Scaling interventions and treatment services to reduce mortality stemming from OUD is critical for turning back the opioid epidemic, yet empiric data are lacking regarding how risk changes over the ...course of care. Burns et al show substantial reductions in hazards of overdose accrue after 60 continuous days on medication.
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BFBNIB, DOBA, FSPLJ, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, SIK, UILJ, UKNU, UL, UM, UPUK, VSZLJ
Potential differences in buprenorphine treatment outcomes across various treatment settings are poorly characterized in multi-state administrative data. We thus evaluated the association of opioid ...use disorder (OUD) treatment setting and insurance type with risk of buprenorphine discontinuation among commercial insurance and Medicaid enrollees initiated on buprenorphine.
In this observational, retrospective cohort study using the Merative MarketScan databases (2006-2016), we analyzed buprenorphine retention in 58,200 US adults with OUD. Predictor variables included insurance status (Medicaid vs commercial) and treatment setting, operationalized as substance use disorder (SUD) specialty treatment facility versus outpatient primary care physicians (PCPs) versus outpatient psychiatry, ascertained by linking physician visit codes to buprenorphine prescriptions. Treatment setting was inferred based on timing of prescriber visit claims preceding prescription fills. We estimated time to buprenorphine discontinuation using multivariable cox regression.
Among enrollees with OUD receiving buprenorphine, 26,168 (45.0%) had prescriptions from SUD facilities without outpatient buprenorphine treatment, with the remaining treated by outpatient PCPs (n = 23,899, 41.1%) and psychiatrists (n = 8133, 13.9%). Overall, 50.6% and 73.3% discontinued treatment at 180 and 365 days respectively. Buprenorphine discontinuation was higher among enrollees receiving prescriptions from SUD facilities (aHR = 1.031.01-1.06) and PCPs (aHR = 1.071.05-1.10). Medicaid enrollees had lower buprenorphine retention than those with commercial insurance, particularly those receiving buprenorphine from SUD facilities and PCPs (aHR = 1.241.20-1.29 and aHR = 1.391.34-1.45 respectively, relative to comparator group of commercial insurance enrollees receiving buprenorphine from outpatient psychiatry).
Buprenorphine discontinuation is high across outpatient PCP, psychiatry, and SUD treatment facility settings, with potentially lower treatment retention among Medicaid enrollees receiving care from SUD facilities and PCPs.
Cannabis use in some individuals can meaningfully introduce de novo risk for the initiation of opioid use and development of opioid use disorder. These risks may be particularly high during ...adolescence when cannabis use may disrupt critical periods of neurodevelopment. Current research studying the combination of genetic and environmental factors involved in substance use disorders is poorly understood. More research is needed, particularly to identify which adolescents are most at risk and to develop effective interventions addressing contributing factors such as trauma and psychiatric comorbidity.
Objective:Although buprenorphine treatment reduces risk of overdose and death in opioid use disorder, most patients discontinue treatment within a few weeks or months. Adverse health outcomes ...following buprenorphine discontinuation were compared among patients who were successfully retained beyond 6 months of continuous treatment, a minimum treatment duration recently endorsed by the National Quality Forum.Methods:A retrospective longitudinal cohort analysis was performed using the MarketScan multistate Medicaid claims database (2013–2017), covering 12 million beneficiaries annually. The sample included adults (18–64 years of age) who received buprenorphine continuously for ≥180 days by cohorts retained for 6–9 months, 9–12 months, 12–15 months, and 15–18 months. For outcome assessment in the postdiscontinuation period, patients had to be continuously enrolled in Medicaid for 6 months after buprenorphine discontinuation. Primary adverse outcomes included all-cause emergency department visits, all-cause inpatient hospitalizations, opioid prescriptions, and drug overdose (opioid or non-opioid).Results:Adverse events were common across all cohorts, and almost half of patients (42.1%−49.9%) were seen in the emergency department at least once. Compared with patients retained on buprenorphine for 6–9 months (N=4,126), those retained for 15–18 months (N=931) had significantly lower odds of emergency department visits (odds ratio=0.75, 95% CI=0.65–0.86), inpatient hospitalizations (odds ratio=0.79, 95% CI=0.64–0.99), and filling opioid prescriptions (odds ratio=0.67, 95% CI=0.56–0.80) in the 6 months following discontinuation. Approximately 5% of patients across all cohorts experienced one or more medically treated overdoses.Conclusions:Risk of acute care service use and overdose were high following buprenorphine discontinuation irrespective of treatment duration. Superior outcomes became significant with treatment duration beyond 15 months, although rates of the primary adverse outcomes remained high.
