Alcohol, Opioids, & other Substance Disorders

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Alcohol, Opioids, & other Substance Disorders

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Medical diagnoses of “diseases of despair” increase in Pennsylvania

11/10/20


https://www.news-medical.net/news/20201 ... laims.aspx


Medical diagnoses involving alcohol-related disorders, substance-related disorders and suicidal thoughts and behaviors – commonly referred to as diseases of despair – increased in Pennsylvania health insurance cbetween the years 2007 and 2018, according to researchers from Penn State Clinical and Translational Science Institute and Highmark Health Enterprise Analytics.

Princeton economists Anne Case and Angus Deaton proposed the concept of deaths of despair in 2015. Case and Deaton's research observed a decline in life expectancy of middle-aged white men and women between 1999 and 2015 – the first such decline since the flu pandemic of 1918.

They theorized that this decline is associated with the social and economic downturn in rural communities and small towns.

These changes include loss of industry, falling wages, lower marriage rates, increasing barriers to higher education, an increase in one-parent homes and a loss of social infrastructure.


" It is theorized that these changes have fostered growing feelings of despair including disillusionment, precariousness and resignation in many peoples' lives. Despair can trigger emotional, cognitive, behavioral and even biological changes, increasing the likelihood of diseases that can progress and ultimately culminate in deaths of despair."

- Daniel George, Associate Professor of Humanities and Public Health Sciences, Penn State College of Medicine

With the Commonwealth's considerable rural and small-town population, particularly around Penn State campuses, Penn State Clinical and Translational Science Institute led a research study to understand the rate of diseases of despair in Pennsylvania. Institute researchers collaborated with Highmark Health, one of the state's largest health insurance providers. Highmark provides employer-sponsored, individual, Affordable Care Act and Medicare plans.

Highmark Health's Enterprise Analytics team analyzed the claims of more than 12 million people on their plans from 2007 to 2018. Penn State did not have access to Highmark member data or individual private health information.

Although the insurance claims included members from neighboring states, including West Virginia, Delaware and Ohio, the majority of the claims were from Pennsylvania residents. Researchers reported their results in BMJ Open.

The researchers defined diseases of despair as diagnoses related to alcohol use, substance use and suicidal thoughts or behaviors.
They searched the claims data for the International Classification of Diseases (ICD) codes related to these diagnoses. ICD codes form a standardized system maintained by the World Health Organization and are used in health records and for billing.

The researchers found that the rate of diagnoses related to diseases of despair increased significantly in the Highmark claims in the past decade. Nearly one in 20 people in the study sample was diagnosed with a disease of despair.

Between 2009 and 2018, the rates of alcohol-, substance- and suicide-related diagnoses increased by 37 percent, 94 percent and 170 percent, respectively. Following Case and Deaton's findings, the researchers saw the most substantial percentage increase in disease of despair diagnoses among men ages 35 to 74, followed by women ages 55 to 74 and 18 to 34.

The rate of alcohol-related diagnoses significantly increased among men and women ages 18 and over. The most dramatic increases were among men and women ages 55 to 74. Rates increased for men in this age group by 50 percent and 80 percent for women.

The rate of substance-related diagnoses roughly doubled for men and women ages 35 to 54 and increased by 170 percent in ages 55 to 74. In 2018, the most recent year of claims included in the study, rates of substance-use diagnoses were highest in 18-to-34-year-olds.

The rate of diagnoses related to suicidal thoughts and behaviors increased for all age groups. Among 18-to-34-year-olds, rates increased by at least 200 percent. The rate for all other age groups increased by at least 60 percent.

The type of insurance patients had also mattered. People with Medicare insurance had 1.5 times higher odds of having a disease of despair diagnosis and those with Affordable Care Act insurance had 1.3 times higher odds.

One increase stood out to researchers: among infants, substance-related diagnoses doubled.

"This increase was entirely attributable to neonatal abstinence syndrome and corresponded closely with increases in substance-related disorders among women of childbearing age," said Emily Brignone, senior research scientist, Highmark Health Enterprise Analytics.

Neonatal abstinence syndrome occurs when a baby withdraws from substances, especially opioids, exposed to in the womb.

Future research can concentrate on identifying "hot spots" of diseases of despair diagnoses in the Commonwealth to then study the social and economic conditions in these areas. With this data, researchers can potentially create predictive models to identify communities at risk and develop interventions.

"We found a broad view of who is impacted by increases in diseases of despair, which cross racial, ethnic and geographic groups," said Dr. Jennifer Kraschnewski, professor of medicine, public health sciences and pediatrics. "Although originally thought to mostly affect rural communities, these increases in all middle-aged adults across the rural-urban continuum likely foreshadows future premature deaths."
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Re: Alcohol, Opioids, & other Substance Disorders

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Recommendations to help ensure access to high-quality opioid use disorder treatment

2/25/21


https://www.news-medical.net/news/20210 ... tment.aspx


On January 14, 2021, the Department of Health and Human Services (HHS) submitted notice to the Federal Register that it would issue practice guidelines that exempt physicians from the requirement to apply for a waiver to prescribe buprenorphine to treat opioid use disorder (OUD) in up to 30 patients at one time. This exemption has been placed on hold by the Biden administration and may require legislative change to implement. An exemption to the X-waiver has the potential to help reverse the morbidity and mortality associated with the opioid overdose epidemic, although without accompanying changes and attention it will not be enough.

