Buprenorphine Prescribing Research Articles

Perceived organizational support for the treatment of opioid use disorder and its association with primary care provider treatment willingness and medication prescribing.

Buprenorphine is a highly effective medication for opioid use disorder (MOUD; OUD), which can be prescribed alongside naloxone in the primary care setting as part of a harm reduction approach to OUD. Despite this potential, implementation challenges have limited adoption of MOUD. To address barriers at the organizational level, we need better tools to measure perceived organizational support for the treatment of OUD and use of MOUD in the primary care setting. In this study, we developed an OUDSUPPORT measure to assess the relationship between organizational culture and critical treatment attitudes and behaviors in primary care. We conducted a statewide survey of 404 primary care-aligned health professionals (PCPs) in Ohio. We analyzed the survey data using descriptive and bivariate statistics. Additionally, three stepwise multivariable regression models assess the relationship between organizational support and three primary outcomes: willingness to treat OUD; receipt of the X-waiver, which was previously required to prescribe buprenorphine; and naloxone prescribing, independent of individual and county-level predictors. The OUDSUPPORT measure demonstrated satisfactory psychometric properties, and was associated with meaningful treatment outcomes. PCPs perceived the strongest organizational support for a shared mission of providing care to people with OUD. The least commonly endorsed form of organizational support was for prescribing buprenorphine. Perceived organizational support was associated with increased willingness to treat OUD (b = 0.26; 95 % CI: 0.17, 0.35); higher odds of having received the X-waiver (OR = 1.63; 95 % CI: 1.26, 2.12); and higher odds of naloxone prescribing (OR = 1.71; 95 % CI: 1.30, 2.25). OUDSUPPORT is a multidimensional measure of perceived organizational support for the treatment of OUD, which was associated with treatment willingness, receipt of buprenorphine prescribing training, and naloxone prescribing among PCPs. Implementation strategies to increase buprenorphine prescribing in the primary care setting must include efforts to decrease stigma, and address hesitance related to MOUD and harm reduction at the administrative level, in addition to addressing well known barriers at the individual prescriber level.

Estimating prevalence of opioid misuse in North Carolina counties from 2016-2021: An integrated abundance model approach.

The overdose epidemic remains largely driven by opioids, but county-level prevalence of opioid misuse is unknown. Without this information, public health and policy responses are limited by a lack of knowledge on the scope of the problem. Using an integrated abundance model, we estimate annual county-level prevalence of opioid misuse for counties in North Carolina from 2016 to 2021. The model integrates county-level observed counts of illicit opioid overdose deaths, people receiving prescriptions for buprenorphine, and people served by treatment programs. It also incorporates state-level survey estimates of misuse prevalence. County-level social and environmental covariates are also accounted for in the model. Data are integrated through a Bayesian hierarchical model to estimate posterior distributions of the parameters. In general, the estimated prevalence of misuse was decreasing over the study period. Estimated prevalence was above average in the western and southeastern parts of the state. We also estimated that the proportion of people who misuse opioids who fatally overdosed increased sharply over the study period as the median estimated proportion in 2021 was more than 8 times greater than 2016. The proportion of people who misuse opioids who received buprenorphine and were served by treatment programs increased over the study period. Estimates from our integrated abundance model fill an important gap in public health knowledge about the local prevalence of people who misuse opioids and can be used to inform an adequate and equitable allocation of resources to communities across the state.

Evaluation of a Program Designed to Support Implementation of Prescribing Medication for Treatment of Opioid Use Disorder in Primary Care Practices.

