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BACKGROUND: Alcohol use disorders (AUD) are prevalent and responsible for substantial morbidity and mortality; yet efficacious treatments are underused. Previous studies have identified demographic and clinical predictors of medication fills, yet these studies typically do not include patients who were prescribed a medication but did not fill it. OBJECTIVES: To examine rates of and factors associated with prescription order and prescription fill for medications for AUD (MAUD) among individuals diagnosed with AUD in outpatient settings. DESIGN: In a cross-sectional analysis, we used multivariate logistic regression to identify factors associated with prescription order and fill. PATIENTS: We used data from the Optum Labs Data Warehouse that linked 2016-2021 de-identified claims and electronic health record (EHR) data, allowing us to observe prescription orders and whether they were filled. We identified 14,674 patients aged ≥ 18 who had an index outpatient encounter with an AUD diagnosis in the EHR. KEY MEASURES: We computed the proportion for whom a MAUD prescription was ordered within 1 year of index visit, and for whom one was filled within 30 days of the order. KEY RESULTS: 5.8% of the sample had a MAUD prescription order within 1 year of their index visit. Among those with an order, 87% filled their MAUD prescription within 30 days of receipt (i.e., 5.1% of full sample). After multivariable adjustment, receipt of a MAUD prescription order was more likely for patients who were female (adjusted odds ratio (aOR) [95%CI] = 1.44 [1.24-1.67]), or had moderate or severe AUD (1.74 [1.50-2.01]). Patients receiving an order were more likely to fill it if they had a comorbid mental disorder (1.64 [1.09-2.49]). CONCLUSIONS: The low rate of prescription orders was notable. Low use of MAUD appears to result chiefly from prescription order decisions, rather than from prescription fill decisions made by patients.
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INTRODUCTION: People with substance use disorders (SUD) face many barriers to receiving evidence-based treatments including access to and cost of treatment. People who use drugs face stigma that limits access to traditional office-based clinics. With the goal of reducing morbidity and mortality, mobile clinics reduce many of these barriers by providing harm reduction and on-demand low-threshold medical care. METHODS: In 2020 Massachusetts Department of Public Health (DPH) Mobile Addiction Services Program expanded a program called Community Care in Reach building on its success in reducing barriers to care and increasing patient encounters. In the current evaluation we conducted site visits to the four new mobile clinics and conducted one individual semi-structured provider interview at each of the four clinics. In addition, we supported a monthly learning collaborative of staff in four agencies involved with this initiative. The current evaluation used the RE-AIM framework to analyze the implementation of the mobile clinics. RESULTS: Clinicians described many challenges and opportunities. The typical patient is unhoused, having a substance use disorder, and disconnected from traditional pathways to care. Clinicians are able to initiate people on buprenorphine largely due to the trust they establish with patients. Referral networks are facilitated by established community linkages. The philosophy of care is patient-centered. Mobile clinics provide a wide range of healthcare services including harm reduction, although finding a location to park and relations with police can be challenging. The workflow is uneven due to the model that is built on unscheduled visits. CONCLUSION: This study provides insight into how mobile clinics address the gaps in care for persons with OUD and fatal opioid overdoses. Harm reduction services are a critical intervention and financial sustainability of mobile clinics has to be tested.