The combination of the COVID-19 pandemic and the opioid overdose epidemic fueled by high-potency synthetic opioids have led to increased overdoses. However, national and state leadership, health professions schools, and health care systems in the US have not responded sufficiently. More than 83,000 drug overdose deaths occurred in the US in a 1-year period ending in June 2020, the highest number of overdose deaths ever recorded in a 12-month period, and an increase of more than 21% compared with the previous year.

Nationally, 67% of opioid overdose deaths involved fentanyl in 2018 and drug overdoses increased most among non-Hispanic Black individuals. Despite these devastating losses, access to evidence-based care to prevent opioid overdose and treat OUD remains highly regulated, restricted, and very limited, particularly among Black individuals with OUD and in rural communities. It is estimated that only 18% of individuals with OUD in the US receive highly effective medications, such as buprenorphine or methadone, to treat OUD. For many, the COVID-19 pandemic has further limited access to medications for OUD (MOUD).

Unlike other medical conditions, treatment of OUD has substantial and unique restrictions imposed by US federal and state laws. Such restrictions do not facilitate access to care; on the contrary, they impede it. Methadone for OUD must be administered or dispensed by an accredited, registered, and certified opioid treatment program. The Drug Addiction Treatment Act of 2000 (DATA 2000) requires that prescribers of buprenorphine apply for a waiver (ie, X-waiver) to prescribe once certain educational and practice requirements have been met. However, this restriction has outlived any usefulness.

Although appropriate training is essential to care for any disease, federal law does not require such training or registration to prescribe for other diseases (and more specifically, not for prescribing opioids for other indications such as pain). However, health professions schools are mandated by entities such as the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) to provide training to treat most other diseases. As of 2018, only 1 of 191 medical schools provided training to their students that was sufficient to meet the DATA 2000 training requirement.

Additionally, neither AAMC nor the ACGME require competency in OUD evaluation and treatment in medical education. Together, the absence of health professions school and graduate education; prescribing restrictions; stigma and misinformation among patients, families, and health care professionals; archaic payment structures and systems that emphasize acute care models over long-term treatment; care largely separate and uncoordinated from the rest of health care; and lack of support for patients' psychosocial needs have impeded the large expansion of MOUD treatment that is required to meet the need.

In an effort to address the vast need for MOUD treatment accessibility in the US, the HHS exemption proposed changes as follows. Physicians would need to place an "X" on the prescription, note that the prescription is to treat OUD, maintain separate records for such patients, prescribe to patients in the state in which they practice, and limit prescribing to no more than 30 patients at one time. Physicians who want to treat more than 30 individuals with OUD would need to seek additional training through the current 8-hour DATA 2000 mechanism. Notably, these guidelines do not apply to the large workforce of advanced practice clinicians who remain mandated to complete 24 hours of training to prescribe buprenorphine.

Relaxing restrictions on physician prescribing does have the potential to expand access to treatment and reduce opioid overdose deaths as it has in other countries. For example, in France, buprenorphine became available in 1995 and an estimated 3% of patients with OUD were treated that year with MOUD; by 2006, 67% of the 180000 people with OUD were treated with methadone (n=26000) or buprenorphine (n = 95000) in a setting with relaxed MOUD regulations. Rates of prescribing continue to be high, although over time, initiation of prescribing has shifted somewhat from primary care to specialized addiction treatment centers. While there are some cautionary tales from the rapid expansion of buprenorphine prescribing in France, such as subtherapeutic buprenorphine dosing, it has been estimated that a similar increase in prescribing in the US that occurred in France could have potentially led to an estimated 37000 fewer deaths in 2018 alone if it were used appropriately, adherence was high, and the same conditions were being treated in the US as in France.

Inaction is not an option when 40% of counties in the US do not have a single prescriber of MOUD. The proposed 2021 HHS guidelines represented progress toward MOUD expansion; however, they were far from enough to address the opioid overdose crisis. The US needs to normalize the treatment of OUD among health care professionals and individuals with OUD. Practicing health care professionals should be encouraged and incentivized to prescribe and obtain any needed training or support. OUD identification, evaluation, and treatment education should be integrated in all health care professions schools and should be implemented throughout all health care systems. It is also important to emphasize that medical management of OUD is effective, that buprenorphine alone at therapeutic doses can improve outcomes and prevent overdose, and that detoxification alone is insufficient to prevent overdose and treat OUD.

Buprenorphine prescribing by trained health care professionals can promote high-quality care and the new exemption could increase that prescribing. However, much more will need to be done. These additional steps include eliminating limits on the number of patients who could be treated by individual clinicians. One estimate suggests that by eliminating patient limits, the US could potentially treat nearly 800?000 additional individuals with OUD. Further needed actions include allowing prescribing by advanced practice clinicians; advocating for addiction training efforts at health professions schools, postgraduate programs, and as part of continuing education to make up for previously absent training; allowing office-based methadone treatment to ensure expansion to all types of MOUD; enforcing parity of benefits and insurance coverage for treatment; and addressing the stigma of addiction and addiction treatment. The effects of regulatory changes should be studied after implementation.