Offering medication for opioid use disorder (MOUD) in primary care can increase access to effective opioid use disorder treatment and help address the US opioid crisis. We describe a primary care office-based opioid treatment program and addiction consultation service model designed to support small, rural clinics to increase their capacity for MOUD. This is an evaluation of an intervention to increase clinic capacity to offer MOUD. The intervention consists of a standardized curriculum, addiction medicine consultants, practice facilitation, and financial incentives. Fifteen Colorado primary care practices participated from January 2022 through January 2023. Primary outcomes included overall change in the number of active buprenorphine prescriptions and implementation of MOUD milestones before and after the intervention. The mean number of active buprenorphine prescriptions in the 3 months preceding the intervention (baseline) increased from 2.1 (SD = 7.7) to 11.3 (SD = 11.2) at 13 months. Adjusted means from the Poisson model demonstrated significant improvement over time (P <.001). Mean implementation of MOUD milestones ranged from 23% to 40% at baseline and grew to 84% to 93% by the end of the program (P <.001). This model supported primary care practices that were initially doing little to no MOUD prescribing, to prescribe at significantly higher levels by the end of the program. This scalable model for addiction consultation in primary care settings illustrates how education and support to clinical teams can help practices makes changes, especially those with limited MOUD experience.

Different forms of stigma and rural primary care professionals' willingness to prescribe buprenorphine.

Buprenorphine and other medications for opioid use disorder (MOUD) are highly effective but substantially under prescribed in the rural United States. Among the most cited barriers to buprenorphine prescribing is stigma, yet little progress has been made in developing successful strategies to reduce stigma and increase access to life-saving medication. One of the key challenges to developing successful implementation strategies is understanding the different types of stigma that limit implementation. This study draws from qualitative interviews with 23 primary care professionals (PCPs) in rural Ohio. We conducted semi-structured interviews focused on prior experiences with buprenorphine, willingness to prescribe it, prior buprenorphine training, and barriers to prescribing. Thematic analysis resulted in 3 forms of stigma that must be addressed to improve implementation. PCPs discussed 3 key forms of stigma that limit buprenorphine prescribing in rural areas: 1) stigma towards patients-PCPs feared being harmed by patients with opioid use disorder (OUD) if they began prescribing buprenorphine; 2) stigma towards providers-PCPs believed their clinics would be stigmatized if they began treating addiction; and 3) stigma towards buprenorphine-PCPs worried they might unintentionally harm patients through prescribing a partial opioid agonist. Stigma remains a critical barrier to buprenorphine prescribing among rural PCPs but is not limited to negative attitudes towards people with OUD. Buprenorphine is also stigmatized and PCPs fear becoming stigmatized if they prescribe the medication. Implementation research is urgently needed to test whether multicomponent stigma-reduction strategies increase access to buprenorphine in rural communities.

The impact of buprenorphine prescriber data on geospatial access to treatment in HEALing Communities Study communities, 2022.

The location of buprenorphine treatment providers in the United States is pivotal to the understanding of regional factors associated with prescription and uptake. We evaluated how distinct data sources of treatment providers and their associated locations contribute to the differences observed when measuring buprenorphine accessibility. We compared buprenorphine treatment provider data from the Drug Enforcement Administration (DEA) and data from the behavioral health treatment locator from the Substance Abuse and Mental Health Services Administration (SAMHSA) for July 2022. Both DEA and SAMHSA data, while similar in spirit, vary substantially in how and why each data set is collected. DEA registration was required by law, while SAMHSA data was an opt-in registry of provider-submitted details. Analyzing the underlying semantics of the data is important for understanding the contextual factors driving observable differences in analytical outputs. We measured accessibility using enhanced two-step floating catchment area (E2SFCA) analysis in three states participating in the HEALing Communities Study (Kentucky, Ohio, Massachusetts). Within communities, we compared decile rankings of accessibility per census tract using each data source. We linked prescribing data from Kentucky's prescription drug monitoring program (PDMP) to measure accessibility using providers prescribing buprenorphine. We explored the significance of localized rank exchanges using neighbor set local indicators of mobility association (LIMA). The number and rate of providers per capita differed substantially at the community level between data sources in the three states. These differences were less impactful in the spatial context of buprenorphine accessibility, which required both supply and demand in regions smaller than our intervention communities. Shifts did occur when measuring the intercommunity decile ranking of accessibility of census tracts, but LIMA results indicated that these rank exchanges were not significant. When analyzing accessibility within a community using E2SFCA analyses, either DEA or SAMHSA data sources are acceptable; linkage to Kentucky's PDMP demonstrated that SAMHSA provider data is equally suitable to PDMP data for research studies involving spatial relationships with providers while being both significantly easier to obtain and less sensitive. When analyzing treatment provider rates per capita, results may vary substantially across these different data sources. Therefore, context must be considered when choosing an appropriate data source to use.

