Literature Collection

OBJECTIVES: The opioid overdose epidemic is escalating. Increasing access to medications for opioid use disorder in primary care is crucial. The impact of the US Department of Health and Human Services' policy change removing the buprenorphine waiver training requirement on primary care buprenorphine prescribing remains unclear. We aimed to investigate the impact of the policy change on primary care providers' likelihood of applying for a waiver and the current attitudes, practices, and barriers to buprenorphine prescribing in primary care. METHODS: We used a cross-sectional survey with embedded educational resources disseminated to primary care providers in a southern US academic health system. We used descriptive statistics to aggregate survey data, logistic regression models to evaluate whether buprenorphine interest and familiarity correlate with clinical characteristics, and a χ(2) test to evaluate the effect of the educational intervention on screening. RESULTS: Of the 54 respondents, 70.4% reported seeing patients with opioid use disorder, but only 11.1% had a waiver to prescribe buprenorphine. Few nonwaivered providers were interested in prescribing, but perceiving buprenorphine to be beneficial to the patient population was associated with interest (adjusted odds ratio 34.7, P < 0.001). Two-thirds of nonwaivered respondents reported the policy change having no impact on their decision to obtain a waiver; however, among interested providers, it increased their likelihood of obtaining a waiver. Barriers to buprenorphine prescribing included lack of clinical experience, clinical capacity, and referral resources. Screening for opioid use disorder did not increase significantly after the survey. CONCLUSIONS: Although most primary care providers reported seeing patients with opioid use disorder, interest in prescribing buprenorphine was low and structural barriers remained the dominant obstacles. Providers with a preexisting interest in buprenorphine prescribing reported that removing the training requirement was helpful.

IMPORTANCE: Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined. OBJECTIVE: To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing. DESIGN, SETTING, AND PARTICIPANTS: This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022. INTERVENTION: Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity. MAIN OUTCOMES AND MEASURES: The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100 000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed. RESULTS: A total of 8 166 963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111939.

Evidence-based treatment of opioid use disorder, the prevention of opioid overdose and other opioid-related harms, and safe and effective pain management are priorities for the Veterans Health Administration (VHA). The VHA Office of Health Services Research and Development hosted a State-of-the-Art Conference on "Effective Management of Pain and Addiction: Strategies to Improve Opioid Safety" on September 10-11, 2019. This conference convened a multidisciplinary group to discuss and achieve consensus on a research agenda and on implementation and policy recommendations to improve opioid safety for Veterans. Participants were organized into three workgroups: (1) managing opioid use disorder; (2) Long-term opioid therapy and opioid tapering; (3) managing co-occurring pain and substance use disorder. Here we summarize the implementation and policy recommendations of each workgroup and highlight important cross-cutting issues related to telehealth, care coordination, and stepped care model implementation.

BACKGROUND: Although opioid agonist therapy is effective in treating opioid use disorders (OUD), retention in opioid agonist therapy is suboptimal, in part, due to quality of care issues. Therefore, we sought to describe the planning and implementation of a quality improvement initiative aimed at closing gaps in care for people living with OUD through changes to workflow and care processes in Vancouver, Canada. METHODS: The Best-practice in Oral Opioid agoniSt Therapy (BOOST) Collaborative followed the Institute for Healthcare Improvement's Breakthrough Series Collaborative methodology over 18-months. Teams participated in a series of activities and events to support implementing, measuring, and sharing best practices in OAT and OUD care. Teams were assigned monthly implementation scores to monitor their progress on meeting Collaborative aims and implementing changes. RESULTS: Seventeen health care teams from a range of health care practices caring for a total of 4301 patients with a documented diagnosis of OUD, or suspected OUD based on electronic medical record chart data participated in the Collaborative. Teams followed the Breakthrough Series Collaborative methodology closely and reported monthly on a series of standardized process and outcome indicators. The majority of (59%) teams showed some improvement throughout the Collaborative as indicated by implementation scores. CONCLUSIONS: Descriptive data from the evaluation of this initiative illustrates its success. It provides further evidence to support the implementation of quality improvement interventions to close gaps in OUD care processes and treatment outcomes for people living with OUD. This system-level approach has been spread across British Columbia and could be used by other jurisdictions facing similar overdose crises.

