Independent community pharmacists' attitudes and intentions toward dispensing buprenorphine/naloxone for opioid use disorder

BACKGROUND

Buprenorphine/naloxone (BUP/NX) for opioid use disorder (OUD) is associated with positive health outcomes; however, challenges accessing prescribed BUP/NX at community pharmacies have been identified.

OBJECTIVE

The theory of planned behavior was applied to determine whether independent community pharmacists' attitudes toward dispensing BUP/NX for OUD predict intentions to dispense.

METHODS

A 40-item survey was administered to 185 Texas Community Pharmacy Enhanced Services Network pharmacists. The survey assessed intentions to dispense BUP/NX (3 items), attitudes toward BUP/NX (24 items), current barriers to dispensing BUP/NX (2 items), and demographics (10 items). Inferential statistics determined associations among pharmacists' attitudes, practice setting characteristics, and intentions to dispense BUP/NX. Regression analysis determined whether attitude predicted intention to dispense BUP/NX, controlling for practice setting and demographic characteristics.

RESULTS

Responses were obtained from 82 community independent pharmacists (response rate = 44%). Respondents were predominantly non-Hispanic white (45.8%) and women (56.6%) and practiced in pharmacies with an average 1129.1 (± 1034.5) dispensed prescriptions/week. Pharmacists had positive intentions (6.2 ± 3.5) and attitudes (14.4 ± 24.9) toward dispensing BUP/NX and attitudes did not predict intentions to dispense (P = 0.330). Positive drivers of attitude were related to improving patient outcomes, fulfilling a community need, and absence of conflicts with pharmacists' personal and religious beliefs. A negative driver of attitude was financial reimbursement/loss. Pharmacists dispensing 2000 or more prescriptions/week had higher intentions (b = 3.22, P = 0.014) to dispense than those dispensing less than 500 prescriptions/week. The most common barrier to dispense BUP/NX was "refill was too soon" (54.8%).

CONCLUSION

Community independent pharmacists had positive attitudes toward and intentions of dispensing BUP/NX for OUD. However, attitudes did not predict intentions to dispense. Negative drivers of attitudes were related to factors not within pharmacists' control, such as time to refill or financial reimbursement.Future studies focused on community pharmacy-based access to BUP/NX are warranted to elucidate issues that are impactful in improving pharmacists' dispensing intentions and behavior.

Buprenorphine Out-of-Pocket Costs and Discontinuation in Privately Insured Adults With Opioid Use Disorder

This cohort study examined the association between out-of-pocket costs for an initial buprenorphine prescription and its discontinuation among commercially insured US adults with opioid use disorder.

Updated Estimates of Annual U.S. Health System Spending from a Hypothetical National Naloxone Co-Prescribing Mandate

Background: Naloxone-prescription opioid co-prescribing mandates have increasingly been proposed and adopted in the U.S., at both the national and state levels, as a public health intervention for mitigating the impacts of opioid overdoses. In this study, we assess whether a hypothetical national, naloxone co-prescribing mandate has become less costly for the U.S. health system since 2018. Methods: We expand and update an existing economic model of naloxone co-prescribing to estimate annual health system spending. We refresh the model inputs through 2021 to reflect changes to the opioid and naloxone landscapes, expand the model to account for more types of market responses, and develop additional scenarios around alternate implementation strategies such as bulk purchasing. Results: We estimate annual spending increases across all retail opioid patients of $1.4-$4.0 billion with naloxone nasal sprays and auto-injectors, and $0.6-$0.9 billion with traditional injectable naloxone formulations. We also find that bulk purchasing could lead to higher spending increases in some patient populations absent volume discounts. Conclusions: Our estimates are substantially lower than prior research. Key drivers include lower prices for naloxone, higher current naloxone distribution, a longer approved shelf life for naloxone, and lower estimated sizes for some patient populations. Additional research is needed to estimate the potential benefits of naloxone co-prescribing for mitigating opioid overdoses, and whether they could outweigh spending increases. Steps that could make this policy more beneficial or less costly include targeting higher risk patient populations and promoting large-scale purchasing agreements with volume discounts to help offset potential price increases.

Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial

BACKGROUND

More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically.

METHODS

We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness.

DISCUSSION

This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.

Injection Drug Use Frequency Before and After Take-Home Naloxone Training

Importance

Concerns that take-home naloxone (THN) training may lead to riskier drug use (as a form of overdose risk compensation) remain a substantial barrier to training implementation. However, there was limited good-quality evidence in a systematic review of the association between THN access and subsequent risk compensation behaviors.

Objective

To assess whether THN training is associated with changes in overdose risk behaviors, indexed through injecting frequency, in a cohort of people who inject drugs.

Design, Setting, and Participants

This cohort study used prospectively collected self-reported behavioral data before and after THN training of participants in The Melbourne Injecting Drug User Cohort Study (SuperMIX). Annual interviews were conducted in and around Melbourne, Victoria, Australia, from 2008 to 2021. SuperMIX participants were adults who regularly injected heroin or methamphetamine in the 6 months preceding their baseline interview. The current study included only people who inject drugs who reported THN training and had participated in at least 1 interview before THN training.

Exposure

In 2017, the SuperMIX baseline or follow-up survey began asking participants if and when they had received THN training. The first THN training date that was recorded was included as the exposure variable. Subsequent participant interviews were excluded from analysis.

Main Outcomes and Measures

Injecting frequency was the primary outcome and was used as an indicator of overdose risk. Secondary outcomes were opioid injecting frequency, benzodiazepine use frequency, and the proportion of the time drugs were used alone. Fixed-effects generalized linear (Poisson) multilevel modeling was used to estimate the association between THN training and the primary and secondary outcomes. Time-varying covariates included housing status, income, time in study, recent opioid overdose, recent drug treatment, and needle and syringe coverage. Findings were expressed as incidence rate ratios (IRRs) with 95% CIs.

Results

There were 1328 participants (mean [SD] age, 32.4 [9.0] years; 893 men [67.2%]) who completed a baseline interview in the SuperMIX cohort, and 965 participants completed either a baseline or follow-up interview in or after 2017. Of these 965 participants, 390 (40.4%) reported THN training. A total of 189 people who inject drugs had pretraining participant interviews with data on injecting frequency and were included in the final analysis (mean [SD] number of interviews over the study period, 6.2 [2.2]). In fixed-effects regression analyses adjusted for covariates, there was no change in the frequency of injecting (IRR, 0.91; 95% CI, 0.69-1.20; P = .51), opioid injecting (IRR, 0.95; 95% CI, 0.74-1.23; P = .71), benzodiazepine use (IRR, 0.96; 95% CI, 0.69-1.33; P = .80), or the proportion of reported time of using drugs alone (IRR, 1.04; 95% CI, 0.86-1.26; P = .67) before and after THN training.