Opioid use disorder prevalence in 57 New York counties from 2017 to 2019: A Bayesian evidence synthesis.

Prevalence estimates of opioid use disorder (OUD) at local levels are critical for public health planning and surveillance, yet largely unavailable across the US especially at the local county level. We used a Bayesian evidence synthesis approach to estimate the prevalence of OUD for 57 counties across New York State for 2017-2019 and compare rates of OUD across counties as well as assess the extent of undiagnosed OUD. We developed a generative model to assess conditional probabilistic relations between different subgroups of the OUD population defined by diagnosis, treatment, and overdose fatality. Average OUD prevalence from 2017 to 2019 ranged from 2.4 % (Westchester County) to 8.3 % (Sullivan County). Overall OUD prevalence estimates were relatively stable year to year, from 4.5 % in 2018 and 4.6 % in both 2017 and 2019. The Bayesian evidence synthesis estimate is consistently higher than the percentage diagnosed in Medicaid, by age and sex. By 2019, the estimated proportion of OUD that was undiagnosed ranged from 16.7 % in Clinton County to 62.7 % in Onondaga County. Counties with relatively high overdose death rates and low buprenorphine prescription percentages had the highest estimated level of undiagnosed OUD. OUD prevalence varied considerably across the state. We identified counties with high OUD and overdose levels and a high proportion of undiagnosed OUD, providing insight into areas of the state in need of rapid expansion of services for people with OUD. Bayesian evidence synthesis approaches for OUD prevalence estimation represent a reliable and rigorous approach to providing local areas with information on OUD magnitude.

Understanding the opioid syndemic in North Carolina: A novel approach to modeling and identifying factors.

The opioid epidemic is a significant public health challenge in North Carolina, but limited data restrict our understanding of its complexity. Examining trends and relationships among different outcomes believed to reflect opioid misuse provides an alternative perspective to understand the opioid epidemic. We use a Bayesian dynamic spatial factor model to capture the interrelated dynamics within six different county-level outcomes, such as illicit opioid overdose deaths, emergency department visits related to drug overdose, treatment counts for opioid use disorder, patients receiving prescriptions for buprenorphine, and newly diagnosed cases of acute and chronic hepatitis C virus and human immunodeficiency virus. We design the factor model to yield meaningful interactions among predefined subsets of these outcomes, causing a departure from the conventional lower triangular structure in the loadings matrix and leading to familiar identifiability issues. To address this challenge, we propose a novel approach that involves decomposing the loadings matrix within a Markov chain Monte Carlo algorithm, allowing us to estimate the loadings and factors uniquely. As a result, we gain a better understanding of the spatio-temporal dynamics of the opioid epidemic in North Carolina.

Framework to Action: Developing and Implementing a Statewide Network to Expand Opioid Treatment Access Using SHIFT-Evidence in Texas

Background: In Texas, the expansion of access to effective treatments for opioid use disorder remains a significant public health challenge. This study aimed to demonstrate the application of the Successful Healthcare Improvement from Translating Evidence in Complex Systems (SHIFT-Evidence) framework in developing and implementing a statewide network for office-based opioid treatment (OBOT) to underserved populations. Methods: We identified systemic gaps in access to medications for opioid use disorder (MOUD) across Texas, using a targeted needs assessment of barriers and facilitators to buprenorphine prescribing. Findings were integrated into a planning template based on SHIFT-Evidence, which guided the identification of additional barriers across the health care system and iterative selection of strategies to address implementation barriers at multiple health care system levels, drawing on the Expert Recommendations for Implementing Change taxonomy. Strategies were prioritized based on feasibility and impact. To evaluate the program’s effectiveness in expanding access to MOUD, we conducted a descriptive analysis of data from the Texas Department of State Health Services’ Clinical Management for Behavioral Health Services data system to assess geographic reach and clients served within the program. Results: Applying SHIFT-Evidence provided a structured process for identifying key barriers occurring at multiple levels (patient, prescriber, and prescriber organization) and selecting tailored strategies to address each. This approach supported the successful development and expansion of an OBOT provider network, increasing access to treatment services from 6 provider organizations (10 locations) serving 52 clients in fiscal year 2019 to 23 provider organizations (48 locations) serving 1311 clients in fiscal year 2023. Conclusions: The comprehensive, multilevel approach supported by the application of SHIFT-Evidence effectively facilitated prioritization and planning to address systemic gaps across multiple health care system levels. The successful enhancement of treatment access highlights the framework’s utility in supporting improvements within complex health care systems.

