Buprenorphine prescribing for opioid use disorder in medical practices: can office-based out-patient care address the opiate crisis in the United States?

Opioid use disorder (OUD) remains a serious public health issue, and treating adults with OUD is a major priority in the United States. Little is known about trends in the diagnosis of OUD and in buprenorphine prescribing by physicians in office-based medical practices. We sought to characterize OUD diagnoses and buprenorphine prescribing among adults with OUD in the United States between 2006 and 2015. We used a repeated cross-sectional design, based on data from the 2006-15 National Ambulatory Medical Care Surveys that surveyed nationally representative samples of office-based out-patient physician visits. Adult patients aged 18 years or older with a diagnosis of OUD (n = 1034 unweighted) were included. Buprenorphine prescribing was defined by whether visits involved buprenorphine or buprenorphine-naloxone, or not. We also examined other covariates (e.g. age, gender, race and psychiatric comorbidities). We observed an almost tripling of the diagnosis of OUD from 0.14% in 2006-10 to 0.38% in 2011-15 in office-based medical practices (P < 0.001). Among adults diagnosed with OUD, buprenorphine prescribing increased from 56.1% in 2006-10 to 73.6% in 2011-15 (P = 0.126). Adults with OUD were less likely to receive buprenorphine prescriptions if they were Hispanic [adjusted odds ratio (aOR) = 0.26; 95% confidence interval (CI) = 0.11, 0.60], had Medicaid insurance (aOR = 0.27; 95% CI = 0.10, 0.74) or were diagnosed with other psychiatric disorders (aOR = 0.45; 95% CI = 0.25, 0.83) or substance use disorders (aOR = 0.19; 95% CI = 0.09, 0.41). In office-based medical practices in the United States, diagnoses for opioid use disorder and buprenorphine prescriptions for adults with opioid use disorder increased from 0.14 and 56.1%, respectively, in 2006-10 to 0.38 and 73.6% in 2011-15.

Rhee TG ，Rosenheck RA 《-》

Evaluation of medications used for opioid use disorder in emergency departments: A cross-sectional analysis of the 2020 National Hospital Ambulatory Medical Care Survey.

Opioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs. NHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18-64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI. There was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0-128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33-241.90) and Western region (OR43.77, 95%CI 2.97-645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001-0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41-152.33; OR: 13.84, 95%CI: 3.58-53.51, respectively). Our study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift.

Lee S ，Sun L ，Vakkalanka JP 《-》

Injectable naltrexone, oral naltrexone, and buprenorphine utilization and discontinuation among individuals treated for opioid use disorder in a United States commercially insured population.

We investigated prescribing patterns for four opioid use disorder (OUD) medications: 1) injectable naltrexone, 2) oral naltrexone, 3) sublingual or oralmucosal buprenorphine/naloxone, and 4) sublingual buprenorphine as well as transdermal buprenorphine (which is approved for treating pain, but not OUD) in a nationally representative claims-based database (Truven Health MarketScan®) of commercially insured individuals in the United States. We calculated the prevalence of OUD in the database for each year from 2010 to 2014 and the proportion of diagnosed patient months on OUD medication. We compared characteristics of individuals diagnosed with OUD who did and did not receive these medications with bivariate descriptive statistics. Finally, we fit a Cox proportional hazards model of time to discontinuation of therapy as a function of therapy type, controlling for relevant confounders. From 2010 to 2014, the proportion of commercially insured individuals diagnosed with OUD grew by fourfold (0.12% to 0.48%), but the proportion of diagnosed patient-months on medication decreased from 25% in 2010 (0.05% injectable naltrexone, 0.4% oral naltrexone, 23.1% sublingual or oralmucosal buprenorphine/naloxone, 1.5% sublingual buprenorphine, and 0% transdermal buprenorphine) to 16% in 2014 (0.2% injectable naltrexone, 0.4% oral naltrexone, 13.8% sublingual or oralmucosal buprenorphine/naloxone, 1.4% sublingual buprenorphine, and 0.3% transdermal buprenorphine). Individuals who received medication therapy were more likely to be male, younger, and have an additional substance use disorder compared with those diagnosed with OUD who did not receive medication therapy. Those prescribed injectable naltrexone were more often male, younger, and diagnosed with additional substance use disorders compared with those prescribed other medications for opioid use disorder (MOUDs). At 30 days after initiation, 52% for individuals treated with injectable naltrexone, 70% for individuals treated with oral naltrexone, 31% for individuals treated with sublingual or oralmucosal buprenorphine/naloxone, 58% for individuals treated with sublingual buprenorphine, and 51% for individuals treated with transdermal buprenorphine discontinued treatment. In the Cox proportional hazard model, use of injectable naltrexone, oral naltrexone, sublingual buprenorphine, and transdermal buprenorphine were all associated with significantly greater hazard of discontinuing therapy beginning >30days after MOUD initiation (HR=2.17, 2.54, 1.15, and 2.21, respectively, 95% CIs 2.04-2.30, 2.45-2.64, 1.10-1.19, and 2.11-2.33), compared with the use of sublingual or oralmucosal buprenorphine/naloxone. This analysis demonstrates that the use of evidence-based medication therapies has not kept pace with increases in OUD diagnoses in commercially insured populations in the United States. Among those who have been treated, discontinuation rates >30days after initiation are high. The proportion treated with injectable naltrexone, oral naltrexone, and transdermal buprenorphine grew over time but remains small, and the discontinuation rates are higher among those treated with these medications compared with those treated with sublingual or oralmucosal buprenorphine/naloxone. In the face of the opioid overdose and addiction crisis, new efforts are needed at the provider, health system, and policy levels so that MOUD availability and uptake keep pace with new OUD diagnoses and OUD treatment discontinuation is minimized.

Morgan JR ，Schackman BR ，Leff JA ，Linas BP ，Walley AY ... -  《-》

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians.

Rowan K ，Shah SV ，Binns S ，Murphy E ，Satorius J ，Ghobadi A ，Krauss D ，Robbins C ，Schoebel V ，Knudson A ，Kepley H ，Bureau of Health Workforce Substance Use Disorder Evaluation Team ... -  《JAMA Network Open》

Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts.

Schiff DM ，Nielsen T ，Hoeppner BB ，Terplan M ，Hansen H ，Bernson D ，Diop H ，Bharel M ，Krans EE ，Selk S ，Kelly JF ，Wilens TE ，Taveras EM ... -  《JAMA Network Open》