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Jones NR, Nielsen S, Farrell M, Ali R, Gill A, Larney S, Degenhardt L. Retention of opioid agonist treatment prescribers across New South Wales, Australia, 2001-2018: Implications for treatment systems and potential impact on client outcomes. Drug Alcohol Depend 2021; 219:108464. [PMID: 33360851 PMCID: PMC7855715 DOI: 10.1016/j.drugalcdep.2020.108464] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/19/2020] [Accepted: 11/21/2020] [Indexed: 01/27/2023]
Abstract
BACKGROUND There has been much research on the efficacy and effectiveness of opioid agonist treatment (OAT), but less on its implementation and sustainability. A challenge internationally has been recruiting and retaining prescribers. This paper aims to characterise the prescribers in terms of OAT prescribing behaviours. METHODS Retrospective cohort study in New South Wales, Australia. Participants were 2199 OAT prescribers between 1 st August 2001-19th September 2018.We examined trends in initiation and cessation of OAT prescribers. Adjusted hazard ratios were calculated to estimate prescriber retention, adjusting for year of initiation, practice type, client load and treatment prescribed. RESULTS The rate of prescribers ceasing OAT prescribing has been increasing over time: a prescriber who initiated between 2016-2017 had over four times the risk of cessation compared with one who initiated before 2001, AHR: 4.77; [3.67-6.21]. The highest prescriber cessation rate was in prescribers who had prescribed for shorter time periods. The annual percentage of prescribers who ceased prescribing among those who prescribed for ≤5 years increased from 3% in 2001 to 20 % in 2017. By 2017 more prescribers were discontinuing prescribing than new prescribers were starting. Approximately 87 % (n = 25,167) of OAT clients were under the care of 20 % of OAT prescribers (n = 202); half had been prescribing OAT for 17+ years. CONCLUSIONS OAT prescribing is increasingly concentrated in a small group of mature prescribers, and new prescribers are not being retained. There is a need to identify and respond to the reasons that contribute to newer prescribers to cease prescribing and put in place strategies to increase retention and broaden the base of doctors involved in such prescribing.
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Affiliation(s)
- Nicola R Jones
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
| | - Suzanne Nielsen
- Monash Addiction Research Centre and Eastern Health Clinical School, Monash University, Melbourne, Australia.
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
| | - Robert Ali
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia; School of Medicine, The University of Adelaide, Australia.
| | - Anthony Gill
- NSW Ministry of Health, Level 6, 100 Christie St, St Leonards NSW 2065, Australia.
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia; Department of Family Medicine and Emergency Medicine, Université de Montréal and Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Canada.
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of NSW, Sydney NSW 2052, Australia.
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Cioe K, Biondi BE, Easly R, Simard A, Zheng X, Springer SA. A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder. J Subst Abuse Treat 2020; 119:108146. [PMID: 33138929 DOI: 10.1016/j.jsat.2020.108146] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 07/02/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery. METHODS This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review. RESULTS There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD. CONCLUSION This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.
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Affiliation(s)
- Katharine Cioe
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Breanne E Biondi
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America
| | - Rebecca Easly
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Amanda Simard
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Xiao Zheng
- Yale University, New Haven, CT 06520, United States of America
| | - Sandra A Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, United States of America.
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Haffajee RL, Andraka-Christou B, Attermann J, Cupito A, Buche J, Beck AJ. A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder. Subst Abuse Treat Prev Policy 2020; 15:69. [PMID: 32928272 PMCID: PMC7491096 DOI: 10.1186/s13011-020-00312-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 09/03/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications. METHODS To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods. RESULTS Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD. CONCLUSIONS Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.
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Affiliation(s)
- Rebecca L. Haffajee
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- RAND Corporation, Boston, MA USA
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MA USA
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI USA
| | - Barbara Andraka-Christou
- Department of Health Management & Informatics, University of Central Florida, Orlando, FL USA
- Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL USA
| | - Jeremy Attermann
- the National Council for Behavioral Health, Washington, D.C, USA
| | - Anna Cupito
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Jessica Buche
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Angela J. Beck
- From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI USA
- Injury Prevention Center, Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI USA
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI USA
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Tsai AC, Kiang MV, Barnett ML, Beletsky L, Keyes KM, McGinty EE, Smith LR, Strathdee SA, Wakeman SE, Venkataramani AS. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med 2019; 16:e1002969. [PMID: 31770387 PMCID: PMC6957118 DOI: 10.1371/journal.pmed.1002969] [Citation(s) in RCA: 195] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.
