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Background: Assessments to determine patients' treatment needs and preferences when they begin substance use disorder (SUD) treatment are essential. The objectives of this paper are to identify the perspectives of providers who conduct assessments on (1) assessments' utility in determining the level of care where patients will receive treatment, (2) strategies to engage patients in treatment during assessments, and (3) assessment strengths and shortcomings. Methods: Semi-structured interviews were conducted with 30 California treatment providers who routinely perform SUD assessments for Medicaid beneficiaries. Interviews asked about the utility of assessment tools in determining appropriate levels of care, patient engagement during assessments, and strengths and shortcomings of intake assessment processes. Interviews were audio-recorded, transcribed, and analyzed by multiple researchers using template analysis. Results: Providers reported that assessments linked to level-of-care decision rules sometimes generate recommendations inconsistent with their clinical judgment, and that the timing of assessments can influence the quality of the information collected. Providers described engagement strategies that help patients feel more comfortable during assessments and that encourage more thoughtful and accurate responses. Providers valued assessments that helped ensure comprehensive collection of patient information, that allowed flexibility to probe for additional information and context, and that facilitated treatment planning. Providers did not like assessments that were long and repetitive or those that did not collect detailed information about patients' mental health and recovery environments. Conclusions: Assessments can be improved if providers conduct them in a manner that makes patients feel comfortable while building trust and rapport. Ensuring that assessments are not long or repetitive and giving comprehensive assessments once patients have developed trusting relationships with treatment programs can improve assessment processes. Further research is needed to optimize SUD assessments.
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Transtornos Relacionados ao Uso de Substâncias , Humanos , Medicaid , Participação do Paciente , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados UnidosRESUMO
Background: In general, research has found that patient-centered substance use disorder treatment is positively correlated with improved patient outcomes. However, little research has examined what factors make intake assessments-the first step in addiction treatment-patient-centered. Methods: We conducted interviews with 30 Medicaid-enrolled individuals who received addiction treatment in California about their experiences with the intake assessment process. Results: Participants reported that the intake assessment process evoked strong feelings, both positive and negative. Some participants said that answering detailed questions about their substance use, mental health, and social relationships, for example, was cathartic and gave them helpful insights. Other participants found the questions invasive, exhausting, and anxiety provoking. Participants also emphasized how critical it is for the person conducting the assessment to be supportive, nonjudgmental, and attentive. Participants recommended delaying the comprehensive assessment because they did not feel physically or emotionally ready to complete the intake. Conclusions and recommendations: Patients' introduction to addiction treatment is typically the intake assessment. By understanding how patients experience intake assessments, providers can make the process more patient-centered, which may lead to improved patient outcomes.
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Comportamento Aditivo , Transtornos Relacionados ao Uso de Substâncias , Transtornos de Ansiedade , Humanos , Medicaid , Transtornos Relacionados ao Uso de Substâncias/psicologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados UnidosRESUMO
Background: Identifying and effectively treating individuals with substance use disorders (SUDs) is an important priority for state Medicaid programs, given the enormous toll that SUDs take on individuals, their families, and their communities. In this paper, we describe how the Healthcare Effectiveness Data and Information Set (HEDIS) measure "Identification of Alcohol and Other Drug Services" can be used, along with eligible population prevalence rates, to expand states' ability to track how well their Medicaid programs identify enrollees with SUDs and link them with treatment (measured by initiation and engagement performance measures). Methods: We use the 2009 Medicaid MAX data on utilization and enrollment along with information from the National Survey of Drug Use and Health (NSDUH) to obtain state-level estimates of alcohol and drug abuse and dependence among Medicaid beneficiaries for 7 illustrative states. We calculate identification, initiation, and engagement measures using specifications from the National Committee on Quality Assurance (NCQA). Results: NSDUH data showed that the eligible population prevalence rate (the average rate of alcohol or drug abuse or dependence) among the 7 states was 10.0%, whereas the average identification rate was 2.9%. The gap between the prevalence and identification rates ranged from 5.1% to 11.0% among the 7 states. The initiation rates ranged from 36.9% to 57.1%. The states' engagement rates ranged from 11.8% to 31.1%, although rates differ by age, gender, and race/ethnicity in some states. Conclusion: Including identification along with initiation and engagement measures allows states to determine how well they are performing in a more complete spectrum from need, to recognition and documentation of enrollees with SUDs, to initiation of treatment, to continuation of early treatment.
