Correlates of Long-Term Opioid Abstinence After Randomization to Methadone Versus Buprenorphine/Naloxone in a Multi-Site Trial

Pivotal role of orexin signaling in the posterior paraventricular nucleus of the thalamus during the stress-induced reinstatement of oxycodone-seeking behavior

BACKGROUND

The orexin (OX) system has received increasing interest as a potential target for treating substance use disorder. OX transmission in the posterior paraventricular nucleus of the thalamus (pPVT), an area activated by highly salient stimuli that are both reinforcing and aversive, mediates cue- and stress-induced reinstatement of reward-seeking behavior. Oral administration of suvorexant (SUV), a dual OX receptor (OXR) antagonist (DORA), selectively reduced conditioned reinstatement of oxycodone-seeking behavior and stress-induced reinstatement of alcohol-seeking behavior in dependent rats.

AIMS

This study tested whether OXR blockade in the pPVT with SUV reduces oxycodone or sweetened condensed milk (SCM) seeking elicited by conditioned cues or stress.

METHODS

Male Wistar rats were trained to self-administer oxycodone (0.15 mg/kg, i.v., 8 h/day) or SCM (0.1 ml, 2:1 dilution [v/v], 30 min/day). After extinction, we tested the ability of intra-pPVT SUV (15 µg/0.5 µl) to prevent reinstatement of oxycodone or SCM seeking elicited by conditioned cues or footshock stress.

RESULTS

The rats acquired oxycodone and SCM self-administration, and oxycodone intake correlated with signs of physical opioid withdrawal, confirming dependence. Following extinction, the presentation of conditioned cues or footshock elicited reinstatement of oxycodone- and SCM-seeking behavior. Intra-pPVT SUV blocked stress-induced reinstatement of oxycodone seeking but not conditioned reinstatement of oxycodone or SCM seeking or stress-induced reinstatement of SCM seeking.

CONCLUSIONS

The results indicate that OXR signaling in the pPVT is critical for stress-induced reinstatement of oxycodone seeking, further corroborating OXRs as treatment targets for opioid use disorder.

The role of social connection in opioid use disorder treatment engagement

OBJECTIVE

Medications for opioid use disorder (OUD or MOUD) treatment combining pharmacotherapy with psychosocial support are effective for managing OUD. However, treatment engagement remains a challenge, with retention rates ∼30%-50%. Although social connection has been identified as important to recovery, it remains unclear whether and how social factors can bolster participation in treatment.

METHOD

Individuals receiving MOUD at three outpatient treatment programs (N = 82) and healthy community controls (N = 62) completed validated measures assessing social connection including (a) size, diversity, and embeddedness of social networks; (b) perceived social support and criticism within familial relationships; and (c) subjective social status. For those receiving MOUD, we also examined how aspects of social connection related to opioid (re)use and treatment engagement (medication adherence, group, and individual meeting attendance) assessed over ∼8 weeks/person.

RESULTS

Compared to controls, individuals receiving MOUD had smaller and less diverse and embedded social networks (Cohen's d > 0.4), and despite similar levels of perceived social support (d = 0.02), reported higher levels of social criticism (d = 0.6) and lower subjective social status (d = 0.5). Within the MOUD group, higher social network indices correlated specifically with higher therapeutic group attendance (Rs > 0.30), but not medication adherence, while higher levels of perceived criticism correlated with more frequent opioid use (R = 0.23). Results were mostly robust to control for sociodemographic variables, psychological distress/COVID-19, and treatment duration, but differed by MOUD type/program.

CONCLUSIONS

These findings highlight the potential importance of assessing an individual's social capital, promoting positive social connection, and continuing to assess the implementation and value of psychosocial support in MOUD treatment. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Low-dose buprenorphine initiation and treatment continuation among hospitalized patients with opioid dependence: A retrospective cohort study

BACKGROUND

Buprenorphine is an effective treatment for both opioid use disorder (OUD) and chronic pain, but buprenorphine's pharmacology complicates treatment initiation for some patients. Low-dose buprenorphine initiation is a novel strategy that may reduce precipitated withdrawal. Few studies describe what patient populations benefit most from low-dose initiations and the clinical parameters that impact treatment continuation. This study aimed to 1) describe experiences with low-dose buprenorphine initiation, including both successes and failures among hospitalized patients in an urban underserved community; 2) identify patient- and treatment-related characteristics associated with unsuccessful initiation and treatment discontinuation; and 3) assess buprenorphine treatment continuation after discharge.