Understanding MAT access in the context of unused MAT capacity in the United States: when increasing rural MAT capacity is not enough

BackgroundSection 1262 Consolidated Appropriations Act of 2023 eliminates the federal DATA waiver registration requirement to prescribe buprenorphine for opioid use disorder (OUD), along with patient limits, perhaps as a way to increase provider capacity to prescribe buprenorphine. Understanding the factors that influence provider capacity, patient access, and whether community need for MAT is met could inform how to capitalize on DATA waiver eliminations in the United States.MethodsThis observational study utilized required reporting from two cohorts of the Rural Communities Opioid Response Program (RCORP). Consortia (N = 80) provided data on OUD/SUD-related services, service area information, consortium membership, and grant progress, including barriers to and facilitators of achievements. These data were combined with National Survey of Drug Use and Health (NSDUH) and U.S. Census Bureau’s 2016−2020 American Community Survey (ACS) 5-Year Estimates Data to examine MAT capacity, access, and service area need.ResultsA 79% increase in potential buprenorphine prescribers from 2019 to 2022 resulted in 1,060 rural providers with the ability to prescribe buprenorphine. The number of individuals who received MAT increased by 42% over the same three years, with over 20,000 individuals receiving MAT by the end of the funding period. While both capacity and access did increase, an additional 11,454 individuals could have potentially received buprenorphine if all waivered providers prescribed to a conservative patient limit of thirty patients. 70% of consortia provided MAT to at least 11.5% of their estimated service area need (national rate of MAT provision among individuals 18 years and older with an OUD), indicating unused MAT capacity was not related to lack of service area need. Provider (e.g., concerns of clinical complexity), patient (e.g., mistrust of the healthcare system), pharmacy (e.g., cost concerns), and pharmacist (e.g., stigma) barriers impacted MAT provision and availability.ConclusionMAT treatment capacity is a necessary but not exclusive requirement for increasing access to MAT. Addressing the multi-faceted barriers to prescribing MAT, particularly buprenorphine, will be critical to ensure the Consolidated Appropriations Act of 2023 does in fact result in a larger workforce that actually prescribes buprenorphine and a pharmacy system that stocks these medications.

Examining the Impact of Eliminating the X Waiver on Buprenorphine Dispensation in 63 Counties in Pennsylvania.

Opioid overdose rates continue to rise in the United States while access to treatment options remains limited. The X waiver, which allowed clinicians to prescribe buprenorphine, a medication for opioid use disorder (MOUD), in an outpatient setting, was eliminated in December 2022 with hopes of increasing buprenorphine access. We used a quasi-experimental approach to evaluate how eliminating the X waiver affected buprenorphine prescribing in Pennsylvania. Drawing on Pennsylvania Prescription Drug Monitoring Program data from July 1, 2016, to December 31, 2023, we used a difference-in-differences (DD) approach to assess changes in buprenorphine prescribing between Pennsylvania counties with the proportion of X-waivered providers per county population above the median versus counties with the proportion below the median, before and after the elimination of the X waiver. We also tested whether areas most affected by the opioid epidemic with the highest rates of opioid overdose were more impacted by the X-waiver elimination, using opioid overdose death rates from a pretreatment baseline period (2016-2018) for each county. Thirty-one counties were categorized as above the median and 32 as below the median. We did not observe a significant difference in the effects of eliminating the X waiver on buprenorphine dispensation (DD estimate: -0.6%, 95% CI: -7.5%-6.2%) between above versus below-the-median counties in Pennsylvania. We also did not find a significant effect of the X-waiver elimination on buprenorphine dispensation in counties most affected by the opioid epidemic (difference-in-difference-in-differences estimate 1.6%, 95% CI: -10.2%-13.4%). We found no evidence that eliminating the X waiver had a significant impact on buprenorphine dispensing in Pennsylvania in counties with fewer waivered prescribers or higher fatal overdose rates. Additional efforts to increase buprenorphine use will likely need to address systemic barriers and stigma limiting MOUD access.

