Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019.
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ABSTRACT: Background
Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration.Methods
We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive statistics to summarize aspects of our sample and logistic regression to identify predictors of MOUD receipt during incarceration.Results
Of the 279 pregnant people with OUD included in the analysis, only 40.1% (n = 112) received MOUD during incarceration, including 67 (59.8%) who received methadone and 45 (40.1%) who received buprenorphine. Less than one-third of the participants were referred to a community MOUD provider (n = 83, 30%) on return to the community. Significant predictors of MOUD receipt included medium/close custody level during incarceration, incarceration during the latter portion of the study period, pre-incarceration heroin use, and receipt of pre-incarceration MOUD.Conclusions
Although prisons can serve as an important site of retention in MOUD for some pregnant people, there were substantial gaps in initiation of MOUD and retention in MOUD among pregnant people with OUD imprisoned in the Southeast during the study period.
SUBMITTER: Knittel AK
PROVIDER: S-EPMC8946772 | biostudies-literature | 2022 Mar
REPOSITORIES: biostudies-literature
Publications
Medications for opioid use disorder during pregnancy: Access and continuity in a state women's prison facility, 2016-2019.
Knittel Andrea K AK Swartzwelder Rita A RA Zarnick Samantha S Tsujimoto Tamy Harumy Moraes THM Horne Timelie T Lin Feng-Chang FC Edwards James J Amos Elton E Alexander James J Thorp John J Jones Hendree E HE
Drug and alcohol dependence 20220115
<h4>Background</h4>Although medications to treat opioid use disorder (MOUD) are the standard of care during pregnancy, there are many potential gaps in the cascade of care for pregnant people experiencing incarceration.<h4>Methods</h4>We conducted a retrospective cohort study of pregnant people with opioid use disorder incarcerated in a Southeastern women's prison from 2016 to 2019. The primary outcomes were access to MOUD during incarceration and continuity in the community. We used descriptive ...[more]
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Project description:BackgroundGiven the personal and public consequences of untreated/undertreated OUD among persons involved in the justice system, an increasing number of jails and prisons are incorporating medication for opioid use disorder (MOUD) into their system. Estimating the costs of implementing and sustaining a particular MOUD program is vital to detention facilities, which typically face modest, fixed health care budgets. We developed a customizable budget impact tool to estimate the implementation and sustainment costs of numerous MOUD delivery models for detention facilities.MethodsThe aim is to describe the tool and present an application of a hypothetical MOUD model. The tool is populated with resources required to implement and sustain various MOUD models in detention facilities. We identified resources via micro-costing techniques alongside randomized clinical trials. The resource-costing method is used to assign values to resources. Resources/costs are categorized as (a) fixed, (b) time-dependent, and (c) variable. Implementation costs include (a), (b), and (c) over a specified timeframe. Sustainment costs include (b) and (c). The MOUD model example entails offering all three FDA-approved medications, with methadone and buprenorphine provided by vendors, and naltrexone by the jail/prison facility.ResultsFixed resources/costs are incurred only once, including accreditation fees and trainings. Time-dependent resources/costs are recurring, but fixed over a given time-period; e.g., medication delivery and staff meetings. Variable resources/costs are those that are a direct function of the number of persons treated, such as the medication provided to each patient. Using nationally representative prices, we estimated fixed/sustainment costs to be $2919/patient, over 1 year. This article estimates annual sustainment costs to be $2885/patient.ConclusionThe tool will serve as a valuable asset to jail/prison leadership, policymakers, and other stakeholders interested in identifying/estimating the resources and costs associated with alternative MOUD delivery models, from the planning stages through sustainment.
