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The American Journal of Managed Care March 2019
Fragmented Ambulatory Care and Subsequent Emergency Department Visits and Hospital Admissions Among Medicaid Beneficiaries
Lisa M. Kern, MD, MPH; Joanna K. Seirup, MPH; Mangala Rajan, MBA; Rachel Jawahar, PhD, MPH; and Susan S. Stuard, MBA
Incorrect and Missing Author Initials in Affiliations and Authorship Information
From the Editorial Board: Austin Frakt, PhD
Austin Frakt, PhD
Implications of Eligibility Category Churn for Pediatric Payment in Medicaid
Deena J. Chisolm, PhD; Sean P. Gleeson, MD, MBA; Kelly J. Kelleher, MD, MPH; Marisa E. Domino, PhD; Emily Alexy, MPH; Wendy Yi Xu, PhD; and Paula H. Song, PhD
Factors Influencing Primary Care Providers’ Decisions to Accept New Medicaid Patients Under Michigan’s Medicaid Expansion
Renuka Tipirneni, MD, MSc; Edith C. Kieffer, PhD, MPH; John Z. Ayanian, MD, MPP; Eric G. Campbell, PhD; Cengiz Salman, MA; Sarah J. Clark, MPH; Tammy Chang, MD, MPH, MS; Adrianne N. Haggins, MD, MSc; Erica Solway, PhD, MPH, MSW; Matthias A. Kirch, MS; and Susan D. Goold, MD, MHSA, MA
Did Medicaid Expansion Matter in States With Generous Medicaid?
Alina Denham, MS; and Peter J. Veazie, PhD
Access to Primary and Dental Care Among Adults Newly Enrolled in Medicaid
Krisda H. Chaiyachati, MD, MPH, MSHP; Jeffrey K. Hom, MD, MSHP; Charlene Wong, MD, MSHP; Kamyar Nasseh, PhD; Xinwei Chen, MS; Ashley Beggin, BS; Elisa Zygmunt, MSW; Marko Vujicic, PhD; and David Grande, MD, MPA
Medicare Annual Wellness Visit Association With Healthcare Quality and Costs
Adam L. Beckman, BS; Adan Z. Becerra, PhD; Anna Marcus, BS; C. Annette DuBard, MD, MPH; Kimberly Lynch, MPH; Emily Maxson, MD; Farzad Mostashari, MD, ScM; and Jennifer King, PhD
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Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing
Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
Gender Differences in Prescribing of Zolpidem in the Veterans Health Administration
Guneet K. Jasuja, PhD; Joel I. Reisman, AB; Renda Soylemez Wiener, MD, MPH; Melissa L. Christopher, PharmD; and Adam J. Rose, MD, MSc
Cost Differential of Immuno-Oncology Therapy Delivered at Community Versus Hospital Clinics
Lucio Gordan, MD; Marlo Blazer, PharmD, BCOP; Vishal Saundankar, MS; Denise Kazzaz; Susan Weidner, MS; and Michael Eaddy, PharmD, PhD
Health Insurance Literacy: Disparities by Race, Ethnicity, and Language Preference
Victor G. Villagra, MD; Bhumika Bhuva, MA; Emil Coman, PhD; Denise O. Smith, MBA; and Judith Fifield, PhD

Common Elements in Opioid Use Disorder Guidelines for Buprenorphine Prescribing

Timothy J. Atkinson, PharmD, BCPS, CPE; Andrew J.B. Pisansky, MD, MS; Katie L. Miller, PharmD, BCPS; and R. Jason Yong, MD, MBA
This article presents a synthesis of opioid use disorder guidelines and a framework to link them to claims data and recognize higher-quality practice, monitor outcomes, and individualize intervention.
METHODS

PubMed, Embase, and Google Scholar were searched using the terms opioid use disorder, medication assisted treatment, opioid addiction, opioid dependence, and buprenorphine prescribing, filtering search results for systematic reviews and guidelines. Fifteen guidelines were initially identified, including 10 from the United States and 5 international. US guidelines were included if they specifically addressed office-based opioid treatment (OBOT) with buprenorphine and were excluded if they were written for individual states or regions, health conditions, or age groups. International guidelines were included if medications and treatment paradigms resembled practice in the United States. For example, international guidelines were excluded if they promoted pharmaceutically prepared heroin as a treatment option or if prescribing and dispensing of medication-assisted treatment (MAT) did not require a medical license. Guidelines were independently reviewed by the authors and categorized according to common themes modeled after the CDC’s “Common Elements in Guidelines for Prescribing Opioids for Chronic Pain.”11 An initial list of common elements for MAT and OBOT was created, with topics commonly proposed by the individual guidelines retained and those that seemed to be contextually unique to a particular guideline omitted. The collection of common elements was individually verified through searches of available state Medicaid and commercial medical and pharmacy claims data provided by axialHealthcare, Inc. Simple measurement strategies were sufficient for many of the common elements because they were readily identifiable in claims data. However, others required creation of definitions and application of specialized analytics.

