Elizabeth M. Oliva

Pharmacotherapy of Alcohol Use Disorders by the Veterans Health Administration: Patterns of Receipt and Persistence

OBJECTIVE This study assessed changes since 2007 at Veterans Health Administration (VHA) facilities (N=129) in use of the medications approved by the U.S. Food and Drug Administration for treatment of alcohol use disorders. METHODS VHA data from fiscal years (FYs) 2008 and 2009 were used to identify patients with a diagnosis of an alcohol use disorder who received oral or extended-release naltrexone, disulfiram, or acamprosate as well as the proportion of days covered (PDC) in the 180 days after initiation and the time to first ten-day gap in possession (persistence) for each medication. Multilevel, mixed-effects logistic regression models examined the association between patient and facility characteristics and use of medications. RESULTS Nationally, 3.4% of VHA patients with an alcohol use disorder received medications in FY 2009 (11,165 of 331,635 patients), up from 3.0% in FY 2007. Use of medications by patients at the facilities ranged from 0% to 12%. In fully adjusted analyses, facilities offering evening and weekend services had higher rates of medication receipt, but other facility characteristics, such as having prescribers on the addiction programs staff or using medication to treat opioid or tobacco dependence, were unrelated to medication receipt. The mean PDC of acamprosate was significantly lower than mean PDCs of the other medications (p<.05), and persistence in use of naltrexone was significantly greater than use of acamprosate and significantly less than use of disulfiram (p<.05). CONCLUSIONS Use of these medications is increasing but remains variable across the VHA system. Interventions are needed to optimize initiation of and persistence in use of these medications.

Barriers to Use of Pharmacotherapy for Addiction Disorders and How to Overcome Them

Substance use disorders are highly prevalent, debilitating conditions for which effective pharmacotherapies exist with a broad evidence base, yet pharmacotherapy for the treatment of addiction disorders is underutilized. The goals of this review are to describe the barriers that may contribute to poor adoption and utilization of pharmacotherapy for alcohol and opioid dependence at the system, provider, and patient level and to discuss ways to overcome those barriers. Multifaceted efforts directed at all three levels may be needed to speed pharmacotherapy adoption. More research is needed to help us better understand barriers from patients’ perspectives. Strategies to promote adoption of pharmacotherapy for addiction disorders should be modified to fit the needs of the practice, system, and individual patients. Pharmacotherapy is a valuable tool in the clinical armamentarium of addiction treatment; thus, overcoming barriers to implementation may improve clinical and social outcomes.

Pharmacotherapy for alcohol dependence: perceived treatment barriers and action strategies among Veterans Health Administration service providers.

Although access to and consideration of pharmacological treatments for alcohol dependence are consensus standards of care, receipt of these medications by patients is generally rare and highly variable across treatment settings. The goal of the present project was to survey and interview the clinicians, managers, and pharmacists affiliated with addiction treatment programs within Veterans Health Administration (VHA) facilities to learn about their perceptions of barriers and facilitators regarding greater and more reliable consideration of pharmacological treatments for alcohol dependence. Fifty-nine participants from 19 high-adopting and 11 low-adopting facilities completed the survey (facility-level response rate = 50%) and 23 participated in a structured interview. The top 4 barriers to increased consideration and use of pharmacotherapy for alcohol dependence were consistent across high- and low-adopting facilities and included perceived low patient demand, pharmacy procedures or formulary restrictions, lack of provider skills or knowledge regarding pharmacotherapy for alcohol dependence, and lack of confidence in treatment effectiveness. Low patient demand was rated as the most important barrier for oral naltrexone and disulfiram, whereas pharmacy or formulary restrictions were rated as the most important barrier for acamprosate and extended-release naltrexone. The 4 strategies rated across low- and high-adopting facilities as most likely to facilitate consideration and use of pharmacotherapy for alcohol dependence were more education to patients about existing medications, more education to health care providers about medications, increased involvement of physicians in treatment for alcohol dependence, and more compelling research on existing medications. This knowledge provides a foundation for designing, deploying, and evaluating targeted implementation efforts.

Trends in Opioid Agonist Therapy in the Veterans Health Administration: Is Supply Keeping up with Demand?

