Mark J. Sorbero

The impact of buprenorphine on treatment of opioid dependence in a Medicaid population: Recent service utilization trends in the use of buprenorphine and methadone

BACKGROUND Buprenorphine provides an important option for individuals with opioid dependence who are unwilling or unable to attend a licensed methadone opioid agonist treatment program to receive opioid agonist therapy (OAT). Little empirical information is available, however, about the extent to which buprenorphine has increased the percentage of opioid dependent individuals receiving OAT, nor to what extent buprenorphine is being used in office based settings. METHODS Using administrative data from the largest Medicaid managed behavioral health organization in a large mid-Atlantic state, we used multivariate regression to examine rates and predictors of opioid agonist use and treatment setting for 14,386 new opioid dependence treatment episodes during 2007-2009. RESULTS Despite an increase in the use of buprenorphine, the percentage of new treatment episodes involving OAT is unchanged due to a decrease in the percentage of episodes involving methadone. Use of buprenorphine was significantly more common in rural communities, and 64% of buprenorphine use was in office-based settings. CONCLUSION Buprenorphine use has increased in recent years, with the greatest use in rural communities and in office based settings. However, the percentage of new opioid dependence treatment episodes involving an opioid agonist is unchanged, suggesting the need for further efforts to increase buprenorphine use among urban populations.

Supply of buprenorphine waivered physicians: The influence of state policies

Buprenorphine, an effective opioid use disorder treatment, can be prescribed only by buprenorphine-waivered physicians. We calculated the number of buprenorphine-waivered physicians/100,000 county residents using 2008-11 Buprenorphine Waiver Notification System data, and used multivariate regression models to predict number of buprenorphine-waivered physicians/100,000 residents in a county as a function of county characteristics, state policies and efforts to promote buprenorphine use. In 2011, 43% of US counties had no buprenorphine-waivered physicians and 7% had 20 or more waivered physicians. Medicaid funding, opioid overdose deaths, and specific state guidance for office-based buprenorphine use were associated with more buprenorphine-waivered physicians, while encouraging methadone programs to promote buprenorphine use had no impact. Our findings provide important empirical information to individuals seeking to identify effective approaches to increase the number of physicians able to prescribe buprenorphine.

Use of a computerized medication shared decision making tool in community mental health settings: Impact on psychotropic medication adherence.

Healthcare reform emphasizes patient-centered care and shared decision-making. This study examined the impact on psychotropic adherence of a decision support center and computerized tool designed to empower and activate consumers prior to an outpatient medication management visit. Administrative data were used to identify 1,122 Medicaid-enrolled adults receiving psychotropic medication from community mental health centers over a two-year period from community mental health centers. Multivariate linear regression models were used to examine if tool users had higher rates of 180-day medication adherence than non-users. Older clients, Caucasian clients, those without recent hospitalizations, and those who were Medicaid-eligible due to disability had higher rates of 180-day medication adherence. After controlling for sociodemographics, clinical characteristics, baseline adherence, and secular changes over time, using the computerized tool did not affect adherence to psychotropic medications. The computerized decision tool did not affect medication adherence among clients in outpatient mental health clinics. Additional research should clarify the impact of decision-making tools on other important outcomes such as engagement, patient-prescriber communication, quality of care, self-management, and long-term clinical and functional outcomes.

Growth In Buprenorphine Waivers For Physicians Increased Potential Access To Opioid Agonist Treatment, 2002–11

Opioid use disorders are a significant public health problem, affecting two million people in the United States. Treatment with buprenorphine, methadone, or both is predominantly offered in methadone clinics, yet many people do not receive the treatment they need. In 2002 the Food and Drug Administration approved buprenorphine for prescription by physicians who completed a course and received a waiver from the Drug Enforcement Administration, exempting them from requirements in the Controlled Substances Act. To determine the waiver programs impact on the availability of opioid agonist treatment, we analyzed data for the period 2002-11 to identify counties with opioid treatment shortages. We found that the percentage of counties with a shortage of waivered physicians fell sharply, from 98.9 percent in 2002 to 46.8 percent in 2011. As a result, the percentage of the US population residing in what we classified as opioid treatment shortage counties declined from 48.6 percent in 2002 to 10.4 percent in 2011. These findings suggest that the increase in waivered physicians has dramatically increased potential access to opioid agonist treatment. Policy makers should focus their efforts on further increasing the number and geographical distribution of physicians, particularly in more rural counties, where prescription opioid misuse is rapidly growing.

