RESUMO
BACKGROUND: Rural cancer survivors may face greater challenges receiving survivorship care than urban cancer survivors. PURPOSE: To test for rural versus urban inequities and identify other correlates of discussions about cancer survivorship care with healthcare professionals. METHODS: Data are from the 2017 Medical Expenditure Panel Survey (MEPS), which included a cancer survivorship supplement. Adult survivors were asked if they discussed with a healthcare professional 5 components of survivorship care: need for follow-up services, lifestyle/health recommendations, emotional/social needs, long-term side effects, and a summary of treatments received. The Behavioral Model of Health Services guided the inclusion of predisposing, enabling, and need factors in ordered logit regression models of each survivorship care variable. RESULTS: A significantly lower proportion of rural than urban survivors (42% rural, 52% urban) discussed in detail the treatments they received, but this difference did not persist in the multivariable model. Although 69% of rural and 70% of urban ssurvivors discussed in detail their follow-up care needs, less than 50% of both rural and urban survivors discussed in detail other dimensions of survivorship care. Non-Hispanic Black race/ethnicity and time since treatment were associated with lower odds of discussing 3 or more dimensions of survivorship care. CONCLUSIONS: This study found only a single rural/urban difference in discussions about survivorship care. With the exception of discussions about the need for follow-up care, rates of discussing in detail other dimensions of survivorship care were low among rural and urban survivors alike.
Assuntos
Sobreviventes de Câncer , Disparidades em Assistência à Saúde , População Rural , Sobrevivência , População Urbana , Humanos , Feminino , Masculino , População Rural/estatística & dados numéricos , Pessoa de Meia-Idade , Sobreviventes de Câncer/estatística & dados numéricos , População Urbana/estatística & dados numéricos , Adulto , Idoso , Disparidades em Assistência à Saúde/estatística & dados numéricos , Neoplasias/terapia , Neoplasias/mortalidade , Estados Unidos , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricosRESUMO
BACKGROUND: Limited information exists about testing for human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) among Medicaid enrollees after starting medication for opioid use disorder (MOUD), despite guidelines recommending such testing. Our objectives were to estimate testing prevalence and trends for HIV, HBV, and HCV among Medicaid enrollees initiating MOUD and examine enrollee characteristics associated with testing. METHODS: We conducted a serial cross-sectional study of 505 440 initiations of MOUD from 2016 to 2019 among 361 537 Medicaid enrollees in 11 states. Measures of MOUD initiation; HIV, HBV, and HCV testing; comorbidities; and demographics were based on enrollment and claims data. Each state used Poisson regression to estimate associations between enrollee characteristics and testing prevalence within 90 days of MOUD initiation. We pooled state-level estimates to generate global estimates using random effects meta-analyses. RESULTS: From 2016 to 2019, testing increased from 20% to 25% for HIV, from 22% to 25% for HBV, from 24% to 27% for HCV, and from 15% to 19% for all 3 conditions. Adjusted rates of testing for all 3 conditions were lower among enrollees who were male (vs nonpregnant females), living in a rural area (vs urban area), and initiating methadone or naltrexone (vs buprenorphine). Associations between enrollee characteristics and testing varied across states. CONCLUSIONS: Among Medicaid enrollees in 11 US states who initiated medications for opioid use disorder, testing for human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and all 3 conditions increased between 2016 and 2019 but the majority were not tested.
Assuntos
Infecções por HIV , Hepatite C , Transtornos Relacionados ao Uso de Opioides , Feminino , Estados Unidos/epidemiologia , Humanos , Masculino , Vírus da Hepatite B , Medicaid , Hepacivirus , HIV , Prevalência , Estudos Transversais , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Hepatite C/diagnóstico , Hepatite C/tratamento farmacológico , Hepatite C/epidemiologia , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologiaRESUMO
OBJECTIVES: The purpose of this study was to measure sexually transmitted infection (STI) testing among Medicaid enrollees initiating preexposure prophylaxis (PrEP) to prevent human immunodeficiency virus. Secondary data are in the form of Medicaid enrollment and claims data in six states in the US South. METHODS: Research partnerships in six states in the US South developed a distributed research network to accomplish study aims. Each state identified all first-time PrEP users in fiscal year 2017-2018 (combined N = 990) and measured the presence of STI testing for chlamydia, syphilis, and gonorrhea through 2019. Each state calculated the percentage of individuals with at least one STI test during 3-, 6-, and 12-month follow-up periods. RESULTS: The proportion of first-time PrEP users that received an STI test varied by state: 37% to 67% of all of the individuals in each state who initiated PrEP received a test within the first 6 months of PrEP treatment and 50% to 77% received a test within the first 12 months. CONCLUSIONS: Although the Centers for Disease Control and Prevention recommends STI testing at least every 6 months for PrEP users, our analysis of Medicaid data suggests that STI testing occurs less frequently than recommended in populations at elevated risk of syphilis, gonorrhea, and chlamydia.
