Publications

Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes. We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013–2014, n = 660, and 2016–2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site’s average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation. The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%). Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.

Chelsea L. Shover, Amanda Abraham, Thomas D’Aunno, Peter D. Friedmann, Keith Humphreys, The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs, Journal of Substance Abuse Treatment, Volume 105, 2019, Pages 44-50, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2019.07.012.

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The Affordable Care Act (ACA) prompted sweeping changes to Medicaid, including expanding insurance coverage to an estimated 12 million previously uninsured Americans, and imposing new parity requirements on benefits for behavioral health services, including substance use disorder treatment. Yet, limited evidence suggests that these changes have reduced the number of uninsured in substance use disorder treatment, or increased access to substance use disorder treatment overall. This study links data from a nationally-representative study of outpatient substance use disorder treatment programs and a unique national survey of state Medicaid programs to capture changes in insurance coverage among substance use disorder treatment patients after ACA implementation. Medicaid expansion was associated with a 15.7-point increase in the percentage of patients insured by Medicaid in substance use disorder treatment programs and a 13.7-point decrease in the percentage uninsured. Restrictions in state Medicaid benefits and utilization policies were associated with a decreased percentage of Medicaid patients in treatment. Moreover, Medicaid expansion was not associated with a change in the total number of clients served over the study period. Our findings highlight the important role Medicaid has played in increasing insurance coverage for substance use disorder treatment.

Christina M. Andrews, Harold A. Pollack, Amanda J. Abraham, Colleen M. Grogan, Clifford S. Bersamira, Thomas D’Aunno, Peter D. Friedmann, Medicaid coverage in substance use disorder treatment after the affordable care act, Journal of Substance Abuse Treatment, Volume 102, 2019, Pages 1-7, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2019.04.002.

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Established in 2014, state health insurance exchanges have greatly expanded substance use disorder (SUD) treatment coverage in the United States as qualified health plans (QHPs) within the exchanges are required to conform to parity provisions laid out by the Affordable Care Act and the Mental Health Parity and Addiction Equity Act (MHPAEA). Coverage improvements, however, have not been even as states have wide discretion over how they meet these regulations. In this study, we assessed the extent to which state insurance departments regulate the types of SUD services and medications plans must provide, as well as their use of utilization controls. Data were collected as part of the National Drug Abuse Treatment System Survey, a nationally-representative, longitudinal study of substance use disorder treatment. Data were obtained from state Departments of Insurance via a 15-minute internet-based survey. States varied widely in regulations on QHPs’ administration of SUD treatment benefits. Some states required plans to cover all 11 SUD treatment services and medications we assessed in the study, whereas others did not require plans to cover anything at all. Nearly all states allowed the plans to employ utilization controls, but reported little guidance regarding how they should be used. Although some states have taken full advantage of the health insurance exchanges to increase access to SUD treatment, others seem to have done the bare minimum required by the ACA. By not requiring coverage for the entire SUD continuum of care, states are hindering client access to appropriate types of care necessary for recovery.

Tran Smith, B., Seaton, K., Andrews, C., Grogan, C. M., Abraham, A., Pollack, H., … Humphreys, K. (2017). Benefit requirements for substance use disorder treatment in state health insurance exchanges. The American Journal of Drug and Alcohol Abuse, 44(4), 426–430. https://doi.org/10.1080/00952990.2017.1411934

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We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. The ACA’s infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA’s Medicaid expansion.

Amanda J. Abraham, Bikki Tran Smith, Christina M. Andrews, Clifford S. Bersamira, Colleen M. Grogan, Harold A. Pollack, and Peter D. Friedmann: Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation American Journal of Public Health 109, 885_891, https://doi.org/10.2105/AJPH.2019.305052

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To examine the association between potential inappropriate prescribing practices of opioids and deaths among opioid users in the Georgia Medicaid population. A retrospective analysis of individual pharmacy claims data from Georgia Medicaid from 2009 through 2014. The sample was restricted to patients without cancer aged 18 to 64 years with an opioid prescription and included 3,562,227 observations representing 401,488 individuals. A descriptive analysis and a multivariate logistic regression analysis were conducted. Results indicate a total of 14,516 deaths among opioid users in the study sample, of whom approximately 42% experienced at least 1 incidence of potential inappropriate prescribing practices. Regression results indicate that the odds of opioid users experiencing death were 1.76 times higher for those who experienced at least 1 incidence of potential inappropriate prescribing practices of opioids compared with those who did not experience any incidence, even after controlling for other covariates (P <.001). Moreover, opioid users in managed care Medicaid were less likely to experience death compared with fee-for-service (FFS) enrollees. The results indicate a positive and statistically significant association between potential inappropriate opioid prescribing practices and deaths among opioid users in Georgia Medicaid, with FFS enrollees experiencing higher rates of death compared with managed care enrollees. Appropriate policies and interventions targeted at reducing potential inappropriate prescribing practices may help reduce the risk factors associated with mortality among opioid users in this population.

Jayawardhana J, Abraham AJ, Perri M. Deaths among opioid users: impact of potential inappropriate prescribing practices. Am J Manag Care. 2019 Apr 1;25(4):e98-e103. PMID: 30986018; PMCID: PMC7083064.

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We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability. The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87). Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.

Christina M. Andrews, Amanda J. Abraham, Colleen M. Grogan, Melissa A. Westlake, Harold A. Pollack, Peter D. Friedmann, “Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs”, American Journal of Public Health 109, no. 3 (March 1, 2019): pp. 434-436. https://doi.org/10.2105/AJPH.2018.304856

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To 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.

