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McLean K, Murphy J, Kruis N. "I think we're getting better but we're still not there": Provider-based stigma and perceived barriers to care for people who use opioids (PWUO). J Subst Use Addict Treat 2024; 159:209270. [PMID: 38103831 DOI: 10.1016/j.josat.2023.209270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/18/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD - is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care. METHODS This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population. RESULTS Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO. CONCLUSIONS Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma - blameworthiness - in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma.
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Affiliation(s)
- Katherine McLean
- Penn State Greater Allegheny, 4000 University Dr., McKeesport, PA 15131, United States of America.
| | - Jennifer Murphy
- Penn State Berks, 1801 Broadcasting Rd, Reading, PA 19610, United States of America.
| | - Nathan Kruis
- Penn State Altoona, 3000 Ivyside Park, Altoona, PA 16601, United States of America.
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McLeman B, Gauthier P, Lester LS, Homsted F, Gardner V, Moore SK, Joudrey PJ, Saldana L, Cochran G, Harris JP, Hefner K, Chongsi E, Kramer K, Vena A, Ottesen RA, Gallant T, Boggis JS, Rao D, Page M, Cox N, Iandiorio M, Ambaah E, Ghitza U, Fiellin DA, Marsch LA. Implementing a pharmacist-integrated collaborative model of medication treatment for opioid use disorder in primary care: study design and methodological considerations. Addict Sci Clin Pract 2024; 19:18. [PMID: 38500166 PMCID: PMC10949656 DOI: 10.1186/s13722-024-00452-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Pharmacists remain an underutilized resource in the treatment of opioid use disorder (OUD). Although studies have engaged pharmacists in dispensing medications for OUD (MOUD), few studies have evaluated collaborative care models in which pharmacists are an active, integrated part of a primary care team offering OUD care. METHODS This study seeks to implement a pharmacist integrated MOUD clinical model (called PrIMO) and evaluate its feasibility, acceptability, and impact across four diverse primary care sites. The Consolidated Framework for Implementation Research is used as an organizing framework for study development and interpretation of findings. Implementation Facilitation is used to support PrIMO adoption. We assess the primary outcome, the feasibility of implementing PrIMO, using the Stages of Implementation Completion (SIC). We evaluate the acceptability and impact of the PrIMO model at the sites using mixed-methods and combine survey and interview data from providers, pharmacists, pharmacy technicians, administrators, and patients receiving MOUD at the primary care sites with patient electronic health record data. We hypothesize that it is feasible to launch delivery of the PrIMO model (reach SIC Stage 6), and that it is acceptable, will positively impact patient outcomes 1 year post model launch (e.g., increased MOUD treatment retention, medication regimen adherence, service utilization for co-morbid conditions, and decreased substance use), and will increase each site's capacity to care for patients with MOUD (e.g., increased number of patients, number of prescribers, and rate of patients per prescriber). DISCUSSION This study will provide data on a pharmacist-integrated collaborative model of care for the treatment of OUD that may be feasible, acceptable to both site staff and patients and may favorably impact patients' access to MOUD and treatment outcomes. TRIAL REGISTRATION The study was registered on Clinicaltrials.gov (NCT05310786) on April 5, 2022, https://www. CLINICALTRIALS gov/study/NCT05310786?id=NCT05310786&rank=1.
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Affiliation(s)
- Bethany McLeman
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA.
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.
| | - Phoebe Gauthier
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Laurie S Lester
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Vernon Gardner
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
| | - Sarah K Moore
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Paul J Joudrey
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Lisa Saldana
- Lighthouse Institute, Chestnut Health Systems, Eugene, OR, USA
| | - Gerald Cochran
- University of Utah, Salt Lake City, UT, USA
- Greater Intermountain Node, NIDA Drug Abuse Treatment Clinical Trials Network, Salt Lake City, UT, USA
| | | | | | | | | | | | | | - Tess Gallant
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Jesse S Boggis
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | - Deepika Rao
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
| | | | - Nicholas Cox
- University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | | | - Ekow Ambaah
- Harbor Care Health & Wellness, Nashua, NH, USA
| | - Udi Ghitza
- National Institute on Drug Abuse, North Bethesda, MD, USA
| | - David A Fiellin
- New England Consortium Node, NIDA Drug Abuse Treatment Clinical Trials Network, New Haven, CT, USA
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lisa A Marsch
- Northeast Node, NIDA Drug Abuse Treatment Clinical Trials Network, Hanover, NH, USA
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Hanover, NH, USA
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Andraka-Christou B, Golan O, Totaram R, Ohama M, Saloner B, Gordon AJ, Stein BD. Prior authorization restrictions on medications for opioid use disorder: trends in state laws from 2005 to 2019. Ann Med 2023; 55:514-520. [PMID: 36724766 PMCID: PMC9897778 DOI: 10.1080/07853890.2023.2171107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
RESEARCH OBJECTIVE Medications for opioid use disorder (MOUDs) - including methadone, buprenorphine, and naltrexone - are the most effective treatments for opioid use disorder (OUD). Historically, insurers have required prior authorization for MOUD, but prior authorization is often reported as a key barrier to MOUD prescribing. Some states have passed laws prohibiting MOUD prior authorization requirements. We sought to identify the frequency of MOUD prior authorization prohibitions in state laws and to categorize types of prohibitions. METHODS We searched for regulations and statutes present in all U.S. states and Washington DC between 2005 and 2019 using MOUD-related terms in Westlaw legal software. In qualitative software, we coded laws discussing MOUD prior authorization using template analysis - a mixed deductive/inductive approach. Finally, we used coded laws to identify frequencies of states with prior authorization prohibitions, including changes over time. RESULTS No states had laws prohibiting MOUD prior authorization between 2005 and 2015, with the first prohibition appearing in 2016. By 2019, fifteen states had MOUD prior authorization prohibitions. States varied significantly in their approach to prohibiting