The Implementation Climate for Integrating Buprenorphine Prescribing into Rural Primary Care.

Rural communities have been significantly affected by opioid use disorder (OUD) and related harms but have less access to evidence-based medications for opioid use disorder (MOUD), such as buprenorphine. Given the shortage of specialists in these areas, rural primary care is an important setting to expand buprenorphine access, but implementation is limited. To explore implementation climate factors that support or hinder buprenorphine implementation in rural primary care. A qualitative study design using in-depth interviews. Primary care physicians, nurse practitioners (NPs), and physician associates (PAs) practicing in rural Ohio counties. Between December 2022 and March 2023, we interviewed participants about their perspectives on buprenorphine prescribing, including using rural primary care as an implementation setting for buprenorphine. Using a deductive, framework-based approach, codes were grouped based on the Consolidated Framework for Implementation Research (CFIR) inner setting factors that contribute to a positive implementation climate for an intervention. Three implementation climate constructs emerged as decision points for whether to implement buprenorphine in rural primary care: (1) relative priority: the extent to which OUD treatment should be prioritized over other chronic diseases; (2) compatibility: whether buprenorphine prescribing protocols are compatible with the rural primary care setting; (3) tension for change: the extent to which current buprenorphine access shortages in rural communities can be tolerated. Participants expressed mixed perspectives on whether the implementation climate in rural primary care currently supports buprenorphine prescribing. Implementation strategies targeted toward the implementation climate are critical to support buprenorphine prescribing in rural primary care.

DEA again extends flexibility for virtual buprenorphine induction

As the Drug Enforcement Administration (DEA) adds another year to flexibilities for prescribing of buprenorphine through telemedicine, evidence from the addiction treatment community continues to suggest the benefits of making this COVID‐era change permanent.

Buprenorphine prescribing practices for older adults in 2019 and 2020.

Opioid use disorder (OUD) prevalence has increased threefold among Medicare beneficiaries 65 years and older (hereafter "older adults") since 2013, with a prevalence of 15.7 per 1000 Medicare beneficiaries in 2018. Yet, access to treatment that addresses the needs of older adults with OUD is limited, including patterns of buprenorphine prescribing to older adults. Therefore, we sought to describe buprenorphine treatment patterns among older adults and prescribing clinician specialties. We conducted a retrospective observational study using 2019-2020 IQVIA Real World Data-Longitudinal Prescriptions. High-prescribing clinicians are those who prescribed buprenorphine to >15 unique older adults within a calendar year. We used T-test and chi-square tests to compare characteristics associated with differences in prescribing. Among 26,202 clinicians prescribing buprenorphine to 67,921 unique older adults, 1232 (5%) prescribed to more than 15 older adults (mean 28.1, SD = 23.6), corresponding to buprenorphine prescribing for 24,672 (36%) older adults. Among older adults dispensed buprenorphine, the majority (58%) were 66-70 years of age and male (54%). Individuals older than 70 years (44%) and males (51%) were slightly more common among high prescribers than non-high-prescribing clinicians (41% and 49%, respectively). Primary care clinicians (42%) and advance practice providers (APPs) (29%) were the most common specialties prescribing buprenorphine. Most (87%) buprenorphine prescribers were in urban counties; with a slightly higher percentage of high-prescribing clinicians in urban counties (91%). A relatively small subset of clinicians prescribes most buprenorphine to older adults. This work provides evidence of gaps in care delivery. Scalable systems-level interventions should be developed and tested to improve treatment availability mindful of existing clinical infrastructure.