Abraham AJ, Adams GB, Bradford AC, Bradford WD. County-level access to opioid use disorder medications in medicare Part D (2010-2015). Health Serv Res. 2019; 54: 390–398. https://doi.org/10.1111/1475-6773.13113

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There has been a dramatic rise in the number of opioid prescriptions and opioid overdose deaths in the United States over the past 15 years. Misuse and abuse of opioids is also a growing public health concern in the United States. Medicaid enrollees are more likely to be prescribed opioids and are at higher risk of prescription drug overdose compared with non-Medicaid populations. Despite rising opioid drug overdose deaths in Georgia, prevalence of indicators for potential inappropriate prescribing practices has not been examined to date. This study used data from the Georgia individual Medicaid pharmacy claims database from 2009 to 2014. Data sample included 3,562,227 observations (patient prescriptions) representing 401,488 individuals. Outcome measures assessed the trends in the general use of opioids and the indicators of potential inappropriate prescribing practices by providers. These outcome measures were taken from previous expert panels and clinical guidelines (e.g., overlapping prescriptions of opioids, opioids and benzodiazepines, and opioids and buprenorphine/naloxone, as well as high daily doses of opioids). Analyses were stratified by gender, type of insurance (fee-for-service and managed care), age, and race/ethnicity. The average number of opioid prescriptions, average days supply of opioids per patient, and average daily dose of opioids per patient increased over time across all demographic categories with older, fee-for-service, male, and missing race groups experiencing higher use across all 6 years compared with their counterparts. A similar pattern was observed for average number of incidences of potential inappropriate prescribing of opioids in this population from 2009 to 2014. The percentage of Medicaid enrollees with at least 1 or more indicators of potential inappropriate prescriptions slightly increased from 17.17% to 18.21% during the study time frame. Moreover, the incidence rate of indicators for potential inappropriate prescribing of opioids also increased over time across all demographic groups, with the oldest age group (55-64 years) experiencing the largest increment. The incidence rate of potential inappropriate prescribing practices per patient increased more than 58% over the 6 years. The results of this study show that potentially inappropriate prescribing practices are common and are increasing over time in the Georgia Medicaid population across all demographic categories, with individuals who are listed in the missing race category, have fee-for-service plans, and are older experiencing the largest increments. These findings indicate that patients in certain demographic groups could be at higher risk for experiencing adverse health outcomes related to inappropriate prescribing of opioids. Further research is needed to explore which policy tools or interventions might be more effective in reducing inappropriate prescribing practices in this population.

Jayawardhana, Jayani, Abraham, Amanda J., Perri, Matthew. Opioid Analgesics in Georgia Medicaid: Trends in Potential Inappropriate Prescribing Practices by Demographic Characteristics, 2009-2014. Journal Article. 2018. Journal of Managed Care & Specialty Pharmacy. 886-894. 24. 9. 10.18553/jmcp.2018.24.9.886 [doi]

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The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.

Christina M. Andrews, Colleen M. Grogan, Bikki Tran Smith, Amanda J. Abraham, Harold A. Pollack, Keith Humphreys, Melissa A. Westlake, and Peter D. Friedmann. Medicaid Benefits For Addiction Treatment Expanded After Implementation Of The Affordable Care Act. Health Affairs 2018 37:8, 1216-1222

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Opioid-related mortality increased by 15.6% from 2014 to 2015 and increased almost 320% between 2000 and 2015. Recent research finds that the use of all pain medications (opioid and nonopioid collectively) decreases in Medicare Part D and Medicaid populations when states approve medical cannabis laws (MCLs). The association between MCLs and opioid prescriptions is not well understood. To examine the association between prescribing patterns for opioids in Medicare Part D and the implementation of state MCLs. Longitudinal analysis of the daily doses of opioids filled in Medicare Part D for all opioids as a group and for categories of opioids by state and state-level MCLs from 2010 through 2015. Separate models were estimated first for whether the state had implemented any MCL and second for whether a state had implemented either a dispensary-based or a home cultivation only–based MCL. The primary outcome measure was the total number of daily opioid doses prescribed (in millions) in each US state for all opioids. The secondary analysis examined the association between MCLs separately by opioid class. From 2010 to 2015 there were 23.08 million daily doses of any opioid dispensed per year in the average state under Medicare Part D. Multiple regression analysis results found that patients filled fewer daily doses of any opioid in states with an MCL. The associations between MCLs and any opioid prescribing were statistically significant when we took the type of MCL into account: states with active dispensaries saw 3.742 million fewer daily doses filled (95% CI, −6.289 to −1.194); states with home cultivation only MCLs saw 1.792 million fewer filled daily doses (95% CI, −3.532 to −0.052). Results varied by type of opioid, with statistically significant estimated negative associations observed for hydrocodone and morphine. Hydrocodone use decreased by 2.320 million daily doses (or 17.4%) filled with dispensary-based MCLs (95% CI, −3.782 to −0.859; P = .002) and decreased by 1.256 million daily doses (or 9.4%) filled with home-cultivation–only-based MCLs (95% CI, −2.319 to −0.193; P = .02). Morphine use decreased by 0.361 million daily doses (or 20.7%) filled with dispensary-based MCLs (95% CI, −0.718 to −0.005; P = .047). Medical cannabis laws are associated with significant reductions in opioid prescribing in the Medicare Part D population. This finding was particularly strong in states that permit dispensaries, and for reductions in hydrocodone and morphine prescriptions.

Bradford AC, Bradford WD, Abraham A, Bagwell Adams G. Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population. JAMA Intern Med. 2018;178(5):667–672. doi:10.1001/jamainternmed.2018.0266

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We collected primary data from the 2013–2014 wave of the National Drug Abuse Treatment System Survey. We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs. Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine. Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states. Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.

