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Winiker AK, Schneider KE, Hamilton White R, O'Rourke A, Grieb SM, Allen ST. A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia. Harm Reduct J 2023; 20:69. [PMID: 37264367 PMCID: PMC10233537 DOI: 10.1186/s12954-023-00795-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/11/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia. METHODS From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data. RESULTS Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff. CONCLUSIONS Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.
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Affiliation(s)
- Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA.
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Rebecca Hamilton White
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
| | - Allison O'Rourke
- DC Center for AIDS Research, Department of Psychological and Brain Sciences, George Washington University, 2125 G St. NW, Washington, DC, 20052, USA
| | - Suzanne M Grieb
- Center for Child and Community Health Research, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, 21224, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway St., Baltimore, MD, 21205, USA
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Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in 11 U.S. states. Drug Alcohol Depend 2022; 237:109518. [PMID: 35691255 DOI: 10.1016/j.drugalcdep.2022.109518] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prompt access to prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) is vital for patients with opioid use disorder (OUD), but multiple studies have documented pharmacy-level barriers. METHODS A cross-sectional secret shopper telephone audit was conducted in a sample of 5734 actively licensed pharmacies in 11 U.S. states from May 2020-April 2021. Primary outcomes included availability of 14 generic BUP/NX 8/2 mg and one unit of NNS 4 mg. Outcomes were compared by pharmacy type, county metropolitan status, state Medicaid expansion status, and state drug overdose death rate. RESULTS Data from 4984 pharmacies (3402 chain and 1582 independent) were analyzed. Both medications were available in 41.2 % of pharmacies, BUP/NX was available in 48.3%, and NNS was available in 69.5%. Chain pharmacies were significantly more likely than independent pharmacies to have both medications available, to have each medication available individually, and to be willing to order BUP/NX. Pharmacies in metropolitan counties were more likely to have BUP/NX available than pharmacies in non-metropolitan counties, pharmacies in Medicaid expansion states were more likely to have both medications available and to have NNS available than pharmacies in non-expansion states, and pharmacies in states with high drug overdose death rates were more likely to have NNS available than pharmacies in states with low drug overdose death rates. CONCLUSIONS BUP/NX and NNS are not readily accessible in many U.S. pharmacies. Deficits in access are most pronounced in independent pharmacies, though county- and state-level factors may also influence availability of these essential medications.
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Davis CS, Lieberman AJ. Laws limiting prescribing and dispensing of opioids in the United States, 1989-2019. Addiction 2021; 116:1817-1827. [PMID: 33245795 DOI: 10.1111/add.15359] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/23/2020] [Accepted: 11/24/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Opioid overdose is a public health emergency in the United States. In an attempt to reduce potentially inappropriate opioid prescribing, many US states have adopted legal restrictions on the ability of medical professionals to prescribe or dispense opioids for pain. This review describes the major elements of relevant US state laws and the ways in which they have changed over time. METHODS Systematic legal review in which two trained legal researchers collected and reviewed all US state laws that limit the amount or duration of opioids that medical professionals may prescribe or dispense for pain. These laws were then coded on a set of pre-selected measures, including when the law was enacted, dosage and duration limits imposed, circumstances in which the restrictions do not apply and whether additional requirements or restrictions apply to prescriptions issued to minors. RESULTS The number of US states with opioid limitation laws increased from 10 in 2016 to 39 by the end of 2019. The provisions of these laws vary between states and have shifted within states over time. At the end of 2019 the modal duration limit was 7 days, with a range of 3 to 31. Fourteen states imposed limits on the dosage of opioids that can be prescribed, ranging from 30 morphine milligram equivalents (MME) to a 120 MME daily maximum. In 16 states, different limits apply to prescriptions issued to minors. CONCLUSIONS The number of US states with opioid limitation laws nearly quadrupled between 2016 and 2019, with a great amount of heterogeneity between state restrictions and changes over time.
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Davis CS, Carr DH, Glenn MJ, Samuels EA. Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Ann Emerg Med 2021; 78:102-108. [PMID: 33781607 DOI: 10.1016/j.annemergmed.2021.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/29/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
Treatment with buprenorphine significantly reduces both all-cause and overdose mortality among individuals with opioid use disorder. Offering buprenorphine treatment to individuals who experience a nonfatal opioid overdose represents an opportunity to reduce opioid overdose fatalities. Although some emergency departments (EDs) initiate buprenorphine treatment, many individuals who experience an overdose either refuse transport to the ED or are transported to an ED that does not offer buprenorphine. Emergency medical services (EMS) professionals can help address this treatment gap. In this Concepts article, we describe the federal legal landscape that governs the ability of EMS professionals to administer buprenorphine treatment, and discuss state and local regulatory considerations relevant to this promising and emerging practice.
