Literature Collection

OBJECTIVE: This study examines the impact of an insurance-mandated change in formulation of buprenorphine/naloxone (BNX) for patients with opioid use disorder treated in a primary care clinic. METHODS: A retrospective cohort study was conducted to determine the proportion of patients who were switched back to the previous BNX formulation and rates of aberrant urine drug tests for the 3 months before and 3 months after a mandated change in BNX from the sublingual film to the rapidly dissolving tablet (BNX-RDT). Aberrant urine drug tests were defined as the presence of cocaine, nonprescribed opioids/benzodiazepines, or the absence of buprenorphine. RESULTS: In all, 186 patients were included in the analysis. At 3 months after the change, 36.0% of patients remained on BNX-RDT at equivalent dose, 9.1% were prescribed a higher dose of BNX-RDT, 52.7% were switched back to their previous formulation after a trial of BNX-RDT, and 2.2% dropped out of care. There was no significant change in the rates of aberrant urine drug tests pre and postchange (36.6% vs 33.7%; P = 0.27) or in any individual component of urine drug testing. Age, sex, and starting dose were not associated with remaining on BNX-RDT at equivalent dose, compared with increasing dose or changing formulation. CONCLUSIONS: Most patients were dissatisfied with the change in formulation and requested a return to the previous formulation. This change did not appear to impact drug use; however, the flexibility that permitted patients to switch back to their previous BNX formulation likely attenuated the policy's impact.

BACKGROUND: The Veterans Health Administration (VHA) has made significant improvements in increasing prescribing of medication treatment for opioid use disorder (MOUD) and medication treatment for alcohol use disorder (MAUD); however, several barriers to treatment retention remain. In an effort to improve MOUD/MAUD retention, a Veterans Affairs (VA) facility established a pharmacist-led substance use disorder (SUD) transitions of care telephone clinic for patients discharged from an inpatient hospitalization on MOUD/MAUD, including buprenorphine/naloxone (BUP/NAL) and extended-release (ER) naltrexone injections. Pharmacists within the clinic assess aspects of treatment retention such as medication tolerability, perceived barriers to continuing treatment, status of current prescriptions, and appointment coordination. OBJECTIVES: The primary objective of this study was to evaluate the impact of a pharmacist-led SUD transitions of care telephone clinic on MOUD/MAUD retention following inpatient initiation in patients with opioid use disorder (OUD) and/or alcohol use disorder (AUD). Secondary objectives included subanalyses of clinic impact on MOUD/MAUD retention based on study medication or diagnoses, health care utilization, and characterization of pharmacist interventions. METHODS: The study identified patients for inclusion from inpatient units at a VA hospital. The study included patients if they were >18 years of age, had a diagnosis of AUD and/or OUD, and were initiated on ER naltrexone or BUP/NAL during admission and continued at discharge from August 1, 2018, to December 31, 2019. The study excluded patients if they declined clinic involvement, transferred facilities, moved beyond the VA catchment area, or were unable to be reached for initial contact after 3 telephone attempts. The intervention group included patients enrolled in the pharmacist-led SUD transitions of care telephone clinic, while the control group included patients initiated on MOUD/MAUD during admission who were eligible but not referred for clinic enrollment. RESULTS/CONCLUSIONS: The study identified a total of 150 patients for inclusion (n = 54 intervention group; n = 96 control group). The study observed a statistically significant difference for the primary endpoint of combined 1- and 3-month MOUD/MAUD retention rates as measured by a continuous, multiple-interval measure of medication acquisition (CMA) of ER naltrexone and BUP/NAL for the intervention group vs. control group (1-month: 77.3% vs. 56.8%, p = 0.004; 3-month: 71.4% vs. 48%, p = 0.0002). When analyzed by study medication, we also observed a statistically significant improvement in continuous use of ER naltrexone for those enrolled in the clinic (1-month: 71.4% vs. 45.9%, p = 0.01; 3-month: 66.7% vs. 34.4%, p = 0.0003). The study did not observe any statistically significant improvements for BUP/NAL (1-month: 87.1% vs. 75.8%, p = 0.13; 3-month: 79.4% vs. 68.5%, p = 0.24) or establishment with a BUP/NAL clinic (90.5% vs. 80% patients established, p = 0.46). Likewise, the study did not observe any statistically significant differences for combined emergency department (ED) visits (1-month: 24.1% vs.17.1% patients with ED visit, p = 0.40; 3-month: 31.5% vs. 29.2% patients with ED visit, p = 0.85) or hospitalizations (1-month: 9.3% vs. 14.6% re-hospitalization, p = 0.45; 3-month: 14.8% vs. 26% re-hospitalization, p = 0.15) for those in the intervention group vs. the control group. Overall, the study observed statistically and clinically significant improvements in MOUD/MAUD retention rates for patients enrolled in a pharmacist-led SUD transitions of care telephone clinic.