Christina M. Andrews, Colleen M. Grogan, Melissa A. Westlake, Amanda J. Abraham, Harold A. Pollack, Thomas A. D’Aunno, Peter D. Friedmann, Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study, Journal of Substance Abuse Treatment, Volume 87, 2018, Pages 50-55, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2018.01.010.

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Medicaid populations have been disproportionately affected by the opioid epidemic. In Georgia, opioid deaths have increased at more than twice the rate of the nation at large. It is unknown if certain populations within the Medicaid unduly receive opioid prescriptions or experience inappropriate prescribing of opioids. Thus, this study examines gender and insurance disparities in the use of opioids and the prevalence of indicators for potential inappropriate prescribing of opioids in the Georgia Medicaid population. Using individual Georgia Medicaid pharmacy claims data from 2012, disparities across gender (male/female) and type of insurance (fee-for-service (FFS)/managed care (MC)) were examined for the general use of opioids and potential inappropriate prescribing practices by providers. These outcome measures were taken from previous clinical guidelines and expert panels. T-tests were conducted to estimate significance in disparities across gender and type of insurance. Average number of opioid prescriptions received and average days of supply of opioids were higher among men than women (P < 0.001), and among FFS patients than MC patients (P < 0.001). Similarly, average incidences of potential inappropriate prescribing of opioids were higher among men (1.41) than women (0.83) (P < 0.001), and among FFS patients (1.60) than MC patients (0.46) (P < 0.001). Results indicate statistically significant disparities among male/female patients and FFS/MC patients in the general use of opioids and in potential inappropriate prescribing of opioids. Policies aimed at curbing potential inappropriate prescribing of opioids, especially among male and FFS enrolees are needed to reduce prescription drug abuse within this population.

Jayani Jayawardhana, Amanda J Abraham, Henry N Young, Matthew Perri, Opioids in Georgia Medicaid: gender and insurance disparities in utilization and potential inappropriate prescribing practices, Journal of Pharmaceutical Health Services Research, Volume 9, Issue 2, June 2018, Pages 101–108, https://doi.org/10.1111/jphs.12215

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As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine. This study draws from the 2013–2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs. State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49–6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31–4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00–1.39, p=.049). State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.

Abraham, A. J., Andrews, C. M., Grogan, C. M., Pollack, H. A., D’Aunno, T., Humphreys, K., & Friedmann, P. D. (2018). State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder. Psychiatric Services, 69(4), 448–455. https://doi.org/10.1176/appi.ps.201700196

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The Medication Research Partnership (MRP), a collaboration between a national commercial health plan and nine addiction treatment centers, implemented organizational and system changes to promote use of federally approved medications for treatment of alcohol and opioid use disorders. A difference-in-differences analysis examined change over time in the percentage of patients receiving a prescription medication for alcohol or opioid use disorders treated in MRP (n = 9) and comparison (n = 15) sites. MRP clinics experienced a 2.4-fold increase in patients receiving an alcohol or opioid prescription (13.2% at baseline to 31.7% at 3 years after MRP initiation); comparison clinics experienced significantly less change (17.6% to 23.5%) with an adjusted difference-in-differences of 12.5% (95% CI [5.4, 19.6], p = .001). MRP sites increased the patients with prescriptions to treat opioid use disorder from 17.0% (baseline) to 36.8% (3 years after initiation), with smaller changes observed in comparison sites (23.2% to 24.0%) and a 3-year post-initiation adjusted difference-in-differences of 19% (95% CI [8.5, 29.5], p = .000). Medications for alcohol use disorders increased in both MRP (9.0% to 26.5%) and comparison sites (11.4% to 23.1%). Promoting the use of medications to support recovery required complex interventions. The Advancing Recovery System Change Model, initially developed in publicly funded systems of care, was successfully adapted for commercial sector use. The model provides a framework for providers and commercial health plans to collaborate and increase patient access to medications.

James H. Ford II, Amanda J. Abraham, Nicoleta Lupulescu-Mann, Raina Croff, Kim A. Hoffman, Kelly Alanis-Hirsch, Mady Chalk, Laura Schmidt, and Dennis McCarty. Promoting Adoption of Medication for Opioid and Alcohol Use Disorders Through System Change. Journal of Studies on Alcohol and Drugs 2017 78:5 , 735-744

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Given the high prevalence of smoking among substance use disorder (SUD) patients, the specialty SUD treatment system is an important target for adoption and implementation of tobacco cessation (TC) services. While research has addressed the impact of tobacco control on individual tobacco consumption, largely overlooked in the literature is the potential impact of state tobacco control policies on availability of services for tobacco cessation. This paper examines the association between state tobacco control policy and availability of TC services in SUD treatment programs in the United States. State tobacco control and state demographic data (n = 51) were merged with treatment program data from the 2012 National Survey of Substance Abuse Treatment Services (n = 10.413) to examine availability of TC screening, counseling and pharmacotherapy services in SUD treatment programs using multivariate logistic regression models clustered at the state-level. Approximately 60% of SUD treatment programs offered TC screening services, 41% offered TC counseling services and 26% offered TC pharmacotherapy services. Results of multivariate logistic regression showed the odds of offering TC services were greater for SUD treatment programs located in states with higher cigarette excise taxes and greater spending on tobacco prevention and control. Findings indicate cigarette excise taxes and recommended funding levels may be effective policy tools for increasing access to TC services in SUD treatment programs. Coupled with changes to insurance coverage for TC under the Affordable Care Act, state tobacco control policy tools may further reduce tobacco use in the United States.

