Project Summary: High quality evidence supports medication assisted treatment (MAT) as the first line
treatment for opioid use disorder (OUD), especially opioid substitution therapy with buprenorphine or
methadone as long-term maintenance of at least one year. Yet patient dropout (typically >50% at six months),
and provider resistance remain major impediments to effective treatment. To date, few studies have examined
patient characteristics that influence key steps in treatment initiation, stabilization, and long-term retention with
buprenorphine. Most published studies assess outcomes for only 2-3 months of active treatment among highly
selected patients in clinical trials. I will draw from the influential, sequential “cascade of care” framework from
the HIV/AIDS field as a conceptual model to identify stage-specific barriers to continuity of buprenorphine
treatment through an adapted OUD treatment cascade. A greater understanding of barriers at each sequential
stage of the cascade including 1) initiation of buprenorphine, 2) stabilization of opioid use, and 3) retention with
long-term treatment response, may inform clinical efforts to improve outcomes and mortality.
Under healthcare reform and Medicaid redesign, increasing numbers of patients receive insurance
reimbursement for substance abuse treatment. I propose to link clinical data from electronic health records
(EHR) to insurance claims data to assess patient factors that promote continuity of care along the cascade.
This strategy will capture critical information (ED visits, diagnoses, treatment services, mortality) that are
outside of a given clinical site's records. Insurance claims data have the advantage of providing near complete
follow up and objective outcomes that do not rely on self-report and reflect real-world clinical complexities.
In order to accomplish these goals and achieve my long-term training objectives of developing
expertise in quantitative methods, epidemiology, and the management and inferential analysis of large
observational data sets, I have articulated five sequential training goals: 1) epidemiologic and statistical data
analysis methods 2) services research, program evaluation, and model design 3) insurance claims data
analysis 4) inferential methods with observational data, and 5) grant writing and administration. To fulfill my
research aims, I will incorporate electronic records from a high-volume, multi-site MAT provider that has started
18,000 patients on buprenorphine since 2009 with frequent in-house urine drug testing. The research will
identify patient characteristics associated with successful buprenorphine initiation, stabilization, and retention
and will model barriers at each stage of the treatment cascade. With these findings, I also seek to evaluate the
clinical utility of each stage by modeling associations between attaining each stage of treatment and improved
clinical outcomes. The results, which will be based on a large, highly generalizable, community-based sample
of adults with OUD presenting for treatment, will evaluate the clinical consequences of long-term MAT
maintenance and help guide quality improvement initiatives.