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Serviços de Saúde Mental/estatística & dados numéricos , Participação do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Adolescente , Adulto , Centers for Medicare and Medicaid Services, U.S. , Feminino , Acessibilidade aos Serviços de Saúde , Pesquisa sobre Serviços de Saúde , Inquéritos Epidemiológicos , Humanos , Masculino , Medicaid , Pessoa de Meia-Idade , Avaliação das Necessidades , Prevalência , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos/epidemiologia , Adulto JovemRESUMO
Spending on psychotropic medications has grown rapidly in recent decades. Using national data on drug expenditures, patent expirations, future drug development and expert interviews, we project that spending will grow more slowly over the period 2012-2020. The average annual increase is projected to be just 3.0 % per year, continuing the steady deceleration in recent years. The main drivers of this expected deceleration include slower development of new drugs, upcoming patent expirations which will lower prices, and payers' growing ability to manage utilization and promote generic use. The slowdown will relieve some cost pressures on payers, particularly Medicare and Medicaid.
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Gastos em Saúde , Psicotrópicos/economia , Descoberta de Drogas , Medicamentos Genéricos/economia , Previsões , Humanos , Medicaid , Medicare , Patentes como Assunto , Estados UnidosAssuntos
Buprenorfina/uso terapêutico , Regulamentação Governamental , Cobertura do Seguro , Medicare Part D , Autorização Prévia , United States Food and Drug Administration , Rotulagem de Medicamentos/legislação & jurisprudência , Política de Saúde , Humanos , Medicare Part C , Medicare Part D/legislação & jurisprudência , Estados UnidosRESUMO
OBJECTIVE: In July 2022, the 988 Suicide and Crisis Lifeline went live. The Lifeline is part of larger federal and state efforts to build comprehensive behavioral health crisis response systems that include mobile crisis units and crisis diversion and stabilization centers. Comprehensive response systems are anticipated to reduce hospitalizations for suicide and other behavioral health crises; however, research testing this assumption has been limited. The authors used Arizona-a state known for its comprehensive crisis system-to determine the association between state implementation of a comprehensive behavioral health crisis response system and suicide-related hospitalizations. METHODS: A comparative interrupted time-series (CITS) design was used to compare changes in suicide-related hospitalizations after the 2015 implementation of Arizona's crisis response system (N=215,063). Data were from the 2010-2019 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID). Nevada (N=84,091 hospitalizations) was used as a comparison state because it is a western state that had not yet implemented a comprehensive crisis system and had available HCUP SID data. The CITS model included controls for time-varying differences in state demographic composition. RESULTS: From 2010 to 2014 to 2019, annual suicide-related hospitalizations in Arizona increased from 122.0 to 324.2 to 584.5, respectively, per 100,000 people, and in Nevada, hospitalizations increased from 94.7 to 263.2 to 595.5, respectively, per 100,000 people. Arizona's crisis response system was associated with a significant relative decrease in the quarterly trend of 2.57 suicide-related hospitalizations per 100,000 people (p=0.033). CONCLUSIONS: More research is needed to understand how the implementation of a comprehensive crisis response system may affect suicide-related hospitalizations.
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Suicídio , Humanos , Arizona/epidemiologia , Custos de Cuidados de Saúde , Hospitalização , DemografiaRESUMO
Parents with serious mental health (MH) and substance use disorders (SUD) can face profound challenges caring for their children. MH/SUD treatment can improve outcomes for both parents and their children. This study evaluated whether parents with Medicaid with MH/SUD conditions whose children had child protective services (CPS) involvement were receiving MH/SUD treatment and whether receipt differed by race. We analyzed the 2020 Child and Caregiver Outcomes Using Linked Data (CCOULD) which contains Medicaid and child welfare records from Kentucky and Florida on 58,551 CPS-involved caregivers. Among caregivers with an MH diagnosis, White individuals were more likely than Black individuals to have received counseling (42% vs. 20%) or an MH medication (69% vs. 52%). Among caregivers with an SUD, White individuals were more likely than Black individuals to have received counseling (43% vs. 20%) or an SUD medication (43% vs. 11%). More effort is needed to connect parents with CPS involvement to MH/SUD treatment, particularly Black parents.