Amanda J. Abraham, Grace Bagwell-Adams, Jayani Jayawardhana, Availability of tobacco cessation services in substance use disorder treatment programs: Impact of state tobacco control policy, Addictive Behaviors, Volume 71, 2017, Pages 12-17, ISSN 0306-4603, https://doi.org/10.1016/j.addbeh.2017.02.007.

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Research has examined the safety, efficacy, feasibility, and cost-effectiveness of buprenorphine for the treatment of opioid dependence, but few studies have examined patient and provider experiences, especially in community health centers. Using de-identified electronic health record system (EHRS) data from 70 OCHIN community health centers (n = 1825), this cross-sectional analysis compared the demographics, comorbidities, and service utilization of patients receiving buprenorphine to those not receiving medication-assisted treatment (MAT). Compared to non-MAT patients, buprenorphine patients were younger and less likely to be Hispanic or live in poverty. Buprenorphine patients were less likely to have Medicaid insurance coverage, more likely to self-pay, and have private insurance coverage. Buprenorphine patients were less likely to have problem medical comorbidities or be coprescribed high-risk medications. It is important for providers, clinic administrators, and patients to understand the clinical application of medications for opioid dependence to ensure safe and effective care within safety net clinics.

Rieckmann, T.R., Gideonse, N., Risser, A. et al. Treating Opioid Dependence with Buprenorphine in the Safety Net: Critical Learning from Clinical Data. J Behav Health Serv Res 44, 351–363 (2017). https://doi.org/10.1007/s11414-017-9553-z

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We used local measures of spatial autocorrelation (LISA) analysis to identify (1) clusters of counties with higher and lower than average rates of opioid use disorders and (2) clusters of counties with higher and lower than average treatment admissions among OTPs that accept Medicaid, adjusting for county population size. Our results reveal several clusters of counties with higher than average rates of opioid use disorder (OUD) and lower than average treatment admissions among OTPs that accept Medicaid. These clusters are highly concentrated in the Southeast region of the country and include Arkansas, Kentucky, Louisiana, Mississippi, and Tennessee. Medicaid enrollees in areas in the Southeast have the largest gaps between county-level OUD rates and estimated county-level capacity for treatment, as measured by county-level total treatment admissions among OTPs that accept Medicaid. Policy makers should consider strategies to increase the availability of OTPs with the capacity to serve Medicaid enrollees.

Abraham, A.J., Andrews, C.M., Yingling, M.E. and Shannon, J. (2018), Geographic Disparities in Availability of Opioid Use Disorder Treatment for Medicaid Enrollees. Health Serv Res, 53: 389-404. https://doi.org/10.1111/1475-6773.12686

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Any historical assessment of the public health legacy of the Obama administration will have to look favorably at the impact of the Affordable Care Act (ACA; Pub L No. 111–148) on the US response to the opioid epidemic, and its ability to incentivize and assist states in taking action to fight against the epidemic. Substance use disorder (SUD) is a major public health issue in the United States, particularly in light of the nation’s growing opioid epidemic. In 2015, more than 12 million Americans reported misusing opioid pain relievers, and nearly one million Americans reported using heroin. The rate of opioid-related overdose deaths has increased more than 200% over the past 15 years, and overdose deaths related to heroin more than tripled from 2011 to 2014. The costs associated with prescription opioid use, abuse, and overdose are high, estimated at $78.5 billion in 2013 alone.

Amanda J. Abraham et al. “The Affordable Care Act Transformation of Substance Use Disorder Treatment”, American Journal of Public Health 107, no. 1 (January 1, 2017): pp. 31-32. https://doi.org/10.2105/AJPH.2016.303558

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Despite considerable empirical evidence that psychosocial interventions improve addiction treatment outcomes across populations, implementation remains problematic. A small body of research points to the importance of research network participation as a facilitator of implementation; however, studies examined limited numbers of evidence-based practices. To address this gap, the present study examined factors impacting implementation of motivational interviewing (MI). This study used data from a national sample of privately funded treatment programs (n = 345) and programs participating in the National Drug Abuse Treatment Clinical Trials Network (CTN) (n = 156). Data were collected via face-to-face interviews with program administrators and clinical directors (2007–2009). Analysis included bivariate t tests and chi-square tests to compare private and CTN programs, and multivariable logistic regression of MI implementation. A majority (68.0%) of treatment programs reported use of MI. Treatment programs participating in the CTN (88.9%) were significantly more likely to report use of MI compared with non-CTN programs (58.5%; P < 0.01). CTN programs (82.1%) also were more likely to use trainers from the Motivational Interviewing Network of Trainers as compared with private programs (56.1%; P < 0.05). Multivariable logistic regression models reveal that CTN-affiliated programs and programs with a psychiatrist on staff were more likely to use MI. Programs that used the Stages of Change Readiness and Treatment Eagerness Scale assessment tool were more likely to use MI, whereas programs placing greater emphasis on confrontational group therapy were less likely to use MI. Findings suggest the critical role of research network participation, access to psychiatrists, and organizational compatibility in adoption and sustained use of MI.

Rieckmann, Traci R. PhD; Abraham, Amanda J. PhD; Bride, Brian E. PhD. Implementation of Motivational Interviewing in Substance Use Disorder Treatment: Research Network Participation and Organizational Compatibility. Journal of Addiction Medicine 10(6):p 402-407, November/December 2016. | DOI: 10.1097/ADM.0000000000000251

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The Affordable Care Act requires state Medicaid programs to cover substance use disorder treatment for their Medicaid expansion population but allows states to decide which individual services are reimbursable. To examine how states have defined substance use disorder benefit packages, we used data from 2013–14 that we collected as part of an ongoing nationwide survey of state Medicaid programs. Our findings highlight important state-level differences in coverage for substance use disorder treatment and opioid use disorder medications across the United States. Many states did not cover all levels of care required for effective substance use disorder treatment or medications required for effective opioid use disorder treatment as defined by American Society of Addiction Medicine criteria, which could result in lack of access to needed services for low-income populations.

