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JAMA Network Open Jun 2023Prior authorization (PA) requirements for buprenorphine are associated with lower provision of the medication for the treatment of opioid use disorder (OUD). While... (Review)
Review
IMPORTANCE
Prior authorization (PA) requirements for buprenorphine are associated with lower provision of the medication for the treatment of opioid use disorder (OUD). While Medicare plans have eliminated PA requirements for buprenorphine, many Medicaid plans continue to require them.
OBJECTIVE
To describe and classify buprenorphine coverage requirements based on thematic analysis of state Medicaid PA forms.
DESIGN, SETTING, AND PARTICIPANTS
This qualitative study used a thematic analysis of 50 states' Medicaid PA forms for buprenorphine between November 2020 and March 2021. Forms were obtained from the jurisdiction's Medicaid websites and assessed for features suggesting barriers to buprenorphine access. A coding tool was developed based on a review of a sample of forms, including fields for behavioral health treatment recommendations or mandates, drug screening requirements, and dosage limitations.
MAIN OUTCOMES AND MEASURES
Outcomes included PA requirements for different buprenorphine formulations. Additionally, PA forms were evaluated for various criteria such as behavioral health, drug screenings, dose-related recommendations or mandates or patient education.
RESULTS
Among the total of 50 US states in the analysis, most states' Medicaid plans required PA for at least 1 formulation of buprenorphine. However, the majority did not require a PA for buprenorphine-naloxone. Four key themes of coverage requirements were identified: restrictive surveillance (eg, requirements for urine drug screenings, random drug screenings, pill counts), behavioral health treatment recommendations or mandates (eg, mandatory counseling or 12-step meeting attendance), interfering with or restricting medical decision-making (eg, maximum daily dosages of 16 mg, requiring additional steps for dosages higher than 16 mg), and patient education (eg, information about adverse effects and interactions with other medications). Eleven states (22%) required urine drug screenings, 6 states (12%) required random urine drug screenings, and 4 states (8%) required pill counts. Fourteen states' forms (28%) recommended therapy, and 7 (14%) required therapy, counseling, or participation in group sessions. Eighteen states (36%) specified dosage maximums; among them, 11 (22%) required additional steps for a daily dosage higher than 16 mg.
CONCLUSION
In this qualitative study of state Medicaid PA requirements for buprenorphine, themes were identified that included patient surveillance with drug screenings and pill counts, behavioral health treatment recommendations or mandates, patient education, and dosing guidance. These results suggest that state Medicaid plans' buprenorphine PA requirements for OUD are in conflict with existing evidence and may negatively affect states' efforts to address the opioid overdose crisis.
Topics: Aged; Humans; United States; Buprenorphine; Medicaid; Prior Authorization; Medicare; Buprenorphine, Naloxone Drug Combination; Opioid-Related Disorders
PubMed: 37318805
DOI: 10.1001/jamanetworkopen.2023.18487 -
The Western Journal of Emergency... Nov 2023Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency...
OBJECTIVE
Buprenorphine is an evidence-based treatment for opioid use disorder that is underused in the emergency department (ED). In this study we evaluated changes in emergency physician knowledge, confidence, and self-efficacy regarding buprenorphine prescribing and working with patients who use drugs after implementation of an ED buprenorphine quality improvement (QI) initiative.
METHODS
An anonymous, online survey was administered to emergency physicians staffing four EDs in New England in 2019 and 2020 before and after an ED QI initiative. Survey questions included novel and previously validated questions to assess confidence, knowledge, self-efficacy, and attitudes about buprenorphine and working with patients who use drugs. Confidence, self-efficacy, and attitude responses were assessed on a Likert scale. Participants received a gift card for survey completion. We analyzed pre- and post- survey responses descriptively and compared them using -tests. Using logistic regression we evaluated the factors associated with buprenorphine prescribing.
RESULTS
Of 95 emergency physicians, 56 (58.9% response rate) completed the pre-intervention survey and 60 (63.2%) completed the post-survey. There was an increase in the number of X-waivered adult emergency physicians and ED buprenorphine prescribing after program implementation. Physician confidence increased from a mean of 3.4 ( 0.8) to 3.9 ( 0.7; scale 1-5, < 0.01). Knowledge about buprenorphine increased from a mean score of 1.4 ( 0.7) to 1.7 ( 0.5, < 0.01). Physician attitudes and self-efficacy did not change. Post-initiative, increased confidence was associated with higher odds of buprenorphine prescribing (odds ratio 4.4; 95% confidence interval 1.07-18.4).
CONCLUSION
After an ED QI initiative, buprenorphine prescribing in the ED increased, as did both physician confidence in working with patients who use drugs and their knowledge of buprenorphine. Increased confidence was associated with higher odds of buprenorphine prescribing and should be a focus of future, buprenorphine implementation strategies in the ED.
