A Longitudinal Examination of Alcohol Pharmacotherapy Adoption in Substance Use Disorder Treatment Programs: Patterns of Sustainability and Discontinuation

Abstract

ABSTRACT. Objective: The objectives of this study were to (a) identify the patterns of disulfi ram (Antabuse) and tablet naltrexone (Revia) adoption over a 48-month period in a nationally representative sample of privately funded programs that deliver substance use disorder treatment; (b) examine predictors of sustainability, later adoption, discontinuation, and nonadoption of disulfi ram and tablet naltrexone; and (c) measure reasons for medication discontinuation. Method: Two waves of data were collected via face-to-face structured interviews with 223 program administrators. Results: These data demonstrated that adoption of medications for alcohol use disorders (AUDs) was a dynamic process. Although nonadoption was the most common pattern, approximately 20% of programs sustained use of the AUD medications and 30% experienced organizational change in adoption over the study period. Bivariate multinomial logistic regression models revealed that organizational characteristics were associated with sustainability including location in a hospital setting, program size, accreditation, revenues from private insurance, referrals from the criminal justice system, number of medical staff, and use of selective serotonin reuptake inhibitors at baseline. Two patterns of discontinuation were found: Programs either discontinued use of all substance use disorder medications or replaced disulfi ram/tablet naltrexone with a newer AUD medication. Conclusions: These fi ndings suggest that adoption of AUD medications may be positively affected by pressure from accreditation bodies, partnering with primary care physicians, medication-specifi c training for medical staff, greater availability of resources to cover the costs associated with prescribing AUD medications, and amending criminal justice contracts to include support for AUD medication use. (J. Stud. Alcohol Drugs, 72, 669-677, 2011)

Adoption of Injectable Naltrexone in U.S. Substance Use Disorder Treatment Programs

“…A study examining the early adoption of injectable naltrexone for AUD found that the percentage of patients with private insurance was positively associated with adoption (Abraham & Roman, 2010). Patient payer source and revenues from private insurance have been linked to greater adoption of other medications for AUD as well (Abraham et al, 2011;Ducharme et al, 2006;Fuller et al, 2005;Thomas et al, 2003). Although public payer sources often cover the use of SUD medications (Lichtenberg and Philipson, 2002), injectable naltrexone is usually covered as a Medicaid medical benefi t rather than a pharmacy benefi t (American Society of Addiction Medicine [ASAM], 2013), unlike other medications, which are almost always covered under pharmacy benefi ts.…”

“…Other studies using samples of prisons, jails, or community corrections agencies indicate that MAT is rarely used (Friedmann et al, 2012;Matusow et al, 2013;Taxman et al, 2007). As a result, a treatment center's connection with the criminal justice system has been shown to be associated with both less adoption and less sustained use of medications for AUD and opioid use disorder (Abraham et al, 2011;Ducharme et al, 2006;Knudsen & Roman, 2012).…”

“…A core set of principles and beliefs stem from the 12-step model, and a center's emphasis on this model has been shown to act as a barrier to the adoption of pharmacotherapies for SUD treatment (Oser & Roman, 2008). For some, medications are incompatible with the 12-steps' value system (Abraham et al, 2011), which emphasizes combinations of individual transformation and overall freedom from drugs as fundamental to successful recovery (Alcoholics Anonymous [AA], 1984). Several researchers found that 12-step groups have historically been seen as antithetical to the use of MAT (Mark et al, 2003;Swift et al, 1998), and members often experience pressure to stop taking medications (Rychtarik et al, 2000).…”

Disparities in Access to Physicians and Medications for the Treatment of Substance Use Disorders Between Publicly and Privately Funded Treatment Programs in the United States

“…Turning back to the use of SUD medication, most previous studies of medication adoption have considered single medications rather than the breadth of pharmacotherapy services Abraham et al, , 2011Fuller et al, 2005;Knudsen et al, 2005;Koch et al, 2006;Roman, 2007, 2008;Roman and Johnson, 2002;Thomas et al, 2003Thomas et al, , 2008. For the present research question, gauging the relationship of physician presence to organizational availability of pharmacotherapies, the number of available SUD medications is the appropriate variable to consider, and this focus is a novel contribution to the literature.…”

The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder

“…The American Society of Addiction Medicine (ASAM) Performance Measures for the Addiction Specialist Physician also include a suggested measure related to receipt of AUD pharmacotherapy (American Society of Addiction Medicine 2014). Changes in prescribing rates could be determined after initiatives to educate clinicians or reduce barriers to pharmacotherapy use (Abraham et al 2011;Harris et al 2016). Electronic decision support could identify individuals with a new diagnosis of moderate to severe AUD (as documented as a problem or diagnosis) and provide information on acamprosate and naltrexone for consideration by the clinician through a passive alert or "infobutton" (Del Fiol et al 2012 …”