Background: The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations. Methods: Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013). Conclusions: These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.
SigmonSC, BisagaA, NunesEV, O'ConnorPG, KostenT, WoodyG. Opioid detoxification and naltrexone induction strategies: recommendations for clinical practice. Am J Drug Alcohol Abuse.2012;38:187–199.
2.
GhitzaHE, TaiB. Challenges and opportunities for integrating preventive substance-use-care services in primary care through the Affordable Care Act. J Health Care Poor Underserved.2014;25:36–45.
3.
Substance Abuse and Mental Health Services Administration (SAMHSA). Results From the 2013 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2014. NSDUH Series H-48, HHS Publication No. (SMA)14–4863. http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf. Published September 2014. Accessed May 29, 2015.
AmatoL, MitrovaZ, DavoliM. Cochrane systematic reviews in the field of addiction: past and future. J Evid Based Med.2013;6:221–228.
7.
RehmJ, GnamW, PopovaS, . The costs of alcohol, illegal drugs, and tobacco in Canada, 2002. J Stud Alcohol Drug. 2007;68:886–895.
8.
ManchikantiL, FellowsAilinani H, PampatiV. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician2010;13:401–435.
Substance Abuse and Mental Health Services Administration (SAMHSA). National Expenditures for Mental Health Services and Substance Abuse Treatment, 1986–2009. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013. HHS Publication No. SMA-13-4740. https://store.samhsa.gov/shin/content/SMA13-4740/SMA13-4740.pdf. Published 2013. Accessed May 27, 2015.
12.
RehmJ, MathersC, PopovaS, ThavorncharoensapM, TeerwattananonY, PatraJ. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373:2223–2233.
13.
TaylorB, IrvingHM, BaliunasD, . Alcohol and hypertension: gender differences in dose–response relationships determined through systematic review and meta-analysis. Addiction. 2009;104:1981–1990.
14.
BanerjeaR, SambamoorthiU, SmelsonD, PogachLM. Chronic illness with complexities: mental illness and substance use among Veteran clinic users with diabetes. Am J Drug Alcohol Abuse.2007;33:807–821.
15.
BeagleholeR, BonitaR. Alcohol: a global health priority. Lancet.2009;373:2173–2174.
16.
BoucheryEE, HarwoodHJ, SacksJJ, SimonCJ, BrewerRD. Economic costs of excessive alcohol consumption in the US, 2006. Am J Prev Med.2011;41:516–524.
17.
GrantBF, StinsonFS, DawsonDA, . Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions. Arch Gen Psychiatry. 2014;61:807–816.
18.
ThorntonLK, BakerAL, LewinTJ, . Reasons for substance use among people with mental disorders. Addict Behav. 2012;37:427–434.
19.
RobinsonJ, SareenJ, CoxBJ, BoltonJM. Role of self-medication in the development of comorbid anxiety and substance use disorders: a longitudinal investigation. Arch Gen Psychiatry.2011;68:800–807.
20.
BirrellL, NewtonNC, TeessonM, TonksZ, SladeT. Anxiety disorders and first alcohol use in the general population. Findings from a nationally representative sample.J Anxiety Disord. 2015;31:108–113.
21.
MorascoBJ, GritznerS, LewisL, OldhamR, TurkDC, DobschaSK. Systematic review of prevalence, correlates, and treatment outcomes for chronic non-cancer pain in patients with comorbid substance use disorder. Pain. 2011;152:488–497.
22.
BatkiSL, MeszarosZS, StrutynskiK, . Medical comorbidity in patients with schizophrenia and alcohol dependence. Schizophr Res.2009;107:139–146.
23.
GarfeinRS, VlahovD, GalaiN, DohertyMC, NelsonKE. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86:655–661.
24.
ArmstrongGL, WasleyA, SimardEP, McQuillanGM, KuhnertWL, AlterMJ. The Prevalence of Hepatitis C Virus Infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144:705–714.
25.
NelsonPK, MathersBM, CowieB, JarlasDD, HoryniakD, DegenhardtL. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. 2011;378:571–583.
26.
