Publications by authors named "Barbara Andraka-Christou"

32 Publications

Criminal problem-solving and civil dependency court policies regarding medications for opioid use disorder.

Subst Abus 2021 Jul 8:1-8. Epub 2021 Jul 8.

Warren Alpert Medical School, Brown University, Providence, RI, USA.

Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's was used to make within-group comparisons between policies and MOUDs. We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Because respondents rarely chose "never" or "always" for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.
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http://dx.doi.org/10.1080/08897077.2021.1944958DOI Listing
July 2021

Stigmatization of medications for opioid use disorder in 12-step support groups and participant responses.

Subst Abus 2021 Jul 2:1-10. Epub 2021 Jul 2.

School of Public Health, Georgia State University, Atlanta, GA, USA.

12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. : We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. : We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. : We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. : Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.
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http://dx.doi.org/10.1080/08897077.2021.1944957DOI Listing
July 2021

Trends in visits to substance use disorder treatment facilities in 2020.

J Subst Abuse Treat 2021 08 11;127:108462. Epub 2021 May 11.

RAND Corporation, Pittsburgh, PA, USA; University of Pittsburgh School of Medicine, USA. Electronic address:

Objective: To describe weekly changes in the number of substance use disorder treatment (SUDT) facility visits in 2020 compared to 2019 using cell phone location data.

Methods: We calculated the percentage weekly change in visits to SUDT facilities from the week of January 5 through the week of October 11, 2020, relative to the week of January 6 through the week of October 13, 2019. We stratified facilities by county COVID-19 incidence per 10,000 residents in each week and by 2018 fatal drug overdose rate. Finally, we conducted a multivariable linear regression analysis examining percent change in visits per week as a function of county-level COVID-19 tercile, a series of calendar month indicators, and the interaction of county-level COVID-19 tercile and month. We repeated the regression analysis replacing COVID-19 tercile with overdose tercile.

Results: Beginning the eleventh week of 2020, the number of visits to SUDT facilities declined substantially, reaching a nadir of 48% of 2019 visits in early July. In contrast to January, there were significantly fewer visits in 2020 compared to 2019 in all subsequent months (p < 0.01 in all months). Multivariable regression results found that facilities in the tercile of counties experiencing the most COVID-19 cases had a significantly greater reduction in the number of SUDT visits in 2020 for the months of June through August than facilities in counties with the fewest COVID-19 rates (p < 0.05). The study found no statistically significant difference in the change in the number of visits by facilities in counties with historically different overdose rates.

Discussion: Our findings support the hypothesis that a reduction has occurred in the average weekly number of visits to SUDT facilities. The size of the effect differs based on the number of COVID-19 cases but not on historical overdose rate.
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http://dx.doi.org/10.1016/j.jsat.2021.108462DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8217724PMC
August 2021

Where did the specialty behavioral health workforce grow between 2011 and 2019? Evidence from census data.

J Subst Abuse Treat 2021 May 19;130:108482. Epub 2021 May 19.

Indiana University, Bloomington, IN, USA; National Bureau of Economic Research, Cambridge, MA, USA.

Importance: Given that mental health and substance use conditions are ongoing major public health problems in the United States, it is important for researchers to understand the behavioral health treatment workforce landscape and to assess whether increases in treatment capacity exist in areas with public health needs.

Objectives: This study quantified national and county-level changes in specialty behavioral health (SBH) workforce outcomes and assessed associations between these measures and age-adjusted drug mortality rate.

Design: Using a novel longitudinal dataset from the U.S. Census Bureau, this study described SBH workforce outcomes in 3130 U.S. counties between 2011 and 2019. The study stratified workforce outcomes, including the number of establishments, likelihood of having establishments, mean number of workers, and average wage of workers per county, by service settings: outpatient, residential, and hospital. The study fitted outcome data at the county level to ordinary least squares regression models as a function of the country's previous year age-adjusted drug mortality rate and county sociodemographic characteristics.

Results: The number of SBH establishments, their workforce, and their wages have increased steadily between 2011 and 2019, with the largest increases occurring in the following settings: outpatient (number of establishments and employment) and residential (average wage). County-level growth of residential SBH establishments was positively and significantly associated with the county's previous year county age-adjusted drug mortality rate. We did not observe a similar positive association between either employment or wages and the mortality rate.

Conclusions: The increase in the number of SBH establishments in recent years may indicate that the SBH workforce is responding to increased need for treatment; however, more work needs to be done to close behavioral health workforce gaps in areas with an elevated drug overdose mortality rate.
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http://dx.doi.org/10.1016/j.jsat.2021.108482DOI Listing
May 2021

Addressing Racial And Ethnic Disparities In The Use Of Medications For Opioid Use Disorder.

Health Aff (Millwood) 2021 06;40(6):920-927

Barbara Andraka-Christou is an assistant professor in the Department of Health Management and Informatics, University of Central Florida, in Orlando, Florida, with a secondary joint appointment in the Department of Internal Medicine. She is also a licensed attorney in the state of Florida.

Social discourse about the opioid crisis in the US has focused on White populations, even though opioid-related deaths have grown at a higher rate among people of color than among non-Hispanic White people in recent years. Medications for opioid use disorder (OUD) are the gold standard for treating OUD and preventing overdose but are underused among people with OUD, with disproportionately low treatment initiation and retention among people of color. Methadone, which is highly stigmatized and has a more burdensome treatment regimen, is the predominant medication for OUD available to people of color. To address disparities in the initiation and retention of treatment using medication for OUD, policy makers should consider strategies such as Medicaid expansion, increased grant funding for federally qualified health centers to provide buprenorphine treatment, retention of temporary telehealth policies that allow remote buprenorphine induction, and regulatory changes to allow methadone treatment in office-based practices.
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http://dx.doi.org/10.1377/hlthaff.2020.02261DOI Listing
June 2021

Toward a Typology of Office-based Buprenorphine Treatment Laws: Themes from a Review of State Laws.

J Addict Med 2021 May 18. Epub 2021 May 18.

Department of Health Management & Informatics, University of Central Florida, Orlando, FL (BA-C, RT), Department of Internal Medicine (Secondary Joint Appointment), University of Central Florida, Orlando, FL (BA-C), Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, Salt Lake City, UT (AJG), RAND Corporation, Santa Monica, CA (KB, RS), School of Public Health, Georgia State University, Atlanta, GA (OR-K), School of Law, Emory University, Atlanta, GA (MG), RAND Corporation, Pittsburgh, PA (BDS), Program for Addiction Research, Clinical Care, Knowledge and Advocacy (PARCKA), Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City UT (AJG).