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Importance: Mental and substance use disorders can interfere with parents' ability to care for their children and are associated with a greater likelihood of child protective services involvement to address child maltreatment. Parent engagement in psychiatric and substance use disorder treatment can prevent child maltreatment and family separations. Objective: To determine whether caregivers with psychiatric or substance use disorders whose children were referred to child protective services received Medicaid-funded psychiatric or substance use disorder treatment. Design, Setting, and Participants: Caregivers listed on child welfare records were linked with their Medicaid records using 2017 to 2020 Medicaid and child welfare data from Florida and Kentucky. Medicaid claims were analyzed to determine if caregivers had a psychiatric or substance use disorder diagnosis and whether those caregivers received counseling or medications. The analysis was conducted in 2023. Exposure: Diagnosis of a psychiatric or substance use disorder in 2020. Main Outcome and Measure: Receipt of psychiatric or substance use disorder counseling or medications. Results: Of the 58â¯551 caregivers, 65% were aged between 26 and 40 years; 69% were female and 31% were male. Overall, 78% identified as White, 20% identified as Black/African American, and less than 1% identified as American Indian/Alaska Native, Asian, or Native Hawaiian/Other Pacific Islander. In 2020, 59% of caregivers with Medicaid and children referred to child protective services had a mental health or substance use disorder diagnosis, compared with 33% of age- and sex-matched Medicaid beneficiaries without children referred to child protective services (P < .001). Among caregivers with a psychiatric disorder, 38% received counseling and 67% received psychiatric medication. Among those with a substance use disorder, 40% received counseling and 38% received a substance use disorder medication. Conclusions and Relevance: In this case-control study, despite Medicaid coverage of an array of effective behavioral health treatments, large portions of caregivers with Medicaid coverage, who need treatment and whose children were referred to child protective services, were not receiving treatment. Medicaid and child welfare agencies should make a greater effort to connect caregivers to behavioral health services.
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Serviços de Proteção Infantil , Transtornos Relacionados ao Uso de Substâncias , Criança , Estados Unidos/epidemiologia , Humanos , Masculino , Feminino , Adulto , Cuidadores , Estudos de Casos e Controles , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , AconselhamentoRESUMO
Use of and spending on mental health services in the United States more than doubled over the past two decades. In 2019, 19.2% of adults received mental health treatment (medications and/or counseling) at a cost of $135 billion. Yet, the United States has no data collection system to determine what proportion of the population benefited from treatment. Experts have for decades called for a learning behavioral health care system: a system that collects data on treatment services and outcomes to generate knowledge to improve practice. As the rates of suicide, depression, and drug overdoses in the United States continue to rise, the need for a learning health care system becomes even more pressing. In this paper, I suggest steps to move toward such a system. First, I describe the availability of data on mental health service use, mortality, symptoms, functioning, and quality of life. In the United States, the best sources of longitudinal information on mental health services received are Medicare, Medicaid, and private insurance claims and enrollment data. Federal and state agencies are starting to link these data to mortality information; however, these efforts need to be substantially expanded and include information on mental health symptoms, functioning, and quality of life. Finally, there must be greater efforts to make the data easier to access such as through standard data use agreements, online analytic tools, and data portals. Federal and state mental health policy leaders should be at the forefront of efforts to create a learning mental health care system.
