical Anthropology for Global Mental Health

Digital health engenders the opportunity to create new effective mental health care models-from substance use recovery to suicide prevention. Anthropological methodologies offer a unique opportunity for the field of global mental health to examine and incorporate contextual mental health needs through attention to the lived experience of illness; engagement with communities; and knowledge of context, structures, and systems. Attending to these diverse mental health needs and conditions as well as the limitations of digital health will allow global mental health researchers, practitioners, and patients to collaboratively create new models for care in the service of equitable, accessible recovery.

Buprenorphine management in the perioperative period: educational review and recommendations from a multisociety expert panel

BACKGROUND

The past two decades have witnessed an epidemic of opioid use disorder (OUD) in the USA, resulting in catastrophic loss of life secondary to opioid overdoses. Medication treatment of opioid use disorder (MOUD) is effective, yet barriers to care continue to result in a large proportion of untreated individuals. Optimal analgesia can be obtained in patients with MOUD within the perioperative period. Anesthesiologists and pain physicians can recommend and consider initiating MOUD in patients with suspected OUD at the point of care; this can serve as a bridge to comprehensive treatment and ultimately save lives.

METHODS

The Board of Directors of the American Society of Regional Anesthesia and Pain Medicine, American Society of Anesthesiologists, American Academy of Pain Medicine, American Society of Addiction Medicine and American Society of Health System Pharmacists approved the creation of a Multisociety Working Group on Opioid Use Disorder, representing the fields of pain medicine, addiction, and pharmacy health sciences. An extensive literature search was performed by members of the working group. Multiple study types were included and reviewed for quality. A modified Delphi process was used to assess the literature and expert opinion for each topic, with 100% consensus being achieved on the statements and each recommendation. The consensus statements were then graded by the committee members using the United States Preventive Services Task Force grading of evidence guidelines. In addition to the consensus recommendations, a narrative overview of buprenorphine, including pharmacology and legal statutes, was performed.

RESULTS

Two core topics were identified for the development of recommendations with >75% consensus as the goal for consensus; however, the working group achieved 100% consensus on both topics. Specific topics included (1) providing recommendations to aid physicians in the management of patients receiving buprenorphine for MOUD in the perioperative setting and (2) providing recommendations to aid physicians in the initiation of buprenorphine in patients with suspected OUD in the perioperative setting.

CONCLUSIONS

To decrease the risk of OUD recurrence, buprenorphine should not be routinely discontinued in the perioperative setting. Buprenorphine can be initiated in untreated patients with OUD and acute pain in the perioperative setting to decrease the risk of opioid recurrence and death from overdose.

Primary care physicians' preparedness to treat opioid use disorder in the United States: A cross-sectional survey

BACKGROUND

Efforts to increase opioid use disorder (OUD) treatment have focused on primary care. We assessed primary care physicians' preparedness to identify and treat individuals with OUD and barriers to increasing buprenorphine prescribing.

METHODS

We conducted a cross-sectional survey from January-August 2020 which assessed perceptions of the opioid epidemic; comfort screening, diagnosing, and treating individuals with OUD with medications; and barriers to obtaining a buprenorphine waiver and prescribing buprenorphine in their practice. Primary care physicians were sampled from the American Medical Association Physician Master File (n = 1000) and contacted up to 3 times, twice by mail and once by e-mail.

RESULTS

Overall, 173 physicians (adjusted response rate 27.3 %) responded. While most were somewhat or very comfortable screening (80.7 %) and diagnosing (79.3 %) OUD, fewer (36.9 %) were somewhat or very comfortable treating OUD with medications. One third of respondents were in a practice where they or a colleague were waivered and 10.7 % of respondents had a buprenorphine waiver. The most commonly cited barriers to both obtaining a waiver and prescribing buprenorphine included lack of access to addiction, behavioral health, or psychiatric co-management, lack of experience treating OUD, preference not to be inundated with requests for buprenorphine, and the buprenorphine training requirement.

