Dataset Information

Medication Treatment of Active Opioid Use Disorder in Veterans With Cirrhosis.

ABSTRACT:

Introduction

Although opioid use disorder (OUD) is common in patients with cirrhosis, it is unclear how medication treatment for OUD (MOUD) is used in this population. We aimed to assess the factors associated with MOUD and mortality in a cohort of Veterans with cirrhosis and OUD.

Methods

Within the Veterans Health Administration Corporate Data Warehouse, we developed a cohort of Veterans with cirrhosis and active OUD, using 2 outpatient or 1 inpatient International Classification of Diseases, ninth revision codes from 2011 to 2015 to define each condition. We assessed MOUD initiation with methadone or buprenorphine over the 180 days following the first OUD International Classification of Diseases, ninth revision code in the study period. We fit multivariable regression models to assess the association of sociodemographic and clinical factors with receiving MOUD and the associations between MOUD and subsequent clinical outcomes, including new hepatic decompensation and mortality.

Results

Among 5,600 Veterans meeting criteria for active OUD and cirrhosis, 722 (13%) were prescribed MOUD over 180 days of follow-up. In multivariable modeling, MOUD was significantly, positively associated with age (adjusted odds ratio [AOR] per year: 1.04, 95% confidence interval (CI): 1.01-1.07), hepatitis C virus (AOR = 2.15, 95% CI = 1.37-3.35), and other substance use disorders (AOR = 1.47, 95% CI = 1.05-2.04) negatively associated with alcohol use disorder (AOR = 0.70, 95% CI = 0.52-0.95), opioid prescription (AOR = 0.51, 95% CI = 0.38-0.70), and schizophrenia (AOR = 0.59, 95% CI = 0.37-0.95). MOUD was not significantly associated with mortality (adjusted hazards ratio = 1.20, 95% CI = 0.95-1.52) or new hepatic decompensation (OR = 0.57, CI = 0.30-1.09).

Discussion

Few Veterans with active OUD and cirrhosis received MOUD, and those with alcohol use disorder, schizophrenia, and previous prescriptions for opioids were least likely to receive these effective therapies.

SUBMITTER: Rogal S

PROVIDER: S-EPMC8819871 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ImportanceMedication for opioid use disorder (MOUD) is the criterion standard treatment for opioid use disorder (OUD), but nationally representative studies of MOUD use in the US are lacking.ObjectiveTo estimate MOUD use rates and identify associations between MOUD and individual characteristics among people who may have needed treatment for OUD.Design, setting, and participantsCross-sectional, nationally representative study using the 2019 National Survey on Drug Use and Health in the US. Participants included community-based, noninstitutionalized adolescent and adult respondents identified as individuals who may benefit from MOUD, defined as (1) meeting criteria for a past-year OUD, (2) reporting past-year MOUD use, or (3) receiving past-year specialty treatment for opioid use in the last or current treatment episode.Main outcomes and measuresThe main outcomes were treatment with MOUD compared with non-MOUD services and no treatment. Associations with sociodemographic characteristics (eg, age, race and ethnicity, sex, income, and urbanicity); substance use disorders; and past-year health care or criminal legal system contacts were analyzed. Multinomial logistic regression was used to compare characteristics of people receiving MOUD with those receiving non-MOUD services or no treatment. Models accounted for predisposing, enabling, and need characteristics.ResultsIn the weighted sample of 2 206 169 people who may have needed OUD treatment (55.5% male; 8.0% Hispanic; 9.9% non-Hispanic Black; 74.6% non-Hispanic White; and 7.5% categorized as non-Hispanic other, with other including 2.7% Asian, 0.9% Native American or Alaska Native, 0.2% Native Hawaiian or Pacific Islander, and 3.8% multiracial), 55.1% were aged 35 years or older, 53.7% were publicly insured, 52.2% lived in a large metropolitan area, 56.8% had past-year prescription OUD, and 80.0% had 1 or more co-occurring substance use disorders (percentages are weighted). Only 27.8% of people needing OUD treatment received MOUD in the past year. Notably, no adolescents (aged 12-17 years) and only 13.2% of adults 50 years and older reported past-year MOUD use. Among adults, the likelihood of past-year MOUD receipt vs no treatment was lower for people aged 50 years and older vs 18 to 25 years (adjusted relative risk ratio [aRRR], 0.14; 95% CI, 0.05-0.41) or with middle or higher income (eg, $50 000-$74 999 vs $0-$19 999; aRRR, 0.18; 95% CI, 0.07-0.44). Compared with receiving non-MOUD services, receipt of MOUD was more likely among adults with at least some college (vs high school or less; aRRR, 2.94; 95% CI, 1.33-6.51) and less likely in small metropolitan areas (vs large metropolitan areas, aRRR, 0.41; 95% CI, 0.19-0.93). While contacts with the health care system (85.0%) and criminal legal system (60.5%) were common, most people encountering these systems did not report receiving MOUD (29.5% and 39.1%, respectively).Conclusions and relevanceIn this cross-sectional study, MOUD uptake was low among people who could have benefited from treatment, especially adolescents and older adults. The high prevalence of health care and criminal legal system contacts suggests that there are critical gaps in care delivery or linkage and that cross-system integrated interventions are warranted.

