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JAMA Network Open May 2020Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting...
IMPORTANCE
Treatment of opioid use disorder (OUD) with buprenorphine decreases opioid use and prevents morbidity and mortality. Emergency departments (EDs) are an important setting for buprenorphine initiation for patients with untreated OUD; however, readiness varies among ED clinicians.
OBJECTIVE
To characterize barriers and facilitators of readiness to initiate buprenorphine for the treatment of OUD in the ED and identify opportunities to promote readiness across multiple clinician types.
DESIGN, SETTING, AND PARTICIPANTS
Using data collected from April 1, 2018, to January 11, 2019, this mixed-methods formative evaluation grounded in the Promoting Action on Research Implementation in Health Services framework included 4 geographically diverse academic EDs. Attending physicians (n = 113), residents (n = 107), and advanced practice clinicians (APCs) (n = 48) completed surveys electronically distributed to all ED clinicians (n = 396). A subset of participants (n = 74) also participated in 1 of 11 focus group discussions. Data were analyzed from June 1, 2018, to February 22, 2020.
MAIN OUTCOMES AND MEASURES
Clinician readiness to initiate buprenorphine and provide referral for ongoing treatment for patients with OUD treated in the ED was assessed using a visual analog scale. Responders (268 of 396 [67.7%]) were dichotomized as less ready (scores 0-6) or most ready (scores 7-10). An ED-adapted Organizational Readiness to Change Assessment (ORCA) and 11 focus groups were used to assess ratings and perspectives on evidence and context-related factors to promote ED-initiated buprenorphine with referral for ongoing treatment, respectively.
RESULTS
Among the 268 survey respondents (153 of 260 were men [58.8%], with a mean [SD] of 7.1 [9.8] years since completing formal training), 56 (20.9%) indicated readiness to initiate buprenorphine for ED patients with OUD. Nine of 258 (3.5%) reported Drug Addiction Treatment Act of 2000 training completion. Compared with those who were less ready, clinicians who were most ready to initiate buprenorphine had higher mean scores across all ORCA Evidence subscales (3.50 [95% CI, 3.35-3.65] to 4.33 [95% CI, 4.13-4.53] vs 3.11 [95% CI, 3.03-3.20] to 3.60 [95% CI, 3.49-3.70]; P < .001) and on the Slack Resources of the ORCA Context subscales (3.32 [95% CI, 3.08-3.55] vs 3.0 [95% CI, 2.87-3.12]; P = .02). Barriers to ED-initiated buprenorphine included lack of training and experience in treating OUD with buprenorphine, concerns about ability to link to ongoing care, and competing needs and priorities for ED time and resources. Facilitators to ED-initiated buprenorphine included receiving education and training, development of local departmental protocols, and receiving feedback on patient experiences and gaps in quality of care.
CONCLUSIONS AND RELEVANCE
Only a few ED clinicians had a high level of readiness to initiate buprenorphine; however, many expressed a willingness to learn with sufficient supports. Efforts to promote adoption of ED-initiated buprenorphine will require clinician and system-level changes.
Topics: Adult; Buprenorphine; Emergency Service, Hospital; Female; Focus Groups; Humans; Male; Middle Aged; Opiate Substitution Treatment; Opioid Epidemic; Opioid-Related Disorders; Practice Patterns, Physicians'; Referral and Consultation; Surveys and Questionnaires; United States
PubMed: 32391893
DOI: 10.1001/jamanetworkopen.2020.4561 -
Cleveland Clinic Journal of Medicine Oct 2022
Topics: Buprenorphine; Humans
PubMed: 36192022
DOI: 10.3949/ccjm.89a.21019 -
Journal of Substance Abuse Treatment May 2021The COVID-19 pandemic has presented challenges for traditional models of opioid use disorder treatment worldwide. Depot buprenorphine became available in Australia...
