Effect of the Communities that HEAL intervention on receipt of behavioral therapies for opioid use disorder: A cluster randomized wait-list controlled trial

BACKGROUND

The U.S. opioid overdose crisis persists. Outpatient behavioral health services (BHS) are essential components of a comprehensive response to opioid use disorder and overdose fatalities. The Helping to End Addiction Long-Term® (HEALing) Communities Study developed the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths in 67 communities in Kentucky, Ohio, New York, and Massachusetts through the implementation of evidence-based practices (EBPs), including BHS. This paper compares the rate of individuals receiving outpatient BHS in Wave 1 intervention communities (n = 34) to waitlisted Wave 2 communities (n = 33).

METHODS

Medicaid data included individuals ≥18 years of age receiving any of five BHS categories: intensive outpatient, outpatient, case management, peer support, and case management or peer support. Negative binomial regression models estimated the rate of receiving each BHS for Wave 1 and Wave 2. Effect modification analyses evaluated changes in the effect of the CTH intervention between Wave 1 and Wave 2 by research site, rurality, age, sex, and race/ethnicity.

RESULTS

No significant differences were detected between intervention and waitlisted communities in the rate of individuals receiving any of the five BHS categories. None of the interaction effects used to test the effect modification were significant.

CONCLUSIONS

Several factors should be considered when interpreting results-no significant intervention effects were observed through Medicaid claims data, the best available data source but limited in terms of capturing individuals reached by the intervention. Also, the 12-month evaluation window may have been too brief to see improved outcomes considering the time required to stand-up BHS.

TRIAL REGISTRATION

Clinical Trials.gov http://www.

CLINICALTRIALS

gov: Identifier: NCT04111939.

Cost of start-up activities to implement a community-level opioid overdose reduction intervention in the HEALing Communities Study

BACKGROUND

Communities That HEAL (CTH) is a novel, data-driven community-engaged intervention designed to reduce opioid overdose deaths by increasing community engagement, adoption of an integrated set of evidence-based practices, and delivering a communications campaign across healthcare, behavioral-health, criminal-legal, and other community-based settings. The implementation of such a complex initiative requires up-front investments of time and other expenditures (i.e., start-up costs). Despite the importance of these start-up costs in investment decisions to stakeholders, they are typically excluded from cost-effectiveness analyses. The objective of this study is to report a detailed analysis of CTH start-up costs pre-intervention implementation and to describe the relevance of these data for stakeholders to determine implementation feasibility.

METHODS

This study is guided by the community perspective, reflecting the investments that a real-world community would need to incur to implement the CTH intervention. We adopted an activity-based costing approach, in which resources related to hiring, training, purchasing, and community dashboard creation were identified through macro- and micro-costing techniques from 34 communities with high rates of fatal opioid overdoses, across four states-Kentucky, Massachusetts, New York, and Ohio. Resources were identified and assigned a unit cost using administrative and semi-structured-interview data. All cost estimates were reported in 2019 dollars.

RESULTS

State-level average and median start-up cost (representing 8-10 communities per state) were $268,657 and $175,683, respectively. Hiring and training represented 40%, equipment and infrastructure costs represented 24%, and dashboard creation represented 36% of the total average start-up cost. Comparatively, hiring and training represented 49%, purchasing costs represented 18%, and dashboard creation represented 34% of the total median start-up cost.

CONCLUSION

We identified three distinct CTH hiring models that affected start-up costs: hospital-academic (Massachusetts), university-academic (Kentucky and Ohio), and community-leveraged (New York). Hiring, training, and purchasing start-up costs were lowest in New York due to existing local infrastructure. Community-based implementation similar to the New York model may have lower start-up costs due to leveraging of existing infrastructure, relationships, and support from local health departments.

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.

Association of Arizona's Implementation of a Behavioral Health Crisis Response System With Suicide Hospitalizations

OBJECTIVE

In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations.

METHODS

A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition.

RESULTS

From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033).

CONCLUSIONS

More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.

Establishing a Protocol for Determining the Costs of an Integrated Set of Evidence-based Practices Aimed at Reducing Opioid Overdose Deaths

OBJECTIVES

In the midst of the opioid overdose crisis, local jurisdictions face a choice of public health interventions. A significant barrier when considering evidence-based practices (EBPs) is the lack of information regarding their implementation cost. This protocol paper provides the methodological foundation for the economic cost evaluations of community-wide strategies on the scale of a national study. It can serve as a resource for other communities, local policymakers, and stakeholders as they consider implementing possible public health strategies in their unique settings.

METHODS

We present a protocol that details (1) the process of identifying, reviewing, and analyzing individual strategies for study-funded and non-study-funded costs; (2) prospective costing tool designation, and; (3) data collection. To do this, we set up working groups with community stakeholders, reviewed financial invoices, and surveyed individuals with detailed knowledge of their community implementation.

DISCUSSION

There were 3 main challenges/limitations. The first was the lack of a standard structure for documenting nonfunded costs associated with each strategy. The second was the need for timely implementation of cost data. The third was generalizability because our study designed its strategies for selected communities due to their high opioid overdose mortality rates. Future steps include more tailored questions to ask during the categorization/filter process and establishing realistic expectations for organizations regarding documenting.

CONCLUSIONS

Data collected will provide a critical methodological foundation for costing large community-based EBP strategies and provide clarity for stakeholders on the cost of implementing EBP strategies to reduce opioid overdose deaths.

Health care use and cost of treatment for adolescents and young adults with opioid use disorder

BACKGROUND

Few studies have examined the cost of medication for opioid use disorder (MOUD) with counseling for the adolescent and young adult population. This study calculated the health care utilization and cost of MOUD treatment, other substance use disorder treatment, and general health care for adolescents and young adults receiving treatment for opioid use disorder.

METHODS

The study randomized youth ages 15 to 21 (N = 288) equally into the two study conditions: extended-release naltrexone (XR-NTX) or treatment as usual (TAU). While participants committed to treatment based on randomization the study observed considerable nonadherence to both randomized conditions. Instead of using the randomly assigned study conditions, we present descriptive costs by the type of MOUD treatment received: XR-NTX only, buprenorphine only, any other combination of MOUD treatments, and no MOUD. Health care use was aggregated over the 6-month period for each participant, and we calculated average/participant utilization for each treatment group. To determine participant costs, we multiplied the unit costs of health care services obtained from the literature by the reported amount of health care utilization for each participant. We then calculated the mean, standard error, median and IQR for MOUD costs, other substance use disorder treatment costs and general healthcare cost from the health care sector perspective.