RESULTS

Seven guidelines met inclusion criteria and were included in the summary of common elements. The 4 from the United States were those of the American Society of Addiction Medicine (ASAM),12 Substance Abuse and Mental Health Services Administration,13,14 Veterans Affairs/Department of Defense,15 and Federation of State Medical Boards.16 Three additional guidelines met inclusion criteria and represented the international community, including those of the World Health Organization,17 the British Columbia Centre on Substance Abuse,18 and the Australian Alcohol and Drug Information Services.19 The common elements are presented here as 3 separate tables and organized by themes that emerged from the MAT guidelines.

Table 112-19 compares recommendations when patients establish care with an MAT provider in an OBOT setting. Guidelines are consistent in recommending a comprehensive medical history, physical examination, mental health assessment, and independent confirmation of OUD diagnosis. A social history and a psychosocial needs assessment are also consistently recommended. Tracking these recommended assessments is not possible in claims data alone without access to the electronic health record. A unique feature in US guidelines is patient selection for OBOT versus an opioid treatment program (OTP), for which an assessment of appropriateness is recommended. OBOT is generally recommended for more stable patients who are motivated and more adherent to treatment. Severe psychiatric disorders, polydrug use, and multiple failed treatment attempts may indicate that a patient is more appropriate for an environment with increased supervision and observed dosing (ie, OTP). Although international guidelines do not reflect the structure of OBOT, they assert that more stable patients may be candidates for “carry” or take-home doses similar to OTPs, which generally require daily observed administration of medications. As the risk and complexity of treatment increase, patient placement is critical, and detailed resources like ASAM’s criteria exist to provide additional guidance.12 Examination of the common elements in Table 112-19 reveals that only a few binary outcomes (eg, new patient visits, prescriptions, or laboratory tests for OUD) can be tracked through claims data, and these are generally available with a single International Classification of Diseases, Tenth Revision, code or procedure code.

Criteria associated with treatment follow-up and monitoring are found in Table 2.12-19 There is consistency in recommended frequency of follow-up for office visits and prescription renewals: Patients are seen frequently at first and then less often over time as adherence to MAT is demonstrated. Frequency of visits may require periodic adjustment in response to changes in patient stability. Significant disagreement exists between guidelines regarding appropriate dosing of buprenorphine. As multiple buprenorphine formulations are now available with varying potency and amounts of naloxone, it should be noted that references to specific doses in the guidelines use buprenorphine-naloxone (Suboxone) as the reference standard. Guidelines agree that most patients achieve stable maintenance doses between 8 mg and 16 mg daily; however, the appropriateness of daily doses higher than 24 mg is more controversial. Some guidelines cite a lack of evidence for improved efficacy and increased risk of diversion at doses greater than 24 mg daily, whereas others indicate that some patients may require up to 32 mg daily.

Monitoring recommendations vary considerably between guidelines, with several specifically recommending verifying abstinence with the state prescription drug monitoring program (PDMP) and utilizing pill counts, but the majority of available guidelines do not provide specific recommendations in this area. Pill counts and verification PDMP queries are not available in claims data. (Please see eAppendix [available at ajmc.com] for additional details.) Guidelines are consistent in recommending urine drug testing (UDT) at baseline and frequently throughout treatment, but they begin to vary in recommendations for additional testing frequency throughout treatment. UDT utilization is readily available in claims data, but these data generally lack information on the outcome and interpretation of UDT. The recommended duration of MAT is relatively consistent across guidelines, where time limits are discouraged and patient preference is emphasized, among other factors. However, longer treatment courses are associated with improved outcomes—one guideline recommends at least 1 year of treatment14 and another recommends a minimum of 2 years.18 Follow-up visits and prescription information, including prescribed dose, are readily available in medical and pharmacy claims data that enable tracking of individual patients during treatment. Duration of treatment can be assessed, but accuracy is highly dependent on length of enrollment with a specific payer.

Table 312-19 examines common elements of nonpharmacologic treatment that are recommended to improve outcomes. Psychosocial interventions and case management are strongly recommended in every guideline. These criteria encompass numerous data elements that are available in claims. The guidelines generally agree that basic needs such as housing, employment, family, and legal concerns can significantly affect treatment and providers should be aware of available community resources. Case management or care coordination services providing assistance are increasingly utilized and/or covered by many benefits providers.20-22 Although there is consensus regarding the value of psychosocial interventions in treatment, the specific therapies recommended vary considerably. Mutual help or 12-step facilitation programs are embraced and recommended within some guidelines14 and not considered equivalent to professional psychotherapy treatment in others.12 In addition, these groups are anonymous and patient involvement is not visible in claims. Relapse is a critical indicator of successful treatment because OUD is a chronic relapsing disorder, with guideline consensus that treatment should be intensified with adjustments to follow-up frequency, length of prescription renewals, and psychosocial interventions in the event of relapse. Tracking relapse through medical claims data is elusive, but achievable, with accurate definitions of measurable related events captured through intelligent design of analytic engines. After multiple relapses despite treatment adjustments, the appropriate treatment setting may need to be reconsidered along with overall risk status. High-risk MAT patients include those with comorbid alcohol abuse, benzodiazepine use, or dependence on a sedative, hypnotic, or anxiolytic, due to their additive central nervous system depressant effects and increased risk of overdose.


 
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