Specialty Substance Use Disorder Research Articles

PATTERNS OF BEHAVIORAL HEALTH SERVICES PROVIDED IN A 2012 NATIONAL SAMPLE OF U.S. OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES: IMPLICATIONS FOR THE TREATMENT OF CO-OCCURRING DISORDERS

s / Drug and Alcohol Dependence 156 (2015) e102–e182 e143 Hapten selection for heroin vaccines Gary R. Matyas2, Fuying Li1,3, Joshua Antoline1,3, Rashmi Jalah4, Oscar Torres4, Zoltan Beck4, Arthur Jacobson1,3, Carl Alving2, Kenner Rice1,3 1 Drug Design and Synthesis Section, National Institute on Drug Abuse, NIH, Bethesda, MD, United States 2 US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States 3 National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, United States 4 US Military HIV Research Program, Herny M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States Aims: The aim of this study is to select a heroin hapten for a heroin vaccine. Heroin rapidly degrades to 6-acetylmophine and morphine after injection. We hypothesize that a heroin hapten can bedesigned that is chemically stable and can induce antibodies that bind to heroin and its metabolites. Methods: Seven different opioid haptens were synthesized. A mercaptopropanamide group was attached as the linker at the C3, C6or thebridgenitrogen. The acetyl groups of heroinwere replaced with acetamide or 2-oxypropyl groups. The haptens were attached to tetanus toxoid and mixed with liposomal lipid A. Mice were immunized with 3 doses every 3 weeks. The sera were assayed for hapten antibodies. The mice were challenged by the subcutaneous route with heroin (0.75–1mg/kg) and efficacy was assessed by nociception assays. Results: Anti-hapten titers ranged from 100,000 to 6,000,000. Mice immunizedwith haptens coupled at the bridge nitrogenwere only partially protected with a % maximal potential effect (%MPE) ≥50. Animals immunized with C3 position haptens were not challengeddue to lowantibody titers.Mice immunizedwith a C6 linked morphine hapten (MorHap) had a %MPE of 35. After optimization of the MorHap conjugation procedure, the %MPE was <10 and was maintained 9 weeks after the last vaccination. Conclusions: The best haptenwasMorHap,which induced high antibody titers that protected the mice from heroin challenge. MorHap was coupled at the C6 position, whereas bridge nitrogen linked haptens induced high titer antibodies, but only had moderate efficacy. Financial support: This work was supported by a Cooperative Agreement (W81XWH-07-2-067) between the Henry M. Jackson Foundation and the US Army Medical Research and Materiel Command; an Avant Garde award fromNIDA (1DP1DA034787-01); and the NIH Intramural Research Programs of NIDA and NIAAA. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.390 PATTERNS OF BEHAVIORAL HEALTH SERVICES PROVIDED IN A 2012 NATIONAL SAMPLE OF U.S. OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES: IMPLICATIONS FOR THE TREATMENT OF CO-OCCURRING DISORDERS Pia M. Mauro, C. Debra M. Furr-Holden, Ramin Mojtabai Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Aims: According to the 2012 National Survey on Drug Use and Health, of the 20.7 million adults meeting substance use disorder (SUD) criteria, 8.4 million (40.7%) had co-occurring mental illness; only 12.2% received specialty treatment for SUD. Facilities often identify theirmain treatment focus, but the categoriesmaynot fully describe clusters of services. To address this potential discrepancy, we empirically derived classes of specialty SUD outpatient treatment facilitiesusingpatternsofbehavioralhealth servicesprovided in the United States. Methods:Data were obtained from the 2012 National Survey of Substance Abuse Treatment Services (N-SSATS). The current study included community-based facilities offering outpatient treatment in the 50 states and the District of Columbia. Latent class analysis (LCA) was used to identify unobserved classes of facilities based on patterns of observed behavioral health services offered. Results: Of the 14,995 facilities participating in the 2012 NSSATS, 11,488 (76.6%) met inclusion criteria. Facility-identified primary treatment focus included SUD treatment (52.0%), mental health (7.5%), SUD and mental health (36.4%), and general health/other (4.1%). Over a third (38.9%) of facilities had special programs or groups for people with co-occurring disorders. Preliminary analyses indicated an 8-class structure distinguishing facilities beyond their primary treatment focus. These findings will be discussed, along with the relationship between empiricallyderived classes and treatment foci. Conclusions: Behavioral health comorbidities are highly prevalent in SUD treatment samples. Given the evolving healthcare environment, understanding the degree to which facilities nationwide provide treatment for co-occurring disorders has clinical and policy implications. Financial Support: Ms. Mauro and Dr. Furr-Holden receive funding from NIDA T32DA007292. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.391 Changes in the pain analgesic and heroin epidemiology