Project description:Background and aimsWhile long-term medication-assisted treatment (MAT) using methadone or buprenorphine is associated with significantly lower all-cause mortality for individuals with opioid use disorder (OUD), periods of initiating or discontinuing treatment are associated with higher mortality risks relative to stable treatment. This study aimed to identify the OUD treatment durations necessary for the elevated mortality risks during treatment transitions to be balanced by reductions in mortality while receiving treatment.DesignSimulation model based on a compartmental model of OUD diagnosis, MAT receipt and all-cause mortality among Veterans with OUD in the United States Veterans Health Administration (VA) in 2017-2018. We simulated methadone and buprenorphine treatments of varying durations using parameters obtained through calibration and published meta-analyses of studies from North America, Europe and Australia.SettingUnited States.ParticipantsSimulated cohorts of 10 000 individuals with OUD.MeasurementsAll-cause mortality over 12 months.FindingsReceiving methadone for 4 months or longer or buprenorphine for 2 months or longer resulted in 54 [95% confidence interval (CI) = 5-90] and 65 (95% CI = 21-89) fewer deaths relative to not receiving MAT for the same duration, using VA-specific mortality rates. We estimated shorter treatment durations necessary to achieve net mortality benefits of 2 months or longer for methadone and 1 month or longer for buprenorphine, using non-VA population literature estimates. Sensitivity analyses demonstrated that necessary treatment durations increased more with smaller mortality reductions on treatment than with larger relative risks during treatment transitions.ConclusionsShort periods (< 6 months) of treatment with either methadone or buprenorphine are likely to yield net mortality benefits for people with opioid use disorder relative to receiving no medications, despite periods of elevated all-cause mortality risk during transitions into and out of treatment. Retaining people with opioid use disorder in treatment longer can increase these benefits.

Project description:Objective: Opioid use disorder (OUD) is a notable concern in the United States (US) and strongly associated with mortality. There is a high prevalence of OUD in patients with posttraumatic stress disorder (PTSD) and the mortality associated with OUD may be exacerbated in patients with PTSD. Medication-assisted treatment (MAT) for OUD has become standard of care for OUD and has been shown to reduce mortality. However, there has been little study of MAT and mortality in patients with PTSD and OUD. Methods: We conducted a retrospective cohort study in U.S. veterans who had newly engaged in PTSD treatment, were diagnosed with OUD and were provided MAT for at least one day between 2004 and 2013. We assessed mortality for one year following the index diagnosis date. We calculated all-cause mortality as well as death by external cause, overdose plus suicide, overdose, and suicide rates per 100,000. We used hazard ratios (HR) and 95% confidence intervals (CI) to compare death rates between patients with high versus low adherence to MAT. We evaluated the impact of high versus low exposure to general substance abuse care. We considered a confidence interval that did not cross one to be significant. Results: A total of 5,901 patients met inclusion criteria. Most patients were men and the average age was 43.3 years (SD = 13.8). The all-cause mortality rate was 1,370 per 100,000 patients. High adherence to MAT resulted in a non-significant, decreased risk for death due to all-cause (HR = 0.73, 95% CI [0.47, 1.13]), external cause (HR = 0.71, 95% CI [0.38, 1.35]), and overdose or suicide (HR = 0.66, 95% CI [0.33, 1.35]). Patients with high exposure (≥ 60 days) to general substance abuse care were significantly less likely to die due to external cause (HR = 0.39, 95% CI [0.18, 0.85]) and overdose or suicide (HR = 0.31, 95% CI [0.12, 0.77]). Conclusions: In patients with PTSD and OUD, improved adherence to MAT and greater exposure to general substance abuse care may result in lower mortality. Studies with longer follow-up and larger sample sizes to assess the impact of MAT on suicide are needed to confirm our findings.