RESULTS

On average, participants in the XR-NTX only group received 2.6 doses of XR-NTX (equivalent to approximately 78 days of treatment). The buprenorphine only group had an average of 97 days of buprenorphine treatment. The XR-NTX only group had higher/patient costs compared to participants in the buprenorphine only group ($10,491 vs. $8765) and higher XR-NTX utilization would further increase costs. Participants in the any other MOUD combination group had the highest total costs ($14,627) while participants in the no MOUD group at the lowest ($3453).

DISCUSSION

Our cost analysis calculates the real-world cost of MOUD treatment and, while not generalizable, provides policy makers an estimate of costs for adolescents and young adults. We found that participants in the XR-NTX only group received fewer days of medication compared to the buprenorphine only group, but their medication costs were higher due to the cost of XR-NTX injections. While the buprenorphine only group had the highest number of days of medication utilization of all the groups, the average number of days of medication utilization was considerably shorter than the six-month treatment period.

Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial

BACKGROUND

More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically.

METHODS

We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness.

DISCUSSION

This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.

Cost and cost-effectiveness of abstinence contingent wage supplements

BACKGROUND

Substance use disorders are correlated with unemployment and poverty. However, few interventions aim to improve substance use, unemployment, and, distally, poverty. The Abstinence-Contingent Wage Supplement (ACWS) randomized controlled trial combined a therapeutic workplace with abstinence-contingent wage supplements to address substance use and unemployment. The ACWS study found that abstinence-contingent wage supplements increased the percentage of participants who had negative drug tests, who were employed, and who were above the poverty line during the intervention period. This study presents the cost of ACWS and calculates the cost-effectiveness of ACWS compared with usual care.

METHODS

To calculate the cost and cost-effectiveness of ACWS, we used activity-based costing methods to cost the intervention and calculated the costs from the provider and healthcare sector perspective. We calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves for negative drug tests and employment.

RESULTS

ACWS cost $11,310 per participant over the 12-month intervention period. Total intervention and healthcare costs per participant over the intervention period were $20,625 for usual care and $30,686 for ACWS. At the end of the intervention period an additional participant with a negative drug test cost $1437 while an additional participant employed cost $915.

CONCLUSIONS

ACWS increases drug abstinence and employment and may be cost-effective at the end of the 12-month intervention period if decision makers are willing to pay the incremental cost associated with the intervention.

Modeling the impact of COVID-19 pandemic-driven increases in alcohol consumption on health outcomes and hospitalization costs in the United States

BACKGROUND AND AIMS

Alcohol consumption increased in the early phases of the COVID-19 pandemic in the United States. Alcohol use disorder (AUD) and risky drinking are linked to harmful health effects. This paper aimed to project future health and cost impacts of shifts in alcohol consumption during the COVID-19 pandemic.

DESIGN

An individual-level simulation model of the long-term drinking patterns for people with life-time AUD was used to simulate 10 000 individuals and project model outcomes to the estimated 25.9 million current drinkers with life-time AUD in the United States. The model considered three scenarios: (1) no change (counterfactual for comparison); (2) increased drinking levels persist for 1 year ('increase-1') and (3) increased drinking levels persist for 5 years ('increase-5').

SETTING

United States.

PARTICIPANTS

Current drinkers with life-time AUD.

MEASUREMENTS

Life expectancy [life-years (LYs)], quality-adjusted life-years (QALYs), alcohol-related hospitalizations and associated hospitalization costs and alcohol-related deaths, during a 5-year period.

FINDINGS

Short-term increases in alcohol consumption (increase-1 scenario) resulted in a loss of 79 000 [95% uncertainty interval (UI]) 26 000-201 000] LYs, a loss of 332 000 (104 000-604 000) QALYs and 295 000 (82 000-501 000) more alcohol-related hospitalizations, costing an additional $5.4 billion ($1.5-9.3 billion) over 5 years. Hospitalizations for cirrhosis of the liver accounted for approximately $3.0 billion ($0.9-4.8 billion) in hospitalization costs, more than half the increase across all alcohol-related conditions. Health and cost impacts were more pronounced for older age groups (51+), women and non-Hispanic black individuals. Increasing the duration of pandemic-driven increases in alcohol consumption in the increase-5 scenario resulted in larger impacts.

CONCLUSIONS

Simulations show that if the increase in alcohol consumption observed in the United States in the first year of the pandemic continues, alcohol-related mortality, morbidity and associated costs will increase substantially over the next 5 years.

Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population

BACKGROUND

A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual.

OBJECTIVE

To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual.

RESEARCH DESIGN

This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge.

SUBJECTS

Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol.

COST MEASURES

Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period.

RESULTS OF BASE CASE ANALYSIS

NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results.

LIMITATIONS

Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records.

CONCLUSION

Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.

The Relationship Between Reductions in WHO Risk Drinking Levels During Treatment and Subsequent Healthcare Costs for the ACTIVE Workgroup

BACKGROUND

Abstinence has historically been considered the target outcome for alcohol use disorder (AUD) treatment, yet recent work has found drinking reductions after AUD treatment, as measured by World Health Organization (WHO) risk drinking levels, are associated with meaningful improvements in functioning, physical health, and quality of life.

OBJECTIVES

This study extends previous analyses of AUD treatment outcomes by estimating the association between changes in WHO risk drinking levels (very high, high, medium, and low, based on average daily alcohol consumption) and healthcare costs.

METHODS

Secondary data analysis of the COMBINE study, a multisite randomized clinical trial of acamprosate, naltrexone and behavioral interventions for AUD. Generalized gamma regression models were used to estimate relationships between WHOrisk drinking level reductions over the course of treatment and healthcare costs in the year after treatment (N = 964) and up to 3 years following treatment (N = 651).

RESULTS

SustainedWHOrisk drinking reductions of 2 or more levels throughout treatment were associated with 52.0% lower healthcare costs ( P < 0.001) in the year following treatment, and 44.0% lower costs ( P < 0.0025) over 3 years. A reduction of exactly 1 level was associated with 34.8% lower costs over 3 years, which was not significant ( P = 0.05). Cost reductions were driven by lower inpatient behavioral health and emergency department utilization.

CONCLUSIONS

Reduction in WHO risk drinking levels of at least 2 levels was associated with lower healthcare costs over 1 and 3 years. Our results add to literature showing drinking reductions are associated with improvement in health.

Cost and Cost-Effectiveness of Incentives for Viral Suppression in People Living with HIV

Only 63% of people living with HIV in the United States are achieving viral suppression. Structural and social barriers limit adherence to antiretroviral therapy which furthers the HIV epidemic while increasing health care costs. This study calculated the cost and cost-effectiveness of a contingency management intervention with cash incentives. People with HIV and detectable viral loads were randomized to usual care or an incentive group. Individuals could earn up to $3650 per year if they achieved and maintained an undetectable viral load. The average 1-year intervention cost, including incentives, was $4105 per patient. The average health care costs were $27,189 per patient in usual care and $35,853 per patient in the incentive group. We estimated a cost of $28,888 per quality-adjusted life-year (QALY) gained, which is well below accepted cost-per-QALY thresholds. Contingency management with cash incentives is a cost-effective intervention for significantly increasing viral suppression.