The COVID-19 pandemic has presented challenges for traditional models of opioid use disorder treatment worldwide. Depot buprenorphine became available in Australia shortly before the height of the COVID-19 pandemic. This timing provided us an opportunity to examine the utilization and uptake of depot buprenorphine, and to understand the particular benefits and implementation challenges associated with this new formulation of opioid agonist treatment.
Topics: Australia; Buprenorphine; COVID-19; Delayed-Action Preparations; Humans; Injections, Subcutaneous; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Quarantine
PubMed: 33303254
DOI: 10.1016/j.jsat.2020.108221 -
BMJ Open Sep 2021Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department...
INTRODUCTION
Buprenorphine-naloxone is recommended as a first-line agent for the treatment of opioid use disorder. Although initiation of buprenorphine in the emergency department (ED) is evidence based, barriers to implementation persist. A comprehensive review and critical analysis of both facilitators of and barriers to buprenorphine initiation in ED has yet to be published. Our objectives are (1) to map the implementation of buprenorphine induction pathway literature and synthesise what we know about buprenorphine pathways in EDs and (2) to identify gaps in this literature with respect to barriers and facilitators of implementation.
METHODS AND ANALYSIS
We will conduct a scoping review to comprehensively search the literature, map the evidence and identify gaps in knowledge. The review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-analyses Protocols Extension for Scoping Reviews and guidance from the Joanna Briggs Institution for conduct of scoping reviews. We will search Medline, APA, PsycINFO, CINAHL, Embase and IBSS from 1995 to present and the search will be restricted to English and French language publications. Citations will be screened in Covidence by two trained reviewers. Discrepancies will be mediated by consensus. Data will be synthesised using a hybrid, inductive-deductive approach, informed by the Consolidated Framework for Implementation Research as well as critical theory to guide further interpretation.
ETHICS AND DISSEMINATION
This review does not require ethics approval. A group of primary knowledge users, including clinicians and people with lived experience, will be involved in the dissemination of findings including publication in peer-reviewed journals. Results will inform future research, current quality improvement efforts in affiliated hospitals, and aide the creation of a more robust ED response to the escalating overdose crisis.
Topics: Buprenorphine; Delivery of Health Care; Diagnostic Tests, Routine; Emergency Service, Hospital; Humans; Opioid-Related Disorders; Research Design; Systematic Reviews as Topic
PubMed: 34580102
DOI: 10.1136/bmjopen-2021-053207 -
JAMA Psychiatry Dec 2022Nonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform...
IMPORTANCE
Nonadherence to buprenorphine may increase patient risk of opioid overdose and increase health care spending. Quantifying the impacts of nonadherence can help inform clinician practice and policy.
OBJECTIVE
To estimate the association between buprenorphine treatment gaps, opioid overdose, and health care spending.
DESIGN, SETTING, AND PARTICIPANTS
This longitudinal case-control study compared patient opioid overdose and health care spending in buprenorphine-treated months with treatment gap months. Individuals who were US Medicare fee-for-service beneficiaries diagnosed with opioid use disorder who received at least 1 two-week period of continuous buprenorphine treatment between 2010 and 2017 were included. Analysis took place between January 2010 and December 2017.
INTERVENTIONS
A gap in buprenorphine treatment in a month lasting more than 15 consecutive days.
MAIN OUTCOMES AND MEASURES
Opioid overdose and total, medical, and drug spending (combined patient out-of-pocket and Medicare spending).