Where Is Buprenorphine Dispensed to Treat Opioid Use Disorders? The Role of Private Offices, Opioid Treatment Programs, and Substance Abuse Treatment Facilities in Urban and Rural Counties

POLICY POINTS Buprenorphine is an effective opioid dependence treatment that has expanded access to care since its 2002 approval, but it can only be prescribed by physicians waivered to treat a limited number of individuals. We examined the impact of 2006 legislation that increased waivered physician patient limits from 30 to 100 on buprenorphine use, and found that 100-patient-waivered physicians were significantly associated with growth in buprenorphine use, with no such relationship for 30-patient-waivered physicians. Policies relaxing patient limits may be more effective in increasing buprenorphine use than alternatives such as opening new substance abuse treatment facilities or increasing the overall number of waivered physicians. CONTEXT Opioid use disorders are a significant public health problem. In 2002, the FDA approved buprenorphine as an opioid use disorder treatment when prescribed by waivered physicians who were limited to treating 30 patients at a time. In 2006, federal legislation raised this number to 100 patients. Although federal legislators are considering increasing these limits further and expanding prescribing privileges to nonphysicians, little information is available regarding the impact of such changes on buprenorphine use. We therefore examined the impact of the 2006 legislation-as well as the association between urban and rural waivered physicians, opioid treatment programs, and substance abuse treatment facilities-on buprenorphine distributed per capita over the past decade. METHODS Using 2004-2011 state-level data on buprenorphine dispensed and county-level data on the number of buprenorphine-waivered physicians and substance abuse treatment facilities using buprenorphine, we estimated a multivariate ordinary least squares regression model with state fixed effects of a states annual total buprenorphine dispensed per capita as a function of the states number of buprenorphine providers. FINDINGS The amount of buprenorphine dispensed has been increasing at a greater rate than the number of buprenorphine providers. The number of physicians waivered to treat 100 patients with buprenorphine in both rural and urban settings was significantly associated with increased amounts of buprenorphine dispensed per capita. There was no significant association in the growth of buprenorphine distributed and the number of physicians with 30-patient waivers. CONCLUSIONS The greater amounts of buprenorphine dispensed are consistent with the potentially greater use of opioid agonists for opioid use disorder treatment, though they also make their misuse more likely. The changes after the 2006 legislation suggest that policies focused on increasing the number of patients that a single waivered physician could safely and effectively treat could be more effective in increasing buprenorphine use than would alternatives such as opening new substance abuse treatment facilities or raising the overall number of waivered physicians.

Predictors of adequate depression treatment among Medicaid-enrolled adults.

OBJECTIVE To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment. DATA SOURCE Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008. STUDY DESIGN We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098). PRINCIPAL FINDINGS Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment. CONCLUSIONS Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.

Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment

Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment Buprenorphine, a medication effective in treating individuals with opioid use disorders,1 can be prescribed in the United States by addiction specialists or by physicians who complete an 8-hour course and obtain a US Drug Enforcement Administration waiver. Waivered prescribers have been restricted to treating up to 30 patients with an opioid use disorder concurrently; after a year, physicians could request that the limit be increased to 100 patients. Policy makers have prioritized increasing capacity to provide buprenorphine to fight the opioid epidemic but lack adequate information about how to do so effectively. Patient censuses of buprenorphine prescribers were examined to provide information on whether patient limits have been a barrier to buprenorphine treatment.

