Catherine A. Fullerton

Medication-Assisted Treatment With Methadone: Assessing the Evidence

OBJECTIVE Detoxification followed by abstinence has shown little success in reducing illicit opioid use. Methadone maintenance treatment (MMT) helps individuals with an opioid use disorder abstain from or decrease use of illegal or nonmedical opiates. This review examined evidence for MMTs effectiveness. METHODS Authors reviewed meta-analyses, systematic reviews, and individual studies of MMT from 1995 through 2012. Databases searched were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, and Published International Literature on Traumatic Stress. The authors rated the level of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness and examined maternal and fetal results of MMT for pregnant women. RESULTS The review included seven randomized controlled trials and two quasi-experimental studies of MMT, indicating a high level of evidence for the positive impact of MMT on treatment retention and illicit opioid use, particularly at doses greater than 60 mg. Evidence suggests positive impacts on drug-related HIV risk behaviors, mortality, and criminality. Meta-analyses were difficult to perform or yielded nonsignificant results. Studies found little association between MMT and sex-related HIV risk behaviors. MMT in pregnancy was associated with improved maternal and fetal outcomes, and rates of neonatal abstinence syndrome were similar for mothers receiving different doses. Reports of adverse events were also found. CONCLUSIONS MMT is associated with improved outcomes for individuals and pregnant women with opioid use disorders. MMT should be a covered service available to all individuals.

Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence

OBJECTIVE Buprenorphine maintenance treatment (BMT) and methadone maintenance treatment (MMT) are pharmacological treatment programs for individuals with opioid use disorders. MMT is discussed in a companion article. This article describes BMT and reviews available research on its efficacy. METHODS Authors reviewed meta-analyses, systematic reviews, and individual studies of BMT from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, and Published International Literature on Traumatic Stress. They chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS Sixteen adequately designed randomized controlled trials of BMT indicated a high level of evidence for its positive impact on treatment retention and illicit opioid use. Seven reviews or meta-analyses were also included. When the medication was dosed adequately, BMT and MMT showed similar reduction in illicit opioid use, but BMT was associated with less risk of adverse events. Results suggested better treatment retention with MMT. BMT was associated with improved maternal and fetal outcomes in pregnancy, compared with no medication-assisted treatment. Rates of neonatal abstinence syndrome were similar for mothers treated with BMT and MMT during pregnancy, but symptoms were less severe for infants whose mothers were treated with BMT. CONCLUSIONS BMT is associated with improved outcomes compared with placebo for individuals and pregnant women with opioid use disorders. BMT should be considered for inclusion as a covered benefit.

Medication Use and Spending Trends Among Children With ADHD in Florida's Medicaid Program, 1996–2005

OBJECTIVE How the introduction of new pharmaceuticals affects spending for treatment of children with attention-deficit hyperactivity disorder (ADHD) is unknown. This study examined trends in use of pharmaceuticals and their costs among children with ADHD from 1996 to 2005. METHODS This observational study used annual cohorts of children ages three to 17 with ADHD (N=107,486 unique individuals during the study period) from Florida Medicaid claims to examine ten-year trends in the predicted probability for medication use for children with ADHD with and without psychiatric comorbidities as well as mental health spending and its components. Additional outcome measures included average price per day and average number of days filled for medication classes. RESULTS Overall, the percentage of children with ADHD treated with ADHD drugs increased from 60% to 63%, and the percentage taking antipsychotics more than doubled, from 8% to 18%. In contrast, rates of antidepressant use declined from 21% to 15%, and alpha agonist use was constant, at 15%. Mental health spending increased 61%, with pharmaceutical spending representing the fastest-rising component (up 192%). Stimulant spending increased 157%, mostly because of increases in price per prescription. Antipsychotic spending increased 588% because of increases in both price and quantity (number of days used). By 2005, long-acting ADHD drugs accounted for over 90% of stimulant spending. CONCLUSIONS Long-acting ADHD drugs have rapidly replaced short-acting stimulant use among children with ADHD. The use of antipsychotics as a second-tier agent in treating ADHD has overtaken traditional agents such as antidepressants or alpha agonists, suggesting a need for research into the efficacy and side effects of second-generation antipsychotics among children with ADHD.

The rise and fall of gabapentin for bipolar disorder: a case study on off-label pharmaceutical diffusion.

Context:Rising drug costs have increased focus on how new pharmaceuticals diffuse into the marketplace. The case of gabapentin use in bipolar disorder provides an opportunity to study the roles of marketing, clinical evidence, and prior authorization (PA) policy on off-label medication use. Design:Observational study using Medicaid administrative and Verispan marketing data. We examined the association between marketing, clinical trials, and prior authorization on gabapentin use. Setting and Patients:Florida Medicaid, bipolar disorder -diagnosed enrollees ages 18 to 64 for fiscal years 1994 to 2004. Results:Gabapentin prescriptions increased from 8/1000 enrollees per quarter in 1994 to a peak of 387/1000 enrollees in 2002. Its uptake tracked marketing efforts towards psychiatrists. The publication of 2 negative clinical trials in 2000 and the discontinuation of marketing expenditures towards psychiatrists were associated with an end to the steep rise in gabapentin prescriptions. After these events gabapentin use remained between 319/1000 and 387/1000 enrollees per quarter until the PA policy, which was associated with a 45% decrease in prescriptions filled. After 1 year, scientific evidence and marketing discontinuation were associated with a 5.4 percentage point decrease in the predicted probability of filling a gabapentin prescription and the PA policy, a 7.1 percentage point decrease. Conclusions:Pharmaceutical marketing can influence off-label medication prescribing, particularly when pharmacologic options are limited. Evidence of inefficacy and/or the cessation of pharmaceutical marketing, and a restrictive formulary policy can alter prescriber behavior away from targeted pharmacologic treatments. These results suggest that both information and policy are important means in altering physician prescribing behavior.