Hapten selection for heroin vaccines

s / Drug and Alcohol Dependence 156 (2015) e102–e182 e143 Hapten selection for heroin vaccines Gary R. Matyas2, Fuying Li1,3, Joshua Antoline1,3, Rashmi Jalah4, Oscar Torres4, Zoltan Beck4, Arthur Jacobson1,3, Carl Alving2, Kenner Rice1,3 1 Drug Design and Synthesis Section, National Institute on Drug Abuse, NIH, Bethesda, MD, United States 2 US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, United States 3 National Institute on Alcohol Abuse and Alcoholism, NIH, Bethesda, MD, United States 4 US Military HIV Research Program, Herny M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, United States Aims: The aim of this study is to select a heroin hapten for a heroin vaccine. Heroin rapidly degrades to 6-acetylmophine and morphine after injection. We hypothesize that a heroin hapten can bedesigned that is chemically stable and can induce antibodies that bind to heroin and its metabolites. Methods: Seven different opioid haptens were synthesized. A mercaptopropanamide group was attached as the linker at the C3, C6or thebridgenitrogen. The acetyl groups of heroinwere replaced with acetamide or 2-oxypropyl groups. The haptens were attached to tetanus toxoid and mixed with liposomal lipid A. Mice were immunized with 3 doses every 3 weeks. The sera were assayed for hapten antibodies. The mice were challenged by the subcutaneous route with heroin (0.75–1mg/kg) and efficacy was assessed by nociception assays. Results: Anti-hapten titers ranged from 100,000 to 6,000,000. Mice immunizedwith haptens coupled at the bridge nitrogenwere only partially protected with a % maximal potential effect (%MPE) ≥50. Animals immunized with C3 position haptens were not challengeddue to lowantibody titers.Mice immunizedwith a C6 linked morphine hapten (MorHap) had a %MPE of 35. After optimization of the MorHap conjugation procedure, the %MPE was <10 and was maintained 9 weeks after the last vaccination. Conclusions: The best haptenwasMorHap,which induced high antibody titers that protected the mice from heroin challenge. MorHap was coupled at the C6 position, whereas bridge nitrogen linked haptens induced high titer antibodies, but only had moderate efficacy. Financial support: This work was supported by a Cooperative Agreement (W81XWH-07-2-067) between the Henry M. Jackson Foundation and the US Army Medical Research and Materiel Command; an Avant Garde award fromNIDA (1DP1DA034787-01); and the NIH Intramural Research Programs of NIDA and NIAAA. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.390 PATTERNS OF BEHAVIORAL HEALTH SERVICES PROVIDED IN A 2012 NATIONAL SAMPLE OF U.S. OUTPATIENT SUBSTANCE USE DISORDER TREATMENT FACILITIES: IMPLICATIONS FOR THE TREATMENT OF CO-OCCURRING DISORDERS Pia M. Mauro, C. Debra M. Furr-Holden, Ramin Mojtabai Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD Aims: According to the 2012 National Survey on Drug Use and Health, of the 20.7 million adults meeting substance use disorder (SUD) criteria, 8.4 million (40.7%) had co-occurring mental illness; only 12.2% received specialty treatment for SUD. Facilities often identify theirmain treatment focus, but the categoriesmaynot fully describe clusters of services. To address this potential discrepancy, we empirically derived classes of specialty SUD outpatient treatment facilitiesusingpatternsofbehavioralhealth servicesprovided in the United States. Methods:Data were obtained from the 2012 National Survey of Substance Abuse Treatment Services (N-SSATS). The current study included community-based facilities offering outpatient treatment in the 50 states and the District of Columbia. Latent class analysis (LCA) was used to identify unobserved classes of facilities based on patterns of observed behavioral health services offered. Results: Of the 14,995 facilities participating in the 2012 NSSATS, 11,488 (76.6%) met inclusion criteria. Facility-identified primary treatment focus included SUD treatment (52.0%), mental health (7.5%), SUD and mental health (36.4%), and general health/other (4.1%). Over a third (38.9%) of facilities had special programs or groups for people with co-occurring disorders. Preliminary analyses indicated an 8-class structure distinguishing facilities beyond their primary treatment focus. These findings will be discussed, along with the relationship between empiricallyderived classes and treatment foci. Conclusions: Behavioral health comorbidities are highly prevalent in SUD treatment samples. Given the evolving healthcare environment, understanding the degree to which facilities nationwide provide treatment for co-occurring disorders has clinical and policy implications. Financial Support: Ms. Mauro and Dr. Furr-Holden receive funding from NIDA T32DA007292. http://dx.doi.org/10.1016/j.drugalcdep.2015.07.391 Changes in the pain analgesic and heroin epidemiology

