Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence

Cebranopadol, a novel long-acting opioid agonist with low abuse liability, to treat opioid use disorder: Preclinical evidence of efficacy

Maintenance therapy with buprenorphine and methadone is the gold standard pharmacological treatment for opioid use disorder (OUD). Despite these compounds demonstrating substantial efficacy, a significant number of patients do not show optimal therapeutic responses. The abuse liability of these medications is also a concern. Here we used rats to explore the therapeutic potential of the new long-acting pan-opioid agonist Cebranopadol in OUD. We tested the effect of cebranopadol on heroin self-administration and yohimbine-induced reinstatement of heroin seeking. In addition, we evaluated the abuse liability potential of cebranopadol in comparison to that of heroin under fixed ratio 1 (FR1) and progressive ratio (PR) operant self-administration contingencies. Oral administration of cebranopadol (0, 25, 50 μg/kg) significantly attenuated drug self-administration independent of heroin dose (1, 7, 20, 60μg/inf). Cebranopadol also reduced the break point for heroin (20 μg/inf). Finally, pretreatment with cebranopadol significantly attenuated yohimbine-induced reinstatement of drug seeking. In abuse liability experiments under FR1 contingency, rats maintained responding for heroin (1, 7, 20, 60μg/inf) to a larger extent than cebranopadol (0.03, 0.1, 0.3, 1.0, 6.0μg/inf). Under PR contingency, heroin maintained responding at high levels at all except the lowest dose, while the break point (BP) for cebranopadol did not differ from that of saline. Together, these data indicate that cebranopadol is highly efficacious in attenuating opioid self-administration and stress-induced reinstatement, while having limited abuse liability properties. Overall, the data suggest clinical potential of this compound for OUD treatment.

The Mobile Overdose Response Program: A mobile, low-threshold opioid use disorder treatment model in Philadelphia

INTRODUCTION

Low-threshold substance use treatment programs may help overcome barriers for marginalized individuals. The aims of this study were to 1) describe participant characteristics and treatment outcomes for a multi-site, Philadelphia-based mobile program providing street-based buprenorphine initiation, stabilization, and referral to ongoing care and 2) examine associations between patient characteristics and successful linkage.

METHODS

We conducted a retrospective cohort study of patients receiving buprenorphine through Prevention Point Philadelphia's mobile overdose response program from 9/2020-12/2021. We abstracted electronic medical record data, including patient characteristics, mobile program treatment, and care linkage. We used descriptive statistics to characterize the sample and assessed the association between patient characteristics and successful care linkage using multi-variable logistic regression.

RESULTS

Two hundred thirty-seven patients initiated buprenorphine in the program across six sites. Mean age was 46. Participants were majority men (67 %); 59 % identified as Black, 33 % identified as White, and 15 % reported Hispanic ethnicity. Most were publicly insured (74 %) and 30 % were unstably housed. Basedline engagement in primary care (32 %), psychiatric treatment (5 %), and counseling (2 %) were low. Most participants reported heroin or fentanyl use at intake (87 %), with high rates of IV drug use (37 %)., and co-occurring substance use and prior buprenorphine treatment experience were common.. 86 % completed ≥1 mobile follow-up visit, and 69 % completed ≥4 mobile program visits. 51 % of patients attended at least one visit at an outside site, and 30 % had ≥2 visits for buprenorphine prescriptions at an outside site. 35 % of the referrals were internal, meaning they went to University-based practices staffed by the mobile unit physicians. In a multivariable logistic regression model, internal referral was associated with significantly increased odds of effective care linkage (aOR 2.47, 95 % CI 1.20-5.09).

CONCLUSIONS

Targeted community outreach with low-threshold substance use care facilitated treatment access among marginalized individuals. Participants showed high levels of engagement with the mobile program, but rates of outside care linkage, while comparable to retention in other low-threshold models, were lower. The only predictor of effective care linkage was referral to brick-and-mortar clinics staffed by mobile unit physicians. These findings support the importance of outreach beyond traditional health care settings to engage high-risk patients with OUD.

Client preferences for the design and delivery of injectable opioid agonist treatment services: Results from a best-worst scaling task

BACKGROUND AND AIMS

Clinical trials support injectable opioid agonist treatment (iOAT) for individuals with opioid use disorder (OUD) for whom other pharmacological management approaches are not well-suited. However, despite substantial research indicating that person-centered care improves engagement, retention and health outcomes for individuals with OUD, structural requirements (e.g. drug policies) often dictate how iOAT must be delivered, regardless of client preferences. This study aimed to quantify clients' iOAT delivery preferences to improve client engagement and retention.

DESIGN

Cross-sectional preference elicitation survey.

SETTING

Metro Vancouver, British Columbia, Canada.

PARTICIPANTS

124 current and former iOAT clients.

MEASUREMENTS

Participants completed a demographic questionnaire package and an interviewer-led preference elicitation survey (case 2 best-worst scaling task). Latent class analysis was used to identify distinct preference groups and explore demographic differences between preference groups.

FINDINGS

Most participants (n = 100; 81%) were current iOAT clients. Latent class analysis identified two distinct groups of client preferences: (1) autonomous decision-makers (n = 73; 59%) and (2) shared decision-makers (n = 51; 41%). These groups had different preferences for how medication type and dosage were selected. Both groups prioritized access to take-home medication (i.e. carries), the ability to set their own schedule, receiving iOAT in a space they like and having other services available at iOAT clinics. Compared with shared decision-makers, fewer autonomous decision-makers identified as a cis-male/man and reported flexible preferences.

CONCLUSIONS

Injectable opioid agonist treatment (iOAT) clients surveyed in Vancouver, Canada, appear to prefer greater autonomy than they currently have in choosing OAT medication type, dosage and treatment schedule.

Reconsidering the usefulness of long-term high-dose buprenorphine

Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial

BACKGROUND AND AIMS

Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose.

DESIGN

Two-arm, randomized trial.

SETTING

Two EDs in Rhode Island, USA.

PARTICIPANTS

ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White.

INTERVENTION AND COMPARATOR

Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW).

MEASUREMENTS

We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period.

FINDINGS

Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11).

CONCLUSIONS

In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

Effectiveness of buprenorphine (naloxone) for opioid dependence does not differ across opioid categories: a retrospective cohort study from India

We aimed to examine whether treatment retention, abstinence, and adherence to buprenorphine-naloxone (BNX) differ among individuals with opioid dependence (OD) across three common categories of opioids- heroin, opium, and low-potency pharmaceutical. In a retrospective cohort study, we analyzed outpatient treatment records from March 2020 through February 2022. Opioid category was determined by lifetime and current opioid use. We defined treatment retention as weeks of uninterrupted clinic attendance. Abstinence and BNX adherence were calculated by weeks of extra-medical opioid-negative and buprenorphine-positive urine screening from treatment initiation. Four-hundred-thirteen patients were eligible; 406 (98.3%) were included in the final analysis. Two-hundred-ninety (71.4%) patients were dependent on heroin; 66 (16.3%) were natural opioid dependent, and 50 (12.3%) were dependent on low-potency pharmaceutical opioids. BNX effectiveness in treatment retention, abstinence, and adherence did not differ in patients dependent on heroin, natural, and low-potency pharmaceutical opioids. Patients on ≥8 mg daily BNX had better retention and adherence than those on <8 mg daily. Patients from lower socioeconomic status (SES) had higher odds of retention, abstinence, and adherence than those from upper/middle SES. Treatment outcomes on BNX did not differ across opioid categories. However, BNX should be dosed adequately.

Initiation and Receipt of Medication for Opioid Use Disorder Among Adolescents and Young Adults in 4 State Medicaid Programs in 2018: Improving Medicaid Quality Metrics

BACKGROUND

Medications for opioid use disorder (MOUD) in youth can reduce harms but many youths do not receive MOUD. Improving quality metrics of MOUD among youth can advance interventions for youth with opioid use disorder (OUD).

METHODS

We relied on 2018 Medicaid claims data from California, Colorado, Massachusetts, and New Mexico. We calculated the percentage of youth with OUD included in the quality metric for initiation, and the percentage who initiated by state. We also calculated the percentage excluded from the quality metric for initiation because they have an existing episode of OUD care and their MOUD receipt. We compared the characteristics of those who initiated/received MOUD to those who did not and compared state estimates after adjusting for age and health conditions.