Recommendations to help ensure access to high-quality medication treatment for opioid use disorder (OUD)

Pass federal legislation to ensure lasting changes on a national scale
Eliminate buprenorphine patient limits and Drug Enforcement Administration audits that discourage prescribing; include advanced practice clinician prescribers in any legislative change; and remove restrictions on methadone prescribing and dispensing outside opioid treatment programs
Improve and provide training for prescribers and health professional teams at all levels
Incentivize training and offset clinician training time; provide a menu of training options appropriate to the needs of the clinician; integrate substantial training into specialty-specific health professions schools, postgraduate programs, continuing education, and maintenance of certification; include patient perspectives in all training; and provide experiential learning, such as apprenticeship models (eg, with mentors), in practice.
Expand access to all forms of OUD treatment shown to have efficacy
Increase access to strategies that reduce consequences of drug use ("harm reduction"); increase access to methadone treatment (eg, via primary care clinicians and pharmacies); and increase access to all treatment options (beyond specialty treatment programs) including medications
Address stigma and include patients receiving medications for OUD (MOUD) in educational campaigns
Enforce Parity (Mental Health Parity and Addiction Equity Act) to ensure equitable coverage and reimbursement for addiction and behavioral health treatments
Ensure equitable access to MOUD in all treatment settings
Study the effects of regulatory changes after implementation

Comprehensive treatment for OUD, including medical, psychiatric, and social services, can and should be provided by experienced clinicians and should be expanded, but MOUD urgently needs to be more accessible. The proposed HHS exemption would offer progress toward achieving that goal even though it was not, as written, a panacea. Improving access while ensuring high-quality care for individuals with OUD to sustain lasting reductions in opioid overdose deaths will require implementing these guidelines and additional strategies, many of which have been suggested for decades. As the new administration considers how to move forward, enacting an improved version of these guidelines and durable legislative changes to ensure access to high-quality MOUD offers a possibility to meaningfully address the overdose crisis.

Source:

Yale University

Journal reference:


Weimer, M.B., et al. (2021) Removing One Barrier to Opioid Use Disorder Treatment, Is It Enough?. JAMA. doi.org/10.1001/jama.2021.0958.
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Therapeutic Solutions International Files Patent on NeuroLeukin™ Personalized Immunotherapy for Opioid Addiction

Campbell Neurosciences Division Expands its "Regenerative Psychiatry" Approach to Address the $179 Billion Dollar Prescription Opioid Epidemic

12/21/20


https://www.prnewswire.com/news-release ... 96771.html


OCEANSIDE, Calif., Dec. 21, 2020 /PRNewswire/ -- Therapeutic Solutions International, Inc., (OTC Markets: TSOI), announced today novel data and filing of a patent covering utilization of its NeuroLeukin™ product for altering molecular pathways associated with opioid addiction. In a series of animal experiments NeuroLeukin™ was demonstrated to reduce activation of TLR-4, which is one of the major innate immune pathways associated with opioid tolerance and addiction1.

It is estimated that the current opioid use epidemic costs the health care system approximately $179 Billion annually2. Campbell Neurosciences, the Company's Division focused on suicide prevention has previously filed intellectual property on utilizing NeuroLeukin™ to reduce suicidal ideations.

"The common biochemical pathways of opioid addiction and suicidal ideation should be no surprise given the inherent relationship between these two conditions," said Dr. James Veltmeyer, Chief Medical Officer of the Company and co-inventor of the patent. "Currently we have 2 clinical trials on the Federal ClinicalTrials.gov website dealing with immunological quantification of psychiatric disorders: suicide and gambling. We are excited to take NeuroLeukin™ into the clinic, which to my knowledge represents the first immunotherapeutic approach for opioid addiction."

"Immunotherapy, which at one point was considered on the fringe of medicine, has blossomed into what is expected to be a 126-billion-dollar annual market in 20263, given its recent successes in the treatment of cancer," said Famela Ramos, Vice President of Business Development and co-inventor of the patent. "We are excited to position ourselves as the potential leaders in applying immunotherapy to mental disorders, an approach that we like to call "regenerative psychiatry."

"Having seen many close friends of mine suffer the horrible effects of opioid addiction, I am proud to be co-inventor on an approach which has the potential to revolutionize the way drug addiction is seen by the medical community," said Wais Kaihani, consultant to the Company.

"I am thankful for our internationally renowned scientific advisory board, which is comprised of immunologists and neurobiologists, that have stimulated our Company to enter such an unexplored space in which very little therapeutic interventions exist," said Timothy Dixon, President and CEO of the Company and co-inventor. "We are 100% dedicated to ending the opioid crisis or catalyzing development of novel approaches to accelerate an end to this tragic and avoidable loss of life."
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Scientists receive $3.9 million to optimize treatment for opioid use disorder

10/28/20


https://www.news-medical.net/news/20201 ... order.aspx



Drawing upon their experience and expertise in telehealth, collaborative care models, substance use disorders, depression and health information technology, Indiana University School of Medicine and Regenstrief Institute faculty have been awarded $3.9 million over four years to collaborate with Kaiser Permanente Washington Health Research Institute scientists on a trial to optimize treatment for opioid use disorder.

They will test whether a scalable, telehealth-delivered collaborative care model can motivate primary care patients who are dependent on opioids and also have depression to increase engagement in evidence-based treatments for pain and opioid-use disorder, while simultaneously improving depression symptoms.