The Impact of Long-Acting Medications on Attention-Deficit/Hyperactivity Disorder Treatment Disparities

OBJECTIVE Long-acting stimulants have increased medication adherence for many children diagnosed with attention deficit/hyperactivity disorder (ADHD), but it is unknown whether the increase has been similar across racial/ethnic groups. Our objective was to determine whether differences in medication utilization and adherence among white, black, and Hispanic ADHD-diagnosed children and adolescents narrowed following the introduction of long-acting stimulants in the 1990s. METHODS We conducted a retrospective analysis of Florida Medicaid claims data from fiscal years 1996-2005. At each of three cross sections, we identified children and adolescents 3-17 years of age with at least two claims with an ADHD diagnosis. We used linear regression to model disparities over the study period in utilization of any ADHD medications (utilization of long-acting medication specifically) and medication adherence, and identified patient level, treatment setting, and geographic contributors to disparities. RESULTS Although ADHD medication utilization was lower for ADHD-diagnosed minorities than whites in all years, minorities were as likely as whites to switch to long-acting medications. The increase in prescribed days following long-acting medication diffusion was comparable for white and black medication users (40 and 43 days, respectively), but lower for Hispanics (27 days). Geography and provider setting helped to explain disparities in medication utilization overall, but disparities in adherence were not explained by any of the covariates. CONCLUSIONS Despite equivalent switching to long-acting medications in the study period, minorities continued to utilize all ADHD medications less than did whites, and for shorter periods. Provider setting helps explain the ADHD medication utilization gap. High-volume, minority-serving providers are potential targets for future interventions related to improved communication about medication and follow-up after medication initiation.

Use of quality measures for Medicaid behavioral health services by state agencies: implications for health care reform.

OBJECTIVE The structure-process-outcome quality framework espoused by Donabedian provides a conceptual way to examine and prioritize behavioral health quality measures used by states. This report presents an environmental scan of the quality measures and satisfaction surveys that state Medicaid managed care and behavioral health agencies used prior to Medicaid expansion in 2014. METHODS Data were collected by reviewing online documents related to Medicaid managed care contracts for behavioral health, quality strategies, quality improvement plans, quality and performance indicators data, annual outcomes reports, performance measure specification manuals, legislative reports, and Medicaid waiver requests for proposals. RESULTS Information was publicly available for 29 states. Most states relied on process measures, along with some structure and outcome measures. Although all states reported on at least one process measure of behavioral health quality, 52% of states did not use any outcomes measures and 48% of states had no structure measures. A majority of the states (69%) used behavioral health measures from the National Committee for Quality Assurances Healthcare Effectiveness Data and Information Set, and all but one state in the sample (97%) used consumer experience-of-care surveys. Many states supplemented these data with locally developed behavioral health indicators that rely on administrative and nonadministrative data. CONCLUSIONS State Medicaid agencies are using nationally recognized as well as local measures to assess quality of behavioral health care. Findings indicate a need for additional nationally endorsed measures in the area of substance use disorders and treatment outcomes.

Reducing Behavioral Health Inpatient Readmissions for People With Substance Use Disorders: Do Follow-Up Services Matter?

OBJECTIVE Individuals with substance use disorders are at high risk of hospital readmission. This study examined whether follow-up services received within 14 days of discharge from an inpatient hospital stay or residential detoxification reduced 90-day readmissions among Medicaid enrollees whose index admission included a substance use disorder diagnosis. METHODS Claims data were analyzed for Medicaid enrollees ages 18-64 with a substance use disorder diagnosis coded in any position for an inpatient hospital stay or residential detoxification in 2008 (N=30,439). Follow-up behavioral health services included residential, intensive outpatient, outpatient, and medication-assisted treatment (MAT). Analyses included data from ten states or fewer, based on a minimum number of index admissions and the availability of follow-up services or MAT. Survival analyses with time-varying independent variables were used to test the association of receipt of follow-up services and MAT with behavioral health readmissions. RESULTS Two-thirds (67.7%) of these enrollees received no follow-up services within 14 days. Twenty-nine percent were admitted with a primary behavioral health diagnosis within 90 days of discharge. Survival analyses showed that MAT and residential treatment were associated with reduced risk of 90-day behavioral health admission. Receipt of outpatient treatment was associated with increased readmission risk, and, in only one model, receipt of intensive outpatient services was also associated with increased risk. CONCLUSIONS Provision of MAT or residential treatment for substance use disorders after an inpatient or detoxification stay may help prevent readmissions. Medicaid programs should be encouraged to reduce barriers to MAT and residential treatment in order to prevent behavioral health admissions.

Handbook of Preventive Interventions for Adults

Description: This timely handbook provides practical information and evidence-based findings on the most effective and current prevention interventions and programmes available regarding adult emotional, mental health, and social problems. Each innovative chapter summarizes the problem, addressing trends, incidence, and risk factors; describes effective prevention interventions; and discusses practice and policy implications, as well as areas for future research. An exceptional resource for practitioners, researchers, and students alike, the Handbook of Preventive Interventions for Adults is an important addition to the mental health field.