States’ implementation of the Affordable Care Act and the supply of physicians waivered to prescribe buprenorphine for opioid dependence

BackgroundAlthough the Affordable Care Act (ACA) is anticipated to affect substance use disorder (SUD) treatment, its impact on the supply of physicians waivered to treat opioid dependence with buprenorphine has not been considered. This study examined whether states more supportive of ACA, meaning those that had opted to expand Medicaid and establish a state-based health insurance exchange, experienced greater growth in physician supply than less supportive states. MethodsBuprenorphine physician supply, including total physician supply, supply of 30-patient physicians, and supply of 100-patient physicians per 100,000 state residents, was measured from June 2013 to May 2015. State characteristics were drawn from multiple secondary sources, with states categorized as ACA-supportive, ACA-hybrid (where states either expanded Medicaid or established a state-based exchange), or ACA-resistant (where states took neither action). Mixed effects regression was used to estimate state-level growth curves to test whether rates of growth varied by states’ approaches to implementing ACA. ResultsThe supply of waivered physicians grew significantly over the two-year period. Rates of growth were significantly lower in ACA-hybrid and ACA-resistant states relative to growth in ACA-supportive states. Average buprenorphine physician supply at baseline varied by region, the percentage of residents covered by Medicaid, and the supply of specialty SUD treatment programs. ConclusionsThis study found a positive impact of the ACA on growth in the supply of buprenorphine-waivered physicians in US states. Future research should address whether the ACA affects the number of patients receiving buprenorphine, Medicaid spending, and the quality of treatment services delivered.

The association of injury with substance use disorder among women of reproductive age: an opportunity to address a major contributor to recurrent preventable emergency department visits?

