Mediating effect of craving on the impact of buprenorphine/naloxone and methadone treatment on opioid use: Results from a randomized controlled trial

BACKGROUND

The relationship between opioid craving and opioid use is unclear. We sought to determine to what extent craving mediated the relationship between opioid agonist therapy and changes in opioid use.

METHODS

Data came from a pragmatic, 24-week, pan-Canadian, multi-centric, open-label, randomized controlled trial comparing flexible buprenorphine/naloxone take-home doses to standard supervised methadone models of care for the treatment of prescription-type opioid use disorder. Participants were randomly allocated to buprenorphine/naloxone or methadone models of care. 270 people with prescription-type opioid use disorder were included in analyses. There were 93 women (34.4%) and 2 transgender (0.7%) participants. Most participants were white (67.4%), 45.9% reported unstable living conditions, and 44.8% had psychiatric comorbidities. Generalized linear mixed models followed by mediation analysis estimated the direct effect of treatment group on Timeline Followback-reported next-week opioid use and the indirect effect through past 24-hour opioid craving measured using the Brief Substance Craving Scale at week 2, 6, 10, 14, 18 and 22.

RESULTS

Upon mediation analysis, the average direct effect of treatment on opioid use was 0.465 (95 % CI = 0.183 to 0.751, p < 0.001). The average causal mediated effect was 0.144 (95 % CI = 0.021 to 0.110; p < 0.001). Craving accounted for 23.6 % of the effect of treatment on opioid use (p < 0.001).

CONCLUSIONS

Past 24-hour craving was associated with increased next-week opioid use; however, craving only partially mediated the effect of buprenorphine/naloxone and methadone on next-week opioid use. Research is needed to develop a comprehensive understanding of factors mediating opioid use during opioid agonist therapy.

A Practical Guide to Implementing an Evidenced-Based Hands-On Naloxone Training

Synthetic opioids contribute to the majority of opioid overdose-related deaths in the United States. Expansion of naloxone training to community laypersons is one strategy to mitigate opioid overdose-related deaths. A hands-on naloxone training demonstrated efficacy in improving opioid knowledge and overdose response in baccalaureate nursing students, Greek-affiliated students, and rural clinicians and staff post-training. The purpose of this practical guide is to provide detailed steps to implement an evidence-based hands-on naloxone training for laypersons in community settings. The hands-on naloxone training consisted of five components: evaluator training, a validated pre-post opioid knowledge questionnaire, an opioid lecture, a performance evaluation, and a satisfaction survey. Post-training, trainees demonstrated increased knowledge related to opioids and overdose response, and they felt comfortable administering naloxone to someone experiencing an opioid overdose. Researchers, educators, and community health nurses can adapt this evidence-based practical guide to train peers and acquaintances who are likely to witness an opioid overdose. Virtual training and multi-lingual protocols should be considered to successfully train diverse groups of community laypersons. An active hands-on naloxone training can improve confidence for community health nurses and other health care professionals, and it may reduce delays in response time and naloxone administration. Nurses can use this hands-on training to educate students, families, community members, and stakeholders how to respond to an opioid overdose event.

Naloxegol versus Methylnaltrexone for Opioid-Induced Constipation in Critically Ill Patients

BACKGROUND

Constipation impacts 58% to 83% of critically ill patients and is associated with increased time on mechanical ventilation, delirium, and increased length of stay (LOS) in the intensive care unit (ICU).

OBJECTIVE

The purpose of this study was to evaluate the efficacy of enteral naloxegol (NGL) versus subcutaneous methylnaltrexone (MNTX) for the management of opioid-induced constipation (OIC) in critically ill patients.

METHODS

A retrospective analysis was conducted on adult patients admitted to the ICU who received a parenteral opioid infusion for at least 4 hours and experienced no bowel movement (BM) within the 48-hour period preceding the administration of NGL or MNTX. The primary outcome was time to first BM from the start of NGL or MNTX therapy. Secondary outcomes included number of BMs 72 hours following NGL or MNTX administration, ICU LOS, and cost-effectiveness.

RESULTS

After exclusion criteria were applied, 110 and 51 patients were included in the NGL and MNTX groups, respectively. With a 10% noninferiority margin, NGL was noninferior to MNTX (Wald statistic = 1.67; P = 0.047). Median time to first BM was 23.7 hours for NGL and 18.3 hours for MNTX patients. Median LOS was 14 days (NGL) and 12 days (MNTX), and the average number of BMs in 72 hours was 3.9 for NGL and 3.8 for MNTX. Using wholesale acquisition cost (WAC), the cost per BM for NGL and MNTX was $21.74 and $170.00, respectively.