RESULTS

Estimates of initiation exclude about half of the youth with OUD because they were in an existing episode of OUD care and could not be observed initiating. Among youth in a new episode of OUD care, only about 1 in 4 initiated and state estimates varied from 18.9% to 40.1%. Among youth with an existing episode of OUD care, more than half received MOUD and state estimates ranged from 35.2% to 71.3%. Youth who initiated MOUD or received MOUD with an existing OUD had more severe OUD but fewer co-occurring substance use disorders or mental or physical health diagnoses. After adjusting for age and health conditions, MOUD still varied substantially across states.

CONCLUSIONS

Most youth with a new OUD diagnosis do not initiate MOUD but more than half of the youth in an existing OUD diagnosis receive MOUD. MOUD quality metrics that are disaggregated, adjusted, and inclusive of youth in an existing episode of care provide additional insight into opportunities to better support youth who might choose MOUD. State differences should be further studied for insight into policies that may affect MOUD.

Variability in Practice of Buprenorphine Treatment by Emergency Department Operational Characteristics

Introduction

We sought to describe emergency department (ED) buprenorphine treatment variability among EDs with varying operational characteristics.

Methods

We performed a retrospective cohort study of adult patients with opioid use disorder discharged from 12 hospital-based EDs within a large healthcare system as a secondary data analysis of a quality improvement study. Primary outcome of interest was buprenorphine treatment rate. We described treatment rates between EDs, categorized by tertile of operational characteristics including annual census, hospital and intensive care unit (ICU) admission rates, ED length of stay (LOS), and boarding time. Secondary outcomes were ED LOS and 30-day return rates.

Results

There were 7,469 unique ED encounters for patients with opioid use disorder between January 2020-May 2021, of whom 759 (10.2%) were treated with buprenorphine. Buprenorphine treatment rates were higher in larger EDs and those with higher hospital and ICU admission rates. Emergency department LOS and 30-day ED return rate did not have consistent associations with buprenorphine treatment.

Conclusion

Rates of treatment with ED buprenorphine vary according to the operational characteristics of department. We did not observe a consistent negative relationship between buprenorphine treatment and operational metrics, as many feared. Additional funding and targeted resource allocation should be prioritized by departmental leaders to improve access to this evidence-based and life-saving intervention.

How I manage severe bacterial infections in people who inject drugs

BACKGROUND

Injecting drug use is a risk factor for severe bacterial infection, but there is limited high-quality evidence to guide clinicians providing care to people who inject drugs. Management can be complicated by mistrust, stigma, and competing patient priorities.

OBJECTIVES

To review the management of severe infections in people who inject drugs, using an illustrative clinical scenario of complicated Staphylococcus aureus bloodstream infection.

SOURCES

The discussion is based on recent literature searches of relevant topics. Very few randomized clinical trials have focussed specifically on the management of severe bacterial infections among people who inject drugs. Most recommendations are, therefore, based on observational studies, extrapolation from other patient groups, and the experience and opinions of the authors.

CONTENT

We discuss evidence and options regarding the following management issues for severe bacterial infections among people who inject drugs: initial management of sepsis; indications for surgical management; assessment and management of substance dependence; approaches to antibiotic administration following clinical stability; opportunistic health promotion; and secondary prevention of bacterial infections. Throughout, we highlight the importance of harm reduction and strategies to optimize patient engagement in care through a patient-centred approach.

IMPLICATIONS

We advocate for a multi-disciplinary trauma-informed approach to the management of severe bacterial infection among people who inject drugs. We emphasize the need for pragmatic trials to inform management guidelines, including those that are co-designed with the community. In particular, research is needed to establish the comparative effectiveness, safety, and cost-effectiveness of inpatient intravenous antibiotics vs. early oral antibiotic switch, outpatient parenteral therapy, and long-acting lipoglycopeptide antibiotics in this scenario.

Target trial emulation for comparative effectiveness research with observational data: Promise and challenges for studying medications for opioid use disorder

Medications for opioid use disorder (MOUD) increase retention in care and decrease mortality during active treatment; however, information about the comparative effectiveness of different forms of MOUD is sparse. Observational comparative effectiveness studies are subject to many types of bias; a robust framework to minimize bias would improve the quality of comparative effectiveness evidence. This paper discusses the use of target trial emulation as a framework to conduct comparative effectiveness studies of MOUD with administrative data. Using examples from our planned research project comparing buprenorphine-naloxone and extended-release naltrexone with respect to the rates of MOUD discontinuation, we provide a primer on the challenges and approaches to employing target trial emulation in the study of MOUD.

Development and validation of machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans treated with buprenorphine for opioid use disorder

BACKGROUND

Buprenorphine for opioid use disorder (B-MOUD) is essential to improving patient outcomes; however, retention is essential.

OBJECTIVE

To develop and validate machine-learning algorithms predicting retention, overdoses, and all-cause mortality among US military veterans initiating B-MOUD.

METHODS

Veterans initiating B-MOUD from fiscal years 2006-2020 were identified. Veterans' B-MOUD episodes were randomly divided into training (80%;n = 45,238) and testing samples (20%;n = 11,309). Candidate algorithms [multiple logistic regression, least absolute shrinkage and selection operator regression, random forest (RF), gradient boosting machine (GBM), and deep neural network (DNN)] were used to build and validate classification models to predict six binary outcomes: 1) B-MOUD retention, 2) any overdose, 3) opioid-related overdose, 4) overdose death, 5) opioid overdose death, and 6) all-cause mortality. Model performance was assessed using standard classification statistics [e.g., area under the receiver operating characteristic curve (AUC-ROC)].

RESULTS

Episodes in the training sample were 93.0% male, 78.0% White, 72.3% unemployed, and 48.3% had a concurrent drug use disorder. The GBM model slightly outperformed others in predicting B-MOUD retention (AUC-ROC = 0.72). RF models outperformed others in predicting any overdose (AUC-ROC = 0.77) and opioid overdose (AUC-ROC = 0.77). RF and GBM outperformed other models for overdose death (AUC-ROC = 0.74 for both), and RF and DNN outperformed other models for opioid overdose death (RF AUC-ROC = 0.79; DNN AUC-ROC = 0.78). RF and GBM also outperformed other models for all-cause mortality (AUC-ROC = 0.76 for both). No single predictor accounted for >3% of the model's variance.

CONCLUSIONS

Machine-learning algorithms can accurately predict OUD-related outcomes with moderate predictive performance; however, prediction of these outcomes is driven by many characteristics.

A combined intervention strategy to increase linkage to and retention in substance use treatment for individuals accessing hospital-based services: study protocol

Background

In 2020, New Mexico had the highest alcohol related death and the 11th highest drug overdose rate in the U.S. Towards the long-term goal of addressing this public health problem, we are implementing and evaluating an multi-level intervention designed to identify adults at risk of substance use disorder (SUD) and encourage linkage to and retention in treatment. The first level includes equipping the ED and medical inpatient units of a safety-net hospital with a method to screen individuals at risk of a SUD. The second level includes Seeking Safety (SS), a trauma-specific treatment for PTSD and SUD; and pharmacotherapy for SUD. Motivational Interviewing (MI) is used throughout both levels. Using the SPIRIT guidelines and checklist, this study protocol describes the multi-level intervention and the methodology we are using to assess feasibility and effectiveness.

Methods

We are using a Type 1 hybrid implementation design with a non-randomized approach (ISRCTN registration # ISRCTN33100750). We aim to enroll 110 adults ( ≧ 18 ) who screen positive for unhealthy use of alcohol, prescription medications (used nonmedically) and/or illicit drugs. Peer support workers are responsible for screening, using MI to increase engagement in screening and treatment and delivery of SS. Pharmacotherapy is provided by addiction clinical specialists. Treatment is provided post hospital discharge via telehealth to increase access to care. Participants are identified through (1) review of electronic health records for individuals with a chief or secondary complaint or mental health condition relating to alcohol and/or other drug use, (2) referrals from clinical staff and (3) screening in the ED and medical inpatient units. Feasibility is being measured through process data. Effectiveness will be determined by changes in two primary outcomes: (i) PTSD symptom severity; and (ii) substance use.

Discussion

Our study will expand on research related to the implementation of treatment strategies for patients presenting at EDs and admitted to medical inpatients units wherein there is a significant window of opportunity to link patients with follow-up behavioral and clinical services for alcohol and/or drug misuse. The challenges associated with implementation and strategies that have been helpful to address these challenges will further inform the field.