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Affiliation(s)
- Corey S Davis
- Harm Reduction Legal Project, Network for Public Health Law, Los Angeles, CA.
| | | | - Melody J Glenn
- Department of Emergency Medicine, University of Arizona, and Banner University Medical Center Tucson, Tucson, AZ
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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Davis CS, Samuels EA. Continuing increased access to buprenorphine in the United States via telemedicine after COVID-19. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 93:102905. [PMID: 32811685 PMCID: PMC7428767 DOI: 10.1016/j.drugpo.2020.102905] [Citation(s) in RCA: 52] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/21/2020] [Accepted: 08/05/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Corey S Davis
- Harm Reduction Legal Project, Network for Public Health Law, 3701 Wilshire Blvd. #750, Los Angeles, CA 90010, USA.
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI, USA; Overdose Prevention Program, Rhode Island Department of Public Health, Providence, RI, USA
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Pashmineh Azar AR, Cruz-Mullane A, Podd JC, Lam WS, Kaleem SH, Lockard LB, Mandel MR, Chung DY, Simoyan OM, Davis CS, Nichols SD, McCall KL, Piper BJ. Rise and regional disparities in buprenorphine utilization in the United States. Pharmacoepidemiol Drug Saf 2020; 29:708-715. [PMID: 32173955 DOI: 10.1002/pds.4984] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 01/09/2020] [Accepted: 02/11/2020] [Indexed: 12/20/2022]
Abstract
PURPOSE Buprenorphine is an opioid partial agonist used to treat opioid use disorder. While several policy changes have attempted to increase buprenorphine availability, access remains well below optimal levels. This study characterized how buprenorphine utilization in the United States has changed over time and whether there are regional disparities in distribution of the medication. METHODS The amount of buprenorphine distributed from 2007 to 2017 was obtained from the Drug Enforcement Administration's Automated Reports and Consolidated Ordering System. Data were expressed as the percent change and milligrams per person in each state. The formulations and cost for prescriptions covered by Medicaid (2008 to 2018) were also examined. RESULTS Buprenorphine distributed to pharmacies increased about 7-fold (476.8 to 3179.9 kg) while the quantities distributed to hospitals grew 5-fold (18.6 to 97.6 kg) nationally from 2007 to 2017. Buprenorphine distribution per person was almost 20-fold higher in Vermont (40.4 mg/person) relative to South Dakota (2.1 mg/person). There was a strong association between the number of physicians authorized to prescribe buprenorphine and distribution per state (r[49] = +0.94, P < .0005). The buprenorphine/naloxone sublingual film (Suboxone) was the predominant formulation (92.6% of 0.31 million Medicaid prescriptions) in 2008 but accounted for less than three-fifth (57.3% of 6.56 million prescriptions) in 2018. CONCLUSIONS Although buprenorphine availability has substantially increased over the last decade, distribution was very nonhomogeneous across the United States.
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Affiliation(s)
- Amir R Pashmineh Azar
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Alexandra Cruz-Mullane
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Jaclyn C Podd
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Warren S Lam
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Suhail H Kaleem
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Laura B Lockard
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Mark R Mandel
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Daniel Y Chung
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Olapeju M Simoyan
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA.,Geisinger Marworth Treatment Center, Waverly, Pennsylvania, USA
| | - Corey S Davis
- Network for Public Health Law, Los Angeles, California, USA
| | - Stephanie D Nichols
- Department of Pharmacy Practice, University of New England, Portland, Maine, USA.,Department of Psychiatry, Tufts University, Medford, Massachusetts, USA
| | - Kenneth L McCall
- Department of Pharmacy Practice, University of New England, Portland, Maine, USA
| | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA.,Center for Pharmacy Innovation and Outcomes, Geisinger Precision Health Center, Forty Fort, Pennsylvania, USA
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Over the counter naloxone needed to save lives in the United States. Prev Med 2020; 130:105932. [PMID: 31770540 DOI: 10.1016/j.ypmed.2019.105932] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 11/12/2019] [Accepted: 11/22/2019] [Indexed: 12/19/2022]
Abstract
The United States continues to face a public health emergency of opioid-related harm, the effects of which could be dramatically reduced through increased access to the opioid antagonist naloxone. Unfortunately, naloxone is too often unavailable when and where it is most needed, partly due to its continued status as a prescription medication. Although states and the federal Food and Drug Administration (FDA) have acted to increase access to naloxone, these changes are insufficient to address this unprecedented crisis. In this Commentary, we argue that FDA can and should immediately reclassify naloxone from prescription-only to over-the-counter status, a change that could save hundreds if not thousands of lives in the United States every year.