Objectives: Buprenorphine is a gold standard treatment for opioid use disorder (OUD). Some US states have passed laws regulating office-based buprenorphine treatment (OBBT) for OUD, with requirements beyond those required in federal law. We sought to identify themes in state OBBT laws.

Methods: Using search terms related to medications for OUD, we searched Westlaw software for state regulations and statutes in 51 US jurisdictions from 2005 to 2019. We identified and inductively analyzed OBBT laws for themes.

Results: Since 2005, 10 states have passed a total of 181 OBBT laws. We identified the following themes: (1) provider credentials: state licensure for OBBT providers and continuing medical education requirements; (2) new patients: objective symptoms patients must have before receiving OBBT and exceptions for special populations; (3) educating patients: general informed consent requirements, and specific information to provide; (4) counseling: minimum counselor credentials, minimum counseling frequency, counseling alternatives; (5) patient monitoring: required prescription drug monitoring checks, frequency of drug screening, and responses to lost/stolen medications; (6) enhanced clinician monitoring: evidence-based treatment protocols, minimum clinician-patient contact frequency, health assessment requirements, and individualized treatment planning; and (7) patient safety: reconciling prescriptions, dosage limitations, naloxone coprescribing, tapering, and office closures.

Conclusions: Some laws codify practices for which scientific consensus is lacking. Additionally, some OBBT laws resemble opioid treatment programs and pain management regulations. Results could serve as the basis for a typology of office-based treatment laws, which could facilitate empirical examination of policy impacts on treatment access and quality.
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http://dx.doi.org/10.1097/ADM.0000000000000863DOI Listing
May 2021

Common themes in early state policy responses to substance use disorder treatment during COVID-19.

Am J Drug Alcohol Abuse 2021 Apr 28:1-11. Epub 2021 Apr 28.

RAND Corporation, Pittsburgh, PA, USA.

: Limited research has examined how states have changed policies for treatment of substance use disorder (SUD) during the COVID-19 pandemic.: We aimed to identify themes in state policy responses to the pandemic in the context of SUD treatment. Identifying themes in policy responses provides a framework for subsequent evaluations of the relationship between state policies and health service utilization.: Between May and June 2020, we searched all Single State Agencies for Substance Abuse Services (SSA) websites for statements of SUD treatment policy responses to the pandemic. We conducted Iterative Categorization of policies for outpatient programs, opioid treatment programs, and other treatment settings to identify themes in policy responses.: We collected 220 documents from SSA websites from 45 states and Washington D.C. Eight specific themes emerged from our content analysis: delivery of pharmacological and non-pharmacological services, obtaining informed consent and documentation for remote services, conducting health assessments, facility operating procedures and staffing requirements, and permissible telehealth technology and billing protocols. Policy changes often mirrored federal guidance, for instance, by expanding methadone take-home options for opioid treatment programs. The extent and nature of policy changes varied across jurisdictions, including telehealth technology requirements and staffing flexibility.: States have made significant policy changes to SUD treatment policies during COVID-19, particularly regarding telehealth and facilitation of remote care. Understanding these changes could help policymakers prioritize guidance during the pandemic and for future health crises. Impacts of policies on disparate treatment populations, including those with limited technological access, should be considered.
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http://dx.doi.org/10.1080/00952990.2021.1903023DOI Listing
April 2021

It will end in tiers: A strategy to include "dabblers" in the buprenorphine workforce after the X-waiver.

Subst Abus 2021 2;42(2):153-157. Epub 2021 Apr 2.

RAND Corporation, Pittsburgh, PA, USA.

Buprenorphine is one of the gold standard medication treatments for opioid use disorder (OUD), with proven effectiveness in preventing overdose, increasing abstinence, and improving quality of life. In the United States, buprenorphine can be legally prescribed and administered in office-based settings from clinicians who are specially credentialed to provide that care under the X-waiver. We believe the X-waiver will ultimately be repealed, but there is a need for a variety of strategies to create a new treatment system after the X-waiver. Building a new tier of treatment capacity will require educational outreach, systems strategies, and enhanced payments.
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http://dx.doi.org/10.1080/08897077.2021.1903659DOI Listing
April 2021

The Association Between Scope of Practice Regulations and Nurse Practitioner Prescribing of Buprenorphine After the 2016 Opioid Bill.

Med Care Res Rev 2021 Apr 1:10775587211004311. Epub 2021 Apr 1.

University of California, San Francisco, CA, USA.

This article examines the relationship between federal regulations, state scope-of-practice regulations on nurse practitioners (NPs), and buprenorphine prescribing patterns using pharmacy claims data from Optum's deidentified Clinformatics Data Mart between January 2015 and September 2018. The county-level proportion of patients filling prescriptions written by NPs was low even after the 2016 Comprehensive Addiction and Recovery Act (CARA), 2.7% in states that did not require physician oversight of NPs, and 1.1% in states that did. While analyses in rural counties showed higher rates of buprenorphine prescriptions written by NPs, rates were still considerably low: 3.7% in states with less restrictive regulations and 1.1% in other states. These results indicate that less restrictive scope-of-practice regulations are associated with greater NP prescribing following CARA. The small magnitude of the changes indicates that federal attempts to expand treatment access through CARA have been limited.
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http://dx.doi.org/10.1177/10775587211004311DOI Listing
April 2021

A pilot study of U.S. college students' 12-step orientation and the relationship with medications for opioid use disorder.

J Am Coll Health 2021 Feb 12:1-9. Epub 2021 Feb 12.

Department of Health Management & Informatics, University of Central Florida, Orlando, Florida, USA.

Objective: To examine undergraduate college students' attitudes toward 12-step support group utilization for opioid use disorder (OUD) and associations with previous experience with medications for OUD (MOUD). A convenience sample of undergraduate students at two major U.S. universities during Fall 2018 and Spring 2019. A cross-sectional online survey of agreement with three 12-step orientation measures, MOUD experience, and demographic variables. 1,281 students responded. Among 12-step orientation measures, respondents were most likely to agree that people with OUD should reach out to others in recovery. MOUD experience was significantly and negatively associated with agreement on each 12-step orientation measure. Religiosity/spirituality was positively associated with agreement that people with OUD should accept lack of control over OUD while placing trust in a higher power. Students with MOUD experience may be aware of anti-MOUD stigma in peer support groups and thus less likely to agree with 12-step orientation measures.
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http://dx.doi.org/10.1080/07448481.2020.1865376DOI Listing
February 2021

Whose opinion matters about medications for opioid use disorder? A cross-sectional survey of social norms among court staff.