MOUD prior authorization. In 2019, it was more common for states to have MOUD prior authorization prohibitions applying to all insurers (n = 10 states) than to only Medicaid (n = 7 states) or only non-Medicaid insurers (n = 1 state). In 2019, general prior authorization prohibitions (n = 10 states) were more common than prohibitions only applicable to medications on the formulary, prohibitions only applicable to medications on the preferred drug list, prohibitions only applicable during the first 5 days of treatment, and prohibitions only applicable during the first 30 days of treatment. CONCLUSIONS The number of states with an MOUD prior authorization law prohibition increased in recent years. Such laws could help expand access to life-saving OUD treatments by making it easier for clinicians to prescribe MOUD.KEY MESSAGESNo states had MOUD prior authorization prohibitions between 2005 and 2015 in state statutes or regulations, and only one state had such a prohibition in 2016.By 2019, fifteen states had an MOUD prior authorization prohibition law.States varied significantly in their approach to prohibiting MOUD prior authorization, including with respect to the insurer type, duration of the prohibition, and applicable medication.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL, USA
- CONTACT Barbara Andraka-Christou School of Global Health Management and Informatics, University of Central Florida, 525 W Livingston Street, Suite 401, Orlando, 32801FL, USA
| | - Olivia Golan
- School of Public Health, Georgia State University, Atlanta, GA, USA
| | - Rachel Totaram
- School of Global Health Management and Informatics, University of Central Florida, Orlando, FL, USA
| | - Maggie Ohama
- The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Brendan Saloner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Incze MA, Garland EL. Mobilizing Primary Care Against the Opioid Crisis in the Post X-Waiver Era. J Gen Intern Med 2023; 38:3618-3620. [PMID: 37653205 PMCID: PMC10713878 DOI: 10.1007/s11606-023-08382-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 08/16/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, University of Utah, Salt Lake City, USA.
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, USA.
| | - Eric L Garland
- Center On Mindfulness and Integrative Health Intervention Development, College of Social Work, University of Utah, Salt Lake City, USA
- Veterans Health Care Administration VISN 19 Whole Health Flagship Site Located at the VA Salt Lake City Health Care System, Salt Lake City, USA
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Christine PJ, Larochelle MR, Lin L(A, McBride J, Tipirneni R. Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder. JAMA Health Forum 2023; 4:e233549. [PMID: 37862034 PMCID: PMC10589810 DOI: 10.1001/jamahealthforum.2023.3549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 08/17/2023] [Indexed: 10/21/2023] Open
Abstract
Importance Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. Objective To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. Design, Setting, and Participants This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Exposures Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. Main Outcomes and Measures The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Results Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). Conclusions and Relevance In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.
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Affiliation(s)
- Paul J. Christine
- Section of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora
| | - Marc R. Larochelle
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Lewei (Allison) Lin
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Addiction Center, Department of Psychiatry, University of Michigan Medical School, Ann Arbor
| | - Jonathon McBride
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor
| | - Renuka Tipirneni
- Division of General Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor
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Hall NY, Le L, Abimanyi-Ochom J, Teesson M, Mihalopoulos C. Identifying the most common barriers to opioid agonist treatment in an Australian setting. Aust J Prim Health 2023; 29:445-454. [PMID: 36934460 DOI: 10.1071/py22269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 02/20/2023] [Indexed: 03/20/2023]
Abstract
BACKGROUND Opioid use disorder is a public health concern in Australia. Opioid agonist treatment (OAT) is effective at treating and minimising harm from opioid use disorder, yet is underused in Australia due to client barriers. Although these barriers have been reported, the barriers that are most important to clients is unclear. The aim of this paper was to determine the most important OAT barriers to Australian clients. METHODS A cross-sectional, self-completed survey was given to 204 opioid-dependent clients who attended needle and syringe sites in Australia. Participants were given 15 OAT barrier statements, which they answered using a 5-point Likert scale (1=strongly disagree, 2=disagree, 3=neutral, 4=agree and 5=strongly agree). The Likert scale data are presented using the count method and the mean Likert scores (for the whole sample and for subgroups). RESULTS The two methods determined that the four most important barriers to OAT were stigma, lack of support services, no flexibility and enjoy using opioids. Furthermore, those who used prescription opioids (compared with heroin) were female or non-binary (compared with male), were not currently using OAT (compared with current OAT), were younger (compared with older) and had high dependence scores (compared with low dependence scores) were impacted more by certain OAT barriers. CONCLUSIONS Policies around improving support services, reducing stigma and increasing flexibility would be beneficial to reduce barriers to OAT in Australia. Second, certain groups were more vulnerable to OAT barriers, emphasising the importance to better tailor opioid treatment programs to these specific populations to increase treatment engagement.
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Affiliation(s)
- Natasha Yvonne Hall
- School of Health and Social Development, Deakin University, Burwood, Vic., Australia
| | - Long Le
- Public Health and Preventative Medicine, Monash University, Melbourne, Vic., Australia
| | - Julie Abimanyi-Ochom
- School of Health and Social Development, Deakin University, Burwood, Vic., Australia
| | - Maree Teesson
- Faculty of Medicine and Health, The University of Sydney, Camperdown, NSW, Australia
| | - Cathy Mihalopoulos
- Public Health and Preventative Medicine, Monash University, Melbourne, Vic., Australia
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Mahone A, Enich M, Treitler P, Lloyd J, Crystal S. Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers. Am J Drug Alcohol Abuse 2023; 49:606-617. [PMID: 37506336 PMCID: PMC10826857 DOI: 10.1080/00952990.2023.2234075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023]
Abstract
Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.