CONCLUSION AND RELEVANCE

This study determined that NGL and MNTX had similar time to BM. NGL appears to be a safe and effective alternative with cost-saving potential in treating OIC in critically ill patients.

Managing emergency department patients with opioid use disorder

As the United States continues to grapple with the opioid crisis, emergency clinicians are on the front lines of managing patients with opioid use disorder. This issue reviews tools and best practices in emergency department management of patients with opioid overdose and opioid withdrawal, and how substance use history will inform treatment planning and disposition. As growing evidence shows that medications for opioid use disorder (MOUD)- buprenorphine, methadone, and naltrexone-can have lasting impacts on patients' addiction recovery, strategies for assessing patient readiness for MOUD and overcoming barriers to emergency department initiation of these medications are reviewed. Newer approaches to buprenorphine dosing (high-dose, low-dose, home induction, and long-acting injectable dosing) are also reviewed.

A population-based time-series analysis of opioid agonist treatment dispensed during pregnancy

BACKGROUND AND AIMS

Identifying effective opioid treatment options during pregnancy is a high priority due to the growing prevalence of opioid use disorder across North America. We assessed the temporal impact of three population-level interventions on the use of opioid agonist treatment (OAT) during pregnancy in Ontario, Canada.

DESIGN

This was a population-based time-series analysis to identify trends in the monthly prevalence of pregnant people dispensed methadone and buprenorphine. The impact of adding buprenorphine/naloxone to the public drug formulary, the release of pregnancy-specific guidance and the start of the COVID-19 pandemic were assessed.

SETTING AND PARTICIPANTS

The study was conducted in Ontario, Canada between 1 July 2013 and 31 March 2022, comprising people who delivered a live or stillbirth in any Ontario hospital during the study period.

MEASUREMENTS

We identified any prescription for methadone or buprenorphine dispensed between the estimated conception date and delivery date and calculated the monthly prevalence of OAT-exposed pregnancies among all pregnant people in Ontario.

FINDINGS

Overall, rates of OAT during pregnancy have declined since mid-2018. Methadone-exposed pregnancies decreased from 0.46% of all pregnancies in Ontario in 2015 to a low of 0.16% in 2022. In the primary analysis, none of the interventions had a statistically significant impact on overall OAT rates; however, in the stratified analyses, there was a small increase in buprenorphine after the formulary change [0.006%, 95% confidence interval (CI) = 0.0032-0.0081, P < 0.0001] and a decrease in buprenorphine after the release of the 2017 guidelines (-0.005%, 95% CI = -0.0080 to -0.0020, P = 0.001) and the start of the COVID-19 pandemic (-0.003%, 95% CI = -0.0054 to -0.0006, P = 0.015).

CONCLUSION

Despite changes in guidance and funding, opioid agonist treatment during pregnancy has been declining in Ontario, Canada since 2018.

High-Dose Buprenorphine Initiation in the Management of Opioid Use Disorder in Pregnancy

Buprenorphine is commonly used as a treatment for opioid use disorder (OUD). Transition to buprenorphine traditionally has been done using a low-dose initiation regimen due to concerns surrounding precipitated withdrawal. There are increasing data supporting use of a high-dose initiation regimen in the nonpregnant population. This retrospective case series describes six individuals with OUD who underwent high-dose buprenorphine initiation in pregnancy. There were no instances of sedation, respiratory depression, supplemental oxygen use, or death. All individuals were successfully transitioned to buprenorphine. These findings provide support for high-dose buprenorphine initiation in pregnancy, but future large studies are needed.

Extended-release versus oral buprenorphine as opioid maintenance treatment during pregnancy-maternal and neonatal outcomes

OBJECTIVE

To get information on subcutaneous extended-release buprenorphine as opioid maintenance treatment during pregnancy, we compared it to orally administered buprenorphine and buprenorphine-naloxone treatments. We hypothesized that maternal and neonatal outcomes do not differ between the treatment groups. Study design In this population-based cohort study, 60 pregnant individuals receiving non-changed opioid maintenance treatment for opioid use disorder with a buprenorphine product from the time before conception to the time after delivery and their newborns were included. They were divided into three groups based on the pharmacotherapy with subcutaneous extended-release buprenorphine, sublingual buprenorphine, or buprenorphine-naloxone. Statistical analyses were conducted using Fischer's exact tests, ANOVA tests, and Kruskal-Wallis tests. All the statistical tests were two-tailed.