Substance use disorder (SUD) among women of reproductive age is a complex public health problem affecting a diverse spectrum of women and their families, with potential consequences across generations. The goals of this study were 1) to describe and compare the prevalence of patterns of injury requiring emergency department (ED) visits among SUD-positive and SUD-negative women and 2) among SUD-positive women, to investigate the association of specific categories of injury with type of substance used. This study was a secondary analysis of a large, multisource health care utilization data set developed to analyze SUD prevalence, and health and substance abuse treatment outcomes, for women of reproductive age in Massachusetts, 2002 through 2008. Sources for this linked data set included diagnostic codes for ED, inpatient, and outpatient stay discharges; SUD facility treatment records; and vital records for women and for their neonates. Injury data (ICD-9-CM E-codes) were available for 127,227 SUD-positive women. Almost two-thirds of SUD-positive women had any type of injury, compared to 44.8% of SUD-negative women. The mean (±SD) number of events also differed (2.27 ± 4.1 for SUD-positive women vs. 0.73 ± 1.3 for SUD-negative women, p < 0.0001). For four specific injury types, the proportion injured was almost double for SUD-positive women (49.3% vs 23.4%), and the mean (±SD) number of events was more than double (0.72 ± 0.9 vs. 0.26 ± 0.5, p < 0.0001). The numbers and proportions of motor vehicle incidents and falls were significantly higher in SUD-positive women (22.5% vs. 12.5% and 26.6% vs. 11.0%, respectively), but the greatest differences were in self-inflicted injury (11.5% vs. 0.8%; mean ± SD events = 0.19 ± 0.9 vs. 0.009 ± 0.2, p < 0.0001) and purposefully inflicted injury (11.5% vs 1.9%, mean ± SD events = 0.18 ± 0.1 vs. 0.02 ± 0.2, p < 0.0001). In each of the injury categories that we examined, injury rates among SUD-positive women were lowest for alcohol disorders only and highest for alcohol and drug disorders combined. Among 33,600 women identified as using opioids, 2,132 (6.3%) presented to the ED with overdose. Multiple overdose visits were common (mean ± SD = 3.67 ± 6.70 visits). After adjustment for sociodemographic characteristics, psychiatric history, and complex/chronic illness, SUD remained a significant risk factor for all types of injury, but for the suicide/self-inflicted injury category, psychiatric history was by far the stronger predictor. The presence of SUD increases the likelihood that women in the 15- to 49-year age group will present to the ED with injury. Conversely, women with injury may be more likely to be involved in alcohol abuse or other substance use. The high rates of injury that we identified among women with SUD suggest the utility of including a brief, validated screen for substance use as part of an ED injury treatment protocol and referring injured women for assessment and/or treatment when scores indicate the likelihood of SUD.

A conceptual model to facilitate transitions from primary care to specialty substance use disorder care: a review of the literature.

This article presents a conceptual model to help facilitate the transition from primary care to specialty substance use disorder (SUD) care for appropriate patients. Substance misuse is a common health condition among patients presenting to primary care settings and may complicate the treatment of chronic health conditions such as diabetes and hypertension. It is therefore critical that primary care providers be prepared to identify and determine appropriate treatment options for patients presenting with substance misuse. We conducted a narrative review that occurred in three stages: literature review of health care transition models, identification of conceptual domains common across care transition models, and identification of SUD-specific model elements. Findings The conceptual model presented describes patient, provider, and system-level facilitators and barriers to the transition process, and includes intervention strategies that can be utilized by primary care clinics to potentially improve the process of transitioning patients from primary care to SUD care. Recognizing that primary care clinics vary in available resources, we present three examples of care practices along an intensity continuum from low (counseling and referral) to moderate (telephone monitoring) to high (intensive case management) resource demands for adoption. We also provide a list of common outcomes clinics might consider when evaluating the impact of care transition practices in this patient population; these include process outcomes such as patients' increased knowledge of available treatment resources, and health outcomes such as patients' reduced substance use and better quality of life.

State Parity Laws and Access to Treatment for Substance Use Disorder in the United States

The passage of the 2008 Mental Health Parity and Addiction Equity Act and the 2010 Affordable Care Act incorporated parity for substance use disorder (SUD) treatment into federal legislation. However, prior research provides us with scant evidence as to whether federal parity legislation will hold the potential for improving access to SUD treatment. To examine the effect of state-level SUD parity laws on state-aggregate SUD treatment rates and to shed light on the impact of the recent federal SUD parity legislation. We conducted a quasi-experimental study using a 2-way (state and year) fixed-effect method. We included all known specialty SUD treatment facilities in the United States and examined treatment rates from October 1, 2000, through March 31, 2008. Our main source of data was the National Survey of Substance Abuse Treatment Services, which provides facility-level information on specialty SUD treatment. State-level SUD parity laws during the study period. State-aggregate SUD treatment rates in (1) all specialty SUD treatment facilities and (2) specialty SUD treatment facilities accepting private insurance. The implementation of any SUD parity law increased the treatment rate by 9% (P < .001) in all specialty SUD treatment facilities and by 15% (P = .02) in facilities accepting private insurance. Full parity and parity only if SUD coverage is offered increased the SUD treatment rate by 13% (P = .02) and 8% (P = .04), respectively, in all facilities and by 21% (P = .03) and 10% (P = .04), respectively, in facilities accepting private insurance. We found a positive effect of the implementation of state SUD parity legislation on access to specialty SUD treatment. Furthermore, the positive association is more pronounced in states with more comprehensive parity laws. Our findings suggest that federal parity legislation holds the potential to improve access to SUD treatment.