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Affiliation(s)
- Anais Mahone
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901
- School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St. New Brunswick, NJ 08901
| | - Michael Enich
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901
- School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St. New Brunswick, NJ 08901
| | - Peter Treitler
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901
- School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St. New Brunswick, NJ 08901
| | - James Lloyd
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901
| | - Stephen Crystal
- Center for Health Services Research, Institute for Health, Health Care Policy and Aging Research, Rutgers, the State University of New Jersey, 112 Paterson St. 3rd Floor, New Brunswick, NJ 08901
- School of Social Work, Rutgers, the State University of New Jersey, 120 Albany St. New Brunswick, NJ 08901
- School of Public Health, Rutgers, the State University of New Jersey, 683 Hoes Lane West. Piscataway, NJ 08854
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Austin EJ, Chen J, Briggs ES, Ferro L, Barry P, Heald A, Merrill JO, Curran GM, Saxon AJ, Fortney JC, Ratzliff AD, Williams EC. Integrating Opioid Use Disorder Treatment Into Primary Care Settings. JAMA Netw Open 2023; 6:e2328627. [PMID: 37566414 PMCID: PMC10422185 DOI: 10.1001/jamanetworkopen.2023.28627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.
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Affiliation(s)
- Elizabeth J. Austin
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Elsa S. Briggs
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Paul Barry
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Joseph O. Merrill
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Geoffrey M. Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock
- Central Arkansas Veterans Health Care System
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - Anna D. Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Emily C. Williams
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound, Seattle, Washington
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Stringfellow EJ, Lim TY, DiGennaro C, Zhang Z, Paramasivam P, Bearnot B, Humphreys K, Jalali MS. Long-Term Effects of Increasing Buprenorphine Treatment Seeking, Duration, and Capacity on Opioid Overdose Fatalities: A Model-based Analysis. J Addict Med 2023; 17:439-446. [PMID: 37579104 PMCID: PMC10460819 DOI: 10.1097/adm.0000000000001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
OBJECTIVES Because buprenorphine treatment of opioid use disorder reduces opioid overdose deaths (OODs), expanding access to care is an important policy and clinical care goal. Policymakers must choose within capacity limitations whether to expand the number of people with opioid use disorder who are treated or extend duration for existing patients. This inherent tradeoff could be made less acute with expanded buprenorphine treatment capacity. METHODS To inform such decisions, we used a validated simulation model to project the effects of increasing buprenorphine treatment-seeking, average episode duration, and capacity (patients per provider) on OODs in the United States from 2023 to 2033, varying the start time to assess the effects of implementation delays. RESULTS Results show that increasing treatment duration alone could cost lives in the short term by reducing capacity for new admissions yet save more lives in the long term than accomplished by only increasing treatment seeking. Increasing provider capacity had negligible effects. The most effective 2-policy combination was increasing capacity and duration simultaneously, which would reduce OODs up to 18.6% over a decade. By 2033, the greatest reduction in OODs (≥20%) was achieved when capacity was doubled and average duration reached 2 years, but only if the policy changes started in 2023. Delaying even a year diminishes the benefits. Treatment-seeking increases were equally beneficial whether they began in 2023 or 2025 but of only marginal benefit beyond what capacity and duration achieved. CONCLUSIONS If policymakers only target 2 policies to reduce OODs, they should be to increase capacity and duration, enacted quickly and aggressively.
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Affiliation(s)
| | - Tse Yang Lim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
- Harvard T.H. Chan School of Public Health, Boston, MA
| | - Catherine DiGennaro
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
| | - Ziyuan Zhang
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | | | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA
| | - Mohammad S. Jalali
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA
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Griffin BA, Cabreros I, Saloner B, Gordon AJ, Kerber R, Stein BD. Exploring the Association of State Policies and the Trajectories of Buprenorphine Prescriber Patient Caseloads. Subst Abus 2023; 44:136-145. [PMID: 37401501 PMCID: PMC10680051 DOI: 10.1177/08897077231179824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Increasing buprenorphine access is critical to facilitating effective opioid use disorder treatment. Buprenorphine prescriber numbers have increased substantially, but most clinicians who start prescribing buprenorphine stop within a year, and most active prescribers treat very few individuals. Little research has examined state policies' association with the evolution of buprenorphine prescribing clinicians' patient caseloads. METHODS Our retrospective cohort study design derived from 2006 to 2018 national pharmacy claims identifying buprenorphine prescribers and the number of patients treated monthly. We defined persistent prescribers based on results from a k-clustering approach and were characterized by clinicians who did not quickly stop prescribing and had average monthly caseloads greater than 5 patients for much of the first 6 years after their first dispensed prescription. We examined the association between persistent prescribers (dependent variable) and Medicaid coverage of buprenorphine, prior authorization requirements, and mandated counseling policies (key predictors) that were active within the first 2 years after a prescriber's first observed dispensed buprenorphine prescription. We used multivariable logistic regression analyses and entropy balancing weights to ensure better comparability of prescribers in states that did and did not implement policies. RESULTS Medicaid coverage of buprenorphine was associated with a smaller percentage of new prescribers becoming persistent prescribers (OR = 0.72; 95% CI = 0.53, 0.97). There was no evidence that either mandatory counseling or prior authorization was associated with the odds of a clinician being a persistent prescriber with estimated ORs equal to 0.85 (95% CI = 0.63, 1.16) and 1.13 (95% CI = 0.83, 1.55), respectively. CONCLUSIONS Compared to states without coverage, states with Medicaid coverage for buprenorphine had a smaller percentage of new prescribers become persistent prescribers; there was no evidence that the other state policies were associated with changes in the rate of clinicians becoming persistent prescribers. Because buprenorphine treatment is highly concentrated among a small group of clinicians, it is imperative to increase the pool of clinicians providing care to larger numbers of patients for longer periods. Greater efforts are needed to identify and support factors associated with successful persistent prescribing.
