Literature Collection

OBJECTIVES: This study is a follow-up to previous research regarding buprenorphine medication-assisted therapy (MAT) in Johnson City, Tennessee. For-profit MAT clinics were surveyed to determine changes in tapering practice patterns and insurance coverage during the last 3 years. METHODS: Johnson City for-profit MAT clinics; also called office based opioid treatment centers, were surveyed by telephone. Clinic representatives were asked questions regarding patient costs for therapy, insurance coverage, counseling offered onsite, and opportunities for tapering while pregnant. RESULTS: All of the MAT clinics representatives indicated that tapering in pregnancy could be considered even though tapering in pregnancy is contrary to current national guidelines. Forty-three percent of the clinics now accept insurance as compared with 0% in the 2016 study. The average weekly cost per visit remained consistent. CONCLUSIONS: The concept of tapering buprenorphine during pregnancy appears to have become a standard of care for this community, as representatives state it is offered at all of the clinics that were contacted. Representatives from three clinics stated the clinics require tapering, even though national organizations such as the American College of Obstetricians and Gynecologists and the American Society of Addiction Medicine do not recommend this approach. Although patients who have government or other insurance are now able to obtain buprenorphine with no expense at numerous clinics, the high cost for uninsured patients continues to create an environment conducive to buprenorphine diversion.

BACKGROUND: To determine how clinicians with a DATA waiver to prescribe buprenorphine for opioid use disorder (OUD) adapted during the COVID-19 pandemic to emergency authorities, including use of telehealth to prescribe buprenorphine, the challenges faced by clinicians, and strategies employed by them to manage patients with OUD. METHODS: From June 23, 2020 to August 19, 2020, we conducted an electronic survey of U.S. DATA-waivered clinicians. Descriptive statistics and multivariable logistic regression were used for analysis. RESULTS: Among 10,238 respondents, 68 % were physicians, 25 % nursing-related providers, and 6% physician assistants; 28 % reported never prescribing or not prescribing in the 12 months prior to the survey. Among the 72 % of clinicians who reported past 12-month buprenorphine prescribing (i.e. active practitioners during the pandemic) 30 % reported their practice setting closed to in-person visits during COVID-19; 33 % reported remote prescribing to new patients without an in-person examination. The strongest predictors of remote buprenorphine prescribing to new patients were prescribing buprenorphine to larger numbers of patients in an average month in the past year and closure of the practice setting during the pandemic; previous experience with remote prescribing to established patients prior to COVID-19 also was a significant predictor. Among clinicians prescribing to new patients without an in-person examination, 5.5 % reported difficulties with buprenorphine induction, most commonly withdrawal symptoms. CONCLUSIONS: Telehealth practices and prescribing to new patients without an in-person examination were adopted by DATA-waivered clinicians during the first six months of COVID-19. Permanent adoption of these authorities may enable expanded access to buprenorphine treatment.

BACKGROUND AND AIMS: Expanding access to medication-assisted treatment with buprenorphine is a cornerstone of the opioid crisis response, yet buprenorphine remains underutilized. Research has identified multiple barriers to prescribing buprenorphine. This study aimed to examine clinician characteristics, prescribing practices and barriers and incentives to prescribing buprenorphine among clinicians with a federal Drug Addiction Treatment Act of 2000 (DATA) waiver to prescribe buprenorphine for opioid use disorder treatment. DESIGN: Electronic survey of 4225 clinicians conducted between March and April 2018. SETTING: United States. PARTICIPANTS: Clinicians obtaining an initial federal DATA waiver or an increase in authorized patient limit to prescribe buprenorphine for opioid use disorder treatment in 2017. MEASUREMENTS: Descriptive statistics and multivariable logistic regression examined clinician characteristics, prescribing practices and primary barriers and incentives to prescribing buprenorphine or prescribing at or near the authorized patient limit. FINDINGS: Among respondents, 75.5% had prescribed buprenorphine since obtaining a DATA waiver; the mean (standard deviation) number of patients treated in the past month was 26.6 (40.3), and 13.1% of providers were prescribing at or near their patient limit in the past month. Lack of patient demand, cited by 19.4% of clinicians, was the most common primary barrier to prescribing buprenorphine or prescribing to the authorized patient limit, followed by time constraints in practice (14.6%) and insurance reimbursement, prior authorization or other insurance requirements (13.2%). Increased patient demand (22.2%), institutional support for buprenorphine treatment (12.5%) and increased reimbursement (12.2%) were the most endorsed primary incentives for buprenorphine prescribing. Multivariable logistic regression models identified multiple clinician characteristics associated with buprenorphine prescribing and prescribing at or near the authorized patient limit. CONCLUSIONS: US clinicians recently waivered to prescribe buprenorphine for opioid use disorder treatment appear to prescribe well below their patient limit, and many do not prescribe at all.