RESULTS

The frequency of pregnancy or delivery complications did not significantly differ between the group receiving extended-release buprenorphine and the other groups. During pregnancy, 38 % of the women used illicit drugs concomitantly, with equal frequency in the extended-release buprenorphine group and the other groups. Of the neonates, 93 % were born full-term and 90 % got at least eight Apgar points in one minute age, without significant differences between the groups (p = 0.57). The need for pharmacotherapy for neonatal opioid withdrawal syndrome was the lowest in the extended-release buprenorphine group (25 %) and highest in the sublingual buprenorphine group (67 %). Still, the difference between the treatment groups did not reach statistical significance (p = 0.17). Among all neonates, the breastfed infants were less likely to receive pharmacotherapy for withdrawal symptoms than the formula-fed ones (p = 0.048).

CONCLUSIONS

Extended-release buprenorphine with steady drug concentration seems to be a promising pharmacotherapy option during pregnancy for mothers. Maternal health during pregnancy may contribute to the well-being of newborns. Larger trials are urgently needed to confirm these results..

Access to, Experience with, and Attitudes towards Take Home Naloxone: An Online Survey

The opioid public health crisis continues to burden individuals, communities, and economies. Public health opinion has emphasized the need for increased access to harm reduction services, but there is a dearth of information on the views and experiences of people who use opioids. Our study aimed to investigate the prevalence of naloxone use, attitudes, and experiences with naloxone among an online community of people who use drugs. We performed a cross-sectional survey looking at experiences with and attitudes towards take-home naloxone. Data is presented descriptively, with analysis of the differences between people who do and do not use opioids using the χ2 and Fisher's exact tests. There were 1,143 respondents, of whom 70% were from the United States. Only 38% of participants who use opioids had received naloxone training, but 56% of these individuals said that they felt comfortable using a naloxone kit. Nearly all respondents (95%) said they would be willing to use naloxone on someone who had overdosed and approximately 90% would want naloxone used on them in case of an overdose. Regarding harm reduction, 24% of respondents said they had access to safe use programs, and 33% said they had access to clean needle exchange programs. A majority of the participants who use opioids were in favor of having naloxone with them when using drugs and believed naloxone should be freely available. This study demonstrates the receptiveness of take-home naloxone and highlights the need for better implementation of naloxone within communities that use opioids.

Bystander-application of a novel nasal swab optimized for drug delivery is safe and non-traumatic for the general population

OBJECTIVE

The PN Naloxone Nasal Swab (Pocket Naloxone Corp., Bethesda, MD) is a swab optimized for drug delivery and intended for use by non-medical personnel for the emergency treatment of opioid overdose. The aim of this study (PNC-20-003) is to determine the safety of this nasal swab in a real-world environment.

METHODS

This was a single-institution, quantitative-qualitative prospective trial performed at an outpatient clinic. Patients with normal or abnormal nasal structure were recruited. A non-medically trained individual placed the nasal (soaked in fluorescein dye) on each side of the patient's nose. Endoscopy with recording was performed before and after swab placement. An independent reviewer rated degree of staining, mucosal bleeding, and trauma at nasal subsites.

RESULTS

Videos from 32 nasal cavities (16 participants) were reviewed. All cavities had high intensity staining at the septum and the inferior turbinate. No patients had staining within the middle meatus, agger nasi, or olfactory regions. In patients with normal anatomy, obstructive nasal anatomy or prior nasal surgery, all cavities had staining near the nasal septum. Only 7 cavities (22 %) had minor bleeding defined as ooze that stopped in 1-2min, and 3 (9 %) had minor trauma defined as mucosal disruption less than 5mm. There were no significant differences in comparing pre- and post-swab nasal cavity, trauma, or bleeding exams.

CONCLUSIONS

These study results showed that this swab is atraumatic to the nasal mucosal membranes when administered by non-medical personnel. Analysis suggests contact with targeted sites for drug absorption regardless of anatomy.

Naloxone use by Aotearoa New Zealand emergency medical services, 2017-2021

OBJECTIVE

Emergency medical services (EMS) use of naloxone in the prehospital setting is indicated in patients who have significantly impaired breathing or level of consciousness when opioid intoxication is suspected. The present study characterised naloxone use in a nationwide sample of Aotearoa New Zealand road EMS patients to establish a baseline for surveillance of any changes in the future.

METHODS

A retrospective analysis of rates of patients with naloxone administrations was conducted using Hato Hone St John (2017-2021) and Wellington Free Ambulance (2018-2021) electronic patient report form datasets. Patient demographics, presenting complaints, naloxone dosing, and initial and last vital sign clinical observations were described.

RESULTS

There were 2018 patients with an equal proportion of males and females, and patient median age was 47 years. There were between 8.0 (in 2018) and 9.0 (in 2020) naloxone administrations per 100 000 population-years, or approximately one administration per day for the whole country of 5 million people. Poisoning by unknown agent(s) was the most common presenting complaint (61%). The median dose of naloxone per patient was 0.4 mg; 85% was administered intravenously. The median observed change in Glasgow Coma Scale score was +1, and respiratory rate increased by +2 breaths/min.