The trial, MI-CARE (short for More Individualized Care: Assessment and Recovery through Engagement), is supported by the National Institute of Health's (NIH) National Institute of Mental Health, through The Helping to End Addiction Long-term, or the NIH HEAL Initiative, to address the national opioid crisis.

" A patient coming into the doctor's office with a heart problem typically doesn't have to be motivated to follow a treatment regimen, but for mental health issues, in part because of stigma associated with these disorders, patients often need support to become engaged and motivated to adhere to medications and other recommendations from their primary care physician."

- Kurt Kroenke, M.D, Chancellor's Professor of Medicine, IU School of Medicine, Research Scientist, Regenstrief Institute

Kroenke is also a co-principal investigator for the Indiana site.

"In studies that we have conducted and in real world situations during the COVID-19 pandemic, telehealth has shown real potential in supporting patients and families. The MI-CARE trial will evaluate telehealth's value, coupled with collaborative care, in the fight against opioid use."

Opioid use and depression frequently occur simultaneously and reinforce each other. Motivating individuals with opioid use disorder and depression to seek and continue to take evidence-based treatments for their conditions has been an unmet challenge.

These patients are suffering from multiple problems and are in need of pragmatic clinical approaches that work.

"Most doctors are called to medicine by a desire to relieve human suffering. For decades, prescribing opioid medications to treat chronic pain was seen as a way to ease suffering.

That well-intentioned practice has unfortunately contributed to an epidemic of opioid dependence and overdose deaths," said Regenstrief Institute Affiliated Scientist and IU School of Medicine Assistant Professor of Psychiatry Michael Bushey M.D., PhD, principal investigator for the Indianapolis site.

"Providing services for opioid use disorder in primary care is the quickest way to reach the most patients, but we need to provide our primary care providers with the resources they need to be successful. We hope that MI-CARE will allow many more patients in primary care to gain access to evidence-based treatments for opioid use disorder and depression."

The Indiana site of the randomized, controlled MI-CARE trial will evaluate 400 individuals with opioid dependence and depression. Half will receive usual care from their primary care physicians.

The other 200 will be contacted by phone by a behavioral health care nurse and offered the opportunity to receive a nurse-supported telehealth program in collaboration with their primary care team.

This will typically include evidence-based medications for opioid use disorder such as buprenorphine or long-acting naltrexone along with treatment aimed at improving their depression.

Outcomes for both the treatment and usual care groups will be determined from the patients' electronic medical records, which will include clinical, laboratory and other information. Regenstrief Institute Research Scientists David Haggstrom, M.D., and Titus Schleyer, DMD, PhD, lead the data team for the Indiana site of the study.

"We will use cutting edge tools of data science developed at Regenstrief Institute to measure -- with a high degree of accuracy -- opioid use and depression care delivery," said Dr. Haggstrom, interim director of Regenstrief's Center for Health Services Research.

Caring for complex patients, such as patients with co-occurring opioid use disorder and depression can be challenging.

Although treating opioid use disorder in primary care (where most adults receive their medical care) is a public health priority, clinical experience and resources in this area lag behind depression, which, in turn, trails behind the treatment of physical ailments.

Among its goals, the MI-CARE trial is designed to determine if the promises of telehealth and coordinated care can help primary care physicians provide the care that opioid users with depression so clearly need.

Source:

Regenstrief Institute
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Machine learning-based prediction model may enable early diagnosis of opioid use disorder

11/18/20


https://www.news-medical.net/news/20201 ... order.aspx


Researchers have used machine learning, a type of artificial intelligence, to develop a prediction model for the early diagnosis of opioid use disorder. The advance is described in Pharmacology Research & Perspectives.

The model was generated from information in a commercial claim database from 2006 through 2018 of 10 million medical insurance claims from 550,000 patient records. It relied on data such as demographics, chronic conditions, diagnoses and procedures, and medication prescriptions.

The tool led to a diagnosis of opioid use disorder that was on average 14.4 months earlier than it was diagnosed clinically.

" Opioid use disorder has led a very serious epidemic in the U.S. and many other countries, with devastating rates of morbidity and mortality due to missed and delayed diagnoses. The novel ability of our algorithm to identify affected individuals earlier will likely save lives and health care costs."

- Gideon Koren, MD, Senior Author, Ariel University, Israel

Source:

Wiley

Journal reference:

Segal, Z., et al. (2020) Development of a machine learning algorithm for early detection of opioid use disorder. Pharmacology Research & Perspectives. doi.org/10.1002/prp2.669.
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Study finds gaps in opioid use disorder treatment during COVID shutdowns

12/15/20


https://www.news-medical.net/news/20201 ... downs.aspx


In the early months of the COVID-19 pandemic, visits to the doctor declined dramatically. One group of patients that appears to have weathered this trend are those who were already being treated for opioid use disorder. With an increase in telehealth visits, these patients continued to see doctors and get prescription refills at a relatively stable rate, according to a new study led by researchers at Harvard Medical School published Dec. 15 in JAMA.

Still, the researchers note, their analysis found significantly fewer people beginning new courses of medicine to treat opioid use disorder in 2020, compared with the same three-month period in 2019, suggesting that some of those who needed to initiate medication treatment did not do so. Another alarming finding was that there was less urine testing across all patients--established and new alike--during the early months of the pandemic.

