Treatment for Co-Occurring Stimulant and Opioid Use Disorders: Overcoming Barriers in the Era of Polysubstance Use.

This Viewpoint explores the current barriers to implementing contingency management treatment for individuals experiencing both opioid use and stimulant use disorders in the context of high numbers of US overdoses.

Comparison of Treatment Receipt and Hospitalization Among Patients With Stimulant Use Disorder and/or Opioid Use Disorder in the Veterans Health Administration.

OBJECTIVES: Stimulant use is a growing problem, but little is known about service utilization among patients with stimulant use disorder (StUD). In the context of the overdose crisis, much research has focused on patients with opioid use disorder (OUD). It is unclear how the characteristics, treatment receipt, and hospitalization of patients with StUD differ from patients with OUD. METHODS: Electronic health record data were extracted for national Veterans Health Administration patients with a visit from March 1, 2020, to February 28, 2021 with StUD and/or OUD (N = 132,273). We compared patients with StUD without OUD to those with (1) co-occurring StUD + OUD and (2) OUD without StUD. Patient characteristics, substance use disorder treatment, and hospitalizations in the year following patients' first study period visit were descriptively compared. Treatment and hospitalization were also compared in adjusted regression models. RESULTS: Compared with patients with OUD + StUD, those with StUD without OUD were less likely to receive outpatient (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.47-0.50) or any treatment (aOR 0.47, 95% CI 0.46-0.49). Compared with patients with OUD without StUD, those with StUD without OUD were less likely to receive outpatient (aOR 0.51, 95% CI 0.49-0.52) or any treatment (aOR 0.56, 95% CI 0.54-0.58) and more likely to receive residential treatment (aOR 2.18, 95% 2.05-2.30) and to be hospitalized (aOR 1.62, 95% 1.56-1.69). CONCLUSIONS: Patients with StUD may be less likely to receive treatment and more likely to be hospitalized than patients with OUD. Efforts focused on mitigating hospitalization and increasing treatment receipt for patients with StUD are needed.

Association of licensure and relationship requirement waivers with out-of-state tele-mental health care, 2019-2021.

During the COVID-19 public health emergency, states waived in-state licensure and pre-existing patient-physician relationship requirements to increase access to care. We exploit this state telehealth policy variation to estimate the association of in-state licensure requirement waivers and pre-existing patient-physician relationship requirement waivers with out-of-state tele-mental health care utilization of patients diagnosed with COVID-19. Using claims from January 2019 until December 2021 of 2 037 977 commercially insured individuals in 3 metropolitan statistical areas (MSAs) straddling Midwestern state borders, we found increased out-of-state telehealth utilization as a share of out-of-state mental health care by 0.1411 and 0.0575 visits per month or 1679.76% and 467.48% after licensure and relationship waivers, respectively. Within-MSA analyses illustrate an urban-rural digital divide in out-of-state utilization as a share of total or telehealth mental health care. Our findings indicate waivers primarily enhance access to care of established patients by enabling the transition of in-person out-of-state health care online. Interstate medical licensure compact participation may provide broader access to out-of-state tele-mental health care than emergency waivers.

Contingency management for substance use disorders in the U.S. Veterans Health Administration: 2018-2022.

INTRODUCTION: Contingency management (CM) is one of the most effective interventions for substance use disorders (SUDs), including stimulant use disorder. In the United States, the Veterans Health Administration (VHA) led the largest-scale rollout of CM in the US to date, but little is known about characteristics of patients treated and CM clinical practices. METHODS: In this retrospective cohort study, we used VHA electronic health records data to descriptively examine CM treatment course (e.g., number of visits, time between visits, duration of treatment episode) and characteristics of patients receiving CM for SUDs from 2018 to 2022. RESULTS: From January 2018 to September 2022, 2844 patients received CM at 90 VA Health Systems (including 98 VA Medical Center, 7 community-based outpatient clinics, and 15 other sites). The median number of CM visits was 8 (mean = 10.17, SD = 8.12) visits over the course of 1.5 months (median = 45 days, mean = 57.46 days, SD = 62.65). The target substance was stimulants in 86.42 % of visits. Average age of patients was 52.29 years (SD = 12.10), with 55.06 % of patients experiencing homelessness or housing instability, and 97.50 % of patients diagnosed with more than one SUD. Compared to the year prior to the COVID-19 pandemic (03/2019-02/2020; mean = 957.33, SD = 157.71 visits/month), CM visits declined by 83.20 % in the year following the pandemic (03/2020-02/2021; mean = 160.83, SD = 164.14), and have yet to return to pre-pandemic levels. CONCLUSIONS: The CM rollout has been markedly successful in the VHA, with adoption across multiple VHA sites within a complex patient population, indicating the potential for effective, more widespread CM implementation. At the same time, there was a considerable reduction in CM care during the COVID-19 pandemic and CM has not yet returned to pre-pandemic levels. Moreover, only a small minority of VA patients with stimulant use disorder have received CM. Given increasing rates of overdose, including stimulant-involved overdose, it is important to increase CM provision in VHA and non-VHA settings.

