Barriers and facilitators to use of buprenorphine in state-licensed specialty substance use treatment programs: A survey of program leadership.

INTRODUCTION: Medications for opioid use disorder (MOUD), including buprenorphine, reduce overdose risk and improve outcomes for individuals with opioid use disorder (OUD). However, historically, most non-opioid treatment program (non-OTP) specialty substance use treatment programs have not offered buprenorphine. Understanding barriers to offering buprenorphine in specialty substance use treatment settings is critical for expanding access to buprenorphine. This study aims to examine program-level attitudinal, financial, and regulatory factors that influence clients' access to buprenorphine in state-licensed non-OTP specialty substance use treatment programs. METHODS: We surveyed leadership from state-licensed non-OTP specialty substance use treatment programs in New Jersey about organizational characteristics, including medications provided on- and off-site and percentage of OUD clients receiving any type of MOUD, and perceived attitudinal, financial, and regulatory barriers and facilitators to buprenorphine. The study estimated prevalence of barriers and compared high MOUD reach (n = 36, 35 %) and low MOUD reach (n = 66, 65 %) programs. RESULTS: Most responding organizations offered at least one type of MOUD either on- or off-site (n = 80, 78 %). However, 71 % of organizations stated that fewer than a quarter of their clients with OUD use any type of MOUD. Endorsement of attitudinal, financial, and institutional barriers to buprenorphine were similar among high and low MOUD reach programs. The most frequently endorsed government actions suggested to increase use of buprenorphine were facilitating access to long-acting buprenorphine (n = 95, 96 %), education and stigma reduction for clients and families (n = 95, 95 %), and financial assistance to clients to pay for medications (n = 90, 90 %). CONCLUSIONS: Although non-OTP specialty substance use programs often offer clients access to MOUD, including buprenorphine, most OUD clients do not actually receive MOUD. Buprenorphine uptake in these settings may require increased financial support for programs and clients, more robust education and training for providers, and efforts to reduce the stigma associated with medication among clients and their families.

Evaluating the role of Section 1115 waivers on Medicaid coverage and utilization of opioid agonist therapy among substance use treatment admissions.

OBJECTIVE: To examine the impact of Section 1115 waivers on Medicaid coverage and opioid agonist therapy (OAT) utilization among substance use treatment admissions. DATA SOURCE: Treatment Episode Data Set-Admissions (TEDS-A) (2001-2012). STUDY DESIGN: We examined effects of 1115 waiver implementation on proportions of substance use treatment admissions with Medicaid and receiving OAT, using random intercept linear regression. PRINCIPAL FINDINGS: 1115 waiver implementation was associated with an average of a 6 percentage point increase in proportion of all admissions with Medicaid, and 4 percentage point increase among opioid outpatient admissions. Implementation was not associated with change in proportion of opioid outpatient admissions receiving OAT. CONCLUSIONS: 1115 waivers influence Medicaid coverage among substance use treatment admissions. The findings improve our understanding of how state policies impact substance use treatment utilization.

Health insurance coverage is associated with access to substance use treatment among individuals with injection drug use: Evidence from a 12-year prospective study.

OBJECTIVE: Understand how insurance impacts access to services among people who have injected drugs. METHODS: 1748 adults who have injected drugs were assessed at twice-annual study visits between 2006 and 2017 (18,869 visits). Use of specialty substance use treatment, receipt of buprenorphine, and having a regular source of medical care were assessed for association with concurrent insurance coverage. Random intercept logistic regression was used to adjust for potential confounders. RESULTS: When participants acquired insurance, they were more likely to report specialty substance use treatment (aOR 2.0, 95% CI 1.6 to 2.5), a buprenorphine prescription (aOR 3.3, 95% CI 2.0 to 5.5), and a regular source of medical care (aOR 6.3, 95% CI 5.1 to 7.8). CONCLUSION: Insurance is associated with increased use of three important services for individuals who inject drugs. IMPLICATIONS: Expanding insurance may facilitate access to substance use treatment and other needed health services.

U.S. adults with opioid use disorder living with children: Treatment use and barriers to care.

BACKGROUND: U.S. Adults with an opioid use disorder who live with a child have unique treatment needs, but little is known about the treatment use of these adults. METHODS: Data come from the 2010-2014 versions of the National Survey on Drug Use and Health, an annual, nationally representative survey assessing substance use in the United States. Adults (>18) with a heroin or pain-reliever use disorder living in a household with a child (<18) were compared to adults not living with children on their use of substance use treatment, treatment settings, payment sources, perceived unmet need for treatment, and barriers to care using logistic regression to adjust for demographic differences between groups. RESULTS: Of the 820,000 adults with an opioid use disorder living with at least one child, 28% reported receiving any past-year substance use treatment, a rate comparable to adults not living with a child (30%). Among adults reporting unmet treatment need, those who lived with a child were more likely to report that access barriers like not being able to find the right kind of program (aOR 2.9, 95% CI 1.2-7.1), as well as stigma (aOR 4.1, 95% CI 1.5 to 11.2), kept them from receiving care. CONCLUSION: Most adults with opioid use disorder who live with a child are not receiving any substance use treatment. Efforts to expand opioid use disorder treatment programs must include investment in programs that meet the specialized needs of families.

State variations in Medicaid enrollment and utilization of substance use services: Results from a National Longitudinal Study.

Medicaid enrollment varies considerably among states. This study examined the association of Medicaid enrollment with the use of substance health services in the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions of 2001-2005. Instrumental variable methods were used to assess endogeneity of individual-level Medicaid enrollment using state-level data as instruments. Compared to the uninsured, Medicaid covered adults were more likely to use substance use disorder treatment services over the next three years. States that have opted to expand Medicaid enrollment under the Affordable Care Act will likely experience further increases in the use of these service over the coming years.

Trends in insurance coverage and treatment among persons with opioid use disorders following the Affordable Care Act.

PURPOSE: This short communication examines the impact of the Patient Protection and Affordable Care Act (PPACA) on insurance coverage and substance use treatment access among persons with opioid use disorders. METHODS: Data came from the 2010-2015 National Surveys on Drug Use and Health. Among persons with heroin and opioid pain-reliever use disorders, measures of insurance coverage and treatment access were compared before and after the implementation of major PPACA provisions that expanded access to insurance in 2014. RESULTS: The prevalence of uninsured persons among those with heroin use disorders declined dramatically following PPACA implementation (OR 0.59, 95% CI 0.39-0.89), largely due to an increase in the prevalence of Medicaid coverage (OR 1.96, 95% CI 1.21-3.18). There was no evidence of an increase in the prevalence of treatment, but among persons who received treatment, there was an increase in the proportion whose treatment was paid for by insurance (OR 3.75, 95% CI 2.13-3.18). By contrast, there was no evidence the uninsured rate declined among persons with pain-reliever use disorders. CONCLUSIONS: The PPACA Medicaid expansion increased insurance coverage among persons with heroin use disorders, and likely plays an essential role in protecting the health and financial security of this high-risk group. More research is needed on the relationship between insurance acquisition and utilization of substance use treatment.