Post-operative pain control in patients on buprenorphine or methadone for opioid use disorder

OBJECTIVE

This study aimed to determine whether there is a difference in pain scores and opioid consumption after elective surgery in patients maintained on methadone or buprenorphine for opioid use disorder (OUD). Additionally, we investigated the impact of continuing or discontinuing methadone or buprenorphine on post-operative pain outcomes.

DESIGN

A single-center retrospective cohort study.

SETTING

Tertiary care medical center.

PATIENTS AND PARTICIPANTS

Adults aged 18 years or older with OUD maintained on buprenorphine or methadone who underwent elective surgery between January 1, 2017, and January 1, 2021.

INTERVENTIONS

Patients were identified through electronic medical records, and demographic and clinical data were collected.

MAIN OUTCOME MEASURES

The primary outcome was opioid consumption at 24 hours post-operatively, measured in milligram morphine equivalents. The secondary outcome was opioid consumption and pain scores up to 72 hours post-operatively, assessed using a numeric rating scale.

RESULTS

This study included 366 patients (64 percent on buprenorphine and 36 percent on methadone). Opioid utilization significantly increased when buprenorphine was not administered post-operatively. Both groups exhibited comparable total opioid consumption during the post-operative period. In the buprenorphine cohort, pain scores differed significantly based on the receipt of medications for OUD post-operatively.

CONCLUSIONS

This study reinforces existing evidence supporting the continuation of medications for opioid use disorder, specifically buprenorphine and methadone, during the perioperative period. Dissemination of guideline recommendations is essential to ensure optimal post-operative pain management for this patient population.

96-week retention in treatment with extended-release subcutaneous buprenorphine depot injections among people with opioid dependence: Extended follow-up after a single-arm trial

BACKGROUND

The most recent formulation of buprenorphine treatment is extended-release depot injections (BUP-XR) that are administered subcutaneously by health care professionals. This study aimed to observe treatment outcomes of BUP-XR delivered in standard practice during a 96-week follow-up period in a community setting.

METHODS

This study is an extension of the CoLAB study, a prospective single-arm, multicentre, open label trial (N=100, 7 sites in Australia) among people with opioid dependence who received monthly injections of BUP-XR to evaluate the retention in treatment. Participants were followed for 96 weeks, comprising 48 weeks of the CoLAB study followed by a 48-week extension.

RESULTS

Of 100 participants at baseline, 47 were retained on BUP-XR at 96 weeks. The median time retained on monthly depot was 90 weeks. Heroin use (adjusted OR=0.19, P=0.012) in the month prior to baseline was associated with lower odds of retention on BUP-XR. Older age at first opioid use (adjusted OR= 1.08, P=0.009) and longer duration in OAT at baseline (adjusted OR= 1.12, P=0.001) were associated with increased retention. Prevalence of past four-weeks opioid use was estimated at 4% at 96 weeks of treatment (prevalence 0.04, 95%CI: 0.00-0.11) compared to 15% at baseline. Quality of life and medication treatment satisfaction improved over time for those retained in treatment.

CONCLUSION

This is one of the few studies to describe long term (96 week) retention in treatment with BUP-XR in a community setting. It displayed retention rates with 47% of participants completing 96 weeks of treatment with BUP-XR. Patient reported outcomes suggest improvements in client wellbeing.

FUNDING

Indivior.

Exemplar Hospital initiation trial to Enhance Treatment Engagement (EXHIT ENTRE): protocol for CTN-0098B a randomized implementation study to support hospitals in caring for patients with opioid use disorder

BACKGROUND

Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT.

METHODS

Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge.

DISCUSSION

Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals.

TRIAL REGISTRATION

NCT04921787.

Managing Opioid Withdrawal Symptoms During the Fentanyl Crisis: A Review

Illicitly manufactured fentanyl (IMF) is a significant contributor to the increasing rates of overdose-related deaths. Its high potency and lipophilicity can complicate opioid withdrawal syndromes (OWS) and the subsequent management of opioid use disorder (OUD). This scoping review aimed to collate the current OWS management of study populations seeking treatment for OWS and/or OUD directly from an unregulated opioid supply, such as IMF. Therefore, the focus was on therapeutic interventions published between January 2010 and November 2023, overlapping with the period of increasing IMF exposure. A health science librarian conducted a systematic search on November 13, 2023. A total of 426 studies were screened, and 173 studies were reviewed at the full-text level. Forty-nine studies met the inclusion criteria. Buprenorphine and naltrexone were included in most studies with the goal of transitioning to a long-acting injectable version. Various augmenting agents were tested (buspirone, memantine, suvorexant, gabapentin, and pregabalin); however, the liberal use of adjunctive medication and shortened timelines to initiation had the most consistently positive results. Outside of FDA-approved medications for OUD, lofexidine, gabapentin, and suvorexant have limited evidence for augmenting opioid agonist initiation. Trials often have low retention rates, particularly when opioid agonist washout is required. Neurostimulation strategies were promising; however, they were developed and studied early. Precipitated withdrawal is a concern; however, the rates were low and adequately mitigated or managed with low- or high-dose buprenorphine induction. Maintenance treatment continues to be superior to detoxification without continued management. Shorter induction protocols allow patients to initiate evidence-based treatment more quickly, reducing the use of illicit or non-prescribed substances.

County-level factors associated with a mismatch between opioid overdose mortality and availability of opioid treatment facilities

BACKGROUND

Opioid overdose deaths in the United States remain a major public health crisis. Little is known about counties with high rates of opioid overdose mortality but low availability of opioid use disorder (OUD) treatment facilities. We sought to identify characteristics of United States (US) counties with high rates of opioid overdose mortality and low rates of opioid treatment facilities.

METHODS

Rates of overdose mortality from 3,130 US counties were compared with availability of opioid treatment facilities that prescribed or allowed medications for OUD (MOUD), from 2018-2019. The outcome variable, "risk-availability mismatch" county, was a binary indicator of a high rate (above national average) of opioid overdose mortality with a low (below national average) rate of opioid treatment facilities. Covariates of interest included county-level sociodemographics and rates of insurance, unemployment, educational attainment, poverty, urbanicity, opioid prescribing, depression, heart disease, Gini index, and Theil index. Multilevel logistic regression, accounting for the clustering of counties within states, was used to determine associations with being a "risk-availability mismatch" county.

RESULTS

Of 3,130 counties, 1,203 (38.4%) had high rates of opioid overdose mortality. A total of 1,098 counties (35.1%) lacked a publicly-available opioid treatment facility in 2019. In the adjusted model, counties with an additional 1% of: white residents (odds ratio, OR, 1.02; 95% CI, 1.01-1.03), unemployment (OR, 1.11; 95% CI, 1.05-1.19), and residents without insurance (OR, 1.04; 95% CI, 1.01-1.08) had increased odds of being a mismatch county. Counties that were metropolitan (versus non-metropolitan) had an increased odds of being a mismatch county (OR, 1.85; 95% CI, 1.45-2.38).

CONCLUSION

Assessing mismatch between treatment availability and need provides useful information to characterize counties that require greater public health investment. Interventions to reduce overdose mortality are unlikely to be effective if they do not take into account diverse upstream factors, including sociodemographics, disease burden, and geographic context of communities.

Nalmefene Hydrochloride: Potential Implications for Treating Alcohol and Opioid Use Disorder

Nalmefene hydrochloride was first discovered as an opioid antagonist derivative of naltrexone in 1975. It is among the most potent opioid antagonists currently on the market and is differentiated from naloxone and naltrexone by its partial agonist activity at the kappa-opioid receptor which may benefit in the treatment of alcohol use disorder. Oral nalmefene has been approved in the European Union for treatment of alcohol use disorder since 2013. As of 2023, nalmefene is available in the United States as an intranasal spray for reversal of opioid overdose but is not approved for alcohol or opioid use disorder as a maintenance treatment. The substantially longer half-life of nalmefene and 5-fold higher binding affinity to opioid receptors makes it a superior agent over naloxone in the reversal of high potency synthetic opioids like fentanyl and the emerging nitazenes. Nalmefene presents with a comparable side effect profile to other opioid antagonists and should be considered for further development as a maintenance treatment for opioid and other substance use disorders.