RESULTS
Of 34 505 Medicare beneficiaries (17 927 [520%] male; 16 578 [48.1%] female; mean [SD] age, 49.5 [12.7] years; 168 [0.5%] Asian; 2949 [8.5%] Black; 2089 [6.0%] Hispanic; 266 [0.8%] Native American; 28 525 [82.7%] White; 508 [1.5%] other race), 11 524 beneficiaries (33.4%) experienced 1 or more buprenorphine treatment gaps. Treatment gap beneficiaries, compared with nontreatment gap beneficiaries, were more likely to be younger, be male, have a disability, and be Medicaid dual-eligible while less likely to be White, close to a buprenorphine prescriber, and treated with buprenorphine monotherapy (ie, buprenorphine hydrochloride). Beneficiaries were 2.89 (95% CI, 2.20-3.79) times more likely to experience an opioid overdose during buprenorphine treatment gap months compared with treated months. During treatment gap months, spending was $196.41 (95% CI, $110.53-$282.30) more than in treated months. Patients who continued to take buprenorphine dosages of greater than 8 mg/d and 16 mg/d were 2.61 and 2.84 times more likely to overdose in a treatment gap month, respectively, while patients taking buprenorphine dosages of 8 mg/d or less were 3.62 times more likely to overdose in a treatment gap month (maintenance of >16 mg/d: hazard ratio (HR), 2.64 [95% CI, 1.80-3.87]; maintenance of >8 mg/d: HR, 2.84 [95% CI, 2.13-3.78]; maintenance of ≤8 mg/d: HR, 3.62 [95% CI, 1.54-8.50]). Buprenorphine monotherapy was associated with greater risk of overdose and higher spending during treatment gaps months than buprenorphine/naloxone.
CONCLUSIONS AND RELEVANCE
Medicare patients treated with buprenorphine between 2010 and 2017 had a lower associated opioid overdose risk and spending during treatment months than treatment gap months.
Topics: United States; Humans; Aged; Female; Male; Middle Aged; Buprenorphine; Opiate Overdose; Case-Control Studies; Health Expenditures; Medicare
PubMed: 36197659
DOI: 10.1001/jamapsychiatry.2022.3118 -
Addiction (Abingdon, England) Oct 2022Fentanyl is primarily responsible for the current phase of the overdose epidemic in North America. Despite the benefits of treatment with medications for opioid use... (Randomized Controlled Trial)
Randomized Controlled Trial
Impact of fentanyl use on initiation and discontinuation of methadone and buprenorphine/naloxone among people with prescription-type opioid use disorder: secondary analysis of a Canadian treatment trial.
BACKGROUND AND AIMS
Fentanyl is primarily responsible for the current phase of the overdose epidemic in North America. Despite the benefits of treatment with medications for opioid use disorder (MOUD), there are limited data on the association between fentanyl, MOUD type and treatment engagement. The objectives of this analysis were to measure the impact of baseline fentanyl exposure on initiation and discontinuation of MOUD among individuals with prescription-type opioid use disorder (POUD).
DESIGN, SETTING AND PARTICIPANTS
Secondary analysis of a Canadian multi-site randomized pragmatic trial conducted between 2017 and 2020. Of the 269 randomized participants, 65.4% were male, 67.3% self-identified as white and 55.4% had a positive fentanyl urine drug test (UDT) at baseline. Fentanyl-exposed participants were more likely to be younger, to self-identify as non-white, to be unemployed or homeless and to be currently using stimulants than non-fentanyl-exposed participants.
INTERVENTIONS
Flexible take-home dosing buprenorphine/naloxone or supervised methadone models of care for 24 weeks.
MEASUREMENTS
Outcomes were (1) MOUD initiation and (2) time to (a) assigned and (b) overall MOUD discontinuation. Independent variables were baseline fentanyl UDT (predictor) and assigned MOUD (effect modifier).
FINDINGS
Overall, 209 participants (77.7%) initiated MOUD. In unadjusted analyses, fentanyl exposure was associated with reduced likelihood of treatment initiation [odds ratio (OR) = 0.18, 95% confidence interval (CI) = 0.08-0.36] and shorter median times in assigned [20 versus 168 days, hazard ratio (HR) = 3.61, 95% CI = 2.52-5.17] and any MOUD (27 versus 168 days, HR = 3.32, 95% CI = 2.30-4.80). The negative effects were no longer statistically significant in adjusted models, and no interaction between fentanyl and MOUD was observed for any of the outcomes (all P > 0.05).