Barriers to and Facilitators of Buprenorphine Dispensing for Opioid Use Disorder: Evidence from Focus Groups in Appalachian Kentucky

As efforts to increase buprenorphine prescribing continue to intensify, pharmacy dispensing plays an important role in access to essential medications for opioid use disorder. Existing survey research suggests stigma and regulatory concerns are barriers to pharmacists dispensing buprenorphine, but facilitators are less clear, as are in-depth perceptions of pharmacists regarding buprenorphine. To assess barriers and facilitators to buprenorphine dispensing in Appalachian Kentucky using a series of focus groups with pharmacy employees. Between September and October 2023, five structured focus groups were conducted with a total of 19 pharmacists and pharmacy technicians across a mixture of high- and low-buprenorphine-dispensing counties. Investigators independently coded focus group transcriptions using a grounded theory approach to describe current dispensing practices as well as barriers to and facilitators of buprenorphine dispensing. Most participants described dispensing buprenorphine, but there was substantial variation in dispensing practices. Participants identified patient-, provider-, pharmacy-, regulatory-and medication-related barriers to and patient-, provider-, pharmacy-, and regulatory-related facilitators of pharmacy dispensing. Patient- and provider-related barriers accounted for over half of barriers identified. The most common facilitators were also patient- and provider-related. In a series of 5 focus groups with pharmacy staff in Appalachian Kentucky, the most common barriers to buprenorphine dispensing were patient and provider behaviors. Patient stories were the most common facilitators. Interventions to increase pharmacy buprenorphine dispensing should focus on addressing misperceptions regarding behavior, preferably driven by positive patient testimony.

Redefining low-threshold buprenorphine access in an integrated mobile clinic program: Factors associated with treatment retention

IntroductionThe Spot mobile clinic provides low-threshold buprenorphine integrated with clinical and social services in Baltimore City, MD. In 2021, The Spot modified practices to improve engagement including providing extended prescriptions, reducing frequency of toxicology testing, giving up to six months to stabilize on medication, offering maximum doses (up to 32 mg total) daily, and utilizing telemedicine. This study characterizes care retention by examining both the total time in care and the percentage of time with buprenorphine prescription coverage during these practice changes, and examines factors associated with retention. MethodsThis retrospective cohort study includes patients (n = 341) who received a buprenorphine prescription who initiated care on The Spot mobile clinic from September 2021 to October 2022, with follow-up through October 2023. We utilized the Cox proportional hazards model and Kaplan-Meier survival analyses to assess differences in care retention by the factors of patient demographics and clinical characteristics. Additionally, we performed sensitivity analyses using Poisson regression to examine differences between patients with 80 % or greater time with active prescription coverage versus <80 % of time with active prescription coverage. ResultsAfter practice setting changes, retention in care at 90 days was 60 %. Patients whose maximum daily buprenorphine dose was 28 to 32 mg were 80 % less likely to discontinue treatment over the study period than those prescribed ≤16 mg (adjusted hazard ratio of discontinuation: 0.2 [95 % CI: 0.1–0.3]). Engaging in wound care or hepatitis C treatment was associated with higher retention in care, and individuals experiencing homelessness remained engaged at rates comparable to stably housed patients. ConclusionPractice changes aimed to improve access to patient-centered, low-threshold buprenorphine treatment may increase retention in care. Notably, higher doses of buprenorphine and integrated treatment with wound care and hepatitis C treatment were associated with increased retention. Due to gaps in patient care, retention metrics should incorporate total time in care as well as percentage of time with an active buprenorphine prescription.

The Association Between Telehealth Use During Buprenorphine Treatment for Opioid Use Disorder and Clinical Outcomes: A Retrospective Cohort Study.