Rural and urban differences in undersupply of buprenorphine provider availability in the United States, 2018

BACKGROUND

Medications to treat opioid use disorder (OUD) including buprenorphine products are evidence-based and cost-effective tools for combating the opioid crisis. However, limited availability to buprenorphine is pervasive in the United States (US) and may serve to exacerbate the deadly epidemic. Although prior research points to rural counties as especially needy of strategies that improve buprenorphine availability, it is important to investigate the availability of waivered providers according to treatment need as defined by the county-level rate of opioid-overdose deaths (OOD). This study examined differences in buprenorphine provider availability relative to treatment need among rural and urban counties in the US.

METHODS

Buprenorphine provider availability relative to need in each county was defined as the number of waivered providers divided by the rate of OODs (i.e., number of OODs/100,000 population), according to 2018 data. Counties with ratios in the bottom tertile of their state were classified as buprenorphine undersupplied. We estimated logit models to statistically test the association of rurality and state main effects and their interaction terms (independent variables) and the county classified as buprenorphine undersupplied (dependent variable).

RESULTS

A total of 38 states and 2595 counties had sufficient non-suppressed data to remain in the analysis. A larger percent of urban counties (36.43%) than rural counties (32.01%) were classified as buprenorphine undersupplied (p  = 0.001). The likelihood of a rural county being undersupplied varied considerably by state (Chi Square  = 82.88, p  = 0.000). All states with significant (p  < 0.05 or p  < 0.10) interaction terms showed lower likelihood of buprenorphine undersupply in rural counties.

CONCLUSIONS

The rural-urban distribution in undersupply of waivered buprenorphine providers relative to need varied markedly by state. Strategies for improving access to buprenorphine-waivered providers should be state-centric and informed by county-specific indicators of need.

The association of Medicare Part D prior authorization for buprenorphine-naloxone with adherence to opioid use disorder treatment guidelines in the United States

AIMS

To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017.

MEASUREMENTS

Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis.

FINDINGS

PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8).

CONCLUSIONS

US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.

Prior Authorization for Opioid Use Disorder Versus Pain Medications: Lessons Learned for Parity Enforcement

OBJECTIVE

This study characterized the use of prior authorization for opioid use disorder medications as compared with that for opioid pain medications in the United States among Medicare Part D plans.

METHOD

Medicare Part D formulary data from 2017-2019 were used to describe differences in prior authorization between opioid use disorder medications and opioid pain medications.

RESULTS

In 2017, 72% of Medicare Part D formularies required prior authorization for brand buprenorphine-naloxone, whereas 6% of formularies required prior authorization for brand oxycodone. In 2019, 3% of formularies required prior authorization for brand buprenorphine-naloxone, whereas 16% of formularies required prior authorization for brand oxycodone. Throughout the study period, other formulary restrictions such as quantity limits were similar for both medications.

CONCLUSIONS

The disparate use of prior authorization in 2017 for opioid use disorder medications as compared with opioid pain medications suggests that formulary decision making may be inconsistent between medications used to treat substance use disorders and those used to treat pain. If Part D formularies publicly released their decision-making criteria, then there would be a greater understanding of why prior authorization was differentially applied. Greater transparency would help ensure that formulary decisions are not the result of biases and stigma toward substance use disorders.

Stability of Drinking Reductions and Long-term Functioning Among Patients with Alcohol Use Disorder

BACKGROUND

The World Health Organization (WHO) categorizes alcohol consumption according to grams consumed into low-, medium-, high-, and very-high-risk drinking levels (RDLs). Although abstinence has been considered the ideal outcome of alcohol treatment, reductions in WHO RDLs have been proposed as primary outcomes for alcohol use disorder (AUD) trials.

OBJECTIVE

The current study examines the stability of WHO RDL reductions and the association between RDL reductions and long-term functioning for up to 3 years following treatment.

DESIGN AND PARTICIPANTS

Secondary data analysis of patients with AUD enrolled in the COMBINE Study and Project MATCH, two multi-site, randomized AUD clinical trials, who were followed for up to 3 years post-treatment (COMBINE: n = 694; MATCH: n = 806).

MEASURES

Alcohol use was measured via calendar-based methods. We estimated all models in the total sample and among participants who did not achieve abstinence during treatment.

KEY RESULTS

One-level RDL reductions were achieved by 84% of patients at the end of treatment, with 84.9% of those individuals maintaining that reduction at a 3-year follow-up. Two-level RDL reductions were achieved by 68% of patients at the end of treatment, with 77.7% of those individuals maintaining that reduction at a 3-year follow-up. One- and two-level RDL reductions at the end of treatment were associated with significantly better mental health, quality of life (including physical quality of life), and fewer drinking consequences 3 years after treatment (p < 0.05), as compared to no change or increased drinking.

CONCLUSION

AUD patients can maintain WHO RDL reductions for up to 3 years after treatment. Patients who had WHO RDL reductions functioned significantly better than those who did not reduce their drinking. These findings are consistent with prior reports suggesting that drinking reductions, short of abstinence, yield meaningful improvements in patient health, well-being, and functioning.

The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BACKGROUND

Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths.

METHODS

The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined.

DISCUSSION

The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Cost and cost-effectiveness of interim methadone treatment and patient navigation initiated in jail

BACKGROUND

Individuals with opioid use disorder (OUD) who are released from pre-trial detention in jail have a high risk of opioid relapse. While several interventions for OUD initiated during incarceration have been studied, few have had an economic evaluation. As part of a three-group randomized trial, we estimated the cost and cost-effectiveness of a negative urine opioid test. Detainees were assigned to interim methadone (IM) in jail with continued methadone treatment post-release with and without 3 months of post-release patient navigation (PN) compared to an enhanced treatment-as-usual group.

METHODS

We implemented a micro-costing approach from the provider's perspective to estimate the cost per participant in jail and over the 12 months post-release from jail. Economic data included jail-based and community-based service utilization, self-reported healthcare utilization and justice system involvement, and administrative arrest records. Our outcome measure is the number of participants with a negative opioid urine test at their 12-month follow-up. We calculated incremental cost-effectiveness ratios (ICERs) for intervention costs only and costs from a societal perspective.

