Browsing by Subject "Opiate substitution treatment"

Now showing 1 - 4 of 4
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    Clinician Willingness to Prescribe Medications for Opioid Use Disorder to Adolescents in Indiana
    (American Medical Association, 2024-09-03) Aalsma, Matthew C.; Bell, Lauren A.; Schwartz, Katherine; Ouyang, Fangqian; Kolak, Marynia; Monahan, Patrick O.; Mermelstein, Sharon P.; Carson, Ian; Hulvershorn, Leslie A.; Adams, Zachary W.; Psychiatry, School of Medicine
    Importance: Prescribing medications for opioid use disorders (MOUD), including buprenorphine, naltrexone, and methadone, to adolescents remains an underused evidence-based strategy for reducing harms associated with opioid use. Objective: To identify potential associations between clinician- and community-level characteristics regarding clinicians' self-reported willingness to prescribe MOUD to adolescents. Design, setting, and participants: This cross-sectional study included a phone survey of Indiana clinicians and spatial analysis of community-level characteristics. Clinicians were eligible for inclusion in analyses if actively providing health care and listed on the Buprenorphine Practitioner Locator website, a publicly available national registry of clinicians possessing a waiver to legally prescribe buprenorphine (ie, waivered clinicians). Exposures: Community-level characteristics, including total population, rurality or urbanicity, percentage with incomes below the federal poverty line, and racial or ethnic makeup. Main outcomes and measures: Clinicians were asked about their willingness to prescribe MOUD to adolescents younger than 18 years if clinically indicated. Responses were recorded as no, yes, or yes with conditions. Results: Among the 871 clinicians listed on the website as of July 2022, 832 were eligible for inclusion and contacted by phone. Among waivered clinicians, 759 (91.2%) reported being unwilling to prescribe MOUD to adolescents, 73 clinicians (8.8%) reported willingness to prescribe MOUD to adolescents, and only 24 (2.9%) would do so without conditions. A multivariable logistic regression model including spatially lagged community-level variables showed that, among areas with waivered clinicians, clinicians practicing in more populated areas were significantly less likely to prescribe to adolescents (β = 0.65; 95% CI, 0.49-0.87; P = .003). Similarly, those in more rural areas were significantly more likely to prescribe to adolescents (β = 1.27; 95% CI, 1.02-1.58; P = .03). Variation in clinician willingness to prescribe was not explained by other community-level characteristics. Among all waivered clinicians, advanced practice clinicians were less likely than physicians to report willingness to prescribe (β = 0.58; 95% CI, 0.35-0.97; P = .04), as were physicians without any specialty training relevant to MOUD prescribing when compared with family medicine clinicians (β = 0.40; 95% CI, 0.18-0.89; P = .03). A small subgroup of waivered clinicians had training in pediatrics (13 clinicians [1.6%]), and none were willing to prescribe MOUD to adolescents. Conclusions and relevance: From this cross-sectional study, it appears that Indiana adolescents continued to face gaps in access to MOUD treatment, despite its well-established efficacy. Programs that support primary care practitioners, including family medicine clinicians and pediatricians, in safe and appropriate use of MOUD in adolescents may bridge these gaps.
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    Expert Panel Consensus on State-Level Policies to Improve Engagement and Retention in Treatment for Opioid Use Disord
    (American Medical Association, 2022-09-02) Smart, Rosanna; Grant, Sean; Gordon, Adam J.; Pacula, Rosalie Liccardo; Stein, Bradley D.; Social and Behavioral Sciences, School of Public Health
    Importance: In the US, recent legislation and regulations have been considered, proposed, and implemented to improve the quality of treatment for opioid use disorder (OUD). However, insufficient empirical evidence exists to identify which policies are feasible to implement and successfully improve patient and population-level outcomes. Objective: To examine expert consensus on the effectiveness and the ability to implement state-level OUD treatment policies. Evidence review: This qualitative study used the ExpertLens online platform to conduct a 3-round modified Delphi process to convene 66 stakeholders (health care clinicians, social service practitioners, addiction researchers, health policy decision-makers, policy advocates, and persons with lived experience). Stakeholders participated in 1 of 2 expert panels on 14 hypothetical state-level policies targeting treatment engagement and linkage, evidence-based and integrated care, treatment flexibility, and monitoring or support services. Participants rated policies in round 1, discussed results in round 2, and provided final ratings in round 3. Participants used 4 criteria associated with either the effectiveness or implementability to rate and discuss each policy. The effectiveness panel (n = 29) considered policy effects on treatment engagement, treatment retention, OUD remission, and opioid overdose mortality. The implementation panel (n = 34) considered the acceptability, feasibility, affordability, and equitability of each policy. We measured consensus using the interpercentile range adjusted for symmetry analysis technique from the RAND/UCLA appropriateness method. Findings: Both panels reached consensus on all items. Experts viewed 2 policies (facilitated access to medications for OUD and automatic Medicaid enrollment for citizens returning from correctional settings) as highly implementable and highly effective in improving patient and population-level outcomes. Participants rated hub-and-spoke-type policies and provision of financial incentives to emergency departments for treatment linkage as effective; however, they also rated these policies as facing implementation barriers associated with feasibility and affordability. Coercive policies and policies levying additional requirements on individuals with OUD receiving treatment (eg, drug toxicology testing, counseling requirements) were viewed as low-value policies (ie, decreasing treatment engagement and retention, increasing overdose mortality, and increasing health inequities). Conclusions and relevance: The findings of this study may provide urgently needed consensus on policies for states to consider either adopting or deimplementing in their efforts to address the opioid overdose crisis.