Subst Abus 2020 Dec 7:1-16. Epub 2020 Dec 7.

Department of Health Management & Informatics, University of Central Florida, Orlando, Florida, USA.

Background: Criminal problem-solving and dependency courts set treatment standards for opioid use disorder (OUD) but sometimes prohibit or limit utilization of medications for OUD (MOUD). Court staff beliefs about MOUD inform court treatment policies. Court staff MOUD policies may also be influenced by social norms, meaning perceptions of opinions of other individuals/entities about MOUD, including opinions of fellow staff in their court, staff in other courts, the state supreme court, other state agencies, the National Association of Drug Court Professionals (NADCP), federal agencies, and local peer support groups. To date no study has examined social norms among court staff with respect to MOUD. We distributed an online cross-sectional survey in 2019 to all criminal problem-solving and dependency court staff in Florida. Respondents were asked to identify the extent to which they cared about different entities'/individuals' opinions about MOUD and the extent to which they perceived each of those entities/individuals as encouraging MOUD. We hypothesized that court role and court type would be associated with responses. We used descriptive statistics, logistic regressions, and difference of proportions tests to analyze data. 20% of the population ( = 119) completed the survey. Respondents cared most about the opinions of external treatment providers with whom they collaborate, fellow staff in their court, and the NADCP regarding MOUD. Fewer than half felt that any of these entities/individuals encourage methadone or oral buprenorphine. Additionally, fewer than 11% of respondents felt that local twelve-step peer support groups encourage the use of any form of MOUD. MOUD education should target all members of court teams, including collaborating treatment providers. Since court staff care relatively little about the MOUD opinions of staff in other courts, changes in opinions in one court may not affect changes in opinions in a neighboring court. The NADCP should more explicitly state its support for MOUD, and specifically oral buprenorphine and methadone treatment.
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http://dx.doi.org/10.1080/08897077.2020.1846666DOI Listing
December 2020

Designing an "Ideal" Substance Use Disorder Treatment Center: Perspectives of People Who Have Utilized Medications for Opioid Use Disorder.

Qual Health Res 2021 02 19;31(3):512-522. Epub 2020 Nov 19.

University of Central Florida, Orlando, Department of Health Informatics, Florida, USA.

Treatment preferences of people with opioid use disorder (OUD) have been underexplored, especially among those with a history of utilizing medications for opioid use disorder (MOUD). Therefore, we sought to understand preferred characteristics of substance use disorder treatment centers among people recovering from OUD with a history of MOUD utilization. We recruited 30 individuals from eight states through snowball sampling initiated at three syringe exchange programs. Telephone interviews were audio-recorded and transcribed in 2018-2019. Inductive thematic analysis in Dedoose software occurred iteratively with recruitment. The following were "ideal" treatment center themes: a menu of treatment options, including MOUD and nonspiritual peer support groups; an integrated system with multiple care levels (e.g., outpatient, residential); a harm reduction approach, including for goal setting and success measures; adjunctive support services (e.g., housing); and employees with recovery experience and professional education. Many preferences directly related to core principles of person-centered care and harm reduction.
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http://dx.doi.org/10.1177/1049732320971231DOI Listing
February 2021

Beliefs about medications for opioid use disorder among Florida criminal problem-solving court & dependency court staff.

Am J Drug Alcohol Abuse 2020 11 24;46(6):749-760. Epub 2020 Sep 24.

Department of Health Management & Informatics, University of Central Florida , Orlando, FL, USA.

Background: Criminal problem-solving and dependency (child/dependent) court staff refer clients with opioid use disorder (OUD) to treatment and set treatment policies. Negative beliefs regarding the safety and efficacy of medications for opioid use disorder (MOUD) have previously been reported in court staff. MOUD is superior to other OUD interventions, is severely underutilized, and is highly effective even in the absence of behavioral treatment.

Objective: We examined Florida court staff MOUD beliefs, exploring associations with court type and staff role. We also explored beliefs about the relationship of MOUD to child reunification, counseling, polysubstance use, and titration requirements.

Methods: We modified a previously developed cross-sectional survey. We fielded the online survey among all Florida criminal problem-solving and dependency court staff. Likert scale questions were asked about beliefs regarding methadone, buprenorphine, and extended-release naltrexone. We analyzed responses using descriptive statistics and logistic regression.

Results: 154 individuals (26% of the population) responded. Only 1/3 believed MOUD was more effective for OUD than nonpharmacological treatment. 31% believed methadone treatment makes it difficult for parents to regain child custody. Criminal problem-solving court staff were more likely to report certain positive beliefs about naltrexone. Fewer than 10% felt any MOUD should be permitted without counseling. Over 60% felt prescribers should have tapering plans for each MOUD patient. Beliefs were generally more positive for naltrexone than buprenorphine, and more positive for buprenorphine than methadone.

Conclusions: Court staff need education about MOUD efficacy. Policymakers should prohibit courts from banning MOUD and from preventing child reunification for parents utilizing MOUD.
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http://dx.doi.org/10.1080/00952990.2020.1807559DOI Listing
November 2020

A mixed-method comparison of physician-reported beliefs about and barriers to treatment with medications for opioid use disorder.

Subst Abuse Treat Prev Policy 2020 09 14;15(1):69. Epub 2020 Sep 14.

From the Behavioral Health Workforce Research Center, University of Michigan, Ann Arbor, MI, USA.

Background: Evidence demonstrates that medications for treating opioid use disorder (MOUD) -namely buprenorphine, methadone, and extended-release naltrexone-are effective at treating opioid use disorder (OUD) and reducing associated harms. However, MOUDs are heavily underutilized, largely due to the under-supply of providers trained and willing to prescribe the medications.

Methods: To understand comparative beliefs about MOUD and barriers to MOUD, we conducted a mixed-methods study that involved focus group interviews and an online survey disseminated to a random group of licensed U.S. physicians, which oversampled physicians with a preexisting waiver to prescribe buprenorphine. Focus group results were analyzed using thematic analysis. Survey results were analyzed using descriptive and inferential statistical methods.