Assuntos
Gonorreia , Infecções por HIV , Infecções Sexualmente Transmissíveis , Sífilis , Masculino , Estados Unidos/epidemiologia , Humanos , Gonorreia/diagnóstico , Infecções por HIV/diagnóstico , Infecções por HIV/prevenção & controle , Sífilis/diagnóstico , Medicaid , Homossexualidade Masculina , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/prevenção & controleRESUMO
The purpose of this study was to determine if social vs nonsocial cues (peer vs light/tone) can serve as discriminative stimuli to reinstate cocaine seeking. In addition, to assess a potential mechanism, an oxytocin (OT) promoter-linked hM3Dq DREADD was infused into the paraventricular nucleus of the hypothalamus to determine whether peer-induced cocaine seeking is decreased by activation of OT neurons. Male rats underwent twice-daily self-administration sessions, once with cocaine in the presence of one peer (S+) and once with saline in the presence of a different peer (S-). Another experiment used similar procedures, except the discriminative stimuli were nonsocial (constant vs flashing light/tone), with one stimulus paired with cocaine (S+) and the other paired with saline (S-). A third experiment injected male and female rats with OTp-hM3Dq DREADD or control virus into PVN and tested them for peer-induced reinstatement of cocaine seeking following clozapine (0.1 mg/kg). Although acquisition of cocaine self-administration was similar in rats trained with either peer or light/tone discriminative stimuli, the latency to first response was reduced by the peer S+, but not by the light/tone S+. In addition, the effect of the conditioned stimulus was overshadowed by the peer S+ but not by the light/tone S+. Clozapine blocked the effect of the peer S+ in rats receiving the OTp-hM3Dq DREADD virus, but not in rats receiving the control virus. These results demonstrate that a social peer can serve as potent trigger for drug seeking and that OT in PVN modulates peer-induced reinstatement of cocaine seeking.
Assuntos
Clozapina , Transtornos Relacionados ao Uso de Cocaína , Cocaína , Animais , Clozapina/farmacologia , Cocaína/farmacologia , Sinais (Psicologia) , Extinção Psicológica , Feminino , Masculino , Neurônios , Ocitocina/farmacologia , Núcleo Hipotalâmico Paraventricular , Ratos , AutoadministraçãoRESUMO
Impulsivity is a personality trait associated with a heightened risk for drug use and other psychiatric conditions. Because impulsivity-related disorders typically emerge during adolescence, there has been interest in exploring methods for identifying adolescents that will be at risk to develop substance use disorders in adulthood. Here, we used a rodent model to assess inhibitory control (impulsive action) and impulsive decision making (impulsive choice) during adolescence (43-50 days old) or adulthood (93-100 days old) and then examined the impact of development on these impulsivity traits by re-testing rats 50 days later. Impulsive action was not stable from adolescence to adulthood in male rats and was lowest in adult male rats, relative to adolescents and female rats. Impulsive choice was stable across development and unaffected by age or sex. Next, we examined the connection between our model of impulsivity and two measures relevant to substance abuse research: the initiation of voluntary alcohol drinking and dopamine D2 receptor (D2 R) expression in the prelimbic prefrontal cortex. Consumption of saccharin-sweetened ethanol during 30-minute sessions in adulthood was associated with adolescent, but not adult, impulsive action, particularly in male rats. Prelimbic D2 R expression was reduced in individuals with high levels of impulsive choice, and this relationship appeared to be strongest among female rats. The results of this study demonstrate that impulsive choice, along with its connection to D2 R expression, is relatively unchanged by the process of development. For impulsive action, however, individual levels of impulsivity during adolescence predict drinking in adulthood despite changes in the measure during development.
Assuntos
Consumo de Bebidas Alcoólicas/fisiopatologia , Depressores do Sistema Nervoso Central/farmacologia , Etanol/farmacologia , Comportamento Impulsivo/efeitos dos fármacos , Receptores de Dopamina D2/metabolismo , Análise de Variância , Animais , Comportamento de Escolha/efeitos dos fármacos , Feminino , Sistema Límbico/metabolismo , Masculino , Caracteres SexuaisRESUMO
OBJECTIVES: Normal aging results in cognitive decline and nutritional interventions have been suggested as potential approaches for mitigating these deficits. Here, we used rats to investigate the effects of short- and long-term dietary supplementation with the leucine metabolite ß-hydroxy-ß-methyl butyrate (HMB) on working memory and cognitive flexibility. METHODS: Beginning â¼12 months of age, male and female Long-Evans rats were given twice daily access to sipper tubes containing calcium HMB (450â mg/kg) or vehicle (285â mg/kg calcium lactate) in a sucrose solution (20% w/v). Supplementation continued for 1 or 7 months (middle- and old-age (OA) groups, respectively) before testing began. Working memory was assessed by requiring rats to respond on a previously sampled lever following various delays. Cognitive flexibility was assessed by training rats to earn food according to a visual strategy and then, once acquired, shifting to an egocentric response strategy. RESULTS: Treatment with HMB improved working memory performance in middle-age (MA) males and OA rats of both sexes. In the cognitive flexibility task, there was a significant age-dependent deficit in acquisition of the visual strategy that was not apparent in OA males treated with HMB. Furthermore, HMB ameliorated an apparent deficit in visual strategy acquisition in MA females. DISCUSSION: Together, these findings suggest that daily nutritional supplementation with HMB facilitates learning and improves working memory performance. As such, HMB supplementation may mitigate age-related cognitive deficits and may therefore be an effective tool to combat this undesirable feature of the aging process.