| S-EPMC10084043 | biostudies-literature
Project description:ObjectiveTo assess the effectiveness of evidence-based quality improvement (EBQI) as an implementation strategy to expand the use of medications for opioid use disorder (MOUD) within nonspecialty settings.Data sources and study settingWe studied eight facilities in one Veteran Health Administration (VHA) region from October 2015 to September 2022 using administrative data.Study designInitially a pilot, we sequentially engaged seven of eight facilities from April 2018 to September 2022 using EBQI, consisting of multilevel stakeholder engagement, technical support, practice facilitation, and data feedback. We established facility-level interdisciplinary quality improvement (QI) teams and a regional-level cross-facility collaborative. We used a nonrandomized stepped wedge design with repeated cross sections to accommodate the phased implementation. Using aggregate facility-level data from October 2015 to September 2022, we analyzed changes in patients receiving MOUD using hierarchical multiple logistic regression.Data collection/extraction methodsEligible patients had an opioid use disorder (OUD) diagnosis from an outpatient or inpatient visit in the previous year. Receiving MOUD was defined as having been prescribed an opioid agonist or antagonist treatment or a visit to an opioid substitution clinic.Principal findingsThe probability of patients with OUD receiving MOUD improved significantly over time for all eight facilities (average marginal effect [AME]: 0.0057, 95% CI: 0.0044, 0.0070) due to ongoing VHA initiatives, with the probability of receiving MOUD increasing by 0.577 percentage points, on average, each quarter, totaling 16 percentage points during the evaluation period. The seven facilities engaging in EBQI experienced, on average, an additional 5.25 percentage point increase in the probability of receiving MOUD (AME: 0.0525, 95%CI: 0.0280, 0.0769). EBQI duration was not associated with changes.ConclusionsEBQI was effective for expanding access to MOUD in nonspecialty settings, resulting in increases in patients receiving MOUD exceeding those associated with temporal trends. Additional research is needed due to recent MOUD expansion legislation.
| S-EPMC11540584 | biostudies-literature
Project description:BackgroundDespite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted.MethodsGuided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies.ResultsInterviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes-including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators' perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving.ConclusionsThis study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time.
| S-EPMC9207874 | biostudies-literature
Project description:ImportanceGiven that COVID-19 and recent natural disasters exacerbated the shortage of medication for opioid use disorder (MOUD) services and were associated with increased opioid overdose mortality, it is important to examine how a community's ability to respond to natural disasters and infectious disease outbreaks is associated with MOUD access.ObjectiveTo examine the association of community vulnerability to disasters and pandemics with geographic access to each of the 3 MOUDs and whether this association differs by urban, suburban, or rural classification.Design, setting, and participantsThis cross-sectional study of zip code tabulation areas (ZCTAs) in the continental United States excluding Washington, DC, conducted a geospatial analysis of 2020 treatment location data.ExposuresSocial vulnerability index (US Centers for Disease Control and Prevention measure of vulnerability to disasters or pandemics).Main outcomes and measuresDrive time in minutes from the population-weighted center of the ZCTA to the ZCTA of the nearest treatment location for each treatment type (buprenorphine, methadone, and extended-release naltrexone).ResultsAmong 32 604 ZCTAs within the continental US, 170 within Washington, DC, and 20 without an urban-rural classification were excluded, resulting in a final sample of 32 434 ZCTAs. Greater social vulnerability was correlated with longer drive times for methadone (correlation, 0.10; 95% CI, 0.09 to 0.11), but it was not correlated with access to other MOUDs. Among rural ZCTAs, increasing social vulnerability was correlated with shorter drive times to buprenorphine (correlation, -0.10; 95% CI, -0.12 to -0.08) but vulnerability was not correlated with other measures of access. Among suburban ZCTAs, greater vulnerability was correlated with both longer drive times to methadone (correlation, 0.22; 95% CI, 0.20 to 0.24) and extended-release naltrexone (correlation, 0.15; 95% CI, 0.13 to 0.17).Conclusions and relevanceIn this study, communities with greater vulnerability did not have greater geographic access to MOUD, and the mismatch between vulnerability and medication access was greatest in suburban communities. Rural communities had poor geographic access regardless of vulnerability status. Future disaster preparedness planning should match the location of services to communities with greater vulnerability to prevent inequities in overdose deaths.