RESULTS

The average cost of providing patient navigation services per individual beginning in jail and continuing in the community was $283. We find that IM is dominated by ETAU and IM + PN. Per additional participant with a negative opioid urine test, the ICER for IM + PN including intervention costs only is $91 and $305 including societal costs.

CONCLUSIONS

IM + PN is almost certainly the cost-effective choice from both an intervention provider and societal perspective.

Comparison of Medicaid Reimbursements for Psychiatrists and Primary Care Physicians

OBJECTIVE

This study aimed to investigate whether state Medicaid programs systematically reimburse psychiatrists less than they reimburse primary care physicians.

METHODS

This study used outpatient Medicaid claims data from 2014 for 11 U.S. states. Claims with a primary behavioral health diagnosis (i.e., mental or substance use disorder) and an evaluation and management procedure code of 99213 or 99214 were identified. These are the most frequently used procedure codes by both psychiatrists and primary care physicians when treating patients with mental and substance use disorders. Average reimbursements were compared for nonfacility claims submitted by psychiatrists and primary care physicians.

RESULTS

In 9 states, psychiatrists were reimbursed less on average than primary care physicians. In one state, reimbursements were nearly equivalent.

CONCLUSIONS

Disparities in reimbursements across specialties may reduce access to psychiatric specialty care through Medicaid and are inconsistent with the Mental Health Parity and Addiction Equity Act.

Can Alcohol Use Disorder Recovery Include Some Heavy Drinking? A Replication and Extension up to 9 Years Following Treatment

BACKGROUND

Recent research indicates some individuals who engage in heavy drinking following treatment for alcohol use disorder fare as well as those who abstain with respect to psychosocial functioning, employment, life satisfaction, and mental health. The current study evaluated whether these findings replicated in an independent sample and examined associations between recovery profiles and functioning up to 6 years later.

METHODS

Data were from the 3-year and 7- to 9-year follow-ups of subsamples initially recruited for the COMBINE study (3-year follow-up: n = 694; 30.1% female, 21.0% non-White; 7- to 9-year follow-up: n = 127; 38.9% female, 27.8% non-White). Recovery at 3 years was defined by latent profile analyses including measures of health functioning, quality of life, employment, alcohol consumption, and cannabis and other drug use. Functioning at the 7- to 9-year follow-up was assessed using single items of self-rated general health, hospitalizations, and alcohol consumption.

RESULTS

We identified 4 profiles at the 3-year follow-up: (i) low-functioning frequent heavy drinkers (13.9%), (ii) low-functioning infrequent heavy drinkers (15.8%), (iii) high-functioning heavy drinkers (19.4%), and (iv) high-functioning infrequent drinkers (50.9%). At the 7- to 9-year follow-up, the 2 high-functioning profiles had the best self-rated health, and the high-functioning heavy drinking profile had significantly fewer hospitalizations than the low-functioning frequent heavy drinking profile.

CONCLUSIONS

Previous findings showing heterogeneity in recovery outcomes were replicated. Most treatment recipients functioned well for years after treatment, and a subset who achieved stable recovery engaged in heavy drinking and reported good health outcomes up to 9 years after treatment. Results question the long-standing emphasis on drinking practices as a primary outcome, as well as abstinence as a recovery criterion in epidemiologic and treatment outcome research and among stakeholder groups and funding/regulatory agencies. Findings support an expanded recovery research agenda that considers drinking patterns, health, life satisfaction, and functioning.

Association of Formulary Prior Authorization Policies With Buprenorphine-Naloxone Prescriptions and Hospital and Emergency Department Use Among Medicare Beneficiaries

IMPORTANCE

Prior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes.

OBJECTIVE

To determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes.

DESIGN, SETTING, AND PARTICIPANTS

This comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775 874 members were in 1479 Part D plans that always required prior authorization, 113 286 members were in 206 plans that removed prior authorization, 189 461 members were in 489 plans that never required prior authorization, and 619 919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020.

EXPOSURES

Removal or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone.

MAIN OUTCOMES AND MEASURES

Buprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures.

RESULTS

The study population in 2012 included 949 206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550 445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P < .001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year).

CONCLUSIONS AND RELEVANCE

Removing prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.

Screening and Intervention for Suicide Prevention: A Cost-Effectiveness Analysis of the ED-SAFE Interventions

OBJECTIVE

Suicide screening followed by an intervention may identify suicidal individuals and prevent recurring self-harm, but few cost-effectiveness studies have been conducted. This study sought to determine whether the increased costs of implementing screening and intervention in hospital emergency departments (EDs) are justified by improvements in patient outcomes (decreased attempts and deaths by suicide).

METHODS

The Emergency Department Safety Assessment and Follow-up Evaluation (ED-SAFE) study recruited participants in eight U.S. EDs between August 2010 and November 2013. The eight sites sequentially implemented two interventions: universal screening added to treatment as usual and universal screening plus a telephone-based intervention delivered over 12 months post-ED visit. This study calculated incremental cost-effectiveness ratios and cost-effectiveness acceptability curves to evaluate screening and suicide outcome measures and costs for the two interventions relative to treatment as usual. Costs were calculated from the provider perspective (e.g., wage and salary data and rental costs for hospital space) per patient and per site.

RESULTS

Average per-patient costs to a participating ED of universal screening plus intervention were $1,063 per month, approximately $500 more than universal screening added to treatment as usual. Universal screening plus intervention was more effective in preventing suicides compared with universal screening added to treatment as usual and treatment as usual alone.

CONCLUSIONS

Although the choice of universal screening plus intervention depends on the value placed on the outcome by decision makers, results suggest that implementing such suicide prevention measures can lead to significant cost savings.

Estimating Long-Term Drinking Patterns for People with Lifetime Alcohol Use Disorder

Background. There is a lack of data on alcohol consumption over time. This study characterizes the long-term drinking patterns of people with lifetime alcohol use disorders who have engaged in treatment or informal care. Methods. We developed multinomial logit models using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) to estimate short-term transition probabilities (TPs) among the 4 World Health Organization drinking risk levels (low, medium, high, and very high risk) and abstinence by age, sex, and race/ethnicity. We applied an optimization algorithm to convert 3-year TPs from NESARC to 1-year TPs, then used simulated annealing to calibrate TPs to a propensity-scored matched set of participants derived from a separate 16-year study of alcohol consumption. We validated the resulting long-term TPs using NESARC-III, a cross-sectional study conducted on a different cohort. Results. Across 24 demographic groups, the 1-year probability of remaining in the same state averaged 0.93, 0.81, 0.49, 0.51, and 0.63 for abstinent, low, medium, high, and very high-risk states, respectively. After calibration to the 16-year study data (N = 420), resulting TPs produced state distributions that hit the calibration target. We find that the abstinent or low-risk states are very stable, and the annual probability of leaving the very high-risk state increases by about 20 percentage points beyond 8 years. Limitations. TPs for some demographic groups had small cell sizes. The data used to calibrate long-term TPs are based on a geographically narrow study. Conclusions. This study is the first to characterize long-term drinking patterns by combining short-term representative data with long-term data on drinking behaviors. Current research is using these patterns to estimate the long-term cost effectiveness of alcohol treatment.