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Legal and policy changes urgently needed to increase access to opioid agonist therapy in the United States. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:42-48. [PMID: 31336293 DOI: 10.1016/j.drugpo.2019.07.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/22/2019] [Accepted: 07/02/2019] [Indexed: 11/22/2022]
Abstract
The United States continues to face a public health crisis of opioid-related harm, the effects of which could be dramatically reduced through increased access to opioid agonist therapy with the medications methadone and buprenorphine. Despite overwhelming evidence of their efficacy, unduly restrictive federal, state, and local regulation significantly impedes access to these life-saving medications. We outline immediate, concrete steps that federal, state, and local governments can take to change law from barrier to facilitator of evidence-based treatment for opioid use disorder. These include removing onerous restrictions on the prescription and dispensing of buprenorphine and methadone for opioid agonist therapy, requiring insurance coverage of these medications, and mandating that they be provided in correctional settings and promoted by drug courts. Finally, we argue that jurisdictions should proactively offer opioid agonist therapy to individuals at high risk of overdose, remove barriers to establishing methadone treatment facilities, and address underlying social determinants and barriers to treatment. These changes have the ability to save thousands of lives annually.
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Werle N, Zedillo E. We Can't Go Cold Turkey: Why Suppressing Drug Markets Endangers Society. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2018; 46:325-342. [PMID: 30146979 DOI: 10.1177/1073110518782942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
This essay argues that policies aimed at suppressing drug use exacerbate the nation's opioid problem. It neither endorses drug use nor advocates legalizing the consumption and sale of all substances in all circumstances. Instead, it contends that trying to suppress drug markets is the wrong goal, and in the midst of an addiction crisis it can be deadly. There is no single, correct drug policy; the right approach depends crucially on the substance at issue, the patterns of use and supply, and the jurisdiction's culture, institutions, and material resources. Decriminalization is no panacea for a nation's drug problems. Nevertheless, either de jure or de facto decriminalization of personal drug possession is a necessary condition for mitigating this crisis.
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Affiliation(s)
- Nick Werle
- Nick Werle, J.D., is a graduate of Yale Law School, a research associate in the International Drug Policy Unit at the London School of Economics and Political Science, and a fellow at Yale's Solomon Center for Health Law and Policy. He received an MSc in economic policy from University College London and an MSc in risk and finance from the London School of Economics and Political Science with support from the U.K.'s Marshall Scholarship. Ernesto Zedillo, Ph.D., is the director of the Yale Center for the Study of Globalization, professor in the field of international economics and politics, and a member of the Global Commission on Drug Policy. He received his M.A. and Ph.D. in economics from Yale University. He was the president of Mexico from 1994-2000
| | - Ernesto Zedillo
- Nick Werle, J.D., is a graduate of Yale Law School, a research associate in the International Drug Policy Unit at the London School of Economics and Political Science, and a fellow at Yale's Solomon Center for Health Law and Policy. He received an MSc in economic policy from University College London and an MSc in risk and finance from the London School of Economics and Political Science with support from the U.K.'s Marshall Scholarship. Ernesto Zedillo, Ph.D., is the director of the Yale Center for the Study of Globalization, professor in the field of international economics and politics, and a member of the Global Commission on Drug Policy. He received his M.A. and Ph.D. in economics from Yale University. He was the president of Mexico from 1994-2000
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Today’s fentanyl crisis: Prohibition’s Iron Law, revisited. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2017; 46:156-159. [DOI: 10.1016/j.drugpo.2017.05.050] [Citation(s) in RCA: 113] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 05/28/2017] [Indexed: 01/27/2023]
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