Testing a new model of telehealth-delivered treatment for primary care patients with alcohol use disorder: A randomized controlled trial protocol.

BACKGROUND: The majority of adults suffering from alcohol use disorders (AUD) do not receive treatment. To address this gap in care, we must develop new models to increase identification, engagement and delivery of accessible and effective treatment. This paper describes the protocol for a randomized controlled trial (RCT) testing a novel telehealth treatment model for primary care patients with untreated AUD. METHODS: We aim to recruit 300 adults across 2 healthcare systems for this two-arm RCT. Participants, initially identified for recruitment based on AUD-related indicators in their electronic health record (EHR), are RCT-eligible if they meet AUD criteria (mild, moderate, severe), report ≥ 3 drinking days/week in past 30 days, and have not received AUD psychotherapy in the past 90 days. Participants are randomized to an intervention or enhanced usual care control (EUC) condition, both individually-delivered. The intervention includes a telephone-delivered motivational interviewing (MI) engagement session and 8 sessions of MI-Cognitive Behavioral Therapy (MI-CBT). EUC involves AUD psychoeducation, advice to reduce drinking and seek treatment, and provision of community resources. Outcomes will be measured at 3-, 6-, and 12-months; primary outcomes include: AUD psychotherapy initiation and engagement (within the study and external community) and alcohol consumption (percent drinking days and heavy drinking days). CONCLUSIONS: This study addresses whether proactive patient identification and engagement and delivery of patient-centered telehealth psychotherapy to patients with untreated AUD is effective in increasing treatment use and improving alcohol outcomes. If effective, this could be a highly scalable model for reducing the public health impact of AUD. TRIAL REGISTRATION: ClinicalTrials.gov # NCT05410561. University of Michigan HUM00204315. Ann Arbor VA IRB #1655886.

Telehealth and delivery of alcohol use disorder treatment in the Veterans Health Administration.

BACKGROUND: The use of telehealth treatment of alcohol use disorder (AUD) has increased since the start of the COVID-19 pandemic. However, it is unclear which patients are using telehealth and how telehealth visits are associated with treatment duration. This study examined characteristics associated with telehealth use among Veterans Health Administration patients receiving AUD treatment. METHODS: Using a national retrospective cohort study, we examined data from March 01, 2020 to February 28, 2021 to: First, identify patient characteristics associated with (a) any telehealth versus only in-person care for AUD treatment, and (b) video (≥1 video visit) versus only telephone visits for AUD treatment (≥1 telephone visit, no video) among any telehealth users. This analysis used mixed-effects logistic regression models to adjust for potential correlation across patients treated at the same facility. Second, we assessed whether visit modality was associated with the amount of AUD treatment received (number of AUD psychotherapy visits or medication coverage days). This analysis used mixed-effects negative binomial regression models. RESULTS: Among 138,619 patients who received AUD treatment, 52.8% had ≥1 video visit, 38.1% had ≥1 telephone but no video visits, and 9.1% had only in-person visits. In the regression analyses, patients who were male or had an opioid or stimulant use disorder (compared to having no non-AUD substance use disorder) were less likely to receive any telehealth-delivered AUD treatment compared to only in-person AUD treatment. Among patients who received any telehealth-delivered AUD treatment, those who were ≥45 years old (compared to 18-29 years old), Black (compared to White), diagnosed with a cannabis or stimulant use disorder, or diagnosed with a serious mental illness were less likely to receive a video visit than only telephone visits. Receiving any AUD telehealth was associated with receiving more psychotherapy visits and medication coverage days than only in-person care. CONCLUSIONS: Telehealth, a common modality for AUD treatment, supported a greater number of psychotherapy visits and a longer duration of medication treatment for AUD. However, some groups were less likely to receive any video telehealth than telephone visits, suggesting that multiple treatment modalities should remain available to ensure treatment access.