Product attributes important to US adult consumers' use of electronic nicotine delivery systems: a discrete choice experiment

OBJECTIVE

To understand the importance of electronic nicotine delivery systems (ENDS) product attributes to adult consumers in the USA by age and gender.

DESIGN

Cross-sectional survey with a discrete choice experiment (best-worst, case 2, scaling) of 19 choice tasks in which participants answered what would make them most want to use and least want to use an ENDS product.

SETTING AND PARTICIPANTS

A national sample of adults (aged 18+ years) in the USA who had tried an ENDS product at least once.

MEASURES

We included 9 ENDS attributes with levels that varied across 19 choice tasks. We performed a multinomial logistic regression to obtain overall importance scores, attribute-level part-worth utilities and most important attribute.

RESULTS

Of 660 participants, 81% were white, 51% women and 37% had at least a 4-year college degree with an average age of 42.0 years (SD ±19.4). The attributes had the following importance: harms of use 17.6%; general effects 14.1%; cessation aid 12.6%; purchase price 12.1%; monthly cost 12.0%; nicotine content 11.4%; flavour availability 8.4%; device design 7.2%; modifiability 4.6%. Harms of use was the most important attribute for all ages and genders (p<0.05); variation in other important attributes existed by age though not by gender.

CONCLUSION

This study identified the importance of nine ENDS attributes. Perceived harms of use of ENDS use appeared most important, and modifiability was least important. Variation by consumer group existed, which may allow for targeted interventions to modify ENDS use.

Association Between Medicare and FDA Policies and Prior Authorization Requirements for Buprenorphine Products in Medicare Part D Plans

This study describes changes in the proportion of Medicare Part D plans requiring prior authorization for buprenorphine products before and after a 2017 FDA rquirement that the drug’s label emphasize the importance of drug treatment of opioid use disorder.

Vaping cannabis among adolescents: prevalence and associations with tobacco use from a cross-sectional study in the USA

OBJECTIVE

Previous research suggests that some adolescents are using e-cigarette devices to vaporise ('vaping') cannabis in the form of hash oil, tetrahydrocannabinol (THC) wax or oil, or dried cannabis buds or leaves. However, it is unclear how adolescents who vape cannabis use other tobacco products. This study examined the extent to which adolescents reported ever vaping cannabis and investigated how demographic variables and tobacco behaviours were associated with use.

DESIGN

We used cross-sectional data from adolescents (total response rate 64.5%) who participated in the 2017 North Carolina Youth Tobacco Survey. SAS logistic regression survey procedures were used to account for the complex survey design and sampling weights.

SETTING

North Carolina, USA.

PARTICIPANTS

Adolescents in high school (n=2835).

PRIMARY OUTCOME AND MEASURE

Adolescents were asked to indicate whether they had ever used an e-cigarette device with marijuana, THC or hash oil, or THC wax.

RESULTS

Approximately 1 in 10 high school students reported ever vaping cannabis in the overall sample (9.6%). In multivariable models, adolescents who reported using cigars (adjusted OR (aOR) 3.76, 95% CI 2.33 to 6.07), waterpipe (aOR 2.32, 95% CI 1.37 to 3.93) or e-cigarettes (aOR 3.18, 95% CI 2.38 to 4.25) in the past 30 days had higher odds of reporting ever vaping cannabis compared with their counterparts. There was no significant association between use of smokeless tobacco (aOR 0.89, 95% CI 0.42 to 1.91) or use of cigarettes (aOR 1.27, 95% CI 0.71 to 2.29) in the past 30 days and odds of reporting ever vaping cannabis.

CONCLUSIONS

These findings provide evidence that large numbers of high school students who use tobacco products have vaped cannabis. As tobacco control policies-such as communication campaigns or smoke-free laws-increasingly focus on e-cigarettes, attention to understanding how adolescents use e-cigarettes to vape substances other than nicotine is essential.

Re-engineering methadone-Cost-effectiveness analysis of a patient-centered approach to methadone treatment

Methadone maintenance treatment has proven effectiveness in the treatment of opioid use disorder, but significant barriers remain to treatment retention. In a randomized clinical trial, 300 newly-admitted methadone patients were randomly assigned to patient-centered methadone (PCM) v. treatment-as-usual (TAU). In PCM, participants were treated under revised program rules which permitted voluntary attendance at counseling and other changes focused on reducing involuntary discharge, and different staff roles which shifted disciplinary responsibility from the participant's counselor to the supervisor. The study found no significant differences in treatment retention, measures of opioid use, or other patient outcomes. This paper employs an activity-based costing approach to estimate the cost and cost-effectiveness of the two study conditions. We found that service use and costs were similar between PCM and TAU. Specifically, the average cost for PCM patients was $2396 compared to $2292 for standard methadone, while the average length of stay was 2 weeks longer for PCM patients. Incremental cost-effectiveness ratios (ICER) for self-reported heroin use, opioid positive urine screens, and meeting DSM-IV criteria for opioid dependence were mixed, with TAU achieving non-significantly better outcomes at lower treatment episode costs (i.e., economically dominating) for opioid positive urine screens. PCM patients reported slightly more days abstinent from heroin and fewer meet the opioid dependence criteria. While these differences are small and not statistically significant, we can still examine the cost-effectiveness implications. For days, abstinent from heroin, the ICER was $242 for one additional day of abstinence, however, there was notable uncertainty around this estimate. For opioid dependence criteria, the ICER was $1160 for a one-percentage point increase in the probability that a participant no longer met criteria for opioid dependence at follow-up. This economic study finds that patient choice concepts can be introduced into methadone treatment without significant impacts on costs or patient outcomes.

Cost and cost-effectiveness of computerized vs. in-person motivational interventions in the criminal justice system

INTRODUCTION

Although substance use is common among probationers in the United States, treatment initiation remains an ongoing problem. Among the explanations for low treatment initiation are that probationers are insufficiently motivated to seek treatment, and that probation staff have insufficient training and resources to use evidence-based strategies such as motivational interviewing. A web-based intervention based on motivational enhancement principles may address some of the challenges of initiating treatment but has not been tested to date in probation settings. The current study evaluated the cost-effectiveness of a computerized intervention, Motivational Assessment Program to Initiate Treatment (MAPIT), relative to face-to-face Motivational Interviewing (MI) and supervision as usual (SAU), delivered at the outset of probation.

