Relationship of hub and treatment characteristics with client outcomes in the initial Washington State hub and spoke cohort.

Washington State's Hub and Spoke (HS) approach aims to improve availability of opioid use disorder (OUD) treatment. Washington initially funded six hubs with expertise in medications for opioid use disorder (MOUD) that built care networks with referral and treatment partners (spokes). We assessed outcomes for the initial HS cohort, considering the role of HS and treatment characteristics. We conducted a cohort-based observational study using 2017-2019 Medicaid claims data for 2841 HS participants aged 18-64, excluding those with past-month MOUD, in an intent-to-treat analysis. We describe treatment characteristics (MOUD type, treatment setting, and hub type at the initial HS visit, number of outpatient services in their first HS month), and six-month outcomes (MOUD continuity, emergency department (ED) utilization, hospitalization, and intensive SUD treatment). We used multivariable regressions to assess associations with six-month outcomes, adjusting for client characteristics. Two-thirds (68 %) of participants received buprenorphine, 22 % methadone, 5 % naltrexone, and 5 % outpatient without MOUD for their initial visit. Within six months, 45 % had an ED visit, 14 % any hospitalization, and 18 % entered intensive SUD treatment. Only 24 % remained on MOUD for six months. Compared to buprenorphine, the methadone sample had higher odds of MOUD continuity (aOR = 2.81, 95%CI 2.21-3.55), and the naltrexone sample had lower odds (aOR = 0.36, 95%CI 0.19-0.66). FQHC/public health treatment settings had higher odds of MOUD continuity (aOR = 1.70, 95%CI 1.17-2.47) but hub type was not significant. MOUD continuity increased with 2+ outpatient services for the buprenorphine sample (aOR range 2.55-4.73). Odds of intensive SUD treatment were lower for the methadone sample, compared to buprenorphine (aOR = 0.16, 95%CI 0.11-0.23), all settings compared to SUD settings (aOR range 0.32-0.58), and SUD + MH and medical/hospital hubs compared to SUD only hubs (aOR range 0.28-0.41). Most participants did not attain six-month MOUD continuity, despite the HS approach, with variations by MOUD type and treatment setting. The number of outpatient services in the first month for buprenorphine clients was associated with greater odds of MOUD continuity and reduced odds of intensive SUD treatment. More work is needed to improve MOUD continuity for people with OUD within the HS model.

Reif S ，Stewart MT ，Daily SM ，Brolin MF ，Lee MT ，Panas L ，Ritter G ，Shields MC ，Mazel SB ，Wicks JJ ... -  《-》

Emergency department utilization by individuals with opioid use disorder who were recently incarcerated.

Individuals with opioid use disorder (OUD) are highly represented among the incarcerated population and are frequent utilizers of the emergency department (ED). Medications for opioid use disorder (MOUD) are a recognized treatment option for individuals with OUD. Although the field recognizes the benefits of MOUD, we know little about what mitigating effects MOUD offered in jail might have on post-release ED utilization. In this retrospective cohort analysis, we searched electronic medical records (EMR) for incarcerations in the Santa Clara County jail between 8/1/2019 and 8/31/2021 for individuals with OUD (N = 4352) and collected demographic and medication administration data for these individuals. Individuals are considered as having received MOUD if they have at least one administration of methadone, naltrexone, or extended release (XR) buprenorphine during their incarceration. We also collected ED visit data from the same EMR for the 28 days following release from the identified incarcerations. Using logistic regression, we compared ED use within 24 h and 28 days for individuals who are incarcerated and treated with MOUD with those not receiving treatment. Individuals who received methadone or XR buprenorphine during their incarceration were less likely to present at the 28 days following release than those not receiving treatment, after controlling for age, race, sex assigned at birth, preferred language, and housing status. Most individuals accessing the ED within 28 days of release do so within the first seven days, and the greatest volume occurred in the first 24 h. Individuals released before noon had a lower likelihood of ED presentation within 24 h than those released in the afternoon. Offering methadone and XR buprenorphine to individuals with OUD who are incarcerated is beneficial in mitigating ED utilization within 28 days of release, although further research is needed to understand what other contributing variables, especially those related to follow-up care, could be influencing these results. If possible, release times for individuals could be shifted to the morning to maximize reduction in ED use within 24 h of release. Alternatively, further research should investigate why release times appear to influence ED utilization.

Will J ，Abare M ，Olson M ，Chyorny A ，Wilhelm-Leen E ... -  《-》

Factors Associated With the Availability of Medications for Opioid Use Disorder in US Jails.

Flanagan Balawajder E ，Ducharme L ，Taylor BG ，Lamuda PA ，Kolak M ，Friedmann PD ，Pollack HA ，Schneider JA ... -  《JAMA Network Open》

Quality of Opioid Use Disorder Treatment for Persons With and Without Disabling Conditions.