Background: Opioid agonist therapy (OAT) through addiction specialty clinic settings (clinic-based OAT) using methadone or buprenorphine or office-based settings using buprenorphine (office-based OAT) is an evidence-based treatment for opioid dependence. The low number of clinic-based OATs available to veterans (N = 53) presents a barrier to OAT access; thus, the expansion in office-based OAT has been encouraged. Objectives: To examine trends in office-based OAT utilization over time and whether availability of office-based OAT improved the proportion of veterans with opioid use disorders treated with OAT. Methods: We examined Veterans Health Administration (VHA) administrative data for evidence of buprenorphine prescribing and clinic-based OAT clinic stops from October 2003 through September 2010 [fiscal years (FY) 2004–2010]. Results: The number of patients receiving buprenorphine increased from 300 at 27 facilities in FY2004 to 6147 at 118 facilities in FY2010. During this time, the number of patients diagnosed with an opioid use disorder increased by 45%; however, the proportion of opioid use disorder patients receiving OAT remained relatively stable, ranging from 25% to 27%, Conclusions: Office-based OAT utilization and the number of opioid use disorder veterans treated with OAT are increasing at the same rate over time, suggesting that office-based OAT is being used to meet the growing need for OAT care. Although office-based OAT is increasingly being used within the VHA and may be one way the VHA is keeping up with the demand for OAT, more research is needed to understand how to engage a greater proportion of opioid use disorder patients in treatment.

Receipt of opioid agonist treatment in the Veterans Health Administration: Facility and patient factors

BACKGROUND Opioid agonist treatment (OAT)-through licensed clinic settings (C-OAT) using methadone or buprenorphine or office-based settings with buprenorphine (O-OAT)-is an evidence-based treatment for opioid dependence. Because of limited availability of on-site C-OAT (n=28 of 128 facilities) in the Veterans Health Administration (VHA), O-OAT use has been encouraged. This study examined OAT utilization across VHA facilities and the patient and facility factors related to variability in utilization. METHOD We examined 12 months of VHA administrative data (fiscal year [FY] 2008, October 2007 through September 2008) for evidence of OAT utilization and substance use disorder program data from an annual VHA survey. Variability in OAT utilization across facilities and patient and facility factors related to OAT utilization were examined using mixed-effects, logistic regression models. RESULTS Among 128 VHA facilities, 35,240 patients were diagnosed with an opioid use disorder. Of those, 27.3% received OAT: 22.2% received C-OAT and 5.1% received O-OAT with buprenorphine. Substantial facility-level variability in proportions of patients treated with OAT was found, ranging from 0% to 66% with 44% of facilities treating <5%. Significant patient-level predictors of OAT receipt included being male, age ≥56, and without another mental health diagnosis. Significant facility-level predictors included offering any OAT services (C-OAT or O-OAT) and specialty substance abuse treatment services on weekends. CONCLUSION In FY2008, prior to the VHA national mandate of access to buprenorphine OAT, substantial variation in the use of OAT existed, partially explained by patient- and facility-level factors. Implementation efforts should focus on increasing access to this evidence-based treatment, especially in facilities at the low end of the distribution.

Development and applications of the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients’ estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009–9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk.

Sex Differences in Chronic Pain Management Practices for Patients Receiving Opioids from the Veterans Health Administration

BACKGROUND Women experience chronic pain and use pain-related health care at higher rates than men. It is not known whether the pain-related health care female veterans receive is consistent with clinical practice guideline recommendations or whether receipt of this care differs between men and women. OBJECTIVE The aim of this study was to identify whether sex differences in chronic pain management care exist for patients served by the Veterans Health Administration (VHA). DESIGN Data on patient demographics, diagnostic criteria, and health care utilization were extracted from VHA administrative databases for fiscal year 2010 (FY10). PATIENTS Patients in this study included all VHA patients (excluding metastatic cancer patients) who received more than 90 days of a short-acting opioid medication or a long-acting opioid medication prescription in FY10 study. MEASURES Multilevel logistic regressions were conducted to identify sex differences in receipt of guideline-recommended chronic pain management. RESULTS A total of 480,809 patients met inclusion criteria. Female patients were more likely to receive most measures of guideline-recommended care for chronic pain including mental health assessments, psychotherapy, rehabilitation therapy, and pharmacy reconciliation. However, women were more likely to receive concurrent sedative prescriptions, which is inconsistent with guideline recommendations. Most of the observed sex differences persisted after controlling for key demographic and diagnostic differences. CONCLUSIONS Findings suggest that female VHA patients are more likely to receive an array of pain management practices than male patients, including both contraindicated and recommended polypharmacy. Quality improvement efforts to address underutilization of mental health and rehabilitative services for pain by male patients and polypharmacy in female patients should be considered.