The Effects of Prior Authorization Policies on Medicaid-Enrolled Children's Use of Antipsychotic Medications: Evidence from Two Mid-Atlantic States

OBJECTIVE The purpose of this study was to examine the impact of prior authorization policies on the receipt of antipsychotic medication for Medicaid-enrolled children. METHODS Using de-identified administrative Medicaid data from two large, neighboring, mid-Atlantic states from November 2007 through June 2011, we identified subjects <18 years of age using antipsychotics, from the broader group of children and adolescents receiving behavioral health services or any psychotropic medication. Prior authorization for antipsychotics was required for children in State A <6 years of age from September 2008, and for children <13 years of age from August 2009. No such prior authorizations existed in State B during that period. Filled prescriptions were identified in the data using national drug codes. Using a triple-difference strategy (using differences among the states, time periods, and differences in antidepressant prescribing rates among states over the same time periods), we examined the effect of the prior authorization policy on the rate at which antipsychotic prescriptions were filled for Medicaid-enrolled children and adolescents. RESULTS The impact of prior authorization policies on antipsychotic medication use varied by age: Among 6-12 year old children, the impact of the prior authorization policy on antipsychotic medication prescribing was a modest but statistically significant decrease of 0.47% after adjusting for other factors; there was no effect of the prior authorization among children 0-5 years. CONCLUSIONS Prior authorization policies had a modest but statistically significant effect on antipsychotic use in 6-12 year old children, but had no impact in younger children. Future research is needed to understand the utilization and clinical effects of prior authorization and other policies and interventions designed to influence antipsychotic use in children.

Opioid analgesic and benzodiazepine prescribing among Medicaid-enrollees with opioid use disorders: The influence of provider communities.

ABSTRACT Opioid analgesic and benzodiazepine use in individuals with opioid use disorders can increase the risk for medical consequences and relapse. Little is known about rates of use of these medications or prescribing patterns among communities of prescribers. The goal of this study was to examine rates of prescribing to Medicaid-enrollees in the calendar year after an opioid use disorder diagnosis, and to examine individual, county, and provider community factors associated with such prescribing. 2008 Medicaid claims data were used from 12 states to identify enrollees diagnosed with opioid use disorders, and 2009 claims data were used to identify rates of prescribing of each drug. Social network analysis was used to identify provider communities, and multivariate regression analyses was used to to identify patient, county, and provider community level factors associated with prescribing these drugs. The authors also examined variation in rates of prescribing across provider communities. Among Medicaid-enrollees identified with an opioid use disorder, 45% filled a prescription for an opioid analgesic, 37% filled a prescription for a benzodiazepine, and 21% filled a prescription for both in the year following their diagnosis. Females, older individuals, individuals with pain syndromes, and individuals residing in counties with higher rates of poverty were more likely to fill prescriptions. Prescribing rates varied substantially across provider communities, with rates in the highest quartile of prescribing communities over 2.5 times the rates in the lowest prescribing communities. Prescribing opioid analgesics and benzodiazepines to individuals diagnosed with opioid use disorders may increase risk of relapse and overdose. Interventions should be considered that target provider communities with the highest rates of prescribing and individuals at the highest risk.

Impact of a Private Health Insurance Mandate on Public Sector Autism Service Use in Pennsylvania.

OBJECTIVE Many states have implemented regulations (commonly referred to as waivers) to increase access to publicly insured services for autism spectrum disorders (ASD). In recent years, several states have passed legislation requiring improved coverage for ASD services by private insurers. This study examines the impact of such legislation on use of Medicaid-funded ASD services. METHOD We used Medicaid claims data from July 1, 2006, through June 30, 2010, to identify children with ASD and to assess their use of behavioral health services and psychotropic medications. Service and medication use were examined in four consecutive 12-month periods: the 2 years preceding passage of the legislation, the year after passage but before implementation, and the year after implementation. We examined differences in use of services and medications, and used growth rates from nonwaiver children to estimate the impact of the legislation on Medicaid spending for waiver-eligible children with ASD. RESULTS The number of children with ASD receiving Medicaid services increased 20% from 2006-2007 to 2009-2010. The growth rate among children affected by the legislation was comparable to that of other groups before passage of the legislation but decreased after the legislations passage. We project that, without the legislation, growth in this population would have been 46% greater in 2009-2010 than observed, associated with spending of more than