CONCLUSIONS

A national rate of EMS naloxone patients was established; measured clinical effects of naloxone were modest, suggesting many patients had reasons other than opioid toxicity contributing to their symptoms. Naloxone administration rates provide indirect surveillance information about suspected harmful opioid exposures but need to be interpreted with care.

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia

BACKGROUND

The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace.

METHODS

We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work.

RESULTS

One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses.

CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE

Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.

Reducing the Likelihood of Opioid Overdose Fatalities on College and University Campuses: An Action Plan and Model

For more than two decades there has been a continuous rise in opioid overdose related deaths. The majority of the deaths include the age range when, traditionally, individuals are likely to attend college or university. As a result, Vassar College has taken the important initiative and created and implemented a new opioid overdose intervention strategy and action plan called AED+. AED+ expands on the Model of Greater Awareness, Training and Increased Availability of and Accessibility to Life Saving Intervention Devices; a model that was created based on AED devices improving outcomes of out-of-hospital cardiac arrest emergencies. Similar to AED's improving out-of-hospital cardiac arrest outcomes, the + component of the AED+ initiative increases awareness and provides basic, targeted education about naloxone and its use. Furthermore, the education includes information about naloxone's greater availability and its more immediate access across the campus by students, staff, faculty, administrators, and visitors in the event of a suspected opioid overdose. Starting in May 2023, members of the school's Health Service and senior administrative leaders identified it necessary to be proactive and not reactive to managing an opioid overdose in the campus community. Although Vassar College has not recently experienced an opioid overdose, it is confidently projected that these targeted actions will proactively and positively reduce the likelihood of opioid-related fatalities on campus. Furthermore, it is the purpose of this article to share the AED+ model so other colleges and universities can modify it to best fit their unique setting in order to improve opioid overdose outcomes.

Expanding access to Medication for Opioid Use Disorder (MOUD) in jails: A comprehensive program evaluation

INTRODUCTION

Individuals with opioid use disorder (OUD) transitioning from jails or prisons to the community are at high risk of overdose-related death shortly after release. Buprenorphine, methadone, and extended-release naltrexone are FDA-approved medications for opioid use disorder (MOUD) to reduce overdose risk and increase treatment engagement. Despite the evidence, many correctional facilities in the United States do not provide MOUD to their incarcerated population. Albany County Jail and Rehabilitative Services Center (ACCRSC) is a jail in New York State that provides comprehensive MOUD and overdose prevention services to all incarcerated individuals with OUD.

METHODS

MOUD program participants' data was collected during custody and after release to determine whether the program's primary goals of preventing overdose-related mortality and MOUD continuation after release were met. Other quality-of-life metrics were used for program improvements, such as program participants' physical and mental well-being, postrelease housing, employment, access to mental health services, and re-incarceration.

RESULTS

This study included 375 unique individuals who received MOUD treatment at the jail between January 19, 2019, and the end of December 2020, with 56.2 % continuing their treatment and 43.7 % initiating MOUD during custody. Among those who initiated MOUD at ACCRSC, 93.3 % were enrolled in buprenorphine. We identified eight program participant deaths after release within a year after incarceration. The average time between release and death was 233 days, with the shortest time between release and death being 107 days. We found that over half (53.6 %) of program participants using buprenorphine picked up their prescriptions after exiting ACCRSC. Among those who did not, nearly 16 % were unable to do so because they were transferred to another jail or prison that did not provide MOUD care. Overall, nearly 80 % of program participants who were transferred to another correctional facility could not continue their medication.

CONCLUSIONS

MOUD in correctional settings appears to reduce overdose deaths immediately after release. Administering buprenorphine and other types of MOUD in a jail setting has shown relatively high retention for people to fill their first prescription of buprenorphine outside the jail. To ensure high MOUD retention among incarcerated populations, all correctional facilities must provide MOUD care.

Growing importance of high-volume buprenorphine prescribers in OUD treatment: 2009-2018

BACKGROUND

We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018.

METHODS

In this observational cohort study, IQVIA Real World retail pharmacy claims data were used to characterize trends in high-volume buprenorphine prescribers (clinicians with a mean of 30 or more active patients in every month that they were an active prescriber) during 2009-2018. Very high-volume prescribing (mean of 100+ patients per month) was also examined.