Colleen M. Grogan, Christina Andrews, Amanda Abraham, Keith Humphreys, Harold A. Pollack, Bikki Tran Smith, and Peter D. Friedmann. Survey Highlights Differences In Medicaid Coverage For Substance Use Treatment And Opioid Use Disorder Medications. Health Affairs 2016 35:12, 2289-2296
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Medications for treatment of substance use disorders are underutilized in treatment programs in the United States. Little is known about how insurance enrollment within states affects treatment program decisions about whether to offer medications. The primary objective of the study was to examine the impact of health insurance enrollment on availability of substance use disorder medications among treatment programs. Data from the 2012 National Survey of Substance Abuse Treatment Services, National Survey on Drug Use and Health, American Community Survey, Area Health Resource File, and the Substance Abuse and Mental Health Services Administration were combined to examine the impact of state insurance enrollment on availability of substance use disorder medications in treatment programs (N=9,888). A two-level, random-intercept logistic regression model was estimated to account for potential unobserved heterogeneity among treatment programs nested in states. The percentage of state residents with employer-based insurance and Medicaid was associated with greater odds of offering at least one medication among treatment programs. A 5% increase in the rate of private insurance enrollment was associated with a 7.7% increase in the probability of offering at least one medication, and a 5% increase in the rate of state Medicaid enrollment was associated with a 9.3% increase in the probability of offering at least one medication. Results point to the potential significance of health insurance enrollment in shaping the availability of substance use disorder medications. Significant expansions in health insurance enrollment spurred by the Affordable Care Act have the potential to increase access to medications for many Americans.

Abraham, A. J., Rieckmann, T., Andrews, C. M., & Jayawardhana, J. (2017). Health Insurance Enrollment and Availability of Medications for Substance Use Disorders. Psychiatric Services, 68(1), 41–47. https://doi.org/10.1176/appi.ps.201500470

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The Affordable Care Act (ACA) dramatically expands health insurance for addiction treatment and provides unprecedented opportunities for service growth and delivery model reform. Yet most addiction treatment programs lack the staffing and technological capabilities to respond successfully to ACA-driven system change. In light of these challenges, we conducted a national survey to examine how Single State Agencies for addiction treatment—the state governmental organizations charged with overseeing addiction treatment programs—are helping programs respond to new requirements under the ACA. We found that most Single State Agencies provide little assistance to addiction treatment programs. Most agencies are helping programs develop collaborations with other health service programs. However, fewer than half reported providing help in modernizing systems to support insurance participation, and only one in three provided assistance with enrollment outreach. In the absence of technical assistance, it is unlikely that addiction treatment programs will fully realize the ACA’s promise to improve access to and quality of addiction treatment.

Christina Andrews, Amanda Abraham, Colleen M. Grogan, Harold A. Pollack, Clifford Bersamira, Keith Humphreys, and Peter Friedmann. Despite Resources From The ACA, Most States Do Little To Help Addiction Treatment Programs Implement Health Care Reform. Health Affairs 2015 34:5, 828-835

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We report findings from a 3-year, mixed-method study of how treatment systems promoted two evidence-based practices: medication-assisted treatment and continuing care management. We compared outcomes and implementation strategies across 12 state/county agencies responsible for alcohol and drug treatment and their selected treatment centers. Each partnership received 2 years of financial and technical support to increase adoption of evidence-based treatments. Partnerships flexibly applied the Advancing Recovery model to promote the adoption of evidence-based treatments. Most sites achieved a measurable increase in the numbers of patients served with evidence-based practices, up from a baseline of virtually no use. Rates of adopting medication-based treatments were higher than those for continuing care management. Partnerships used a menu of top-down and bottom-up strategies that varied in specifics across sites but shared a general process of incremental testing and piecemeal adaptation. Supported partnerships between providers and policymakers can achieve wider adoption of evidence-based treatment practices. Systems change unfolds through a trial-and-error process of adaptation and political learning that is unique to each treatment system. This leads to considerable state and local variation in implementation strategies and outcomes.

Laura A. Schmidt, Traci Rieckmann, Amanda Abraham, Todd Molfenter, Victor Capoccia, Paul Roman, David H. Gustafson, and Dennis McCarty. Advancing Recovery: Implementing Evidence-Based Treatment for Substance Use Disorders at the Systems Level. Journal of Studies on Alcohol and Drugs 2012 73:3 , 413-422
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Prior research suggests that publicly funded substance use disorder (SUD) treatment programs lag behind privately funded programs in adoption of evidence-based practices, resulting in disparities in access to high-quality SUD treatment. These disparities highlight a critical public health concern because the majority of SUD patients in the United States are treated in the publicly funded treatment sector. This study uses recent data to examine disparities in access to physicians and availability of medications for the treatment of SUDs between publicly and privately funded SUD treatment programs. Data were collected from 595 specialty SUD treatment programs from 2007 to 2010 via face-to-face interviews, mailed surveys, and telephone interviews with treatment program administrators. Publicly funded programs were less likely than privately funded programs to have a physician on staff, even after controlling for several organizational characteristics that were associated with access to physicians. The results of negative binomial regression indicated that, even after taking into account physician access and other organizational variables, publicly funded programs prescribed fewer SUD medications than privately funded SUD treatment programs. Patients seeking treatment in publicly funded treatment programs continue to face disparities in access to high-quality SUD treatment that supports patients’ choices among a range of medication options. However, implementation of the Affordable Care Act may facilitate greater access to physicians and use of medications in publicly funded SUD treatment programs.