Stein MD. Medical consequences of substance abuse. Pyschiatr Clin N Am. 1999;22:351–370.
27.
LeeJ, KresinaTF, CampopianoM, LubranR, ClarkHW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BioMed Res Int.2015;2015:137020. doi: 10.1155/2015/137020. Accessed May 29, 2015.
28.
BonhommeJ, ShimRS, GoodenR, TyusD, RustG. Opioid addiction and abuse in primary care practice: a comparison of methadone and buprenorphine as treatment options. J Natl Med Assoc. 2012;104:342–350.
29.
JanS, GillP, Borawala AS. Utilization patterns of extended-release naltrexone for alcohol dependence. Am J Manag Care. 2011;17:S210–S212.
30.
HaddadMS, ZelenevA, AlticeFL. Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers. J Urban Health. 2015;92:193–213.
31.
KhatriK, HaddadM, AndersonD. Project ECHO: replicating a novel model to enhance access to hepatitis C care in a community health center. J Health Care Poor Underserved. 2013;24:850–858.
32.
SaxonAJ, HserYI, WoodyG, LingW. Medication-assisted treatment for opioid addiction: methadone and buprenorphine. J Food Drug Anal. 2013;21:S69–S72.
33.
AmassL, KamienJB, MikulichSK. Efficacy of daily and alternate-day dosing regimens with the combination buprenorphine–naloxone tablet. Drug Alcohol Depend.2000;58:143–152.
34.
LingW, WessonDR. Clinical efficacy of buprenorphine: comparisons to methadone and placebo. Drug Alcohol Depend. 2003;70:S49–S57.
35.
MattickRP, BreenC, KimberJ, DavoliM. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database Syst Rev. 2008;(2):CD002207. doi: 10.1002/14651858.CD002207.pub3. Accessed May 27, 2015.
MelloNK, MendelsonJH. Behavioral pharmacology of buprenorphine. Drug Alcohol Depend. 1985;14;283–303.
38.
WalshSL, PrestonKL, StitzerML, ConeEJ, BigelowGE. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55:569–580.
39.
LiebschutzJM, CrooksD, HermanD, . Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med.2014;174:1369–1376.
40.
ZanisDA, WoodyGE. One-year mortality rates following methadone treatment discharge. Drug Alcohol Depend. 1998;52:257–260.
41.
YancovitzSR, Des JarlaisDC, PeyserNP, . A randomized trial of an interim methadone maintenance clinic. Am J Public Health. 1991;81:1185–1191.
42.
StancliffS, JosephH, FongC, FurstT, ComerSD, RouxP. Opioid maintenance treatment as a harm reduction tool for opioid-dependent individuals in New York City: the need to expand access to buprenorphine/naloxone in marginalized populations. J Addict Dis. 2012;31:278–287.
43.
JohnsonRE, EissenbergT, StitzerML, StrainEC, LiebsonIA, BigelowGE. A placebo controlled clinical trial of buprenorphine as a treatment for opioid dependence. Drug Alcohol Depend. 1995;40:17–25.
44.
KakkoJ, GrönbladhL, SvanborgKD, . A stepped care strategy using buprenorphine and methadone versus conventional methadone maintenance in heroin dependence: a randomized controlled trial. Am J Psychiatry. 2007;164:797–803.
45.
NielsenS, HillhouseM, WeissRD, . The relationship between primary prescription opioid and buprenorphine–naloxone induction outcomes in a prescription opioid dependent sample. Am J Addict. 2014;23:343–348.
46.
JohnsonRE, JaffeJH, FudalaPJ. A controlled trial of buprenorphine treatment for opioid dependence. JAMA. 1992;267:2750–2755.
47.
FlemingMF, BalousekSL, KlessigCL, MundtMP, BrownDD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain.2007;8:573–582.
48.
DeanRL. The preclinical development of Medisorb Naltrexone, a once a month long acting injection, for the treatment of alcohol dependence. Front Biosci. 2005;10:643–655.
49.
O'LearyG, BorrowJ, WeissRD. Opioid antagonist in the treatment of alcohol dependence. Curr Drug Abuse Rev.2001;3:484–488.