Telehealth in opioid use disorder treatment: policy considerations for expanding access to care

The Ryan Haight Online Pharmacy Consumer Protection Act of 2008 was intended to address the online diversion of controlled substances. However, it inadvertently limited access to care for patients seeking medications for opioid use disorder (MOUD). During the COVID-19 pandemic, temporary flexibility in telemedicine prescriptions for MOUD were implemented. Now, with the conclusion of the public health emergency, policymakers need to develop strategies to maintain some of the lifted restrictions in order to maintain increased access to care for patients with opioid use disorder (OUD). One potential solution to address these issues is the implementation of a hybrid model combining outpatient clinics and telemedicine. This model offers the opportunity to maintain the benefits of telemedicine while ensuring comprehensive and safe care for OUD patients.

Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder

Importance

Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions.

Objective

To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD.

Design, Setting, and Participants

This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023.

Main Outcomes and Measures

Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023.

Results

In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively.

Conclusions and Relevance

In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.

The effect of chronotypes on follow-up outcomes of patients with substance use disorder

Substance use disorder (SUD) can have circadian characteristics and individuals with evening chronotype are more prone to addiction. In this study, the effect of chronotypes on the treatment outcomes of SUD was investigated. The study included 66 patients who were diagnosed with SUD according to DSM-5. Two clinical interviews were conducted at 6-month intervals, and remission/relapse status was evaluated at the second interview. The Structured Clinical Interview Form for DSM-IV Axis I Disorders (SCID-I), Addiction Profile Index Practitioner Form, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Pittsburg Sleep Quality Index and Morningness-Eveningness Questionnaire (MEQ) were applied to the patients. MEQ scores of relapsed patients were found to be different in terms of eveningness than those in remission (45.62 ± 8.70 versus 49.75 ± 7.60, p = 0.045). As the craving and addiction profile index total scores (addiction severity) increased, eveningness chronotype scores also increased (r = - 0.387 and r = - 0.286, respectively). The mean scores of craving and BDI were higher in relapsed patients compared to those in remission (p = 0.003 and p = 0.015, respectively). Our results suggest that patients with SUD had a lower morningness chronotype than the general population; additionally, more relapsed patients had an eveningness chronotype. Thus, chronotypes may play a role in the onset, prevention, and treatment outcome of SUD.

Geographic variation in availability of opioid treatment programs across U.S. communities

Methadone for Opioid Use Disorder (OUD) treatment is only dispensed at Opioid Treatment Programs (OTPs). Little is known about the geographic variation in OTP availability and community characteristics associated with the availability across smaller geographic communities in the U.S. To (1) describe geographic distribution of OTPs and (2) examine OTP availability by community characteristics in the contiguous U.S. at Zip Code Area Tabulation (ZCTA) level. Logistic regression was used to examine community characteristics associated with OTP availability (N = 30,367). Chi-square and t-tests were conducted to examine statistically significant differences in OTP availability. Maps and descriptive statistics were used to examine geographic variation in OTP availability. Only 5% (1,417) of ZCTAs had at least one OTP for a total of 1,682 OTPs. Rural ZCTAs had 50% lower odds of having an OTP compared to urban ZCTAs [AOR 0.5; (95% CI: 0.41-0.60)]. ZCTAs in the lowest income quartile had higher odds of having an OTP compared to ZCTAs in the highest income quartile [AOR 3.4; (95% CI: 2.71-4.18)]. Further, ZCTAs with OTPs had a higher proportion of minority residents [Black: 17.5% vs. 7.2%; Hispanic: 19.2% vs. 9%] and a lower proportion of White residents [55.1% vs. 78.2%]. Nationally, OTPs are extremely scarce with notable regional and urban-rural disparities. Potential solutions to address these disparities are discussed.

Association between comorbid chronic pain or prior hospitalization for mental illness and substance use treatment among a cohort at high risk of opioid overdose

INTRODUCTION

Chronic pain and serious mental illness increase risk of opioid use, and opioid use can exacerbate both conditions. Substance use disorder (SUD) treatment can be lifesaving, but chronic pain and serious mental illness may make recovery challenging. We evaluated the association between current chronic pain and prior hospitalization for mental illness and 90-day SUD treatment engagement, among emergency department (ED) patients at high risk of opioid overdose.

METHODS

We conducted a cohort analysis of 648 ED patients enrolled in a randomized controlled trial in Rhode Island. We linked baseline study data on chronic pain and prior hospitalization for mental illness to statewide administrative data on state-licensed treatment programs (including methadone) and buprenorphine treatment via prescription. We defined treatment engagement as initiation of a state-licensed treatment program, transfer between state-licensed programs/providers, or a buprenorphine prescription (re-)fill. We used modified Poisson models to estimate the association between each baseline comorbidity and treatment engagement within 90 days following the ED visit, adjusted for a priori potential confounders. In an exploratory analysis, models were stratified by baseline treatment status.

RESULTS

The mean age of participants was 37 years; 439 (68 %) were male, and 446 (69 %) had been recently unhoused. Overall, 278 participants (43 %) engaged in treatment within 90 days of the ED visit. Participants with prior hospitalization for mental illness were more likely to engage in treatment than those without (adjusted risk ratio [ARR] = 1.24, 95 % confidence interval [CI] = 1.01-1.53), although this association was only among those already accessing treatment at baseline (ARR = 1.58, 95 % CI = 1.10-2.27). Chronic pain was not associated with 90-day treatment engagement overall (ARR = 1.12, 95 % CI = 0.91-1.38) or within baseline treatment subgroups.

CONCLUSIONS

Among ED patients at high risk of opioid overdose and accessing treatment at baseline, those with prior hospitalization for mental illness (but not chronic pain) were more likely to engage in treatment following the ED visit, which may reflect disproportionate initiation of additional treatment programs, transfer between programs/providers, or ongoing buprenorphine treatment. Touchpoints within the medical system should be leveraged to ensure that everyone, including those with serious mental illness, can access high-quality SUD treatment at the desired intensity level.

Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study

BACKGROUND

Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities.

METHOD

Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software.

RESULTS

Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication.

CONCLUSIONS

OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.

Patient's and healthcare provider's experiences with Opioid Maintenance Treatment (OMT): a qualitative evidence synthesis

BACKGROUND

Opioid Maintenance Treatment (OMT) is the gold standard for people with opioid dependence. However, drop-out rates are high, and many patients do not reach desired outcomes. Understanding patients' and healthcare providers' experiences with the treatment can provide valuable information to improve the quality of OMT and to increase acceptability and accessibility of services. The aim of this systematic review is to explore and synthesise the experiences of OMT among persons with opioid dependence and health care providers, to inform policy makers and practitioners on how to improve OMT outcomes.

METHODS

We conducted a qualitative evidence synthesis. We systematically searched in electronic databases (CINAHL, Embase, MEDLINE, and nordic databases) and searched for grey literature. As we identified many studies that met our inclusion criteria, we purposively sampled a manageable number of studies to include in this review. Two researchers independently extracted and coded data from the included studies and used the Andersen's healthcare utilization model to organize and develop codes. We assessed the methodological limitations of the studies, and our confidence in the findings using GRADE CERQual.

RESULTS

We retrieved 56 relevant studies and purposively sampled 24 qualitative studies of patients' and healthcare providers' experiences with OMT. Our analyses resulted in six main themes: (1) External stigma prevents engagement and retention in treatment, (2) Being identified as in OMT contributed to an increased experience of stigma (3) Inadequate knowledge and expertise among healthcare providers affected patients' treatment experiences, (4) Quality of communication between personnel and patients impacts patients' engagement with treatment and treatment outcomes, (5) Patients wanted help with many aspects of their lives not just medication, and (6) Balancing positive expectations of OMT with treatment stigma. We found that stigma was an overarching theme across these themes.

CONCLUSION

Our findings suggest that OMT could be more beneficial for patients if treatment programs prioritize efforts to diminish societal and OMT provider stigma and find strategies to better address patient needs. Initiatives should focus on improving treatment knowledge among providers, encouraging the use of client perspectives, considering the context of family members, and establishing a more holistic and flexible treatment environment.

Expanding access to medication treatment for opioid use disorders: Findings from the Washington State hub and spoke effort

BACKGROUND

Opioid use disorder (OUD) is a leading cause of preventable death and injury nationwide. Efforts to increase the use of medication for opioid use disorder (MOUD) are needed. In 2017, Washington State implemented a Hub and Spoke (HS) model of care with the primary goal of expanding access to MOUD. We examined changes in MOUD utilization among Washington State Medicaid beneficiaries before and after HS implementation.