Project description:BackgroundDespite the risk of negative sequelae from opioid use disorder (OUD) and clinical guidelines for the use of effective medication treatment for OUD (M-OUD), many Veterans Health Administration (VHA) providers and facilities lag in providing M-OUD. An intensive external facilitation intervention may enhance uptake in low-adopting VHA facilities by engaging stakeholders from multiple clinical settings within a facility (e.g., mental health, primary care, pain specialty clinic, substance use disorder clinics). Our study identified pre-intervention determinants of implementation through qualitative interviews, described strategies employed during the first 6 months of intensive external facilitation, and explored patterns of implementation determinants in relation to early outcomes.MethodsGuided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework, we interviewed stakeholders at low-adopting VHA facilities prior to external facilitation, employed a rapid qualitative analytic process, presented findings during facility visits, and collaboratively created facilitation action plans to achieve goals set by the facilities that would increase M-OUD uptake. The primary outcome was the Substance Use Disorder (SUD)-16, which is a VHA facility-level performance metric consisting of the percent of patients receiving M-OUD among those with an OUD diagnosis. We examined the relationship between pre-implementation factors and 6-month SUD-16 outcomes.ResultsAcross eight VHA facilities, we interviewed 68 participants. Implementation determinants included barriers and facilitators across innovation, context, and recipients constructs of i-PARIHS. Each facility selected goals based on the qualitative results. At 6 months, two facilities achieved most goals and two facilities demonstrated progress. The SUD-16 from baseline to 6 months significantly improved in two facilities (8.4% increase (95 % confidence interval [CI] 4.4-12.4) and 9.9% increase (95% CI 3.6-16.2), respectively). Six-month implementation outcomes showed that the extent to which M-OUD aligns with existing clinical practices and values was a primary factor at all facilities, with six of eight facilities perceiving it as both a barrier and facilitator. External health system barriers were most challenging for facilities with the smallest change in SUD-16.ConclusionsEarly impacts of a multi-faceted implementation approach demonstrated a strong signal for positively impacting M-OUD prescribing in low-adopting VHA facilities. This signal indicates that external facilitation can influence adoption of M-OUD at the facility level in the early implementation phase. These short-term wins experienced by stakeholders may encourage continued adoption and long-term sustainability M-OUD.

Project description:BACKGROUND:Social functioning (SF), the ability to engage with life and fulfill roles may be a salient "patient important outcome" in addiction treatment. It is not known if medication-assisted treatment (MAT) impacts SF in opioid use disorder (OUD). There is a growing evidence to suggest that men and women are impacted differently by OUD. This study is the largest to date to study sex differences in OUD and explore associations between MAT and SF. METHODS:Data were collected from 2736 participants with OUD, enrolled in MAT for varying lengths of time, in outpatient clinics across Ontario. SF was defined according to the Maudsley Addiction Profile's domains of (1) employment, (2) criminal activity, and (3) interpersonal conflict. Using logistic regression analysis, we examined sociodemographic and clinical factors associated with domains of SF. RESULTS:There were 1544 men (56%) and 1192 women (44%) in this study, and ages varied from 17 to 76 years for men and 18 to 69 years for women. At study entry, participants had been on MAT for a median of 2 years. Compared to men, women reported more psychological (mean MAP score 14/40, SD = 9.55, versus 11/40, SD = 8.64; p < 0.001) and physical symptoms (mean MAP score 17/40, SD = 7.70 versus 14/40, SD = 7.74; p < 0.001). More women reported unemployment(74% versus 58%; p < 0.0001) and interpersonal conflict (46% versus 35%; p < 0.0001). Men were more likely than women to report criminal activity (11%, versus 8%; p = 0.001). Psychological symptoms increased the risk of worse SF, across domains, for men and for women. Every year on MAT was associated with a 7% increase in the odds of women engaging with criminal activity (OR = 1.07, 95% CI 1.02, 1.12, p = 0.006). CONCLUSIONS:Men and women had different SF profiles and psychological symptoms scores while on MAT. The length of time on MAT increased the risk of criminal activity in women, and overall, duration of MAT was not associated with improvement in SF. This may suggest that MAT alone may not support continual improvements in SF in OUD.