50.
O'MalleySS, JaffeAJ, ChangG, SchottenfeldRS, MeyerRE, RounsavilleB. Naltrexone and coping skills therapy for alcohol dependence: a controlled study. Arch Gen Psychiatry. 1992;49:881–887.
51.
VolpicelliJ, Krishnan-SarinS, O'MalleyS. Alcoholism pharmacotherapy. In: DavisKL, CharneyD, CoyleJT, NemeroffC, eds. Neuropsychopharmacology: The Fifth Generation of Progress: An Official Publication of the American College of Neuropsychopharmacology.Baltimore, MD: Lippincott Williams & Wilkins; 2002:1445–1459.
52.
KranzlerHR, KirkJ. Efficacy of naltrexone and acamprosate for alcoholism treatment: a meta-analysis. Alcohol Clin Exp Res.2001;25:1335–1341.
53.
GarbuttJC, WestSL, CareyTS, TohrKN, CrewsFT. Pharmacological treatment of alcohol dependence: a review of the evidence. JAMA.1999;281:1318–1325.
BoothbyLA, DoerignPL. Acamprosate for the treatment of alcohol dependence. Clin Ther.2005;27:695–714.
56.
ElissenAM, SteutenLM, LemmensLC, . Meta-analysis of the effectiveness of chronic care management for diabetes: investigating heterogeneity in outcomes. J Eval Clin Pract. 2013;19:753–762. doi:10.1111/j.1365–2753.2012.01817.
57.
KuoS, BryceCL, ZgiborJC, WolfDL, RobertsMS, SmithKJ. Cost-effectiveness of implementing the chronic care model for diabetes care in a military population. J Diabetes Sci Technol. 2011;5:501–513.
58.
SunaertP, BastiaensH, NobelsF, . Effectiveness of the introduction of a chronic care model-based program for type 2 diabetes in Belgium. BMC Health Serv Res. 2010;10:207.
59.
GallagherH, de LusignanS, HarrisK, CatesC. Quality-improvement strategies for the management of hypertension in chronic kidney disease in primary care: a systematic review. Br J Gen Pract. 2010;60:e258–e265.
60.
TaiB, VolkowND. Treatment for substance use disorder: opportunities and challenges under the Affordable Care Act. Soc Work Public Health.2013;28:165–174.
Mental Health Parity and Addiction Equity Act of 2008 (PL 110-460, 12/23/2008). Text from: Public Laws by Law Number. Available from: Thomas (Library of Congress), http://thomas.loc.gov. Accessed May 27, 2015.
63.
Swenson-BrittE, CarrougherG, MartinBW, BrackleyM. Project hope: changing care delivery for the substance abuse patient. Clin Nurse Spec. 2000;14:92–100.
64.
BowmanS, EisermanJ, BeletskyL, StancliffS, BruceRD. Reducing the health consequences of opioid addiction in primary care. Am J Med.2013;126:565–571.
65.
TaiB, SaxonAJ, LingW. Medication-assisted therapy for opioid addiction. J Food Drug Anal. 2013;21:S13-S15.
66.
LawsR, GillespieS, PuroJ, . The community health applied research network (CHARN) data warehouse: a resource for patient-centered outcomes research and quality improvement in underserved, safety net populations. eGEMs.2014;2:11. doi:10.13063/2327-9214.1097
67.
Likumahuwa S1, SongH, SingalR, . Building research infrastructure in community health centers: a Community Health Applied Research Network (CHARN) report. J Am Board Fam Med. 2013;26:579–587. doi:10.3122/jabfm.2013.05.130025.
68.
GuoG, ZhaoHX. Multilevel modeling for binary data. Annu Rev Sociol. 2000;26:441–462.
RaudenbushSW, BrykAS. Hierarchical Linear Models: Applications and Data Analysis Methods. 2nd ed. Thousand Oaks, CA: Sage Publications; 2002.
71.
LiuQ, PierceDA. A note on gauss-hermite quadrature. Biometrika.1994;81:624–629.
72.