METHODS

This is a retrospective cohort study with opioid-dependent (meaning OUD or receiving long-term opioid therapy for chronic pain) patients who underwent low-dose buprenorphine initiation during hospital admission from October 2021 through April 2022. The primary outcome was successful completion of low-dose initiation. Bivariate analysis identified patient- and treatment-related factors associated with unsuccessful initiation. Secondary outcomes were buprenorphine treatment discontinuation at post-discharge follow-up, 30- and 90-days.

RESULTS

Of 28 patients who underwent low-dose buprenorphine initiation, 68 % successfully completed initiation. Unsuccessful initiation was associated with receipt of methadone during admission and higher morphine milligram equivalents (MME) of supplemental opioids. Of 22 patients with OUD, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 46 %, 36 %, and 36 %. Of 6 patients with chronic pain, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 100 %, 100 %, and 83 %.

CONCLUSION

Low-dose buprenorphine initiation can be successful in opioid-dependent hospitalized patients. Patients taking methadone or requiring higher MME of supplemental opioids may have more difficulty with the low-dose buprenorphine initiation approach, but these findings should be replicated in larger studies. This study suggests patient- and treatment-related factors that clinicians could consider when determining the optimal treatment strategy for patients wishing to transition to buprenorphine.

Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus

BACKGROUND

The prevalence and associated overdose death rates from opioid use disorder (OUD) have dramatically increased in the last decade. Despite more available treatments than 20 years ago, treatment access and high discontinuation rates are challenges, as are personalized medication dosing and making timely treatment changes when treatments fail. In other fields such as depression, brief measures to address these tasks combined with an action plan-so-called measurement-based care (MBC)-have been associated with better outcomes. This workgroup aimed to determine whether brief measures can be identified for using MBC for optimizing dosing or informing treatment decisions in OUD.

METHODS

The National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN) in 2022 convened a small workgroup to develop consensus about clinically usable measures to improve the quality of treatment delivery with MBC methods for OUD. Two clinical tasks were addressed: (1) to identify the optimal dose of medications for OUD for each patient and (2) to estimate the effectiveness of a treatment for a particular patient once implemented, in a more granular fashion than the binary categories of early or sustained remission or no remission found in The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

DISCUSSION

Five parameters were recommended to personalize medication dose adjustment: withdrawal symptoms, opioid use, magnitude (severity and duration) of the subjective effects when opioids are used, craving, and side effects. A brief rating of each OUD-specific parameter to adjust dosing and a global assessment or verbal question for side-effects was viewed as sufficient. Whether these ratings produce better outcomes (e.g., treatment engagement and retention) in practice deserves study. There was consensus that core signs and symptoms of OUD based on some of the 5 DSM-5 domains (e.g., craving, withdrawal) should be the basis for assessing treatment outcome. No existing brief measure was found to meet all the consensus recommendations. Next steps would be to select, adapt or develop de novo items/brief scales to inform clinical decision-making about dose and treatment effectiveness. Psychometric testing, assessment of acceptability and whether the use of such scales produces better symptom control, quality of life (QoL), daily function or better prognosis as compared to treatment as usual deserves investigation.

Effects of Bundling Medication for Opioid Use Disorder With an mHealth Intervention Targeting Addiction: A Randomized Clinical Trial

OBJECTIVE

Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes.

METHODS

In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months.

RESULTS

There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90-1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91-1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34-0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01-1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05-1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78-0.99).

CONCLUSIONS

Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization.

Examining the benefit of a higher maintenance dose of extended-release buprenorphine in opioid-injecting participants treated for opioid use disorder

BACKGROUND

BUP-XR (SUBLOCADE®) is the first buprenorphine extended-release subcutaneous injection approved in the USA for monthly treatment of moderate-to-severe opioid use disorder (OUD). Among patients with OUD, those who inject or use high doses of opioids likely require higher doses of buprenorphine to maximize treatment efficacy. The objective of this analysis was to compare the efficacy and safety of 100-mg versus 300-mg maintenance doses of BUP-XR in OUD patients who inject opioids.