Amanda J. Abraham, Hannah K. Knudsen, Traci Rieckmann, and Paul M. Roman. Disparities in Access to Physicians and Medications for the Treatment of Substance Use Disorders Between Publicly and Privately Funded Treatment Programs in the United States. Journal of Studies on Alcohol and Drugs 2013 74:2 , 258-265

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There is a growing body of research supporting the use of buprenorphine and other medication assisted treatments (MATs) for the rapidly accelerating opioid epidemic in the United States. Despite numerous advantages of buprenorphine (accessible in primary care, no daily dosing required, minimal stigma), implementation has been slow. As the field progresses, there is a need to understand the impact of participation in practitioner–scientist research networks on acceptance and uptake of buprenorphine. This paper examines the impact of research network participation on counselor attitudes toward buprenorphine addressing both counselor-level characteristics and program-level variables using hierarchical linear modeling (HLM) to account for nesting of counselors within treatment programs. Using data from the National Treatment Center Study, this project compares privately funded treatment programs (N = 345) versus programs affiliated with the National Institute on Drug Abuse Clinical Trials Network (CTN) (N = 198). Models included 922 counselors in 172 CTN programs and 1203 counselors in 251 private programs. Results of two-level HLM logistic (Bernoulli) models revealed that counselors with higher levels of education, larger caseloads, more buprenorphine-specific training, and less preference for 12-step treatment models were more likely to perceive buprenorphine as acceptable and effective. Furthermore, buprenorphine was 50% more likely to be perceived as effective among counselors working in CTN-affiliated programs as compared to private programs. This study suggests that research network affiliation positively impacts counselors’ acceptance and perceptions of buprenorphine. Thus, research network participation can be utilized as a means to promote positive attitudes toward the implementation of innovations including medication assisted treatment.

Traci R. Rieckmann, Amanda J. Abraham, Anne E. Kovas, Bentson H. McFarland, Paul M. Roman, Impact of research network participation on the adoption of buprenorphine for substance abuse treatment, Addictive Behaviors, Volume 39, Issue 5, 2014, Pages 889-896, ISSN 0306-4603, https://doi.org/10.1016/j.addbeh.2014.01.016.

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The National Institute on Drug Abuse’s Clinical Trials Network (CTN) is a practice-based research network that partners academic researchers with community based substance use disorder (SUD) treatment programs designed primarily to conduct effectiveness trials of promising interventions. A secondary goal of the CTN is to widely disseminate results of these trials and thus improve the quality of SUD treatment in the US. Drawing on data from 156 CTN programs, this study examines the association between involvement in CTN protocols and overall treatment quality measured by a comprehensive index of 35 treatment services. Negative binomial regression models show that treatment programs participating in a greater number of CTN protocols had significantly higher levels of treatment quality, an association that held after controlling for key organizational characteristics. These findings contribute to the growing body of research on the role of practice-based research networks in promoting health care quality.

Amanda J. Abraham, Hannah K. Knudsen, Paul M. Roman, The relationship between Clinical Trial Network protocol involvement and quality of substance use disorder treatment, Journal of Substance Abuse Treatment, Volume 46, Issue 2, 2014, Pages 232-237, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2013.08.021.

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For more than 60 years sociologists have examined public attitudes toward persons with alcohol use disorders (AUDs), but there is little recent data on this topic. Using responses to vignettes administered in a 2003 national computer-assisted telephone survey (N = 1394) of employed Americans, this paper examines three research questions: (1) How willing are Americans to interact with persons with AUDs? (2) How are preferences for social distance shaped by known contact with a problem drinker? (3) How does treatment-seeking behavior of a known problem drinker influence such preferences? Results indicate that respondents are reluctant to interact with persons with AUDs, especially in the context of work and family life. Multivariate analyses reveal that respondents who knew a relative or coworker with a drinking problem were more likely to desire social distance from the alcohol dependent vignette person. Consistent with the social contact thesis, respondents who reported spending more time with a known problem drinker, were less likely to desire social distance from persons with AUDs, as were respondents who reported that the known problem drinker received treatment from a counselor, psychiatrist, or physician. These results suggest that stigma associated with AUDs may be decreased through formal treatment for AUDs, as well as by greater diffusion of knowledge about the positive effects of treatment.

Abraham, A. J., Bride, B. E., & Roman, P. M. (2013). Public Attitudes toward Persons with Alcohol Use Disorders (AUDs): The Role of Social Contact and Treatment-Seeking Behavior. Sociological Focus, 46(4), 267–280. https://doi.org/10.1080/00380237.2013.825542

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Counselor emotional exhaustion has negative implications for treatment organizations as well as the health of counselors. Quality clinical supervision is protective against emotional exhaustion, but research on the mediating mechanisms between supervision and exhaustion is limited. Drawing upon data from 934 counselors affiliated with treatment programs in the National Institute on Drug Abuse’s Clinical Trials Network (CTN), this study examined commitment to the treatment organization and commitment to the counseling occupation as potential mediators of the relationship between quality clinical supervision and emotional exhaustion. The final ordinary least squares (OLS) regression model, which accounted for the nesting of counselors within treatment organizations, indicated that these two types of commitment were plausible mediators of the association between clinical supervision and exhaustion. Higher quality clinical supervision was strongly correlated with commitment to the treatment organization as well as commitment to the occupation of SUD counseling. These findings suggest that quality clinical supervision has the potential to yield important benefits for counselor well-being by strengthening ties to both their employing organization as well the larger treatment field, but longitudinal research is needed to establish these causal relationships.

