Evaluation of State-Led Surveillance of Neonatal Abstinence Syndrome - Six U.S. States, 2018-2021.

Opioid use disorder (OUD) is a significant public health problem in the United States, which affects children as well as adults. During 2010-2017, maternal opioid-related diagnoses increased approximately 130%, from 3.5 to 8.2 per 1,000 hospital deliveries, and neonatal abstinence syndrome (NAS) increased 83%, from 4.0 to 7.3 per 1,000 hospital deliveries (1). NAS, a withdrawal syndrome, can occur among infants following in utero exposure to opioids and other psychotropic substances (2). In 2018, a study of six states with mandated NAS case reporting for public health surveillance (2013-2017) found that mandated reporting helped quantify NAS incidence and guide programs and services (3). To review surveillance features and programmatic development in the same six states, a questionnaire and interview with state health department officials on postimplementation efforts were developed and implemented in 2021. All states reported ongoing challenges with initial case reporting, limited capacity to track social and developmental outcomes, and no requirement for long-term follow-up in state-mandated case reporting; only one state instituted health-related outcomes monitoring. The primary surveillance barrier beyond initial case reporting was lack of infrastructure. To serve identified needs of opioid- or other substance-exposed mother-infant dyads, state health departments reported programmatic successes expanding education and access to maternal medication for opioid use disorder (MOUD), community and provider education or support services, and partnerships with perinatal quality collaboratives. Development of additional infrastructure is needed for states aiming to advance NAS surveillance beyond initial case reporting.

National trends in buprenorphine prescribing before and during the COVID-19 pandemic.

OBJECTIVE: Recent studies have shown that early in the COVID-19 pandemic, rates of buprenorphine prescription dispensing for opioid use disorder (OUD) were relatively stable. However, whether that pattern continued later in the pandemic is unclear. This study examines the monthly rate of dispensed buprenorphine prescriptions during the early period and the later period of the pandemic. METHODS: The study uses interrupted time series analysis to examine buprenorphine prescription dispensed, average day's supply, payment source, and the number of patients with a dispensed buprenorphine prescription. The study utilized January 2019-April 2021 data from IQVIA National Prescription Audit, PayerTrack and Total Patient Tracker databases. RESULTS: After an initial increase in the number of patients prescribed buprenorphine in the early period of the pandemic, the monthly rate of patients prescribed buprenorphine increased at a lower rate compared to the pre-pandemic period (6100 vs 4600/month). The study observed a decline in the number of buprenorphine prescriptions dispensed both in levels and growth rate during the pandemic, but an increase occurred in the average day's supply of buprenorphine prescriptions (17 days pre-pandemic vs 18.6 day during the pandemic). Medicaid became the primary payer of buprenorphine prescriptions as the pandemic continued, while buprenorphine prescriptions paid for by private insurance declined. DISCUSSION: Expanding and maintaining access to treatment for OUD were key priorities in federal and state responses to the COVID-19 pandemic. The results of our study underscore the importance of policy efforts to help increase buprenorphine prescribing for OUD.

Impacts of the Certified Community Behavioral Health Clinic Demonstration on Emergency Department Visits and Hospitalizations.

OBJECTIVE: The Certified Community Behavioral Health Clinic (CCBHC) demonstration is designed to increase access to comprehensive ambulatory care and crisis services, which may reduce emergency department (ED) visits and hospitalizations. This study examined whether the demonstration had an impact on ED visits and hospitalizations in Missouri, Oklahoma, and Pennsylvania. METHODS: This difference-in-differences analysis used Medicaid claims data from 2015 to 2019 to examine service use during a 12-month baseline period and the first 24 months of the demonstration for beneficiaries who received care from CCBHCs and beneficiaries who received care from other behavioral health clinics in the same state, representing care as usual. Propensity score methods were used to develop treatment and comparison groups with similar characteristics. RESULTS: In Pennsylvania and Oklahoma, beneficiaries who received care from CCBHCs had a statistically significant reduction in the average number of behavioral health ED visits, relative to the comparison group (13% and 11% reductions, respectively); no impact on ED visits in Missouri was observed. The demonstration was associated with a statistically significant reduction in all-cause hospitalizations in Oklahoma, when the analysis used a 2-year rather than a 1-year baseline period, and also in Pennsylvania, when hospitalizations were truncated at the 98th percentile to exclude beneficiaries with outlier hospitalization rates. CONCLUSIONS: The CCBHC demonstration reduced behavioral health ED visits in two states, and the study also revealed some evidence of reductions in hospitalizations.

Characteristics and Prescribing Patterns of Clinicians Waivered to Prescribe Buprenorphine for Opioid Use Disorder Before and After Release of New Practice Guidelines.