Background: Patients with opioid use disorder (OUD) represent a high-risk population due to increased rates of adverse health outcomes and death. To evaluate whether telehealth utilization during OUD treatment compared with in-person encounters alone was associated with emergency department (ED) utilization, inpatient admissions, and mortality within three years of initiating buprenorphine. Methods: We conducted a retrospective cohort study within the Veterans Health Administration among Veterans treated for OUD between 2012 and -2022. The primary exposure was modality of care, characterized as telehealth encounters (with or without an in-person visit) compared with in-person visits only. Outcomes included an ED visit, inpatient admission, or mortality within three years of the index buprenorphine prescription. We measured the association between each type of treatment modality and outcomes through Cox proportional hazards regression modeling, adjusting for demographic and clinical covariates and confounders. Findings: Of the 57,021 Veterans diagnosed with OUD and who initiated buprenorphine, 38,072 Veterans met study eligibility criteria. The majority of Veterans were male, non-Hispanic White, 25-44 years of age, and lived in urban areas. Approximately 60% of this entire cohort experienced at least one ED visit, 40% experienced an inpatient admission, and 8% died during follow-up. Telehealth use compared with in-person visits only was associated with reduced ED visits (adjusted hazard ratio [aHR] 0.81; 95% confidence interval [CI] 0.77-0.85), inpatient admissions (aHR: 0.71; 95% CI: 0.67-0.76), and mortality (aHR: 0.80; 95% CI: 0.67-0.94). Conclusions: Telehealth may help overcome barriers to in-person care. During buprenorphine treatment for OUD, telehealth as a point of contact with providers and the health care system may reduce more adverse health outcomes, potentially through improving treatment retention. Qualitative studies may help shed light on the mechanisms through which telehealth directly impacts clinical outcomes.

The Impact of Telehealth on Buprenorphine Prescribing at a Large Federally Qualified Health Center during COVID-19.

This study aims to explore the impact of telehealth on buprenorphine prescribing and retention in care for patients with opioid use disorder (OUD) seen at a large federally qualified health center (FQHC) the year prior to and following the start of the COVID-19 pandemic. We conducted a retrospective study of patients with OUD and at least one medical visit to the FQHC between March 1, 2019, and February 28, 2021. This study utilized March 1, 2020, to delineate the beginning of COVID as the FQHC widely instituted telehealth during the month in response to the pandemic. We examined buprenorphine prescribing before and during year 1 of the pandemic; we applied logistic regression to estimate the association between telehealth and buprenorphine prescribing and we assessed buprenorphine retention through survival analysis. In the year before COVID, 24% of patients (502/2090) received buprenorphine compared with 31% (656/2110) during the first year of COVID (P < 0.01). Patients with at least one telehealth visit were three times more likely to receive buprenorphine compared to those without telehealth (odds ratio: 3.2, confidence interval: 2.1-5.0). Among those who received buprenorphine, those with at least one telehealth visit were retained in buprenorphine care longer (hazard ratio: 2.7, confidence interval: 1.8-3.9). During the first year of COVID, telehealth was associated with increased likelihood that patients received buprenorphine; those who had telehealth remained in buprenorphine care longer compared to those who only had office-based visits. Increasing buprenorphine access through telehealth can play a significant role in retention in care for OUD.

Associations Between State Policies Facilitating Telehealth and Buprenorphine Episode Initiation and Duration Early in the COVID Pandemic : State Telehealth Policies and Buprenorphine.

State policies facilitating telehealth implemented early in COVID may support buprenorphine treatment of opioid use disorder. However, little empirical information is available about those policies' effects. Examine association between state policies that may facilitate telehealth use and buprenorphine treatment. Retrospective cohort study using 2019-2020 national pharmacy data on dispensed buprenorphine prescriptions. State policies implemented after March 3, 2020, public health emergency declaration requiring private insurers' telehealth reimbursement to be commensurate with in-person service reimbursement, authorizing Medicaid reimbursement for audio-only telehealth, allowing physicians to provide cross-state telehealth services, and allowing psychologists to provide cross-state telehealth services. (a) Duration of treatment episodes started between March 1 and March 13 in both 2019 and 2020, and (b) daily numbers of new buprenorphine treatment episodes from March 13 through December 31 in each year. We found little change in the number of new buprenorphine treatment episodes started in 2020 compared to 2019 and an increase in treatment duration of 10.3days (95%CI 8.3 to 12.2days) for episodes started in March 2020 before the public health emergency declaration compared to the comparable 2019 period. States implementing a telehealth parity policy in 2020 had 7.3% (95%CI - 13.3% to - 0.4%) fewer new buprenorphine treatment episodes. States joining the psychologist interstate compact in 2020 after the public health emergency declaration had treatment episodes 7.97days longer (95%CI 0.78 to 15.16) than other states. None of the other policies examined was associated with changes in new treatment episodes or treatment duration. Policies undertaken during the pandemic we examined were associated with few significant changes in buprenorphine treatment initiation and duration. Findings suggest realizing the benefits of telehealth and other policy changes for buprenorphine may require more extensive implementation and infrastructure support.