Opioid agonist medication, including methadone, is considered the first-line treatment for opioid use disorder. Methadone, when taken daily, reduces the risk of fatal overdose; however, overdose risk increases following medication cessation. Amid an overdose epidemic accelerated by the proliferation of fentanyl, ensuring continuity of methadone treatment during the COVID-19 pandemic is a vital public health priority. (Am J Public Health. 2021;111(12):2115-2117. https://doi.org/10.2105/AJPH.2021.306523).

BACKGROUND: As the death toll continues to rise in the opioid overdose epidemic, increasing access to medications for opioid use disorder (OUD), such as buprenorphine, is vital. Psychiatric clinical pharmacist practitioners (CPPs) can help bridge the gap in care but are limited in their ability to prescribe buprenorphine given federal restrictions. OBJECTIVE: This study aimed to describe a pharmacist-psychiatrist collaborative practice designed to increase access to buprenorphine for OUD in rural communities by maximizing the CPP role. PRACTICE DESCRIPTION: A CPP operating under a scope of practice with prescriptive authority to manage substance use disorders (SUDs) and comorbid mental health conditions was hired in June of 2020 at a rural Veterans Affairs (VA) hospital in Tomah, Wisconsin. PRACTICE INNOVATION: A collaborative agreement with X-waivered psychiatrists was established to manage buprenorphine for patients with OUD. EVALUATION METHODS: A retrospective chart review was conducted on all patients with an OUD diagnosis from July 1, 2020, to October 31, 2021, to assess the use of medications for OUD, comorbid psychiatric, and SUD diagnoses; active naloxone prescription; and CPP involvement in care. For patients prescribed buprenorphine, their average wait time to initiation appointment was calculated in days and compared before and after CPP implementation. RESULTS: As of October 31, 2021, there were 60 patients with OUD cared for by the Tomah VA, of whom 28 received buprenorphine comanaged with the CPP. On average, those requesting urgent access appointment for buprenorphine assessment from the CPP were seen for same-day induction appointments compared with historically an average of a 6.1 day wait for outpatient appointments and 5.8 days for scheduled inpatient inductions. CONCLUSION: Collaborative approaches to buprenorphine management with a CPP improve access to care. Although collaboration decreases time burden for X-waivered psychiatrists, care could be more efficient and timely if a CPP could independently induct, stabilize, and manage patients on buprenorphine.

OBJECTIVE: To determine whether a pharmacistled intervention would increase the number of naloxone prescriptions and naloxone administration education in a primary care family medicine setting. DESIGN: Prospective quality improvement intervention in an academic family medicine clinic. METHODS: We surveyed providers about naloxone knowledge, prescribing habits, and prescribing barriers. We identified patients on chronic opioid therapy, through electronic health records for the year 2019. Overdose risk categories based upon morphine milligram equivalent doses and concomitant benzodiazepine use were used to determine patients who met criteria for naloxone. Pharmacists phoned qualified patients to discuss overdose risk and naloxone benefits. Patients who accepted naloxone prescriptions used their local pharmacy through a department-approved standing order set. RESULTS: From the survey results, there were 47 of 54 provider responses, and the majority noted that they do not routinely prescribe naloxone in high-risk patients. The predominant barriers were lack of time during visit and naloxone administration education. The population of patients from chart review included 93 high-risk patients with a mean age of 58 years. During the time of intervention, 71 patients remained eligible for naloxone coprescribing. Of the patients contacted, 29 (40 percent) accepted the intervention prescription, and subsequently, 22 picked up their prescription from the pharmacy. Sixteen received counseling with a support person. Twelve patients had naloxone already at home, and two received counseling with a support person. CONCLUSION: The naloxone prescribing intervention is achievable. The results of this intervention support identifying patients at increased risk of opioid overdose and offer education of a support person for naloxone in a large academic family medicine clinic.

BACKGROUND: Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization's stance on this issue. ISSUE: The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply. RECOMMENDATIONS: It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.