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BACKGROUND: Medicare coverage excludes some levels of substance use disorder (SUD) care, such as intensive outpatient and residential treatment. Expanding access to SUD treatment could increase Medicare spending. However, these costs could be offset if SUD treatment resulted in cost savings from reducing SUD-related medical events and SUD-related medical comorbidities. METHODS: This study estimated cost savings from expanding access to SUD treatment for persons with opioid use disorders (OUD) using three methods. First, we compared total Medicare fee-for-service spending on individuals with OUD and no treatment with OUD medications (MOUD) to Medicare spending on individuals without OUD after matching on age/sex/Medicare-Medicaid eligibility status. Second, we compared Medicare spending on individuals with OUD who received MOUD to spending individuals with OUD who did not receive MOUD. Third, we determined OUD-attributable Medicare spending for comorbid physical and mental conditions with a strong association with OUD. RESULTS: Beneficiaries with OUD but no MOUD totaled $15.8 billion more than beneficiaries without OUD. Beneficiaries with OUD but no MOUD totaled $12.1 billion more than individuals with OUD and MOUD. Lastly, Medicare spending on OUD-attributable comorbidities was $4.7 billion if all medical and mental health comorbidities were included and $3.0 billion with only medical comorbidities. The totals could be 1.7 times higher if Medicare Advantage enrollees were included. CONCLUSION: Expanding Medicare coverage of appropriate levels of care could improve access to effective treatment and reduce the costs associated with untreated OUD. This will likely result in substantial Medicare cost savings.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Idoso , Humanos , Estados Unidos , Medicare , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Resultado do Tratamento , Analgésicos Opioides/uso terapêutico , Tratamento de Substituição de OpiáceosRESUMO
OBJECTIVES: The aims of the study are to review the current research on the association between access to medications for opioid use disorders (MOUD) and race, to identify gaps in research methods, and to propose new approaches to end racialized disparities in access to MOUD. METHODS: We conducted a literature review of English language peer-reviewed published literature from 2010 to 2021 to identify research studies examining the association between race and use of, or access to, MOUD. RESULTS: We reviewed 21 studies related to access to MOUD for Black and White populations. Of the 21 studies, 16 found that Black individuals had lower use of, or access to, MOUD than White individuals, 2 found the opposite among patients in specialty addiction treatment, 1 found that the difference changed over time, and 2 found that distance to opioid treatment programs was shorter for Black residents than for White residents. CONCLUSIONS: To improve future research, we recommend that researchers (1) be clearer on how race is conceptualized and interpreted; (2) explicitly evaluate the intersection of race and other factors that may influence access such as income, insurance status, and geography; (3) use measures of perceived racism, unconscious bias, and self-identified race; (4) collect narratives to better understand why race is associated with lower MOUD access and identify solutions; and (5) evaluate the effect of policies, programs, and clinical training on reducing racial disparities. A multitude of studies find that Black individuals have lower access to MOUD. Researchers must now identify effective solutions for reducing these disparities.
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Buprenorfina , Disparidades em Assistência à Saúde , Transtornos Relacionados ao Uso de Opioides , Humanos , Negro ou Afro-Americano , Buprenorfina/uso terapêutico , Acessibilidade aos Serviços de Saúde , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/complicações , BrancosRESUMO
OBJECTIVES: Patient experience surveys (PESs) are an important component of determining the quality of health care. There is an absence of PES data available to people seeking to identify higher quality substance use disorder treatment providers. Our project aimed to correct this by implementing a PES for substance use disorder treatment providers and publicly disseminating PES information. METHODS: We created a population frame of all addiction providers in 6 states. Providers were asked to disseminate a survey invitation letter directing patients to a survey Web site. No personally identifiable information was exchanged. We developed a 10-question survey, reflecting characteristics National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), Substance Abuse and Mental Health Services Administration (SAMHSA) have identified as reflecting higher-quality addiction treatment. RESULTS: Nineteen percent of facilities participated; among participating facilities, 9627 patients completed the survey. Patient experience varied significantly by facility with the percentage of a facility's patients who chose the most positive answer varying widely. We calculated that between-facility reliability will meet or exceed 0.80 for facilities with 20 or more responding patients. We searched for but did not find evidence of data falsification. CONCLUSIONS: This cost-efficient survey protocol is low burden for providers and patients. Results suggest significant differences in quality of care among facilities, and facility-level results are important to provide to consumers when they evaluate the relative patient-reported quality of facilities. The data are not designed to provide population-based statistics. As more facilities and patients per facility participate, public-facing PES data will be increasingly useful to consumers seeking to compare and choose facilities.