INTRODUCTION: Co-occurring substance use disorders (SUDs) are common among people with opioid use disorder (OUD) and known to hinder receipt of medications for OUD (MOUD). It is important to understand how MOUD care implemented outside of SUD specialty settings impacts access for patients with co-occurring SUDs. The Veterans Health Administration's (VA) Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative was implemented in primary care, mental health, and pain clinics in 18 VA facilities, and was found to increase MOUD receipt. This study assessed the SCOUTT initiative's impact among patients with and without co-occurring SUDs. METHODS: This study used a controlled interrupted time series design. We extracted electronic health record data for patients with OUD with visits in SCOUTT intervention or matched comparison clinics during the post-implementation year (9/1/2018-8/31/2019). We examined the monthly proportion of patients who received MOUD in SCOUTT intervention or comparison clinics (primary care, mental health, and pain clinics), or in a VA SUD specialty clinic (where patients may have been referred), during the pre- and post-implementation years. Segmented logistic regression models estimated pre-post changes in outcomes (immediate level change from the final month of the pre-implementation period to the first month of the post-implementation period, change in trend/slope) in intervention vs. comparison facilities, adjusting for patient characteristics and pre-implementation trends. We stratified analyses by the presence of co-occurring SUDs. RESULTS: Among patients without co-occurring SUDs, the pre-post trend/slope change in MOUD received in SCOUTT intervention or comparison clinics was greater in intervention vs. comparison facilities (adjusted odds ratio [aOR]: 1.06, 95% confidence interval [CI]: 1.02-1.10), and the immediate increase in MOUD received in SUD clinics was greater in intervention vs. comparison facilities (aOR: 1.12, 95% CI: 1.02-1.22). These changes did not significantly differ in intervention vs. comparison facilities among patients with co-occurring SUDs. CONCLUSIONS: The SCOUTT initiative may have increased MOUD receipt primarily among patients without co-occurring SUDs. Focusing on increasing MOUD receipt for patients with co-occurring SUDs may improve the overall effectiveness of MOUD implementation efforts.

Hepatitis C virus (HCV) infection is a public health issue that claims the lives of 350,000 individuals globally every year. Primary care providers are increasingly prescribing HCV medications with more modern, simplified administrations. Individuals with HCV are disproportionately affected by behavioral health challenges and substance use disorders. Integrated behavioral health providers can work in concert with their patients' primary care teams to provide innovative treatment programs to help support the needs of HCV care. We used simple and multivariable logistic regression to determine the association between receipt of behavioral health consultation and two outcomes on the care continuum: insurance approval for treatment and initiated HCV treatment regimen. These models were fitted using theoretically hypothesized variables and multivariable regression models included age, sex, and race/ethnicity as potential confounders. From January 2015 to May 2017, 189 patients at health centers were referred for onsite HCV primary care treatment. Of these, 142 were approved for participation, and 132 started treatment. Simple regression revealed a significant association between behavioral health consultation and treatment approval; however, behavioral health consultation was non-significant in the multivariable model for treatment approval. For initiating HCV treatment, onsite behavioral health consultation was significantly associated in both the unadjusted and adjusted regression models. Integrating behavioral health services for patients seeking HCV treatment may improve movement across the care continuum, optimizing patient's HCV health outcomes. Behavioral health consultation in primary care settings should be studied further to improve HCV treatment outcomes for patients with behavioral health and substance use disorders.