| S-EPMC9020217 | biostudies-literature
Project description:ImportanceIdentifying prescription needs of adults returning from prison can inform intervention design to mitigate high morbidity and mortality during reentry to the community.ObjectiveTo characterize the prevalence and factors associated with continuity of medication use for treatment of chronic illness among adults returning to the community from prison.Design, setting, and participantsThis retrospective cohort study linked administrative records and prescription claims from the Wisconsin Department of Corrections and the Medicaid program. The study included all adults (aged 18-64 years) released from a Wisconsin state correctional facility between April 1, 2015, and June 30, 2017, after incarceration of at least 31 days who enrolled in Medicaid within the month of release. Analyses were conducted between May 2022 and May 2024.ExposureReceipt of a prescription medication commonly used for treatment of certain chronic conditions during the last 3 months of incarceration.Main outcomes and measuresThe primary outcome was medication continuity, which was defined as having a prescription medication claim in the first 6 months after release that was within the same chronic condition therapeutic class as the medication received during the last 3 months of incarceration.ResultsThis cohort study included 13 792 individual releases representing 12 960 individuals from the Wisconsin state prison system who immediately enrolled in Medicaid upon release. These individuals had a mean (SD) age of 35.5 (10.5) years; 89.5% were male. In terms of race, 38.5% of individuals were Black and 57.2% were White. For one-third of individual Medicaid-enrolled releases (4302 [31.2%]), the individual received a prescription medication for a chronic condition. Prescription continuity was observed for 51.7%, with variability across drug class ranging from less than 20.0% to 71.6%. Classes with the highest continuity (eg, thyroid agents) were also those that treated serious chronic conditions, although gaps between realized and clinically recommended care remained. Continuity varied by race, sex, and age. Individuals with continuity were more likely to have had an outpatient visit in the 6 months following release than those without continuity (93.9% vs 55.6%; P < .001) despite similar Medicaid enrollment.Conclusions and relevanceIn this study, prescription continuity between prison release and the community was limited, even for drugs with high clinical need and relevance for population health and especially among individuals who did not receive outpatient care in the 6 months post incarceration. These findings suggest that effective transitional care interventions may need to include increased emphasis on connecting with clinicians.
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Project description:ObjectiveTo identify geographic disparities in access to opioid use disorder (OUD) treatment medications and county demographic and economic characteristics associated with access to buprenorphine and oral naltrexone prescribers in Medicare Part D.Data sources/study settingWe utilized data from the Medicare Part D Prescription Drug Event Standard Analytic File (2010-2015).Study design/data collectionWe used logistic regression to examine county-level access to OUD medication prescribers.Principal findingsThere was a 5.6 percentage point increase in counties with access to an OUD prescriber over the study period. However, in 2015, 60 percent of US counties lacked access to a Medicare Part D buprenorphine prescriber and over 75 percent lacked access to an oral naltrexone prescriber. Increased access to OUD prescribers was largely concentrated in urban counties. Results of logistic regression indicate regional differences and potential racial disparities in access to OUD prescribers.ConclusionsTo improve access to buprenorphine and naltrexone treatment for Medicare Part D enrollees, CMS may consider implementing educational and training initiatives focused on OUD treatment, offering training to obtain a buprenorphine waiver at no cost to providers, and sending targeted information to providers in low OUD treatment capacity areas.
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Project description:AimTo test the effect of the duration of medication for opioid use disorder (MOUD) use during pregnancy on maternal, perinatal and neonatal outcomes.DesignRetrospective cohort analysis of claims, encounter and pharmacy data.SettingPennsylvania, USA.ParticipantsWe analyzed 13 320 pregnancies among 10 741 women with opioid use disorder aged 15-44 years enrolled in Pennsylvania Medicaid between 2009 and 2017.MeasurementsWe examined five outcomes during pregnancy and for 12 weeks postpartum: (1) overdose, (2) postpartum MOUD continuation, (3) preterm birth (< 37 weeks gestation), (4) term low birth weight (< 2500 g at ≥ 37 weeks) and (5) neonatal abstinence syndrome (NAS). Our primary exposure was the duration (count of weeks) of any MOUD use, including methadone or buprenorphine, during pregnancy.FindingsAmong 13 320 pregnancies, 306 (2.3%) were complicated by an overdose, 1753 (13.2%) resulted in a preterm birth and 6787 (50.9%) continued MOUD postpartum. Among infants, 874 (7.6%) were low birth weight at term and 7706 (57.9%) were diagnosed with NAS. As the duration of MOUD use increased, we found a statistically significant decrease in the rate of overdose and preterm birth, a statistically significant increase in the rate of postpartum MOUD continuation and NAS and a decline in term low birth weight. Specifically, for each additional week of MOUD, the adjusted odds of overdose decreased by 2% [adjusted odds ratio (aOR) = 0.98; 95% confidence interval (CI) = 0.97, 0.99], preterm birth decreased by 1% (aOR = 0.99; 95% CI = 0.99, 1.00), postpartum MOUD continuation increased by 95% (aOR = 1.95; 95% CI = 1.87, 2.04) and NAS increased by 41% (aOR = 1.41; 95% CI = 1.35, 1.47). The odds of term low birth weight did not change (aOR = 1.00; 95% CI = 0.99, 1.00), although the rate declined with a longer duration of MOUD use during pregnancy.ConclusionsLonger duration of medication for opioid use disorder use during pregnancy appears to be associated with improved maternal and perinatal outcomes.