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Transtornos Relacionados ao Uso de Substâncias , Humanos , Estados Unidos , Reprodutibilidade dos Testes , Inquéritos e Questionários , Transtornos Relacionados ao Uso de Substâncias/terapia , Avaliação de Resultados da Assistência ao PacienteRESUMO
OBJECTIVES: When clients begin substance use disorder (SUD) treatment, it is critical to ensure that they receive treatment that matches their needs and preferences. A growing number of payors are requiring the use of multidimensional assessments such as assessments based on the American Society of Addiction Medicine (ASAM) criteria, which describe 6 dimensions that should be used to inform decisions about patient placement. However, ASAM guidance does not list specific questions to ask or instruments to use to elicit this information. This paper evaluates differences among the assessment tools being used by SUD service systems that are required to use ASAM-based assessments to make patient placement decisions. METHODS: We analyzed 29 different ASAM-based assessments being used by California counties to make patient placement decisions using conventional and summative content analysis techniques. RESULTS: All assessments were organized by the 6 ASAM dimensions. However, some of them only ask 1 or 2 questions per dimension, while others ask over 20, and some ask over 100 depending on patient responses. There is significant heterogeneity in the information the assessments collect and how it is used to generate patient placement decisions. Among the 29 assessments examined, there are 8 different algorithms or instructions on how to translate information from assessments into level of care recommendations. CONCLUSIONS: The differences among the ASAM-based assessments examined in this paper suggest a need to implement fidelity standards, enhance training, and create resources to help systems create and utilize assessment and patient placement tools that are consistent across the SUD treatment field.
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Transtornos Relacionados ao Uso de Substâncias , Humanos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/terapiaRESUMO
AIMS: To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine-naloxone compared with those enrolled in plans that did not use PA. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine-naloxone between March 2012 and July 2017. MEASUREMENTS: Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine-naloxone for at least 180 days; co-use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis. FINDINGS: PA was significantly associated with a lower likelihood of testing for hepatitis B [-3.5, 95% confidence interval (CI) = -4.4, -2.7] and C (-5.9, 95% CI = -6.9, -4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (-1.1, 95% CI = -2.5, 0.4) or liver function testing (1.3, 95% CI = -0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (-25.5, 95% CI = -26.8, -24.1) and with fewer drug screens (-2.5, 95% CI = -3.0, -2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine-naloxone (0.3, 95% CI = -1.2, 1.8). PA was associated with fewer outpatient visits (-2.1, 95% CI = -3.0, -1.2) and fewer outpatient visits with an OUD diagnosis (-1.7, 95% CI = -2.1, -1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine-naloxone induction (-28.9, 95% CI = -29.6, -28.3) but a greater likelihood of only using benzodiazepines after buprenorphine-naloxone induction (10.6, 95% CI = 9.3, 11.8). CONCLUSIONS: US Medicare patients subject to prior authorization for buprenorphine-naloxone are not more likely to receive high-quality treatment for opioid use disorder than patients not subject to prior authorization.
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Buprenorfina , Medicare Part D , Transtornos Relacionados ao Uso de Opioides , Idoso , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Combinação Buprenorfina e Naloxona/uso terapêutico , Estudos Transversais , Humanos , Antagonistas de Entorpecentes/uso terapêutico , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Autorização Prévia , Estados UnidosRESUMO
OBJECTIVE: Addiction treatment via telehealth expanded to unprecedented levels during the COVID-19 pandemic. This study aimed to clarify whether the research evidence on the efficacy of telehealth-delivered substance use disorder treatment and the experience of providers using telehealth during the pandemic support continued use of telehealth after the pandemic and, if so, under what circumstances. METHODS: Data sources included a literature review on the efficacy of telehealth for substance use disorder treatment, responses to a 2020 online survey from 100 California addiction treatment providers, and interviews with 30 California treatment providers and other stakeholders. RESULTS: Eight published studies were identified that compared addiction treatment via telehealth with in-person treatment. Seven found telehealth treatment as effective but not more effective than in-person treatment in terms of retention, therapeutic alliance, and substance use. One Canadian study found that telehealth facilitated methadone prescribing and improved retention. In the survey results reported here, California addiction treatment providers said that more than 50% of their patients were being treated via telehealth for intensive outpatient treatment, individual counseling, group counseling, and intake assessment. They were most confident that individual counseling via telehealth was as effective as in-person individual counseling and less sure about the relative effectiveness of telehealth-delivered medication management, group counseling, and intake assessments. CONCLUSIONS: Telehealth may help engage patients in addiction treatment by improving access and convenience. Additional research is needed to confirm that benefit and to determine how best to tailor telehealth to each patient's circumstances and with what mix of in-person and telehealth services.