Assuntos
Envelhecimento/efeitos dos fármacos , Cognição/efeitos dos fármacos , Memória de Curto Prazo/efeitos dos fármacos , Valeratos/farmacologia , Animais , Suplementos Nutricionais , Modelos Animais de Doenças , Feminino , Masculino , Ratos , Ratos Long-EvansRESUMO
Compared to adults, adolescents are at heightened risk for drug abuse and dependence. One of the factors contributing to this vulnerability may be age-dependent differences in reward processing, with adolescents approaching reward through stimulus-directed, rather than goal-directed, processes. However, the empirical evidence for this in rodent models of adolescence, particularly those that investigate both sexes, is limited. To address this, male and female rats that were adolescents (P30) or adults (P98) at the start of the experiment were trained in a Pavlovian approach (PA) task and were subsequently tested for the effects of reward devaluation, extinction, and re-acquisition. We found significant interactions between age and sex: females had enhanced acquisition of PA and poorer extinction, relative to males, while adolescents and females were less sensitive to reward devaluation than male adults. These results suggest that females and adolescents exhibit reward behavior that is more stimulus-directed, rather than goal-directed.
Assuntos
Comportamento Animal/fisiologia , Condicionamento Clássico/fisiologia , Extinção Psicológica/fisiologia , Recompensa , Caracteres Sexuais , Fatores Etários , Animais , Feminino , Masculino , Ratos , Ratos Sprague-DawleyRESUMO
INTRODUCTION: Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY. METHODS: Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation. RESULTS: The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period. CONCLUSIONS: LAI-bup access, utilization, and retention increased after several policy changes.
Assuntos
Buprenorfina , COVID-19 , Preparações de Ação Retardada , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Humanos , Kentucky/epidemiologia , Estudos Retrospectivos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologia , COVID-19/epidemiologia , Buprenorfina/administração & dosagem , Buprenorfina/uso terapêutico , Feminino , Masculino , Adulto , Preparações de Ação Retardada/uso terapêutico , Tratamento de Substituição de Opiáceos/métodos , Pessoa de Meia-Idade , Acessibilidade aos Serviços de Saúde/legislação & jurisprudência , Estados Unidos/epidemiologia , Medicaid/legislação & jurisprudência , Analgésicos Opioides/administração & dosagem , Analgésicos Opioides/uso terapêutico , Injeções , Política de Saúde/legislação & jurisprudência , Autorização Prévia/legislação & jurisprudência , TelemedicinaRESUMO
Importance: Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids. Objective: To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location. Design, Setting, and Participants: This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023. Main Outcomes and Measures: The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code). Results: In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001). Conclusions and Relevance: In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.
Assuntos
Buprenorfina , Acessibilidade aos Serviços de Saúde , Medicaid , Transtornos Relacionados ao Uso de Opioides , Humanos , Medicaid/estatística & dados numéricos , Buprenorfina/uso terapêutico , Buprenorfina/provisão & distribuição , Estados Unidos , Estudos Transversais , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Farmácias/estatística & dados numéricos , Serviços Comunitários de Farmácia/estatística & dados numéricos , Tratamento de Substituição de Opiáceos/estatística & dados numéricos , Antagonistas de Entorpecentes/uso terapêutico , Antagonistas de Entorpecentes/provisão & distribuiçãoRESUMO
Importance: Buprenorphine significantly reduces opioid-related overdose mortality. From 2002 to 2022, the Drug Addiction Treatment Act of 2000 (DATA 2000) required qualified practitioners to receive a waiver from the Drug Enforcement Agency to prescribe buprenorphine for treatment of opioid use disorder. During this period, waiver uptake among practitioners was modest; subsequent changes need to be examined. Objective: To determine whether the Communities That HEAL (CTH) intervention increased the rate of practitioners with DATA 2000 waivers and buprenorphine prescribing. Design, Setting, and Participants: This prespecified secondary analysis of the HEALing Communities Study, a multisite, 2-arm, parallel, community-level, cluster randomized, open, wait-list-controlled comparison clinical trial was designed to assess the effectiveness of the CTH intervention and was conducted between January 1, 2020, to December 31, 2023, in 67 communities in Kentucky, Massachusetts, New York, and Ohio, accounting for approximately 8.2 million adults. The participants in this trial were communities consisting of counties (n = 48) and municipalities (n = 19). Trial arm randomization was conducted using a covariate constrained randomization procedure stratified by state. Each state was balanced by community characteristics including urban/rural classification, fatal opioid overdose rate, and community population. Thirty-four communities were randomized to the intervention and 33 to wait-list control arms. Data analysis was conducted between March 20 and September 29, 2023, with a focus on the comparison period from July 1, 2021, to June 30, 2022. Intervention: Waiver trainings and other educational trainings were offered or supported by the HEALing