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Unidades Móviles de Salud , Trastornos Relacionados con Opioides , Humanos , Trastornos Relacionados con Opioides/epidemiología , Trastornos Relacionados con Opioides/terapia , Trastornos Relacionados con Opioides/prevención & control , Accesibilidad a los Servicios de Salud , Investigación Cualitativa , Buprenorfina/uso terapéutico , Massachusetts , Tratamiento de Sustitución de Opiáceos/métodos , Reducción del DañoRESUMEN
BACKGROUND: The national opioid crisis continues to intensify, despite the fact that opioid use disorder (OUD) is treatable and opioid overdose deaths are preventable through first-line treatment with medications for opioid use disorder (MOUD). This study identifies and categorizes payment-related barriers that impact MOUD access and retention from both the provider and patient perspectives and provides insight into how these barriers can be addressed. METHODS: We performed a critical review of the literature (peer-reviewed studies and relevant documents from the gray literature) to identify payment-related access and retention barriers to MOUD. We used the results of this review to develop an analytic framework to understand how payment impacts MOUD access and retention for both providers and patients. In addition, we reviewed action plans developed by Massachusetts communities that participated in the Healing Communities Study (HCS) to analyze which payment-related barriers were addressed through the study. RESULTS: We identified 18 payment-related barriers that patients or providers face when initiating or continuing MOUD with either methadone or buprenorphine in Opioid Treatment Programs (OTP) and non-OTP settings. Patient-related barriers mainly relate to health insurance coverage or the design of health plans (e.g., cost sharing, covered benefits) resulting in direct (medical and non-medical) and indirect costs that can affect both access and retention, especially as they relate to services provided in OTPs. Provider-related barriers include low reimbursement and administrative burden and are most likely to impact access to MOUD. Evidence-based strategies to expand MOUD as part of the HCS in Massachusetts targeted about half of the patient and provider payment-related barriers identified. CONCLUSION: Patients and providers face an array of payment-related barriers that impact access to and retention on MOUD, most of which relate to inadequate health insurance coverage, features of health plans, and key federal and state policies. As new regulatory policies are enacted that expand access to MOUD, such as greater flexibility in OTPs and MOUD delivered via telehealth, it will be important to align these delivery changes with payment reform involving payers, providers, and policymakers.
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Buprenorfina , Accesibilidad a los Servicios de Salud , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides , Humanos , Trastornos Relacionados con Opioides/economía , Trastornos Relacionados con Opioides/tratamiento farmacológico , Accesibilidad a los Servicios de Salud/economía , Buprenorfina/uso terapéutico , Buprenorfina/economía , Tratamiento de Sustitución de Opiáceos/economía , Metadona/uso terapéutico , Metadona/economía , Massachusetts , Estados Unidos , Analgésicos Opioides/economía , Analgésicos Opioides/uso terapéuticoRESUMEN
Background: During the past two decades of cannabis legalization, the prevalence of medical cannabis (MC) use has increased and there has also been an upward trend in alcohol consumption. As less restricted cannabis laws generate more adult cannabis users, there is concern that more individuals may be simultaneously using medical cannabis with alcohol. A few studies have examined simultaneous use of medical cannabis with alcohol, but none of those studies also assessed patients' current or previous non-medical cannabis use. This paper explores simultaneous alcohol and medical cannabis use among medical cannabis patients with a specific focus on previous history of cannabis use and current non-medical cannabis use. Methods: A retrospective cohort study of MC patients (N = 319) from four dispensaries located in New York. Bivariate chi-square tests and multivariable logistic regression are used to estimate the extent to which sociodemographic and other factors were associated with simultaneous use. Results: Approximately 29% of the sample engaged in simultaneous use and a large share of these users report previous (44%) or current (66%) use of cannabis for non-medical purposes. MC patients who either previously or currently use cannabis non-medicinally, men, and patients using MC to treat a pain-related condition, were significantly more likely to report simultaneous alcohol/MC use. Conclusions: Findings indicate that there may be differential risks related to alcohol/MC use, which should be considered by cannabis regulatory policies and prevention/treatment programs. If patients are using cannabis and/or alcohol to manage pain, clinicians should screen for both alcohol and cannabis use risk factors.
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Cannabis , Alucinógenos , Marihuana Medicinal , Adulto , Masculino , Humanos , Marihuana Medicinal/uso terapéutico , Estudios Retrospectivos , Consumo de Bebidas Alcohólicas/epidemiología , Etanol , DolorRESUMEN
BACKGROUND: In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care. AIMS: To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability. METHODS: We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far. RESULTS: The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders. DISCUSSION: A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends. IMPLICATIONS FOR HEALTH POLICY: For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models. IMPLICATIONS FOR FURTHER RESEARCH: For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.