CONCLUSIONS

While most primary care physicians reported comfort screening and diagnosing OUD, fewer were comfortable treating OUD with medications such as buprenorphine and even fewer were waivered to do so. Addressing provider self-efficacy and willingness, and identifying effective, coordinated, and comprehensive models of care may increase OUD treatment with buprenorphine.

A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder

BACKGROUND

The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery.

METHODS

This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review.

RESULTS

There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD.

CONCLUSION

This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

Improving Access to Evidence-Based Medical Treatment for Opioid Use Disorder: Strategies to Address Key Barriers within the Treatment System

Even though evidence-based treatment for opioid use disorders (OUD) is effective, almost four in five Americans with OUD do not receive any form of treatment. The gap in access to evidence-based care, including treatment with medications for OUD, stems in part from barriers to change within the health care system. This paper includes nine key barriers that prevent access to evidence-based care, including stigma; inadequate clinical training; a dearth of addiction specialists; lack of integration of MOUD provision in practice; regulatory, statutory, and data sharing restrictions; and financial barriers. Action from a number of actors is urgently needed to address this crisis.

Perceptions and preferences for long-acting injectable and implantable medications in comparison to short-acting medications for opioid use disorders

Aim

Treatment for opioid use disorders has recently evolved to include long-acting injectable and implantable formulations of medications for opioid use disorder (MOUD). Incorporating patient preferences into treatment for substance use disorders is associated with increased motivation and treatment satisfaction. This study sought to assess treatment preferences for long-acting injectable and implantable MOUD as compared to short-acting formulations among individuals with OUD.

Methods

We conducted qualitative, semi-structured telephone interviews with forty adults recruited from across the United States through Craigslist advertisements and flyers posted in treatment programs. Eligible participants scored a two or greater on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool, indicative of a past-year OUD. Interviews were transcribed, coded, and thematically analyzed.

Results

Twenty-four participants (60%) currently or previously had been prescribed MOUD. Sixteen participants (40%) expressed general opposition to MOUD, citing concerns that MOUD is purely financial gain for pharmaceutical companies and/or a "band aid" solution replacing one drug with another, rather than a path to abstinence. Some participants expressed personal preference for long-acting injectable (n = 16/40: 40%) and implantable formulations (n = 12/40: 30%) over short-acting formulations. About half of the participants were not willing to use injectables (n = 19/40: 48%) or implantables (n = 22/40: 55%), preferring short-acting formulations. Mixed evaluations of long- and short-acting MOUD focused on considerations of medication-related beliefs (privacy, concern over an embedded foreign body), the medication-related burden (convenience, provision of structure and support, medication administration, potential side effects), and medication-taking practices (potential for non-prescribed use, control over dosage, and duration of treatment).

Conclusions

Though many participants personally prefer short-acting to long-acting MOUD, some were open to including long-acting formulations in the range of options for those with OUD. Participants felt long-acting formulations may reduce medication-related burden and the risk of diversion. Conversely, participants expressed concern about invasive administration and loss of control over their treatment. Results suggest support for expanded access to a variety of formulations of MOUD. The use of shared decision making may also help patients select the formulation best aligned with their experiences, values, and treatment goals.

Substance Use Stigma, Primary Care, and the New York State Prescription Drug Monitoring Program

Prescription drug monitoring programs (PDMPs) are databases that track controlled substances at the provider, patient, and pharmacy levels. While these databases are widely available at the state level throughout the United States, several jurisdictions in recent years have mandated the use of these systems by health care providers. This study explores the implementation of mandatory PDMP technology in primary care practice and the effects on treatment of people with possible substance use disorders. Findings are based on 53 in-depth interviews with primary care providers in New York City, collected shortly following the passage of legislation mandating use of a PDMP by health care providers in New York State. Findings suggest that use of the PDMP highlighted tensions between provider stigma toward substance use disorders and the clinical care of people who use drugs, challenging their stereotypes and biases. The parallel clinical and law enforcement purposes of PDMP technology placed providers in dual roles as clinicians and enforcers and encouraged the punitive treatment of patients. Finally, PDMP technology standardized the clinical assessment process toward a "diagnosis first" approach, consistent with prior scholarship on the implementation of emerging medical technologies.