Conclusions and Relevance

This cohort study of people who inject drugs found no evidence of an increase in injecting frequency, along with other markers of overdose risk, after THN training and supply. The findings suggest that THN training should not be withheld because of concerns about risk compensation and that advocacy for availability and uptake of THN is required to address unprecedented opioid-associated mortality.

The Utilization of Low Dose Naltrexone for Chronic Pain

Naltrexone is a mu-opioid receptor antagonist with a long half-life compared with naloxone. Both of these drugs, along with others, were developed with the intention of reversing the effects of opioid abuse or toxicity. Evidence has also shown that naltrexone has a benefit in preventing relapse by reducing opioid cravings and reducing symptoms of opioid withdrawal. The benefits of this drug were not only shown with opioid abuse. In 1984 this drug was also approved for alcohol abuse. Naltrexone has been proven to decrease alcohol relapse by decreasing the craving. Apart from these approved indications for the use of naltrexone, with time, it has been seen that this drug has a benefit in treating chronic pain. A number of studies have shown the benefits of this drug with inflammatory bowel disease, fibromyalgia, multiple sclerosis, diabetic neuropathy, and complex regional pain syndrome, among others. More studies are needed to approve this medication for specific chronic pain conditions.

Effects of Buprenorphine/Naloxone and Methadone on Depressive Symptoms in People with Prescription Opioid Use Disorder: A Pragmatic Randomised Controlled Trial

OBJECTIVE

This study aimed to evaluate the effectiveness of flexible take-home dosing of buprenorphine/naloxone (BUP/NX) and methadone standard model of care in reducing depressive symptoms in people with prescription-type opioid use disorder (POUD). This trial also evaluated whether improvements in depressive symptoms were mediated by opioid use.

METHODS

Analyzed data came from the OPTIMA study (clinicaltrials.gov identifier: NCT03033732), a pragmatic randomised controlled trial comparing flexible take-home dosing of BUP/NX and methadone standard model of care for reducing opioid use in people with POUD. A total of 272 participants were recruited in four Canadian provinces. Participants were randomised 1:1 to BUP/NX or methadone. After treatment induction, past two-week opioid use was measured using the Timeline Followback every two weeks for a total of 24 weeks. Depressive symptoms were measured with the Beck Depression Inventory at baseline, weeks 12 and 24.

RESULTS

Both BUP/NX and methadone significantly reduced depressive symptoms at week 12 (aβ ± SE = -3.167 ± 1.233; P < 0.001) and week 24 (aβ ± SE = -7.280 ± 1.285; P < 0.001), with no interaction between type of treatment and time (P = 0.284). Improvements in depressive symptoms were only partially mediated by a reduction in opioid use (proportion mediated = 36.8%; 95% confidence interval = -1.158 to -0.070; P = 0.015).

CONCLUSIONS

BUP/NX and methadone showed similar effectiveness in decreasing comorbid depressive symptoms in people with POUD. This effect was partially explained by a reduction in opioid use. As both treatments seem equally effective, clinicians are encouraged to tailor the selection of OAT to patients' needs and characteristics.

Impact of Universal Screening and Automated Clinical Decision Support for the Treatment of Opioid Use Disorder in Emergency Departments: A Difference-in-Differences Analysis

STUDY OBJECTIVE

Emergency department (ED)-initiated buprenorphine improves outcomes in patients with opioid use disorder; however, adoption varies widely. To reduce variability, we implemented a nurse-driven triage screening question in the electronic health record to identify patients with opioid use disorder, followed by targeted electronic health record prompts to measure withdrawal and guide next steps in management, including initiation of treatment. Our objective was to assess the impact of screening implementation in 3 urban, academic EDs.

METHODS

We conducted a quasiexperimental study of opioid use disorder-related ED visits using electronic health record data from January 2020 to June 2022. The triage protocol was implemented in 3 EDs between March and July 2021, and 2 other EDs in the health system served as controls. We evaluated changes in treatment measures over time and used a difference-in-differences analysis to compare outcomes in the 3 intervention EDs with those in the 2 controls.

RESULTS

There were 2,462 visits in the intervention hospitals (1,258 in the preperiod and 1,204 in the postperiod) and 731 in the control hospitals (459 in the preperiod and 272 in the postperiod). Patient characteristics within the intervention and control EDs were similar across the time periods. Compared with the control hospitals, the triage protocol was associated with a 17% greater increase in withdrawal assessment, using the Clinical Opioid Withdrawal Scale (COWS) (95% CI 7 to 27). Buprenorphine prescriptions at discharge also increased by 5% (95% CI 0% to 10%), and naloxone prescriptions increased by 12% points (95% CI 1% to 22%) in the intervention EDs relative to controls.

CONCLUSION

An ED triage screening and treatment protocol led to increased assessment and treatment of opioid use disorder. Protocols designed to make screening and treatment the default practice have promise in increasing the implementation of evidence-based treatment ED opioid use disorder care.

Theophylline reverses oxycodone's but not fentanyl's respiratory depression in mice while caffeine is ineffective against both opioids

RATIONALE

The opioid epidemic remains a pressing public health crisis in the United States. Most of these overdose deaths are a result of lethal respiratory depression. In recent years the increasing incidence of opioid-involved overdose deaths has been driven by fentanyl, which is more resistant to adequate reversal by naloxone (NARCAN ®) than semi-synthetic or classical morphinan predecessors like oxycodone and heroin. For this and other reasons (e.g., precipitating withdrawal) non-opioidergic pharmacotherapies to reverse opioid-depressed respiration are needed. Methylxanthines are a class of stimulant drugs including caffeine and theophylline which exert their effects primarily via adenosine receptor antagonism. Evidence suggests methylxanthines can stimulate respiration by enhancing neural activity in respiratory nuclei in the pons and medulla independent of opioid receptors. This study aimed to determine whether caffeine and theophylline can stimulate respiration in mice when depressed by fentanyl and oxycodone.

METHODS

Whole-body plethysmography was used to characterize fentanyl and oxycodone's effects on respiration and their reversal by naloxone in male Swiss Webster mice. Next, caffeine and theophylline were tested for their effects on basal respiration. Finally, each methylxanthine was evaluated for its ability to reverse similar levels of respiratory depression induced by fentanyl or oxycodone.

RESULTS AND CONCLUSIONS

Oxycodone and fentanyl dose-dependently reduced respiratory minute volume (ml/min; MVb) that was reversible by naloxone. Caffeine and theophylline each significantly increased basal MVb. Theophylline, but not caffeine, completely reversed oxycodone-depressed respiration. In contrast, neither methylxanthine elevated fentanyl-depressed respiration at the doses tested. Despite their limited efficacy for reversing opioid-depressed respiration when administered alone, the methylxanthines safety, duration, and mechanism of action supports further evaluation in combination with naloxone to augment its reversal of opioid-depressed respiration.