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Affiliation(s)
| | | | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J. Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
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Incze MA, Sehgal SL, Hansen A, Garcia L, Stolebarger L. Evaluation of a Primary Care-Based Multidisciplinary Transition Clinic for Patients Newly Initiated on Buprenorphine in the Emergency Department. Subst Abus 2023; 44:220-225. [PMID: 37675904 DOI: 10.1177/08897077231188592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
BACKGROUND Care transitions represent vulnerable events for patients newly initiating medications for opioid use disorder (MOUD). Multidisciplinary primary care-based transition clinics may improve care linkage and retention in MOUD treatment. Additionally, these interventions may help primary care clinicians (PCPs) overcome barriers to adopting MOUD into practice. In this evaluation, we assessed the impact of a primary care-based transition clinic for patients newly initiating buprenorphine for opioid use disorder (OUD) in the emergency department. METHODS We conducted a retrospective program evaluation within a single academic health system involving adults who newly initiated buprenorphine for OUD through an emergency department-based program and were referred to follow up in either a dedicated multidisciplinary primary care-based transition clinic (SPARC) vs referral to usual primary care (UPC). We performed descriptive analyses comparing patient demographics, referral volume, linkage to care, treatment retention, and markers of high-quality care between the 2 groups. A log-rank test was used to determine the difference in probabilities of retention between SPARC and UPC over 6 months. RESULTS Over 12 months, the number of referrals to SPARC was greater than to UPC (N = 64 vs N = 26). About 58% of patients referred to SPARC attended an initial visit vs 38% referred to UPC. Treatment retention was consistently greater in SPARC than UPC (1 m: 90% vs 60%; 3 m: 76% vs 40%; 6 m: 60% vs 30%). Markers of care quality including naloxone provision (100% vs 80%) and infectious screening (81% vs 40%) were greater in SPARC clinic. SPARC was associated with a statistically significant increased probability of retention in treatment as compared to UPC (P < .01). CONCLUSIONS In this observational evaluation, a primary care-based multidisciplinary transition clinic for patients initiating buprenorphine MOUD was associated with expanded access to longitudinal OUD treatment and superior linkage to care, retention in care, and quality of care compared to referral to usual primary care. Further research using a more rigorous research design is required to further evaluate these findings.
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Affiliation(s)
- Michael A Incze
- Division of General Internal Medicine, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Sonia L Sehgal
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Annika Hansen
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Luke Garcia
- Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Laura Stolebarger
- Program for Addiction Research, Clinical Care, Knowledge, and Advocacy (PARCKA), University of Utah School of Medicine, Salt Lake City, UT, USA
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12
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Claypool AL, DiGennaro C, Russell WA, Yildirim MF, Zhang AF, Reid Z, Stringfellow EJ, Bearnot B, Schackman BR, Humphreys K, Jalali MS. Cost-effectiveness of Increasing Buprenorphine Treatment Initiation, Duration, and Capacity Among Individuals Who Use Opioids. JAMA Health Forum 2023; 4:e231080. [PMID: 37204803 PMCID: PMC10199347 DOI: 10.1001/jamahealthforum.2023.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 03/26/2023] [Indexed: 05/20/2023] Open
Abstract
Importance Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity. Objective To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity. Design and Setting This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US. Interventions Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination. Main Outcomes and Measures Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective. Results Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously. Conclusion and Relevance This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.
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Affiliation(s)
- Anneke L. Claypool
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Catherine DiGennaro
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - W. Alton Russell
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- School of Population and Global Health, McGill University, Montreal, Quebec, Canada
| | - Melike F. Yildirim
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Alan F. Zhang
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Zuri Reid
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Erin J. Stringfellow
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, California
| | - Mohammad S. Jalali
- Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
- MIT Sloan School of Management, Cambridge, Massachusetts
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13
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Andraka-Christou B, Simon KI, Bradford WD, Nguyen T. Buprenorphine Treatment For Opioid Use Disorder: Comparison Of Insurance Restrictions, 2017-21. Health Aff (Millwood) 2023; 42:658-664. [PMID: 37126752 PMCID: PMC10275692 DOI: 10.1377/hlthaff.2022.01513] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
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.
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Affiliation(s)
| | - Kosali I Simon
- Kosali I. Simon, Indiana University, Bloomington, Indiana
| | | | - Thuy Nguyen
- Thuy Nguyen, University of Michigan, Ann Arbor, Michigan
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Molfenter T, Kim H, Kim JS, Kisicki A, Knudsen HK, Horst J, Brown R, Madden LM, Toy A, Haram E, Jacobson N. Enhancing Use of Medications for Opioid Use Disorder Through External Coaching. Psychiatr Serv 2023; 74:265-271. [PMID: 36196533 PMCID: PMC10836327 DOI: 10.1176/appi.ps.202100675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This randomized controlled trial tested whether external coaching influences addiction treatment providers' utilization of medications to treat opioid use disorder (MOUDs). METHODS This study recruited 75 unique clinical sites in Florida, Ohio, and Wisconsin, including 61 sites in specialty treatment agencies and 14 behavioral health sites within health systems. The trial used external coaching to increase use of MOUDs in the context of a learning collaborative and compared it with no coaching and no learning collaborative (control condition). Outcome measures of MOUD capacity and utilization were monthly tabulations of licensed buprenorphine slots (i.e., the number of patients who could be treated based on the buprenorphine waiver limits of the site's providers), buprenorphine use, and injectable naltrexone administration. RESULTS The coaching and control arms showed no significant difference at baseline. Although buprenorphine slots increased in both arms during the 30-month trial, growth increased twice as fast at the coaching sites, compared with the control sites (average monthly rate of 6.1% vs. 3.0%, respectively, p<0.001). Buprenorphine use showed a similar pattern; the monthly growth rate in the coaching arm was more than twice the rate in the control arm (5.3% vs. 2.4%, p<0.001). Coaching did not have an impact on injectable naltrexone, which grew less than 1% in both arms over the trial period. CONCLUSIONS External coaching can increase organizational capacity for and growth of buprenorphine use. Future research should explore the dimensions of coaching practice, dose, and delivery modality to better understand and enhance the coaching function.