METHODS

The intervention took place in probation departments in two U.S. cities. The baseline sample comprised 316 participants (MAPIT = 104, MI = 103, and SAU = 109), 90% (n = 285) of whom completed the 6-month follow-up. Costs were estimated from study records and time logs kept by interventionists. The effectiveness outcome was self-reported initiation into any treatment (formal or informal) within 2 and 6 months of the baseline interview. The cost-effectiveness analysis involved assessing dominance and computing incremental cost-effectiveness ratios and cost-effectiveness acceptability curves. Implementation costs were used in the base case of the cost-effectiveness analysis, which excludes both a hypothetical license fee to recoup development costs and startup costs. An intent-to-treat approach was taken.

RESULTS

MAPIT cost $79.37 per participant, which was ~$55 lower than the MI cost of $134.27 per participant. Appointment reminders comprised a large proportion of the cost of the MAPIT and MI intervention arms. In the base case, relative to SAU, MAPIT cost $6.70 per percentage point increase in the probability of initiating treatment. If a decision-maker is willing to pay $15 or more to improve the probability of initiating treatment by 1%, estimates suggest she can be 70% confident that MAPIT is good value relative to SAU at the 2-month follow-up and 90% confident that MAPIT is good value at the 6-month follow-up.

CONCLUSIONS

Web-based MAPIT may be good value compared to in-person delivered alternatives. This conclusion is qualified because the results are not robust to narrowing the outcome to initiating formal treatment only. Further work should explore ways to improve access to efficacious treatment in probation settings.

The Relationship Between End-of-Treatment Alcohol Use and Subsequent Healthcare Costs: Do Heavy Drinking Days Predict Higher Healthcare Costs?

BACKGROUND

A challenge for evaluating alcohol treatment efficacy is determining what constitutes a "good" outcome or meaningful improvement. Abstinence at the end of treatment is an unambiguously good outcome; however, a focus on abstinence ignores the potential benefits of patients reducing their drinking to less problematic levels. Patients may be drinking at low-risk levels at the end of treatment but may be high-functioning and impose few social costs. In this study, we estimate the relationship between drinking at the end of COMBINE treatment and subsequent healthcare costs with an emphasis on heavy and nonheavy drinking levels.

METHODS

Indicators of heavy drinking days (HDDs; 5+ drinks for men, 4+ for women) and nonheavy drinking days (non-HDDs) during the last 30 days of COMBINE treatment were constructed for 748 patients enrolled in the COMBINE Economic Study. Generalized linear models were used to model total costs following COMBINE treatment as a function of drinking indicators. Different model specifications analyzed alternative counts of HDDs (e.g., 1 HDD and 2 to 30 HDDs), and groups having Both non-HDDs and HDDs.

RESULTS

Patients with HDDs had 66.4% (p < 0.01) higher healthcare costs than those who were abstinent. Having more than 2 HDDs was associated with the highest costs (75.9%, p < 0.01). Patients with non-HDDs had costs that were not significantly different than abstainers, even if they also had HDDs. However, those with HDDs only had costs 91.7% higher than abstainers (p < 0.01).

CONCLUSIONS

Having HDDs at the end of treatment is associated with higher costs. Patients who had Only HDDs at the end of treatment had worse subsequent outcomes than those who had Both non-HDDs and HDDs. These findings offer new context for evaluating treatment outcomes and provide new information on the association of drinking with consequences.

Patterns of Twitter Behavior Among Networks of Cannabis Dispensaries in California

Background

Twitter represents a social media platform through which medical cannabis dispensaries can rapidly promote and advertise a multitude of retail products. Yet, to date, no studies have systematically evaluated Twitter behavior among dispensaries and how these behaviors influence the formation of social networks.

Objectives

This study sought to characterize common cyberbehaviors and shared follower networks among dispensaries operating in two large cannabis markets in California.

Methods

From a targeted sample of 119 dispensaries in the San Francisco Bay Area and Greater Los Angeles, we collected metadata from the dispensary accounts using the Twitter API. For each city, we characterized the network structure of dispensaries based upon shared followers, then empirically derived communities with the Louvain modularity algorithm. Principal components factor analysis was employed to reduce 12 Twitter measures into a more parsimonious set of cyberbehavioral dimensions. Finally, quadratic discriminant analysis was implemented to verify the ability of the extracted dimensions to classify dispensaries into their derived communities.

Results

The modularity algorithm yielded three communities in each city with distinct network structures. The principal components factor analysis reduced the 12 cyberbehaviors into five dimensions that encompassed account age, posting frequency, referencing, hyperlinks, and user engagement among the dispensary accounts. In the quadratic discriminant analysis, the dimensions correctly classified 75% (46/61) of the communities in the San Francisco Bay Area and 71% (41/58) in Greater Los Angeles.

Conclusions

The most centralized and strongly connected dispensaries in both cities had newer accounts, higher daily activity, more frequent user engagement, and increased usage of embedded media, keywords, and hyperlinks. Measures derived from both network structure and cyberbehavioral dimensions can serve as key contextual indicators for the online surveillance of cannabis dispensaries and consumer markets over time.

Consumers' Preferences for Electronic Nicotine Delivery System Product Features: A Structured Content Analysis

To inform potential governmental regulations, we aimed to develop a list of electronic nicotine delivery system (ENDS) product features important to U.S. consumers by age and gender. We employed qualitative data methods. Participants were eligible if they had used an ENDS at least once. Groups were selected by age and gender (young adult group aged 18–25, n = 11; middle-age group aged 26–64, n = 9; and women’s group aged 26–64, n = 9). We conducted five individual older adult interviews (aged 68–80). Participants discussed important ENDS features. We conducted a structured content analysis of the group and interview responses. Of 34 participants, 68% were white and 56% were female. Participants mentioned 12 important ENDS features, including: (1) user experience; (2) social acceptability; (3) cost; (4) health risks/benefits; (5) ease of use; (6) flavors; (7) smoking cessation aid; (8) nicotine content; (9) modifiability; (10) ENDS regulation; (11) bridge between tobacco cigarettes; (12) collectability. The most frequently mentioned ENDS feature was modifiability for young adults, user experience for middle-age and older adults, and flavor for the women’s group. This study identified multiple features important to ENDS consumers. Groups differed in how they viewed various features by age and gender. These results can inform ongoing regulatory efforts.