Inflammatory Bowel Disease Hospitalizations Are Similar for Patients Receiving Televisit-Delivered Outpatient Care and Those Receiving Traditional In-Person Care.

INTRODUCTION: The coronavirus disease 2019 pandemic resulted in widespread expansion of telehealth. However, there are concerns that telehealth-delivered outpatient care may limit opportunities for managing complications and preventing hospitalizations for patients with inflammatory bowel disease (IBD). We aimed to assess the association between outpatient IBD care delivered through televisit (video or phone) and IBD-related hospitalizations. METHODS: We conducted a case-control study of patients with IBD who had an IBD-related index hospitalization between April 2021 and July 2022 and received their care in the Veterans Health Administration. We matched these hospitalized patients to controls who were not hospitalized based on age, sex, race, Charlson comorbidity index, IBD type, IBD-related emergency department use, IBD-related hospitalizations, and outpatient gastroenterology visits in the preceding year. The variable of interest was the percentage of total clinic visits delivered through televisit in the year before the index hospitalization. We compared the risk of IBD-related hospitalization by exposure to televisit-delivered care using conditional logistic regression. RESULTS: We identified 534 patients with an IBD-related hospitalization and 534 matched controls without an IBD-related hospitalization during the study period. Patients with IBD with a higher percentage of televisit-delivered (vs in-person) outpatient care were less likely to be hospitalized during the study period (for every 10% increase in televisit use, odds ratio 0.97, 95% confidence interval 0.94-1.00; P = 0.03). DISCUSSION: Televisit-delivered outpatient IBD care is not associated with higher risk of IBD-related hospitalization. These findings may reassure clinicians that televisit-delivered outpatient care is appropriate for patients with complex chronic diseases such as IBD.

Prescriptions for Buprenorphine in Michigan Following an Education Intervention.

Importance: Buprenorphine is an underused treatment for opioid use disorder (OUD) that can be prescribed in general medical settings. Founded in 2017, the Michigan Opioid Collaborative (MOC) is an outreach and educational program that aims to address clinician and community barriers to buprenorphine access; however, the association between the MOC and buprenorphine treatment is unknown. Objective: To evaluate the association between MOC service use and county-level temporal trends of density of buprenorphine prescribers and patients receiving buprenorphine. Design, Setting, and Participants: This cohort study exploited staggered implementation of MOC services across all Michigan counties. Difference-in-difference analyses were conducted by applying linear fixed-effects regression across all counties to estimate the overall association of MOC engagement with outcomes and linear regression for each MOC-engaged county separately to infer county-specific results using data from May 2015 to August 2020. Analyses were conducted from September 2021 to November 2023. Exposures: MOC engagement. Main Outcomes and Measures: County-level monthly numbers of buprenorphine prescribers and patients receiving buprenorphine (per 100 000 population). Results: Among 83 total counties, 57 counties (68.7%) in Michigan were engaged by MOC by 2020, with 3 (3.6%) initiating engagement in 2017, 19 (22.9%) in 2018, 27 (32.5%) in 2019, and 8 (9.6%) in 2020. Michigan is made up of 83 counties with a total population size of 9 990 000. A total of 5 070 000 (50.8%) were female, 1 410 000 (14.1%) were African American or Black, 530 000 (5.3%) were Hispanic or Latino, and 7 470 000 (74.7%) were non-Hispanic White. The mean (SD) value of median age across counties was 44.8 (6.4). The monthly increases in buprenorphine prescriber numbers in the preengagement (including all time points for nonengaged counties) and postengagement periods were 0.07 and 0.39 per 100 000 population, respectively, with the absolute difference being 0.33 (95% CI, 0.12-0.53) prescribers per 100 000 population (P = .002). The numbers of patients receiving buprenorphine increased by an average of 0.6 and 7.15 per 100 000 population per month in preengagement and postengagement periods, respectively, indicating an estimated additional 6.56 (95% CI, 2.09-11.02) patients receiving buprenorphine per 100 000 population (P = .004) monthly increase after engagement compared with before. Conclusions and Relevance: In this cohort study measuring buprenorphine prescriptions in Michigan over time, counties' engagement in OUD-focused outreach and clinician education services delivered by a multidisciplinary team was associated with a temporal increase in buprenorphine prescribers and patients receiving buprenorphine.