" It is encouraging to see that people who were engaged in treatment for opioid use disorder before the pandemic kicked in were still getting needed care during the early months of social distancing and shutdowns. But it's concerning that new patients who needed help might not have been getting it and that important follow-up tools such as urine testing were not being used as often."

- Haiden Huskamp, Study Senior Author, the Henry J. Kaiser Professor of Health Care Policy, Blavatnik Institute, HMS

The findings reveal what worked and didn't work during the shutdown and could help inform preventive strategies to avert lapses in care during future pandemics, the team said.

With much of the nation under stay-at-home recommendations in the spring of 2020, many physician practices limited in-person patient visits, switching to telemedicine whenever possible. At the same time, the researchers said, stressors such as social isolation, unemployment and anxiety about the pandemic itself, likely contributed to increased opioid use and overdoses.

Understandably, many were concerned that people already battling opioid problems before the pandemic would no longer receive the same level of care and that fewer patients would start treatment during the pandemic, the researchers said.

To examine how these factors affected the treatment of established and new patients with opioid use disorder, the researchers compared trends in prescription fills, outpatient visits and urine tests among privately insured individuals in the early months of 2020 with the same months in 2019. The team used data from a proprietary insurance database that includes claims for commercial and Medicare Advantage enrollees.

The study looked at individuals who were ages 18-64 and continuously enrolled with medical, behavioral health and pharmacy benefits from January to May 2020 and from January to May 2019, dividing them into two groups. One group of 16,000 individuals were already receiving opioid-use-disorder medication, and one group of more than 6 million individuals who were not receiving such medication.

For both groups, the researchers examined the weekly and cumulative percentage of individuals who got at least one prescription for treatment of opioid use disorder in March, April and May, had at least one visit to a clinician and had at least one urine test to detect traces of opioids. The researchers also examined the proportion of weekly visits that were telemedicine appointments rather than in-person visits.

The analysis showed that during the first three months of the pandemic there was no decrease in medication fills and no decrease in clinician visits among those already being treated with medication, with telehealth visits making up for the decrease in in-person visits.

However, the study revealed that during that period fewer individuals started taking medication for opioid-use disorder and less urine testing was conducted across all patients.

Among individuals already receiving medication, more people filled at least one prescription in March, April and May of 2020 than they did in March, April and May of 2019 (68 percent vs. 66 percent).

The percentage of patients who had at least one clinician visit in March, April and May was not significantly different between 2020 and 2019.

The percentage of individuals receiving at least one urine test was lower in 2020 than in 2019 (11 percent vs. 14 percent).

In 2020, visits delivered via telemedicine increased from less than 1 percent in week one (the week of March 1) to almost 24 percent in week 13.

Among individuals not receiving medication in January and February, the percentage receiving at least one fill in March, April and May of 2020 was lower than during those months in 2019 (0.12 percent vs. 0.16 percent).

Both the percentage of patients who had at least one visit in March, April and May (0.13 percent vs. 0.14 percent) and those who received at least one urine test (0.08 percent vs. 0.12 percent) were lower in 2020 than in 2019. The proportion of clinician visits conducted via telemedicine increased from 0.60 percent in the first week of 2020 to 31.82 percent in week 13.

In a study published earlier this year, the same group of researchers reported on the experience of physicians treating people with opioid use disorders during the pandemic. This study found many clinicians were able to maintain relationships with existing patients via telemedicine yet they did not feel comfortable initiating treatment for new patients who they had not met face-to-face. Those physicians also reported reducing urine testing to protect patients from COVID-19 exposure. The researchers noted that some of the reductions in levels of care may also have been because fewer patients are seeking care during the pandemic. The researchers say these factors likely account for the trends found in their latest study.

"There's no doubt that, like much of the health care system, our capacity to deliver care for people with opioid use disorder was challenged by the coronavirus pandemic. The good news is that many physicians were able to use telemedicine to maintain access for their patients and stay on their meds," said study co-author Ateev Mehrotra, associate professor of health care policy and of medicine at HMS and a hospitalist at Beth Israel Deaconess Medical Center.

The lessons learned, are clear, the research team said.

"Going forward, we need to do a better job of making sure that patients can safely receive all of the follow-up care they need, including adequate monitoring of their opioid use disorder through periodic urine drug testing, which is an important component of care that can inform a patient's treatment," Huskamp said. "We also need to make sure that new patients aren't falling through the cracks."

Source:

Harvard Medical School

Journal reference:

Huskamp, H.A., et al. (2020) Treatment of Opioid Use Disorder Among Commercially Insured Patients in the Context of the COVID-19 Pandemic. JAMA. doi.org/10.1001/jama.2020.21512.
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Study pinpoints predictors of timely enrollment in therapy for opioid use disorder

12/16/20

https://www.news-medical.net/news/20201 ... order.aspx


For people living with opioid use disorder, the path to treatment is not always clear-cut. Sometimes, there's no path at all.

The gap between those recommended for medications for opioid use disorder -- with methadone, buprenorphine or other medications prescribed -- and those who ultimately receive it is wide and persisting. At the epicenter, accounting for more than one third of individuals with an opioid use disorder, are Medicaid recipients.