RESULTS

Overall, 94,491 clinicians prescribed buprenorphine dispensed during 2009-2018. The proportion of active prescribers meeting high-volume criteria increased from 7.4 % in 2009 to 16.7 % in 2018. High-volume prescribers accounted for 80 % of dispensed buprenorphine prescriptions during 2009-2018; very high-volume prescribers accounted for 26 %. Adult primary care physicians consistently comprised the majority of high-volume prescribers. Addiction specialists were much more likely to be high-volume prescribers compared to other specialties, including psychiatrists and pain specialists. By 2018, the proportion of prescriptions from high-volume prescribers paid by Medicaid had doubled to 40 %, accompanied by a decline in both self-pay and commercial insurance. High-volume prescribers were overwhelmingly concentrated in urban counties with the highest fatal overdose rates. In 2018, the highest density of high-volume prescribers was in New England and the mid-Atlantic region.

CONCLUSIONS

Growth in high-volume prescribers outpaced the overall growth in buprenorphine prescribers across 2009-2018. High-volume prescribers play an increasingly central role in providing medication for OUD in the U.S., yet results indicate key regional variation in the availability of high-volume buprenorphine prescribers.

Overdose responses among rural people who use drugs: A multi-regional qualitative study

BACKGROUND

Efforts to distribute naloxone have equipped more people with the ability to reverse opioid overdoses but people who use drugs are often reluctant to call 911 due to concerns for legal repercussions. Rural communities face unique challenges in reducing overdose deaths compared to urban communities, including limited access to harm reduction services as well as greater concerns about stigma and privacy.

METHODS

The Rural Opioid Initiative was funded in 2017 to better understand the health-related harms associated with the opioid crisis in rural US communities and consists of eight studies spanning ten states and 65 counties. Each study conducted semi-structured qualitative interviews with people who use drugs to understand contextual factors influencing drug use and health behaviors. We analyzed qualitative data from seven studies with data available at the time of analysis to understand peer response to overdose.

RESULTS

Of the 304 participants interviewed, 55% were men, 70% were white, 80% reported current injection drug use, and 60% reported methamphetamine use. Similar to what has been found in studies focused on urban settings, people who use drugs in rural communities use a range of strategies to reverse overdoses, including non-evidence-based approaches. Several reported that multiple doses of naloxone are needed to reverse overdose. Three themes emerged around the willingness to call 911, including (1) hesitancy to call 911 for fear of legal consequences, (2) negative perceptions or experiences with law enforcement officers, and (3) efforts to obtain medical intervention while avoiding identification/law enforcement involvement.

CONCLUSION

People who use drugs employ multiple strategies to attempt overdose reversal, including non-evidence-based approaches. Greater education about the most effective and least harmful strategies is needed. Reluctance to call 911 is rooted in concerns about potential legal consequences as well as perceptions about law enforcement officers, which may be heightened in rural communities where people who use drugs are more easily identified by law enforcement. People who use drugs will go to great strides to connect their peers to needed medical services, suggesting that comprehensive interventions to reduce interactions with law enforcement officers and eliminate legal consequences for reporting overdoses are critical.

Reducing overdose deaths among persons with opioid use disorder in connecticut

BACKGROUND

People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary.

METHODS

We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons.

RESULTS

Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime.

CONCLUSIONS

Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

How Ohio public library systems respond to opioid-related substance use: a descriptive analysis of survey results

BACKGROUND

Public libraries in the United States have experienced increases in opioid-related substance use in their communities and on their premises. This includes fatal and non-fatal overdose events. Some libraries have adopted response measures in their branches to deter substance use or prevent overdose. A small number of libraries around the nation have decided to stock the opioid antagonist naloxone (Narcan) for staff to administer to patrons who experience overdose. This response measure has generated extensive media attention. Although Ohio ranks fourth in age-adjusted drug mortality rate in the United States, there has been no investigation of whether Ohio libraries are observing opioid-related transactions, consumption, and/or overdose events, or which measures they have adopted in response to these activities. We conducted a multimethod survey with Ohio public library directors to identify the response measures they have adopted. We present descriptive findings from the quantitative and qualitative items in our survey.

METHODS

We conducted a cross-sectional 54-item multimethod survey of public library system directors (one per system) in Ohio. Directors of each of Ohio's public library systems were invited to participate via email.

RESULTS

Of 251 library systems, 56 responded (22.3% response rate), with 34 respondents (60.7%) indicating awareness of opioid-related transactions, consumption, and/or overdose on their premises. Most (n = 43, 76.8%) did not stock naloxone in their buildings. Over half (n = 34, 60.7%) reported implementing one or more non-naloxone response measures. These measures focus on improving security for staff and patrons, deterring opioid-related transactions (purchases and exchanges) and consumption, and providing educational events on substance use. Nearly half (n = 25, 47.2%) partner with community organizations to provide opioid response measures. A similar proportion reported adequate funding to respond to opioid-related substance use (n = 23, 45.1%), and most (n = 38, 74.5%) reported adequate support from their boards and communities. Few respondents have implemented evaluations of their response measures.