METHODS

This was a secondary analysis of a randomized, double-blind, placebo-controlled study in which adults with moderate or severe OUD received monthly injections of BUP-XR (2 × 300-mg doses, then 4 × 100-mg or 300-mg maintenance doses) or placebo for 24 weeks. Abstinence was defined as opioid-negative urine drug screens combined with negative self-reports collected weekly. Each participant's percentage abstinence was calculated after the first, second, and third maintenance doses in opioid-injecting and non-injecting participants. The proportion of participants achieving opioid abstinence in each group was also calculated weekly. Treatment retention rate following the first maintenance dose was estimated for opioid-injecting participants with Kaplan-Meier method. Risk-adjusted comparisons were made via inverse propensity weighting using propensity scores. Buprenorphine plasma concentration-time profiles were compared between injecting and non-injecting participants. The percentages of participants reporting treatment-emergent adverse events were compared between maintenance dose groups within injecting and non-injecting participants separately.

RESULTS

BUP-XR 100-mg and 300-mg maintenance doses were equally effective in non-injecting participants. However, in opioid-injecting participants, the 300-mg maintenance dose delivered clinically meaningful improvements over the 100-mg maintenance dose for treatment retention and opioid abstinence. Exposure-response analyses confirmed that injecting participants would require higher buprenorphine plasma concentrations compared to non-injecting opioid participants to achieve similar efficacy in terms of opioid abstinence. Importantly, both 100- and 300-mg maintenance doses had comparable safety profiles, including hepatic safety events.

CONCLUSIONS

These analyses show clear benefits of the 300-mg maintenance dose in injecting participants, while no additional benefit was observed in non-injecting participants relative to the 100-mg maintenance dose. This is an important finding as opioid-injecting participants represent a high-risk and difficult-to-treat population. Optimal buprenorphine dosing in this population might facilitate harm reduction by improving abstinence and treatment retention.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02357901.

Nighttime Sleep and Respiratory Disturbances in Individuals Receiving Methadone to Treat Opioid Use Disorder

ABSTRACT

Opioids are a leading cause of drug overdose deaths in the United States. Methadone used as medication for opioid use disorder (MOUD) reduces drug cravings and promotes abstinence. However, individuals in methadone-based MOUD treatment commonly report subjective sleep complaints and are at risk for respiratory depression from opioids. We investigated nighttime sleep and respiratory function in eight individuals (six women, two men; ages 31-68 years) in their first 90 days of methadone-based MOUD treatment. Participants underwent overnight cardiorespiratory polysomnography. Sleep and respiratory variables were characterized with descriptive statistics for comparison to reference data from similarly aged healthy adults. Although participants spent 8.1 ± 0.3 hours (mean ± SD ) in bed, their total sleep time was only 6.8 ± 1.3 hours. They exhibited longer sleep latency and intermittent wakefulness. Sleep structure was irregular, with disrupted sleep cycles. Participants also displayed a decreased amount of N1 sleep and an increased amount of N3 sleep, compared with reference data. Participants showed respiratory depression, with an average apnea-hypopnea index of 16.5 ± 8.9 events per hour. Central sleep apneas comprised 69.1% ± 20.9% of the respiratory events. A Cheyne-Stokes-like breathing pattern, consisting of 30-second cycles of three central sleep apneas, was observed in 75% of participants. Our results suggest that individuals early in methadone-based MOUD treatment experience disordered sleep and respiratory disturbances. Such nighttime physiological changes may have serious long-term health consequences and contribute to unintended overdose rates. Identifying and treating MOUD individuals with sleep apnea could reduce risk of death.