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Planes de Aranceles por Servicios , Medicaid , Estados Unidos , Humanos , Instituciones de Atención AmbulatoriaRESUMEN
PURPOSE: Over 29 million Americans have alcohol use disorder (AUD). Though there are effective medications for AUD (MAUD) that can be prescribed within primary care, they are underutilized. We aimed to explore how primary care physicians familiar with MAUD make prescribing decisions and to identify reasons for underuse of MAUD within primary care. METHODS: We conducted semistructured interviews with 19 primary care physicians recruited from a large online database of medical professionals. Physicians had to have started a patient on MAUD within the last 6 months in an outpatient setting. Inductive and deductive thematic analysis was informed by the theory of planned behavior. RESULTS: Physicians endorsed that it is challenging to prescribe MAUD due to several reasons, including: (1) somewhat negative personal beliefs about medication effectiveness and likelihood of patient adherence; (2) competing demands in primary care that make MAUD a lower priority; and, (3) few positive subjective norms around prescribing. To make MAUD prescribing a smaller component of their practice, physicians reported applying various rules of thumb to select patients for MAUD. These included recommending MAUD to the patients who seemed the most motivated to reduce drinking, those with the most severe AUD, and those who were also receiving other treatments for AUD. CONCLUSIONS: There is a challenging implementation context for MAUD due to competing demands within primary care. Future research should explore which strategies for identifying a subset of patients for MAUD are the most appropriate and most likely to improve population health and health equity.
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Alcoholismo , Equidad en Salud , Médicos de Atención Primaria , Humanos , Alcoholismo/tratamiento farmacológico , Investigación Cualitativa , Toma de DecisionesRESUMEN
BACKGROUND: The Affordable Care Act (ACA) aimed to expand mental health service use in the US, by expanding access to health insurance. However, the gap in mental health utilization by race and ethnicity is pronounced: members of racial and ethnic minoritized groups remain less likely to use mental health services than non-Hispanic White individuals even after the ACA. AIMS OF THE STUDY: This study assessed the effect of the Affordable Care Act (ACA) on mental health services use in one large state (California), and whether that effect differed among racial and ethnic groups. Also, it tested for change in racial and ethnic disparities after the implementation of the ACA, using four measures of mental health care. METHODS: Using pooled California Health Interview Survey (CHIS) data from 2011-2018, logistic regression and Generalized Linear Models (GLM) were estimated. Disparities were defined using the Institute of Medicine (IOM) definition. Primary outcomes were any mental health care in primary settings; in specialty settings, any prescription medication for mental health problems, and number of annual visits to mental health services. RESULTS: Findings suggested that the change in Hispanic-non-Hispanic White disparities in prescription medication use under the ACA was statistically significant, narrowing the gap by 7.23 percentage points (p<.05). However, the disparity in other measures was not significantly reduced. DISCUSSION: These findings suggest that the magnitude of the increase in primary and specialty mental health services among racial and ethnic minorities was not large enough to significantly reduce racial and ethnic disparities. One possible explanation is that non-financial factors played a role, such as language barriers, attitudinal barriers from home culture norms, and systemic barriers due to mental health professional shortages and a limited number of mental health care providers of color. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Integrated approaches that coordinate specialty and primary care mental health services may be needed to promote mental healthcare access for members of racial and ethnic minoritized groups. IMPLICATIONS FOR HEALTH POLICIES: Federal and state policies aiming to improve mental health services use have historically given more weight to financial determinants, but this has not been enough to significantly reduce racial/ethnic disparities. Thus, policies should pay more attention to non-financial determinants. IMPLICATIONS FOR FURTHER RESEARCH: Assessing underlying mechanisms of non-financial factors that moderate the effectiveness of the ACA is a worthwhile goal for future research. Future studies should examine the extent to which non-financial factors intervene in the relationship between the implementation of the ACA and mental health services use.