Communities Study research sites in each state to help build practitioner capacity. Main Outcomes and Measures: The rate of practitioners with a DATA 2000 waiver (overall, and stratified by 30-, 100-, and 275-patient limits) per 100â¯000 adult residents aged 18 years or older during July 1, 2021, to June 30, 2022, were compared between the intervention and wait-list control communities. The rate of buprenorphine prescribing among those waivered practitioners was also compared between the intervention and wait-list control communities. Intention-to-treat and per-protocol analyses were performed. Results: A total of 8â¯166â¯963 individuals aged 18 years or older were residents of the 67 communities studied. There was no evidence of an effect of the CTH intervention on the adjusted rate of practitioners with a DATA 2000 waiver (adjusted relative rate [ARR], 1.04; 95% CI, 0.94-1.14) or the adjusted rate of practitioners with a DATA 2000 waiver who actively prescribed buprenorphine (ARR, 0.97; 95% CI, 0.86-1.10). Conclusions and Relevance: In this randomized clinical trial, the CTH intervention was not associated with increases in the rate of practitioners with a DATA 2000 waiver or buprenorphine prescribing among those waivered practitioners. Supporting practitioners to prescribe buprenorphine remains a critical yet challenging step in the continuum of care to treat opioid use disorder. Trial Registration: ClinicalTrials.gov Identifier: NCT04111939.
Assuntos
Buprenorfina , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Adulto , Humanos , Buprenorfina/uso terapêutico , Análise de Dados , Escolaridade , Intenção , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Adolescente , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
WC 44 and WC 10 are phenylpiperazines with low (23 fold) to moderate (42 fold) selectivity for dopamine D3 receptors (D3Rs) over D2Rs, respectively. WC 44 is a full D3R agonist in the forskolin-stimulated adenylyl cyclase (AC) assay, whereas WC 10 has little efficacy. In contrast to their opposite effects in the AC assay, these drugs often produce similar behavioral effects, suggesting that the AC assay does not predict the efficacy of these drugs in vivo. Here, we examined whether Fos protein expression induced by these drugs would be more consistent with their behavioral effects in vivo. Rats received either vehicle, WC 10 (5.6 mg/kg, i.p.), WC 44 (10.0 mg/kg, i.p), cocaine (10.0 mg/kg, i.p.), or cocaine with WC 10 (5.6 mg/kg, i.p.) or with WC 44 (10.0 mg/kg, i.p). Locomotion was monitored for 90 min and the brains were harvested for immunohistochemistry. Both WC 10 and WC 44 decreased spontaneous and cocaine-induced locomotion. Both compounds also increased Fos expression relative to saline in the dorsal striatum and nucleus accumbens core and shell, and relative to cocaine alone in the nucleus accumbens shell. The findings suggest that even though these compounds have different efficacy in the AC bioassy, they produce similar brain activation and attenuation of cocaine hyperlocomotion. Together with our previous research demonstrating that these compounds down-shift the cocaine self-administration dose-effect function, the findings support the idea that D3R-selective compounds may be useful for cocaine dependence medications development.
Assuntos
Cocaína/farmacologia , Piperazinas/farmacologia , Proteínas Proto-Oncogênicas c-fos/metabolismo , Animais , Cocaína/administração & dosagem , Corpo Estriado/efeitos dos fármacos , Corpo Estriado/metabolismo , Corpo Estriado/fisiologia , Combinação de Medicamentos , Locomoção/efeitos dos fármacos , Masculino , Núcleo Accumbens/efeitos dos fármacos , Núcleo Accumbens/metabolismo , Núcleo Accumbens/fisiologia , Piperazinas/administração & dosagem , Proteínas Proto-Oncogênicas c-fos/genética , Ratos , Ratos Sprague-Dawley , Receptores de Dopamina D3/agonistasRESUMO
BACKGROUND: Kentucky has one of the highest opioid overdose mortality rates in the United States. Accurate estimates of people with opioid use disorder (OUD) are critical to plan for the scope of interventions required to reduce overdose and opioid misuse. Commonly used household surveys are known to underestimate OUD at the state-level and do not provide county-level estimates. METHODS: We performed a multi-sample capture-recapture analysis to estimate OUD prevalence in Kentucky in 2018 and 2019. We utilized four statewide datasets that were linked at the individual level: 1) Registry of Vital Statistics, 2) Emergency Medical Services (EMS), 3) Kentucky's Prescription Drug Monitoring Program (PDMP), and 4) Kentucky Medicaid. We included persons aged 18-64 years who resided in Kentucky between 2018 and 2019. We identified individuals with administrative data consistent with OUD in each of the datasets, including a fatal opioid-involved overdose (Vital Statistics), EMS runs for suspected opioid overdose, receipt of buprenorphine for OUD treatment (PDMP), or Medicaid claims for OUD. Observed and estimated counts of OUD cases and prevalence of OUD among the adult population in Kentucky. RESULTS: The estimated statewide OUD prevalence was 5.5 % and 5.9 % for 2018 and 2019, respectively, ranging from 1.3 % to 17.7 % across Kentucky counties. As expected, counties with the highest OUD rates were Appalachian counties (eastern area) of the state. CONCLUSIONS: Our analysis reveals a substantially larger proportion of KY residents have OUD than previously estimated. Our approach offers a model for states needing county-level estimates of OUD.