INTRODUCTION: US opioid overdoses and deaths continue to increase, despite historic national investment to mitigate risk and improve access to evidence-based treatment. Unfortunately, implementation of emergency department (ED) buprenorphine - an effective medical treatment for opioid use disorder (OUD) - has been limited. Our objective was to assess the effectiveness of an electronic health record (EHR)-integrated, interruptive clinical decision support (CDS) tool to improve rates of ED initiated OUD treatment. METHODS: This is an observational, pre-post study of a CDS tool designed to identify and facilitate treatment of patients with OUD using electronic health record data. Patients were included if treated at our urban, academic ED between May 1, 2022, and November 8, 2023. The CDS triggered based on a rules-based algorithm using routinely collected EHR data which were identified from a previously validated EHR OUD phenotype. Outcomes are organized under a modified RE-AIM framework, with the primary outcome, Effectiveness, measured by the proportion of OUD patients receiving buprenorphine (administered/prescribed; filled prescriptions). Secondary outcomes include patient Reach, clinician Adoption, and fidelity to Implementation. Chi Square tests and Bayesian structural time-series models evaluate differences in outcomes before and after CDS implementation (CausalImpact package v1.3.0 in R v4.4.0). RESULTS: There were 171,221 total ED visits during the study period. Patient characteristics before and after CDS implementation were similar. CDS triggered in 4.7 % (2754/58,173) of encounters after initiation of intervention, reaching 116 unique emergency medicine providers and 2566 ED patients. Clinicians adopted the CDS, accessing the OUD treatment pathway link or ordering a social work consult for substance use, in 27 % (1266/4746) of CDS alerts. When compared to the pre-implementation period, CDS implementation was associated with increased buprenorphine administration in the ED by 31 % (95 % CI: 16-47 %, p = 0.001), buprenorphine prescribing from the ED by 20 % (95 % CI: 5-38 %, p = 0.007), and the buprenorphine fill rate at an affiliated ED pharmacy by 17 % (95 % CI: 1-36 %, p = 0.017). CONCLUSIONS: Implementation of an EHR-integrated, CDS was associated with increased ED buprenorphine administration, prescribing, and prescription fills among ED patients with OUD. Further efforts are needed to assess maintenance strategies that improve adoption, minimize interruptiveness, and optimize workflow congruence.

CONTEXT: Exploratory buprenorphine ingestions in young children have been associated with clinically significant toxicity. However, detailed data on the clinical presentation and management of these patients are lacking. In an attempt to obtain more comprehensive data, we sought to examine a single center cohort of patients with report of buprenorphine exposure and provide descriptive analysis of rates of respiratory depression, time to respiratory depression, interventions, disposition, and outcomes. STUDY DESIGN: We performed a retrospective cohort study at a single pediatric tertiary care center of children between the age of 6 months and 7 years of age hospitalized between 1 January 2006 and 1 September 2014 with report of buprenorphine or buprenorphine/naloxone exposure. Patients with possible exposure to more than one agent were excluded. We extracted clinical findings, including time to respiratory depression, interventions, and disposition from the medical record. RESULTS: Eighty-eight patients met the inclusion criteria. Seven patients were excluded. The median age was 24 months [IQR 18-30]. 20 patients (23%) received activated charcoal while 48 (55%) were treated with naloxone. 36 (41%) patients were admitted to the ICU. Observed clinical effects included respiratory depression (83%), oxygen saturation by pulse oximetry (SpO2) < 93% (28%), depressed mental status (80%), miosis (77%), and emesis (45%). Median time from exposure to respiratory depression was 263 min [IQR 105-486]. The median hospital length of stay was 22 h [IQR 20-26] and was positively associated with estimated exposure dose (p = 0.002). CONCLUSION: Pediatric patients exposed to buprenorphine are likely to exhibit signs and symptoms of opioid toxicity, including respiratory depression, altered mental status and miosis. Although the majority of patients developed signs of clinical toxicity within 8 h of reported exposure, the optimum duration of monitoring remains unclear.