CONCLUSIONS

Ohio public libraries are responding to evidence of opioid-related transactions, consumption, and/or overdose on their premises with a range of measures that focus on substance use prevention and deterrence. Most Ohio library systems do not stock naloxone. Respondents indicated they prefer to call 911 and let first responders handle overdose events. The majority of respondents indicated their library systems have political capacity to respond to evidence of opioid-related substance use on their premises, but have limited operational and functional capacity. Findings suggest the need to revisit assumptions that public libraries are willing to stock naloxone to respond to overdose events, and that libraries have the resources to respond robustly to opioid-related transactions, consumption, and/or overdose on their premises.

Low-dose naltrexone for post-COVID fatigue syndrome: a study protocol for a double-blind, randomised trial in British Columbia

INTRODUCTION

A significant proportion of individuals suffering from post COVID-19 condition (PCC, also known as long COVID) can present with persistent, disabling fatigue similar to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and post-viral fatigue syndromes. There remains no clear pharmacological therapy for patients with this subtype of PCC, which can be referred to as post-COVID fatigue syndrome (PCFS). A low dose of the opioid antagonist naltrexone (ie, low-dose naltrexone (LDN)) has emerged as an off-label treatment for treating fatigue and other symptoms in PCC. However, only small, non-controlled studies have assessed LDN in PCC, so randomised trials are urgently required.

METHODS AND ANALYSIS

A prospective, randomised, double-blind, parallel arm, placebo-controlled phase II trial will be performed to assess the efficacy of LDN for improving fatigue in PCFS. The trial will be decentralised and open to eligible individuals throughout the Canadian province of British Columbia (BC). Participants will be recruited through the province-wide Post-COVID-19 Interdisciplinary Clinical Care Network (PC-ICCN) and research volunteer platform (REACH BC). Eligible participants will be 19-69 years old, have had a confirmed or physician-suspected SARS-CoV-2 infection at least 3 months prior and meet clinical criteria for PCFS adapted from the Institute of Medicine ME/CFS criteria. Individuals who are taking opioid medications, have a history of ME/CFS prior to COVID-19 or history of significant liver disease will be excluded. Participants will be randomised to an LDN intervention arm (n=80) or placebo arm (n=80). Participants in each arm will be prescribed identical capsules starting at 1 mg daily and follow a prespecified schedule for up-titration to 4.5 mg daily or the maximum tolerated dose. The trial will be conducted over 16 weeks, with assessments at baseline, 6, 12 and 16 weeks. The primary outcome will be fatigue severity at 16 weeks evaluated by the Fatigue Severity Scale. Secondary outcomes will include pain Visual Analogue Scale score, overall symptom severity as measured by the Patient Phenotyping Questionnaire Short Form, 7-day step count and health-related quality of life measured by the EuroQol 5-Dimension questionnaire.

ETHICS AND DISSEMINATION

The trial has been authorised by Health Canada and approved by The University of British Columbia/Children's and Women's Health Centre of British Columbia Research Ethics Board. On completion, findings will be disseminated to patients, caregivers and clinicians through engagement activities within existing PCC and ME/CFS networks. Results will be published in academic journals and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT05430152.

High-dose naloxone formulations are not as essential as we thought

Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.

Barriers to Buprenorphine Dispensing by Medicaid-Participating Community Retail Pharmacies

Importance

Controlled substances have regulatory requirements under the US Federal Controlled Substance Act that must be met before pharmacies can stock and dispense them. However, emerging evidence suggests there are pharmacy-level barriers in access to buprenorphine for treatment for opioid use disorder even among pharmacies that dispense other opioids.

Objective

To estimate the proportion of Medicaid-participating community retail pharmacies that dispense buprenorphine, out of Medicaid-participating community retail pharmacies that dispense other opioids and assess if the proportion dispensing buprenorphine varies by Medicaid patient volume or rural-urban location.

Design, Setting, and Participants

This serial cross-sectional study included Medicaid pharmacy claims (2016-2019) data from 6 states (Kentucky, Maine, North Carolina, Pennsylvania, Virginia, West Virginia) participating in the Medicaid Outcomes Distributed Research Network (MODRN). Community retail pharmacies serving Medicaid-enrolled patients were included, mail-order pharmacies were excluded. Analyses were conducted from September 2022 to August 2023.

Main Outcomes and Measures

The proportion of pharmacies dispensing buprenorphine approved for opioid use disorder among pharmacies dispensing an opioid analgesic or buprenorphine prescription to at least 1 Medicaid enrollee in each state. Pharmacies were categorized by median Medicaid patient volume (by state and year) and rurality (urban vs rural location according to zip code).