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Affiliation(s)
- Alexander C. Tsai
- Center for Global Health, Massachusetts General Hospital, Boston,
Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Mbarara University of Science and Technology, Mbarara,
Uganda
| | - Mathew V. Kiang
- Center for Population Health Sciences, Stanford University School of
Medicine, Stanford, California, United States of America
| | - Michael L. Barnett
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Department of Health Policy and Management, Harvard T. H. Chan School of
Public Health, Boston, Massachusetts, United States of America
- Division of General Internal Medicine and Primary Care, Brigham and
Women’s Hospital, Boston, Massachusetts, United States of
America
| | - Leo Beletsky
- Northeastern University School of Law, Boston, Massachusetts, United
States of America
- Bouvé College of Health Sciences, Northeastern University, Boston,
Massachusetts, United States of America
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Katherine M. Keyes
- Mailman School of Public Health, Columbia University, New York City, New
York, United States of America
| | - Emma E. McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg
School of Public Health, Baltimore, Maryland, United States of
America
| | - Laramie R. Smith
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of
California at San Diego School of Medicine, San Diego, California, United States
of America
| | - Sarah E. Wakeman
- Harvard Medical School, Boston, Massachusetts, United States of
America
- Department of Medicine, Massachusetts General Hospital, Boston,
Massachusetts, United States of America
| | - Atheendar S. Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of
Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
of America
- Leonard Davis Institute of Health Economics, University of Pennsylvania,
Philadelphia, Pennsylvania, United States of America
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Nixon LL, Marlinga JC, Hayden KA, Mrklas KJ. Barriers and facilitators to office-based opioid agonist therapy prescribing and effective interventions to increase provider prescribing: protocol for a systematic review. Syst Rev 2019; 8:186. [PMID: 31345258 PMCID: PMC6657163 DOI: 10.1186/s13643-019-1076-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Accepted: 06/24/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Opiate agonist therapy (OAT) prescribing rates by family physicians are low in the context of community-based, comprehensive primary care. Understanding the factors that support and/or inhibit OAT prescribing within primary care is needed. Our study objectives are to identify and synthesize documented barriers to, and facilitators of, primary care opioid agonist prescribing, and effective strategies to inform intervention planning and support increased primary care OAT prescribing. METHODS/DESIGN We will systematically search EMBASE, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, MEDLINE, and gray literature in three domains: primary care providers, opioid agonist therapy, and opioid abuse. We will retain and assess primary studies reporting documented participation, or self-reported willingness to participate, in OAT prescribing; and/or at least one determinant of OAT prescribing; and/or strategies to address determinants of OAT prescribing from the perspective of primary care providers in comprehensive, community-based practice settings. There will be no restrictions on study design or publication date. Studies limited to specialty clinics with specialist prescribers, lacking extractable data, or in languages other than English or French will be excluded. Two reviewers will perform abstract review and data extraction independently. We will assess the quality of included studies using the Joanna Briggs Institute Critical Appraisal Tool. We will use a framework method of analysis to deductively code barriers and facilitators and to characterize effective strategies to support prescribing using a combined, modified a priori framework comprising the Theoretical Domains Framework and the Consolidated Framework for Implementation Research. DISCUSSION To date, no synthesis has been undertaken of the barriers and facilitators or effective interventions promoting OAT prescribing by primary care clinicians in community-based comprehensive care settings. Enacting change in physician behaviors, community-based programming, and health services is complex and best informed by using theoretical frameworks that allow the analysis of the available data to assist in designing and implementing interventions. In light of the current opioid crisis, increasing the capacity of primary care clinicians to provide OAT is an important strategy to curb morbidity and mortality from opioid use disorder. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD86835.
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Affiliation(s)
- Lara L. Nixon
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Room G012 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - Jazmin C. Marlinga
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Room G012 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
| | - K. Alix Hayden
- Libraries & Cultural Resources, University of Calgary, 2500 University Drive NW, Calgary, AB T2N 4N1 Canada
| | - Kelly J. Mrklas
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB T2N 4N1 Canada
- Strategic Clinical Networks™, System Innovation and Programs, Alberta Health Services, 403 - 29th Street NW, Calgary, AB T2N 2T9 Canada
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Barry DT, Irwin KS, Jones ES, Becker WC, Tetrault JM, Sullivan LE, Hansen H, O'Connor PG, Schottenfeld RS, Fiellin DA. Integrating buprenorphine treatment into office-based practice: a qualitative study. J Gen Intern Med 2009; 24:218-25. [PMID: 19089500 PMCID: PMC2628993 DOI: 10.1007/s11606-008-0881-9] [Citation(s) in RCA: 95] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 10/06/2008] [Accepted: 11/17/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians' attitudes towards this new medical practice has been largely neglected. OBJECTIVE To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers. DESIGN Qualitative study using individual and group semi-structured interviews. PARTICIPANTS Twenty-three practicing office-based physicians in New England. APPROACH Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team. RESULTS Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians' perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians' practices. CONCLUSIONS Addressing physicians' perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices.
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Affiliation(s)
- Declan T Barry
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT 06519-1187, USA.
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Redko C, Rapp RC, Carlson RG. Pathways of Substance Users Linking (Or Not) With Treatment. JOURNAL OF DRUG ISSUES 2007; 37:597-618. [PMID: 18167518 PMCID: PMC2168035 DOI: 10.1177/002204260703700306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This qualitative paper describes different pathways substance users experience as they decide whether to link to treatment or not after being assessed in a centralized intake unit in a Midwestern city. The narratives of 16 participants who did not link with treatment were compared with the narratives of 20 participants who did. Narratives from both groups described similar themes that were experienced differently. Nonlinkers were characterized by pretreatment abstinence, a negative experience with previous treatment, little previous engagement in a treatment career, and meaningful social support coming from AA. Linkers were more likely to continue using drugs before treatment entry, yet they described more readiness for treatment and were more engaged in a treatment career. The treatment careers approach provides a broader framework for understanding linkage versus nonlinkage to treatment.
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Affiliation(s)
- Cristina Redko
- Ph.D., is a research scientist and ethnographer in the Center for Interventions, Treatment & Addictions Research in the Boonshoft School of Medicine of Wright State University. M.S.W., is an assistant professor in the Wright State University School of Medicine. Ph.D., is professor and director of the Center for Interventions, Treatment & Addictions Research at Wright State University
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