In an effort to gather information that might help to close that gap, researchers at the Brown University School of Public Health analyzed Medicaid databases to identify predictors of timely enrollment in treatment for those who experienced an opioid overdose or were diagnosed with opioid use disorder.

The findings, published in the journal Drug and Alcohol Dependence, show that 58% of Medicaid recipients did not enroll in treatment within six months of an overdose, and that prior overdose, alcohol use disorder and back problems were predictors of non-enrollment. Conversely, frequent visits to the emergency room or a primary care provider were associated with timely enrollment.

The researchers used multiple linked, state-level databases available through the Rhode Island Executive Office of Health and Human Services to conduct the study of 17,449 Medicaid recipients in Rhode Island.


" These findings underscore the need to enhance pathways to treatment, and we provide several recommendations to that end."

- Alexandria Macmadu, Study Author and Brown Doctoral Candidate in Epidemiology

By pinpointing predictors of enrollment, and non-enrollment, researchers and physicians can get a clearer sense of where they need to connect with people to encourage treatment: in settings that provide mental health care, emergency departments, treatment programs for other substance use disorders, and even pain clinics.

Based on the findings, the researchers generated a two-tiered approach to enhance existing systems of care and ensure maximum exposure to pathways to treatment for OUD at the state level.

Interventions in these high-impact settings to improve screening for OUD and referrals to treatment are among the first steps in stemming the opioid epidemic, the researchers say.

"When it comes to treatment for opioid use disorder, we need to meet people where they are," said Brandon Marshall, an associate professor of epidemiology at Brown and corresponding author of the study. "We can have the best treatment options out there, but they won't do any good if we can't deliver these options in a timely, accessible and non-judgmental way to everyone who might benefit."

Because frequent visits to a primary care provider or emergency department were closely tied to receiving timely treatment, Macmadu said that's a great place to start -- and Rhode Island is already a national leader in that regard, she noted. Compared to other states, medications for OUD are easy to access, available when needed and covered by insurance. There are no waiting lists for the treatment, and enrollment has been growing steadily for several years, according to data from multiple state health agencies.

"Emergency department-based initiation is an incredible approach to use," Macmadu said. "These findings have tremendous implications for other states that wish to replicate the increased engagement in treatment we've been able to achieve in Rhode Island."

In addition to screenings and early interventions, Macmadu said that establishing on-demand buprenorphine induction -- in which patients receive their first dose of the medication -- at key facilities and incorporating peer recovery specialists -- individuals who are in recovery themselves and can help to engage and support peers in the early stages of recovery -- into overdose response are key to mitigating barriers to treatment.

Not all solutions are health care-based, however. Medicaid recipients tend to be lower-income than the broader population, and enhancing transportation support would have a remarkable impact their ability to receive the care they need.

"If you would like to engage in treatment, but you don't have transportation, or you have to navigate the logistical issues of childcare, it can be incredibly difficult," Macmadu said.

Above all, the researchers agree that the simplest, most impactful step toward stemming the tide of overdose is removing the stigma associated with medications for OUD.

Despite years of research that show medications for OUD are the most effective, evidence-based treatment, there is an enduring misconception among patients, physicians and the public that if a person is a patient at a methadone clinic, they're still addicted to something, and that it's not "real recovery," Macmadu explained.

Kimberly Paull, director of data and analytics at EOHHS and one of the co-authors of the paper, said one of the most critical findings of the study was uncovered during focus group conversations with participants -- that no improvement is possible if negative beliefs about medications for OUD persist.

"If we have bias, fear and discrimination about treating a disease with a medication, we are hurting people," Paull said. "We are not showing up to save lives."

Source:

Brown University

Journal reference:


Macmadu, A., et al. (2020) Predictors of enrollment in opioid agonist therapy after opioid overdose or diagnosis with opioid use disorder: A cohort study. Drug and Alcohol Dependence. doi.org/10.1016/j.drugalcdep.2020.108435.
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Recommendations to help ensure access to high-quality opioid use disorder treatment

2/25/21


https://www.news-medical.net/news/20210 ... tment.aspx


On January 14, 2021, the Department of Health and Human Services (HHS) submitted notice to the Federal Register that it would issue practice guidelines that exempt physicians from the requirement to apply for a waiver to prescribe buprenorphine to treat opioid use disorder (OUD) in up to 30 patients at one time. This exemption has been placed on hold by the Biden administration and may require legislative change to implement. An exemption to the X-waiver has the potential to help reverse the morbidity and mortality associated with the opioid overdose epidemic, although without accompanying changes and attention it will not be enough.

The combination of the COVID-19 pandemic and the opioid overdose epidemic fueled by high-potency synthetic opioids have led to increased overdoses. However, national and state leadership, health professions schools, and health care systems in the US have not responded sufficiently. More than 83,000 drug overdose deaths occurred in the US in a 1-year period ending in June 2020, the highest number of overdose deaths ever recorded in a 12-month period, and an increase of more than 21% compared with the previous year.