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Affiliation(s)
- Todd Molfenter
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Hanna Kim
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Jee-Seon Kim
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Abby Kisicki
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Hannah K Knudsen
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Julie Horst
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Randy Brown
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Lynn M Madden
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Alex Toy
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Eric Haram
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
| | - Nora Jacobson
- (Molfenter, Kisicki, Horst, Toy), Department of Educational Psychology (H. Kim, J.-S. Kim), Department of Family Medicine and Community Health (Brown), Institute for Clinical and Translational Research and School of Nursing (Jacobson), University of Wisconsin-Madison, Madison; Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, Lexington (Knudsen); APT Foundation and Department of Internal Medicine, Yale University, New Haven, Connecticut (Madden); Haram Consulting, Bowdoinham, Maine (Haram)
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Luderer H, Enman N, Gerwien R, Braun S, McStocker S, Xiong X, Koebele C, Cannon C, Glass J, Maricich Y. A Prescription Digital Therapeutic to Support Unsupervised Buprenorphine Initiation for Patients With Opioid Use Disorder: Protocol for a Proof-of-Concept Study. JMIR Res Protoc 2023; 12:e43122. [PMID: 36662568 PMCID: PMC9898828 DOI: 10.2196/43122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Home-based (unsupervised) buprenorphine initiation is considered safe and effective, yet many patients report barriers to successful treatment initiation. Prescription digital therapeutics (PDTs) are software-based disease treatments regulated by the US Food and Drug Administration (FDA). The reSET-O PDT was authorized by the FDA in 2018 and delivers behavioral treatment for individuals receiving buprenorphine for opioid use disorder (OUD). A prototype PDT (PEAR-002b) designed for use with reSET-O was developed to assist in unsupervised buprenorphine initiation. OBJECTIVE The primary objective of this pilot study is to evaluate the acceptability of PEAR-002b in individuals with OUD who use it to support buprenorphine initiation, their unsupervised buprenorphine initiation success rate, and their medication adherence. METHODS Ten adults with OUD will be recruited for acceptability and feasibility testing. Outcomes will be assessed using week-1 visit attendance, participant interviews and satisfaction surveys, and urine drug screening (UDS). Three tools will be used in the study: PEAR-002b, reSET-O, and EmbracePlus. PEAR-002b includes a new set of features designed for use with reSET-O. The mechanism of action for the combined PEAR-002b and reSET-O treatment is a program of medication dosing support during week 1 of the initiation phase, cognitive behavioral therapy, and contingency management. During the medication initiation phase, participants are guided through a process to support proper medication use. PEAR-002b advises them when to take their buprenorphine based on provider inputs (eg, starting dose), self-reported substance use, and self-reported withdrawal symptoms. This study also administers the EmbracePlus device, a medical-grade smartwatch, to pilot methods for collecting physiologic data (eg, heart rate and skin conductance) and evaluate the device's potential for use along with PDTs that are designed to improve OUD treatment initiation. Home buprenorphine initiation success will be summarized as the proportion of participants attending the post-buprenorphine initiation visit (week 1) and the proportion of participants who experience buprenorphine initiation-related adverse events (eg, precipitated withdrawal). Acceptability of PEAR-002b will be evaluated based on individual participants' ratings of ease of use, satisfaction, perceived helpfulness, and likelihood of recommending PEAR-002b. Medication adherence will be evaluated by participant self-report data and confirmed by UDS. UDS data will be summarized as the mean of individual participants' proportion of total urine samples testing positive for buprenorphine or norbuprenorphine over the 4-week study. RESULTS This project was funded in September 2019. As of September 2022, participant enrollment is ongoing. CONCLUSIONS This is the first study to our knowledge to develop a PDT that assists with unsupervised buprenorphine initiation with the intent to better support patients and prescribers during this early phase of treatment. This pilot study will assess the acceptability and utility of a digital therapeutic to assist individuals with OUD with unsupervised buprenorphine initiation. TRIAL REGISTRATION ClinicalTrials.gov NCT05412966; https://clinicaltrials.gov/ct2/show/NCT05412966. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/43122.