Fentanyl-induced reward seeking is sex and dose dependent and is prevented by D-cysteine ethylester

Introduction: Despite their inclination to induce tolerance, addictive states, and respiratory depression, synthetic opioids are among the most effective clinically administered drugs to treat severe acute/chronic pain and induce surgical anesthesia. Current medical interventions for opioid-induced respiratory depression (OIRD), wooden chest syndrome, and opioid use disorder (OUD) show limited efficacy and are marked by low success in the face of highly potent synthetic opioids such as fentanyl. D-Cysteine ethylester (D-CYSee) prevents OIRD and post-treatment withdrawal in male/female rats and mice with minimal effect on analgesic status. However, the potential aversive or rewarding effects of D-CYSee have yet to be fully characterized and its efficacy could be compromised by interactions with opioid-reward pathology. Methods: Using a model of fentanyl-induced conditioned place preference (CPP), this study evaluated 1) the dose and sex dependent effects of fentanyl to induce rewarding states, and 2) the extent to which D-CYSee alters affective state and the acquisition of fentanyl-induced seeking behaviors. Results: Fentanyl reward-related effects were found to be dose and sex dependent. Male rats exhibited a range-bound dose response centered at 5 µg/kg. Female rats exhibited a CPP only at 50 µg/kg. This dose was effective in 25% of females with the remaining 75% showing no significant CPP at any dose. Pretreatment with 100 mg/kg, but not 10 mg/kg, D-CYSee prevented acquisition of fentanyl seeking in males while both doses were effective at preventing acquisition in females. Discussion: These findings suggest that D-CYSee is an effective co-treatment with prescribed opioids to reduce the development of OUD.

Methadone maintenance treatment and impulsivity: premature responding

INTRODUCTION

Previous research showed that methadone maintenance treatment (MMT) is linked to impulsivity, with higher impulsivity levels being associated with for example, increased drug use. One aspect of impulsivity, most commonly studied in rodent research, is premature responding, the failure to wait for a starting signal. Premature responding is of high translational significance since it predicts the development of addiction-like behaviors in rodents.

METHODS

We assessed 45 MMT patients and 46 demographically matched (age, sex, education, and handedness) healthy volunteers (HVs) on premature responding alongside action and inhibition of instructed and intentional trials using the Intentional Hand Task (IHT).

RESULTS

The results showed markedly enhanced premature responses in the MMT vs. the HV group, which correlated positively with methadone dosage in the MMT patients. Throughout the task, MMT patients were faster across all trial parts and less accurate in response to instructed trials compared to HVs.

CONCLUSIONS

The increase in premature motor reactions during variable waiting periods alongside increased motion speed and lower accuracy might reflect a specific motor inhibition deficit in MMT, a subcomponent of impulsivity not previously assessed in MMT. Incorporating an experimentally defined measure of impulsivity, such as premature responding, into existing test batteries used by clinicians might enable more tailored treatments addressing the increased impulsivity levels and associated dysfunctional behaviors in MMT.

Retention in Office-Based Opioid Treatment and Impact on Emergency Department Use in Adolescents and Young Adults With Opioid Use Disorder

PURPOSE

Longer retention in medication treatment (MT) of addiction is associated with improved health outcomes among adults with opioid use disorder. MT remains underutilized among adolescents and young adults (AYA); factors associated with MT retention are not well-defined and effect of retention on treatment outcomes is unknown. This study examined patient characteristics associated with retention in an office-based opioid treatment program for AYA patients and determined the impact of retention time on emergency department (ED) utilization.

METHODS

This was a retrospective study of AYA patients from January 1, 2009, to December 31, 2020. Retention time was the difference between first and last appointment, analyzing follow-up periods of one and two years. Linear regression assessed factors associated with retention. Negative binomial regression showed effect of retention on ED utilization.

RESULTS

A total of 407 patients were included. Factors positively associated with retention were diagnosis of anxiety, depression, and nicotine use disorder, White race, private insurance, and Medicaid insurance; however, stimulant/cocaine use disorder was negatively associated (one-year follow-up, p ≤ .028; two-year follow-up, p ≤ .017). Longer retention was associated with reduced risk of ED utilization at one-year (incident rate ratio = 0.84, 95% confidence interval: 0.72-0.99; p = .03) and two-year follow-ups (incident rate ratio = 0.86 95% confidence interval: 0.77-0.96; p = .008).