Nationally, 67% of opioid overdose deaths involved fentanyl in 2018 and drug overdoses increased most among non-Hispanic Black individuals. Despite these devastating losses, access to evidence-based care to prevent opioid overdose and treat OUD remains highly regulated, restricted, and very limited, particularly among Black individuals with OUD and in rural communities. It is estimated that only 18% of individuals with OUD in the US receive highly effective medications, such as buprenorphine or methadone, to treat OUD. For many, the COVID-19 pandemic has further limited access to medications for OUD (MOUD).

Unlike other medical conditions, treatment of OUD has substantial and unique restrictions imposed by US federal and state laws. Such restrictions do not facilitate access to care; on the contrary, they impede it. Methadone for OUD must be administered or dispensed by an accredited, registered, and certified opioid treatment program. The Drug Addiction Treatment Act of 2000 (DATA 2000) requires that prescribers of buprenorphine apply for a waiver (ie, X-waiver) to prescribe once certain educational and practice requirements have been met. However, this restriction has outlived any usefulness.

Although appropriate training is essential to care for any disease, federal law does not require such training or registration to prescribe for other diseases (and more specifically, not for prescribing opioids for other indications such as pain). However, health professions schools are mandated by entities such as the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) to provide training to treat most other diseases. As of 2018, only 1 of 191 medical schools provided training to their students that was sufficient to meet the DATA 2000 training requirement.

Additionally, neither AAMC nor the ACGME require competency in OUD evaluation and treatment in medical education. Together, the absence of health professions school and graduate education; prescribing restrictions; stigma and misinformation among patients, families, and health care professionals; archaic payment structures and systems that emphasize acute care models over long-term treatment; care largely separate and uncoordinated from the rest of health care; and lack of support for patients' psychosocial needs have impeded the large expansion of MOUD treatment that is required to meet the need.

In an effort to address the vast need for MOUD treatment accessibility in the US, the HHS exemption proposed changes as follows. Physicians would need to place an "X" on the prescription, note that the prescription is to treat OUD, maintain separate records for such patients, prescribe to patients in the state in which they practice, and limit prescribing to no more than 30 patients at one time. Physicians who want to treat more than 30 individuals with OUD would need to seek additional training through the current 8-hour DATA 2000 mechanism. Notably, these guidelines do not apply to the large workforce of advanced practice clinicians who remain mandated to complete 24 hours of training to prescribe buprenorphine.

Relaxing restrictions on physician prescribing does have the potential to expand access to treatment and reduce opioid overdose deaths as it has in other countries. For example, in France, buprenorphine became available in 1995 and an estimated 3% of patients with OUD were treated that year with MOUD; by 2006, 67% of the 180000 people with OUD were treated with methadone (n=26000) or buprenorphine (n = 95000) in a setting with relaxed MOUD regulations. Rates of prescribing continue to be high, although over time, initiation of prescribing has shifted somewhat from primary care to specialized addiction treatment centers. While there are some cautionary tales from the rapid expansion of buprenorphine prescribing in France, such as subtherapeutic buprenorphine dosing, it has been estimated that a similar increase in prescribing in the US that occurred in France could have potentially led to an estimated 37000 fewer deaths in 2018 alone if it were used appropriately, adherence was high, and the same conditions were being treated in the US as in France.

Inaction is not an option when 40% of counties in the US do not have a single prescriber of MOUD. The proposed 2021 HHS guidelines represented progress toward MOUD expansion; however, they were far from enough to address the opioid overdose crisis. The US needs to normalize the treatment of OUD among health care professionals and individuals with OUD. Practicing health care professionals should be encouraged and incentivized to prescribe and obtain any needed training or support. OUD identification, evaluation, and treatment education should be integrated in all health care professions schools and should be implemented throughout all health care systems. It is also important to emphasize that medical management of OUD is effective, that buprenorphine alone at therapeutic doses can improve outcomes and prevent overdose, and that detoxification alone is insufficient to prevent overdose and treat OUD.

Buprenorphine prescribing by trained health care professionals can promote high-quality care and the new exemption could increase that prescribing. However, much more will need to be done. These additional steps include eliminating limits on the number of patients who could be treated by individual clinicians. One estimate suggests that by eliminating patient limits, the US could potentially treat nearly 800?000 additional individuals with OUD. Further needed actions include allowing prescribing by advanced practice clinicians; advocating for addiction training efforts at health professions schools, postgraduate programs, and as part of continuing education to make up for previously absent training; allowing office-based methadone treatment to ensure expansion to all types of MOUD; enforcing parity of benefits and insurance coverage for treatment; and addressing the stigma of addiction and addiction treatment. The effects of regulatory changes should be studied after implementation.

Recommendations to help ensure access to high-quality medication treatment for opioid use disorder (OUD)

Pass federal legislation to ensure lasting changes on a national scale
Eliminate buprenorphine patient limits and Drug Enforcement Administration audits that discourage prescribing; include advanced practice clinician prescribers in any legislative change; and remove restrictions on methadone prescribing and dispensing outside opioid treatment programs
Improve and provide training for prescribers and health professional teams at all levels
Incentivize training and offset clinician training time; provide a menu of training options appropriate to the needs of the clinician; integrate substantial training into specialty-specific health professions schools, postgraduate programs, continuing education, and maintenance of certification; include patient perspectives in all training; and provide experiential learning, such as apprenticeship models (eg, with mentors), in practice
Expand access to all forms of OUD treatment shown to have efficacy
Increase access to strategies that reduce consequences of drug use ("harm reduction"); increase access to methadone treatment (eg, via primary care clinicians and pharmacies); and increase access to all treatment options (beyond specialty treatment programs) including medications
Address stigma and include patients receiving medications for OUD (MOUD) in educational campaigns
Enforce Parity (Mental Health Parity and Addiction Equity Act) to ensure equitable coverage and reimbursement for addiction and behavioral health treatments
Ensure equitable access to MOUD in all treatment settings
Study the effects of regulatory changes after implementation