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Affiliation(s)
| | - Nicole Enman
- Pear Therapeutics (US), Inc, Boston, MA, United States
| | | | - Stephen Braun
- Pear Therapeutics (US), Inc, Boston, MA, United States
| | | | - Xiaorui Xiong
- Pear Therapeutics (US), Inc, Boston, MA, United States
| | | | | | - Joseph Glass
- Kaiser Permanente Washington Health Research Institute, Seattle, WA, United States
| | - Yuri Maricich
- Pear Therapeutics (US), Inc, Boston, MA, United States
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Andraka-Christou B, Page C, Schoebel V, Buche J, Haffajee RL. Perceptions of buprenorphine barriers and efficacy among nurse practitioners and physician assistants. Addict Sci Clin Pract 2022; 17:43. [PMID: 35945636 PMCID: PMC9364483 DOI: 10.1186/s13722-022-00321-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 07/11/2022] [Indexed: 11/25/2022] Open
Abstract
Background Medications for opioid use disorder (MOUDs), including methadone, buprenorphine, and naltrexone, decrease mortality and morbidity for people with opioid use disorder (OUD). Buprenorphine and methadone have the strongest evidence base among MOUDs. Unlike methadone, buprenorphine may be prescribed in office-based settings in the U.S., including by nurse practitioners (NPs) and physician assistants (PAs) who have a federal waiver and adhere to federal patient limits. Buprenorphine is underutilized nationally, particularly in rural areas, and NPs/PAs could help address this gap. Therefore, we sought to identify perceptions of buprenorphine efficacy and perceptions of prescribing barriers among NPs/PAs. We also sought to compare perceived buprenorphine efficacy and perceived prescribing barriers between waivered and non-waivered NPs/PAs, as well as to compare perceived buprenorphine efficacy to perceived naltrexone and methadone efficacy. Methods We disseminated an online survey to a random national sample of NPs/PAs. We used Mann–Whitney U tests to compare between waivered and non-waivered respondents. We used non-parametric Friedman tests and post-hoc Wilcoxon signed-rank tests to compare perceptions of medication types. Results 240 respondents participated (6.5% response rate). Most respondents agreed buprenorphine is efficacious and believed counseling and peer support should complement buprenorphine. Buprenorphine was generally perceived as more efficacious than both naltrexone and methadone. Perceived buprenorphine efficacy and prescribing barriers differed by waiver status. Non-waivered practitioners were more likely than waivered practitioners to have concerns about buprenorphine affecting patient mix. Among waivered NPs/PAs, key buprenorphine prescribing barriers were insurance prior authorization and detoxification access. Conclusions Our results suggest that different policies should target perceived barriers affecting waivered versus non-waivered NPs/PAs. Concerns about patient mix suggest stigmatization of patients with OUD. NP/PA education is needed about comparative medication efficaciousness, particularly regarding methadone. Even though many buprenorphine treatment patients benefits from counseling and/or peer support groups, NPs/PAs should be informed that such psychosocial treatment methods are not necessary for all buprenorphine patients.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management and Informatics, University of Central Florida, 500 W Livingston Ave, Suite 400, FL, Orlando, USA. .,Department of Internal Medicine, University of Central Florida, 6850 Lake Nona Blvd, Orlando, FL, 32827, USA.
| | - Cory Page
- Behavioral and Physical Health and Aging Services Administration, Department of Health and Human Services, Lansing, MI, USA
| | - Victoria Schoebel
- School of Public Health, University of Minnesota, Minneapolis, MI, USA
| | - Jessica Buche
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca L Haffajee
- Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington D.C., USA.,Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA
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Andraka-Christou B, Saloner B, Gordon AJ, Totaram R, Randall-Kosich O, Golan M, Stein BD. Laws for expanding access to medications for opioid use disorder: a legal analysis of 16 states & Washington D.C. Am J Drug Alcohol Abuse 2022; 48:492-503. [PMID: 35772010 DOI: 10.1080/00952990.2022.2082301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/14/2022] [Accepted: 05/23/2022] [Indexed: 05/18/2023]
Abstract
Background: Medications for opioid use disorder (MOUDs) are the gold standard for OUD treatment but are underused. To our knowledge, no published study has systematically identified and categorized state policy innovations for expanding MOUD utilization.Objective: We sought to identify and categorize state MOUD policy innovations.Methods: Within a stratified random sample of 16 U.S. states and Washington D.C. we searched for 2019 state statutes and regulations related to MOUD in Westlaw legal database. We then identified laws that appeared designed to increase MOUD utilization and categorized them using a template analysis approach.Results: We found 82 laws with one or more MOUD expansion policies. We identified six high-level MOUD expansion policy categories: 1) policies expanding the availability of waivered buprenorphine providers; 2) needs assessments and policies increasing public MOUD awareness; 3) criminal justice system policies; 4) Substance use disorder (SUD) treatment and sober living facility policies; 5) insurance policies; and 6) hospital policies. SUD treatment and housing facility policies, as well as insurance policies, were most common.Conclusions: Multipronged approaches are being pursued by several states to increase MOUD access. Our results can inform policymakers of MOUD expansion approaches in other jurisdictions. Policy categories can serve as the basis for policy variables for future analyses of policy effects.
