Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System

Hawkins, Eric J.; Malte, Carol A.; Gordon, Adam J.; Williams, Emily C.; Hagedorn, Hildi; Drexler, Karen; Blanchard, Brittany E.; Burden, Jennifer L.; Knoeppel, Jennifer; Danner, Anissa N.; Lott, Aline; Liberto, Joseph; Saxon, Andrew J.

doi:10.1001/jamanetworkopen.2021.37238

Cited by 21 publications

(22 citation statements)

References 52 publications

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“…Video, Telephone, and In-Person Buprenorphine Treatment for OUD During the COVID-19 Pandemic Buprenorphine treatment retention was a binary variable defined as having at least 90 days of buprenorphine coverage with no more than a 30-day gap in coverage from the patient's first buprenorphine fill during the year following COVID-19-related changes. This definition has been used in prior studies examining buprenorphine retention in the VHA, 37 and allows for standardized comparison of retention regardless of whether a patient initiated buprenorphine during or prior to the study period.…”

Section: Jama Network Open | Substance Use and Addictionmentioning

confidence: 99%

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

et al. 2022

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ImportanceThe coronavirus disease 2019 (COVID-19) pandemic prompted policy changes to allow increased telehealth delivery of buprenorphine, a potentially lifesaving medication for opioid use disorder (OUD). It is unclear how characteristics of patients who access different treatment modalities (in-person vs telehealth, video vs telephone) vary, and whether modality is associated with retention—a key indicator of care quality.ObjectivesTo compare patient characteristics across receipt of different treatment modalities and to assess whether modality was associated with retention during the year following COVID-19–related policy changes.Design, Setting, and ParticipantsThis cross-sectional study was conducted in the national Veterans Health Administration. Participants included patients who received buprenorphine for OUD during March 23, 2020, to March 22, 2021. Analyses examining retention were stratified by buprenorphine initiation time (year following COVID-19–related changes; prior to COVID-19–related changes).ExposuresPatient characteristics; treatment modality (at least 1 video visit, at least 1 telephone visit but no video, only in-person).Main Outcomes and MeasuresTreatment modality; 90-day retention.ResultsAmong 17 182 patients, 7094 (41.3%) were aged 30 to 44 years and 6251 (36.4%) were aged 45 to 64 years; 15 835 (92.2%) were male, 14 085 (82.0%) were White, and 16 292 (94.8%) were non-Hispanic; 6547 (38.1%) had at least 1 video visit, 8524 (49.6%) had at least 1 telephone visit but no video visit, and 2111 (12.3%) had only in-person visits. Patients who were younger, male, Black, unknown race, Hispanic, non–service connected, or had specific mental health/substance use comorbidities were less likely to receive any telehealth. Among patients who received telehealth, those who were older, male, Black, non–service connected, or experiencing homelessness and/or housing instability were less likely to have video visits. Retention was significantly higher for patients with telehealth compared with only in-person visits regardless of initiation time (for initiated in year following COVID-19–related changes: adjusted odds ratio [aOR], 1.31; 95% CI, 1.12-1.53; for initiated prior to COVID-19–related changes: aOR, 1.23; 95% CI, 1.08-1.39). Among patients with telehealth, higher retention was observed in those with video visits compared with only telephone for patients who initiated in the year following COVID-19 (aOR, 1.47; 95% CI, 1.26-1.71).Conclusions and RelevanceIn this cross-sectional study, many patients accessed buprenorphine via telephone and some were less likely to have any video visits. These findings suggest that discontinuing or reducing telephone access may disrupt treatment for many patients, particularly groups with access disparities such as Black patients and those experiencing homelessness. Telehealth was associated with increased retention for both new and continuing patients.

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Section: Jama Network Open | Substance Use and Addictionmentioning

confidence: 99%

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

et al. 2022

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“…Slightly higher rates of MOUD (28%) were observed across Veterans Health Administration (VHA) residential treatment clinics (2012), with provider and staff education and engagement associated with higher rates [ 11 ]. A provider MOUD education initiative [ 12 ] in VHA non-addiction speciality clinics showed significant increases in proportions of OUD patients prescribed MOUD, and of clinicians prescribing MOUD (mostly buprenorphine) post-initiative [ 13 ]. However, MOUD retention rate was lower in education initiative clinic patients than in comparison clinic patients.…”

Section: Introductionmentioning

confidence: 99%

Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials

Bergen

Baurley

Ervin

et al. 2022

IJERPH

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The impact of agonist dose and of physician, staff and patient engagement on treatment have not been evaluated together in an analysis of treatment for opioid use disorder. Our hypotheses were that greater agonist dose and therapeutic engagement would be associated with reduced illicit opiate use in a time-dependent manner. Publicly-available treatment data from six buprenorphine efficacy and safety trials from the Federally-supported Clinical Trials Network were used to derive treatment variables. Three novel predictors were constructed to capture the time weighted effects of buprenorphine dosage (mg buprenorphine per day), dosing protocol (whether physician could adjust dose), and clinic visits (whether patient attended clinic). We used time-in-trial as a predictor to account for the therapeutic benefits of treatment persistence. The outcome was illicit opiate use defined by self-report or urinalysis. Trial participants (N = 3022 patients with opioid dependence, mean age 36 years, 33% female, 14% Black, 16% Hispanic) were analyzed using a generalized linear mixed model. Treatment variables dose, Odds Ratio (OR) = 0.63 (95% Confidence Interval (95%CI) 0.59–0.67), dosing protocol, OR = 0.70 (95%CI 0.65–0.76), time-in-trial, OR = 0.75 (95%CI 0.71–0.80) and clinic visits, OR = 0.81 (95%CI 0.76–0.87) were significant (p-values < 0.001) protective factors. Treatment implications support higher doses of buprenorphine and greater engagement of patients with providers and clinic staff.