Taking opioids in times of crisis: Institutional oversight, chronic pain and suffering in an integrated healthcare delivery system in the U.S

BACKGROUND

Opioid treatment for chronic pain has garnered heightened public attention and political pressure to control a devastating public health crisis in the United States (U.S.). Resulting policy changes, together with ongoing public and political attention, have pushed health care systems and providers to lower doses or deprescribe and taper patients off opioids. However, little attention has been paid to the impact of such practice changes on patients who had relied on opioid treatment to manage their chronic pain. The aim of this article is to explore experiences with opioid-related care under aggressive tapering efforts and concomitant heightened monitoring and institutional oversight among patients with chronic pain in an integrated delivery system through in-depth interviews.

METHODS

We interviewed 97 patients with chronic pain who were assigned to the usual care arm of the Pain Program for Active Coping and Training (PPACT) study. These patients had been prescribed opioids as part of their treatment regimens and taken opioids closely monitored by their health care providers. We followed the framework method for coding and analysing transcripts using NVivo 12.

RESULTS

The experiences of these patients during this period of change can be understood through three interconnected themes: (1) many patients taking opioids experience debilitating physical side effects; (2) navigating opioid treatment contributes to significant emotional distress among many patients with chronic pain and; (3) the quality of patients' relationship with their primary care provider can be negatively affected by negotiations regarding long-term opioid treatment for chronic pain.

CONCLUSION

We highlight the importance of utilizing communication approaches that are patient-centered and include shared decision making during the tapering and/or deprescribing processes of opioids and ensuring alternative pain treatments are available to patients with chronic pain.

Depot Buprenorphine Injection In The Management Of Opioid Use Disorder: From Development To Implementation

Buprenorphine has pharmacologic advantages over methadone, especially buprenorphine's better safety profile. The true significance of buprenorphine's introduction lies in returning the care of those suffering from opioid use disorder (OUD) to the hands of the physician. The clinical success of buprenorphine has been meager, in part because most physicians have not been exposed to treating these patients. For physicians inclined to treat OUD, the barriers to buprenorphine's implementation have been onerous and largely counter to the norms of medical practice. Some notable concerns pertain to buprenorphine's clinical pharmacology like street diversion, unintended use and accidental poisoning. Recently, injectable buprenorphine preparations have been introduced to mitigate these latter shortcomings. Yet, the injectable preparations' clinical and commercial success has fallen far short of expectation. Here, we review the clinical pharmacology of these products and their expected clinical advantages for the manufacturers, clinicians, policy makers and patients, and offer our perspective, as clinicians and researchers, on how things can improve. Questions remain whether clinicians are willing to overcome barriers to treat OUD using these medications.

Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment

At least 2.3 million people in the U.S. have an opioid use disorder, less than 40% of whom receive evidence-based treatment. Buprenorphine used as part of medication-assisted treatment has high potential to address this gap because of its approval for use in non-specialty outpatient settings, effectiveness at promoting abstinence, and cost effectiveness. However, less than 4% of licensed physicians are approved to prescribe buprenorphine for opioid use disorder, and approximately 47% of counties lack a buprenorphine-waivered physician. Existing policies contribute to workforce barriers to buprenorphine provision and access. Providers are reticent to prescribe buprenorphine because of workforce barriers, such as (1) insufficient training and education on opioid use disorder treatment, (2) lack of institutional and clinician peer support, (3) poor care coordination, (4) provider stigma, (5) inadequate reimbursement from private and public insurers, and (6) regulatory hurdles to obtain the waiver needed to prescribe buprenorphine in non-addiction specialty treatment settings. Policy pathways to addressing these provider workforce barriers going forward include providing free and easy-to-access education for providers about opioid use disorders and medication-assisted treatment, eliminating buprenorphine waiver requirements for those licensed to prescribe controlled substances, enforcing insurance parity requirements, requiring coverage of evidence-based medication-assisted treatment as essential health benefits, and providing financial incentives for care coordination across healthcare professional types-including behavioral health counselors and other non-physicians in specialty and non-specialty settings.