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Disparidades en Atención de Salud , Servicios de Salud Mental , Humanos , California , Accesibilidad a los Servicios de Salud , Patient Protection and Affordable Care Act , Estados Unidos , Minorías Étnicas y RacialesRESUMEN
INTRODUCTION: Health plans are key players in substance use treatment in the United States, and the opioid crisis presents new challenges for them. This article is part of the HEALing Communities Study (HCS) funded by NIH, which seeks to facilitate communities' adoption of activities that might reduce overdose deaths, including overdose prevention education and naloxone distribution, medication for opioid use disorder, and safer opioid prescribing. We examine how health plans in one state (Massachusetts) are adapting to encourage and sustain activities that help communities to address opioid use disorder (OUD). METHODS: We conducted semi-structured interviews with managers of behavioral health services at eight health plans in Massachusetts that that have Medicare, Medicaid, and commercial lines of business. Two plans in this sample contract with a specialized behavioral health organization ("carve-out"). The interviewees also completed a survey on policies regarding access to treatment and opioid prescribing. Interviews were recorded and transcribed and analyzed using thematic analysis. Analysis of the data included intended influence of the policies at three levels: member level (micro), group or community level (meso), and system or institutional level (macro). RESULTS: All health plans developed strategies to increase access to treatment for OUD, primarily through eliminating or decreasing cost-sharing, eliminating pre-authorization for MOUD, and increasing supply of providers. Health plans encourage qualified practitioners to offer MOUD, but most do not provide incentives or training. Identifying high risk populations is a focus of health plans in this sample. Naloxone is a covered benefit in all health plans, although with variation in monthly limits and cost-sharing. Most health plans take measures to influence opioid prescribing. Health plans' activities are predominately aimed at the micro (member) level with little ability to influence at the macro (wider system-level changes). CONCLUSION: This study provides insight into how health plans develop strategies to address the rise in OUD and fatal opioid overdoses, many of which are key in the HCS initiative. How active a role health plans play in addressing the opioid crisis varies, even within the insurance industry in one state (Massachusetts).
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Analgésicos Opioides , Trastornos Relacionados con Opioides , Anciano , Humanos , Estados Unidos , Analgésicos Opioides/efectos adversos , Medicare , Epidemia de Opioides , Pautas de la Práctica en Medicina , Naloxona/uso terapéutico , Trastornos Relacionados con Opioides/prevención & controlRESUMEN
With overdose deaths increasing, improving access to harm reduction and low barrier substance use disorder treatment is more important than ever. The Community Care in Reach® model uses a mobile unit to bring both harm reduction and clinical care for addiction to people experiencing barriers to office-based care. These mobile units provide many resources and services to people who use drugs, including safer consumption supplies, naloxone, medication for substance use disorder treatment, and a wide range of primary and preventative care. This protocol outlines the evaluation plan for the Community in Care® model in MA, USA. Using the RE-AIM framework, this evaluation will assess how mobile services engage new and underserved communities in addiction services and primary and preventative care.
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Trastornos Relacionados con Opioides , Humanos , Trastornos Relacionados con Opioides/prevención & control , Reducción del DañoRESUMEN
BACKGROUND: Starting in 2008, Vietnam's national MMT program expanded quickly, but it is struggling with increasing attrition rates and poor adherence among patients. Several studies have reported on MMT retention and adherence, but no overview has yet been published. The objective of this study is to fill that gap and to review factors associated with retention and adherence in MMT in Vietnam. METHODS: A systematic search was conducted using databases of literature - Pubmed, Cochrane, Scopus, Academic search premiere, and SoINDEX. Peer-reviewed empirical studies with full text in English discussing retention attrition and adherence regarding MMT in Vietnam were selected. The results were synthesized using qualitative methods. RESULTS: Adherence and retention rates varied among the 11 included studies. In general, patients in mountainous provinces had lower adherence and retention rates than those in big cities. Retention rates decreased with the studies' follow-up period and had a downward trend over time. Factors associated with adherence and retention can be classified into three groups: individual, community, and institutional factors. Important individual factors areage, education, awareness of MMT and HIV, and co-occurring disorders and comorbidities. Stigma is the major community risk factor, and methadone daily dose, the distance between home and clinic, and clinic's service hours are the three most important institutional factors. CONCLUSIONS: The literature reviewed identifies important factors associated with MMT adherence and retention in Vietnam. The findings suggest further research exploring both subjective and objective factors and more policies to remove social and structural barriers to enhance treatment outcomes.