Diagnostic accuracy of brief PTSD screening instruments in military veterans

Post-traumatic stress disorder (PTSD) is prevalent but is under-detected and under-treated, despite available efficacious treatments. To improve detection rates, screening instruments such as the PTSD Checklist (PCL) and the Primary Care–PTSD (PC-PTSD) screen have been widely used. However, validation of these screening instruments among patients seeking treatment in substance use disorder (SUD) specialty treatment clinics and general mental health (MH) treatment clinics is limited. Therefore, this study assessed the area under the ROC curve (AUC), sensitivity, specificity, efficiency, and positive and negative predictive values of the PCL, PC-PTSD, and five abbreviated versions of the PCL in detecting PTSD among samples of patients seeking treatment in SUD specialty treatment (n=158) and general MH treatment settings (n=242). A computer-assisted structured diagnostic interview (C-DIS-IV) was used to ascertain patient DSM-IV PTSD diagnostic status. Based on the C-DIS-IV, prevalence of PTSD was found to be 36.7 and 52.9% in the SUD and MH samples, respectively. The PCL, PC-PTSD, and five abbreviated versions of the PCL were found to have adequate psychometric properties for screening patients in SUD (AUC ranged from 0.80 to 0.86) and MH (AUC ranged from 0.77 to 0.80) outpatient treatment settings.

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.

Prior research suggests that publicly funded substance use disorder (SUD) treatment programs lag behind privately funded programs in adoption of evidence-based practices, resulting in disparities in access to high-quality SUD treatment. These disparities highlight a critical public health concern because the majority of SUD patients in the United States are treated in the publicly funded treatment sector. This study uses recent data to examine disparities in access to physicians and availability of medications for the treatment of SUDs between publicly and privately funded SUD treatment programs. Data were collected from 595 specialty SUD treatment programs from 2007 to 2010 via face-to-face interviews, mailed surveys, and telephone interviews with treatment program administrators. Publicly funded programs were less likely than privately funded programs to have a physician on staff, even after controlling for several organizational characteristics that were associated with access to physicians. The results of negative binomial regression indicated that, even after taking into account physician access and other organizational variables, publicly funded programs prescribed fewer SUD medications than privately funded SUD treatment programs. Patients seeking treatment in publicly funded treatment programs continue to face disparities in access to high-quality SUD treatment that supports patients' choices among a range of medication options. However, implementation of the Affordable Care Act may facilitate greater access to physicians and use of medications in publicly funded SUD treatment programs.

Correlates of Specialty Substance Use Disorder Treatment Among Female Patients in the Veterans Health Administration

We examined patient- and facility-level correlates of specialty substance use disorder (SUD) outpatient treatment receipt (at least 1 visit) and engagement (visit count) for female Veterans Health Administration patients in 2008. Overall, 33% of 15,653 females with SUD received specialty SUD outpatient treatment. Treatment receipt and engagement were positively related to being age 31 to 55, having a psychiatric comorbidity, and receiving treatment at facilities providing women's services. Additional facility-level factors related to treatment receipt were treatment at a facility with comorbid psychiatric services and more licensed psychosocial treatment providers per patient. More prescribers per patient was associated with more treatment engagement.