STUDY OBJECTIVE: Naloxone, an opioid-antagonist deliverable by an intra-nasal route, has become widely available and utilized by law enforcement officers as well as basic life support (BLS) providers in the prehospital setting. This study aimed to determine the frequency of repeat naloxone dosing in suspected narcotic overdose (OD) patients and identify patient characteristics. METHODS: A retrospective chart review of patients over 17 years of age with suspected opioid overdose, treated with an initial intranasal (IN) dose of naloxone and subsequently managed by paramedics, was performed from April 2014 to June 2016. Demographic data was analyzed using descriptive statistics to identify those aspects of the history, physical exam findings. Results: A sample size of 2166 patients with suspected opioid OD received naloxone from first responders. No patients who achieved GCS 15 after treatment required redosing; 195 (9%) received two doses and 53 patients received three doses of naloxone by advanced life support. Patients were primarily male (75.4%), Caucasian (88.2%), with a mean age of 36.4 years. A total of 76.7% of patients were found in the home, 23.1% had a suspected mixed ingestion, and 27.2% had a previous OD. Two percent of all patients required a third dose of naloxone. CONCLUSION: In this prehospital study, we confirmed that intranasal naloxone is effective in reversing suspected opioid toxicity. Nine percent of patients required two or more doses of naloxone to achieve clinical reversal of suspected opioid toxicity. Two percent of patients received a third dose of naloxone.

OBJECTIVE: To develop effective pharmacy-based interventions to mitigate harm from opioid use disorders. Programs include responsible opioid prescribing, expanded access to medication-assisted treatment (MAT), naloxone, and community interventions. SETTING: Clinical pharmacists practicing at Indian Health Service (IHS) locations in the Southwest, Midwest, and Great Lakes regions. These pharmacists serve culturally diverse American Indian populations throughout the United States and interface with tribal and federal programs to impact the opioid epidemic in Indian Country. PRACTICE DESCRIPTION: Pharmacists have reduced barriers to care by expanding clinical practices to include novel approaches in pain management clinics and MAT programs. PRACTICE INNOVATION: As part of a multidisciplinary team, IHS pharmacists provide comprehensive patient care while focusing on the prevention of opioid dependence and opioid overdose death. EVALUATION: Pharmacists have also expanded professional competencies to include coprescribing naloxone and training first responders on naloxone use. RESULTS: Pharmacists within IHS have proactively completed advanced training on responsible opioid prescribing, augmented services to increase access to MAT for American Indians and Alaska Natives, and increased access to naloxone for opioid overdose reversal. Pharmacists have also developed a comprehensive training program and program measurement tools for law enforcement officers serving in tribal communities. These materials were used to train 350 officers in 6 districts and conduct a mass naloxone dispensing initiative across Indian Country. Pharmacists have consequently developed successful community coalitions that are focused on saving lives. CONCLUSIONS: Pharmacist involvement in key initiatives including responsible opioid prescribing, expanded access to MAT, and expanded access to naloxone for trained first responders, coupled with an emphasis on enhanced education, illustrates pharmacists' impact with the opioid epidemic.

BACKGROUND: Naloxone co-prescribing to individuals at increased opioid overdose risk is a key component of opioid overdose prevention efforts. OBJECTIVE: Examine naloxone co-prescribing in the general population and assess how co-prescribing varies by individual and community characteristics. DESIGN: Retrospective cross-sectional study. We conducted a multivariable logistic regression of 2017-2018 de-identified pharmacy claims representing 90% of all prescriptions filled at retail pharmacies in 50 states and the District of Columbia. PATIENTS: Individuals with opioid analgesic treatment episodes > 90 days MAIN MEASURES: Outcome was co-prescribed naloxone. Predictor variables included insurance type, primary prescriber specialty, receipt of concomitant benzodiazepines, high-dose opioid episode, county urbanicity, fatal overdose rates, poverty rates, and primary care health professional shortage areas. KEY RESULTS: Naloxone co-prescribing occurred in 2.3% of long-term opioid therapy episodes. Medicaid (aOR 1.87, 95%CI 1.84 to 1.90) and Medicare (aOR 1.48, 95%CI 1.46 to 1.51) episodes had higher odds of naloxone co-prescribing than commercial insurance episodes, while cash pay (aOR 0.77, 95%CI 0.74 to 0.80) and other insurance episodes (aOR 0.81, 95%CI 0.79 to 0.83) had lower odds. Odds of naloxone co-prescribing were higher among high-dose opioid episodes (aOR 3.19, 95%CI 3.15 to 3.23), when concomitant benzodiazepines were prescribed (aOR 1.12, 95%CI 1.10 to 1.14), and in counties with higher fatal overdose rates. CONCLUSION: Co-prescription of naloxone represents a tangible clinical action that can be taken to help prevent opioid overdose deaths. However, despite recommendations to co-prescribe naloxone to patients at increased risk for opioid overdose, we found that co-prescribing rates remain low overall. States, insurers, and health systems should consider implementing strategies to facilitate increased co-prescribing of naloxone to at-risk individuals.