The Developmental Significance of Late Adolescent Substance Use for Early Adult Functioning.

This study examines the predictive significance of late adolescent substance use groups (i.e., abstainers, experimental users, at-risk users, and abusers) for early adult adaptation. Participants (N = 159) were drawn from a prospective longitudinal study of first-born children of low-income mothers. At 17.5 years of age, participants were assigned to substance use groups on the basis of their level of substance use involvement. At 26 years, early adult competence was assessed in the areas of education, work, romantic relationships, and global adaptation. Results indicate that 17.5-year substance use group membership significantly predicted high school completion, regular involvement in a long-term romantic relationship, good or better work ethic, and good or better global adjustment at 26 years when controlling for gender; IQ; 16-year internalizing and externalizing behavior problems, parental monitoring, and peer competence; and current substance use at 26 years. Group comparisons indicate that late adolescent substance use experimenters were significantly more likely in early adulthood to have (a) a high school diploma or higher level of education compared with abstainers (OR = 8.83); (b) regular involvement in long-term romantic relationships (OR = 3.23), and good or better global adaptation (OR = 4.08) compared with at-risk users; and (c) good or better work ethic (OR = 4.04) compared with abusers. This research indicates that patterns of late adolescent substance use has implications for early adult functioning in salient developmental domains.

Correlates of Specialty Substance Use Disorder Treatment Among Female Patients in the Veterans Health Administration

We examined patient- and facility-level correlates of specialty substance use disorder (SUD) outpatient treatment receipt (at least 1 visit) and engagement (visit count) for female Veterans Health Administration patients in 2008. Overall, 33% of 15,653 females with SUD received specialty SUD outpatient treatment. Treatment receipt and engagement were positively related to being age 31 to 55, having a psychiatric comorbidity, and receiving treatment at facilities providing womens services. Additional facility-level factors related to treatment receipt were treatment at a facility with comorbid psychiatric services and more licensed psychosocial treatment providers per patient. More prescribers per patient was associated with more treatment engagement.

Medical providers' knowledge and concerns about opioid overdose education and take-home naloxone rescue kits within Veterans Affairs health care medical treatment settings

BACKGROUND Overdose from opioids is a serious public health and clinical concern. Veterans are at increased risk for opioid overdose compared with the civilian population, suggesting the need for enhanced efforts to address overdose prevention in Department of Veterans Affairs (VA) health care settings, such as primary care clinics. METHODS Prescribing providers (N = 45) completed surveys on baseline knowledge and concerns about the VA Overdose Education and Naloxone Distribution (OEND) initiative prior to attending an OEND educational training. RESULTS Survey items were grouped into 4 OEND-related categories, reflecting (1) lack of knowledge/familiarity/comfort; (2) concerns about iatrogenic effects; (3) concerns about impressions of unsafe opioid prescribing; and (4) concerns about risks of naloxone prescribing. Although certain OEND-related categories were associated with each other, concerns related to iatrogenic effects of OEND (e.g., patients will use more opioids and/or be less likely to see treatment) and lack of knowledge/familiarity/comfort with OEND were endorsed more than concerns related to giving impressions of unsafe opioid prescribing. The majority of providers endorsed the belief that those prescribing opioids to patients should be responsible for providing overdose education to those patients. System-wide naloxone prescription rates and sources increased over 320% following initiation of OEND expansion efforts, although these increases cannot be viewed as a direct result of the in-service trainings. CONCLUSIONS Findings demonstrate that some providers believe they lack knowledge of opioid overdose prevention techniques and hold concerns about OEND implementation. More training of medical providers outside substance use treatment settings is needed, with particular attention to concerns about harmful consequences resulting from the receipt of naloxone.