METHODS

We used Medicaid claims data to examine longitudinal changes in MOUD use for beneficiaries with OUD. We conducted a comparative interrupted time series analysis to examine the association between HS policy implementation and rates of MOUD utilization, overall and by type of medication.

RESULTS

Between 2016 and 2019, a period of increasing OUD prevalence, rates of MOUD utilization among Washington Medicaid beneficiaries increased overall from 39.7 to 50.5. Following HS implementation, rates of MOUD use grew at a significantly greater rate in the HS cohort than in the non-HS cohort (β=0.54, SE=0.02, p< 0.0001, 95% CI 0.49, 0.59). Analyses by medication type show that this rate increase was primarily due to buprenorphine use (β= 0.61, SE= 0.02, p< 0.0001, 95% CI 0.57, 0.65).

CONCLUSION

Improved systems of care are needed to make MOUD accessible to all patients in need. The Washington HS model is one strategy that may facilitate and expand MOUD use, particularly buprenorphine. Over the study period, Washington State saw increased use of buprenorphine, which was an emphasis of their HS model.

Outcome in methadone maintenance treatment of immigrants from the former Union of Soviet Socialist Republics

CONTEXT

Immigrants from the former Union of Soviet Socialist Republics (USSR) are more prevalent in Methadone maintenance treatment (MMT) in Israel than their percentage in the general population.

AIMS

To compare their characteristics and outcomes to those of Israeli-born and other immigrant patients.

METHODS

Retention and survival since admission (June/1993-Dec/2022) until leaving treatment (for retention), or at the end of follow-up were analyzed. Vital data was taken from a national registry. Predictors were estimated using Kaplan-Meier and Cox regression models.

RESULTS

The USSR patients (N = 262) compared with other immigrants (N = 132) and Israeli-born (N = 696) were more educated (≥ 12y) (p < 0.001), admitted to MMT at a younger age (p < 0.001), following a shorter duration of opioid usage (p < 0.001). More of them ever injected drugs (p < 0.001) and ever drank alcohol (p < 0.001). One-year retention was comparable (77.2% vs. 75.6% and 72%, p = 0.2) as did opioid discontinuation in those who stayed (p = 0.2). Former USSR patients had longer cumulative retention of their first admission (p = 0.05) with comparable overall retention since first admission, and survival, although the age of death was younger. Specific origin within the former USSR found immigrants from the Russian Federation with the best outcome, and those from Ukraine as having high HIV seropositive and shorter retention.

CONCLUSIONS

Despite several characteristics known to be associated with poor outcomes, former USSR immigrants showed better adherence to MMT, reflected by their longer cumulative retention in their first admission, lower rate of readmissions, and a comparable survival and overall retention in treatment. An in depth study is needed in order to understand why they decease at a younger age.

Barriers and Best Practices on the Management of Opioid Use Disorder

Opioids refer to chemicals that agonize opioid receptors in the body resulting in analgesia and sometimes, euphoria. Opiates include morphine and codeine; semi-synthetic opioids include heroin, hydrocodone, oxycodone, and buprenorphine; and fully synthetic opioids include tramadol, fentanyl and methadone. In 2021, an estimated 5.6 million individuals met criteria for opioid use disorder. This article provides an overview of the pharmacology of heroin and non-prescription fentanyl (NPF) and its synthetic analogues, and summarizes the literature related to the management of opioid use disorder, overdose, and withdrawal. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population. This is followed by a description of barriers to treatment and best practices for management with a discussion on recent updates and their potential impact on this patient population.

Mobile Medication Adherence Platform for Buprenorphine (MAP4BUP): A Phase I feasibility, usability and efficacy pilot randomized clinical trial

BACKGROUND/AIM

Poor medication adherence is one of the main barriers to the long-term efficacy of buprenorphine/naloxone (BUP/NAL). The aims of this pilot investigation were to examine if a Bluetooth-enabled pill cap and mobile application is a feasible, usable tool for increasing BUP/NAL adherence among people with an opioid use disorder.

METHODS

This pilot randomized clinical trial (RCT; total n = 41) lasted 12 weeks and was conducted in two office-based BUP/NAL provider locations in Spokane, WA and Coeur d'Alene, ID from January 2020 to September of 2021 with an 11-month gap due to COVID-19. Patients receiving BUP/NAL who consented to participate were randomized to receive the pill cap device (PLY group; n = 19) or a service as usual (SAU group; n = 22) group that included an identical but inactive cap for their bottle. The PLY group received reminders via text and voice, and the support of a "helper" (e.g., friend) to monitor pill cap openings.

RESULTS

Most participants in PLY group found the device both feasible (92.86 %) and usable (78.57 %). Most participants liked using the device (92.86 %) and were satisfied with the device (85.71 %). While not statistically different from one another, medication adherence per the Medication Possession Ratio was 75 % in the SAU group and 84 % in the PLY group. Pill cap openings were significantly higher in the PLY group with an average of 91.8 openings versus the SAU group's average of 56.7 (p < 0.05).

CONCLUSION

The devices was feasible, usable, and patients had high levels of satisfaction. The device was associated with increased pill openings.

Series of (([1,1'-Biphenyl]-2-yl)methyl)sulfinylalkyl Alicyclic Amines as Novel and High Affinity Atypical Dopamine Transporter Inhibitors with Reduced hERG Activity

Currently, there are no FDA-approved medications for the treatment of psychostimulant use disorders (PSUD). We have previously discovered "atypical" dopamine transporter (DAT) inhibitors that do not display psychostimulant-like behaviors and may be useful as medications to treat PSUD. Lead candidates (e.g., JJC8-091, 1) have shown promising in vivo profiles in rodents; however, reducing hERG (human ether-à-go-go-related gene) activity, a predictor of cardiotoxicity, has remained a challenge. Herein, a series of 30 (([1,1'-biphenyl]-2-yl)methyl)sulfinylalkyl alicyclic amines was synthesized and evaluated for DAT and serotonin transporter (SERT) binding affinities. A subset of analogues was tested for hERG activity, and the IC50 values were compared to those predicted by our hERG QSAR models, which showed robust predictive power. Multiparameter optimization scores (MPO > 3) indicated central nervous system (CNS) penetrability. Finally, comparison of affinities in human DAT and its Y156F and Y335A mutants suggested that several compounds prefer an inward facing conformation indicating an atypical DAT inhibitor profile.

Effect of a Co-Located Bridging Recovery Initiative on Hospital Length of Stay Among Patients With Opioid Use Disorder: The BRIDGE Randomized Clinical Trial

Importance

Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and postdischarge outcomes remains unclear.

Objective

To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD.

Design, Setting, and Participants

This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic.

Intervention

The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD.

Main Outcomes and Measures

The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis.

Results

Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio [AOR], 0.94 [95% CI, 0.65-1.37]; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 [95% CI, 0.32-0.92]), more readmissions (AOR, 2.17 [95% CI, 1.25-3.76]), and higher care costs (AOR, 2.25 [95% CI, 1.51-3.35]), with no differences in ED visits (AOR, 1.15 [95% CI, 0.68-1.94]) or deaths (AOR, 0.48 [95% CI, 0.08-2.72]) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 [95% CI, 1.32-4.26]) and have more MOUD refills (AOR, 6.17 [95% CI, 3.69-10.30]) and less likely to experience an overdose (AOR, 0.11 [95% CI, 0.03-0.41]).

Conclusions and Relevance

This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships.

Trial Registration

ClinicalTrials.gov Identifier: NCT04084392.

Continuation of Buprenorphine During Hospitalization and Subsequent Retention in Therapy: an Observational Study in Veterans Administration Hospitals

BACKGROUND

Inpatient hospitalization has the potential to disrupt buprenorphine therapy.

OBJECTIVE

Among patients receiving outpatient buprenorphine prior to admission, we determined the rate of discontinuation during medical and surgical admissions to VA hospitals and its association with subsequent post-discharge continuation of buprenorphine therapy.

DESIGN AND MAIN MEASURES

We conducted an observational study using Veterans Administration data from 10/1/2018 to 3/31/2020 for all medical and surgical admissions where Veterans had active buprenorphine prescriptions at the time of admission. Pre-admission buprenorphine prescriptions were categorized as either sublingual (presumed indication for opioid use disorder (OUD)) or buccal/topical (presumed indication for pain). The primary measure of post-discharge buprenorphine receipt was any outpatient buprenorphine prescription dispensed between 1 day prior to discharge and 60 days following discharge.