Results: Study findings suggest that physicians have higher perceptions of efficacy for methadone and buprenorphine than for extended-release naltrexone, including for patients with co-occurring mental health disorders. Insurance obstacles, such as prior authorization requirements, were the most commonly cited barrier to prescribing buprenorphine and extended-release naltrexone. Regulatory barriers, such as the training required to obtain a federal waiver to prescribe buprenorphine, were not considered significant barriers by many physicians to prescribing buprenorphine and naltrexone in office-based settings. Nor did physicians perceive diversion to be a prominent barrier to prescribing buprenorphine. In focus groups, physicians identified financial, logistical, and workforce barriers-such as a lack of addiction treatment specialists-as additional barriers to prescribing medications to treat OUD.

Conclusions: Additional education is needed for physicians regarding the comparative efficacy of different OUD medications. Governmental policies should mandate full insurance coverage of and prohibit prior authorization requirements for OUD medications.
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http://dx.doi.org/10.1186/s13011-020-00312-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7491096PMC
September 2020

College students' perceived knowledge of and perceived helpfulness of treatments for opioid use disorder at two American universities.

Am J Drug Alcohol Abuse 2020 09 16;46(5):589-603. Epub 2020 Jun 16.

Department of Sociology, University of Central Florida , Orlando, Florida.

The U.S. is experiencing an opioid overdose health crisis, largely driven by opioid use disorder (OUD). College students have relatively high rates of substance use disorders. To identify perceived knowledge of and perceived helpfulness of various OUD treatments, including medications for OUD (MOUD), among college students. A convenience sample of students enrolled at two public universities during Fall 2018/Spring 2019 were recruited for an online cross-sectional survey. Questions examined reported knowledge of and perceived helpfulness of MOUD (i.e. methadone, buprenorphine, naltrexone) and non-MOUD treatments for OUD (e.g. peer support groups, individual counseling, group counseling, outpatient treatment). Logistic regression examined associations between knowledge, perceived helpfulness, and demographic variables. We received 1,439 responses and kept 1,280 (39% male; 61% female). Respondents were significantly more likely to report knowledge about non-MOUD treatments than MOUD treatments (48.7% of respondents reported being very knowledgeable about individual counseling, 4.4% about methadone, 3.8% about naltrexone, and 3.4% about buprenorphine). Among those reporting at least some MOUD knowledge, few perceived MOUD as helpful/very helpful (methadone 14%, naltrexone 14%, and buprenorphine 11%). Among those reporting at least some counseling knowledge, 71% felt counseling was helpful/very helpful. Perceived treatment knowledge was significantly and positively associated with perceived treatment helpfulness. Students had more positive attitudes toward non-MOUD treatments than toward MOUD despite greater efficacy of the latter for OUD. Colleges could provide information about MOUD during orientation, in course work, through student extracurricular organizations, or through college health clinics.
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http://dx.doi.org/10.1080/00952990.2020.1757686DOI Listing
September 2020

Clinical perspectives on hospitals' role in the opioid epidemic.

BMC Health Serv Res 2020 Jun 8;20(1):521. Epub 2020 Jun 8.

Department of Health Outcomes and Biomedical Informatics; College of Medicine, University of Florida, Gainesville, USA.

Background: Policymakers, legislators, and clinicians have raised concerns that hospital-based clinicians may be incentivized to inappropriately prescribe and administer opioids when addressing pain care needs of their patients, thus potentially contributing to the ongoing opioid epidemic in the United States. Given the need to involve all healthcare settings, including hospitals, in joint efforts to curb the opioid epidemic, it is essential to understand if clinicians perceive hospitals as contributors to the problem. Therefore, we examined clinical perspectives on the role of hospitals in the opioid epidemic.

Methods: We conducted individual semi-structured interviews with 23 clinicians from 6 different acute care hospitals that are part of a single healthcare system in the Midwestern United States. Our participants were hospitalists (N = 12), inpatient registered nurses (N = 9), and inpatient adult nurse practitioners (N = 2). In the interviews, we asked clinicians whether hospitals play a role in the opioid epidemic, and if so, how hospitals may contribute to the epidemic. We used a qualitative thematic analysis approach to analyze coded text for patterns and themes and examined potential differences in themes by respondent type using Dedoose software.

Results: The majority of clinicians believed hospitals contribute to the opioid epidemic. Multiple clinicians cited Center for Medicare and Medicaid Services' (CMS) reimbursement policy and the Joint Commission's report as drivers of inappropriate opioid prescribing in hospitals. Furthermore, numerous clinicians stated that opioids are inappropriately administered in the emergency department (ED), potentially as a mechanism to facilitate discharge and prevent re-admission. Many clinicians also described how overreliance on pre-populated pain care orders for surgical (orthopedic) patients, may be contributing to inappropriate opioid use in the hospital. Finally, clinicians suggested the following initiatives for hospitals to help address the crisis: 1) educating patients about negative consequences of using opioids long-term and setting realistic pain expectations; 2) educating medical staff about appropriate opioid prescribing practices, particularly for patients with complex chronic conditions (chronic pain; opioid use disorder (OUD)); and 3) strengthening the hospital leadership efforts to decrease inappropriate opioid use.

Conclusions: Our findings can inform efforts at decreasing inappropriate opioid use in hospitals.
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http://dx.doi.org/10.1186/s12913-020-05390-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7281936PMC
June 2020

Receipt of training about medication for opioid use disorder from pharmaceutical manufacturers: A preliminary study of Florida criminal problem-solving and dependency court staff.

Drug Alcohol Rev 2020 07 11;39(5):583-587. Epub 2020 May 11.

Richard M. Fairbanks School of Law, Indiana University, Indianapolis, USA.

Introduction And Aims: People with opioid use disorder are prevalent in criminal problem-solving courts and dependency courts, which have rehabilitative aims. Medication for opioid use disorder (MOUD) is the standard of care. Court staff set treatment policies for court clients. They may receive training from MOUD manufacturers, but no studies have examined court staff receipt of such training.

Design And Methods: To examine receipt of training from MOUD manufacturers, we designed a cross-sectional survey for court staff. We distributed it online to all Florida court staff in criminal problem-solving or dependency courts (n = 585). Outcome variables were receipt of training from one or more MOUD manufacturers and training source. Covariates included dichotomous measures of court type, staff role, gender and rurality. Logistic regression models estimated the relationship between receipt of training and covariates.