Continuation versus Interruption of Buprenorphine/Naloxone in Adult Veterans Undergoing Surgery: Examination of Postoperative Pain and Opioid Utilization in a National Retrospective Cohort Study.

Prescription rates for buprenorphine in opioid use disorder are increasing, and recent guidelines recommend its continuation during and after surgery; however, evidence from clinical outcome studies is limited. We tested the hypotheses that 1) perioperative continuation of buprenorphine does not result in higher pain scores and 2) that this approach does not result in higher supplemental postoperative opioid requirements. The Veterans Affairs Corporate Data Warehouse was queried for patients who underwent surgery while being prescribed buprenorphine/naloxone for opioid use disorder between 2010 and 2020. Analysis of the prescription record was used to infer buprenorphine management, and a 3:1 matched control set of patients without buprenorphine prescriptions was generated. We examined patients who continued buprenorphine, patients who had buprenorphine interrupted, and control patients. The primary outcome was time-weighted average postoperative pain scores from inpatient and outpatient sources within 72 hours of surgery. The secondary outcome was postoperative average daily morphine equivalent opioid requirements within two weeks of surgery. A total of 1,881 surgical procedures in 1,673 patients taking buprenorphine for opioid use disorder were included; these procedures were matched to 5,748 control patients (5,775 procedures) without a buprenorphine prescription. Among the 1,881 procedures, 1,186 (63%) continued buprenorphine through the perioperative period while 695 (37%) interrupted buprenorphine. Pain scores were clinically similar for all three groups (4.1 ± 1.9 control [n = 3284], 4.9 ± 2.0 continued buprenorphine [n = 662], and 5.5 ± 1.7 interrupted buprenorphine [n = 419]; P < 0.001).Patients who continued buprenorphine did not require significantly more supplemental opioids as compared to controls (39.7 mg morphine equivalents/day ± 1.9 versus 36.5 ± 0.7, P = 0.23), and patients who interrupted buprenorphine received more supplemental opioids than those who continued it (74.2 ± 4.5 mg morphine equivalents/day versus 39.7 ± 1.9,respectively; P < 0.001). Continuation of buprenorphine is not associated with higher average pain scores or postoperative opioid requirements, supporting recently published guidelines.

Buprenorphine Administration and Prescribing at Emergency Departments: A National Analysis from 2014-2021.

Emergency department (ED)-initiated buprenorphine provides a low barrier access point and safety net to mitigate opioid overdose risk and increase treatment engagement. We sought to describe trends and patterns of buprenorphine utilization from the ED using national data. This is a retrospective review of the National Hospital Ambulatory Medical Care Survey between 2014 and 2021. Our primary outcomes were trends in ED buprenorphine utilization. We described patient demographics, visit characteristics, and conducted trend analyses. We utilized logistic regression to determine predictors of buprenorphine prescribing. Between 2014 and 2021, there were 341,875 ED visits in which buprenorphine was administered, with no change over time (P = 0.08). There were 392,031 visits where buprenorphine was prescribed at ED discharge, with an increase over time (P = 0.01). The largest rise in rate for discharge prescriptions occurred between 2019 and 2020 (37,737 [0.03%] visits vs 126,041 [0.10%]) (233% increase in rate, P < 0.0001). Although there was an increase in buprenorphine prescribing at ED discharge, there was no increase in administration. The acceleration in prescribing between 2019 and 2020 suggests that the ED may have been a safety net for patients who lost access to addiction care during COVID-19. Future studies should explore reasons for disparities and barriers to buprenorphine utilization.