Factors Associated With First Utilization of Different Types of Care for Alcohol Problems

The purpose of this research was to investigate whether factors associated with first obtaining care for alcohol problems vary by source of care. This study used data from the National Epidemiologic Survey on Alcohol and Related Conditions to examine initiation of different types of care over a 3-year follow-up interval among individuals with baseline alcohol use disorders who had not previously obtained any care (n = 2,170). Three hierarchical, mutually exclusive types of care were compared: substance use disorder (SUD) specialty sources, general medical but no SUD specialty sources, and nonmedical sources only. Having injured oneself or someone else because of drinking was associated with initiating all three types of care. Additional factors associated with initiating care from SUD specialty treatment sources (vs. no care) comprised male sex, alcohol use disorder severity, major financial problems, and nondependent tobacco/drug use. Factors associated with initiating care from general medical but not SUD specialty sources (vs. no care) comprised marriage/cohabitation, college student status, number of medical conditions, and other substance dependence. Factors associated with obtaining care only from nonmedical sources (vs. no care) comprised low income and anxiety disorder. When direct comparisons were made among types of care, factors drawing individuals into general medical care for reasons not necessarily related to alcohol problems were those that primarily distinguished utilization of general medical sources from the other two types of care. Results support the importance of screening in general medical practice and student health services as an important means of identifying individuals in need of brief intervention or more intensive SUD treatment and reiterate the importance of nonmedical sources for individuals whose alcohol problems might never be addressed in routine medical visits.

Validation of the treatment identification strategy of the HEDIS addiction quality measures: concordance with medical record review

BackgroundStrategies to accurately identify the occurrence of specific health care events in administrative data is central to many quality improvement and research efforts. Many health care quality measures have treatment identification strategies based on diagnosis and procedure codes - an approach that is inexpensive and feasible but usually of unknown validity. In this study, we examined if the diagnosis/procedure code combinations used in the 2006 HEDIS Initiation and Engagement quality measures to identify instances of addiction treatment have high concordance with documentation of addiction treatment in clinical progress notes.MethodsFour type of records were randomly sampled from VHA electronic medical data: (a) Outpatient records from a substance use disorder (SUD) specialty clinic with a HEDIS-qualified substance use disorder (SUD) diagnosis/CPT code combination (n = 700), (b) Outpatient records from a non-SUD setting with a HEDIS-qualified SUD diagnosis/CPT code combination (n = 592), (c) Specialty SUD Inpatient/residential records that included a SUD diagnosis (n = 700), and (d) Non-SUD specialty Inpatient/residential records that included a SUD diagnosis (n = 700). Clinical progress notes for the sampled records were extracted and two raters classified each as documenting or not documenting addiction treatment. Rates of concordance between the HEDIS addiction treatment identification strategy and the raters' judgments were calculated for each record type.ResultsWithin SUD outpatient clinics and SUD inpatient specialty units, 92% and 98% of sampled records had chart evidence of addiction treatment. Of outpatient encounters with a qualifying diagnosis/procedure code combination outside of SUD clinics, 63% had chart evidence of addiction treatment. Within non-SUD specialty inpatient units, only 46% of sampled records had chart evidence of addiction treatment.ConclusionsFor records generated in SUD specialty settings, the HEDIS strategy of identifying SUD treatment with diagnosis and procedure codes has a high concordance with chart review. The concordance rate outside of SUD specialty settings is much lower and highly variable between facilities. Therefore, some patients may be counted as meeting the 2006 HEDIS Initiation and Engagement criteria without having received the specified amount (or any) addiction treatment.

