Identifying Opioid Treatment Programs in Medicaid claims data to support quality improvement.

Opioid Stewardship in Cardiac Anesthesia Practice

Exploring the Multiple Roles of Acupuncture in Alleviating the Opioid Crisis.

Assessing Outcomes for Consumers in New York's Assisted Outpatient Treatment Program

Health system data incompletely capture the social risk factors for drug overdose. This study aimed to improve the accuracy of a machine-learning algorithm to predict opioid overdose risk by integrating human services and criminal justice data with health claims data to capture the social determinants of overdose risk. This prognostic study included Medicaid beneficiaries (n = 237,259) in Allegheny County, Pennsylvania enrolled between 2015 and 2018, randomly divided into training, testing, and validation samples. We measured 290 potential predictors (239 derived from Medicaid claims data) in 30-day periods, beginning with the first observed Medicaid enrollment date during the study period. Using a gradient boosting machine, we predicted a composite outcome (i.e., fatal or nonfatal opioid overdose constructed using medical examiner and claims data) in the subsequent month. We compared prediction performance between a Medicaid claims only model to one integrating human services and criminal justice data with Medicaid claims (i.e., integrated model) using several metrics (e.g., C-statistic, number needed to evaluate [NNE] to identify one overdose). Beneficiaries were stratified into risk-score decile subgroups. The samples (training = 79,087, testing = 79,086, validation = 79,086) had similar characteristics (age = 38±18 years, female = 56%, white = 48%, having at least one overdose = 1.7% during study period). Using the validation sample, the integrated model slightly improved on the Medicaid claims only model (C-statistic = 0.885; 95%CI = 0.877–0.892 vs. C-statistic = 0.871; 95%CI = 0.863–0.878), with small corresponding improvements in the NNE and positive predictive value. Nine of the top 30 most important predictors in the integrated model were human services and criminal justice variables. Using the integrated model, approximately 70% of individuals with overdoses were members of the top risk decile (overdose rates in the subsequent month = 47/10,000 beneficiaries). Few individuals in the bottom 9 deciles had overdose episodes (0-12/10,000). Machine-learning algorithms integrating claims and social service and criminal justice data modestly improved opioid overdose prediction among Medicaid beneficiaries for a large U.S. county heavily affected by the opioid crisis.

Pharmacy administration and dispensing of methadone for methadone maintenance treatment (MMT) can expand treatment access for opioid use disorder (OUD). This study investigated the feasibility and acceptability of a novel model permitting an opioid treatment program (OTP) physician to prescribe methadone for OUD treatment through collaboration with a partnered pharmacy. Non-randomized, single-arm, open-label feasibility trial. One OTP and one community pharmacy in the United States. One OTP physician, two pharmacists and 20 MMT patients receiving between six and 13 take-home methadone doses at 5-160mg/day. Patients' methadone administration and dispensing of take-home doses was transferred from the OTP to the pharmacy for 3months. Primary outcome was medication adherence. Secondary outcomes were recruitment, treatment retention, substance use, counseling attendance at the OTP, pharmacist prescription drug monitoring program (PDMP) use, safety and satisfaction. Of 29 patients eligible at pre-screen, 20 patients (69%) enrolled into the study. Recruitment occurred from 6August 2020 to 10 October 2020. Treatment retention rate at month 3 was 80% (16 of 20). Two participants returned early to the OTP because of a work/schedule change, one due to pregnancy and one following a non-study-related hospitalization. Medication adherence among 16 patients who were retained was 100%. Intervention fidelity was 100%. All participants attended random call-back visits. None showed evidence of tampering/diversion of methadone. Pharmacists checked the PDMP at all visits. All participants attended psychosocial counseling as planned. There were no positive urine screens for illicit opioid use and no study-related adverse events. All participants endorsed 'pharmacy is the right location for receiving methadone for MMT', 88% endorsed 'convenient or very convenient to receive methadone at the pharmacy' and 88% were satisfied or very satisfied with the quality of treatment offered. This feasibility trial has found pharmacy administration and dispensing of physician-prescribed methadone for methadone maintenance treatment to be feasible and acceptable.

Commentary on Burns et al. (2015): retention in buprenorphine treatment.