Results: Twenty-one percent of Florida criminal problem-solving and dependency court staff completed the survey. The most common receipt of training was from the manufacturer of extended-release naltrexone (36%), followed by buprenorphine (24%) and methadone (11%). Fifty-seven percent of those who received training received it from more than one MOUD manufacturer. Criminal problem-solving court staff were more likely than dependency court staff to receive training from MOUD manufacturers. Court program co-ordinators were more likely than other staff roles to receive training from MOUD manufacturers.

Discussion And Conclusions: A large minority of respondents received training from a MOUD manufacturer, primarily from extended-release naltrexone's manufacturer, raising concerns regarding information accuracy and conflicts of interest. Court staff should seek MOUD training from academic institutions and non-profit organisations instead.
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http://dx.doi.org/10.1111/dar.13090DOI Listing
July 2020

Assessing the impact of drug courts on provider-directed marketing efforts by manufactures of medications for the treatment of opioid use disorder.

J Subst Abuse Treat 2020 03 12;110:49-58. Epub 2019 Dec 12.

Paul H. O'Neill School of Public & Environmental Affairs, Indiana University-Bloomington, United States of America.

Background: Opioid use disorder (OUD) has become an increasingly consequential public health concern, especially in the United States where 47,600 opioid overdose deaths occurred in 2017 (Scholl, Seth, Kariisa, Wilson, & Baldwin, 2019). Medications for OUD (MOUD) are effective for decreasing opioid-related morbidity and mortality, including within the criminal justice system (Hedrich et al., 2012; Medications for Opioid Use Disorder Save Lives, 2019; Moore et al., 2019).While a stronger evidence base exists for agonist MOUD than for antagonist MOUD, a national study of drug courts found that half prohibited agonist MOUD (Matusow et al., 2013).Furthermore, recent media reports suggest that the pharmaceutical manufacturer of an antagonist MOUD has marketed its product towards drug court judges (Goodnough & Zernike, 2017; Harper, 2017). However, no study to date has systematically examined the relationship between MOUD marketing practices and drug courts. This ecological study examines the association at the county level between MOUD manufacturer payments to prescribers and drug court locations.

Method: We extracted provider-directed payments from Centers for Medicare and Medicaid Services (CMS)'s Sunshine Act Open Payments data 2014-2017, isolating those records mentioning any MOUD. We compared provider-directed payments for two major MOUDs: buprenorphine and extended-release naltrexone, in counties with and without drug courts.

Results: The presence of any adult drug courts in the county is associated with a 7.86 percentage-point increase in the likelihood of providers in that county receiving any MOUD-related payments (about 22.46% of the sample mean, p<0.001) and with a 10.70% increase in the amount of these payments per 1000 county residents (p<0.001). The association between other forms of drug courts such as juvenile drug courts and Driving-Under-the-Influence courts (DUI) courts are less significant and slightly smaller in magnitude compared to those of adult drug courts. We did not find significant difference between payments by the manufacturer of Vivitrol and manufacturers of Zubsolv, Bunavail, and Suboxone (oral forms of buprenorphine).

Conclusions: Our results show an ecological association at the county level between MOUD manufacturer payments to prescribers and drug court presence. However, we did not examine a causal association between these variables.
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http://dx.doi.org/10.1016/j.jsat.2019.12.004DOI Listing
March 2020

Factors That Influence Changes to Existing Chronic Pain Management Plans.

J Am Board Fam Med 2020 Jan-Feb;33(1):42-50

From Applied Decision Science, LLC, Dayton, OH (JD, LGM); Department of Health Management & Informatics, University of Central Florida, Orlando, FL (BTAC); University of Florida Gainesville, FL (RLC); Department of Anesthesiology and Public Health Science, Wake Forest University School of Medicine, Winston Salem, NC (RWH); Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, IN (SMD, ECD, CAH); Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN (SA); Department of Internal Medicine, Indiana University School of Medicine, Indianapolis, IN (BWM); Center for Biomedical Informatics, Regenstrief Institute, Indianapolis, IN (BWM, CAH).

Background: The objective of this qualitative study is to better understand primary care clinician decision making for managing chronic pain. Specifically, we focus on the factors that influence changes to existing chronic pain management plans. Limitations in guidelines and training leave clinicians to use their own judgment and experience in managing the complexities associated with treating patients with chronic pain. This study provides insight into those judgments based on clinicians' first-person accounts. Insights gleaned from this study could inspire innovations aimed at supporting primary care clinicians (PCCs) in managing chronic pain.

Methods: We conducted 89 interviews with PCCs to obtain their first-person perspective of the factors that influenced changes in treatment plans for their patients. Interview transcripts were analyzed thematically by a multidisciplinary team of clinicians, cognitive scientists, and public health researchers.

Results: Seven themes emerged through our analysis of factors that influenced a change in chronic pain management: 1) change in patient condition; 2) outcomes related to treatment; 3) nonadherent patient behavior; 4) insurance constraints; 5) change in guidelines, laws, or policies; 6) approaches to new patients; and 7) specialist recommendations.

Conclusions: Our analysis sheds light on the factors that lead PCCs to change treatment plans for patients with chronic pain. An understanding of these factors can inform the types of innovations needed to support PCCs in providing chronic pain care. We highlight key insights from our analysis and offer ideas for potential practice innovations.
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http://dx.doi.org/10.3122/jabfm.2020.01.190284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301400PMC
April 2021

An Analysis of Primary Care Clinician Communication About Risk, Benefits, and Goals Related to Chronic Opioid Therapy.

MDM Policy Pract 2019 Jul-Dec;4(2):2381468319892572. Epub 2019 Dec 10.

Department of Health Policy and Management, Indiana University Richard M. Fairbanks School of Public Health, Indianapolis, Indiana.

Safe opioid prescribing and effective pain care are particularly important issues in the United States, where decades of widespread opioid prescribing have contributed to high rates of opioid use disorder. Because of the importance of clinician-patient communication in effective pain care and recent initiatives to curb rising opioid overdose deaths, this study sought to understand how clinicians and patients communicate about the risks, benefits, and goals of opioid therapy during primary care visits. We recruited clinicians and patients from six primary care clinics across three health systems in the Midwest United States. We audio-recorded 30 unique patients currently receiving opioids for chronic noncancer pain from 12 clinicians. We systematically analyzed transcribed, clinic visits to identify emergent themes. Twenty of the 30 patient participants were females. Several patients had multiple pain diagnoses, with the most common diagnoses being osteoarthritis ( = 10), spondylosis ( = 6), and low back pain ( = 5). We identified five themes: 1) communication about individual-level and population-level risks, 2) communication about policies or clinical guidelines related to opioids, 3) communication about the limited effectiveness of opioids for chronic pain conditions, 4) communication about nonopioid therapies for chronic pain, and 5) communication about the goal of the opioid tapering. Clinicians discuss opioid-related risks in varying ways during patient visits, which may differentially affect patient experiences. Our findings may inform the development and use of more standardized approaches to discussing opioids during primary care visits.
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http://dx.doi.org/10.1177/2381468319892572DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6906357PMC
December 2019

Comparison of Rural vs Urban Direct-to-Physician Commercial Promotion of Medications for Treating Opioid Use Disorder.