Prevalence and correlates of specialty substance use disorder treatment for Department of Veterans Affairs Healthcare System patients with high alcohol consumption

Objective Current substance use disorder (SUD) treatment guidelines suggest that SUD treatment may be indicated for individuals with elevated levels of alcohol consumption. The Department of Veterans Affairs (VA) considers patients with AUDIT-C scores of ≥8 as candidates for specialty care, however rates of SUD treatment based on AUDIT-C cutoffs remain understudied. We sought to identify SUD treatment rates and to identify patient characteristics that were associated with SUD treatment for VA patients with elevated AUDIT-C scores. Methods The study sample included 10,384 ambulatory care VA patients with AUDIT-C scores of ≥8, who had not received SUD treatment in the past 60 days. Data were ascertained from the 2005 Survey of Health Experiences of Patients, a confidential mailed patient satisfaction survey (results were not available to providers). The outcome variable was the receipt of VA specialty SUD treatment in the year after the survey completion, as ascertained by VA administrative data. We identified rates of SUD treatment, and conducted unadjusted F tests and adjusted logistic regression analyses to identify patient characteristics that were associated with treatment entry. Results Approximately 3.9% of veterans with AUDIT-C scores of ≥8 received SUD treatment in the year after being surveyed. Adjusted analyses revealed that treatment was more likely among persons with a mental health diagnosis (OR = 3.31, CI = 2.30–4.76) and among racial/ethnic minority groups. Conclusions Very few veterans who reported elevated alcohol consumption on SHEP received specialty SUD treatment in the year after being surveyed. Increased efforts should be made to intervene with patients who have elevated levels of alcohol consumption.

HEDIS Initiation and Engagement Quality Measures of Substance Use Disorder Care: Impact of Setting and Health Care Specialty

Many health care systems track the HEDIS measures of initiation and engagement in substance use disorder (SUD) care. However, the impact of setting of care (inpatient vs. outpatient) and health care specialty (SUD, psychiatric, other) on the likelihood of patients meeting the initiation and engagement criteria are unknown. If the vast majority of initiation and engagement occurs within SUD specialty clinics, then these quality measures could be used to discriminate among and incentivize SUD clinic managers. However, if these criteria are satisfied in different settings and specialties, then they should be considered characteristics of the entire facility, rather than just specialty SUD units. Using a Markov model, the probabilities of advancing to treatment initiation and engagement given initial setting and specialty of care were estimated for 320,238 SUD-diagnosed Veterans Health Affairs (VA) patients. Patients in SUD specialty units progressed more often (diagnosis to initiation, initiation to engagement) than patients in other specialties. Progression through the criteria differed for inpatients vs. outpatients. Approximately 25% of initiation and over 40% of engagement occurred outside of SUD specialty care. VA patients who have contact with SUD specialty treatment have higher rates of advancing to initiation, and from initiation to engagement, compared to SUD-diagnosed patients in psychiatric or other medical locations. Even so, a substantial portion of initiation and engagement occurs outside of SUD specialty units. Therefore, these quality measures should be considered measures of facility performance rather than measures of the quality of SUD specialty care. The usual combining of inpatient and outpatient performance on these measures into overall facility scores clouds measurement and interpretation.

Malpractice?

Although the Affordable Care Act (ACA) is anticipated to affect substance use disorder (SUD) treatment, its impact on the supply of physicians waivered to treat opioid dependence with buprenorphine has not been considered. This study examined whether states more supportive of ACA, meaning those that had opted to expand Medicaid and establish a state-based health insurance exchange, experienced greater growth in physician supply than less supportive states.Buprenorphine physician supply, including total physician supply, supply of 30-patient physicians, and supply of 100-patient physicians per 100,000 state residents, was measured from June 2013 to May 2015. State characteristics were drawn from multiple secondary sources, with states categorized as ACA-supportive, ACA-hybrid (where states either expanded Medicaid or established a state-based exchange), or ACA-resistant (where states took neither action). Mixed effects regression was used to estimate state-level growth curves to test whether rates of growth varied by states’ approaches to implementing ACA.The supply of waivered physicians grew significantly over the two-year period. Rates of growth were significantly lower in ACA-hybrid and ACA-resistant states relative to growth in ACA-supportive states. Average buprenorphine physician supply at baseline varied by region, the percentage of residents covered by Medicaid, and the supply of specialty SUD treatment programs.This study found a positive impact of the ACA on growth in the supply of buprenorphine-waivered physicians in US states. Future research should address whether the ACA affects the number of patients receiving buprenorphine, Medicaid spending, and the quality of treatment services delivered.