Moving Naloxone Over the Counter Is Necessary but Not Sufficient

Naloxone is an opioid antagonist that is available in numerous formulations and can be easily administered to avert death from opioid overdose. Amid a historic overdose crisis in the United States, naloxone has a crucial role in stemming the loss of life. However, it remains largely inaccessible to the public. Recently, the U.S. Food and Drug Administration announced the approval of the first over-the-counter formulation of naloxone. Although this historic change provides an important opportunity to increase distribution of naloxone, we must take careful steps during this transition so that it does not paradoxically threaten overall access to this life-saving medication. Specifically, we must ensure that a larger supply of naloxone will meet the newly increased demand at a sustainable price for consumers who are most in need. We must also continue to prioritize comprehensive methods of distribution, such as overdose education and naloxone distribution programs, that serve as important tools to reach the most vulnerable populations. In addition, simultaneous investment in harm-reduction strategies, such as supervised consumption spaces, is critical to ensure that naloxone is available in settings where its life-saving potential can be most fully realized.

Structure-Activity Relationship Study of Cannabidiol-Based Analogs as Negative Allosteric Modulators of the μ-Opioid Receptor

The US faces an unprecedented surge in fatal drug overdoses. Naloxone, the only antidote for opiate overdose, competes at the mu opioid receptor (μOR) orthosteric site. Naloxone struggles against fentanyl-class synthetic opioids that now cause ∼80% of deaths. Negative allosteric modulators (NAMs) targeting secondary sites may noncompetitively downregulate μOR activation. (-)-Cannabidiol ((-)-CBD) is a candidate μOR NAM. To explore its therapeutic potential, we evaluated the structure-activity relationships among CBD analogs to identify NAMs with increased potency. Using a cyclic AMP assay, we characterize reversal of μOR activation by 15 CBD analogs, several of which proved more potent than (-)-CBD. Comparative docking investigations suggest that potent compounds interact with a putative allosteric pocket to stabilize the inactive μOR conformation. Finally, these compounds enhance naloxone displacement of fentanyl from the orthosteric site. Our results suggest that CBD analogs offer considerable potential for the development of next-generation antidotes for opioid overdose.

Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India

OBJECTIVE

Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups.

METHODS

We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status.

RESULTS

Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome.

CONCLUSION

Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.

Buprenorphine adherence and illicit opioid use among patients in treatment for opioid use disorder

Background: Buprenorphine is a partial mu opioid agonist medication that has been shown to decrease non-prescribed opioid use, cravings, and opioid related morbidity and mortality. There is an assumption that full adherence is needed to achieve ideal treatment outcomes, and that non-adherence is associated with ongoing opioid use. However, literature documenting the strength of that assertion is lacking.Objectives: Evaluate the association between daily buprenorphine adherence and illicit opioid use.Methods: Secondary analysis of a 12-week randomized controlled trial of adults with opioid use disorder who recently initiated buprenorphine. Weekly study visits included self-report of daily buprenorphine adherence over the past 7 days (Timeline Follow Back method) and urine drug tests (UDT). A log-linear regression model accounting for clustering by participant was used to assess the association between buprenorphine adherence and illicit opioid use. Buprenorphine adherence was measured as a continuous variable (0-7 days).Results: Among 78 participants (56 men, 20 women, 2 nonbinary) with 737 visits, full 7-day adherence was reported at 70% of visits. The predominant form of non-adherence was missed doses (92% of cases). Each additional day of adherence was associated with an 8% higher rate of negative UDT for illicit opioids (RR = 1.08; 95% CI:1.03-1.13, p = .0002).Conclusion: In this sample of participants starting buprenorphine, missed doses were not uncommon. Fewer missed days was significantly associated with a lower risk of illicit opioid use. These findings suggest that efforts to minimize the number of missed days of buprenorphine are beneficial for treatment outcomes.

Buprenorphine/naloxone initiation and referral as a quality improvement intervention for patients who live with opioid use disorder: quantitative evaluation of provincial spread to 107 rural and urban Alberta emergency departments

OBJECTIVES

Opioid use disorder is a major public health concern that accounts for a high number of potential years of life lost. Buprenorphine/naloxone is a recommended treatment for opioid use disorder that can be started in the emergency department (ED). We developed an ED-based program to initiate buprenorphine/naloxone for eligible patients who live with opioid use disorder, and to provide unscheduled, next-day follow-up referrals to an opioid use disorder treatment clinic (in person or virtual) for continuing patient care throughout Alberta.

METHODS

In this quality improvement initiative, we supported local ED teams to offer buprenorphine/naloxone to eligible patients presenting to the ED with suspected opioid use disorder and refer these patients for follow-up care. Process, outcome, and balancing measures were evaluated over the first 2 years of the initiative (May 15, 2018-May 15, 2020).

RESULTS

The program was implemented at 107 sites across Alberta during our evaluation period. Buprenorphine/naloxone initiations in the ED increased post-intervention at most sites with baseline data available (11 of 13), and most patients (67%) continued to fill an opioid agonist prescription at 180 days post-ED visit. Of the 572 referrals recorded at clinics, 271 (47%) attended their first follow-up visit. Safety events were reported in ten initiations and were all categorized as no harm to minimal harm.

CONCLUSIONS

A standardized provincial approach to initiating buprenorphine/naloxone in the ED for patients living with opioid use disorder was spread to 107 sites with dedicated program support staff and adjustment to local contexts. Similar quality improvement approaches may benefit other jurisdictions.

Long-Term Effects of Increasing Buprenorphine Treatment Seeking, Duration, and Capacity on Opioid Overdose Fatalities: A Model-based Analysis

OBJECTIVES

Because buprenorphine treatment of opioid use disorder reduces opioid overdose deaths (OODs), expanding access to care is an important policy and clinical care goal. Policymakers must choose within capacity limitations whether to expand the number of people with opioid use disorder who are treated or extend duration for existing patients. This inherent tradeoff could be made less acute with expanded buprenorphine treatment capacity.

METHODS

To inform such decisions, we used a validated simulation model to project the effects of increasing buprenorphine treatment-seeking, average episode duration, and capacity (patients per provider) on OODs in the United States from 2023 to 2033, varying the start time to assess the effects of implementation delays.

RESULTS

Results show that increasing treatment duration alone could cost lives in the short term by reducing capacity for new admissions yet save more lives in the long term than accomplished by only increasing treatment seeking. Increasing provider capacity had negligible effects. The most effective 2-policy combination was increasing capacity and duration simultaneously, which would reduce OODs up to 18.6% over a decade. By 2033, the greatest reduction in OODs (≥20%) was achieved when capacity was doubled and average duration reached 2 years, but only if the policy changes started in 2023. Delaying even a year diminishes the benefits. Treatment-seeking increases were equally beneficial whether they began in 2023 or 2025 but of only marginal benefit beyond what capacity and duration achieved.

CONCLUSIONS

If policymakers only target 2 policies to reduce OODs, they should be to increase capacity and duration, enacted quickly and aggressively.