JAMA Netw Open 2019 12 2;2(12):e1916520. Epub 2019 Dec 2.

Department of Public Administration and Policy, University of Georgia, Athens, Georgia.

Importance: In the United States, access to medications prescribed for opioid use disorder (OUD) is lower in rural counties than in urban counties. Considering the positive associations between direct-to-physician promotion of opiates and OUD medications and their prescribing rates, a study examining the association between pharmaceutical promotion of these medications and county-level rurality has merit.

Objective: To assess whether rural counties received less pharmaceutical promotion of OUD medications compared with urban counties.

Design, Setting, And Participants: This cross-sectional county-level study used all reported direct-to-physician pharmaceutical payments from manufacturers of medications prescribed for OUD from January 1, 2014, through December 31, 2017, as well as demographic and economic data at the county level from 3140 US counties. Logistic regression was used with year and state-level fixed effects to compare rural county and urban county odds of receiving any promotion of OUD medications. A negative binomial model was used with year and state-level fixed effects to compare the mean pharmaceutical payments per physician and per population in rural vs urban counties.

Main Outcomes And Measures: A binary indicator for whether physicians in a county received any promotion related to OUD medications in a year. The second outcome was the value of promotion (eg, meals), with dollar amount of payments for each county by year. Counties were separated into metropolitan, micropolitan, and rural categories using the National Center for Health Statistics Urban-Rural Classification Scheme.

Results: Of 3140 US counties with 18 318 physicians to whom promotion of OUD medications was directed, 1166 (37.1%) were metropolitan (16 740 physicians [91.4%]), 641 (20.4%) were micropolitan (1049 physicians [5.7%]), and 1333 (42.5%) were rural (529 physicians [2.9%]). Compared with physicians in metropolitan counties, physicians in rural counties had reduced odds of receiving any promotion (adjusted odds ratio, 0.57; 95% CI, 0.44-0.74) and received lower payments (adjusted incidence rate ratio, 0.24; 95% CI, 0.17-0.34).

Conclusions And Relevance: The study findings suggest that promotion for OUD medications is less likely to occur in rural counties and that this difference in promotion of OUD medications may be associated with differential commercial costs and benefits of promotion in rural settings.
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http://dx.doi.org/10.1001/jamanetworkopen.2019.16520DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902747PMC
December 2019

Introduction to the special issue on innovative interventions and approaches to expand medication assisted treatment: Seizing research opportunities made available by the opioid STR program.

J Subst Abuse Treat 2020 01 23;108:1-3. Epub 2019 Oct 23.

Arnold Ventures, United States of America. Electronic address:

The 21st Century Cures Act is the most significant piece of U.S. legislation aimed at tackling the opioid epidemic to date. This special issue comprises papers reflecting medication-assisted treatment (MAT)-related research made possible through the Cures Act-authorized State Targeted Response (STR) grant mechanism. Work related to both STR evaluation and original research conducted within the context of STR activities are included in the issue, with topics including community assessments of MAT-related needs, MAT access and linkage, criminal justice-oriented MAT implementation, and adjunctive MAT supports and treatments. All of the research represented this issue is early-stage, with results reflecting data collected primarily within the first of STR's two year funding cycle. While such formative work does have inherent limitations, the gravity of the opioid epidemic requires rapid assessment and dissemination of results to inform the public health response in a manner that will have a timely and meaningful impact.
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http://dx.doi.org/10.1016/j.jsat.2019.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385752PMC
January 2020

Comparing Reasons for Starting and Stopping Methadone, Buprenorphine, and Naltrexone Treatment Among a Sample of White Individuals With Opioid Use Disorder.

J Addict Med 2020 Jul/Aug;14(4):e44-e52

Department of Health Management & Informatics, University of Central Florida, Orlando, FL.

Objectives: Despite their efficacy, medications for opioid use disorder (MOUD) are underutilized in the United States. Nonetheless, few studies have explored reasons why individuals choose to start MOUD or discontinue MOUD after starting, especially extended-release naltrexone. We sought to identify reasons why individuals start and stop MOUD, including the differences between starting and stopping the 3 most common formulations: methadone, sublingual buprenorphine, and extended-release naltrexone.

Methods: We conducted 31 semistructured interviews over the phone with a sample of white individuals with a history of MOUD utilization. Participants were recruited using snowball sampling from 8 US states. Interviews were audio-recorded, transcribed, coded in Dedoose software, and analyzed using thematic analysis and modified event structure analysis.

Results: Participants primarily learned about methadone and buprenorphine from other individuals with OUD. Participants primarily became interested in starting buprenorphine and methadone after seeing the medications work effectively in peers, though methadone was perceived as a last resort. In contrast, participants primarily learned about and became interested in naltrexone after receiving information from health practitioners. Participants frequently stopped MOUD to prevent medication or health service dependence. Participants also felt stigma and external pressure to stop buprenorphine and methadone, but not naltrexone. Some participants identified relapse and medication termination by health providers or the criminal justice system as reasons for stopping MOUD.

Conclusions: Given the frequency with which participants identified informal peer education as a reason for starting methadone and buprenorphine, peers with MOUD experience may be a trusted source of information for individuals seeking OUD treatment. Further research is needed to assess whether incorporating peer support specialists with MOUD experience into formal SUD treatment would expand MOUD utilization, retain patients in treatment, and/or improve OUD treatment outcomes.
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http://dx.doi.org/10.1097/ADM.0000000000000584DOI Listing
June 2021

Court personnel attitudes towards medication-assisted treatment: A state-wide survey.

J Subst Abuse Treat 2019 09 28;104:72-82. Epub 2019 Jun 28.

Department of Health Policy & Management, Indiana University Richard M. Fairbanks School of Public Health, United States of America.