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COVID-19 , Telemedicina , Assistência Ambulatorial , Canadá , Humanos , Pandemias , Telemedicina/métodosRESUMO
OBJECTIVE: Medication for opioid use disorder (MOUD) is effective but underused. Measuring the percentage of a provider's patients with an opioid use disorder (OUD) who receive MOUD may drive quality improvement and stimulate greater use of medications. This study introduces and tests a provider-level measure of MOUD receipt. METHODS: The study used claims and enrollment data from 32 states in the 2014 Medicaid Analytic Extract to measure the proportion of a provider's patients who received MOUD within 30 days of their OUD diagnosis. The research team assessed measure reliability with several tests to establish the effect of provider on MOUD receipt; and assessed the validity by correlation with a measure of emergency department visits or hospitalizations related to substance use. RESULTS: The sample included 434,484 individuals treated for OUD by one or more of 9398 providers. The mean provider score was 38 %, indicating that 38 % of the average provider's patients received an MOUD within 30 days of an OUD diagnosis (44 % for clinicians [N = 5344] and 31 % for facilities [N = 4054]). Provider performance varied considerably. The interquartile ranges were 11 %-79 % and 9 %-45 % among clinicians and facilities, respectively. The measure reliably distinguished between lower- and higher-performing providers and demonstrated convergent validity, as indicated by a significant and moderately sized negative correlation between MOUD receipt and substance use-related hospitalizations or emergency department visits. CONCLUSIONS: The measure may help to improve access to MOUD and OUD outcomes by identifying providers who could benefit from technical assistance, quality improvement initiatives, and resources to expand MOUD prescribing.
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Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Analgésicos Opioides/uso terapêutico , Buprenorfina/uso terapêutico , Prescrições de Medicamentos , Humanos , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Reprodutibilidade dos Testes , Estados UnidosRESUMO
INTRODUCTION: This study aimed to determine the prevalence of treated and untreated substance use disorders among Medicare beneficiaries, the characteristics of Medicare beneficiaries with substance use disorders, and reasons for their unmet needs. METHODS: This study used data from the National Survey of Drug Use and Health, 2015-2019. Substance use disorder was defined based on DSM-IV dependence or abuse criteria. Descriptive analyses were conducted in 2021, including testing for differences in unadjusted means. RESULTS: Approximately 1.7 million Medicare beneficiaries were estimated to have past-year substance use disorder (8% of Medicare beneficiaries aged <65 years and 2% aged ≥65 years). Overall, 77% had an alcohol use condition, 16% had a prescription drug use condition, and 10% had a marijuana use condition. Of those who had past-year substance use disorder, 11% received treatment for their condition. Common reasons for not receiving treatment were lack of motivation (41%), financial barriers (33%), concern about what others might think (24%), logistical barriers such as lack of transportation (21%), and uncertainty about treatment efficacy (13%). Medicare beneficiaries with substance use disorders were more than twice as likely to have past-year serious psychological distress as those without substance use disorders (44% vs 21%, p<0.001 for those aged <65 years; 14% vs 4%, p<0.001 for those aged ≥65 years). Percentages of past-year suicidal ideation were also much higher among Medicare beneficiaries with substance use disorders than without (24% vs 6%, p<0.001 for those aged <65 years; 7% vs 2%, p=0.006 for those aged ≥65 years). CONCLUSIONS: Few Medicare beneficiaries who need substance use disorder treatment receive it. Reducing Medicare coverage gaps and stigma may help meet this need.
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Transtornos Mentais , Medicamentos sob Prescrição , Transtornos Relacionados ao Uso de Substâncias , Idoso , Comorbidade , Humanos , Medicare , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Prevalência , Transtornos Relacionados ao Uso de Substâncias/epidemiologia , Transtornos Relacionados ao Uso de Substâncias/terapia , Estados Unidos/epidemiologiaRESUMO
OBJECTIVE: The authors aimed to describe the development and testing of quality measures included in a public-facing addiction treatment facility search engine. METHODS: An addiction treatment facility survey was created that queried providers in six U.S. states about whether they offered the services and used the processes identified by federal agencies and nonprofit organizations as signs of higher-quality addiction treatment. Four insurance claims-based quality measures were created to capture the percentage of a provider's patients with opioid use disorder receiving opioid use disorder medications, who filled prescriptions for such medication for at least 180 days, who received follow-up care after treatment for substance use disorder in inpatient or residential settings, or who had a substance use disorder-related hospitalization or emergency department visit. A patient experience-of-care survey captured patients' perceptions of the quality of the addiction treatment. The project was undertaken from November 2018 through July 2020. RESULTS: The authors tested the measures by using 1,245 facility surveys, 7,970 patients' experience-of-care surveys, and four claims-based measures submitted by 129, 136, 283, and 408 addiction treatment providers. Statistical testing demonstrated that the quality measures were reliable and valid. The quality measure scores varied among providers, capturing a wide performance range. A public website containing quality measures launched in July 2020 in the six states and has been accessed by thousands of consumers. CONCLUSIONS: This study developed valid, reliable, and useful addiction treatment quality measures. Dissemination of these measures may help consumers select among providers and help providers, policy makers, and payers improve quality.