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Metadona , Tratamiento de Sustitución de Opiáceos , Humanos , Vietnam , Tratamiento de Sustitución de Opiáceos/métodos , Metadona/uso terapéutico , Factores de Riesgo , Cumplimiento y Adherencia al TratamientoRESUMEN
BACKGROUND: Bipolar disorder is among the top 10 causes of disability worldwide. The Short-Form Six-Dimension (SF-6D) is a frequently used measure of preference-based health-related quality of life (HRQOL). However, this measure's psychometric performance has not been tested in outpatient patients with bipolar disorder. AIMS OF THE STUDY: This study assessed the psychometric properties of the SF-6D, including convergent validity, known-groups validity, and responsiveness. METHODS: We examined convergent validity between the SF-6D and four condition-specific measures of functioning (LIFE-RIFT), life satisfaction (QLESQ), depressive symptoms (MADRS), and manic symptoms (YMRS). We used known-groups validity tests to compare the SF-6D health utility values estimated for patients in different clinical states, including depression, mania, hypomania, and recovered. We assessed the responsiveness of the SF-6D by comparing the sensitivity of the SF-6D utility values to longitudinal changes in the four condition-specific measures during the same period of time. We conducted all analyses using data from 2,627 participants in the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) clinical trial. RESULTS: The SF-6D demonstrated moderate (0.3-0.7) convergence with the LIFE-RIFT, QLESQ, and MADRS measures. Convergence with the manic symptoms measure (YMRS) was weak (<0.3). For known-groups validity, the SF-6D distinguished the recovered state from the three symptomatic clinical states. For responsiveness, the measure did not show floor or ceiling effects. The SF-6D utility value increased when mental health improved, with a small ES of 0.3 over the 1-year period, which was comparable to the four condition-specific measures. DISCUSSION: The SF-6D demonstrated moderate convergent validity, moderate responsiveness, and it can distinguish the differences between known-groups that had been identified in literature. The SF-6D may be a suitable measure of preference-based HRQOL for patients with bipolar disorder, but caution is needed due to its lower convergence with the YMRS mania scale. LIMITATIONS: The subsample of patients in manic episode was small, which may reduce the reliability of study findings regarding this specific clinical state. In terms of generalizability, the STEP-BD study sample is based on patients who received treatment in bipolar specialty clinics affiliated with academic medical centers, which may be different from other outpatient clinics. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The mean health utility value for patients with hypomania is significantly lower than the mean value for recovered patients. This finding emphasizes the importance of treating hypomania. IMPLICATION FOR HEALTH POLICIES: This study validates an existing approach toward generating health utility values for bipolar disorder. These utility values can be used to create quality-adjusted life years (QALYs), which are the most commonly used measure of health benefit in cost-effectiveness studies. IMPLICATIONS FOR FURTHER RESEARCH: Studies with larger samples of patients with mania are needed to study measures of health utility in this patient population.
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Trastorno Bipolar , Calidad de Vida , Humanos , Psicometría/métodos , Manía , Pacientes Ambulatorios , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
BACKGROUND: Office-Based Opioid Treatment (OBOT) is a delivery model which seeks to make medications for opioid use disorder (MOUD), particularly buprenorphine, widely available in general medical clinics and offices. Despite evidence supporting its effectiveness and cost-effectiveness, uptake of the OBOT model has been relatively slow. One important barrier to faster diffusion of OBOT may be the financial challenges facing clinics that could adopt it. METHODS: We review key features and variants of the OBOT model, then discuss different approaches that have been used to fund it, and the findings from previous economic analyses of OBOT's impact on organizational finances. We conclude by discussing the implications of these analyses for the financial sustainability of the OBOT delivery model. RESULTS: Like other novel services, OBOT poses challenges for providers due to its reliance on services which are 'non-billable' in a fee-for-service environment. A variety of approaches exist for covering the non-billable costs, but which approaches are feasible depends on local payer policies. The scale of the challenges varies with clinic size, organizational affiliations and the policies of the state where the clinic operates. Small clinics in a purely fee-for-service environment may be particularly challenged in pursuing OBOT, given the need to fund a dedicated staff and extra administrative work. The current pandemic may pose both opportunities and challenges for the sustainability of OBOT, with expanded access to telemedicine, but also uncertainty about the durability of the expansion. CONCLUSION: The reimbursement environment for OBOT delivery varies widely around the US, and is evolving as Medicare (and possibly other payers) introduce alternative payment approaches. Clinics considering adoption of OBOT are well advised to thoroughly investigate these issues as they make their decision. In addition, payers will need to rethink how they pay for OBOT to make it sustainable.