Assuntos
Overdose de Drogas , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Adulto , Humanos , Estados Unidos , Kentucky , Prevalência , Overdose de Opiáceos/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Overdose de Drogas/epidemiologiaRESUMO
OBJECTIVE: To describe the process of establishing a Methadone Central Registry (MCR) as part of the HEALing (Helping to End Addiction Long-termSM) Communities Study (HCS) and to support recommendations with evidence of its functionality relative to Medicaid claims data for monitoring utilization of methadone, an evidence-based treatment for opioid use disorder. DESIGN AND PARTICIPANTS: The manuscript authors were active participants in establishing the MCR and include representation from state government, Opioid Treatment Programs (OTPs), and HCS university partners. Secondary data were obtained from Kentucky's (KY's) MCR and Medicaid claims from July 2020 through June 2021. The functionality of data obtained from the MCR, as measured by data completeness and timeliness, is compared with Medicaid claims, the current standard. MAIN OUTCOMES: Central registry and Medicaid data were each aggregated statewide and at the HCS-KY county level. Dual levels of analysis were selected to inform stakeholders at the study and state levels. Descriptive statistics were calculated for the number of patients in methadone treatment. RESULTS: Statewide, the MCR provided a daily record of all individuals receiving methadone through an OTP within 72 hours. In contrast, Medicaid claims processing lagged 9 months and captured 57-62 percent of patients in the MCR. CONCLUSIONS: Replacing a fax-based system, an MCR meets the converging need of providers, regulatory authorities, and researchers to monitor utilization, patient dual enrollment, and treatment outcomes. Implementation strategies included key stakeholder engagement, state partner leadership, training, and federal funding. Adoption of an MCR is recommended.
RESUMO
BACKGROUND: Congenital syphilis can cause severe morbidity, including miscarriage and stillbirth, and rates are increasing rapidly within the United States. However, congenital syphilis can be prevented with early detection and treatment of syphilis during pregnancy. Current screening recommendations propose that all women should be screened early in pregnancy, whereas women with elevated risks for congenital syphilis should be screened again later in pregnancy. The rapid increase in congenital syphilis rates suggests that there are still gaps in prenatal syphilis screening. OBJECTIVE: This study aimed to examine associations between the odds of prenatal syphilis screening and sexually transmitted infection history or other patient characteristics across 3 states with elevated rates of congenital syphilis. STUDY DESIGN: We used the Medicaid claims data from Kentucky, Louisiana, and South Carolina for women with deliveries between 2017 and 2021. Within each state, we examined the log-odds of prenatal syphilis screening as a function of the mother's health history, demographic factors, and Medicaid enrollment history. Patient history was established using a 4-year lookback period of the Medicaid claims data; in state A, sexually transmitted infection surveillance data were used to improve the sexually transmitted infection history. RESULTS: The prenatal syphilis screening rates varied by state, ranging from 62.8% to 85.1% of deliveries to women without a recent history of sexually transmitted infections and from 78.1% to 91.1% of deliveries to women with a previous sexually transmitted infection. For the main outcome of syphilis screening at any time during pregnancy, deliveries associated with previous sexually transmitted infections had 1.09 to 1.37 times higher adjusted odds ratios of undergoing screening. Deliveries to women with continuous Medicaid coverage throughout the first trimester also had higher odds of syphilis screening at any time (adjusted odds ratio, 2.45-3.15). Among deliveries to women with a previous sexually transmitted infection, only 53.6% to 63.6% underwent first-trimester screening and this rate was still just 55.0% to 69.5% when considering only deliveries to women with a previous sexually transmitted infection and full first-trimester Medicaid coverage. Fewer delivering women underwent third-trimester screening (20.3%-55.8% of women with previous sexually transmitted infection). Compared with deliveries to White women, deliveries to Black women had lower odds of first-trimester screening (adjusted odds ratio, 0.85 in all states) but higher odds of third-trimester screening (adjusted odds ratio, 1.23-2.03), potentially impacting maternal and birth outcomes. For state A, linkage to surveillance data doubled the rate of detection of a previous sexually transmitted infection because 53.0% of deliveries by women with a previous sexually transmitted infection would not have had sexually transmitted infection history detected using Medicaid claims alone. CONCLUSION: A previous sexually transmitted infection and continuous preconception Medicaid enrollment were associated with higher rates of syphilis screening, but Medicaid claims alone do not fully capture the sexually transmitted infection history of patients. The overall screening rates were lower than would be expected given that all women should undergo prenatal screening, but the rates in the third trimester were particularly low. Of note, there are gaps in early screening for non-Hispanic Black women who had lower odds of first-trimester screening when compared with non-Hispanic White women despite being at elevated risk for syphilis.