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Comportamento Aditivo , Transtornos Relacionados ao Uso de Opioides , Assistência ao Convalescente , Humanos , Pacientes Internados , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológicoRESUMO
OBJECTIVES: The study aimed to determine the prevalence of documented side effects and drugdrug interactions in older adults using antidepressants and their implications for adherence. DESIGN: Data were from the MarketScan Medicare Database,which comprises insurance claims from retirees with employer-sponsored Medicare supplemental insurance. Subjects were aged 65 years or older, new antidepressant users, and had a depression diagnosis between July 1, 2001, and December 31, 2006.Twelve commonly reported antidepressant side effects were identified in the month after drug initiation through International Classification of Diseases, Ninth Revision,Clinical Modification diagnoses. Potential drug- drug interactions involving an antidepressant and another drug were identified during the 1 year after antidepressant initiation using MicroMedex DRUG-REAX software. Multinomial logistic regression was used to determine the association of side effects and potential interactions with refills rates, switching, and discontinuation. RESULTS: The presence of a side effect was associated with a 4.7 percentage point increase in the probability of switching (from 16.5% to 21.7%) and a 3.7 percentage point increase in the discontinuation rate (from 22% to 25.7%). Among the 39,512 treatment-naive antidepressants users, 25.4% hadpotential contraindicated or major interactions, 36.1% had moderate interactions,and 38.5% had minor or no interactions. The presence of potential contraindicated or potential major interactions increased the probability of switching by 19.5 percentage points and had a minimal effect on discontinuation. CONCLUSION: Although antidepressant medications have been demonstrated to be effective in treatment of geriatric depression, this study highlights the complexity of antidepressant prescribing in this population and the need for clinicians to be aware of potential drug- drug interactions and side effects.
Assuntos
Antidepressivos/efeitos adversos , Antidepressivos/uso terapêutico , Depressão/tratamento farmacológico , Adesão à Medicação/estatística & dados numéricos , Sistemas de Notificação de Reações Adversas a Medicamentos/estatística & dados numéricos , Idoso , Depressão/psicologia , Interações Medicamentosas , Feminino , Humanos , Masculino , Padrões de Prática Médica/estatística & dados numéricosRESUMO
OBJECTIVES: The substance use disorder (SUD) treatment field has conducted significant research on creating intake tools and processes that best match patients to the most appropriate treatment setting, but less research has been conducted on how those tools impact the patient experience. The study took advantage of a natural experiment in California to evaluate whether the implementation of American Society of Addiction Medicine (ASAM) assessment criteria and a computer-facilitated intake assessment based on the ASAM criteria affects patient experiences and patient-centeredness during intake relative to patients receiving intake assessments not based on ASAM criteria. METHODS: We analyzed surveys completed by 851 patients covered by Medi-Cal who were receiving specialty SUD treatment at 33 providers across 10 California counties about their experiences and perceptions of the intake assessment process. To account for differences in patient mix, we used inverse-probability weighting and computed differences in the weighted means for patients across non-ASAM, ASAM, and computerized-ASAM patients. RESULTS: We have found that patients who underwent intake based on ASAM assessment criteria or computerized ASAM assessment experienced a more patient-centered intake. We also found that patients who received ASAM-based assessments were more satisfied with their choice of treatment setting. CONCLUSIONS: This evidence is encouraging for the SUD treatment field, especially considering that many Medicaid programs are adopting ASAM or similar patient placement criteria and multidimensional assessments. Future research should consider whether increases in the patient-centeredness of assessments are associated with increased retention in SUD treatment and other positive treatment outcomes.