People with opioid use disorder (OUD) are frequently in contact with the court system and have markedly higher rates of fatal opioid overdose. Opioid intervention courts (OIC) were developed to ...address increasing rates of opioid overdose among court defendants by engaging court staff in identification of treatment need and referral for opioid-related services and building collaborations between the court and OUD treatment systems. The study goal was to understand implementation barriers and facilitators in referring and engaging OIC clients in OUD treatment.
Semi-structured interviews were conducted with OIC stakeholders (n = 46) in 10 New York counties in the United States, including court coordinators, court case managers, and substance use disorder treatment clinic counselors, administrators, and peers. Interviews were recorded and transcribed and thematic analysis was conducted, guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework, employing both inductive and deductive coding.
Results were conceptualized using EPIS inner (i.e., courts) and outer (i.e., OUD treatment providers) implementation contexts and bridging factors that impacted referral and engagement to OUD treatment from the OIC. Inner factors that facilitated OIC implementation included OIC philosophy (e.g., non-punitive, access-oriented), court organizational structure (e.g., strong court staff connectedness), and OIC court staff and client characteristics (e.g., positive medications for OUD MOUD attitudes). The latter two also served as barriers (e.g., lack of formalized procedures; stigma toward MOUD). Two outer context entities impacted OIC implementation as both barriers and facilitators: substance use disorder treatment programs (e.g., attitudes toward the OIC and MOUD; operational characteristics) and community environments (e.g., attitudes toward the opioid epidemic). The COVID-19 pandemic and bail reform were macro-outer context factors that negatively impacted OIC implementation. Facilitating bridging factors included staffing practices that bridged court and treatment systems (e.g., peers); barriers included communication and cultural differences between systems (e.g., differing expectations about OIC client success).
This study identified key barriers and facilitators that OICs may consider as this model expands in the United States. Referral to and engagement in OUD treatment within the OIC context requires ongoing efforts to bridge the treatment and court systems, and reduce stigma around MOUD.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
•Co-occurring psychiatric disorders are common in people with opioid use disorder (OUD).•Buprenorphine is underused in people with OUD and co-occurring psychiatric disorders.•Buprenorphine ...discontinuation is common in people with OUD and co-occurring psychiatric disorders.
As the overdose crisis continues in the U.S. and Canada, opioid use disorder (OUD) treatment outcomes for people with co-occurring psychiatric disorders are not well characterized. Our objective was to examine the influence of co-occurring psychiatric disorders on buprenorphine initiation and discontinuation.
This retrospective cohort study used multi-state administrative claims data in the U.S. to evaluate rates of buprenorphine initiation (relative to psychosocial treatment without medication) in a cohort of 236,198 people with OUD entering treatment, both with and without co-occurring psychiatric disorders, grouping by psychiatric disorder subtype (mood, psychotic, and anxiety-and-related disorders). Among people initiating buprenorphine, we assessed the influence of co-occurring psychiatric disorders on buprenorphine retention. We used multivariable Poisson regression to estimate buprenorphine initiation and Cox regression to estimate time to discontinuation, adjusting for all 3 classes of co-occurring disorders simultaneously and adjusting for baseline demographic and clinical characteristics.
Buprenorphine initiation occurred in 29.3% of those with co-occurring anxiety-and-related disorders, compared to 25.9% and 17.5% in people with mood and psychotic disorders. Mood (adjusted-risk-ratioaRR=0.8295% CI=0.82-0.83) and psychotic disorders (aRR=0.950.94-0.96) were associated with decreased initiation (versus psychosocial treatment), in contrast to greater initiation in the anxiety disorders cohort (aRR=1.061.05-1.06). We observed an increase in buprenorphine discontinuation associated with mood (adjusted-hazard-ratioaHR=1.201.17-1.24) and anxiety disorders (aHR=1.121.09-1.14), in contrast to no association between psychotic disorders and buprenorphine discontinuation.
We observed underutilization of buprenorphine among people with co-occurring mood and psychotic disorders, as well as high buprenorphine discontinuation across anxiety, mood, and psychotic disorders.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
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