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Affiliation(s)
- Barbara Andraka-Christou
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL, USA
| | - Brendan Saloner
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Adam J Gordon
- and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care SystemInformatics, Decision-Enhancement, Salt Lake City, UT, USA
- Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Rachel Totaram
- School of Global Health Management & Informatics, University of Central Florida, Orlando, FL, USA
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Lanham HJ, Papac J, Olmos DI, Heydemann EL, Simonetti N, Schmidt S, Potter JS. Survey of Barriers and Facilitators to Prescribing Buprenorphine and Clinician Perceptions on the Drug Addiction Treatment Act of 2000 Waiver. JAMA Netw Open 2022; 5:e2212419. [PMID: 35552721 PMCID: PMC9099423 DOI: 10.1001/jamanetworkopen.2022.12419] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Holly J. Lanham
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
| | - Jennifer Papac
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
| | - Daniela I. Olmos
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
| | - Emily L. Heydemann
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
| | - Nathalia Simonetti
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
| | - Susanne Schmidt
- Department of Population Health Sciences, University of Texas Health Science Center San Antonio
| | - Jennifer S. Potter
- Department of Psychiatry and Behavioral Sciences, University of Texas Health Science Center San Antonio
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Oles W, Alexander M, Kumar N, Howell B, O’Connor PG, Madden LM, Barry DT. Characterizing the social support and functioning of a low-threshold medication for opioid use disorder treatment cohort at intake. BMC Psychiatry 2022; 22:236. [PMID: 35366844 PMCID: PMC8976510 DOI: 10.1186/s12888-022-03884-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 03/14/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite the growing morbidity and mortality rates associated with opioid use disorder, a large gap still exists between treatment need and capacity. Low-threshold clinics utilizing medication for opioid use disorder (MOUD) treatment can increase treatment access but are understudied, and little is known about how patient demographic characteristics are associated with their social support and functioning in these settings. METHODS We used multivariate regression to estimate associations between demographic characteristics and self-reported social support or functioning indicators among patients receiving MOUD in a low-threshold clinic using several validated instruments administered at intake: Behavior and Symptom Identification Scale, Brief Pain Inventory, and Life Events Checklist for DSM-5. Patients initiating MOUD treatment between April 1 and December 31, 2017, with complete surveys were included (N=582). RESULTS Patients were primarily male (62%), aged 34 or older (53%), non-Hispanic White (79%), separated or not married (86%), and unemployed (64%). Over 20% did not live in a house or apartment in the past month. Women were more likely to "get along" with people outside their family or in social situations and to identify their partner as their source of support. Women, non-White, and older patients were at higher risk of social functioning-disrupting events (physical/sexual assaults or experiencing chronic pain), while employment and housing were protective against exposure to these trauma-related events. However, employment and housing also decreased the odds of talking with others about substance use. The aforementioned results were obtained from multivariate logistic regression models and were significant to p<0.05. CONCLUSIONS Variation in support and functioning by demographic characteristics suggests that treatment facilities may benefit from adopting strategies that take baseline disparities in support and functioning into account.
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Affiliation(s)
- William Oles
- grid.47100.320000000419368710Human Nature Lab, Yale Institute for Network Science, Yale University, New Haven, CT USA
| | - Marcus Alexander
- Human Nature Lab, Yale Institute for Network Science, Yale University, New Haven, CT, USA.
| | - Navin Kumar
- grid.47100.320000000419368710Human Nature Lab, Yale Institute for Network Science, Yale University, New Haven, CT USA ,grid.47100.320000000419368710Department of Sociology, Yale University, New Haven, CT USA
| | - Benjamin Howell
- grid.47100.320000000419368710Section of General Internal Medicine, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT USA ,grid.281208.10000 0004 0419 3073VA Connecticut Healthcare System, New Haven, CT USA
| | - Patrick G. O’Connor
- grid.47100.320000000419368710Section of Internal Medicine, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT USA
| | - Lynn M. Madden
- grid.47100.320000000419368710Section of Internal Medicine, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT USA ,grid.422797.d0000 0004 0558 5300APT Foundation, New Haven, CT USA
| | - Declan T. Barry
- grid.422797.d0000 0004 0558 5300APT Foundation, New Haven, CT USA ,grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, New Haven, CT USA
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20
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Knudsen HK, Hartman J, Walsh SL. The effect of Medicaid expansion on state-level utilization of buprenorphine for opioid use disorder in the United States. Drug Alcohol Depend 2022; 232:109336. [PMID: 35123365 PMCID: PMC8885876 DOI: 10.1016/j.drugalcdep.2022.109336] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Research on the impact of Medicaid expansion on buprenorphine utilization has largely focused on the Medicaid program. Less is known about its associations with total buprenorphine utilization and non-Medicaid payers. METHODS Monthly prescription data (June 2013-May 2018) for proprietary and generic sublingual as well as buccal buprenorphine products were purchased from IQVIA®. Population-adjusted state-level utilization measures were constructed for Medicaid, commercial insurance, Medicare, cash, and total utilization. A difference-in-differences (DID) approach with population weights estimated the association between Medicaid expansion and buprenorphine utilization, while controlling for treatment capacity. RESULTS Monthly total buprenorphine prescriptions increased by 68% overall and increased 283% for Medicaid, 30% for commercial insurance, and 143% for Medicare. Cash prescriptions decreased by 10%. The DID estimate for Medicaid expansion was not statistically significant for total utilization (-19.780, 95% CI = -45.118, 5.558, p = .123). For Medicaid buprenorphine utilization, there was a significant increase of 27.120 prescriptions per 100,000 total state residents (95% CI = 9.458, 44.782, p = .003) in expansion states versus non-expansion states post-Medicaid expansion. Medicaid expansion had a negative effect on commercial insurance (DID estimate = -37.745, 95% CI = -62.946, -12.544, p = .004), cash utilization (DID estimate = -6.675, 95% CI = -12.627, -0.723, p = .029), and Medicare utilization (DID estimate = -1.855, 95% CI = -3.697, -0.013, p = .048). DISCUSSION The associations between Medicaid expansion and buprenorphine utilization varied across different types of payers, such that the overall impact of Medicaid expansion on buprenorphine utilization was not significant.