Topics: Adult; Humans; Buprenorphine; Self Efficacy; Quality Improvement; Health Knowledge, Attitudes, Practice; Opioid-Related Disorders; Emergency Service, Hospital; Physicians; Opiate Substitution Treatment
PubMed: 38165180
DOI: 10.5811/westjem.59477 -
Therapie 2020
Topics: Analgesics, Opioid; Buprenorphine; Humans; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 33039103
DOI: 10.1016/j.therap.2020.09.007 -
The International Journal on Drug Policy Jul 2022Structural vulnerabilities for people who use drugs (PWUD) were exacerbated by the COVID-19 pandemic. In this context, federal lawmakers in the United States (U.S.)...
BACKGROUND
Structural vulnerabilities for people who use drugs (PWUD) were exacerbated by the COVID-19 pandemic. In this context, federal lawmakers in the United States (U.S.) invoked an exemption to the 2008 Ryan Haight Act requiring in-person evaluation to prescribe buprenorphine for treatment of opioid use disorder (OUD), which allowed for the initiation and maintenance of buprenorphine via telehealth. Despite the potential for telehealth to address some of the geographic disparities in OUD treatment access, recent research has suggested that significant barriers to buprenorphine also exist at the pharmacy level. The purpose of this study was to qualitatively assess how efforts to increase access to buprenorphine via telehealth are implemented by prescribers and pharmacists and experienced by patients.
METHODS
Participant observation and semi-structured interviews focused on telehealth for OUD treatment and buprenorphine prescribing and dispensing were conducted with patients (n = 19), prescribers and clinic staff (n = 24), and pharmacists (n = 10) in Pennsylvania and California between May 2020 - May 2021.
FINDINGS
While participants stated that telehealth for OUD treatment was a welcome option, pharmacy-level barriers to buprenorphine persisted. Geographical distance from patient to provider or pharmacist continued to serve as "red flags" for pharmacists, leading to pharmacy-level "red tape:" gatekeeping measures including geographic restrictions, telephone prescription "confirmations," prescription cancellations and refusals. Patients' unmet expectations of buprenorphine access in some cases led to unanticipated risks including a return to injection drug use.
CONCLUSION
Challenges to increasing buprenorphine access persist in the U.S. even in settings where telehealth is implemented, and telehealth may inadvertently produce new barriers for some patients. Despite national support for policies aimed at increasing access to treatment for substance use disorders rather than punishment, policy shifts from punishment to treatment have not permeated evenly across all geographic areas and populations. Perceived threats of Drug Enforcement Administration (DEA) enforcement, and self-defensive institutional practices in pharmacies, reinforce ideologies of drug law enforcement, leading to poor patient outcomes including lack of buprenorphine access.
Topics: Humans; Buprenorphine; COVID-19 Drug Treatment; Opiate Substitution Treatment; Opioid-Related Disorders; Pandemics; Pharmacies; Pharmacy; Telemedicine; United States
PubMed: 35561484
DOI: 10.1016/j.drugpo.2022.103703 -
American Journal of Public Health Dec 2019
Topics: Buprenorphine; Drug and Narcotic Control; Humans; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; United States
PubMed: 31693402
DOI: 10.2105/AJPH.2019.305370 -
The Western Journal of Emergency... Jun 2022Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose... (Review)
Review
INTRODUCTION
Medications for opioid use disorder (MOUD), including buprenorphine, represent an evidence-based treatment that supports long-term recovery and reduces risk of overdose death. Patients in crisis from opioid use disorder (OUD) often seek care from emergency departments (ED). The New York Medication for Addiction Treatment and Electronic Referrals (MATTERS) network is designed to support ED-initiated buprenorphine and urgent referrals to long-term care for patients suffering from OUD.
METHODS
Using the PRECEDE-PROCEED implementation science framework, we provide an overview of the creation of the MATTERS network in Western New York. We also include an explanation of how the network was designed and launched as a response to the opioid epidemic. Finally, we analyzed the program's outputs and outcomes, thus far, as it continues to grow across the state.
RESULTS
The New York MATTERS network was created and implemented in 2019 with a single hospital referring patients with OUD to three local clinics. In the social assessment and situational analysis phase, we describe the opioid epidemic and available resources in the region at the outset of the program. In the epidemiological assessment phase, we quantify the epidemic on the state and regional levels. In the educational and ecological assessment, we review local ED practices and resources. In the administrative and policy assessment and intervention alignment phase, the program's unique framework is reviewed. In the piloting phase, we describe the initial deployment of New York MATTERS. Finally, in the process evaluation phase, we depict the early lessons we learned. By the beginning of 2021, the New York MATTERS network included 35 hospitals that refer to 47 clinics throughout New York State.
CONCLUSION
The New York MATTERS network provides a structured approach to reduce barriers to ED-initiated buprenorphine and urgent referral to long-term care. An implementation framework provides a structured means of evaluating this best practice model.
Topics: Analgesics, Opioid; Buprenorphine; Emergency Service, Hospital; Humans; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 35980408
DOI: 10.5811/westjem.2022.3.54680 -
Journal of Acquired Immune Deficiency... Aug 2022HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL)...