Telehealth-delivered Psychotherapy for the Treatment of Alcohol Use Disorder: Patient Perspectives in the Age of COVID-19.

OBJECTIVES: The COVID-19 pandemic precipitated increases in alcohol use and ushered in virtually delivered health care, creating an opportunity to examine the impacts of telehealth on alcohol use disorder (AUD) treatment. To understand these impacts, we explored perspectives on telehealth-delivered psychotherapy among individuals with AUD. METHODS: This was a qualitative study using semi-structured interviews. Participants (N = 31) were patients with AUD who had received telehealth-delivered AUD psychotherapy in the last 2 years (n = 11) or had never experienced AUD psychotherapy (n = 20), recruited from two large academically-affiliated health care systems in Michigan between July and August 2020. Participants were asked about perceived barriers and facilitators to AUD psychotherapy, benefits and drawbacks of telehealth-delivered AUD psychotherapy, and changes needed to improve psychotherapy delivery. Interviews were transcribed, coded, and analyzed iteratively using thematic analysis. RESULTS: Participants identified factors relating to perceptions of and experience with telehealth-delivered AUD psychotherapy. Findings reflected four major themes: treatment accessibility, treatment flexibility, treatment engagement, and stigma. Perceptions about telehealth's impact on treatment accessibility varied widely and included benefits (e.g., eliminating transportation challenges) and barriers (e.g., technology costs). Treatment flexibility and treatment engagement factors included the ability to use phone and video and perceptions of receiving care via telehealth, respectively. Telehealth impacts on treatment stigma were also a key theme. CONCLUSIONS: Overall, perceptions of telehealth treatment for AUD varied. Participants expressed the importance of options, flexibility, and collaborating on decisions with providers to determine treatment modality. Future research should explore who benefits most from telehealth and avenues to enhance implementation.

Removal of Medicaid Prior Authorization Requirements and Buprenorphine Treatment for Opioid Use Disorder.

Importance: Buprenorphine treatment for opioid use disorder (OUD) is associated with decreased morbidity and mortality. Despite its effectiveness, buprenorphine uptake has been limited relative to the burden of OUD. Prior authorization (PA) policies may present a barrier to treatment, though research is limited, particularly in Medicaid populations. Objective: To assess whether removal of Medicaid PAs for buprenorphine to treat OUD is associated with changes in buprenorphine prescriptions for Medicaid enrollees. Design, Setting, and Participants: This state-level, serial cross-sectional study used quarterly data from 2015 through the first quarter (January-March) of 2019 to compare buprenorphine prescriptions in states that did and did not remove Medicaid PAs. Analyses were conducted between June 10, 2021, and August 15, 2023. The study included 23 states with active Medicaid PAs for buprenorphine in 2015 that required similar PA policies in fee-for-service and managed care plans and had at least 2 quarters of pre- and postperiod buprenorphine prescribing data. Exposures: Removal of Medicaid PA for at least 1 formulation of buprenorphine for OUD. Main Outcomes and Measures: The main outcome was number of quarterly buprenorphine prescriptions per 1000 Medicaid enrollees. Results: Between 2015 and the first quarter of 2019, 6 states in the sample removed Medicaid PAs for at least 1 formulation of buprenorphine and had at least 2 quarters of pre- and postpolicy change data. Seventeen states maintained buprenorphine PAs throughout the study period. At baseline, relative to states that repealed PAs, states that maintained PAs had lower buprenorphine prescribing per 1000 Medicaid enrollees (median, 6.6 [IQR, 2.6-13.9] vs 24.1 [IQR, 8.7-27.5] prescriptions) and lower Medicaid managed care penetration (median, 38.5% [IQR, 0.0%-74.1%] vs 79.5% [IQR, 78.1%-83.5%] of enrollees) but similar opioid overdose rates and X-waivered buprenorphine clinicians per 100 000 population. In fully adjusted difference-in-differences models, removal of Medicaid PAs for buprenorphine was not associated with buprenorphine prescribing (1.4% decrease; 95% CI, -31.2% to 41.4%). For states with below-median baseline buprenorphine prescribing, PA removal was associated with increased buprenorphine prescriptions per 1000 Medicaid enrollees (40.1%; 95% CI, 0.6% to 95.1%), while states with above-median prescribing showed no change (-20.7%; 95% CI, -41.0% to 6.6%). Conclusions and Relevance: In this serial cross-sectional study of Medicaid PA policies for buprenorphine for OUD, removal of PAs was not associated with overall changes in buprenorphine prescribing among Medicaid enrollees. Given the ongoing burden of opioid overdoses, continued multipronged efforts are needed to remove barriers to buprenorphine care and increase availability of this lifesaving treatment.