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Buprenorfina , Trastornos Relacionados con Opioides , Anciano , Instituciones de Atención Ambulatoria , Analgésicos Opioides/uso terapéutico , Buprenorfina/uso terapéutico , Humanos , Medicare , Tratamiento de Sustitución de Opiáceos , Trastornos Relacionados con Opioides/tratamiento farmacológico , Atención Primaria de Salud , Estados UnidosRESUMEN
OBJECTIVE: To examine the relationships between nonpharmacological treatment (NPT) utilization and opioid prescriptions and doses and whether these relationships vary according to the type of NPT service received. DATA SOURCE: Secondary data from the US Military Health System, nationwide. STUDY DESIGN: Patterns of NPT utilization and opioid prescriptions were analyzed over the 23 months after initial pain treatment (index visit). Regression models were used to examine the relationship between opioid prescription use in a given month and NPT service utilization in the three preceding months, using person fixed effects to control for time-invariant patient characteristics, as well as time fixed effects. Analyses were stratified by whether the patient filled an opioid prescription in the first 30 days post index visit. DATA EXTRACTION METHODS: Administrative data on health care utilization were extracted from the US Military Health System Data Repository for Army service members who returned from deployments in Afghanistan and Iraq that ended in fiscal years 2008 to 2014 and had at least one outpatient visit with a primary diagnosis of musculoskeletal pain in the subsequent year. PRINCIPAL FINDINGS: Utilization of any NPT service in the past 3 months was positively associated with filling an opioid prescription in the given month, regardless of whether the patient was initially prescribed opioids (percentage point difference [PP] =2.87, P < 0.01) or not (PP = 0.83, P < 0.01). However, for those not initially prescribed opioids, use of any NPT service in the past 3 months was negatively associated with mean daily opioid dose in the given month (morphine milligram equivalent dose = -0.4017, P < 0.01). For those initially prescribed opioids, NPT was not associated with opioid dose. CONCLUSIONS: NPT only reduced the prescription opioid daily dose for some patients, whereas the probability of receiving an opioid prescription was positively associated with NPT. Future research should assess whether recent system-level policies and program changes influence referral and opioid prescribing patterns.
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Analgésicos Opioides/uso terapéutico , Terapias Complementarias/estadística & datos numéricos , Terapia por Ejercicio/estadística & datos numéricos , Personal Militar/estadística & datos numéricos , Dolor Musculoesquelético/tratamiento farmacológico , Adulto , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: The opioid crisis has put an increasing strain on US states over the last two decades. In response, all states have passed legislation to implement a portfolio of policies to address the crisis. Although effects of some of these policies have been studied, research into factors associated with state policy adoption decisions has largely been lacking. We address this gap by focusing on factors associated with adoption of naloxone access laws (NAL), which aim to increase the accessibility and availability of naloxone in the community as a harm reduction strategy to reduce opioid-related morbidity and mortality. METHODS: We used event history analysis (EHA) to identify predictors of the diffusion of naloxone access laws (NAL) from 2001, when the first NAL was passed, to 2017, when all states had adopted NAL. A variety of state characteristics were included in the model as potential predictors of adoption. RESULTS: We found that state adoption of NAL increased gradually, then more rapidly starting in 2013. Consistent with this S-shaped diffusion process, the strongest predictor of adoption was prior adoption by neighboring states. Having a more conservative political ideology and having a higher percentage of residents who identified as evangelical Protestants were associated with later adoption of NAL. CONCLUSION: States appear to be influenced by their neighbors in deciding whether and when to adopt NAL. Advocacy for harm reduction policies like NAL should take into account the political and religious culture of a state.