Background: Despite its efficacy, medication-assisted treatment (MAT) is rarely available in the criminal justice system in the United States, including in problem-solving courts or diversionary settings. Previous studies have demonstrated criminal justice administrators' hostility towards MAT, especially in prisons and jails. Yet, few studies have examined attitudes among court personnel or compared beliefs among different types of personnel. Also, few studies have explored the relationship between MAT education/training and attitudes. Finally, few studies have directly compared attitudes towards methadone, oral buprenorphine, and extended-release naltrexone in the criminal justice system.

Methods: We modified a survey by Matusow et al. (2013) to explore justice professionals' MAT attitudes, including associations with demographic variables, court role, and previous MAT education/training. After piloting the survey, we distributed it to a convenience sample of justice professionals registered for an educational summit held in Indiana in 2018. Data was analyzed using descriptive and inferential statistical methods.

Results: 231 Indiana court employees who had registered for a state MAT educational summit completed the survey prior to the summit, including judges, probation officers, law enforcement personnel, attorneys, probation officers, program directors, counselors, and case managers. Overall, participants had significantly more positive attitudes towards extended-release naltrexone than towards other medications (p value <0.01). Court employee average attitudes towards methadone were significantly more negative than average attitudes towards oral buprenorphine; and average attitudes towards oral buprenorphine were significantly more negative than average attitudes towards extended-release naltrexone (p value <0.01). Employment as a prosecutor or law enforcement officer was associated with more negative attitudes towards oral buprenorphine and methadone (p value <0.05). Exposure to previous MAT training was associated with more positive attitudes for all medications (p value <0.05). Compared to participants with graduate degrees, participants with less education had significantly more negative attitudes towards extended-release naltrexone (p < 0.05). Gender, age, rurality, and personal/family recovery history were not associated with differences in attitudes.

Conclusion: As expected, court employees' attitudes significantly differ by medication, with average attitudes towards agonist medications being more negative than attitudes towards extended-release naltrexone. Despite a larger evidence base for the efficacy of methadone and oral buprenorphine, justice personnel may have more positive attitudes towards extended-release naltrexone due to targeted marketing by the pharmaceutical manufacturer, fears about diversion or misuse of agonist medications, and historic criminal justice hostility towards agonist medications. Importantly, previous education/training regarding MAT is associated with more positive attitudes, suggesting that more awareness-raising or capacity building educational interventions are needed, especially for prosecutors and law enforcement personnel.
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http://dx.doi.org/10.1016/j.jsat.2019.06.011DOI Listing
September 2019

Provider-directed marketing may increase prescribing of medications for opioid use disorder.

J Subst Abuse Treat 2019 09 1;104:104-115. Epub 2019 Jul 1.

Department of Public Administration and Policy, University of Georgia, 201C Baldwin Hall, Athens, GA 30602, United States of America. Electronic address:

Background: Opioid use disorder (OUD) has become an increasingly grave public health concern, especially in the United States where approximately 80% of the global opioid supply is consumed. Despite greater awareness of the present overdose crisis, potentially life-saving OUD pharmacotherapy (medications for opioid use disorder or MOUD) utilization remains low. This study examines the extent of provider-directed marketing (detailing) for MOUD drugs and identifies any associations between a provider's receipt of detailing and their prescribing of MOUD drugs to Medicare Part D beneficiaries.

Method: We combined Open Payments data on all provider-directed payments from pharmaceutical manufacturers with physician-level data on all MOUD prescriptions filled in Medicare Part D. We estimated the adjusted difference in Medicare days supply for all MOUD drugs (collectively) and separately for each MOUD drug that was associated with receipt of payments.

Results: The Open Payments data show that $7.0 million MOUD-specific promotional payments were made by pharmaceutical manufacturers to 12,056 US physicians from 2014 to 2016, which is <1/6th of the $50.3 million made in overall non-MOUD opioid-related promotional payments to 76,992 US physicians during that same period. Prescribers who received any MOUD-specific payments prescribed 1080 daily MOUD-related doses per year more than peers who did not receive any MOUD-specific payments (p < 0.001). The data also show the relatively greater association between receipt of detailing and Suboxone prescriptions compared to Vivitrol.

Conclusions: Provider-directed marketing by MOUD manufacturers has been found to be significantly and positively associated with incidence of MOUD prescribing in Medicare Part D, as well as with the quantity of MOUD prescribed.
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http://dx.doi.org/10.1016/j.jsat.2019.06.014DOI Listing
September 2019

College Student Preferences for Substance Use Disorder Educational Videos: A Qualitative Study.

Subst Use Misuse 2019 12;54(8):1400-1407. Epub 2019 Mar 12.

c Maurer School of Law , Indiana University , Bloomington , IN , USA.

Background: College student preferences regarding substance use disorder (SUD) education and treatment-related education have been understudied, despite this population's relatively high risk of developing SUDs and low help-seeking rates. We sought to identify students' preferences regarding content, style, and format of educational online videos about SUDs and SUD treatment.

Method: We held six, two-hour long focus groups with college student participants from Indiana University from 2017 to 2018 during which participants were shown drafts of scripts, mock-up images, and animation and then asked open-ended questions about their preferences and suggested changes. Focus groups were audio recorded and transcribed. Researchers then undertook thematic analysis of focus groups: independently coding transcripts for data related to the research questions, conducting consensus coding, and then analyzing coded data for themes.

Results: 39 students participated in focus groups, approximately half of whom were undergraduate students and the other half were graduate students. They preferred animated video characters that were relatable to college students but abstract enough to represent a range of students, such as stick figures with backpacks. They preferred conversational narration with subtle humor and references to realistic reasons for college students using drugs or alcohol. Participants encouraged inclusion of information about SUD impacts on school, work, and relationships, in addition to physical health. Participants opposed any content or style that could be interpreted as fear-mongering. They requested more information regarding medication-assisted treatment efficacy and less information about side effects.

Conclusion: College students have unique cultural needs, necessitating tailored educational interventions about SUD and SUD treatments.
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http://dx.doi.org/10.1080/10826084.2019.1581816DOI Listing
March 2020

Balancing Patient-Centered and Safe Pain Care for Nonsurgical Inpatients: Clinical and Managerial Perspectives.

Jt Comm J Qual Patient Saf 2019 04 24;45(4):241-248. Epub 2018 Dec 24.

Background: Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient centered, meaning that it is respectful of patients' values, preferences, and experiences. However, little is known about delivering care in cases in which these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population.

Methods: To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, the research team conducted in-depth, semistructured interviews with hospitalists, registered nurses, and health care managers from one health care system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach.