Impact of COVID-19 on stimulant use disorder treatment: A national cohort study in the Veterans Health Administration.

OBJECTIVE: Rates of stimulant overdose have increased dramatically, which may have been exacerbated by treatment disruptions during the pandemic, but no recent studies have examined use of stimulant use disorder (StUD) treatment. METHODS: In this retrospective cohort study (March 2018 to February 2022) of national Veterans Health Administration patients, we use an interrupted time-series analysis to examine the impact of COVID-19 (starting in March 2020) on treatment use for StUD. RESULTS: The number of patients receiving StUD care was increasing pre-COVID (22,640-23,020, February 2018-February 2020) but dropped post-pandemic to 18,578 in February 2022. The monthly number of patients receiving StUD care increased by 34.6 patients per month (95% CI, 1.1-68.0; P=0.04) before March 2020, decreased by 2803.3 patients (95% CI, -3912.3 to -1694.3; P <0.001) in March 2020, and, accounting for pre-COVID trends, further decreased by 85.85 patients per month (95% CI,-148.9.2 to -23.0; P =0.01) after March 2020. CONCLUSIONS: Care for StUD drastically declined during the COVID-19 pandemic and has yet to show signs of a return to pre-pandemic levels despite surging rates of stimulant-involved overdose deaths and a critical need to engage people with StUD in care.

Telemedicine-delivered treatment for substance use disorder: A scoping review.

INTRODUCTION: The COVID pandemic prompted a significant increase in the utilization of telemedicine (TM) for substance use disorder (SUD) treatment. As we transition towards a "new normal" policy, it is crucial to comprehensively understand the evidence of TM in SUD treatment. This scoping review aims to summarize existing evidence regarding TM's acceptability, quality, effectiveness, access/utilization, and cost in the context of SUD treatment in order to identify knowledge gaps and inform policy decisions regarding TM for SUDs. METHOD: We searched studies published in 2012-2022 from PubMed, Cochrane Library, Embase, Web of Science, and other sources. Findings were synthesized using thematic analysis. RESULTS: A total of 856 relevant articles were screened, with a final total of 42 articles included in the review. TM in SUD treatment was perceived to be generally beneficial and acceptable. TM was as effective as in-person SUD care in terms of substance use reduction and treatment retention; however, most studies lacked rigorous designs and follow-up durations were brief (≤3 months). Telephone-based TM platforms (vs video) were positively associated with older age, lower education, and no prior overdose. Providers generally consider TM to be affordable for patients, but no relevant studies were available from patient perspectives. CONCLUSIONS: TM in SUD treatment is generally perceived to be beneficial and acceptable and as effective as in-person care, although more rigorously designed studies on effectiveness are still lacking. Access and utilization of TM may vary by platform. TM service quality and costs are the least studied and warrant further investigations.

Perceived risk of harm for different methods of cannabis consumption: A brief report.

BACKGROUND: Emerging adults' (EAs; ages 18-25) perceived risk of cannabis-related harms has decreased in recent decades, potentially contributing to their high prevalence of cannabis consumption. With the changing cannabis policy and product landscape, it is critical to understand perceived risk related to different consumption methods (e.g., smoking, dabbing). We examined differences in cannabis risk perceptions by method and consumption patterns. METHODS: EAs recruited from an emergency department (N=359, 71.3% female, 53.5% Black) completed assessments on individual characteristics, cannabis/other substance use, and perceived risk of cannabis-related harm for four different methods (smoking, vaping, dabbing, ingestion) and two use frequencies (occasional, regular). Analyses examined associations between variables of interest and three mutually exclusive groups: no cannabis use, smoking-only, and multiple/other methods. RESULTS: Forty-two percent of EAs reported no past 3-month cannabis use, 22.8% reported smoking only, and 35.1% reported consumption via multiple/other methods. Among all participants, the methods and frequency with the largest number of EAs endorsing any perceived risk from cannabis were dabbing and vaping cannabis regularly; smoking occasionally had the smallest number of EAs endorsing perceived risk. A greater proportion of EAs in the no use group viewed vaping cannabis regularly as having the most risk (63.6%), whereas the largest proportion of EAs in the smoking-only (64.6%) and multiple/other methods (47.2%) groups perceived dabbing regularly as having the most risk. CONCLUSIONS: This work shows that EAs vary in perceptions of risk across methods of cannabis use and can inform potential directions for public health and policy efforts.