CONCLUSIONS
Both buprenorphine/naloxone and methadone may be appropriate treatment options for people with prescription-type opioid use disorder regardless of fentanyl exposure. Other characteristics of fentanyl-exposed individuals appear to be driving the association with poorer treatment outcomes.
Topics: Analgesics, Opioid; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Canada; Female; Fentanyl; Humans; Male; Methadone; Opiate Substitution Treatment; Opioid-Related Disorders; Prescriptions
PubMed: 35712892
DOI: 10.1111/add.15954 -
Journal of Substance Abuse Treatment Apr 2021Improving access to medications for opioid use disorder (MOUD) is a national priority; however, these efforts commonly focus on the provider. Access to buprenorphine...
BACKGROUND
Improving access to medications for opioid use disorder (MOUD) is a national priority; however, these efforts commonly focus on the provider. Access to buprenorphine through retail pharmacies and stigma associated with filling prescriptions for MOUD pose additional barriers for patients when embarking on their road to recovery.
METHODS
This study performed a pre-post retrospective chart review to evaluate the potential positive impact on patient retention when providing buprenorphine at office visits instead of at pharmacies. Study staff reviewed electronic medical records to document patient retention in treatment at 6 months as the primary outcome. The study evaluated as secondary outcomes missed office visits, medication adherence, illicit drug use (that drug testing results identified), and drug-related emergency department (ED) utilization. Study staff documented outcomes for patients given their buprenorphine medication at their office visit (n = 154) compared with randomly selected patients prescribed buprenorphine from the same office-based opioid treatment clinic who had to go to retail pharmacies to fill their prescriptions (n = 154).
RESULTS
Patients receiving buprenorphine at their office visit demonstrated a 52.2% higher retention rate after 6 months compared to the control group (p = .005). Patients were more likely to attend scheduled office visits (p = .046), less likely to test positive for nonprescribed/illicit drugs (p < .001), and less likely to utilize the ED for drug-related reasons (p = .018) when the program alleviated the need to fill buprenorphine prescriptions at retail pharmacies and began to offer the pharmacy services at office visits.
CONCLUSIONS
Provision of buprenorphine to patients at their treatment visit was associated with higher patient retention rates and better health outcomes compared with patients who filled their buprenorphine at pharmacies prior to the program's integration of medication provision at patient office visits. Understanding how alleviating barriers to medication access impacts retention in care has meaningful implications for opioid use disorder patients and treatment providers.
Topics: Analgesics, Opioid; Buprenorphine; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Retrospective Studies
PubMed: 33612191
DOI: 10.1016/j.jsat.2020.108256 -
JAMA Network Open May 2023Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization.
IMPORTANCE
Buprenorphine is underutilized as a treatment for opioid use disorder (OUD); state policies may improve buprenorphine access and utilization.
OBJECTIVE
To assess buprenorphine prescribing trends following New Jersey Medicaid initiatives designed to improve access.
DESIGN, SETTING, AND PARTICIPANTS
This cross-sectional interrupted time series analysis included New Jersey Medicaid beneficiaries who were prescribed buprenorphine and had 12 months continuous Medicaid enrollment, OUD diagnosis, and no Medicare dual eligibility, as well as physician or advanced practitioners who prescribed buprenorphine to Medicaid beneficiaries. The study used Medicaid claims data from 2017 to 2021.
EXPOSURE
Implementation of New Jersey Medicaid initiatives in 2019 that removed prior authorizations, increased reimbursement for office-based OUD treatment, and established regional Centers of Excellence.
MAIN OUTCOMES AND MEASURES
Rate of buprenorphine receipt per 1000 beneficiaries with OUD; percentage of new buprenorphine episodes lasting at least 180 days; buprenorphine prescribing rate per 1000 Medicaid prescribers, overall and by specialty.