Better Biomarkers, Faster Drugs, Stronger Models: Progress Towards Precision Psychiatry

The 21st century has brought novel therapies and new therapeutic targets for major depressive disorder (MDD). Until recently all antidepressant medications targeted monoamines-serotonin, norepinephrine, and dopamine- and their regulatory systems. But growing evidence has suggested that individuals who fail to respond to a monoaminergic treatment are likely to fail to respond to other monoaminergic options. The emergence in recent years of treatment targets beyond the monoaminergic systems (e.g. κ-opioid antagonists, ketamine and other NMDA modulators, neurosteroids) has cultivated hopes for not only greater efficacy in treating depression, but also improved precision in targeting specific phenotypes and symptoms. Concurrently, an expanding repertoire of diagnostic and assessment tools-such as smartphone-based experience sampling and brain imaging-is moving the field toward more reliable and symptom-specific measurement with greater descriptive and prescriptive power. Taken together, these diagnostic tools and treatment options herald a new era of "precision psychiatry"-the selection and implementation of an optimal treatment for an individual patient's particular needs. Anhedonia offers an example of the new precision psychiatry. Anhedonia has moved from merely one among several criteria for depression to a transdiagnostic psychopathology which can be understood neurobiologically, assessed quantitatively, and centered as a primary target in research and development of novel pharmacotherapies. We describe functional testing of reward circuits in the development of kappa-opioid antagonists for anhedonia. This offers a lens for understanding how and under what circumstances other novel treatments, such as psychedelics, might find a place in the future landscape of precision psychiatric care.

Precipitated Opioid Withdrawal Treated With Ketamine in a Hospitalized Patient: A Case Report

BACKGROUND

Although initiating buprenorphine in the presence of full opioid agonists has always been a clinical dilemma, the transition to primarily fentanyl in the drug supply has increased the urgency to find appropriate treatments for precipitated opioid withdrawal (POW). Although rare, lack of evidence on how to best treat POW threatens clinician and patient comfort in initiating life-saving medication for opioid use disorder. Ketamine has been used in emergency department settings to treat POW; this is the first case report of ketamine use in a hospitalized patient.

CASE SUMMARY

A 38-year-old male patient with severe opioid use disorder presented to the emergency department with suicidality and opioid withdrawal 24 hours after last fentanyl use. In the first 24 hours of admission, he received sublingual buprenorphine-naloxone (BNX) 16-4 mg, resulting in Clinical Opiate Withdrawal Scale score increasing from 13 to over 36. The patient was admitted, and addiction medicine was consulted. The patient was diagnosed with POW, started on ketamine infusion, and given additional BNX 8-2 mg. Twelve hours after the ketamine infusion, the patient's Clinical Opiate Withdrawal Scale score improved to 18 but remained elevated. He received a second ketamine infusion plus additional BNX with complete resolution of symptoms within 8 hours, and he was stabilized and discharged on BNX 24-6 mg daily.

CLINICAL SIGNIFICANCE

Ketamine is a promising treatment for POW due to its potentiation of μ-opioid receptor-mediated signaling. This is the first case to describe POW in the inpatient hospital setting. More research is needed to establish the effectiveness and feasibility of ketamine as treatment for POW.

Patient's perceptions of buprenorphine use receiving treatment for cancer

OBJECTIVE

To assess knowledge and attitudes toward opioids and buprenorphine (BUP) of patients with cancer.

DESIGN

Single-site, single-intervention telephone survey of patients under palliative care at the cancer center.

OUTCOMES

Forty percent of the participants recognized the word "buprenorphine," and 28 percent recognized BUP indication for addiction treatment. Four percent addressed potential BUP misuse. None recognized BUP indication for pain. Seventy-one percent were not worried about addiction or dependency while using opioids to treat their cancer-related-pain, and 73 percent were not worried about being stigmatized in the healthcare setting about their pain regimens. Patients on opioids for less than 3 months were most strongly correlated with the fear of addiction and stigma.

CONCLUSION

This study identifies patients' knowledge gap regarding BUP products for pain, which gives professionals the opportunity to provide education. This study identified that patients are most worried early on about addiction and stigma when using opioids.

Pennsylvania's Community Coordination Strategy to Reduce Opioid Overdose Deaths

OBJECTIVE

The Pennsylvania Opioid Overdose Reduction Technical Assistance Center (ORTAC) was developed to provide community-level support across Pennsylvania with the goal of reducing the opioid-related overdose death (ODD) rate via coalition building/coordination and tailored technical assistance. This study evaluates the initial effects of ORTAC engagement on county-level opioid ODD reductions.

METHOD

Using quasi-experimental difference-in-difference models, we compared ODD per 100,000 population per quarter between 2016 and 2019 in the 29 ORTAC-implementing counties against the 19 nonengaged counties while controlling for county-level time-varying confounders (e.g., naloxone administration by law enforcement).

RESULTS

Before ORTAC implementation, the average ODD/100,000 was 8.92 per 100,000 (SD = 3.62) in ORTAC counties and 5.62 per 100,000 (SD = 2.17) for the 19 comparison counties. Relative to the pre-study rate, there was an estimated 30% decrease in the ODD/100,000 within implementing counties after the first two quarters of ORTAC implementation. In the second year after ORTAC implementation, the estimated difference between ORTAC and non-ORTAC counties reached a high of 3.80 fewer deaths per 100,000. Overall, analyses indicated that ORTAC's service was associated with avoiding 1,818 opioid ODD in the 29 implementing counties in the 2 years following implementation.

CONCLUSIONS

Findings reinforce the impact of coordinating communities around addressing the ODD crisis. Future policy efforts should provide a suite of overdose reduction strategies and intuitive data structures that can be tailored to individual communities' needs.

The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees

INTRODUCTION

Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose.

METHODS

The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training.

RESULTS

Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course.

DISCUSSION

These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs.

CONCLUSIONS

Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.

Spatiotemporal Analysis Exploring the Effect of Law Enforcement Drug Market Disruptions on Overdose, Indianapolis, Indiana, 2020-2021

Objectives. To test the hypothesis that law enforcement efforts to disrupt local drug markets by seizing opioids or stimulants are associated with increased spatiotemporal clustering of overdose events in the surrounding geographic area. Methods. We performed a retrospective (January 1, 2020 to December 31, 2021), population-based cohort study using administrative data from Marion County, Indiana. We compared frequency and characteristics of drug (i.e., opioids and stimulants) seizures with changes in fatal overdose, emergency medical services nonfatal overdose calls for service, and naloxone administration in the geographic area and time following the seizures. Results. Within 7, 14, and 21 days, opioid-related law enforcement drug seizures were significantly associated with increased spatiotemporal clustering of overdoses within radii of 100, 250, and 500 meters. For example, the observed number of fatal overdoses was two-fold higher than expected under the null distribution within 7 days and 500 meters following opioid-related seizures. To a lesser extent, stimulant-related drug seizures were associated with increased spatiotemporal clustering overdose. Conclusions. Supply-side enforcement interventions and drug policies should be further explored to determine whether they exacerbate an ongoing overdose epidemic and negatively affect the nation's life expectancy. (Am J Public Health. 2023;113(7):750-758. https://doi.org/10.2105/AJPH.2023.307291).