Association between self-reports of being high and perceptions about the safety of drugged and drunk driving

This study examines the relationship between self-reports of being high on marijuana and perceptions about driving high or drunk. Data were collected in 2014 from an online convenience sample of adult, past 30-day marijuana and hashish users in Colorado and Washington (n = 865). Respondents were asked, "Were you high or feeling the effects of marijuana or hashish when you took this survey?" Logistic regression was used to assess the relationship between being high and beliefs about driving high, controlling for demographics and marijuana use. Respondents who reported being high at the time of survey administration had higher odds of agreeing with the statements, "I can safely drive under the influence of marijuana" (OR = 3.13, P < 0.001) and "I can safely drive under the influence of alcohol" (OR = 3.71, P < 0.001) compared with respondents who did not report being high. Respondents who were high also had higher odds of being open to driving high under certain circumstances. Being high may influence perceptions about the safety of drugged and drunk driving. The effectiveness of public health messages to prevent drugged and drunk driving may depend in part on how persuasive they are among individuals who are high.

Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial

BACKGROUND

Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs.

METHODS

This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions.

RESULTS

We describe the background and rationale for the study, its aims, hypotheses, and study design.

CONCLUSIONS

Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215.

Nonmedical prescription pain reliever and alcohol consumption among cannabis users

BACKGROUND

This study examined poly-drug use involving the use of cannabis with nonmedical prescription pain reliever use (NMPR) and alcohol use.

METHODS

Computer-assisted survey data from the National Survey on Drug Use and Health were examined. The NSDUH is an annual, cross-sectional survey of non-institutionalized citizens in the United States (ages 12+). Replicate analyses were conducted using the 2013 and 2003 survey waves.

RESULTS

Higher levels of cannabis use were consistently associated with more frequent consumption of prescription pain relievers, with findings replicating in both 2013 and 2003. While the prevalence of dual users declined from 2003 (2.5%) to 2013 (2.3%), the average number of days used among dual users increased by an average of 20 days over that period. These changes largely occurred among those aged 35 or older, males, whites, and non-illicit drug users. Past-year marijuana use increased by 16% (10.8-12.6%, p-value<.001) whereas NMPR decreased by 15% (4.9-4.2%, p-value<.001). The largest changes occurred after 2011. Persons using the most cannabis generally had higher levels of alcohol use relative to those using the least amount of cannabis. There was a significant increase in the prevalence of dual use between 2003 (10.2%) and 2013 (11.6%), while the prevalence of past-year alcohol use remained relatively stable.

CONCLUSIONS

Clinical efforts and public health interventions should consider the possible co-ingestion of cannabis with NMPR and alcohol, as concomitant use may portend negative health effects in the short and long-term.

Brief intervention for problem drug use in safety-net primary care settings: a randomized clinical trial

IMPORTANCE

Although brief intervention is effective for reducing problem alcohol use, few data exist on its effectiveness for reducing problem drug use, a common issue in disadvantaged populations seeking care in safety-net medical settings (hospitals and community health clinics serving low-income patients with limited or no insurance).

OBJECTIVE

To determine whether brief intervention improves drug use outcomes compared with enhanced care as usual.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical trial with blinded assessments at baseline and at 3, 6, 9, and 12 months conducted in 7 safety-net primary care clinics in Washington State. Of 1621 eligible patients reporting any problem drug use in the past 90 days, 868 consented and were randomized between April 2009 and September 2012. Follow-up participation was more than 87% at all points.

INTERVENTIONS

Participants received a single brief intervention using motivational interviewing, a handout and list of substance abuse resources, and an attempted 10-minute telephone booster within 2 weeks (n = 435) or enhanced care as usual, which included a handout and list of substance abuse resources (n = 433).

MAIN OUTCOMES AND MEASURES

The primary outcomes were self-reported days of problem drug use in the past 30 days and Addiction Severity Index-Lite (ASI) Drug Use composite score. Secondary outcomes were admission to substance abuse treatment; ASI composite scores for medical, psychiatric, social, and legal domains; emergency department and inpatient hospital admissions, arrests, mortality, and human immunodeficiency virus risk behavior.

RESULTS

Mean days used of the most common problem drug at baseline were 14.40 (SD, 11.29) (brief intervention) and 13.25 (SD, 10.69) (enhanced care as usual); at 3 months postintervention, means were 11.87 (SD, 12.13) (brief intervention) and 9.84 (SD, 10.64) (enhanced care as usual) and not significantly different (difference in differences, β = 0.89 [95% CI, -0.49 to 2.26]). Mean ASI Drug Use composite score at baseline was 0.11 (SD, 0.10) (brief intervention) and 0.11 (SD, 0.10) (enhanced care as usual) and at 3 months was 0.10 (SD, 0.09) (brief intervention) and 0.09 (SD, 0.09) (enhanced care as usual) and not significantly different (difference in differences, β = 0.008 [95% CI, -0.006 to 0.021]). During the 12 months following intervention, no significant treatment differences were found for either variable. No significant differences were found for secondary outcomes.

CONCLUSIONS AND RELEVANCE

A one-time brief intervention with attempted telephone booster had no effect on drug use in patients seen in safety-net primary care settings. This finding suggests a need for caution in promoting widespread adoption of this intervention for drug use in primary care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00877331.

Costs of alcohol screening and brief intervention in medical settings: a review of the literature

OBJECTIVE

This article summarizes the literature on the implementation costs of alcohol screening and brief intervention (SBI) in medical settings.

METHOD

Electronic databases were searched using SBI- and cost-related terms. Methodological approaches and cost estimates were abstracted from each study and categorized based on the cost methodology. Costs were updated to 2009 U.S. dollars. To determine a summary cost measure, we excluded outliers and computed the median of the remaining cost estimates.

RESULTS

Seventeen studies with cost estimates were identified for further study. Costs ranged from $0.51 to $601.50 per screen and from $3.41 to $243.01 per brief intervention (BI). Cost estimates were lower when an activity-based cost methodology was used, in primary care settings, and when the provider was not a doctor. The median summary cost of a screen is approximately $4, and the median summary cost of a BI is approximately $48.

CONCLUSIONS

Screening cost estimates had more variation than BI cost estimates. Provider type and service delivery time drive the cost variation. Interpretation of cost differences was limited by insufficient reporting of the cost methodology. Cost estimates presented here are similar in size to the Healthcare Common Procedure Coding System and Current Procedural Terminology reimbursement amounts, suggesting that insurance-based service reimbursement may be sufficient to sustain alcohol SBI in practice.