Comprehensive treatment for OUD, including medical, psychiatric, and social services, can and should be provided by experienced clinicians and should be expanded, but MOUD urgently needs to be more accessible. The proposed HHS exemption would offer progress toward achieving that goal even though it was not, as written, a panacea. Improving access while ensuring high-quality care for individuals with OUD to sustain lasting reductions in opioid overdose deaths will require implementing these guidelines and additional strategies, many of which have been suggested for decades. As the new administration considers how to move forward, enacting an improved version of these guidelines and durable legislative changes to ensure access to high-quality MOUD offers a possibility to meaningfully address the overdose crisis.

Source:

Yale University

Journal reference:


Weimer, M.B., et al. (2021) Removing One Barrier to Opioid Use Disorder Treatment, Is It Enough?. JAMA. doi.org/10.1001/jama.2021.0958.
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Re: Alcohol, Opioids, & other Substance Disorders

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COVID-19 pandemic limits access to opioid dependency treatment, increases overdose deaths

4/16/21


https://www.news-medical.net/news/20210 ... eaths.aspx


COVID-19 has been associated with increases in opioid overdose deaths, which may be in part because the pandemic limited access to buprenorphine, a treatment used for opioid dependency, according to a new study led by Princeton University researchers.

The researchers found that Americans who were already taking opioids did not experience disruptions in their supply. Patients who were not previously taking opioids for pain management were less likely to receive a new prescription in the first months of the pandemic, but prescriptions for new patients soon bounced back to previous levels.

At the same time, fewer new patients entered into medication-assisted treatment for opioid addiction, which may have contributed to a spike in overdose deaths, according to the study, which was published in the JAMA Network Open, a journal of the American Medical Association.

" Medication-assisted treatment has been shown to prevent overdose deaths, so disruptions in access to treatment have likely played a role in increasing overdose deaths during the pandemic."

- Janet Currie, Henry Putnam Professor, Economics and Public Affairs

Currie is also the co-director of the Center for Health and Wellbeing (CHW) at Princeton University's School of Public and International Affairs.

Prescribing patterns may be partially accounted for by the role of telemedicine. According to Currie, "Providers found it relatively easy to continue to serve existing patients remotely, but it was more difficult to bring new patients into care."

Currie conducted the study with Jonathan Zhang, a postdoctoral research associate at CHW, Molly Schnell Ph.D. '18, and Hannes Schwandt, a former postdoctoral research scholar at Princeton. Schnell and Schwandt are both now at Institute for Policy Research at Northwestern University.

The researchers explored the pandemic's impact on the opioid crisis by using a large national database of more than 90 million prescriptions for opioid analgesics and buprenorphine.

First, they looked at prescriptions of opioid pain medications for new and existing patients. They also counted prescriptions for buprenorphine prescribed for opioid-use disorder and distinguished between new and existing patients entering and maintaining treatment for opioid dependency.

To compare to the past, the researchers reviewed statistics dating back to 2018. They then studied two time periods to capture the initial and medium-term impacts of COVID-19: the onset of the pandemic (between March and May 2020) and a period when things returned to a more normal level of activity (May to September 2020).

They took several factors into account, including the total number of prescriptions filled, the strength of the drugs prescribed, and the average dispensed pills per prescription.

The research team concluded that patients who were already taking opioid pain medication did not experience a disruption in care. Although the number of weekly prescriptions fell slightly at the start of the pandemic, the amount of medication dispensed remained flat because providers increased the amount prescribed per prescription.

There was initially a sharp drop in new opioid prescriptions from March to May 2020, followed by a rapid rebound to predicted levels. Given the downward trend in opioid prescribing, it is possible that some of these patients may never use opioids, thereby reducing future opioid addictions.

Patterns were different for buprenorphine treatment for opioid dependency. Patients who were already in treatment retained access to these drugs during the pandemic. There was little to no change in the number of prescriptions or doses prescribed for these patients.

However, the number of buprenorphine prescriptions for new patients decreased by almost a quarter at the beginning of the pandemic and had returned to 90% of predicted levels by late August.

The researchers estimate that about 37,000 fewer people received buprenorphine treatment for opioid dependency as a result of the pandemic. This reduced access to treatment for opioid addiction may have increased overdose deaths.

The study's findings shed light on the importance of access to treatment for opioid addiction and that cracks in the U.S. health care delivery system exacerbated and increased due to COVID-19. The researchers are hopeful that understanding prescription patterns -- and obstacles to care -- will help to improve outcomes for patients suffering from addiction.

Source:

Princeton University, Woodrow Wilson School of Public and International Affairs

Journal reference:

Currie, J. M., et al. (2021) Prescribing of Opioid Analgesics and Buprenorphine for Opioid Use Disorder During the COVID-19 Pandemic. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2021.6147.
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