Results: Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (for example, an opioid-naive patient with a fracture), vs. more difficult (for example, a patient with opioid use disorder). Participants reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach.

Conclusion: Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes.
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http://dx.doi.org/10.1016/j.jcjq.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6491228PMC
April 2019

Pain clinic definitions in the medical literature and U.S. state laws: an integrative systematic review and comparison.

Subst Abuse Treat Prev Policy 2018 05 22;13(1):17. Epub 2018 May 22.

Department of Social and Behavioral Science, Richard M. Fairbanks School of Public Health, Indiana University, 1050 Wishard Blvd, Indianapolis, IN, 46202, USA.

Background: In response to widespread opioid misuse, ten U.S. states have implemented regulations for facilities that primarily manage and treat chronic pain, called "pain clinics." Whether a clinic falls into a state's pain clinic definition determines the extent to which it is subject to oversight. It is unclear whether state pain clinic definitions model those found in the medical literature, and potential differences lead to discrepancies between scientific and professionally guided advice found in the medical literature and actual pain clinic practice. Identifying discrepancies could assist states to design laws that are more compatible with best practices suggested in the medical literature.

Methods: We conducted an integrative systematic review to create a taxonomy of pain clinic definitions using academic medical literature. We then identified existing U.S. state pain clinic statutes and regulations and compared the developed taxonomy using a content analysis approach to understand the extent to which medical literature definitions are reflected in state policy.

Results: In the medical literature, we identified eight categories of pain clinic definitions: 1) patient case mix; 2) single-modality treatment; 3) multidisciplinary treatment; 4) interdisciplinary treatment; 5) provider supervision; 6) provider composition; 7) marketing; and 8) outcome. We identified ten states with pain clinic laws. State laws primarily include the following definitional categories: patient case mix; single-modality treatment, and marketing. Some definitional categories commonly found in the medical literature, such as multidisciplinary treatment and interdisciplinary treatment, rarely appear in state law definitions.

Conclusions: This is the first study to our knowledge to develop a taxonomy of pain clinic definitions and to identify differences between pain clinic definitions in U.S. state law and medical literature. Future work should explore the impact of different legal pain clinic definitions on provider decision-making and state-level health outcomes.
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http://dx.doi.org/10.1186/s13011-018-0153-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5964673PMC
May 2018

A qualitative study comparing physician-reported barriers to treating addiction using buprenorphine and extended-release naltrexone in U.S. office-based practices.

Int J Drug Policy 2018 04 8;54:9-17. Epub 2018 Jan 8.

Department of Biology, College of Arts & Sciences, Indiana University-Bloomington, IN, United States.

Aim: Our aim was to compare physician-reported barriers to sublingual buprenorphine (BUP) and extended-release naltrexone (XR-NLT) prescribing in U.S. office-based practices, and to identify potential policies for minimizing these barriers. Only one previous qualitative study has examined physician-reported barriers to prescribing XR-NLT and no qualitative study has compared physician-reported barriers between the two medications.

Methods: Researchers conducted individual semi-structured and in-depth interviews with 20 licensed physicians in four U.S. states between January 2016 and May 2017. Interview questions included general barriers to addiction treatment in office-based settings, barriers specific to BUP and XR-NLT prescribing, and potential government policies to decrease barriers. Researchers conducted thematic analysis of transcribed interviews. They developed and pilot tested a coding template based on a sample of transcripts, independently coded transcripts in Dedoose software, conducted consensus coding to eliminate coding discrepancies, and then assessed data for themes using research questions as a guide.

Results: General barriers to office-based OUD treatment included limited physician education, limited insurance reimbursement, stigma, and perceptions of "difficult" patients. Barriers specific to BUP prescribing included regulatory restrictions, liability fears, and restrictions imposed by the criminal justice system. Barriers specific to XR-NLT prescribing included limited access to medically-supervised opioid detoxification, lack of awareness of the medication, and patient fears or disinterest. Participants without experience prescribing either medication emphasized barriers to treating OUD in general. Participants with experience prescribing BUP and/or XR-NLT described barriers to treating OUD in general as well as barriers specific to each medication. Policy makers should increase access to addiction medicine education, mandate insurance coverage of both medications and inpatient detoxification, prohibit excessive insurance prior authorization requirements, increase insurance reimbursement for behavioral healthcare, and incentivize interdisciplinary collaboration.

Conclusions: While overlap exists, some barriers to BUP prescribing differ from barriers to XR-NLT prescribing.
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http://dx.doi.org/10.1016/j.drugpo.2017.11.021DOI Listing
April 2018

Psychiatric Co-Morbidities in Pregnant Women with Opioid Use Disorders: Prevalence, Impact, and Implications for Treatment.

Curr Addict Rep 2017 9;4(1):1-13. Epub 2017 Mar 9.

Ruth Lilly Medical Library, Indiana University, Indianapolis, IN USA.

Purpose Of Review: This review seeks to investigate three questions: What is the prevalence of comorbid psychiatric diagnoses among pregnant women with opioid use disorder (OUD)? How do comorbid psychiatric illnesses impact pregnant women with OUD? And how do comorbid psychiatric illnesses affect the ability of pregnant women with OUD to adhere to and complete OUD treatment?

Recent Findings: Based on this literature review, 25-33% of pregnant women with OUD have a psychiatric comorbidity, with depression and anxiety being especially common. However, of the 17 studies reviewed only 5 have prevalence rates of dual diagnosis in pregnant women with OUD as their primary outcome measures, their N's were typically small, methods for determining psychiatric diagnosis were variable, and many of the studies were undertaken with women presenting for treatment which carries with its implicit selection bias. Of the women enrolled in treatment programs for SUD, those with psychiatric comorbidity were more likely to have impaired psychological and family/social functioning than those without psychiatric comorbidity. Greater severity of comorbid psychiatric illness appears to predict poorer adherence to treatment, but more research is needed to clarify this relationship with the psychiatric illness is less severe.

Summary: While cooccurrence of psychiatric disorders in pregnant women with opioid use disorder appears to be common, large population-based studies with validated diagnostic tools and longitudinal assessments are needed to obtain definitive rates and characteristics of cooccurring illnesses. Integrated prenatal, addiction, and psychiatric treatment in a setting that provides social support to pregnant patients with OUD is most effective in maintaining women in treatment. More research is still needed to identify optimal treatment settings, therapy modalities, and medication management for dually diagnosed pregnant women with OUD.
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http://dx.doi.org/10.1007/s40429-017-0132-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350195PMC
March 2017