Results

In 2016, 72.0% (95% CI, 70.9%-73.0%) of the 7038 pharmacies that dispensed opioids also dispensed buprenorphine to Medicaid enrollees, increasing to 80.4% (95% CI, 79.5%-81.3%) of 7437 pharmacies in 2019. States varied in the percent of pharmacies dispensing buprenorphine in Medicaid (range, 73.8%-96.4%), with significant differences between several states found in 2019 (χ2 P < .05), when states were most similar in the percent of pharmacies dispensing buprenorphine. A lower percent of pharmacies with Medicaid patient volume below the median dispensed buprenorphine (69.1% vs 91.7% in 2019), compared with pharmacies with above-median patient volume (χ2 P < .001).

Conclusions and Relevance

In this serial cross-sectional study of Medicaid-participating pharmacies, buprenorphine was not accessible in up to 20% of community retail pharmacies, presenting pharmacy-level barriers to patients with Medicaid seeking buprenorphine treatment. That some pharmacies dispensed opioid analgesics but not buprenorphine suggests that factors other than compliance with the Controlled Substance Act influence pharmacy dispensing decisions.

A case of naltrexone-induced acute eosinophilic pneumonia

Acute eosinophilic pneumonia (AEP) is a rare cause of acute respiratory failure. Clinical presentations can range from dyspnoea, fever and cough, to rapidly progressive and potentially fulminant respiratory failure. While its exact cause is often unknown, associations with inhalational injuries and exposures to new medications have been described.We report a case of a middle-aged, non-smoking man with a history of alcohol use disorder. He presented with 4 days of shortness of breath that started hours after taking injectable naltrexone (Vivitrol). The patient had rapidly worsening hypoxaemia, necessitating emergent bronchoscopy with transbronchial biopsies and bronchoalveolar lavage which showed 66% eosinophils. The patient was intubated for the procedure and unable to get extubated due to worsening hypoxaemic respiratory failure with high fractional inspired oxygen requirements. Chest radiograph showed worsening lung infiltrates and with a high index of suspicion for AEP, he was started empirically on methylprednisolone. He had rapid improvement in his respiratory status and was extubated on day 5 of admission then discharged on day 8. Histopathological examination confirmed acute/subacute eosinophilic pneumonia. A 3-week post-discharge follow-up chest radiograph confirmed the full resolution of pulmonary infiltrates.Naltrexone-induced AEP is rare, with only six other cases reported in the literature. Careful history taking and prompt evaluation for AEP are important given the potential for rapid progression to acute hypoxic respiratory failure and the excellent response to steroid treatment.

Addressing System and Clinician Barriers to Emergency Department-initiated Buprenorphine: An Evaluation of Post-intervention Physician Outcomes

Introduction

Emergency departments (ED) are in the unique position to initiate buprenorphine, an evidence-based treatment for opioid use disorder (OUD). However, barriers at the system and clinician level limit its use. We describe a series of interventions that address these barriers to ED-initiated buprenorphine in one urban ED. We compare post-intervention physician outcomes between the study site and two affiliated sites without the interventions.

Methods

This was a cross-sectional study conducted at three affiliated urban EDs where the intervention site implemented OUD-related electronic note templates, clinical protocols, a peer navigation program, education, and reminders. Post-intervention, we administered an anonymous, online survey to physicians at all three sites. Survey domains included demographics, buprenorphine experience and knowledge, comfort with addressing OUD, and attitudes toward OUD treatment. Physician outcomes were compared between the intervention site and the control sites with bivariate tests. We used logistic regression controlling for significant demographic differences to compare physicians' buprenorphine experience.

Results

Of 113 (51%) eligible physicians, 58 completed the survey: 27 from the intervention site, and 31 from the control sites. Physicians at the intervention site were more likely to spend <75% of their work week in clinical practice and to be in medical practice for <7 years. Buprenorphine knowledge (including status of buprenorphine prescribing waiver), comfort with addressing OUD, and attitudes toward OUD treatment did not differ significantly between the sites. Physicians were 4.5 times more likely to have administered buprenorphine at the intervention site (odds ratio [OR] 4.5, 95% confidence interval 1.4-14.4, P = 0.01), which remained significant after adjusting for clinical time and years in practice, (OR 3.5 and 4.6, respectively).

Conclusion

Physicians exposed to interventions addressing system- and clinician-level implementation barriers were at least three times as likely to have administered buprenorphine in the ED. Physicians' buprenorphine knowledge, comfort with addressing and attitudes toward OUD treatment did not differ significantly between sites. Our findings suggest that ED-initiated buprenorphine can be facilitated by addressing implementation barriers, while physician knowledge, comfort, and attitudes may be harder to improve.