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Sobredosis de Droga , Trastornos Relacionados con Opioides , Analgésicos Opioides/uso terapéutico , Sobredosis de Droga/epidemiología , Humanos , Naloxona/uso terapéutico , Antagonistas de Narcóticos/uso terapéutico , Epidemia de Opioides , Trastornos Relacionados con Opioides/tratamiento farmacológico , Estados UnidosRESUMEN
Background: States are rapidly moving to reverse marijuana prohibition, most frequently through legalization of medical marijuana laws (MMLs), and there is concern that marijuana legalization may affect adolescent marijuana use. Methods: This natural-experimental study used state Youth Risk Behavior Survey (YRBS) data collected from participants in grades 9-12 from 1991 to 2015 in 46 states (N = 1,091,723). Taking advantage of heterogeneity across states in MML status and MML dispensary design, difference-in-difference estimates compared states with enacted MMLs/dispensaries to non-MML/dispensaries states. Multivariable logistic regression modeling was used to adjust for state and year effects, and student demographics. The main outcome assessed was past 30-day adolescent marijuana use ["any" and "heavy" (≥20)]. Results: In the overall sample, the adjusted odds of adolescents reporting any past 30-day marijuana use was lower in states that enacted MMLs at any time during the study period (OR 0.94, 95% CI 0.89 to 0.99; p < .05), and in states with operational dispensaries in 2015 (OR 0.93, 95% CI 0.88 to 0.99; p < .05). Among grade cohorts, only 9th graders showed a significant effect, with lower odds of use with MML enactment. We found no effects on heavy marijuana use. Conclusions: This study found no evidence between 1991 and 2015 of increases in adolescents reporting past 30-day marijuana use or heavy marijuana use associated with state MML enactment or operational MML dispensaries. In a constantly evolving marijuana policy landscape, continued monitoring of adolescent marijuana use is important for assessing policy effects.
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Cannabis , Fumar Marihuana , Uso de la Marihuana , Marihuana Medicinal , Trastornos Relacionados con Sustancias , Adolescente , Humanos , Fumar Marihuana/epidemiología , Uso de la Marihuana/epidemiología , Marihuana Medicinal/uso terapéutico , Estados Unidos/epidemiologíaRESUMEN
Since 2014, 32 states implemented Medicaid expansion by removing the categorical criteria for childless adults and by expanding income eligibility to 138% of the federal poverty level (FPL) for all non-elderly adults. Previous studies found that the Affordable Care Act (ACA) Medicaid expansion improved rates of being insured, unmet needs for care due to cost, number of physician visits, and health status among low-income adults. However, a few recent studies focused on the expansion's effect on racial/ethnic disparities and used the National Academy of Medicine (NAM) disparity approach with a limited set of access measures. This quasi-experimental study examined the effect of Medicaid expansion on racial/ethnic disparities in access to health care for U.S. citizens aged 19 to 64 with income below 138% of the federal poverty line. The difference-in-differences model compared changes over time in 2 measures of insurance coverage and 8 measures of access to health care, using National Health Interview Survey (NHIS) data from 2010 to 2016. Analyses used the NAM definition of disparities. Medicaid expansion was associated with significant decreases in uninsured rates and increases in Medicaid coverage among all racial/ethnic groups. There were differences across racial/ethnic groups regarding which specific access measures improved. For delayed care and unmet need for care, decreases in racial/ethnic disparities were observed. After the ACA Medicaid expansion, most access outcomes improved for disadvantaged groups, but also for others, with the result that disparities were not significantly reduced.
