Literature Collection

Background: A cascade of care (CoC) model may improve understanding of gaps in addiction treatment availability and quality over current single measure methods. Despite increased funding, opioid overdose rates remain high. Therefore, it is critical to understand where the health-care system is failing to provide appropriate care for people with opioid use disorder (OUD) diagnoses, and to assess disparities in receipt of medication for OUD (MOUD).Objective: Using a CoC framework, assess treatment quality and outcomes for OUD in the Florida Medicaid population in 2017/2018 by demographics and primary vs. secondary diagnosis.Methods: Data from Florida Medicaid claims for 2017 and 2018 were used to calculate the number of enrollees who were diagnosed, began MOUD, were retained on medication for a minimum of 180 days, and who died.Results: Only 28% of those diagnosed with OUD began treatment with an FDA approved MOUD (buprenorphine, methadone, or injectable naltrexone). Once on medication, 38% of newly diagnosed enrollees were retained in treatment for180 days. Those who remained on MOUD for 180 days had a hazard ratio of death of 0.226 (95% CI = 0.174 to 0.294) compared to those that did not initiate MOUD, a reduction in mortality from 10% without MOUD to 2% with MOUD.Conclusions: Initiating medication after OUD diagnosis offers the greatest opportunity for intervention to reduce overdose deaths, though efforts to increase retention are also warranted. Analyzing claims data with CoC identifies system functioning for specific populations, and suggests policies and clinical pathways to target for improvement.

In 2007, the Veterans Health Administration (VHA) began national implementation of Primary Care-Mental Health Integration (PCMHI) services. A major goal was to enhance mental health access and address unmet treatment needs. Integrated care services have been shown to improve depression identification1 and enhance engagement in specialty mental health treatment.2 Szymanski et al. examined a sample of VHA users in fiscal year (FY) 2010 and documented positive associations between receipt of PCMHI services on the day of a positive depression screen and initiation of depression treatment within 12 weeks.3 The authors noted as a study limitation that individuals who had received same-day PCMHI services may have had unmeasured differences in symptom severity or willingness to initiate depression treatment, as compared with other study patients.3 Also, in the years since 2010, VHA implementation of PCMHI services has expanded substantially. The present analysis re-evaluates the influence of same-day PCMHI services on initiation of depression treatment, for a more recent period and adjusting for patient propensity to have received PCMHI and/or Specialty Mental Health (SMH) clinic services on the day of the initial positive depression screen in primary care (PC). METHODS For FY2017 data, we applied methods from the FY2010 study,3 adding use of propensity score weights to adjust for patient likelihood of receiving same-day PCMHI and/or SMH services.4, 5 Generalized boosted models4, 5 were used to create the weights, with location of same-day services as the outcome. Separate propensity score–weighted logistic regressions assessed initiation within 12 weeks of antidepressant pharmacotherapy, psychotherapy, and either treatment.4 Analyses used SAS (version 9.3) and R software (version 3.4.2). The study was conducted as part of ongoing operations in the VHA Office of Mental Health and Suicide Prevention. RESULTS Table 1 presents sample characteristics, by type of services received. Compared with patients receiving same-day PCMHI, the “PC only” patients were older (38.4% vs. 23.1% were 65+ years old); less likely to be Hispanic (7.7% vs. 8.9%); more likely to be male (87.8% vs. 85.7%), married (49.2% vs. 45.8%), with a prior mental health diagnosis (16.7% vs. 13.3%) and prior VHA outpatient use (67.1% vs. 64.6%); and had lower baseline PHQ-2 (Patient Health Questionnaire) scores (4.64 vs. 4.83).

BACKGROUND: People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment. METHODS: Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models. RESULTS: Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences). CONCLUSIONS: Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.