Rabe-HeskethS, SkrondalA, PicklesA. Maximum likelihood estimation of limited and discrete dependent variable models with nested random effects. J Econometr. 2005;128:301–323.
MuenchJ.Screening and brief intervention practice systems and implementation. In: SaitzR, ed. Addressing Unhealthy Alcohol Use in Primary Care. New York, NY: Springer; 2013:171–188.
75.
SpandorferJM, IsraelY, TurnerBJ. Primary care physicians’ views on screening and management of alcohol abuse: inconsistencies with national guidelines. J Fam Pract.1999;48:899–902
76.
CookBL, AlegriaM. Racial-ethnic disparities in substance abuse treatment: the role of criminal history and socioeconomic status. Psychiatr Serv. 2011;62:1273–1281.
77.
EvonDM, SimpsonKM, EssermanD, VermaA, SmithS, FriedMW. Barriers to accessing care in patients with chronic hepatitis C: the impact of depression. Aliment Pharmacol Ther. 2010;32:1163–1173.
78.
ReifS, GolinCE, SmithSR. Barriers to accessing HIV/AIDS care in North Carolina: rural and urban differences. AIDS Care. 2005;17:558–565.
79.
FernándezA, Rubio-ValeraM, BellónJA, . DASMAP investigators. Recognition of anxiety disorders by the general practitioner: results from the DASMAP study. Gen Hosp Psychiatry. 2012;34:227–233.
80.
WittchenHU, KesslerRC, BeesdoK, KrauseP, HöflerM, HoyerJ. Generalized anxiety and depression in primary care: prevalence, recognition, and management. J Clin Psychiatry. 2002;63(Suppl 8):24–34.
81.
VermaniM, MarcusM, KatzmanMA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord. 2011;13:e1-e10.
82.
O'CleirighC, MagidsonJF, SkeerM, MayerKH, SafrenSA. Prevalence of psychiatric and substance abuse symptomatology among HIV-infected gay and bisexual men in HIV primary care. Psychosomatics. 2015; 56(5): 470–478.
83.
IsraelskiDM, PrentissDE, LubegaS, . Psychiatric co-morbidity in vulnerable populations receiving primary care for HIV/AIDS. AIDS Care. 2007;19:220–225.
84.
RobinsonJ, SareenJ, CoxBJ, BoltonJ. Self-medication of anxiety disorders with alcohol and drugs: results from a nationally representative sample. J Anxiety Disord. 2009;23:38–45.
85.
HasinD, KilcoyneB. Comorbidity of psychiatric and substance use disorders in the United States: current issues and findings from the NESARC. Curr Opin Psychiatry. 2012;25:165–171.
86.
ConwayKP, ComptonW, StinsonFS, GrantBF. Lifetime comorbidity of DSM-IV mood and anxiety disorders and specific drug use disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2006;67:247–257.
87.
LydiardBR, BradyK, BallengerJC, HowellEF, MalcolmR. Anxiety and mood disorders in hospitalized alcoholic individuals. Am J Addict. 1992;1:325–331.
88.
BransonBM, HandsfieldHH, LampeMA. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006;55(RR-14):1–17; quiz CE11–CE14.
89.
ChouR, CottrellEB, WassonN, RahmanB, GuiseJM. Screening for hepatitis C virus infection in adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med.2013;158:101–108.
Mayer KH, Crawford P, Dant L, Gillespite S, Vandermeer M, Muench J, Long T, Quach T, Chaudhry A, Crane HM, Lembdo D, Mills R, McBurnie MA. HIV and Hepatitis C Virus screening practices among primary care providers in a geographically diverse sample of U.S. community health centers. AIDS Patient Care STDS. 2016; 30(6): 237–246.
92.
Rieckmann T, Gideonse N, Risser A, Devoe JE, Abraham A.Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data. Journal of Behavioral Health Services & Research. Under Review.
93.
TkaczJ, SevertJ, CacciolaJ, RuetschC. Compliance with buprenorphine medication-assisted treatment and relapse to opioid use. Am J Addict. 2012;21:55–62.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