| S-EPMC8578145 | biostudies-literature
Project description:BackgroundWe examined the impact of expanded access to medications for opioid use disorder (MOUD) in a unified prison and jail system on post-release, opioid-related overdose mortality.MethodsWe developed a microsimulation model to simulate a population of 55,000 persons at risk of opioid-related overdose mortality in Rhode Island. The effect of an extended-release (XR) naltrexone only intervention and the effect of providing access to all three MOUD (i.e., methadone, buprenorphine, and XR-naltrexone) at release from incarceration on cumulative overdose death over eight years (2017-2024) were compared to the standard of care (i.e., limited access to MOUD).ResultsIn the standard of care scenario, the model predicted 2385 opioid-related overdose deaths between 2017 and 2024. An XR-naltrexone intervention averted 103 deaths (4.3% reduction), and access to all three MOUD averted 139 deaths (5.8% reduction). Among those with prior year incarceration, an XR-naltrexone only intervention and access to all three MOUD reduced overdose deaths by 22.8% and 31.6%, respectively.ConclusionsExpanded access to MOUD in prison and jail settings can reduce overdose mortality in a general, at-risk population. However, the real-world impact of this approach will vary by levels of incarceration, treatment enrollment, and post-release retention.
| S-EPMC7790977 | biostudies-literature
Project description:BackgroundFor patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients.ObjectiveWhile Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How "Community Care," healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown.DesignData for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015-2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time.ParticipantsAll 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinics MAIN MEASURES: The average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems.Key resultsFrom 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems.ConclusionsStrategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.
| S-EPMC9870655 | biostudies-literature
Project description:ObjectiveTo document pregnancy and birthing experiences of young, Black pregnant women in one geographic area to make recommendations for improving young Black women's pregnancy and birthing experiences.MethodsParticipants were recruited through The YoungMoms Study (R01 DA04640101A1) in Pittsburgh, Pennsylvania, and included Black or biracial participants ages 16-23 (n = 25). Individual interviews were conducted from March 2022-July 2022 to assess pre-, peri-, and post-natal healthcare system encounters; experiences of structural and obstetric racism and discrimination in healthcare settings while obtaining prenatal care; attitudes around healthcare systems and medical professionals; effects of COVID-19 pandemic on participants lives and the impact of enacted healthcare policies in their perinatal experience; substance use changes during pregnancy; and coping mechanisms for stress. NVivo 13 was used to code transcripts, then major themes and subthemes were identified using thematic content analysis and based on grounded theory.ResultsTwenty-five interviews were conducted, and four themes emerged from participant experiences of racial discrimination in healthcare settings; (1) awareness of historical racism that influences perinatal care; (2) clinical providers assume participant substance use and enact reproductive coercion; (3) clinical providers question validity of Black women's birthing complaint; and (4) Young Black pregnant women know and will express what they desire in their perinatal experience if asked.ConclusionsYoung Black pregnant women encounter structural racism and intersectional bias from healthcare providers. By centering the perspectives and experiences of this overlooked population, public health researchers and clinical providers can utilize anti-racist frameworks to create more equitable, just practices in reproductive healthcare.
| S-EPMC10722556 | biostudies-literature