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    Improving Uptake of Emergency Department-initiated Buprenorphine: Barriers and Solutions
    (Department of Emergency Medicine, School of Medicine, University of California, Irvine, 2022-07-11) Kelly, Timothy D.; Hawk, Kathryn F.; Samuels, Elizabeth A.; Strayer, Reuben J.; Hoppe, Jason A.; Emergency Medicine, School of Medicine
    Emergency departments (ED) are increasingly providing buprenorphine to persons with opioid use disorder. Buprenorphine programs in the ED have strong support from public health leaders and emergency medicine specialty societies and have proven to be clinically effective, cost effective, and feasible. Even so, few ED buprenorphine programs currently exist. Given this imbalance between evidence-based practice and current practice, proven behavior change approaches can be used to guide local efforts to expand ED buprenorphine capacity. In this paper, we use the theory of planned behavior to identify and address the 1) clinician factors, 2) institutional factors, and 3) external factors surrounding ED buprenorphine implementation. By doing so, we seek to provide actionable and pragmatic recommendations to increase ED buprenorphine availability across different practice settings.
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    Trends in Access to Medications for Opioid Use Disorder
    (American Medical Association, 2025-04-04) Gupta, Sumedha; James, Aditya; Miles, Jennifer; Samples, Hillary; Crystal, Stephen; Simon, Kosali; Economics, School of Liberal Arts
    Importance: Medicaid, the largest payer for medications for opioid use disorder (MOUD), disenrolled more than 19.1 million individuals by March 2024 after the continuous coverage requirement ended in April 2023-a process termed Medicaid unwinding-but the impact on buprenorphine receipt remains unknown. Objective: To assess the association between Medicaid unwinding and dispensing of prescription buprenorphine, overall and by payment sources nationally and by state. Design, setting, and participants: Cross-sectional study of buprenorphine dispensing (age ≥18 years) from April 2020 to March 2024 using the IQVIA Longitudinal Prescription (LRx) database containing more than 90% of US retail pharmacy claims. Interrupted time-series estimated levels and trends of buprenorphine prescription dispensation before and after Medicaid unwinding. Main outcomes and measures: The number of patients with filled buprenorphine prescriptions each month was analyzed by payer type (Medicaid, Medicare, commercial, or self-pay) and by state. Stratified analyses assessed state factors, including automated (ex parte) Medicaid renewal rates (higher or lower than the median), income verification sources used for automated renewals (≤3, 4-5, or 6-7), and Affordable Care Act Medicaid expansion status. Results: Of the 2 405 970 adults who filled buprenorphine prescriptions between April 2020 and March 2024, 1 154 866 (48%) had at least 1 fill covered by Medicaid, 288 716 (12%) by Medicare, 1 106 746 (46%) by commercial insurance, and 264 657 (11%) by self-pay. Medicaid unwinding was associated with reversal of previously increasing trends in buprenorphine prescriptions, with 2.9% fewer patients (-23 855 [95% CI, -32 661 to -15 054]) receiving buprenorphine each month by 8 months after unwinding vs the month before unwinding began. This decline was driven by a 12.7% drop in patients with Medicaid-paid fills (-46 545 [95% CI, -51 362 to -41 730]), partially offset by increases in patients with commercial (6.12%, 19 809 [95% CI, 12 109 to 27 509]) and self-paid (7.24%, 2525 [95% CI, 1246 to 3805]) fills. Sixteen states saw overall declines in buprenorphine use after unwinding, with reductions among patients with Medicaid-covered prescriptions in 36 states, partially offset by increases in patients with commercial insurance covered fills (32 states) and self-paid fills (23 states). Buprenorphine prescriptions remained stable in states with above-median automated Medicaid renewal rates and more income verification sources, whereas states with below-median automated renewal rates, fewer verification sources, and nonexpansion state status experienced smaller offsets for Medicaid-related losses, highlighting importance of state-specific policies. Conclusions and relevance: This cross-sectional study of Medicaid unwinding and filled buprenorphine prescriptions found that although shifts to commercial and self-pay sources mitigated some losses, rising self-pay reliance poses affordability barriers that threaten treatment continuity. Addressing access disparities is critical amid persistently high US overdose rates.