Hannah K. Knudsen, Paul M. Roman, Amanda J. Abraham, Quality of clinical supervision and counselor emotional exhaustion: The potential mediating roles of organizational and occupational commitment, Journal of Substance Abuse Treatment, Volume 44, Issue 5, 2013, Pages 528-533, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2012.12.003.

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Data from a national study of 345 privately funded, community-based substance use disorder (SUD) treatment centers were used to investigate social workers’ knowledge, perceptions of effectiveness, and perceptions of the acceptability of medication assisted treatments (MATs) for SUDs. Results reveal the importance of exposure to MATs for social workers to develop a knowledge base regarding the effectiveness of various pharmacological agents. Results also underline the importance of social workers’ perceptions of effectiveness in forming opinions regarding the acceptability of the use of MATs in SUD treatment. Lastly, a 12-Step orientation toward treatment has a negative influence on social workers’ opinions regarding the acceptability of MATs.

Bride, B. E., Abraham, A. J., Kintzle, S., & Roman, P. M. (2013). Social Workers’ Knowledge and Perceptions of Effectiveness and Acceptability of Medication Assisted Treatment of Substance Use Disorders. Social Work in Health Care, 52(1), 43–58. https://doi.org/10.1080/00981389.2012.725457

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Racial and ethnic minorities and injection drug users (IDUs) are at increased risk of HIV infection. However, the associations between these caseload characteristics and the availability of onsite HIV testing in substance use disorder treatment programs are unknown. This study uses data collected in 2008–2009 from 198 program administrators of treatment programs participating in the National Institute on Drug Abuse’s Clinical Trials Network to address this gap in the literature. Results show positive associations between the percentages of African American, Hispanic, and IDU patients and the odds of offering non-rapid onsite HIV testing versus no onsite testing. The associations between racial/ethnic composition and the availability of rapid HIV testing were more complicated. These findings suggest that many programs are responding to the needs of at-risk populations. However, programs and their patients may benefit from greater adoption of rapid testing which is less costly and better ensures that patients receive their results.

Amanda J. Abraham, Lauren A. O’Brien, Hannah K. Knudsen, Brian E. Bride, G. Rush Smith, Paul M. Roman, Patient characteristics and availability of onsite non-rapid and rapid HIV testing in US substance use disorder treatment programs, Journal of Substance Abuse Treatment, Volume 44, Issue 1, 2013, Pages 120-125, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2012.03.004.

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The purpose of this study was to examine factors that may be associated with variation in social workers’ perceptions of effectiveness, perceptions of acceptability, and use of psychosocial evidence-based practices (EBPs) for the treatment of substance use disorders (SUD) in comparison to other SUD counselors who are non–social workers. A national sample of 1,140 counselors in private SUD treatment settings completed a mailed survey. Overall, counselors perceive both motivational interviewing (MI) and contingency management (CM) to be effective and acceptable interventions, with MI perceived to be both more effective and more acceptable than CM. The results of this study also shed light on the factors associated with perceptions of effectiveness and acceptability of MI and CM. The results of this study underscore the importance of exposure to EBPs in the development of positive attitudes toward and use of EBPs. In particular, professional networks are an important route to introduce social workers to EBPs, as is professional training on specific EBPs. Efforts to increase the uptake of evidence-based SUD interventions should not be limited to dissemination of information regarding effectiveness; rather, efforts should also be expended to expose social workers to EBPs.

Brian E. Bride, Sara Kintzle, Amanda J. Abraham, Paul M. Roman, Counselor Attitudes toward and Use of Evidence-based Practices in Private Substance Use Disorder Treatment Centers: A Comparison of Social Workers and Non–Social Workers, Health & Social Work, Volume 37, Issue 3, August 2012, Pages 135–145, https://doi.org/10.1093/hsw/hls022

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Little is known about the organizational and environmental factors associated with the employment of nurses in substance abuse treatment programs. Using data collected from the administrators of 250 publicly funded substance abuse treatment programs, this study examined the organizational and environmental correlates of nurse employment in these settings. Negative binomial regression models indicated that the number of nurses employed by treatment programs was positively associated with government ownership, location within a healthcare setting, and the availability of detoxification services. Outpatient-only programs employed fewer nurses than programs with inpatient/residential services. Two environmental factors were associated with nurse employment. Programs that more strongly endorsed a scale of financial barriers employed significantly fewer nurses, whereas programs indicating that funding from state contracts could be used to pay for healthcare providers employed significantly more nurses. These findings suggest that organizational decisions about employing nurses may reflect both the characteristics of the program and the funding environment. Future research should continue to examine the employment of nurses in substance abuse treatment settings, particularly given the shifting environment due to the implementation of healthcare reform.

Knudsen, Hannah K. PhD; Abraham, Amanda J. PhD. The Employment of Nurses in Publicly Funded Substance Abuse Treatment Programs. Journal of Addictions Nursing 23(3):p 174-180, October 2012. | DOI: 10.1097/JAN.0b013e31826f4c25

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Treatment providers in the US have been slow to adopt medications to treat alcohol use disorders (AUDs). This study examines the availability of AUD medications in a nationally representative sample of specialty AUD treatment programs (N=293). Data were collected via face-to-face administrative interviews from 2009 to 2012. Less than 25% of specialty AUD programs prescribed disulfiram, tablet naltrexone, acamprosate, or injectable naltrexone. Adoption was more likely in larger programs, those accredited by JC/CARF, and those with a higher percentage of private insurance revenues, and significantly less likely in programs with a higher percentage of criminal justice revenues. Analyses suggest that lack of access to physicians, cost of medications, and lack of knowledge about newer AUD medications are key barriers to wider implementation of AUD medications. Results indicate the potential value of targeted cost benefit analyses as well as efforts for improved education about advantages of the use of medications in AUD treatment.