Assuntos
Complicações Infecciosas na Gravidez , Infecções Sexualmente Transmissíveis , Sífilis Congênita , Sífilis , Gravidez , Humanos , Feminino , Estados Unidos/epidemiologia , Sífilis/diagnóstico , Sífilis/epidemiologia , Sífilis/complicações , Sífilis Congênita/diagnóstico , Sífilis Congênita/epidemiologia , Sífilis Congênita/prevenção & controle , Complicações Infecciosas na Gravidez/diagnóstico , Complicações Infecciosas na Gravidez/epidemiologia , Complicações Infecciosas na Gravidez/prevenção & controle , Etnicidade , Medicaid , Infecções Sexualmente Transmissíveis/diagnóstico , Infecções Sexualmente Transmissíveis/epidemiologia , Infecções Sexualmente Transmissíveis/prevenção & controle , Diagnóstico Pré-NatalRESUMO
Importance: Early COVID-19 mitigation strategies placed an additional burden on individuals seeking care for opioid use disorder (OUD). Telemedicine provided a way to initiate and maintain transmucosal buprenorphine treatment of OUD. Objective: To examine associations between transmucosal buprenorphine OUD treatment modality (telemedicine vs traditional) during the COVID-19 public health emergency and the health outcomes of treatment retention and opioid-related nonfatal overdose. Design, Setting, and Participants: This retrospective cohort study was conducted using Medicaid claims and enrollment data from November 1, 2019, to December 31, 2020, for individuals aged 18 to 64 years from Kentucky and Ohio. Data were collected and analyzed in June 2022, with data updated during revision in August 2023. Exposures: The primary exposure of interest was the modality of the transmucosal buprenorphine OUD treatment initiation. Relevant patient demographic and comorbidity characteristics were included in regression models. Main Outcomes and Measures: There were 2 main outcomes of interest: retention in treatment after initiation and opioid-related nonfatal overdose after initiation. For outcomes measured after initiation, a 90-day follow-up period was used. The main analysis used a new-user study design; transmucosal buprenorphine OUD treatment initiation was defined as initiation after more than a 60-day gap in buprenorphine treatment. In addition, uptake of telemedicine for buprenorphine was examined, overall and within patients initiating treatment, across quarters in 2020. Results: This study included 41â¯266 individuals in Kentucky (21â¯269 women [51.5%]; mean [SD] age, 37.9 [9.0] years) and 50â¯648 individuals in Ohio (26â¯425 women [52.2%]; mean [SD] age, 37.1 [9.3] years) who received buprenorphine in 2020, with 18â¯250 and 24â¯741 people initiating buprenorphine in Kentucky and Ohio, respectively. Telemedicine buprenorphine initiations increased sharply at the beginning of 2020. Compared with nontelemedicine initiation, telemedicine initiation was associated with better odds of 90-day retention with buprenorphine in both states (Kentucky: adjusted odds ratio, 1.13 [95% CI, 1.01-1.27]; Ohio: adjusted odds ratio, 1.19 [95% CI, 1.06-1.32]) in a regression analysis adjusting for patient demographic and comorbidity characteristics. Telemedicine initiation was not associated with opioid-related nonfatal overdose (Kentucky: adjusted odds ratio, 0.89 [95% CI, 0.56-1.40]; Ohio: adjusted odds ratio, 1.08 [95% CI, 0.83-1.41]). Conclusions and Relevance: In this cohort study of Medicaid enrollees receiving buprenorphine for OUD, telemedicine buprenorphine initiation was associated with retention in treatment early during the COVID-19 pandemic. These findings add to the literature demonstrating positive outcomes associated with the use of telemedicine for treatment of OUD.