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“…Unfortunately, we do not have the data required to examine the outcomes of such policies across all states and the entire study period, nor do we have sufficient current prescribing data to examine the outcomes associated with more recent policy changes. Our analytic approach does not allow us to examine US guidelines and nonpolicy efforts designed to increase buprenorphine prescribing, and we do not have systematic information about other efforts that may occur locally, regionally, or within health systems, such as the Veterans Administration . Our data also do not allow us to examine the outcomes of policies implemented during the COVID-19 pandemic that might be associated with dispensing of buprenorphine to treat OUD.…”

Section: Discussionmentioning

confidence: 99%

“…15,16 Before the waiver requirement was removed at the end of 2022, most medical practitioners were required to receive 8 hours (physicians) or 24 hours (advanced practice clinicians) of specialized education to obtain one. Prior to the removal of the waiver requirement, the federal government and some state governments had enacted other policies that might influence the buprenorphine prescribing workforce, including increasing the number of patients waivered clinicians were permitted to treat, 17 allowing advanced practice clinicians to prescribe buprenorphine for OUD, 17,18 implementing mentoring and external facilitation intervention programs, [19][20][21] requiring additional continuing medical education (CME) for buprenorphine prescribers, 22 and requiring training in substance use disorder treatment for all controlled substance prescribers. 23 The number of buprenorphine prescribers has grown substantially.…”

Section: Introductionmentioning

confidence: 99%

Association of Selected State Policies and Requirements for Buprenorphine Treatment With Per Capita Months of Treatment

et al. 2023

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ImportanceExpanding the use of buprenorphine for treating opioid use disorder is a critical component of the US response to the opioid crisis, but few studies have examined how state policies are associated with buprenorphine dispensing.ObjectiveTo examine the association of 6 selected state policies with the rate of individuals receiving buprenorphine per 1000 county residents.Design, Setting, and ParticipantsThis cross-sectional study used 2006 to 2018 US retail pharmacy claims data for individuals dispensed buprenorphine formulations indicated for treating opioid use disorder.ExposuresState implementation of policies requiring additional education for buprenorphine prescribers beyond waiver training, continuing medical education related to substance misuse and addiction, Medicaid coverage of buprenorphine, Medicaid expansion, mandatory prescriber use of prescription drug monitoring programs, and pain management clinic laws were examined.Main Outcomes and MeasuresThe main outcome was buprenorphine treatment months per 1000 county residents as measured using multivariable longitudinal models. Statistical analyses were conducted from September 1, 2021, through April 30, 2022, with revised analyses conducted through February 28, 2023.ResultsThe mean (SD) number of months of buprenorphine treatment per 1000 persons nationally increased steadily from 1.47 (0.04) in 2006 to 22.80 (0.55) in 2018. Requiring that buprenorphine prescribers receive additional education beyond that required to obtain the federal X-waiver was associated with significant increases in the number of months of buprenorphine treatment per 1000 population in the 5 years following implementation of the requirement (from 8.51 [95% CI, 2.36-14.64] months in year 1 to 14.43 [95% CI, 2.61-26.26] months in year 5). Requiring continuing medical education for physician licensure related to substance misuse or addiction was associated with significant increases in buprenorphine treatment per 1000 population in each of the 5 years following policy implementation (from 7.01 [95% CI, 3.17-10.86] months in the first year to 11.43 [95% CI, 0.61-22.25] months in the fifth year). None of the other policies examined was associated with a significant change in buprenorphine months of treatment per 1000 county residents.Conclusions and RelevanceIn this cross-sectional study of US pharmacy claims, state-mandated educational requirements beyond the initial training required to prescribe buprenorphine were associated with increased buprenorphine use over time. The findings suggest requiring education for buprenorphine prescribers and training in substance use disorder treatment for all controlled substance prescribers as an actionable proposal for increasing buprenorphine use, ultimately serving more patients. No single policy lever can ensure adequate buprenorphine supply; however, policy maker attention to the benefits of enhancing clinician education and knowledge may help to expand buprenorphine access.

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Accessibility to Medication for Opioid Use Disorder After Interventions to Improve Prescribing Among Nonaddiction Clinics in the US Veterans Health Care System

Abstract: This quality improvement study assesses whether a Veterans Affairs initiative was associated with increased prescribing of medications for opioid use disorder.

Cited by 21 publications

References 52 publications

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

Use of and Retention on Video, Telephone, and In-Person Buprenorphine Treatment for Opioid Use Disorder During the COVID-19 Pandemic

Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials

Association of Selected State Policies and Requirements for Buprenorphine Treatment With Per Capita Months of Treatment

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