Abraham, A., & Roman, P. M. (2012). Availability of medications for the treatment of alcohol use disorders: Data from US specialty treatment systems. Journal of Substance Use and Addiction Treatment, 43(3).

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The employment of physicians by substance abuse treatment organizations is understudied, despite physicians’ importance in implementing pharmacotherapy and integrating treatment into the broader system of medical care. Drawing on data collected from 249 publicly funded treatment organizations, this study examined organizational and environmental factors associated with the employment of physicians in these settings. A negative binomial regression model indicated that greater numbers of physicians were employed when organizations offered detoxification services, were embedded in health care settings, and were larger in size. Funding barriers, including the costs of physicians and inadequate reimbursement by funders, were negatively associated with physician employment. Programs unaware that they could use state contract funding to pay for medical staff employed fewer numbers of physicians than programs aware of this type of state policy. Attempts to increase physician employment in substance abuse treatment may require attention to both organizational and environmental factors rather than simply trying to attract individuals to the field. Increasing physician employment may be challenging in the current economic climate.

Hannah K. Knudsen, Carrie B. Oser, Amanda J. Abraham, Paul M. Roman, Physicians in the substance abuse treatment workforce: Understanding their employment within publicly funded treatment organizations, Journal of Substance Abuse Treatment, Volume 43, Issue 2, 2012, Pages 152-160, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2011.12.003.

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Given that most addiction counselors enter the field unprepared to implement psychosocial evidence-based practices (EBPs), surprisingly little is known about the extent to which substance abuse treatment centers provide their counselors with formal training in these treatments. This study examines the extent of formal training that treatment centers provide their counselors in cognitive behavioral therapy (CBT), motivational interviewing (MI), contingency management (CM), and brief strategic family therapy (BSFT). Face-to-face interviews with 340 directors of a nationally representative sample of privately funded US substance abuse treatment centers. Although a substantial number of treatment centers provide their counselors with formal training in EBPs that they use with their clients, coverage is far from complete. For example, of those centers that use CBT, 34% do not provide their counselors with any formal training in CBT (either initially or annually), and 61% do not provide training in CBT that includes supervised training cases. Sizable training gaps exist for MI, CM, and BSFT as well. The large training gaps found in this study give rise to concerns regarding the integrity with which CBT, MI, CM, and BSFT are being delivered by counselors in private US substance abuse treatment centers. Future research should examine the generalizability of our findings to other types of treatment centers (e.g., public) and to the implementation of other EBPs.

Todd A. Olmstead, Amanda J. Abraham, Steve Martino, Paul M. Roman, Counselor training in several evidence-based psychosocial addiction treatments in private US substance abuse treatment centers, Drug and Alcohol Dependence, Volume 120, Issues 1–3, 2012, Pages 149-154, ISSN 0376-8716, https://doi.org/10.1016/j.drugalcdep.2011.07.017.

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Despite growing interest in the use of evidence-based treatment practices for treating substance use disorders, adoption of medications by treatment programs remains modest. Drawing on resource dependence and institutional theory, this study examined the relationships between adoption of medications by treatment programs and their perceptions about the state policy environment. Data were collected through mailed surveys and telephone interviews with 250 administrators of publicly funded substance abuse treatment programs in the United States between 2009 and 2010. Multiple imputation and multivariate logistic regression were used to estimate the associations between perceptions of the state policy environment and the odds of adopting at least one medication for the treatment of substance use disorders. A total of 91 (37%) programs reported having prescribed any medication for treatment of a substance use disorder. Programs were significantly more likely to have adopted at least one medication if they perceived greater support for medications by the Single State Agency. The odds of adoption were significantly greater if the program was aware that at least one medication was included on their state’s Medicaid formulary and that state-contract funding permitted the purchase of medications. States may play significant roles in promoting the adoption of medications, but adequate dissemination of information about state policies and priorities may be vital to further adoption. Future research should continue to study the relationships between the adoption of medications for treating substance use disorders and the evolving policy environment. (Psychiatric Services 63:19–25, 2012)

Knudsen, H. K., & Abraham, A. J. (2012). Perceptions of the State Policy Environment and Adoption of Medications in the Treatment of Substance Use Disorders. Psychiatric Services, 63(1), 19–25. https://doi.org/10.1176/appi.ps.201100034

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Identifying facilitators of more rapid buprenorphine adoption may increase access to this effective treatment for opioid dependence. Using a diffusion of innovations theoretical framework, we examine the extent to which programs’ interorganizational institutional and resource-based linkages predict the likelihood of being an earlier adopter, later adopter, or nonadopter of buprenorphine. Data were derived from face-to-face interviews with administrators of 345 privately funded substance abuse treatment programs in 2007–2008. Results of multinomial logistic regression models show that interorganizational and resource linkages were associated with timing of adoption. Programs reporting membership in provider associations were more likely to be earlier adopters of buprenorphine. Programs that relied more on resource linkages, such as detailing activities by pharmaceutical companies and the National Institute on Drug Abuse website, were more likely to be earlier adopters of buprenorphine. These findings suggest that institutional and resource-based interorganizational linkages may expose programs to effective treatments, thereby facilitating more rapid and sustained adoption of innovative treatment techniques.

Sarah A. Savage, Amanda J. Abraham, Hannah K. Knudsen, Tanja C. Rothrauff, Paul M. Roman, Timing of buprenorphine adoption by privately funded substance abuse treatment programs: The role of institutional and resource-based interorganizational linkages, Journal of Substance Abuse Treatment, Volume 42, Issue 1, 2012, Pages 16-24, ISSN 0740-5472, https://doi.org/10.1016/j.jsat.2011.06.009.

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