BackgroundThough methadone has been shown to effectively treat opioid use disorder, many barriers prevent individuals from accessing and maintaining treatment. Barriers are prevalent in less populated areas where treatment options are limited. This study examines barriers to retention in methadone treatment in a small Midwest community and identifies factors associated with greater endorsement of barriers.MethodsPatients at an opioid treatment program (N = 267) were recruited to complete a computer-based survey onsite. Surveys assessed demographics, opioid misuse, depression and anxiety symptoms, trauma history and symptoms, social support, and barriers to retention in treatment (e.g., childcare, work, housing, transportation, legal obligations, cost, health). Descriptive statistics were used to examine individual barriers and multiple regression was calculated to identify demographic and psychosocial factors associated with greater cumulative barriers.ResultsMost participants reported at least one barrier to retention in treatment and more than half reported multiple barriers. Travel hardships and work conflicts were the most highly endorsed barriers. Past year return to use (B = 2.31, p = 0.004) and more severe mental health symptomology (B = 0.20, p = 0.038) were associated with greater cumulative barriers. Greater levels of social support were associated with fewer barriers (B = − 0.23, p < 0.001).ConclusionThis study adds to the limited research on barriers to retention in methadone treatment among patients in rural and small urban communities. Findings suggest flexible regulations for dispensing methadone, co-location or care coordination, and family or peer support programs may further reduce opioid use and related harms in small communities. Individuals with past year return to use reported a greater number of barriers, highlighting the time following return to use as critical for wraparound services and support. Those with co-occurring mental health issues may be vulnerable to poor treatment outcomes, as evidenced by greater endorsement of barriers. As social support emerged as a protective factor, efforts to strengthen informal support networks should be explored as adjunctive services to methadone treatment.

Bridge clinic implementation of “72-hour rule” methadone for opioid withdrawal management: Impact on opioid treatment program linkage and retention in care

COVID-19 Could Change the Way We Respond to the Opioid Crisis-for the Better.

The opioid epidemic has been an ongoing public health concern in the United States (US) for the last few decades. The number of overdose deaths involving opioids, hereafter referred to as overdose deaths, has increased yearly since the mid-1990s. One treatment modality for opioid use disorder (OUD) is medication-assisted treatment (MAT). As of 2022, only three pharmacotherapy options have been approved by the Food and Drug Administration (FDA) for treating OUD: buprenorphine, methadone, and naltrexone. Unlike buprenorphine and naltrexone, methadone dispensing and administrating are restricted to opioid treatment programs (OTPs). To date, Tennessee has no medication units, and administration and dispensing of methadone is limited to licensed OTPs. This review details the research process used to develop a policy draft for medication units in Tennessee. This review is comprised of three parts: (1) a rapid review aimed at identifying obstacles and facilitators to OTP access in the US, (2) a descriptive analysis of Tennessee’s geographic availability of OTPs, pharmacies, and federally qualified health centers (FQHCs), and (3) policy mapping of 21 US states’ OTP regulations. In the rapid review, a total of 486 articles were imported into EndNote from PubMed and Embase. After removing 152 duplicates, 357 articles were screened based on their title and abstract. Thus, 34 articles underwent a full-text review to identify articles that addressed the accessibility of methadone treatment for OUD. A total of 18 articles were identified and analyzed. A descriptive analysis of Tennessee’s availability of OTP showed that the state has 22 OTPs. All 22 OTPs were matched to a county and a region based on their address resulting in 15 counties (16%) and all three regions having at least one OTP. A total of 260 FQHCs and 2294 pharmacies are in Tennessee. Each facility was matched to a county based on its address resulting in 70 counties (74%) having at least one FQHC and 94 counties (99%) having at least one pharmacy. As of 31 December 2022, 17 states mentioned medication units in their state-level OTP regulations. Utilizing the regulations for the eleven states with medication units and federal guidelines, a policy draft was created for Tennessee’s medication units.