KEY RESULTS

A total of 830 unique inpatient hospitalizations to medical or surgical services occurred among Veterans receiving sublingual (48.3%) or buccal/topical (51.7%) buprenorphine prior to admission. Fewer than half (43.9%) of these patients received buprenorphine at some point during the medical or surgical portion of their hospital stay. Among the 766 patients discharged from a medical or surgical unit, 74.3% received an outpatient buprenorphine prescription within the 60 days following discharge (80.2% sublingual and 69.1% buccal/topical). Among patients who had received buprenorphine during the final 36 h prior to discharge, subsequent outpatient buprenorphine receipt was observed in 94.0%, compared to only 63.7% among those not receiving buprenorphine during the final 36 h (χ2 = 83.5, p < 0.001).

CONCLUSION

Inpatient buprenorphine administrations near the time of discharge were highly predictive of continued outpatient therapy and a significant subset of patients did not continue or reinitiate buprenorphine therapy following discharge. As recommendations for perioperative and inpatient management of buprenorphine coalescence around continuation, efforts are needed to optimize hospital-based buprenorphine practices.

Improving the quality of counseling and clinical supervision in opioid treatment programs: how can technology help?

BACKGROUND

The opioid epidemic has resulted in expanded substance use treatment services and strained the clinical workforce serving people with opioid use disorder. Focusing on evidence-based counseling practices like motivational interviewing may be of interest to counselors and their supervisors, but time-intensive adherence tasks like recording and feedback are aspirational in busy community-based opioid treatment programs. The need to improve and systematize clinical training and supervision might be addressed by the growing field of machine learning and natural language-based technology, which can promote counseling skill via self- and supervisor-monitoring of counseling session recordings.

METHODS

Counselors in an opioid treatment program were provided with an opportunity to use an artificial intelligence based, HIPAA compliant recording and supervision platform (Lyssn.io) to record counseling sessions. We then conducted four focus groups-two with counselors and two with supervisors-to understand the integration of technology with practice and supervision. Questions centered on the acceptability of the clinical supervision software and its potential in an OTP setting; we conducted a thematic coding of the responses.

RESULTS

The clinical supervision software was experienced by counselors and clinical supervisors as beneficial to counselor training, professional development, and clinical supervision. Focus group participants reported that the clinical supervision software could help counselors learn and improve motivational interviewing skills. Counselors said that using the technology highlights the value of counseling encounters (versus paperwork). Clinical supervisors noted that the clinical supervision software could help meet national clinical supervision guidelines and local requirements. Counselors and clinical supervisors alike talked about some of the potential challenges of requiring session recording.

CONCLUSIONS

Implementing evidence-based counseling practices can help the population served in OTPs; another benefit of focusing on clinical skills is to emphasize and hold up counselors' roles as worthy. Machine learning technology can have a positive impact on clinical practices among counselors and clinical supervisors in opioid treatment programs, settings whose clinical workforce continues to be challenged by the opioid epidemic. Using technology to focus on clinical skill building may enhance counselors' and clinical supervisors' overall experiences in their places of work.

Predictors of concurrent heroin use among patients on opioid maintenance treatment in France: a multilevel study over 11 years

BACKGROUND

Consistent reports from health professionals suggest that heroin is commonly used by patients undergoing opioid maintenance treatment (OMT) in France, potentially jeopardizing their recovery process. However, there has been no formal epidemiological assessment on the matter.

METHODS

We use a yearly updated compendium retrieving information on patients admitted in treatment centres in France between 2010 and 2020. Given the hierarchical nature of the data collection, we conduct 2-level modified Poisson regressions to estimate the risks of past month heroin use among patients on OMT.

RESULTS

Despite an overall decreasing trend over time, heroin use among patients on OMT is indeed common, with half of patients declaring concurrent use. Our study unveils differentiated risks of heroin use vary according to the type of OMT, with patients on methadone more likely to use heroin compared to those on buprenorphine. The use of multilevel-related measures also uncovers high heterogeneity among patients' profiles, reflecting different stages in the treatment process, as well as differentiated practices across treatment centres.

CONCLUSION

Opioid maintenance treatment is associated with heroin use, in particular when methadone is involved. The heterogeneity among patients on OMT should be given particular attention, as it underscores the need for tailored interventions.

Evaluation of opioid use disorder treatment outcomes in patients receiving split daily versus once daily dosing of buprenorphine-naloxone

INTRODUCTION

In clinical practice, sublingual (SL) buprenorphine-naloxone is prescribed as once daily or split daily dosing for the management of opioid use disorder (OUD). Evidence is lacking that assesses how split daily buprenorphine-naloxone affects OUD outcomes. This study aims to evaluate how the dosing frequency of SL buprenorphine-naloxone impacts therapy effectiveness when treating patients with OUD.

METHODS

This retrospective analysis included adult outpatients prescribed treatment with SL buprenorphine-naloxone for OUD between July 1, 2016, and March 1, 2020. The study excluded patients with sickle cell disease, recent methadone treatment, or pregnancy. We characterized study groups by dosing frequency, either once daily or split dosing. The study compared retention in treatment, medication adherence, adherence to treatment program, and hospital encounters between groups.

RESULTS

The study screened eight-hundred and seven patients, and included 250 patients newly prescribed SL buprenorphine-naloxone. Fifty-seven patients (22.8 %) were prescribed once daily dosing and 193 patients (77.2 %) were prescribed split daily dosing. The study found no significant differences noted in 12-month rates of treatment retention (52.6 % vs. 45.6 %, p = .35). These outcomes remained similar when assessed at three and six months. Within a year of buprenorphine-naloxone initiation, the study found no differences in the percentage of patients with hospitalizations (26.3 % vs. 38.3 %, p = .10), median number of hospitalizations (2 vs. 2), or proportion of days covered by a prescription ≥80 % (93.3 % vs. 92.0 %, p = .82).

CONCLUSIONS

In this study, patients receiving once daily buprenorphine-naloxone had similar treatment outcomes to patients receiving split dosing. Further controlled studies are necessary to evaluate which patients are more likely to benefit from split dosing.

At a Crossroads: Opioid Use Disorder, the X-Waiver, and the Road Ahead

Background: Buprenorphine/naloxone (Suboxone) is widely considered the first-line treatment for opioid use disorder (OUD), which causes significant morbidity and mortality in the United States, but prior to 2023, practitioners interested in prescribing buprenorphine/naloxone for OUD needed a special Drug Enforcement Administration certification (the X-Waiver) that imposed a patient cap and other limitations. The Consolidated Appropriations Act of 2023 considerably decreased the restrictions on prescribing practitioners. Buprenorphine/naloxone can now be prescribed like any other prescription opioid, excluding methadone. The historic context for the opioid crisis, OUD, the X-Waiver, and additional initiatives that may be needed beyond legislative change to effectively address OUD are the subjects of this review. Methods: To develop this review of the opioid crisis, OUD, and OUD treatment, we conducted a literature search of the PubMed database and constructed a timeline of the opioid crisis and changes in OUD treatment, specifically the X-Waiver, to characterize the historic context of OUD and the X-Waiver against the background of the opioid crisis. Results: The opioid crisis has had pervasive public health and economic impacts in the United States. Major changes to the treatment of OUD have occurred as a result of the Drug Addiction Treatment Act of 2000 that imposed the X-Waiver and the Consolidated Appropriations Act of 2023 that repealed the X-Waiver. Conclusion: The repeal of the X-Waiver is predicted to increase the accessibility of buprenorphine/naloxone in the United States. However, additional work beyond legislative change, including institutional support and reduction of stigma and disparities, is needed to substantially improve outcomes for OUD patients.

Dental Disorders Reported to the FDA Adverse Event Reporting System in Association with Buprenorphine: An Analysis by Ingredient Composition and Route of Administration

BACKGROUND

Prior research has suggested buprenorphine-containing medications may be associated with an increased risk of dental disorders. However, published data describing adverse dental reactions in buprenorphine users by active ingredient composition and route of administration are limited.

OBJECTIVE

The purpose of this study was to evaluate the influence of formulation on spontaneous reporting of dental disorders among patients treated with buprenorphine.