Assuntos
Buprenorfina , COVID-19 , Overdose de Opiáceos , Transtornos Relacionados ao Uso de Opioides , Telemedicina , Estados Unidos/epidemiologia , Humanos , Feminino , Adulto , Buprenorfina/uso terapêutico , Analgésicos Opioides/uso terapêutico , Medicaid , Tratamento de Substituição de Opiáceos , Estudos de Coortes , Estudos Retrospectivos , Pandemias , COVID-19/complicações , Transtornos Relacionados ao Uso de Opioides/epidemiologiaRESUMO
BACKGROUND: Treatment guidelines recommend regular urine drug testing (UDT) for persons initiating buprenorphine for opioid use disorder (OUD). However, little is known about UDT utilization. We describe state variation in UDT utilization and examine demographic, health, and health care utilization factors associated with UDT in Medicaid. METHODS: We used Medicaid claims and enrollment data from persons initiating buprenorphine treatment for OUD during 2016-2019 in 9 states (DE, KY, MD, ME, MI, NC, PA, WI, WV). The main outcome was at least 1 UDT within 180 days of buprenorphine initiation, the secondary outcome was at least 3. Logistic regression models included demographics, pre-initiation comorbidities, and health service use. State estimates were pooled using meta-analysis. RESULTS: The study cohort included 162,437 Medicaid enrollees initiating buprenorphine. The percent receiving ≥1 UDT varied from 62.1% to 89.8% by state. In the pooled analysis, enrollees with pre-initiation UDT had much higher odds of ≥1 UDT after initiation (aOR=3.83, 3.09-4.73); odds were also higher for enrollees with HIV, HCV, and/or HBV infection (aOR=1.25, 1.05-1.48) or who initiated in later years (2018 v 2016: aOR=1.39, 1.03-1.89; 2019 v 2016: aOR=1.67, 1.24-2.25). The odds of having ≥3 UDT were lower with pre-initiation opioid overdose (aOR=0.79, 0.64-0.96) and higher with pre-initiation UDT (aOR=2.63, 2.13-3.25) or OUD care (aOR=1.35, 1.04-1.74). The direction of associations with demographics varied by state. CONCLUSIONS: Rates of UDT increased over time and there was variability among states in UDT rates and demographic predictors of UDT. Pre-initiation conditions, UDT, and OUD care were associated with UDT.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Humanos , Buprenorfina/uso terapêutico , Atenção à Saúde , Medicaid , Tratamento de Substituição de Opiáceos , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Medication for opioid use disorder (MOUD) is evidence-based treatment during pregnancy and postpartum. Prior studies show racial/ethnic differences in receipt of MOUD during pregnancy. Fewer studies have examined racial/ethnic differences in MOUD receipt and duration during the first year postpartum and in the type of MOUD received during pregnancy and postpartum. METHODS: We used Medicaid administrative data from 6 states to compare the percentage of women with any MOUD and the average proportion of days covered (PDC) with MOUD, overall and by type of MOUD, during pregnancy and four postpartum periods (1-90 days, 91-180 days, 181-270 days, and 271-360 days postpartum) among White non-Hispanic, Black non-Hispanic, and Hispanic women diagnosed with OUD. RESULTS: White non-Hispanic women were more likely to receive any MOUD during pregnancy and all postpartum periods compared to Hispanic and Black non-Hispanic women. For all MOUD types combined and for buprenorphine, White non-Hispanic women had the highest average PDC during pregnancy and each postpartum period, followed by Hispanic women and Black non-Hispanic women (e.g., for all MOUD types, 0.49 vs. 0.41 vs. 0.23 PDC, respectively, during days 1-90 postpartum). For methadone, White non-Hispanic and Hispanic women had similar average PDC during pregnancy and postpartum, and Black non-Hispanic women had substantially lower PDC. CONCLUSIONS: There are stark racial/ethnic differences in MOUD during pregnancy and the first year postpartum. Reducing these inequities is critical to improving health outcomes among pregnant and postpartum women with OUD.
Assuntos
Buprenorfina , Transtornos Relacionados ao Uso de Opioides , Gravidez , Estados Unidos , Feminino , Humanos , Etnicidade , Medicaid , Disparidades em Assistência à Saúde , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Período Pós-Parto , Buprenorfina/uso terapêutico , Analgésicos Opioides/uso terapêutico , Tratamento de Substituição de OpiáceosRESUMO
INTRODUCTION: Residential treatment is a key component of the opioid use disorder care continuum, but research has not measured well the differences in its use across states at the enrollee level. METHODS: This cross-sectional observational study used Medicaid claims data from nine states to document the prevalence of residential treatment for opioid use disorder and to describe the characteristics of patients receiving care. For each patient characteristic, chi-square and t-tests tested for differences in the distribution between individuals who did and did not receive residential care. RESULTS: Among 491,071 Medicaid enrollees with opioid use disorder, 7.5 % were treated in residential facilities in 2019, though this number ranged widely (0.3-14.6 %) across states. Residential patients were more likely to be younger, non-Hispanic White, male, and living in an urban area. Although residential patients were less likely than those without residential care to be eligible for Medicaid through disability, diagnoses for comorbid conditions were more frequently observed among residential patients. CONCLUSIONS: Results from this large, multi-state study add context to the ongoing national conversation around opioid use disorder treatment and policy, providing a baseline for future work.