Importance: In April 2021, the US Department of Health and Human Services (HHS) released practice guidelines exempting educational requirements to obtain a Drug Addiction Treatment Act (DATA) waiver to treat up to 30 patients with opioid use disorder with buprenorphine. Objective: To compare demographic and practice characteristics of clinicians who received traditional DATA waivers before and after release of the education-exempted HHS practice guidelines and those who were approved under the guidelines. Design, Setting, and Participants: This survey study was conducted electronically from February 1 to March 1, 2022. Eligible survey recipients were US clinicians who obtained an initial DATA waiver between April 2020 and November 2021. Exposure: DATA waiver approval pathway. Main Outcome and Measures: The outcomes were clinician demographic and practice characteristics, buprenorphine prescribing barriers, and strategies to treat patients with opioid use disorder, measured using χ2 tests and z tests to assess for differences among the waivered groups. Results: Of 23 218 eligible clinicians, 4519 (19.5%) responded to the survey. This analysis was limited to 2736 respondents with a 30-patient limit at the time of survey administration who identified their DATA waiver approval pathway. Among these respondents, 1365 (49.9%; female, 831 [61.9%]; male, 512 [38.1%]) received their DATA waiver prior to the education-exempted practice guidelines (prior DATA waiver), 550 (20.1%; female, 343 [63.4%]; male, 198 [36.6%]) received their waiver after guidelines were released but met education requirements (concurrent DATA waiver), and 821 (30.0%; female, 396 [49.2%]; male, 409 [50.8%]) received the waiver under the education-exempted guidelines (practice guidelines). Among practice guidelines clinicians, 500 (60.9%) reported that traditional DATA waiver educational requirements were a reason for not previously obtaining a waiver. Demographic and practice characteristics differed by waiver approval type. Across all groups, a large minority had not prescribed buprenorphine since obtaining a waiver (prior DATA waiver, 483 [35.7%]; concurrent DATA waiver, 226 [41.2%]; practice guidelines, 359 [44.3%]; P < .001). Clinicians who prescribed buprenorphine in the past 6 months reported treating few patients in an average month: 27 practice guidelines clinicians (6.0%) prescribed to 0 patients and 338 (75.1%) to 1 to 4 patients compared with 16 (2.2%) and 435 (59.9%) for prior and 11 (3.6%) and 166 (55.0%) for concurrent DATA waiver clinicians, respectively (P < .001). Across waiver types, clinicians reported multiple challenges to buprenorphine prescribing. Conclusions and Relevance: In this survey of DATA-waivered clinicians, clinician- and systems-level challenges that limit buprenorphine prescribing were observed, even among clinicians approved under the education-exempted guidelines pathway. The findings suggest that as implementation of legislation removing the DATA waiver begins, addressing these barriers could be essential to increasing buprenorphine access.

Receipt of Depression Treatment From General Medical Providers and Specialty Mental Health Providers.

OBJECTIVE: This study compared sociodemographic characteristics and health conditions of adults with a major depressive episode who received treatment from general medical providers or specialty mental health providers. METHODS: The sample included 17,700 respondents ages 18-64 from the 2008-2012 National Survey on Drug Use and Health who met the DSM-IV criteria for a major depressive episode in the past 12 months and of whom 8,900 (61.5%) received treatment for depression. RESULTS: Approximately 21% of adults with a major depressive episode received depression care from general providers only, 19% from specialists only, and 19% from both. Compared with adults receiving care from general providers only, adults who received care from both types of provider were younger, had higher education, were more likely to have suicidal ideation and functional impairment, and were more likely to reside in a county with more psychiatrists providing patient care. These adults, compared with those who received care from a specialty mental health provider only, were more likely to be female, have higher education, have a greater number of general medical comorbidities, and have functional impairment, but they were less likely to be non-Hispanic black or Hispanic. CONCLUSIONS: Adults with major depressive episodes who received depression care from both general and specialty providers differed from those who received care from either provider type. Continued efforts to understand differences in depression care in specialty mental health and general medical settings may help improve the provision of mental health services as health care reform continues.

Differences in patients' perceived helpfulness of depression treatment provided by general medical providers and specialty mental health providers.

OBJECTIVE: This study examined the differences in the level of perceived helpfulness of treatments received for a major depressive episode (MDE) from a general medical provider only, a specialty mental health provider only or both. METHOD: This study examined a sample of 8900 respondents from the 2008-2012 National Survey on Drug Use and Health aged 18-64 who had past 12-month MDE (based on criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition) and received treatment for depression. Generalized ordered logistic regression analyses were conducted to estimate the association between the type of treatment providers and perceived helpfulness of depression treatment. RESULTS: Adults who received depression treatment from either specialty mental health providers alone or from both specialty mental health providers and general medical providers in the past year were more likely to report that treatment helped them. The differences persisted after adjusting for sociodemographic characteristics, comorbid health conditions, receipt of depression medication and severity of depression (adjusted odds ratios across level of perceived helpfulness ranged from 1.63 to 3.96). CONCLUSIONS: This finding calls for greater attention to factors associated with provider type and organizational context that may contribute to differences in perceived helpfulness of depression treatment.

Mobilizing your medications: an automated medication reminder application for mobile phones and hypertension medication adherence in a high-risk urban population.

BACKGROUND: Hypertension frequently accompanies diabetes mellitus, worsening prognosis and complicating medical care for patients. Low medication adherence with multiple medications is a major factor in the inadequate achievement of blood pressure treatment goals. Widespread access to mobile phones offers a new opportunity to communicate with patients and enhance disease self-management. METHODS: We recruited 50 high-risk urban patients with hypertension, who are using at least two prescription medications for hypertension, into an open-label trial using medication reminder software on a mobile phone. Medication adherence was assessed by review of pharmacy refill rates before, during, and after availability of the medication reminder software (pre-activation, activation, and post-activation phase, respectively). RESULTS: Forty-eight patients completed the study. All subjects were insured by Medicaid, 96% were African-American, and the majority had diabetes mellitus. The proportion of days covered for each study phase was as follows: pre-activation phase = 0.54, activation phase = 0.58, and post-activation phase = 0.46. A significant difference was found between the activation and post-activation phases (p = .001). The increase in measured adherence between the pre-activation and activation phases approached significance (p = .057). Forty-six patients completed the pre- and post-Morisky medication adherence survey. The median score rose from 2.0 at baseline to 3.0 at study completion (p < .001). Average blood pressure and level of control during study period improved significantly after initiation of the study and remained improved from baseline through the course of the study. The 48 subjects who completed the study reported a high level of satisfaction with the medication reminder application at the final study visit. CONCLUSIONS: A mobile-phone-based automated medication reminder system shows promise in improving medication adherence and blood pressure in high-cardiovascular-risk individuals.