ObjectiveMedications for opioid use disorder (MOUDs) are regarded as the gold-standard treatment for opioid use disorder in the United States and are widely used in other countries. In the US, the country most impacted by the opioid epidemic, opioid treatment programs (OTPs) are the primary avenue of accessing MOUDs. US federal guidance states that treatment providers should connect patients with recovery community centers (RCCs), if available. RCCs have emerged relatively recently. It is not clear to what extent OTP directors are aware of RCCs. Close collaboration is needed especially in Black communities, as Black Americans face significant disparities in opioid-involved overdoses and deaths.MethodsWe conducted an online survey and interviews of directors of OTPs located near RCCs serving Black communities (operationally defined as located in a ZIP code where ≥25% of residents are Black, as per US Census data). For each such RCC (n = 47 nationwide), we used the SAMHSA Treatment Locator to identify and record data (e.g., types of opioid treatment, treatment approaches, in-house recovery support services) about the three nearest OTPs. The survey asked about the OTP’s referral practices to mutual help organizations (MHOs) and recovery support services, knowledge of and interactions with the nearby RCC, and attitudes toward referral to RCCs, including potential barriers to referral. Interviews discussed barriers and potential solutions.ResultsFifteen OTPs completed surveys (32% of targeted locations), and five directors completed interviews. OTPs participating in the survey were comparable to non-participating OTPs on Locator-reported variables. OTPs provided referral to 12-step MHOs (100%); fewer (80%) were familiar with RCCs, provided referral to RCCs (67%), or knew the nearby RCC (40%). OTP directors (100%) reported that routine referral from the OTP to RCCs makes sense and is valuable. Most common barriers were lack of knowledge of RCCs, worries that RCCs may not be supportive of MOUD use, and lack of personnel to build and maintain connections with RCCs.ConclusionEfforts are needed to increase knowledge about RCCs among OTP leadership and staff. Needed knowledge includes general knowledge (i.e., RCCs are welcoming toward MOUDs; RCCs offer complementing support) and logistical information (e.g., RCC opening hours, transportation, that services are free).

254 Comparing 2017 Medicare Reimbursement of Emergency Physicians by Sex

The United States is in the midst of a devastating opioid misuse epidemic leading to over 33,000 deaths per year from both prescription and illegal opioids. Roughly half of these deaths are attributable to prescription opioids. Federal and state governments have only recently begun to grasp the magnitude of this public health crisis. In 2016, the Centers for Disease Control and Prevention released their Guidelines for Prescribing Opioids for Chronic Pain. While not comprehensive in scope, these guidelines attempt to control and regulate opioid prescribing. Other federal agencies involved with the federal regulatory effort include the Food and Drug Administration (FDA), the Drug Enforcement Agency (DEA), and the Department of Justice. Each federal agency has a unique role in helping to stem the burgeoning opioid misuse epidemic. The DEA, working with the Department of Justice, has enforcement power to prosecute pill mills and physicians for illegal prescribing. The DEA could also implement use of prescription drug monitoring programs (PDMPs), currently administered at the state level, and use of electronic prescribing for schedule II and III medications. The FDA has authority to approve new and safer formulations of immediate- and long-acting opioid medications. More importantly, the FDA can also ask pharmaceutical companies to cease manufacturing a drug. Additionally, state agencies play a critical role in reducing overdose deaths, protecting the public safety, and promoting the medically appropriate treatment of pain. One of the states' primary roles is the regulation of practice of medicine and the insurance industry within their borders. Utilizing this authority, states can both educate physicians about the dangers of opioids and make physician licensure dependent on registering and using PDMPs when prescribing controlled substances. Almost every state has implemented a PDMP to some degree; however, in addition to mandating their use, increased interstate sharing of prescription information would greatly improve PDMPs' effectiveness. Further, states have the flexibility to promote innovative interventions to reduce harm such as legislation allowing naloxone access without a prescription. While relatively new, these types of laws have allowed first responders, patients, and families access to a lifesaving drug. Finally, states are at the forefront of litigation against pharmaceutical manufacturers. This approach is described as analogous to the initial steps in fighting tobacco companies. In addition to fighting for dollars to support drug treatment programs and education efforts, states are pursuing these lawsuits as a means of holding pharmaceutical companies accountable for misleading marketing of a dangerous product.

Medicaid Enrollment and Mental Health Service Use Following Release of Jail Detainees With Severe Mental Illness

The opioid crisis has claimed more than a half-million deaths over the past two decades and is one of the leading causes of injury deaths in the United States. The current study examines: 1) public opinion on the severity of the opioid crisis in terms of lives lost compared to other fatal social events, 2) opinions on who has been most affected by the opioid crisis, and the accuracy of these perceptions, 3) opinions on who is responsible or “to blame” for the crisis and who should fix it and 4) the individual and contextual characteristics that are related to these perceptions. Using data from an October 2019 Amazon Mechanical Turk (MTurk) survey, the Center for Disease Control, and the U.S. Census, we find that the public severely underestimates the death toll of the opioid crisis compared to other fatal events. We also find that public perception of who and where have been most affected is fairly accurate, and such views are highly consistent across different locations, contexts, and sociodemographic characteristics of places and respondents. Additionally, we find that the public collectively views pharmaceutical companies and doctors as responsible for contributing to and fixing the opioid overdose crisis.