SUPPLEMENT INFORMATION

This article is part of a supplement entitled The Behavioral Health Workforce: Planning, Practice, and Preparation, which is sponsored by the Substance Abuse and Mental Health Services Administration and the Health Resources and Services Administration of the U.S. Department of Health and Human Services.

21st Century Cures for the Opioid Crisis: Promise, Impact, and Missed Opportunities

Signed into law in 2016, the landmark 21stCentury Cures Act is as complex as it is divisive. For some stakeholders, including patient groups and representatives of regulated industries, the Act represented a major leap forward in pharmaceutical innovation, human subjects protections, and numerous other provisions. For other observers, this legislation was characterized as a major rollback in important regulations, which would leave patients worse off and the payers holding the bag. The one element of the Act that was relatively uncontroversial covered a number of provisions related to addressing the opioid crisis.

This was by design. Provisions related to this issue were not part of the original legislation and were added to win over additional members of Congress who needed to be brought along to support the legislation. Many of the statute's provisions were intertwined with the Comprehensive Addiction Recovery Act (“CARA”) passed previously, but that legislation was stripped of much of its funding for opioid crisis response.

The War on Drugs That Wasn't: Wasted Whiteness, "Dirty Doctors," and Race in Media Coverage of Prescription Opioid Misuse

The past decade in the U.S. has been marked by a media fascination with the white prescription opioid cum heroin user. In this paper, we contrast media coverage of white non-medical opioid users with that of black and brown heroin users to show how divergent representations lead to different public and policy responses. A content analysis of 100 popular press articles from 2001 and 2011 in which half describe heroin users and half describe prescription opioid users revealed a consistent contrast between criminalized urban black and Latino heroin injectors with sympathetic portrayals of suburban white prescription opioid users. Media coverage of the suburban and rural opioid "epidemic" of the 2000s helped draw a symbolic, and then legal, distinction between (urban) heroin addiction and (suburban and rural) prescription opioid addiction that is reminiscent of the legal distinction between crack cocaine and powder cocaine of the 1980s and 1990s. This distinction reinforces the racialized deployment of the War on Drugs and is sustained by the lack of explicit discussion of race in the service of "color blind ideology." We suggest potential correctives to these racially divergent patterns, in the form of socially responsible media practices and of clinical engagement with public policy.

Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City

BACKGROUND

Geographic and demographic variation in buprenorphine and methadone treatment use in U.S. cities has not been assessed. Identifying variance in opioid maintenance is essential to improving treatment access and equity.

PURPOSE

To examine the differential uptake of buprenorphine treatment in comparison to methadone treatment between 2004 and 2013 in neighborhoods in New York City characterized by income, race and ethnicity.

METHODS

Social area (SA) analysis of residential zip codes of methadone and buprenorphine patients in NYC, which aggregated zip codes into five social areas with similar percentages of residents below poverty, identifying as Black non-Hispanic and as Hispanic, to examine whether treatment rates differed significantly among social areas over time. For each rate, mixed model analyses of variance were run with fixed effects for social area, year and the interaction of social area by year.

RESULTS

Buprenorphine treatment increased in all social areas over time with a significantly higher rate of increase in the social area with the highest income and the lowest percentage of Black, Hispanic, and low-income residents. Methadone treatment decreased slightly in all social areas until 2011 and then increased bringing rates back to 2004 levels. Treatment patterns varied by social area.

CONCLUSIONS

Buprenorphine treatment rates are increasing in all social areas, with slower uptake in moderate income mixed ethnicity areas. Methadone rates have remained stable over time. Targeted investments to promote public sector buprenorphine prescription may be necessary to reduce disparities in buprenorphine treatment and to realize its potential as a public health measure.