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      Association of Racial/Ethnic Segregation With Treatment Capacity for Opioid Use Disorder in Counties in the United States

      research-article
      , BA 1 , , MD, MPH 2 , , DrPH 3 , , MD, MEd 4 , , MD, MPH, MS 5 , 6 , , PhD 1 ,
      JAMA Network Open
      American Medical Association

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          Key Points

          Question

          Does county-level capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation?

          Findings

          In this cross-sectional study of all 3142 counties or county-equivalent units in the US in 2016, counties with highly segregated African American and Hispanic/Latino communities had more facilities to provide methadone per capita, while counties with highly segregated white communities had more facilities to provide buprenorphine per capita.

          Meaning

          These findings suggest that policy reforms are warranted to ensure equal access to both methadone and buprenorphine among all patients with opioid use disorder.

          Abstract

          This cross-sectional study examines the associations of racial/ethnic segregation with county-level availability of methadone and buprenorphine in the US.

          Abstract

          Importance

          Treatment with methadone or buprenorphine is the current standard of care for opioid use disorder. Given the paucity of research identifying which patients will respond best to which medication, both medications should be accessible to all patients so that patients can determine which works best for them. However, given differences in the historical contexts of their initial implementation, access to each of these medications may vary along racial/ethnic lines.

          Objective

          To examine the extent to which capacity to provide methadone and buprenorphine vary with measures of racial/ethnic segregation.

          Design, Setting, and Participants

          This cross-sectional study included all counties and county-equivalent divisions in the US in 2016. Data on racial/ethnic population distribution were derived from the American Community Survey, and data on locations of facilities providing methadone and buprenorphine were obtained from Substance Abuse and Mental Health Services Administration databases. Data were analyzed from August 22, 2018, to September 11, 2019.

          Exposures

          Two county-level measures of racial/ethnic segregation, including dissimilarity (representing the proportion of African American or Hispanic/Latino residents who would need to move census tracts to achieve a uniform spatial distribution of the population by race/ethnicity) and interaction (representing the probability that an African American or Hispanic/Latino resident will interact with a white resident and vice versa, assuming random mixing across census tracts).

          Main Outcomes and Measures

          County-level capacity to provide methadone or buprenorphine, defined as the number of facilities providing a medication per 100 000 population.

          Results

          Among 3142 US counties, there were 1698 facilities providing methadone (0.6 facilities per 100 000 population) and 18 868 facilities providing buprenorphine (5.9 facilities per 100 000 population). Each 1% decrease in probability of interaction of an African American resident with a white resident was associated with 0.6 more facilities providing methadone per 100 000 population. Similarly, each 1% decrease in probability of interaction of a Hispanic/Latino resident with a white resident was associated with 0.3 more facilities providing methadone per 100 000 population. Each 1% decrease in the probability of interaction of a white resident with an African American resident was associated with 8.17 more facilities providing buprenorphine per 100 000 population. Similarly, each 1% decrease in the probability of interaction of a white resident with a Hispanic/Latino resident was associated with 1.61 more facilities providing buprenorphine per 100 000 population.

          Conclusions and Relevance

          These findings suggest that the racial/ethnic composition of a community was associated with which medications residents would likely be able to access when seeking treatment for opioid use disorder. Reforms to existing regulations governing the provisions of these medications are needed to ensure that both medications are equally accessible to all.

          Related collections

          Most cited references23

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          Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

          This comparative effectiveness research study examines associations between opioid use disorder treatment pathways and overdose and opioid-related acute care use as proxies for opioid use disorder recurrence. Question What is the real-world effectiveness of different treatment pathways for opioid use disorder? Findings In this comparative effectiveness research study of 40 885 adults with opioid use disorder that compared 6 different treatment pathways, only treatment with buprenorphine or methadone was associated with reduced risk of overdose and serious opioid-related acute care use compared with no treatment during 3 and 12 months of follow-up. Meaning Methadone and buprenorphine were associated with reduced overdose and opioid-related morbidity compared with opioid antagonist therapy, inpatient treatment, or intensive outpatient behavioral interventions and may be used as first-line treatments for opioid use disorder. Importance Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. Objective To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and Participants This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. Exposures One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and Measures Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. Results A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and Relevance Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.
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            Management of opioid use disorder in the USA: present status and future directions

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              Geographic Distribution of Providers With a DEA Waiver to Prescribe Buprenorphine for the Treatment of Opioid Use Disorder: A 5-Year Update

              Opioid use disorder (OUD) is a substantial public health problem. Buprenorphine is an effective medication-assisted treatment (MAT) for OUD, but access is difficult for patients, especially in rural locations. To improve access, the Comprehensive Addiction and Recovery Act of 2016 extended the ability to get a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine to treat OUD to nurse practitioners (NPs) and physician assistants (PAs). This study summarizes the geographic distribution of waivered physicians, NPs, and PAs at the end of 2017 and compares it to the distribution of waivered physicians 5 years earlier.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                22 April 2020
                April 2020
                22 April 2020
                : 3
                : 4
                : e203711
                Affiliations
                [1 ]Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
                [2 ]Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
                [3 ]Department of Population Health, New York University School of Medicine, New York
                [4 ]Department of Emergency Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
                [5 ]Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts
                [6 ]Grayken Center for Addiction Medicine, Boston Medical Center, Boston, Massachusetts
                Author notes
                Article Information
                Accepted for Publication: February 29, 2020.
                Published: April 22, 2020. doi:10.1001/jamanetworkopen.2020.3711
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Goedel WC et al. JAMA Network Open.
                Corresponding Author: Brandon D. L. Marshall, PhD, Department of Epidemiology, Brown University School of Public Health, 121 S Main St, Box G-S121-2, Providence, RI 02912 ( brandon_marshall@ 123456brown.edu ).
                Author Contributions: Mr Goedel and Dr Marshall had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: Goedel, Shapiro, Tsai, Marshall.
                Acquisition, analysis, or interpretation of data: Goedel, Cerda, Tsai, Hadland, Marshall.
                Drafting of the manuscript: Goedel, Shapiro, Tsai.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Goedel, Tsai.
                Obtained funding: Marshall.
                Administrative, technical, or material support: Shapiro, Marshall.
                Supervision: Cerda, Marshall.
                Conflict of Interest Disclosures: Dr Marshall reported receiving grants from the National Institutes of Health during the conduct of the study and outside the submitted work. No other disclosures were reported.
                Funding/Support: This research was conducted with support from Center for Biomedical Research Excellence (COBRE) on Opioids and Overdose at the Rhode Island Hospital funded by the National Institute of General Medical Sciences (P20GM125507; Principal investigator, Josiah D. Rich, MD). In addition, Mr Goedel is supported by awards from the National Institute of Mental Health (R25MH083620 and F31MH121112) and Dr Hadland is supported by awards from the National Institute on Drug Abuse (K23DA045085 and L40DA042434), the Thrasher Research Fund’s Early Career Award, and the American Pediatric Association’s Young Investigator Award.
                Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Article
                zoi200173
                10.1001/jamanetworkopen.2020.3711
                7177200
                32320038
                478359bf-089e-424f-8a89-491c76db3b67
                Copyright 2020 Goedel WC et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 11 September 2019
                : 29 February 2020
                Categories
                Research
                Original Investigation
                Online Only
                Substance Use and Addiction

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