Benefits and costs of substance abuse treatment programs for state prison inmates: results from a lifetime simulation model

Reflecting drug use patterns and criminal justice policies throughout the 1990s and 2000s, prisons hold a disproportionate number of society's drug abusers. Approximately 50% of state prisoners meet the criteria for a diagnosis of drug abuse or dependence, but only 10% receive medically based drug treatment. Because of the link between substance abuse and crime, treating substance abusing and dependent state prisoners while incarcerated has the potential to yield substantial economic benefits. In this paper, we simulate the lifetime costs and benefits of improving prison-based substance abuse treatment and post-release aftercare for a cohort of state prisoners. Our model captures the dynamics of substance abuse as a chronic disease; estimates the benefits of substance abuse treatment over individuals' lifetimes; and tracks the costs of crime and criminal justice costs related to policing, adjudication, and incarceration. We estimate net societal benefits and cost savings to the criminal justice system of the current treatment system and five policy scenarios. We find that four of the five policy scenarios provide positive net societal benefits and cost savings to the criminal justice system relative to the current treatment system. Our study demonstrates the societal gains to improving the drug treatment system for state prisoners.

The effect of alternative staff time data collection methods on drug treatment service cost estimates

Although a limited number of service cost estimates exist, no study has evaluated how differences in the method used to collect the staff time allocation across treatment services contribute to differences in service cost estimates. Three alternative data collection methods for estimating service-level costs in methadone treatment programs were evaluated: key informants, staff surveys, and staff diaries. We analyzed data from 25 methadone clinics across the United States. Results indicate that for the three primary services offered at methadone clinics-individual counseling, group counseling, and methadone dosing-no statistically significant differences exist in the mean estimates of costs per session across programs. Of the other five services analyzed, we found no statistically significant differences in two of the mean costs per session and a small but statistically significant difference in another service. We found large and statistically significant differences in mean costs for two services, initial patient assessment and initial medical services. Although there is no gold standard available to judge which method is the best to use, we concluded that the key informant method yields more reliable cost estimates compared with the staff methods and is less burdensome to both the treatment programs and to researchers. Our findings suggest that the key informant method is the preferred method for costing substance abuse treatment services.

Cost and cost-effectiveness of the COMBINE study in alcohol-dependent patients

CONTEXT

The COMBINE (Combined Pharmacotherapies and Behavioral Intervention) clinical trial recently evaluated the efficacy of medications, behavioral therapies, and their combinations for the outpatient treatment of alcohol dependence. The costs and cost-effectiveness of these combinations are unknown and of interest to clinicians and policy makers.

OBJECTIVE

To evaluate the costs and cost-effectiveness of the COMBINE Study interventions after 16 weeks of treatment.

DESIGN

A prospective cost and cost-effectiveness study of a randomized controlled clinical trial.

SETTING

Eleven US clinical sites.

PARTICIPANTS

One thousand three hundred eighty-three patients having a diagnosis of primary alcohol dependence.

INTERVENTIONS

The study included 9 treatment groups; 4 groups received medical management for 16 weeks with naltrexone, 100 mg/d, acamprosate, 3 g/d, or both, and/or placebo; 4 groups received the same therapy as mentioned earlier with combined behavioral intervention; and 1 group received combined behavioral intervention only.

MAIN OUTCOMES MEASURES

Incremental cost per percentage point increase in percentage of days abstinent, incremental cost per patient of avoiding heavy drinking, and incremental cost per patient of achieving a good clinical outcome.

RESULTS

On the basis of the mean values of cost and effectiveness, 3 interventions are cost-effective options relative to the other interventions for all 3 outcomes: medical management (MM) with placebo ($409 per patient), MM plus naltrexone therapy ($671 per patient), and MM plus combined naltrexone and acamprosate therapy ($1003 per patient).

CONCLUSIONS

To our knowledge, this is only the second prospective cost-effectiveness study with a randomized controlled clinical trial design that has been performed for the treatment of alcohol dependence. Focusing only on effectiveness, MM-naltrexone-acamprosate therapy is not significantly better than MM-naltrexone therapy. However, considering cost and cost-effectiveness, MM-naltrexone-acamprosate therapy may be a better choice, depending on whether the cost of the incremental increase in effectiveness is justified by the decision maker.

Examining variation in treatment costs: a cost function for outpatient methadone treatment programs

OBJECTIVES

To estimate a hybrid cost function of the relationship between total annual cost for outpatient methadone treatment and output (annual patient days and selected services), input prices (wages and building space costs), and selected program and patient case-mix characteristics.

DATA SOURCES

Data are from a multistate study of 159 methadone treatment programs that participated in the Center for Substance Abuse Treatment's Evaluation of the Methadone/LAAM Treatment Program Accreditation Project between 1998 and 2000.

STUDY DESIGN

Using least squares regression for weighted data, we estimate the relationship between total annual costs and selected output measures, wages, building space costs, and selected program and patient case-mix characteristics.

PRINCIPAL FINDINGS

Findings indicate that total annual cost is positively associated with program's annual patient days, with a 10 percent increase in patient days associated with an 8.2 percent increase in total cost. Total annual cost also increases with counselor wages (p<.01), but no significant association is found for nurse wages or monthly building costs. Surprisingly, program characteristics and patient case mix variables do not appear to explain variations in methadone treatment costs. Similar results are found for a model with services as outputs.

CONCLUSIONS

This study provides important new insights into the determinants of methadone treatment costs. Our findings concur with economic theory in that total annual cost is positively related to counselor wages. However, among our factor inputs, counselor wages are the only significant driver of these costs. Furthermore, our findings suggest that methadone programs may realize economies of scale; however, other important factors, such as patient access, should be considered.

Presenting results of probabilistic sensitivity analysis: the incremental benefit curve

Cost-effectiveness acceptability curves have become a common way of presenting the results of probabilistic sensitivity analysis. However, these curves do not provide information on what the loss of welfare or net benefit (NB) is for cases where a given intervention is not the optimal one. We describe an alternate approach to presenting the results of probabilistic sensitivity analysis called the incremental benefit curve that presents the entire distribution of incremental NB of each intervention for a given WTP value. The incremental benefit curve provides the decision maker information regarding the potential welfare loss with a given intervention for scenarios in which it is not the optimal intervention, and thus would be a useful complement to the acceptability curve.

A Benefit-Cost Analysis of the Kings County District Attorney's Office Drug Treatment Alternative to Prison (DTAP) Program

In October 1990, the Kings County (Brooklyn, NY) District Attorney's Office implemented the Drug Treatment Alternative to Prison (DTAP) program to divert nonviolent felony drug offenders from prison to community-based residential drug treatment. This article presents an estimate of the costs and benefits of the DTAP program based on a cohort of DTAP participants and prison comparisons who entered treatment or prison in 1995–1996 and were tracked for 6 years. The analysis focuses on the criminal justice system (CJS) costs associated with criminal recidivism. Findings show that the DTAP program is cost-beneficial compared to the usual criminal justice process (benefit-cost ratio equals 2.17 after 6 years).