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Affiliation(s)
- Hannah K. Knudsen
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY 40508, USA.,Corresponding author: Hannah K. Knudsen, PhD, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY 40508. Telephone: (859) 323-3947; fax: (859) 257-5232;
| | - Jeanie Hartman
- Substance Use Research Priority Area, University of Kentucky, 845 Angliana Avenue, Room 121, Lexington, KY 40508, USA.
| | - Sharon L. Walsh
- Department of Behavioral Science and Center on Drug and Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 202, Lexington, KY 40508, USA
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21
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Baylis JD, Charron E, Archer S, Garets M, Bryan MA, Foringer J, Kelley AT, Smid MC, Cochran G. Attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation: A comparison of health care professionals in rural communities. Subst Abus 2022; 43:1163-1171. [PMID: 35617634 DOI: 10.1080/08897077.2022.2074593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background: Health care professionals (HCPs) play an important role in opioid misuse and opioid use disorder (OUD) screening/identification, mitigation, and referral to treatment. This study compared attitudes, self-efficacy, and practices related to opioid risk assessment and mitigation among pregnancy and non-pregnancy HCPs in rural communities. Methods: We conducted a secondary analysis of cross-sectional, self-report survey data of HCPs in two rural counties in southern Utah. Pregnancy HCPs were identified by a question asking whether they provide care to pregnant patients. HCPs' attitudes toward their patients with opioid misuse/OUD were measured using the Survey of Attitudes and Perceptions questionnaire. Self-efficacy and practices related to opioid risk assessment and mitigation were captured with questions asking about assessment and screening of opioid use, advisement to change opioid use behavior, and referral to treatment for OUD. We used linear regression analyses to estimate associations between HCPs' attitudes toward patients with opioid misuse/OUD and their self-efficacy and use of opioid risk assessment and mitigation practices. Results: This sample included a total of 132 HCPs, including 82 pregnancy HCPs and 50 non-pregnancy HCPs. Attitudes domains were similar among pregnancy and non-pregnancy HCPs. Among pregnancy HCPs, role adequacy (β = .48, 95% CI = .16-.80), role legitimacy (β = .72, 95% CI = .21-1.22), motivation (β = .68, 95% CI = .14-1.21), and positive task-specific self-esteem (β = 1.52, 95% CI = .70-2.35) were positively associated with more frequent use of opioid risk assessment and mitigation practices, while attitudes were not associated with these practices among non-pregnancy HCPs. Conclusions: Training initiatives that lead to improved HCP attitudes could improve opioid care management among rural pregnancy HCPs. More research is needed to determine approaches to increase the use of opioid risk assessment and mitigation practices among rural non-pregnancy HCPs.
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Affiliation(s)
- Jacob D Baylis
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Elizabeth Charron
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shayla Archer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mitchell Garets
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - M Aryana Bryan
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jacob Foringer
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - A Taylor Kelley
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Marcela C Smid
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Gerald Cochran
- Clinical Care, Knowledge, and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Greater Intermountain Node (GIN), NIH NIDA Clinical Trials Network, University of Utah, Salt Lake City, UT, USA
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22
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Abstract
Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder.
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Affiliation(s)
- Lisa M Blair
- University of Kentucky College of Nursing, Lexington (Drs Blair, Ashford, and Fallin-Bennett and Mss Gentry and Bell); and Perinatal Research and Wellness Center, University of Kentucky College of Nursing, Lexington (Drs Blair, Ashford, and Fallin-Bennett). Ms Gentry is now with Baptist Hospital of Louisville, Kentucky
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Stahler GJ, Mennis J, Baron DA. Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US. Drug Alcohol Depend 2021; 226:108849. [PMID: 34198132 DOI: 10.1016/j.drugalcdep.2021.108849] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/05/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion. METHODS Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors. RESULTS After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776). CONCLUSIONS Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.
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Schuler MS, Dick AW, Stein BD. Growing racial/ethnic disparities in buprenorphine distribution in the United States, 2007-2017. Drug Alcohol Depend 2021; 223:108710. [PMID: 33873027 PMCID: PMC8204632 DOI: 10.1016/j.drugalcdep.2021.108710] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 03/05/2021] [Accepted: 03/11/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess whether per capita buprenorphine distribution varies by regional racial/ethnic composition, Medicaid expansion status, and time period. METHODS Our unit of analysis -- three-digit ZIP codes ("ZIP3s") -- was classified into quintiles based on percentage of White residents. A weighted linear regression model of buprenorphine distribution -- including White resident quintile, waivered prescriber rate, overdose rate, sociodemographic factors, and year fixed effects -- was estimated using national buprenorphine distribution data from 2007 to 2017. We report predictive margins of the buprenorphine distribution rate by quintile, as well as average marginal effects of waivered prescriber rate on buprenorphine distribution rate for each quintile. Analyses were stratified by Medicaid expansion status and time period (2007-2010, 2011-2014, 2015-2017). RESULTS Buprenorphine distribution increased nationally during 2007-2017, yet growth was disproportionately greater for ZIP3s with higher percentages of White residents. Medicaid expansion states exhibited significant differences in buprenorphine distribution across ZIP3 quintiles during 2007-2010, the magnitude of which increased across time periods. Non-expansion states exhibited significant quintile differences during 2011-2014 and 2015-2017. The average marginal effect of increasing the waivered prescriber rate on the distribution rate was consistently smaller in ZIP3s with lower percentages of White residents, particularly in expansion states. CONCLUSIONS We find ecological evidence consistent with racial/ethnic disparities in buprenorphine distribution. Our finding that increasing the waivered prescriber rate had differential effects by ZIP3 racial/ethnic composition suggest that broad initiatives to increase the number of waivered prescribers are likely insufficient to achieve equitable buprenorphine access. Rather, targeted and tailored policy efforts are warranted.
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25
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Affiliation(s)
| | - Steven Shoptaw
- Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - David Goodman-Meza
- Department of Medicine and Department of Family Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Hiromi Ono
- Independent Scholar, Washington D.C., USA
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