METHODS

Adverse event reports submitted to the United States Food and Drug Administration Adverse Event Reporting System (FAERS) between 2015 and 2022 were analyzed. Reporting odds ratios (ROR) and 95% confidence intervals (CI) were calculated to measure disproportionality of dental disorder reporting as classified by 39 Medical Dictionary for Regulatory Activities preferred terms.

RESULTS

Compared to pooled reports for all other drugs across FAERS, both buprenorphine monotherapy (ROR 3.09; 95% CI 2.61-3.66) and combination buprenorphine/naloxone (ROR 14.61; 95% CI 13.34-16.01) were associated with positive disproportionality signals. Signals of disproportionate dental disorder reporting were also detected for buprenorphine medicines administered by sublingual (ROR 20.03; 95% CI 18.04-22.24), buccal (ROR 4.46; 95% CI 3.00-6.61) and oral (ROR 7.17; 95% CI 5.03-10.22) routes, but not for other modalities. In considering active ingredient and route together, sublingual buprenorphine monotherapies (ROR 23.55; 95% CI 17.84-31.11) and sublingual buprenorphine/naloxone (ROR 19.47; 95% CI 17.39-21.80) were each associated with disproportionate reporting of dental disorders.

CONCLUSION

Subject to the limitations of spontaneous adverse event data, this study identified significantly disproportionate reporting of dental disorders to FAERS among patients treated with buprenorphine- containing medications, including formulations administered by sublingual, buccal and oral routes. These findings are consistent with prior data and suggest that regular oral care and proper dental hygiene be emphasized for patients undergoing therapy with orally dissolving buprenorphine.

Navigating Adherence: Unraveling Factors Shaping Opioid Substitution Therapy Compliance

Background and objective In drug-deaddiction programs, dropout is a major problem in any drug de-addiction program, as dependence is a chronic illness known to relapse frequently. Understanding factors that predict dropout can help design targeted interventions to promote follow-up. This study aimed to assess the various sociodemographic characteristics of opioid-dependent subjects on buprenorphine maintenance treatment and dropping out at or before the three-month follow-up period. Method In this study, the sociodemographic characteristics and quality of life (QOL) of 34 opioid-dependent subjects (males, 32, 94%; females, 2, 6%) on the day of their enrolment in an opioid substitution therapy (OST) center were assessed, and a comparison of sociodemographic and drug use pattern was made between those who followed up and those who dropped out by the end of three months. Results Statistical analysis of the various sociodemographic characteristics using appropriate tests yielded that predictors of good follow-up are younger age (F = 4.57907, P = 0.04008), better education (F = 5.07221, P = 0.031305), and being part of a nuclear family. Longer follow-up was associated with shorter opioid intake duration (F = 8.58908, P = 0.006195). Better social relationships, as evidenced by the social relationship domain score of QOL, predicted longer follow-up (F = 8.58908, P = 0.006195). Other characteristics analyzed did not yield significant associations. Conclusions The study unveils the complexity of opioid addiction recovery, revealing the interplay of age, education, family, addiction duration, and support, shaping one's resilience in recovery.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial

Background

Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD.

Methods

The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support.

Results

The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed.

Conclusions

This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes.

Trial Registration

The study is registered at ClinicalTrials.gov (NCT04991974).

Recommandations pour des soins préventifs pour promouvoir l’équité en matière de santé

Contexte:

Malgré des investissements importants dans un système de soins de santé public qui comprend des services préventifs, on continue d’observer des disparités évitables en matière de santé au Canada. L’équipe avait pour objectif de formuler des recommandations pour des soins de santé préventifs qui puissent améliorer l’équité en matière de santé par la priorisation des interventions efficaces à l’intention des groupes défavorisés.

Méthodes:

La ligne directrice a été élaborée par un comité composé de spécialistes en soins primaires et de membres de la patientèle, avec la contribution d’un groupe de patientes-et patientspartenaires ayant vécu diverses expériences. Après avoir sélectionné les sujets à prioriser, nous avons recensé les revues systématiques, les essais randomisés et contrôlés récents sur les méthodes de dépistage et d’autres études pertinentes sur l’efficacité du dépistage et de la prise en charge. Nous avons utilisé l’approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rédiger le rapport. Il en a été de même avec les principes du Guidelines International Network pour la gestion des intérêts concurrents. Les recommandations ont été passées en revue par un comité externe d’experts en contenu avant d’être distribuées à des intervenants à l’échelle nationale pour approbation.

Recommandations:

Nous avons formulé 15 recommandations concernant le dépistage et d’autres soins préventifs et 1 recommandation de nature politique visant à améliorer l’accès aux soins primaires. Ainsi, nous recommandons de prioriser une stratégie de communication pour le dépistage du cancer colorectal à partir de l’âge de 45 ans et pour l’évaluation du risque de maladie cardiovasculaire pour lutter contre les iniquités en matière de santé et promouvoir la santé. Les interventions particulières qui devraient être déployées pour lutter contre les iniquités comprennent l’autodépistage du virus du papillome humain (VPH) et du VIH, et le test de libération de l’interféron γ pour l’infection tuberculeuse. Le dépistage de la dépression, de la toxicomanie, de la violence conjugale et de la pauvreté devrait également permettre aux personnes touchées d’accéder plus facilement à des interventions éprouvées. Nous recommandons une prise de contact systématique avec des professionnels de la santé en soins primaires pour les personnes défavorisées.

Interprétation:

Les interventions préventives éprouvées peuvent aider à combattre les iniquités en matière de santé si la priorité est accordée aux personnes défavorisées. Les médecins, les organisations de santé et les gouvernements devraient adopter des mesures fondées sur des données probantes et en faire le suivi s’ils veulent promouvoir l’équité en matière de santé partout au Canada.

Racialized and beneficiary inequities in medication to treat opioid use disorder receipt within the US Military Health System

BACKGROUND

Medication for opioid use disorder (MOUD) can be critical to managing opioid use disorder (OUD). It is unknown the extent to which US Military Health System (MHS) patients diagnosed with OUD receive MOUD.

METHODS

Healthcare records of MHS-enrolled active duty and retired service members (N = 13,334) with a new (index) OUD diagnosis were included between 2018 and 2021, without 90-day pre-index MOUD receipt were included. Elastic net logistic and Cox regressions evaluated care- and system-level factors associated with 1-year MOUD receipt (primary outcome) and time-to-receipt.

RESULTS

Only 9% of patients received MOUD 1-year post-index; only 4% received MOUD within 14 days. Black patients (OR for receipt 0.38, 95% CI 0.30-0.49), Latinx patients (OR for receipt 0.44, 95% CI 0.33-0.59), and patients whose race and ethnicity was Other (OR for receipt 0.52, 95%CI 0.35, 0.77) experienced lower MOUD access (all p < 0.001). Retirees were more likely to receive MOUD relative to active duty service members (OR for receipt 1.81, 95%CI 1.52, 2.16, p <0.001).

CONCLUSIONS

Institutional racism in MOUD prescribing, combined with the overall low rates of MOUD receipt after OUD diagnosis, highlight the need for evidence-based, multifaceted, and multilevel approaches to OUD care in the Military Health System. Without clear Defense Health Agency policy, including the designation of responsible entities, transparent and ongoing evaluation and responsiveness using standardized methodology, and resourced programming and public health campaigns, MOUD rates will likely remain poor and inequitable.

Calcitonin receptor signaling in nucleus accumbens D1R- and D2R-expressing medium spiny neurons bidirectionally alters opioid taking in male rats

The high rates of relapse associated with current medications used to treat opioid use disorder (OUD) necessitate research that expands our understanding of the neural mechanisms regulating opioid taking to identify molecular substrates that could be targeted by novel pharmacotherapies to treat OUD. Recent studies show that activation of calcitonin receptors (CTRs) is sufficient to reduce the rewarding effects of addictive drugs in rodents. However, the role of central CTR signaling in opioid-mediated behaviors has not been studied. Here, we used single nuclei RNA sequencing (snRNA-seq), fluorescent in situ hybridization (FISH), and immunohistochemistry (IHC) to characterize cell type-specific patterns of CTR expression in the nucleus accumbens (NAc), a brain region that plays a critical role in voluntary drug taking. Using these approaches, we identified CTRs expressed on D1R- and D2R-expressing medium spiny neurons (MSNs) in the medial shell subregion of the NAc. Interestingly, Calcr transcripts were expressed at higher levels in D2R- versus D1R-expressing MSNs. Cre-dependent viral-mediated miRNA knockdown of CTRs in transgenic male rats was then used to determine the functional significance of endogenous CTR signaling in opioid taking. We discovered that reduced CTR expression specifically in D1R-expressing MSNs potentiated/augmented opioid self-administration. In contrast, reduced CTR expression specifically in D2R-expressing MSNs attenuated opioid self-administration. These findings highlight a novel cell type-specific mechanism by which CTR signaling in the ventral striatum bidirectionally modulates voluntary opioid taking and support future studies aimed at targeting central CTR-expressing circuits to treat OUD.