BACKGROUND
HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention.
METHODS
The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites.
RESULTS
Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well.
CONCLUSIONS
Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.
Topics: Buprenorphine; Drug Overdose; HIV Infections; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Practice Patterns, Physicians'
PubMed: 35587832
DOI: 10.1097/QAI.0000000000003001 -
CNS Drugs Jun 2022Opioids are widely used in chronic pain management, despite major concerns about their risk of adverse events, particularly abuse, misuse, and respiratory depression... (Review)
Review
Opioids are widely used in chronic pain management, despite major concerns about their risk of adverse events, particularly abuse, misuse, and respiratory depression from overdose. Multi-mechanistic opioids, such as tapentadol and buprenorphine, have been widely studied as a valid alternative to traditional opioids for their safer profile. Special interest was focused on the role of the nociceptin opioid peptide (NOP) receptor in terms of analgesia and improved tolerability. Nociceptin opioid peptide receptor agonists were shown to reinforce the antinociceptive effect of mu opioid receptor (MOR) agonists and modulate some of their adverse effects. Therefore, multi-mechanistic opioids involving both MOR and NOP receptor activation became a major field of pharmaceutical and clinical investigations. Buprenorphine was re-discovered in a new perspective, as an atypical analgesic and as a substitution therapy for opioid use disorders; and buprenorphine derivatives have been tested in animal models of nociceptive and neuropathic pain. Similarly, cebranopadol, a full MOR/NOP receptor agonist, has been clinically evaluated for its potent analgesic efficacy and better tolerability profile, compared with traditional opioids. This review overviews pharmacological mechanisms of the NOP receptor system, including its role in pain management and in the development of opioid tolerance. Clinical data on buprenorphine suggest its role as a safer alternative to traditional opioids, particularly in patients with non-cancer pain; while data on cebranopadol still require phase III study results to approve its introduction on the market. Other bifunctional MOR/NOP receptor ligands, such as BU08028, BU10038, and AT-121, are currently under pharmacological investigations and could represent promising analgesic agents for the future.
Topics: Analgesics, Opioid; Animals; Buprenorphine; Drug Tolerance; Humans; Isoquinolines; Naltrexone; Opioid Peptides; Pain; Phenylpropionates; Receptors, Opioid, mu; Nociceptin
PubMed: 35616826
DOI: 10.1007/s40263-022-00924-2 -
Journal of Substance Abuse Treatment Apr 2022This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the... (Review)
Review
Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine.
INTRODUCTION
This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.
METHODS
The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.
RESULTS
The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.
CONCLUSIONS
The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.
Topics: Analgesics, Opioid; Buprenorphine; Humans; Methadone; Motivation; Opiate Substitution Treatment; Opioid-Related Disorders
PubMed: 34728134
DOI: 10.1016/j.jsat.2021.108651 -
Journal of Addiction MedicineLow-threshold buprenorphine treatment aims to reduce barriers to evidence-based opioid use disorder treatment. We aimed to describe the treatment philosophy, practices,...
OBJECTIVES
Low-threshold buprenorphine treatment aims to reduce barriers to evidence-based opioid use disorder treatment. We aimed to describe the treatment philosophy, practices, and outcomes of a low-threshold syringe services program (SSP)-based buprenorphine program developed through an SSP-academic medical center partnership.
METHODS
We included all SSP participants who received 1 or more buprenorphine prescription from Feb 5, 2019 to October 9, 2020. We collected data on patient characteristics, substance use, buprenorphine prescriptions, and urine drug tests (UDTs). We evaluated buprenorphine treatment retention using prescription data and buprenorphine adherence using UDTs. We used 2 retention definitions: (1) percentage of patients with buprenorphine prescriptions at 30, 90, and 180 days; and (2) total percentage of days "covered" with buprenorphine prescriptions through 180 days.
RESULTS
One-hundred and eighteen patients received 1 or more buprenorphine prescriptions. Patients were largely middle-aged (mean age 44, standard deviation 11), male (68%), Hispanic (31%) or Non-Hispanic Black (32%), with heroin (90%) and crack/cocaine (62%) use, and injection drug use (59%). Retention was 62%, 43%, and 31% at 30, 90, and 180 days, respectively. The median percentage of days covered with buprenorphine prescriptions through 180 days was 43% (interquartile range 8%-92%). Of the 82 patients who completed 2 or more UDTs, the median percentage of buprenorphine-positive UDTs was 71% (interquartile range 40%-100%).
CONCLUSIONS
In an SSP-based low-threshold buprenorphine treatment program, approximately one-third of patients continued buprenorphine treatment for 180 days or more, and buprenorphine adherence was high. SSPs can be a pathway to buprenorphine treatment for patients at high risk for opioid-related harms.
Topics: Adult; Analgesics, Opioid; Buprenorphine; Humans; Male; Middle Aged; Opiate Substitution Treatment; Opioid-Related Disorders; Program Development; Syringes
PubMed: 34775441
DOI: 10.1097/ADM.0000000000000934