"Macrodosing" Sublingual Buprenorphine and Extended-release Buprenorphine in a Hospital Setting: 2 Case Reports

OBJECTIVES

To describe 2 case reports in which high-dose administration of sublingual buprenorphine/naloxone quickly stabilized fentanyl users who presented to the hospital. To discuss how early administration of extended-release buprenorphine, before the patient is discharged, may improve retention rates for outpatient buprenorphine treatment.

METHODS

Two case reports of fentanyl users presented to the emergency department at the general hospital in Timmins, Canada are described. They were rapidly stabilized on high-dose sublingual buprenorphine/naloxone and then transitioned within 24 to 36 hours to buprenorphine extended-release subcutaneous injection.

RESULTS

In both cases, their withdrawal symptoms quickly resolved, without sedation or precipitated withdrawal. Both patients followed up with the outpatient clinic for another injection of extended-release buprenorphine.

CONCLUSIONS

High-dose sublingual buprenorphine/naloxone followed by early administration of extended-release buprenorphine quickly and safely relieved withdrawal symptoms in 2 fentanyl users who presented to the hospital emergency department. This novel approach shows promise in improving treatment retention rates for patients using fentanyl. Further research is required to evaluate the safety and effectiveness of this approach.

Probing different paradigms of morphine withdrawal on sleep behavior in male and female C57BL/6J mice

Opioid misuse has dramatically increased over the last few decades resulting in many people suffering from opioid use disorder (OUD). The prevalence of opioid overdose has been driven by the development of new synthetic opioids, increased availability of prescription opioids, and more recently, the COVID-19 pandemic. Coinciding with increases in exposure to opioids, the United States has also observed increases in multiple Narcan (naloxone) administrations as a life-saving measures for respiratory depression, and, thus, consequently, naloxone-precipitated withdrawal. Sleep dysregulation is a main symptom of OUD and opioid withdrawal syndrome, and therefore, should be a key facet of animal models of OUD. Here we examine the effect of precipitated and spontaneous morphine withdrawal on sleep behaviors in C57BL/6 J mice. We find that morphine administration and withdrawal dysregulate sleep, but not equally across morphine exposure paradigms. Furthermore, many environmental triggers promote relapse to drug-seeking/taking behavior, and the stress of disrupted sleep may fall into that category. We find that sleep deprivation dysregulates sleep in mice that had previous opioid withdrawal experience. Our data suggest that the 3-day precipitated withdrawal paradigm has the most profound effects on opioid-induced sleep dysregulation and further validates the construct of this model for opioid dependence and OUD.

Changes in Waivered Clinicians Prescribing Buprenorphine and Prescription Volume by Patient Limit

This study uses data from a Drug Enforcement Administration list of Drug Addiction Treatment Act (DATA)–waivered clinicians to examine trends in DATA-waivered clinicians’ active participation in prescribing buprenorphine overall and by patient limits between January 2017 and May 2021.

Racial Inequality in Receipt of Medications for Opioid Use Disorder

BACKGROUND

Since 2010, Black persons in the United States have had a greater increase in opioid overdose-related mortality than other groups, but national-level evidence characterizing racial and ethnic disparities in the use of medications for opioid use disorder (OUD) is limited.

METHODS

We used Medicare claims data from the 2016-2019 period for a random 40% sample of fee-for-service beneficiaries who were Black, Hispanic, or White; were eligible for Medicare owing to disability; and had an index event related to OUD (nonfatal overdose treated in an emergency department or inpatient setting, hospitalization with injection drug use-related infection, or inpatient or residential rehabilitation or detoxification care). We measured the receipt of medications to treat OUD (buprenorphine, naltrexone, and naloxone), the receipt of high-risk medications (opioid analgesics and benzodiazepines), and health care utilization, all in the 180 days after the index event. We estimated differences in outcomes according to race and ethnic group with adjustment for beneficiary age, sex, index event, count of chronic coexisting conditions, and state of residence.

RESULTS

We identified 25,904 OUD-related index events among 23,370 beneficiaries, with 3937 events (15.2%) occurring among Black patients, 2105 (8.1%) among Hispanic patients, and 19,862 (76.7%) among White patients. In the 180 days after the index event, patients received buprenorphine after 12.7% of events among Black patients, after 18.7% of those among Hispanic patients, and after 23.3% of those among White patients; patients received naloxone after 14.4%, 20.7%, and 22.9%, respectively; and patients received benzodiazepines after 23.4%, 29.6%, and 37.1%, respectively. Racial differences in the receipt of medications to treat OUD did not change appreciably from 2016 to 2019 (buprenorphine receipt: after 9.1% of index events among Black patients vs. 21.6% of those among White patients in 2016, and after 14.1% vs. 25.5% in 2019). In all study groups, patients had multiple ambulatory visits in the 180 days after the index event (mean number of visits, 6.6 after events among Black patients, 6.7 after events among Hispanic patients, and 7.6 after events among White patients).

CONCLUSIONS

Racial and ethnic differences in the receipt of medications to treat OUD after an index event related to this disorder among patients with disability were substantial and did not change over time. The high incidence of ambulatory visits in all groups showed that disparities persisted despite frequent health care contact. (Funded by the National Institute on Drug Abuse and the National Institute on Aging.).

Optimally Choosing Medication Type for Patients With Opioid Use Disorder

Patients with opioid use disorder (OUD) tend to get assigned to one of 3 medications based on the treatment program to which the patient presents (e.g., opioid treatment programs tend to treat patients with methadone, while office-based practices tend to prescribe buprenorphine). It is possible that optimally matching patients with treatment type would reduce the risk of return to regular opioid use (RROU). We analyzed data from 3 comparative effectiveness trials from the US National Institute on Drug Abuse Clinical Trials Network (CTN0027, 2006-2010; CTN0030, 2006-2009; and CTN0051 2014-2017), in which patients with OUD (n = 1,459) were assigned to treatment with either injection extended-release naltrexone (XR-NTX), sublingual buprenorphine-naloxone (BUP-NX), or oral methadone. We learned an individualized rule by which to assign medication type such that risk of RROU during 12 weeks of treatment would be minimized, and then estimated the amount by which RROU risk could be reduced if the rule were applied. Applying our estimated treatment rule would reduce risk of RROU compared with treating everyone with methadone (relative risk (RR) = 0.79, 95% confidence interval (CI): 0.60, 0.97) or treating everyone with XR-NTX (RR = 0.71, 95% CI: 0.47, 0.96). Applying the estimated treatment rule would have resulted in a similar risk of RROU to that of with treating everyone with BUP-NX (RR = 0.92, 95% CI: 0.73, 1.11).

Characteristics and health service use of Medicaid-insured individuals filling naloxone under a standing order in Louisiana

BACKGROUND

Naloxone distribution is a key intervention to reduce opioid overdose deaths. On January 23, 2017, Louisiana implemented a standing order that permits pharmacies to dispense naloxone to patients without a patient-specific prescription.

