Developing an opioid use disorder treatment cascade: A review of quality measures

A community outreach intervention to link individuals with opioid use disorders to medication-assisted treatment

Individuals with opioid use disorders (OUD) face significant barriers to accessing medication-assisted treatment (MAT), yet access to MAT is critical to reducing opioid-related fatality. This study evaluated a peer outreach and treatment linkage intervention in Chicago that is part of the Illinois Opioid State Targeted Response (STR) project to assist individuals with OUD in accessing MAT. The study uses the framework of the Opioid Use Disorder Cascade of Care to track progress through successive stages of the intervention and evaluated covariates of successful transitions across stages. Peer outreach workers contacted individuals in high-risk communities, conducted an eligibility screen, and scheduled eligible individuals to meet with project staff for treatment linkage. Over the 12-month study period (July 2017-June 2018), peer outreach workers conducted approximately 3308 encounters with individuals; 83% (n = 1638) were determined to be eligible for the intervention and agreed to an on-site linkage meeting. A majority of these (59%; n = 972) showed to the linkage meeting; most of these (92%, n = 890) were scheduled for a MAT intake appointment; and 86% (n = 765) of those scheduled showed to the MAT intake appointment. Most (91%; n = 696) of those who showed for treatment intake received a first dose, and 72% (n = 498) of these were in treatment at 30 days after their first dose. Several participant characteristics differentiated individuals that continued at each stage of the cascade model from those that did not. These findings demonstrate that the peer outreach and treatment linkage intervention may be successfully used to engage individuals with OUD into treatment.

Monitoring opioid addiction and treatment: Do you know if your population is engaged?

BACKGROUND

Assessment of people affected by opioid-related problems and those receiving care is challenging due to lack of common definitions and scattered information. We sought to fill this gap by demonstrating a method to describe a continuum of opioid addiction care in a large, public safety-net institution.

METHODS

Using 2017 clinical and administrative data from Denver Health (DH), we created operational definitions for opioid use disorder (OUD), opioid misuse (OM), and opioid poisoning (OP). Six stages along a continuum of patient engagement in opioid addiction care were developed, and operational definitions assigned patients to stages for a specific time point of analysis. National data was used to estimate the Denver population affected by OUD, OM and OP.

RESULTS

In 2017, an estimated 6688 people aged ≥12 years were affected by OUD, OM, or OP in Denver; 48.4% (3238/6688) were medically diagnosed in DH. Of those, 32.5% (1051/3238) were in the medication assisted treatment stage, and, of those, 59.8% (629/1051) in the adhered to treatment stage. Among that latter group, 78.4% (493/629) adhered at least 90 days and 52.3% (329/629) for more than one year. Among patients who received medication assisted treatment, less than one third (31.3%, 329/1051) were adherent for more than one year.

CONCLUSIONS

A health-system level view of the continuum of opioid addiction care identified improvement opportunities to better monitor accuracy of diagnosis, treatment capacity, and effectiveness of patient engagement. Applied longitudinally at local, state and national levels, the model could better synergize responses to the opioid crisis.

Association of current and past opioid use disorders with health-related quality of life and employment among US adults

BACKGROUND

To examine the association of current and past Opiate Use Disorder (OUD) with measures of HRQOL and employment in a nationally representative sample of adults.

METHODS

The 2012-2013 National Epidemiological Survey on Alcohol and Related Conditions III (NESARC III) surveyed a nationally representative sample of non-institutionalized civilian adults (≥18 years) in the US (n = 36,309 unweighted). Using DSM-5 criteria, adults without history of OUD were compared to those with current and past OUD. Using the SF-12 items, standard measures of the mental and physical component scores of HRQOL and of quality-adjusted life years (QALYs) were constructed. Employment in the past year (yes/no) was also assessed. Multivariable-adjusted regression analyses were used to adjust for covariates.

RESULTS

Overall, 0.9% of the study sample, representing 2.1 of 235.4 million adults, met criteria for current OUD; 1.2%, representing 2.7 million adults, met criteria for past OUD. Adults with current or past OUD had large and moderately reduced mental component (MCS) and physical health component (PCS) summary scores compared to adults who never had OUD (p < 0.001, respectively). Current OUD was associated with lower odds of being employed compared to never experiencing OUD (Adjusted odds ratio = 0.65; 95% CI: 0.48, 0.88; p = 0.005), as was past OUD. Adjustment for potentially confounding factors reduced the independent association of OUD and HRQOL by about 40-50% but did not change employment comparisons.

CONCLUSION

Adults with current OUD are associated with large reductions in HRQOL and likelihood of not being employed, and adults with past OUD also have considerable residual impairment.

Morphine in Plasma and Cerebrospinal Fluid of Patients Addicted to Opiates Undergoing Surgery: High-performance Liquid Chromatography Method

Background

The prevalence of opium addiction among Iranians is considerable. Since endogenous opioid systems may be altered as a consequence of addiction, it is very important to determine the plasma and cerebrospinal fluid (CSF) levels of morphine in Iranian patients addicted to opiates who will undergo surgery.

Methods

We obtained CSF and plasma samples from 50 volunteers with an established opioid addiction pattern. Samples were analyzed using high-performance liquid chromatography (HPLC). Additionally, frequency of nausea and vomiting, baseline heart rate (BHR), and systolic blood pressure (SBP) were recorded within the surgery and postoperatively during a 10-min interval.

Findings

84% of participants were men with a median age of 39.08 years. Mean score of body mass index (BMI) was 23.30 and most of the participants (46%) used opium in its traditional inhaled form. A higher concentration of morphine in blood was found in comparison with CSF (P < 0.001) in relation to the way of use. However, no statistically significant differences were found in relation to the type of addictive substance. No other association was found between the levels of morphine and the clinical characteristics of the patients. Moreover, results revealed no difference between hemodynamic-related data with blood and CSF level in opium-dependent patients.