Buprenorphine use and courses of care for opioid use disorder treatment within the Veterans Health Administration.

BACKGROUND: Retention of patients in buprenorphine medication treatment for opioid use disorder (B-MOUD) reduces harms associated with opioid use disorder (OUD). We sought to characterize the patients receiving B-MOUD and courses of B-MOUD in a large healthcare system. METHODS: We conducted a retrospective, open cohort study of patients with OUD who either did or did not receive B-MOUD courses within the Veterans Health Administration (VHA) from January 2006 through July 2019, using VHA clinical data. We compared patients receiving or not receiving B-MOUD, characterized B-MOUD courses (e.g., length and doses), and examined persistence, across patient characteristics, over time. We used analyses for normally or non-normally distributed continuous variables, categorical data, and persistence over time (Kaplan-Meier persistence curves). RESULTS: We identified 255,726 Veterans with OUD; 40,431 (15.8%) had received 63,929 B-MOUD courses. Compared to patients with OUD without B-MOUD, patients with B-MOUD were younger, more often of white race, and had more co-morbidities. The frequency of new B-MOUD starts and prevalent B-MOUD patients ranged from 1550 and 1989 in 2007 to 8146 and 16,505 in 2018, respectively. The median duration of B-MOUD was 157 (IQR: 37-537) days for all courses and 33.8% patients had more than one course. The average proportion days covered was 90% (SD: 0.15), and the average prescribed daily dose was 13.44 (SD: 6.5). CONCLUSIONS: Within a VHA B-MOUD cohort, courses increased more than 10-fold from 2006 to 2016 with nearly half of patients experiencing multiple courses. Patient demographics seem to dictate the length of courses.

Pilot trial of a telehealth-delivered behavioral economic intervention promoting cannabis-free activities among adults with cannabis use disorder.

BACKGROUND: Cannabis is increasingly consumed and increasingly perceived as harmless. Among those whose use develops into a cannabis use disorder (CUD), <5% initiate and engage in treatment. Thus, novel options for low-barrier, appealing treatments are needed to foster engagement in care. METHODS: We conducted an open trial of a telehealth-delivered multicomponent behavioral economic intervention for non-treatment-engaged adults with CUD. Participants with CUD were recruited from a health system and screened for eligibility. Participants completed behavioral economic indices (cannabis demand, proportionate cannabis-free reinforcement), measures of cannabis use and mental health symptoms, and provided open-ended feedback on the intervention experience. RESULTS: Of the 20 participants who enrolled and engaged in the initial intervention session, 70% (14 out of 20) completed all intervention components. All participants were satisfied/very satisfied with the intervention and 85.7% reported the telehealth delivery made it at least slightly easier/more likely for them to receive substance use care. Baseline to immediate post-treatment, behavioral economic cannabis demand decreased (intensity: Hedges' g = 0.14, maximum total expenditure: Hedges' g = 0.53, maximum expenditure for a single hit: Hedges' g = 0.10) and proportionate cannabis-free reinforcement (Hedges' g = 0.12) increased. Past-month total cannabis use decreased by 8.9% from baseline to post-treatment (Hedges' g = 0.39), along with decreases in recent depression (Hedges' g = 0.50) and anxiety symptoms (Hedges' g = 0.29). DISCUSSION: These preliminary findings suggest that this behavioral economic intervention was highly acceptable and feasible for adults with untreated CUD. Changes in potential mechanisms of behavior change (cannabis demand, proportionate cannabis-free reinforcement) were consistent with reduced frequency of cannabis use and improved mental health outcomes.

The impact of COVID-19 on trends in alcohol use disorder treatment in Veterans Health Administration.