RESULTS
Of 101 423 Medicaid beneficiaries (mean [SD] age, 41.0 [11.6] years; 54 726 [54.0%] male; 30 071 [29.6%] Black, 10 143 [10.0%] Hispanic, and 51 238 [50.5%] White), 20 090 filled at least 1 prescription for buprenorphine from 1788 prescribers. Policy implementation was associated with an inflection point in buprenorphine prescribing trend; after implementation, the trend increased by 36%, from 1.29 (95% CI, 1.02-1.56) prescriptions per 1000 beneficiaries with OUD to 1.76 (95% CI, 1.46-2.06) prescriptions per 1000 beneficiaries with OUD. Among beneficiaries with new buprenorphine episodes, the percentage retained for at least 180 days was stable before and after initiatives were implemented. The initiatives were associated with an increase in the growth rate of buprenorphine prescribers (0.43 per 1000 prescribers; 95% CI, 0.34 to 0.51 per 1000 prescribers). Trends were similar across specialties, but increases were most pronounced among primary care and emergency medicine physicians (eg, primary care: 0.42 per 1000 prescribers; 95% CI, 0.32-0.53 per 1000 prescribers). Advanced practitioners accounted for a growing percentage of buprenorphine prescribers, with a monthly increase of 0.42 per 1000 prescribers (95% CI, 0.32-0.52 per 1000 prescribers). A secondary analysis to test for changes associated with non-state-specific secular trends in prescribing found that quarterly trends in buprenorphine prescriptions increased in New Jersey relative to all other states following initiative implementation.
CONCLUSIONS AND RELEVANCE
In this cross-sectional study of state-level New Jersey Medicaid initiatives designed to expand buprenorphine access, implementation was associated with an upward trend in buprenorphine prescribing and receipt. No change was observed in the percentage of new buprenorphine treatment episodes lasting 180 or more days, indicating that retention remains a challenge. Findings support implementation of similar initiatives but highlight the need for efforts to support long-term retention.
Topics: United States; Humans; Male; Adult; Female; Buprenorphine; Medicaid; Cross-Sectional Studies; New Jersey; Opioid-Related Disorders
PubMed: 37145594
DOI: 10.1001/jamanetworkopen.2023.12030 -
JAMA Network Open May 2021
Topics: Buprenorphine; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Patient Reported Outcome Measures
PubMed: 33970262
DOI: 10.1001/jamanetworkopen.2021.9708 -
Buprenorphine Treatment By Primary Care Providers, Psychiatrists, Addiction Specialists, And Others.Health Affairs (Project Hope) Jun 2020Substantial increases in opioid-related morbidity and mortality have motivated the implementation of federal policies to expand the buprenorphine prescribing capacity of...
Substantial increases in opioid-related morbidity and mortality have motivated the implementation of federal policies to expand the buprenorphine prescribing capacity of primary care providers and other clinicians. Using a national prescription database that covered 72-92 percent of the US population during 2010-18, we analyzed trends in buprenorphine treatment by prescriber specialty. Buprenorphine treatment rates by primary care providers increased from 12.9 people per 10,000 population in 2010 to 27.4 in 2018. The numbers for psychiatrists and addiction medicine specialists increased from 8.7 to 12.0 per 10,000 and those for other prescribers from 5.8 to 16.3 per 10,000. However, treatment of people ages 15-24 by primary care providers and by psychiatrists and addiction medicine specialists declined significantly. Across all patient age and provider groups, most patients were not retained on buprenorphine for the benchmark period of at least 180 days. Despite a recent national increase in buprenorphine treatment fueled primarily by nonspecialists, challenges persist with buprenorphine access-especially for younger people-and with retaining patients in long-term treatment.
Topics: Adolescent; Adult; Buprenorphine; Humans; Opiate Substitution Treatment; Opioid-Related Disorders; Primary Health Care; Psychiatry; Specialization; Young Adult
PubMed: 32479224
DOI: 10.1377/hlthaff.2019.01622