OBJECTIVES

To examine the characteristics and health service use of Louisiana Medicaid members filling naloxone under the standing order.

METHODS

We conducted a retrospective cohort study of Louisiana Medicaid members from January 23, 2017 to December 31, 2019. We extracted fee-for-service claims and managed care encounters for naloxone dispensed under the standing order.

RESULTS

Overall, there were 2053 naloxone fills by 1912 unique individuals. The total number of naloxone fills increased from 22 in 2017 to 1218 in 2019. Most members (n = 1,586, 83.0%) received any type of health service and 20.4% (n = 391) received an opioid-related health service in the 30 days prior to filling naloxone. Additionally, 12.7% (n = 242) of members had received medication for opioid use disorder (MOUD), and 42.6% (n = 815) filled a prescription opioid analgesic within the 60 days prior to filling naloxone. Nineteen members (1.0%) had an emergency department visit for overdose within 90 days after filling naloxone.

CONCLUSION

Standing orders play an important role in providing access to naloxone, even among Medicaid members who had recent encounters with health care providers. We identified multiple opportunities to improve naloxone prescribing among providers caring for Medicaid-insured people who use opioids, including prescribers of opioid analgesics or MOUD.

"Like it was just everyday business": A qualitative study of pharmacy-based naloxone and syringe customer experience

BACKGROUND

As rates of overdoses involving opioids continue to rise in the United States, community pharmacies are uniquely positioned as a central access point of care for individuals to access harm reduction supplies, such as naloxone and nonprescription syringes (NPS).

OBJECTIVES

This study aimed to identify the facilitators and barriers of obtaining naloxone and NPS at community pharmacies that participated in Respond to Prevent (R2P), a multicomponent intervention to increase dispensing rates of naloxone, buprenorphine, and NPS.

METHODS

Pharmacy customers were recruited to participate in semistructured qualitative interviews conducted immediately after they obtained, or attempted to obtain, naloxone and NPS (when applicable) from R2P-participating pharmacies. Thematic analysis was conducted on the transcribed interviews, and content coding was applied to ethnographic notes and text messages from participants.

RESULTS

Of the 32 participants, most (n = 28, 88%) successfully obtained naloxone and most of those seeking NPS successfully (n = 14, 82%) purchased them as well. Participants reported positive overall experiences at the community pharmacies. Participants described using the intervention advertising materials, as designed, to facilitate the request for naloxone. Many participants shared that they felt respected by pharmacists and that they valued naloxone counseling sessions that were tailored to meet their needs and allowed space for them to ask questions. Barriers included experiences where the intervention did not address structural challenges that prohibited the purchase of naloxone and where certain types of staff lacked knowledge, treated participants poorly, or did not adequately provide expected naloxone counseling.

CONCLUSION

Pharmacy customer experiences obtaining naloxone and NPS in R2P-participating pharmacies identify facilitators and barriers to access that may be used to reform implementation and future interventions. Barriers identified can help enhance strategies or inform policies to improve pharmacy-based harm reduction supply distribution not addressed through existing interventions.

Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone (SWIFT): A stepped wedge hybrid type 1 effectiveness-implementation study

BACKGROUND

Extended-release injectable naltrexone (XR-NTX) is an effective treatment for opioid use disorder (OUD), but initiation remains a barrier to implementation. Standard practice requires a 10- to 15-day inpatient admission prior to XR-NTX initiation and involves a methadone or buprenorphine taper followed by a 7- to 10-day washout, as recommended in the Prescribing Information for XR-NTX. A 5- to 7-day rapid induction approach was developed that utilizes low-dose oral naltrexone and non-opioid medications.

METHODS

The CTN-0097 Surmounting Withdrawal to Initiate Fast Treatment with Naltrexone (SWIFT) study was a hybrid type I effectiveness-implementation trial that compared the effectiveness of the standard procedure (SP) to the rapid procedure (RP) for XR-NTX initiation across six community inpatient addiction treatment units, and evaluated the implementation process. Sites were randomized to RP every 14 weeks in an optimized stepped wedge design. Participants (target recruitment = 450) received the procedure (SP or RP) that the site was implementing at time of admission. The hypothesis was RP will be non-inferior to SP on proportion of inpatients who receive XR-NTX, with a shorter admission time for RP. Superiority testing of RP was planned if the null hypothesis of inferiority of RP to SP was rejected.

DISCUSSION

If RP for XR-NTX initiation is shown to be effective, the shorter inpatient stay could make XR-NTX more feasible and have an important public health impact expanding access to OUD pharmacotherapy. Further, a better understanding of facilitators and barriers to RP implementation can help with future translatability and uptake to other community programs.

TRIAL REGISTRATION

NCT04762537 Registered February 21, 2021.

Case series: Voluntary discontinuation of sublingual buprenorphine treatment for opioid use disorder using extended-release buprenorphine

BACKGROUND AND OBJECTIVES

Despite its efficacy, patients may still seek to voluntarily discontinue sublingual (SL) buprenorphine treatment, but little guidance exist on how to safely conduct a taper. We, therefore, report on the use of extended-release buprenorphine (XR-BUP) to facilitate voluntary treatment discontinuation.

METHODS

A case series (n = 4).

RESULTS

Four individuals interested in voluntary discontinuation of sublingual buprenorphine treatment were transitioned to varying durations of XR-BUP, after which all were able to discontinue buprenorphine with minimal withdrawal symptoms. One individual had a brief recurrence to illicit opioid use. All remained engaged in treatment.

DISCUSSION AND CONCLUSIONS

The use of XR-BUP, given its long terminal half-life, may be a helpful option for individuals who are interested in voluntary buprenorphine discontinuation. Collaboration with the patient must include information about the risk of lapse to use and overdose following discontinuation.

SCIENTIFIC SIGNIFICANCE

The cases reported here provide preliminary support for the use of XR-BUP to help individuals discontinue buprenorphine treatment. There is only one other case series showing the use of XR-BUP in helping individuals successfully discontinue buprenorphine treatment. Buprenorphine discontinuation is clinically relevant and there is little guidance in the current literature.

The Pharmacokinetics of Subcutaneous Methylnaltrexone Bromide in Rhesus Macaques (Macaca mulatta)

Opioids are an integral component of pain management for nonhuman primates. These potent analgesics also adverse gastrointestinal (GI) effects that include constipation, bloating, and delayed gastric emptying. Methylnaltrexone bromide (MNTX) is a selective, peripherally acting μ- and κ-opioid receptor antagonist that can be used to mitigate the GI effects associated with opioid administration. Unlike naltrexone, a similar drug in this class, MNTX possesses an N-methyl-quaternary amine group that prevents it from crossing the blood brain barrier. This blockage allows inhibition of peripheral GI opioid receptors without affecting opioid-mediated analgesia in the central nervous system. We conducted a pharmacokinetic analysis of MNTX in serum and CSF of 6 healthy juvenile male rhesus macaques after subcutaneous administration of a 0.15-mg/kg dose. We hypothesized that the macaques would demonstrate a Tmax of 0.5 h, similar to that of humans, and that no MNTX would be detected in the CSF. This treatment resulted in a peak serum concentration of 114 ± 44 ng/mL at 0.25 ± 0.00 h; peak CSF at concentrations were 0.34 ± 0.07 ng/mL at the Tmax. These data show that subcutaneous administration of MNTX to rhesus macaques may block peripheral adverse effects of opioids without interfering with their central analgesic effects.