Thomas CP ，Stewart MT ，Ledingham E ，Adams RS ，Panas L ，Reif S ... -  《JAMA Network Open》

Patient outcomes following buprenorphine treatment for opioid use disorder: A retrospective analysis of the influence of patient- and prescriber-level characteristics in Massachusetts, USA.

Opioid use disorder (OUD) is treatable with buprenorphine/naloxone (buprenorphine), but many patients discontinue treatment prematurely. The aim of this study was to assess the influence of patient- and prescriber-level characteristics relative to several patient outcomes following the initiation of buprenorphine treatment for OUD. This was a retrospective observational investigation. We used the Public Health Data Warehouse from the Massachusetts Department of Public Health to construct a sample of patients who initiated buprenorphine treatment between 2015 and 2019. We attributed each patient to a prescriber based on information from prescription claims. We used multilevel models to assess the influence of patient- and prescriber-level characteristics on each outcome. Massachusetts, USA. The study cohort comprised 37 955 unique patients and 2146 prescribers. Among patients, 64.6% were male, 52.6% were under the age of 35 and 82.2% were White, non-Hispanic. For insurance coverage, 72.1% had Medicaid. The outcome measures were poor medication continuity, treatment discontinuation and opioid overdose, all assessed within a 12-month follow-up period that began with a focal prescription for buprenorphine. Each patient had a single follow-up period. Poor medication continuity was defined as medication gaps totaling more than 7 days during the initial 180 days of buprenorphine treatment and treatment discontinuation was defined as having a medication gap for 2 consecutive months within the 12-month follow-up period. The patient-level rates for poor medication continuity, treatment discontinuation and opioid overdose were 59.7% [95% confidence interval (CI) = 59.2-60.2], 57.4% (95% CI = 56.9-57.9) and 10.3% (95% CI = 10.0-10.6), respectively, with 1.1% (95% CI = 1.0-1.2) experiencing a fatal opioid overdose. At the patient level, after adjustment for covariates, adverse outcomes were associated with race/ethnicity as both Black, non-Hispanic and Hispanic patients had worse outcomes than did White, non-Hispanic patients (Black, non-Hispanic -- poor continuity: 1.50, 95% CI = 1.34-1.68; discontinuation: 1.44, 95% CI = 1.30-1.60; Hispanic -- poor continuity: 1.21, 95% CI = 1.12-1.31; discontinuation: 1.38, 95% CI = 1.28-1.48). Patients with insurance coverage through Medicaid also had worse outcomes than those with commercial insurance (poor continuity: 1.18, 95% CI = 1.11-1.26; discontinuation: 1.09, 95% CI = 1.03-1.16; overdose: 1.98, 95% CI = 1.75-2.23). Pre-treatment mental health conditions and other types of chronic illness were also associated with worse outcomes (History of mental health conditions -- poor continuity: 1.11, 95% CI = 1.06-1.17; discontinuation: 1.05, CI = 1.01-1.10; overdose: 1.47, 95% CI = 1.36-1.60; Chronic health conditions -- poor continuity: 1.15, 95% CI = 1.05-1.27; discontinuation: 1.15, 95% CI = 1.05-1.26; overdose: 1.83, 95% CI = 1.60-2.10; History of substance use disorder other than for opioids -- poor continuity: 1.54, 95% CI = 1.46-1.62; discontinuation: 1.54, 95% CI = 1.47-1.62; overdose: 1.93, 95% CI = 1.80-2.07). At the prescriber level, after adjustments for covariates, adverse outcomes were associated with clinical training, as primary care physicians had higher rates of adverse outcomes than psychiatrists (poor continuity: 1.12, 95% CI = 1.02-1.23; discontinuation: 1.04, 95% CI = 1.01-1.09). A larger prescriber panel size, based on number of patients being prescribed buprenorphine, was also associated with higher rates of adverse outcomes (poor continuity: 1.36, 95% CI = 1.27-1.46; discontinuation: 1.21, 95% CI = 1.14-1.28; overdose: 1.10, 95% CI = 1.01-1.19). Between 9% and 15% of the variation among patients for the outcomes was accounted for at the prescriber level. Patient- and prescriber-level characteristics appear to be associated with patient outcomes following buprenorphine treatment for opioid use disorder. In particular, patients' race/ethnicity and insurance coverage appear to be associated with substantial disparities in outcomes, and prescriber characteristics appear to be most closely associated with medication continuity during early treatment.

Young GJ ，Zhu T ，Hasan MM ，Alinezhad F ，Young LD ，Noor-E-Alam M ... -  《-》