Using quality improvement approaches to increase emergency department provider engagement in research participant enrollment during COVID-19 and opioid overdose public health emergencies

PURPOSE

We utilized quality improvement (QI) approaches to increase emergency department (ED) provider engagement with research participant enrollment during the opioid crisis and coronavirus disease (COVID-19) pandemic. The context of this work is the Evaluating Microdosing in the Emergency Department (EMED) study, a randomized trial offering buprenorphine/naloxone to ED patients through randomization to standard or microdosing induction. Engaging providers is crucial for participant recruitment to our study. Anticipating challenges sustaining long-term engagement after a 63% decline in provider referrals four months into enrollments, we applied Plan-Do-Study-Act (PDSA) cycles to develop and implement an engagement strategy to increase and sustain provider engagement by 50% from baseline within 9 months.

METHODS

Our engagement strategy was centered on Coffee Carts rounds: 5-min study-related educational presentations for providers on shift; and a secondary initiative, a Suboxone Champions program, to engage interested providers as study-related peer educators. We used provider referrals to our team as a proxy for study engagement and report the percent change in mean weekly referrals across two PDSA cycles relative to our established referral baseline.

RESULTS

A QI approach afforded real-time review of interventions based on research and provider priorities, increasing engagement via mean weekly provider referrals by 14.5% and 49% across two PDSA cycles relative to baseline, respectively.

CONCLUSIONS

Our Coffee Carts and Suboxone Champions program are efficient, low-barrier, educational initiatives to convey study-related information to providers. This work supported our efforts to maximally engage providers, minimize burden, and provide life-saving buprenorphine/naloxone to patients at risk of fatal overdose.

Buprenorphine Prescribing and Challenges Faced Among National Health Service Corps Clinicians

Importance

The National Health Service Corps (NHSC) Loan Repayment Program (LRP) expansion in fiscal year (FY) 2019 intended to improve access to medication for opioid use disorder (MOUD) by adding more clinicians who could prescribe buprenorphine. However, some clinicians still face barriers to prescribing, which may vary between rural and nonrural areas.

Objective

To examine the growth in buprenorphine prescribing by NHSC clinicians for Medicaid beneficiaries during the NHSC LRP expansion and describe the challenges to prescribing that persist in rural and nonrural areas.

Design, Setting, and Participants

This cross-sectional study analyzed preexpansion and postexpansion Medicaid claims data to evaluate the percentage of prescriptions of buprenorphine filled during FY 2017 through 2021. This study also analyzed challenges and barriers to prescribing MOUD between rural and urban areas, using results from annual surveys conducted with NHSC clinicians and sites from FY 2019 through FY 2021.

Exposure

Prescribing of buprenorphine by NHSC clinicians.

Main Outcomes and Measures

The main outcomes were the percentage and number of Medicaid beneficiaries with opioid use disorder (OUD) who filled a prescription for buprenorphine before and after the LRP expansion and the challenges NHSC clinicians and sites faced in providing substance use disorder and OUD services. Survey results were analyzed using descriptive statistics.

Results

During FYs 2017 through 2021, 7828 NHSC clinicians prescribed buprenorphine (standard LRP: mean [SD] age, 38.1 [8.4] years and 4807 females [78.9%]; expansion LRPs: mean [SD] age, 39.4 [8.1] years and 1307 females [75.0%]). A total of 3297 NHSC clinicians and 4732 NHSC sites responded to at least 1 survey question to the 3 surveys. The overall percentage of Medicaid beneficiaries with OUD who filled a prescription for buprenorphine during the first 2.5 years post expansion increased significantly from 18.9% before to 43.7% after expansion (an increase of 123 422 beneficiaries; P < .001). The percentage more than doubled among beneficiaries living in areas with a high Social Vulnerability Index score (from 17.0% to 36.7%; an increase of 31 964) and among beneficiaries living in rural areas (from 20.8% to 55.7%; an increase of 45 523). However, 773 of 2140 clinicians (36.1%; 95% CI, 33.6%-38.6%) reported a lack of mental health services to complement medication for OUD treatment, and 290 of 1032 clinicians (28.1%; 95% CI, 24.7%-31.7%) reported that they did not prescribe buprenorphine due to a lack of supervision, mentorship, or peer consultation.

Conclusions and Relevance

These findings suggest that although the X-waiver requirement has been removed and Substance Abuse and Mental Health Services Administration guidelines encourage all eligible clinicians to screen and offer patients with OUD buprenorphine, as permissible by state law, more trained health care workers and improved care coordination for counseling and referral services are needed to support comprehensive OUD treatment.