BACKGROUND AND AIMS: The COVID-19 pandemic disrupted health-care provision in the United States and prompted increases in telehealth-delivery of care. This study measured alcohol use disorder (AUD) treatment trends across visit modalities before and during COVID-19. DESIGN, SETTING, PARTICIPANTS AND MEASUREMENTS: We conducted a national, retrospective cohort study with interrupted time-series models to estimate the impact of COVID-19 on AUD treatment in the Veterans Health Administration (VHA) in the United States during pre-COVID-19 (March 2019 to February 2020) and COVID-19 (March 2020 to February 2021) periods. We analyzed monthly trends in telephone, video and in-person visits for AUD treatment and compared patient and treatment characteristics of patients receiving AUD treatment between the pre-COVID-19 and COVID-19 periods. AUD was defined using International Classification of Diseases, 10th revision (ICD-10) codes for alcohol abuse (F10.1) and alcohol dependence (F10.2), which have previously been used to study AUD in VHA. FINDINGS: The predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the beginning of the pre-COVID period was 13.8% (n = 49 494). The predicted percentage decreased by 4.3% (P = 0.001) immediately at the start of the COVID-19 period due to a decline in AUD psychotherapy. Despite an increase of 0.3% per month (P = 0.026) following the start of COVID-19, the predicted percentage of VHA patients with an AUD diagnosis receiving any AUD treatment at the end of the study period remained below the pre-COVID-19 period. In February 2021, AUD psychotherapy visits were primarily delivered by video (50%, 58 748), followed by in-person (36.6%, 43 251) and telephone (13.8%, 16 299), while AUD pharmacotherapy visits were delivered by telephone (38.9%, 3623) followed by in-person (34.3%, 3193) and video (26.8%, 2498) modalities. Characteristics of VHA patients receiving AUD treatment were largely similar between pre-COVID-19 and COVID-19 periods. CONCLUSIONS: Despite increased telehealth use, the percentage of United States Veterans Health Administration patients with an alcohol use disorder (AUD) diagnosis receiving AUD treatment declined during COVID-19 (March 2020 to February 2021) mainly due to a decrease in psychotherapy.

Variation in Clinical Characteristics and Longitudinal Outcomes in Individuals with Opioid Use Disorder Diagnosis Codes.

BACKGROUND: Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. OBJECTIVE: (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. DESIGN: Longitudinal observational cohort study. PARTICIPANTS: National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. MAIN MEASURES: Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. KEY RESULTS: Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. CONCLUSIONS: Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population.

Telemedicine along the cascade of care for substance use disorders during the COVID-19 pandemic in the United States.

BACKGROUND: The COVID-19 pandemic has changed the landscape of healthcare service delivery. This review aims to describe telemedicine-delivered substance use disorder (SUD) treatments and services along the cascade of care in the U.S. after the start of the COVID-19 pandemic. METHODS: A literature review was conducted on PubMed, Embase, Web of Science, and Cochrane Library (Wiley). English-language articles that describe any healthcare services for patients with SUDs using telemedicine in the U.S. since the onset of the COVID-19 pandemic were identified (N = 33). We narratively summarized telemedicine-based service provision along the cascade of SUD care, such as screening/assessment, prescription, monitoring, recovery support, and other services. RESULTS: Soon after the onset of COVID-19 and mandated restrictions, cadres of healthcare providers from different specialties mobilized to ramp up video- and audio-based services to remotely treat patients with SUDs. Medication prescription (48.5%) and individual counseling (39.4%) were the most frequently reported services delivered via telemedicine. Other steps of SUD care delivered by telemedicine characterized in our review included SUD screening and assessment (30.3%), induction (21.2%), medication management (27.3%), monitoring (27.3%), recovery support (15.2%), and referral (24.2%). Feasibility issues and challenges to implementing telemedicine included patients' lack of access to technology and health insurance coverage, providers' capacity limits and concerns, and clinics' financial and office-space constraints. CONCLUSION: The COVID-19 pandemic has offered a window of opportunity to advance telemedicine expertise by formalizing clinical guidance and routinizing provider in-service training in virtual SUD treatment. Findings suggest enhanced efforts to reduce disparities in telemedicine-based services.

Linking a Survey of Clinician Benzodiazepine-Related Beliefs to Risk of Benzodiazepine Prescription Fills Among Patients in Medicare.

In this pilot study, we used a Medicare sample to identify primary care clinicians who prescribed a benzodiazepine (BZD) in 2017 and surveyed a random sample (n = 100) about BZD prescribing. Among 61 respondents, 11.5% (SD 5.9) of their patient panels filled a BZD prescription. Patients of primary care clinicians who agreed that potential harms to long-term BZD users were low had a greater BZD fill risk relative to patients of disagreeing primary care clinicians (adjusted risk ratio 1.31; 95% CI, 1.01-1.7). We highlight the potential of using Medicare claims to sample clinicians. Using claims-based objective measures presents a new method to inform the development of behavior-change interventions.