Conclusion

Quantification of plasma and CSF morphine, both immediately before initiation of surgery and subsequently on recovery room, showed that although clinical efficacy of systemic morphine was poor in addicted patients, it had no effect on patients' hemodynamic variable and following complications after surgery.

Management of opioid use disorder in the USA: present status and future directions

Opioid use disorder is characterised by the persistent use of opioids despite the adverse consequences of its use. The disorder is associated with a range of mental and general medical comorbid disorders, and with increased mortality. Although genetics are important in opioid use disorder, younger age, male sex, and lower educational attainment level and income, increase the risk of opioid use disorder, as do certain psychiatric disorders (eg, other substance use disorders and mood disorders). The medications for opioid use disorder, which include methadone, buprenorphine, and extended-release naltrexone, significantly improve opioid use disorder outcomes. However, the effectiveness of medications for opioid use disorder is limited by problems at all levels of the care cascade, including diagnosis, entry into treatment, and retention in treatment. There is an urgent need for expanding the use of medications for opioid use disorder, including training of health-care professionals in the treatment and prevention of opioid use disorder, and for development of alternative medications and new models of care to expand capabilities for personalised interventions.

A Quality Framework for Emergency Department Treatment of Opioid Use Disorder

Emergency clinicians are on the front lines of responding to the opioid epidemic and are leading innovations to reduce opioid overdose deaths through safer prescribing, harm reduction, and improved linkage to outpatient treatment. Currently, there are no nationally recognized quality measures or best practices to guide emergency department quality improvement efforts, implementation science researchers, or policymakers seeking to reduce opioid-associated morbidity and mortality. To address this gap, in May 2017, the National Institute on Drug Abuse's Center for the Clinical Trials Network convened experts in quality measurement from the American College of Emergency Physicians' (ACEP's) Clinical Emergency Data Registry, researchers in emergency and addiction medicine, and representatives from federal agencies, including the National Institute on Drug Abuse and the Centers for Medicare & Medicaid Services. Drawing from discussions at this meeting and with experts in opioid use disorder treatment and quality measure development, we developed a multistakeholder quality improvement framework with specific structural, process, and outcome measures to guide an emergency medicine agenda for opioid use disorder policy, research, and clinical quality improvement.

Development of a Cascade of Care for responding to the opioid epidemic

Amid worsening opioid overdose death rates, the nation continues to face a persistent addiction treatment gap limiting access to quality care for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and extended-release naltrexone) have high quality evidence demonstrating reductions in drug use and overdose events, but most individuals with OUD do not receive them. The development of a unified public health framework, such as a Cascade of Care, could improve system level practice and treatment outcomes. In response to feedback from many stakeholders over the past year, we have expanded upon the OUD treatment cascade, first published in 2017, with additional attention to prevention stages and both individual-level and population-based services to better inform efforts at the state and federal level. The proposed cascade framework has attracted considerable interest from federal agencies including the Centers for Disease Control and Prevention (CDC) and National Institute on Drug Abuse (NIDA) along with policy-makers nationwide. We have reviewed recent literature and evidence-based interventions related to prevention, identification, and treatment of individuals with OUD and modeled updated figures from the 2016 National Survey on Drug Use and Health. Many currently employed interventions (prescriber guidelines, prescription monitoring programs, naloxone rescue) address prevention of OUD or downstream complications but not treatment of the underlying disorder itself. An OUD Cascade of Care framework could help structure local and national efforts to combat the opioid epidemic by identifying key targets, interventions, and quality indicators across populations and settings to achieve these ends. Improved data collection and reporting methodology will be imperative.

Patient Barriers and Facilitators to Medications for Opioid Use Disorder in Primary Care

Introduction: This study explored factors influencing patient access to medications for opioid use disorder (OUD), particularly for individuals eligible but historically suboptimal follow-up with in-house referrals to office-based opioid treatment (OBOT). Objectives: In-depth qualitative interviews among a mostly underserved sample of adults with OUD elicited: 1) knowledge and experiences across the OUD treatment cascade; and 2) more nuanced elements of patient-centered care, including shared decision making with providers, experiences in OBOT versus specialty addiction treatment, transitioning from methadone to buprenorphine or extended-release naltrexone (XR-NTX), and voluntary discontinuation of medications for OUD. Methods: We conducted semi-structured qualitative interviews between January and February of 2018 among adult inpatient detoxification program patients with OUD (n = 23). Preliminary analysis of interviews yielded key themes and ideas that were coded from a grounded theory approach. Results: Willingness to engage with OBOT was influenced by a complex array of practical considerations, including access to patient-centered care in OBOT settings, positive experiences with illicitly obtained buprenorphine, and differential experiences pertaining to OBOT versus specialty addiction treatment. Responses were generally favorable towards OBOT with buprenorphine, yet knowledge regarding extended-release naltrexone was limited. Respondents were often frustrated by clinicians when requesting to transition from methadone to buprenorphine or XR-NTX. Lastly, participants elucidated limited access to OBOT programs in underserved neighborhoods and suburban settings. Conclusion: Limited access to patient-centered care in OBOT with buprenorphine and extended-release naltrexone may exacerbate challenges to retention and/or reengagement with OUD care.

Naltrexone: A History and Future Directions

Trying to kick drug addiction without medicines is said to be like relying on willpower to overcome diabetes or asthma. Enter naltrexone, which has been around since 1984 and reduces the cravings for drugs and alcohol by fine-tuning the brain's chemical reward system. Why has it recently increased in popularity? How does it compare to similar strategies? Has it made a difference? Our authors, who have long studied addiction and the brain, confront a drug and alcohol addiction problem that today kills more Americans each day than gun violence or car accidents.