Implementation Facilitation to Promote Emergency Department-Initiated Buprenorphine for Opioid Use Disorder

Importance

Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused.

Objective

To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy.

Design, Setting, and Participants

This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022.

Exposure

A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback.

Main Outcomes and Measures

The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed.

Results

A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits).

Conclusions and Relevance

In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine.

Trial Registration

ClinicalTrials.gov Identifier: NCT03023930.

Characterizing and combating the opioid epidemic in the Los Angeles County jail system

INTRODUCTION

Opioid overdose-related morbidity and mortality is a pressing public health crisis. Successful overdose reversal through bystander administration of naloxone is well documented, but there is an absence of literature on the implementation and impact of widespread naloxone access in a correctional setting during incarceration. The objective of this study was to describe our efforts to combat opioid overdose, prevent deaths, and examine and identify opioid use and predictors of opioid use through factors including age, sex assigned at birth, and ethnicity among the incarcerated population within the Los Angeles County jail system.

METHODS

We retrospectively analyzed self-reported substance use information from all newly incarcerated persons from September 2018 to December 2020 to characterize opioid use in the Los Angeles County Jail system and used multivariable logistic regression analysis to determine predictors of substance use. We analyzed data on all cases of naloxone administration by custody personnel (i.e., all correctional officers) during the same period by examining patient demographic information, hospital discharge diagnosis, and patient outcome information. To describe naloxone training and access for incarcerated persons as an overdose prevention strategy, we reviewed electronic health record data on patient health outcomes for all cases of naloxone administration by an incarcerated person.

RESULTS

A total of 6.4 % (11,881 of 187,528) of incarcerated persons reported opioid use. In the multivariable analysis, reported substance use was most significantly associated with any ethnicity other than Black (aOR for White =11.2; 95 % CI 10.4, 12.0, aOR for Hispanic/Latinx 3.0; 95 % CI 2.8, 3.2, aOR for All Others; 5.2 95 % CI 4.6, 5.8) and being <65 years old. Naloxone was administered by custody personnel to a total of 129 patients, where 122 (94.6 %) survived and 7 (5.4 %) died. After the deployment of naloxone in jail housing units, there were two instances of bystander naloxone administration by incarcerated persons that led to successful opioid overdose reversal and survival.

CONCLUSIONS

The expansion of naloxone availability to both custody personnel and incarcerated persons is an effective and warranted method to ensure timely naloxone administration and successful overdose reversal in a correctional setting.

Standard Naloxone Prescribing for Palliative Care Cancer Patients on Opioid Therapy: A Single-Site Quality Improvement Pilot to Assess Attitudes and Access

BACKGROUND

Limited data exist on when to offer naloxone to cancer patients on opioid therapy.

MEASURES

We assessed patient and clinician attitudes on naloxone education (done via surveys at initial and follow up visits) and prescribing rates (via chart reviews) at a single ambulatory palliative care practice. Pharmacy records assessed naloxone dispense rates.

INTERVENTION

During a three-month period, all new patients receiving opioid therapy were offered naloxone. Standardized educational materials on opioid safety and naloxone use were created and shared by clinical team.

OUTCOMES

Naloxone prescribing rates increased from 5% to 66%. 92% (n = 23) of clinicians reported education/prescribing took ≤ five minutes, and 100% reported either a positive or neutral impact on the encounter. A total of 81% (n = 25) of patients reported no increased worry about opioid use, 68% (n = 21) felt safer with naloxone, and 97% rated the encounter as neutral or positive. 88% (n = 37) of prescriptions were dispensed and 67% of patients (n = 16) paid <$10.

CONCLUSIONS/LESSONS LEARNED

Opioid safety education and naloxone prescribing can be done quickly and is well-received by clinicians and patients.

Statewide Policy to Increase Provision of Take-Home Naloxone at Emergency Department Visits for Opioid Overdose, Rhode Island, 2018‒2019

In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. (Am J Public Health. 2023;113(4):372-377. https://doi.org/10.2105/AJPH.2022.307213).

Effects of buprenorphine on opioid craving in comparison to other medications for opioid use disorder: A systematic review of randomized controlled trials

BACKGROUND

Craving is a distressing symptom of opioid use disorder (OUD) that can be alleviated with medications for OUD (MOUD). Buprenorphine is an effective MOUD that may suppress craving; however, treatment discontinuation and resumed opioid use is common during the early phases of treatment. More information on the craving response through the high-risk period of initiating buprenorphine may provide meaningful information on how to better target craving, which in turn may enhance outcomes. This systematic review investigated buprenorphine doses and formulations on craving during the induction and maintenance phases of treatment, and for context also compared the craving response to other MOUD (i.e., methadone, extended-release naltrexone [XR-NTX]).

METHODS

PubMed, PsycInfo, Embase, and Cochrane Central databases were searched for randomized trials of buprenorphine versus placebo, various buprenorphine formulations/doses, or other MOUD that included a measure of opioid craving.

RESULTS

A total of 10 studies were selected for inclusion. Buprenorphine and buprenorphine/naloxone (BUP/NAL) were each associated with lower craving than placebo over time. Craving was greater among those prescribed lower versus higher buprenorphine doses. In comparison to other MOUD, buprenorphine or BUP/NAL was linked to greater craving than methadone in 3 of the 6 studies. BUP/NAL was associated with greater reported craving than XR-NTX.

DISCUSSION

Craving is reduced over time with buprenorphine and BUP/NAL, although other MOUD may provide greater reductions in craving. Although there is currently considerable variability in the measurement of craving, it may be a valuable concept to address with individuals receiving MOUD, especially early in treatment.

Efficacy and Safety of Naldemedine Administration for Opioid-Induced Constipation in Cancer Patients with Poor Performance Status

Background: Constipation is a concern among patients with Eastern Cooperative Oncology Group (ECOG) performance status (PS) of 3 and 4. Objectives: To assess naldemedine's efficacy and safety in cancer patients on opioids with poor PS. Design: Multicenter, retrospective study. Setting/Subjects: Japanese cancer patients with ECOG performance status 3 or 4 who received naldemedine. Measurements: Frequency of defecations before/after naldemedine use. Responders were patients whose defecation frequency increased to ≥3 times/week, from baseline ≥1 defecations/week over seven days after naldemedine administration. Results: Seventy-one patients were analyzed; 66.1% were responders (95% confidence interval: 54.5%-76.1%). Defecation frequency increased significantly after naldemedine in the overall population (6 vs. 2, p < 0.0001) and among those who defecated <3 times/week before naldemedine (4.5 vs. 1, p < 0.0001). Diarrhea (38.0%) of all grades was the most common adverse event; 23 (85.2%) events were classified as Grade 1 or 2. Conclusion: Naldemedine is effective and safe among cancer patients with poor PS.