Assuntos
Medicaid , Transtornos Relacionados ao Uso de Opioides , Estados Unidos/epidemiologia , Humanos , Masculino , Estudos Transversais , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Tratamento Domiciliar , PrevalênciaRESUMO
Importance: Federal and state agencies granted temporary regulatory waivers to prevent disruptions in access to medication for opioid use disorder (MOUD) during the COVID-19 pandemic, including expanding access to telehealth for MOUD. Little is known about changes in MOUD receipt and initiation among Medicaid enrollees during the pandemic. Objectives: To examine changes in receipt of any MOUD, initiation of MOUD (in-person vs telehealth), and the proportion of days covered (PDC) with MOUD after initiation from before to after declaration of the COVID-19 public health emergency (PHE). Design, Setting, and Participants: This serial cross-sectional study included Medicaid enrollees aged 18 to 64 years in 10 states from May 2019 through December 2020. Analyses were conducted from January through March 2022. Exposures: Ten months before the COVID-19 PHE (May 2019 through February 2020) vs 10 months after the PHE was declared (March through December 2020). Main Outcomes and Measures: Primary outcomes included receipt of any MOUD and outpatient initiation of MOUD via prescriptions and office- or facility-based administrations. Secondary outcomes included in-person vs telehealth MOUD initiation and PDC with MOUD after initiation. Results: Among a total of 8â¯167â¯497 Medicaid enrollees before the PHE and 8â¯181â¯144 after the PHE, 58.6% were female in both periods and most enrollees were aged 21 to 34 years (40.1% before the PHE; 40.7% after the PHE). Monthly rates of MOUD initiation, representing 7% to 10% of all MOUD receipt, decreased immediately after the PHE primarily due to reductions in in-person initiations (from 231.3 per 100â¯000 enrollees in March 2020 to 171.8 per 100â¯000 enrollees in April 2020) that were partially offset by increases in telehealth initiations (from 5.6 per 100â¯000 enrollees in March 2020 to 21.1 per 100â¯000 enrollees in April 2020). Mean monthly PDC with MOUD in the 90 days after initiation decreased after the PHE (from 64.5% in March 2020 to 59.5% in September 2020). In adjusted analyses, there was no immediate change (odds ratio [OR], 1.01; 95% CI, 1.00-1.01) or change in the trend (OR, 1.00; 95% CI, 1.00-1.01) in the likelihood of receipt of any MOUD after the PHE compared with before the PHE. There was an immediate decrease in the likelihood of outpatient MOUD initiation (OR, 0.90; 95% CI, 0.85-0.96) and no change in the trend in the likelihood of outpatient MOUD initiation (OR, 0.99; 95% CI, 0.98-1.00) after the PHE compared with before the PHE. Conclusions and Relevance: In this cross-sectional study of Medicaid enrollees, the likelihood of receipt of any MOUD was stable from May 2019 through December 2020 despite concerns about potential COVID-19 pandemic-related disruptions in care. However, immediately after the PHE was declared, there was a reduction in overall MOUD initiations, including a reduction in in-person MOUD initiations that was only partially offset by increased use of telehealth.
Assuntos
COVID-19 , Transtornos Relacionados ao Uso de Opioides , Estados Unidos/epidemiologia , Humanos , Feminino , Masculino , Pandemias , COVID-19/epidemiologia , Medicaid , Estudos Transversais , Transtornos Relacionados ao Uso de Opioides/tratamento farmacológico , Transtornos Relacionados ao Uso de Opioides/epidemiologiaRESUMO
INTRODUCTION: The rates of syphilis among pregnant women and infants have increased in recent years, particularly in the U.S. South. Although state policies require prenatal syphilis testing, recent screening rates comparable across Southern states are not known. The purpose of this study is to measure syphilis screening among Medicaid enrollees with delivery in states in the U.S. South. METHODS: A total of 6 state-university research partnerships in the U.S. South developed a distributed research network to analyze Medicaid claims data using a common analytic approach for enrollees with delivery in fiscal years 2017-2018 and 2018-2019 (combined N=504,943). In 2020-2021, each state calculated the percentage of enrollees with delivery with a syphilis screen test during the first trimester, third trimester, and at any point during pregnancy. Percentages for those with first-trimester enrollment were compared with the percentages of those who enrolled in Medicaid later in pregnancy. RESULTS: Prenatal syphilis screening during pregnancy ranged from 56% to 91%. Screening was higher among those enrolled in Medicaid during the first trimester than in those enrolled later in pregnancy. CONCLUSIONS: Despite state laws requiring syphilis screening during pregnancy, screening was much lower than 100%, and states varied in syphilis screening rates among Medicaid enrollees. Findings indicate that access to Medicaid in the first trimester is associated with higher rates of syphilis screening and that efforts to improve access to screening in practice settings are needed.