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

INTRODUCTION

The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma.

METHODS

The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation.

RESULTS

Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation.

CONCLUSIONS

NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.

Barriers, perceived benefits and preferences to exercise in adults with an opioid use disorder in the U.S

Introduction

Over 10 million Americans misuse opioids and more than 5 million have been diagnosed with an opioid use disorder (OUD). In 2021, over 100,000 Americans died of a drug overdose and more than 75% of these deaths involved an opioid. Exercise has been shown to increase abstinence and decrease anxiety and depression in people with a substance use disorder. However, only a few small trials have focused on persons with OUD who often experience additional challenges including chronic pain, mental health disorders and cardio-metabolic abnormalities.

Methods

We aimed to describe the barriers, perceived benefits and preferences to exercise in adults with OUD in residential treatment in the U.S. as part of a larger study. We conducted 33 individually administered, semi-structured interviews and transcribed audiotapes verbatim, conducted coding and thematic analysis using NVivo v12 software (QSR International Inc.).

Results

Our sample had nearly equal representation of males and females and, was predominantly Caucasian (88%) with a mean of age of 34.5 (s.d. 7.5) years old. Participants stated that exercise helps to reduce drug cravings, anxiety, depression and pain and improve mood, physical health and build "normalcy". Barriers included lack of time, access to resources, fear of poor health and triggering pain. Participants preferred moderate intensity exercise 3 times/week and 30-60 min sessions.

Conclusions

Our findings indicate that adults with OUD believe exercise is a valuable tool to use in their recovery but they encounter several barriers. Many barriers, however, could be overcome with structured programs offered by residential treatment centers.

Financial Sustainability of Novel Delivery Models in Behavioral Health Treatment

BACKGROUND

In the US, much of the research into new intervention and delivery models for behavioral health care is funded by research institutes and foundations, typically through grants to develop and test the new interventions. The original grant funding is typically time-limited. This implies that eventually communities, clinicians, and others must find resources to replace the grant funding -otherwise the innovation will not be adopted. Diffusion is challenged by the continued dominance in the US of fee-for-service reimbursement, especially for behavioral health care.

AIMS

To understand the financial challenges to disseminating innovative behavioral health delivery models posed by fee-for-service reimbursement, and to explore alternative payment models that promise to accelerate adoption by better addressing need for flexibility and sustainability.

METHODS

We review US experience with three specific novel delivery models that emerged in recent years. The models are: collaborative care model for depression (CoCM), outpatient based opioid treatment (OBOT), and the certified community behavioral health clinic (CCBHC) model. These examples were selected as illustrating some common themes and some different issues affecting diffusion. For each model, we discuss its core components; evidence on its effectiveness and cost-effectiveness; how its dissemination was funded; how providers are paid; and what has been the uptake so far.

RESULTS

The collaborative care model has existed for longest, but has been slow to disseminate, due in part to a lack of billing codes for key components until recently. The OBOT model faced that problem, and also (until recently) a regulatory requirement requiring physicians to obtain federal waivers in order to prescribe buprenorphine. Similarly, the CCBHC model includes previously nonbillable services, but it appears to be diffusing more successfully than some other innovations, due in part to the approach taken by funders.

DISCUSSION

A common challenge for all three models has been their inclusion of services that were not (initially) reimbursable in a fee-for-service system. However, even establishing new procedure codes may not be enough to give providers the flexibility needed to implement these models, unless payers also implement alternative payment models.

IMPLICATIONS FOR HEALTH CARE PROVISION AND USE

For providers who receive time-limited grant funding to implement these novel delivery models, one key lesson is the need to start early on planning how services will be sustained after the grant ends.

IMPLICATIONS FOR HEALTH POLICY

For research funders (e.g., federal agencies), it is clearly important to speed up the process of obtaining coverage for each novel delivery model, including the development of new billable service codes, and to plan for this as early as possible. Funders also need to collaborate with providers early in the grant period on sustainability planning for the post-grant environment. For payers, a key lesson is the need to fold novel models into stable existing funding streams such as Medicaid and commercial insurance coverage, rather than leaving them at the mercy of revolving time-limited grants, and to provide pathways for contracting for innovations under new payment models.

IMPLICATIONS FOR FURTHER RESEARCH

For researchers, a key recommendation would be to pay greater attention to the payment environment when designing new delivery models and interventions.

Access to medication for opioid use disorder supported by telemedicine and healthcare coverage: A web-based survey during the COVID-19 pandemic

Background and Aims

Medications for opioid use disorder (MOUD) are highly effective in improving treatment outcomes and reducing overdose. Concerns about interrupted access to critical MOUD services led to expansion of telemedicine services during the COVID-19 pandemic in the US. The current study tested the hypothesis that telemedicine usage and healthcare coverage would be significantly associated with access to MOUD in the early phase of the COVID-19 pandemic.

Design

A cross-sectional online survey was administered to a non-probability sample from June 18-July 19, 2020 using the Amazon Mechanical Turk platform.

Setting

Northeastern United States during the early phase of the COVID-19 pandemic. At the time of the survey, federal regulators had waived the longstanding requirement for in-office visits for MOUD prescription receipt and provided guidance on increasing third-party payer reimbursement rates for telehealth visits in order to mitigate barriers to care associated with COVID-19 safety guidelines.

Participants

Individuals 18 years or older residing in Connecticut, Massachusetts, New Jersey, New York, or Rhode Island were eligible to complete the survey. The analytic sample was participants who reported using opioids not as prescribed by a physician in the past seven days.

Measurements

Demographics, telemedicine usage, and healthcare coverage were assessed as explanatory variables. The primary outcome was whether participants reported ability to access MOUD in the past four weeks.

Findings

In this sample of individuals who used illicit opioids in the past week (N = 191), one in two individuals who utilized telehealth or had healthcare coverage were able to access MOUD, whereas only one in five of their respective counterparts who did not have telehealth access or healthcare coverage were able to access these medications.

Conclusions

Telemedicine and healthcare coverage were associated with greater MOUD access early in the COVID-19 pandemic, when barriers to care were high. Such findings speak to the importance of not only extending but also formalizing temporary policy changes instituted during the pandemic to allow MOUD prescribing via telemedicine.

Differences in medicaid expansion effects on buprenorphine treatment utilization by county rurality and income: A pharmacy data claims analysis from 2009-2018

Background

Although use of buprenorphine for treating opioid use disorder increased over the past decade, buprenorphine utilization remains limited in lower-income and rural areas. We examine how the Affordable Care Act Medicaid expansion influenced buprenorphine initiation rates by county income and evaluate how associations differ by county rural-urban status.

Methods

This study used nationwide 2009-2018 IQVIA retail pharmacy data and a comparative interrupted time series framework-a hybrid framework combining regression discontinuity and difference-in-difference approaches. We used piecewise linear estimation to quantify changes in buprenorphine initiation rates before and after Medicaid expansion.

Results

The sample included observations from 376,704 county-months. We identified 5,227,340 new buprenorphine treatment episodes, with an average of 9.2 new buprenorphine episodes per month per 100,000 county residents. Among urban counties, those with the lowest median incomes experienced significantly larger increases in buprenorphine initiation rates associated with Medicaid expansion than counties with higher median incomes (5-year rates difference est=3525.3, se=1695.3, p = 0.04). However, among rural counties, there was no significant association between buprenorphine initiation rates and county median income after Medicaid expansion (5-year rates difference est=979.0, se=915.8, p = 0.29).

Conclusions

Medicaid expansion was associated with a reduction in income-related buprenorphine disparities in urban counties, but not in rural counties. To achieve more equitable buprenorphine access, future policies should target low-income rural areas.

Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic

OBJECTIVES

Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic.

DESIGN

Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases.

SETTING

USA.

PARTICIPANTS

Patients who were dispensed methadone at US opioid treatment programmes (OTPs).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone.

RESULTS

Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions.

CONCLUSIONS

There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.