Increasing Access to Medications for Opioid Use Disorder in Primary Care: Removing the Training Requirement May Not Be Enough.

BACKGROUND: Substance use disorders, including opioid use disorder (OUD), are understood as chronic diseases with a relapsing and remitting course and no known cure. Medications for OUD (MOUD) are well established with decades of evidence supporting their safety and efficacy; however, treatment access remains poor and inequitable. Buprenorphine is an MOUD that can be prescribed in a primary care outpatient setting, although regulatory and administrative challenges are a barrier to prescribing it. Recent regulatory changes offer an opportunity to expand the number of family doctors who treat OUD. METHODS: We offered free, easily accessible buprenorphine "x-waiver training" led by a team of primary care clinicians. In addition, we provided wrap-around support for MOUD clinical questions and administrative needs with experienced family medicine mentors. RESULTS: More than 400 clinicians attended our trainings, including medical students, residents, and attending physicians. Of the 101 attending physicians who completed our trainings, only 30 went on to apply for an x-wavier, and of those only 7 were currently prescribing when contacted 12 months later. CONCLUSION: Our experience indicates that removing the training requirement is a necessary first step but is unlikely to result in major changes to rates of prescribing without other significant cultural changes.

Are Increasing Trends in Opioid-Related Hospitalizations Attributable to Increases in Diagnosis Recordability? Evidence from 2 Large States.

Based on calculations using all-listed diagnoses, the Agency for Healthcare Research and Quality (AHRQ) reports increasing national trends in opioid-related hospitalizations. It is unclear whether the reported increases are attributable to increases in available diagnosis fields. We leveraged increases in available diagnosis fields, ie, diagnosis recordability, in 2 states to examine their effects on opioid-related hospitalizations, graphically and with nonlinear least squares. Hospitalization data from Texas (1999-2011, N = 36 593 049) and New York (2005-2015Q3, N = 27 582 208) were aggregated to quarter-year in each state. Opioid-related hospitalizations were identified using the same International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Diagnosis Codes as AHRQ. In Texas, the increase in diagnosis recordability resulted in a 29.9% discrete shift in the number of recorded opioid diagnoses and a 3-fold increase in the slope. In New York, a smaller discrete shift (3.1%) and a 3-fold increase in the slope were identified, although a more pronounced change in the trend occurred 5 years earlier (slope change from flat to increasing). Increases in recordability lead to a broader definition of opioid-related hospitalizations, if all-listed diagnoses are used; we found that more hospitalizations are identified using the postchange definition than with the prechange definition (9.7% more in Texas and 4.9% more in New York after 4 years). We conclude that reported increases in opioid-related hospitalizations are partially attributable to increases in diagnosis recordability. Cross-state and temporal comparisons of opioid-related hospitalization rates based on all-listed diagnoses can misrepresent the true relative extent of opioid-related hospital use and therefore of the opioid epidemic.

Geriatric assessment-driven polypharmacy discussions between oncologists, older patients, and their caregivers.

OBJECTIVES: Polypharmacy (PP) and potentially inappropriate medications (PIM) are common in older adults with cancer, increasing the risk of adverse outcomes. Approaches to identifying and addressing PP/PIM are needed. MATERIALS AND METHODS: Patients ≥70 years with advanced cancer were enrolled in this cluster-randomized study. All underwent geriatric assessment (GA), and oncologists randomized to the intervention arm received GA-driven recommendations; no information was provided to oncologists at usual care sites. For patients with PP (≥5 medications or ≥1 high-risk medication), clinic visits with treating oncologists were audiorecorded and transcribed, and discussions regarding PP/PIM identified. Quality of provider response was coded as dismissed, mentioned, acknowledged, or addressed. RESULTS: Forty patient transcripts were analyzed (20 per arm). More discussions occurred in the intervention group (n = 81) versus the usual care group (n = 51). More concerns per patient were brought up in the intervention group (4.1 vs. 2.6, p = 0.07). Physician-initiated discussions were higher in the intervention group (73% vs. 49%, p = 0.006). More PP concerns were "addressed" in the intervention group (59% vs. 45%, p = 0.1). Oncology supportive care medication concerns were more often addressed in the usual care group (58% vs. 18%, p = 0.008), but medication management concerns were addressed more commonly in the intervention group (38% vs. 79%, p = 0.003). CONCLUSION: In this secondary analysis, a GA-driven intervention increased PP discussions, particularly about total number of medications and medication management. PP/PIM concerns were more commonly addressed in the intervention group, except for the subset of conversations about supportive care medications.