Social ecological factors and medication treatment for opioid use disorder among justice-involved rural and urban persons: the Geographic variation in Addiction Treatment Experiences (GATE) longitudinal cohort study protocol

INTRODUCTION

Three medications are Food and Drug Administration approved for the treatment of opioid use disorder (OUD); however, these medications are underused within prisons, which elevates the risk of relapse and overdose when persons with opioid use disorder (POUD) are released. Research is scant regarding the multilevel factors associated with POUDs' willingness to initiate medication treatment for opioid use disorder (MOUD) while in prison and their continued engagement in treatment after release. Furthermore, rural and urban populations have not been compared. The Geographic variation in Addiction Treatment Experiences (GATE) study seeks to identify multilevel factors (ie, individual, personal network, and structural factors) influencing prison-based extended-release injectable naltrexone (XR-NTX) and buprenorphine initiation and will examine predictors of postrelease MOUD use and adverse outcomes (ie, relapse, overdose, recidivism) among both rural and urban POUDs.

METHODS AND ANALYSIS

This mixed methods study employs a social ecological framework. A prospective observational longitudinal cohort study is being conducted with 450 POUDs using survey and social network data collected in prison, immediately postrelease, 6 months postrelease and 12 months postrelease to identify multilevel rural-urban variation in key outcomes. In-depth qualitative interviews are being conducted with POUDs, prison-based treatment staff and social service clinicians. To maximise rigour and reproducibility, we employ a concurrent triangulation strategy, whereby qualitative and quantitative data contribute equally to the analysis and are used for cross-validation when examining scientific aims.

ETHICS AND DISSEMINATION

The GATE study was reviewed and approved by the University of Kentucky's Institutional Review Board prior to implementation. Findings will be disseminated through presentations at scientific and professional association conferences, peer-reviewed journal publications and a summary aggregate report submitted to the Kentucky Department of Corrections.

The effectiveness of a noninterruptive alert to increase prescription of take-home naloxone in emergency departments

OBJECTIVE

Opioid-related overdose (OD) deaths continue to increase. Take-home naloxone (THN), after treatment for an OD in an emergency department (ED), is a recommended but under-utilized practice. To promote THN prescription, we developed a noninterruptive decision support intervention that combined a detailed OD documentation template with a reminder to use the template that is automatically inserted into a provider's note by decision rules. We studied the impact of the combined intervention on THN prescribing in a longitudinal observational study.

METHODS

ED encounters involving an OD were reviewed before and after implementation of the reminder embedded in the physicians' note to use an advanced OD documentation template for changes in: (1) use of the template and (2) prescription of THN. Chi square tests and interrupted time series analyses were used to assess the impact. Usability and satisfaction were measured using the System Usability Scale (SUS) and the Net Promoter Score.

RESULTS

In 736 OD cases defined by International Classification of Disease version 10 diagnosis codes (247 prereminder and 489 postreminder), the documentation template was used in 0.0% and 21.3%, respectively (P < .0001). The sensitivity and specificity of the reminder for OD cases were 95.9% and 99.8%, respectively. Use of the documentation template led to twice the rate of prescribing of THN (25.7% vs 50.0%, P < .001). Of 19 providers responding to the survey, 74% of SUS responses were in the good-to-excellent range and 53% of providers were Net Promoters.

CONCLUSIONS

A noninterruptive decision support intervention was associated with higher THN prescribing in a pre-post study across a multiinstitution health system.

DO HIGHER DOSES OF NALOXONE INCREASE THE RISK OF PULMONARY COMPLICATIONS?

BACKGROUND

Although naloxone has proven to be an effective opioid reversal agent, concern that high doses of naloxone can cause pulmonary edema may prevent health care providers from administering it in initial high doses.

OBJECTIVE

Our aim was to determine whether increased doses of naloxone are correlated with an increase in pulmonary complications in patients presenting to the emergency department (ED) after an opioid overdose.

METHODS

This was a retrospective study of patients treated with naloxone by emergency medical services (EMS) or in the ED at an urban level I trauma center and three associated freestanding EDs. Data were queried from EMS run reports and the medical record and included demographic characteristics, naloxone dosing, administration route, and pulmonary complications. Patients were grouped by naloxone dose received, defined as low (≤ 2 mg), moderate (> 2 mg to ≤ 4 mg), and high (> 4 mg).

RESULTS

Of the 639 patients included, 13 (2.0%) were diagnosed with a pulmonary complication. There was no difference in the development of pulmonary complications across groups (p = 0.676). There was no difference in pulmonary complications based on the route of administration (p = 0.342). The administration of higher doses of naloxone was not associated with longer hospital stays (p = 0.0327).

CONCLUSIONS

Study results suggest that the reluctance of many health care providers to administer larger doses of naloxone on initial treatment may not be warranted. In this investigation, there were no poor outcomes associated with an increase in naloxone administration. Further investigation in a more diverse population is warranted.

Harm Reduction Approach to Increasing Self-reported Safe Medication Storage Among Pregnant and Parenting People Receiving Opioid Use Disorder Treatment

OBJECTIVES

The expansion of access to buprenorphine-naloxone (BUP-NAL) for the treatment of opioid use disorder (OUD) is critical to combat the overdose crisis. Evidence is lacking to guide providers on how to best promote BUP-NAL medication safety for their patients. This study assessed (1) the current medication storage practices among a sample of pregnant and parenting people receiving BUP-NAL for OUD; (2) the feasibility and acceptability of providing a lockbox for safe medication storage.

METHODS

Pregnant and/or parenting patients receiving sublingual BUP-NAL in an outpatient OUD clinic were recruited between June and November 2021. Participants completed a baseline survey, received a lockbox, and a follow-up survey 3 to 8 weeks later. The primary outcome of current self-reported safe medication storage practice was defined by storing BUP-NAL in a locked/latched place "almost always" or "always" on the baseline survey. Outcomes were analyzed using simple proportions.

RESULTS

Sixty-three participants completed the baseline survey, and 50 completed the follow-up survey. Baseline survey results indicated that only a quarter of patients (26.6%) were practicing safe BUP-NAL medication storage practices. At follow up, 93.6% of patients were using the lockbox provided by the study, 93.4% reported being satisfied with the lockbox, and most participants (89.3%) reported safe BUP-NAL medication storage practices.

CONCLUSIONS

Many pregnant and parenting patients with OUD receiving BUP-NAL do not store their medications safely. The provision of a lockbox as part of OUD treatment is a feasible, acceptable, and potentially effective harm reduction intervention.