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Disparidades en Atención de Salud , Medicaid , Adulto , Etnicidad , Accesibilidad a los Servicios de Salud , Humanos , Cobertura del Seguro , Seguro de Salud , Persona de Mediana Edad , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Patient Protection and Affordable Care Act , Estados UnidosRESUMEN
BACKGROUND: Approximately one in four women veterans accessing the Department of Veterans Affairs (VA) engage in unhealthy alcohol use. There is substantial evidence for gender-sensitive screening (AUDIT-C = 3) and brief intervention (BI) to reduce risks associated with unhealthy alcohol use in women veterans; however, VA policies and incentives remain gender-neutral (AUDIT-C = 5). Women veterans who screen positive at lower-risk-level alcohol use (AUDIT-C = 3 or 4) may screen out and therefore not receive BI. This study aimed to examine gaps in implementation of BI practice for women veterans through identifying rates of BI at different alcohol risk levels (AUDIT-C = 3-4; =5-7; =8-12), and the role of alcohol risk level and other factors in predicting receipt of BI. METHODS: From administrative data (2010-2016), we drew a sample of women veterans returning from recent wars who accessed outpatient and/or inpatient care. Of 869 women veterans, 284 screened positive for unhealthy alcohol use at or above a gender-sensitive cut-point (AUDIT-C ≥ 3). We used chart review methods to abstract variables from the medical record and then employed logistic regression comparing women veterans who received BI at varying alcohol risk levels to those who did not. RESULTS: While almost 60% of the alcohol positive-risk sample received BI, among the subset of women veterans who screened positive for lower-risk alcohol use (57%; AUDIT-C = 3 or 4) only 34% received BI. Nurses in primary care programs were less likely to deliver BI than other types of clinicians (e.g., physicians, psychologists, social workers) in mental health programs; further, nurses in women's health programs were less likely to deliver BI than other types of clinicians in mixed-gender programs; Those women veterans with more medical problems were no more likely to receive BI than those with fewer medical problems. CONCLUSIONS: Given that women veterans are a rapidly growing veteran population and a VA priority, underuse of BI for women veterans screening positive at a lower-risk level and those with more medical comorbidities requires attention, as do potential gaps in service delivery of BI in primary care and women's health programs. Women veterans health and well-being may be improved by tailoring screening for a younger cohort of women veterans at high-risk for, or with co-occurring disorders and then training providers in best practices for BI implementation.
Asunto(s)
Alcoholismo , Veteranos , Consumo de Bebidas Alcohólicas , Intervención en la Crisis (Psiquiatría) , Femenino , Humanos , Estados Unidos , United States Department of Veterans AffairsRESUMEN
INTRODUCTION: Vaping has become an increasingly common mode of administration for marijuana among youth, but there are limited data on its prevalence. There is a need to better understand youth prevalence of past 30-day marijuana vaping and its predictors. METHODS: Data were from a nationally representative sample of students from the Monitoring the Future survey in 2018 (N=9,131). This study examined past 30-day prevalence of marijuana vaping, and for a subset with complete data (n=5,755), the predictors of marijuana vaping among respondents asked about that behavior. Bivariate chi-square tests and multivariable logistic regression estimated the extent to which various factors were associated with marijuana vaping. These factors included the current use of various substances, school-related risk behaviors, attitude and risk behaviors related to substance use, and selected sociodemographic variables. RESULTS: Past 30-day prevalence of marijuana vaping was higher among 10th graders, male youth, and those in the Other race/ethnicity category. Students who engaged in current past 30-day alcohol use, cigarette use, binge drinking, and nonmedical use of prescription drugs had significantly greater odds of past 30-day marijuana vaping. Past 30-day use was more common among students with a lower perceived risk of marijuana use, those who claimed that it was easy to obtain a vaporizer or marijuana, students with a lower grade point average, and those with recent truancy. CONCLUSIONS: Past 30-day marijuana vaping is prevalent among U.S. students, and there are robust associations between use and school- and substance-related risk behaviors. These results suggest that the emergence of vaping products might redefine populations at risk, which should be taken into account by marijuana regulatory policies or prevention programs.
Asunto(s)
Conducta del Adolescente , Cannabis , Fumar Marihuana , Uso de la Marihuana , Vapeo , Adolescente , Humanos , Masculino , Fumar Marihuana/epidemiología , Uso de la Marihuana/epidemiología , PrevalenciaRESUMEN
BACKGROUND: Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service. METHODS: We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings. RESULTS: Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model. CONCLUSIONS: Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed.