Impact of the Communities That HEAL Intervention on Buprenorphine-Waivered Practitioners and Buprenorphine Prescribing: A Prespecified Secondary Analysis of the HCS Randomized Clinical Trial

Importance

Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined.

Objective

To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing.

Design, Setting, and Participants

This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022.

Intervention

Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity.

Main Outcomes and Measures

The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100 000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed.

Results

A total of 8 166 963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10).

Conclusions and Relevance

In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder.

Trial Registration

ClinicalTrials.gov Identifier: NCT04111939.

Development and validation of a community-level social determinants of health index for drug overdose deaths in the HEALing Communities Study

INTRODUCTION

Social determinants of health (SDoH), such as socioeconomic status, education level, and food insecurity, are believed to influence the opioid crisis. While global SDoH indices such as the CDC's Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) combine the explanatory power of multiple social factors for understanding health outcomes, they may be less applicable to the specific challenges of opioid misuse and associated outcomes. This study develops a novel index tailored to opioid misuse outcomes, tests the efficacy of this index in predicting drug overdose deaths across contexts, and compares the explanatory power of this index to other SDoH indices.

METHODS

Focusing on four HEALing Communities Study (HCS) states (Kentucky, Massachusetts, New York and Ohio; encompassing 4269 ZIP codes), we identified multilevel SDoH potentially associated with opioid misuse and aggregated publicly available data for each measure. We then leveraged a random forest model to develop a composite measure that predicts age-adjusted drug overdose mortality rates based on SDoH. We used this composite measure to understand HCS and non-HCS communities in terms of overdose risk across areas of varying racial composition. Finally, we compared variance in drug overdose deaths explained by this index to variance explained by the SVI and ADI.

RESULTS

Our composite measure included 28 SDoH measures and explained approximately 89 % percent of variance in age-adjusted drug overdose mortality across HCS states. Health care measures, including emergency department visits and primary care provider availability, were top predictors within the index. Index accuracy was robust within and outside of HCS communities and states. This measure identified high levels of overdose mortality risk in segregated communities.

CONCLUSIONS

Existing SDoH indices fail to explain much variation in area-level overdose mortality rates. Having tailored composite indices can help us to identify places in which residents are at highest risk based on their composite contexts. A comprehensive index can also help to develop effective community interventions for programs such as HCS by considering the context in which people live.

Pediatric Primary Care Provider Perspectives on a Computer-Facilitated Screening and Brief Intervention System for Adolescent Substance Use

PURPOSE

This study aimed to elicit pediatric primary care providers' (PCPs) feedback on the acceptability and feasibility of implementing a tablet computer-facilitated Screening and Brief Intervention (cSBI) system for adolescent substance use in their practices.

METHODS

We trained PCPs at five Boston area practices and enrolled their 12- to 18-year-old patients in a pilot randomized trial of cSBI versus usual care. PCPs completed an 18-item poststudy questionnaire. We computed frequencies and thematically coded open-ended responses.

RESULTS

The analysis sample included 49 of 54 participating PCPs (90.7%). Overall, 89.8% of participants agreed the cSBI system was useful, and 81.6% reported increased confidence in providing brief counseling. Most useful were the immediate availability of screen results, talking points on substance use risks, and counseling prompts. Challenges included time and unfamiliarity with tablet computers. Many suggested electronic health record integration of cSBI to improve efficiency.

CONCLUSIONS

cSBI showed high acceptability and increased confidence among pediatric PCPs. Feasibility could be enhanced by electronic health record integration.

Use of the non-pneumatic anti-shock garment (NASG) to reduce blood loss and time to recovery from shock for women with obstetric haemorrhage in Egypt

Obstetric haemorrhage is one of the leading causes of maternal mortality. In many low-resource settings, delays in transport to referral facilities and in obtaining lifesaving treatment, contribute to maternal deaths. The non-pneumatic anti-shock garment (NASG) is a low-technology pressure device that decreases blood loss, restores vital signs, and has the potential to improve adverse outcomes by helping women survive delays in receiving adequate emergency obstetric care. With brief training, even individuals without medical backgrounds can apply this first-aid device. In this secondary analysis of hospital data from a pre-post intervention study in Egypt (N=364 women with obstetric haemorrhage and shock), 158 received standard care, while 206 received standard care plus the NASG. The NASG significantly reduced blood loss, time to recovery from shock, and, for those with postpartum haemorrhage due to uterine atony who received oxytocin, the NASG had a significant effect on blood loss independent of oxytocin. These results indicate that the NASG may be a valuable innovation for reducing maternal mortality in low-resource settings. Testing at community and household levels will be necessary in order to determine whether the NASG can help women survive the longest delays.