DISCUSSION

Diagnosis of anxiety, depression, nicotine use disorder, and stimulant/cocaine use disorder, and insurance and race can influence retention in MT. Longer retention in MT was associated with lower ED visits, decreasing health care utilization. MT programs should evaluate various interventions to optimize opportunities for increasing retention among their patient cohorts.

Characteristics of patients undergoing medication-assisted -treatment for opioid use disorder and their interest in Tai Chi practice

OBJECTIVES

(1) To explore the characteristics of patients with opioid use disorder (OUD) maintained on either methadone or buprenorphine and (2) to determine the relative acceptability of integrating Tai Chi (TC) practice into an ongoing medication-assisted treatment for opioid use disorder (MOUD) program.

DESIGN

Survey study.

SETTING

The University of Arkansas for Medical Sciences Center for Addiction Services and Treatment Program.

PATIENTS

97 patients receiving MOUD treatment.

MAIN OUTCOMES

Drug use history, treatment status, physical limitation, mental health, pain, and whether participants were interested in using TC to improve health outcomes.

RESULTS

At least 30.9 percent of the sample reported moderate or higher level of limitation in performing rigorous physical activities, pain intensity, and pain interference. Between 37.1 and 61.5 percent of the sample reported various psychiatric symptoms. Methadone patients reported higher levels of physical limitations, especially in rigorous activities (p = .012), climbing several flights of stairs (p = .001), and walking more than a mile (p = .011), but similar levels of pain (ps = .664-.689) and psychiatric symptoms (ps = .262-.879) relative to buprenorphine patients. At least 40.2 percent of participants expressed moderate or higher level of interest in TC for improving health outcomes, with methadone patients more interested in participating to ease mental and sleep problems (p = .005) and improve physical fitness (p = .015) compared to buprenorphine patients.

CONCLUSIONS

High prevalence of physical limitation, pain, and psychiatric comorbidities were found in OUD patients. Since patients were interested in TC to improve their health outcomes, this low-cost intervention, if proven effective, can be integrated into ongoing MOUD programs to improve health in this population.

Buprenorphine versus methadone for the treatment of opioid dependence: a systematic review and meta-analysis of randomised and observational studies

BACKGROUND

Opioid dependence is associated with substantial health and social burdens, and opioid agonist treatment (OAT) is highly effective in improving multiple outcomes for people who receive this treatment. Methadone and buprenorphine are common medications provided as OAT. We aimed to examine buprenorphine compared with methadone in the treatment of opioid dependence across a wide range of primary and secondary outcomes.

METHODS

We did a systematic review and meta-analysis in accordance with GATHER and PRISMA guidelines. We searched Embase, MEDLINE, CENTRAL, and PsycINFO from database inception to Aug 1, 2022; clinical trial registries and previous relevant Cochrane reviews were also reviewed. We included all RCTs and observational studies of adults (aged ≥18 years) with opioid dependence comparing treatment with buprenorphine or methadone. Primary outcomes were retention in treatment at 1, 3, 6, 12, and 24 months, treatment adherence (measured through doses taken as prescribed, dosing visits attended, and biological measures), or extra-medical opioid use (measured by urinalysis and self-report). Secondary outcomes were use of benzodiazepines, cannabis, cocaine, amphetamines, and alcohol; withdrawal; craving; criminal activity and engagement with the criminal justice system; overdose; mental and physical health; sleep; pain; global functioning; suicidality and self-harm; and adverse events. Single-arm cohort studies and RCTs that collected data on buprenorphine retention alone were also reviewed. Data on study, participant, and treatment characteristics were extracted. Study authors were contacted to obtain additional data when required. Comparative estimates were pooled with use of random-effects meta-analyses. The proportion of individuals retained in treatment across multiple timepoints was pooled for each drug. This study is registered with PROSPERO (CRD42020205109).

FINDINGS

We identified 32 eligible RCTs (N=5808 participants) and 69 observational studies (N=323 340) comparing buprenorphine and methadone, in addition to 51 RCTs (N=11 644) and 124 observational studies (N=700 035) that reported on treatment retention with buprenorphine. Overall, 61 studies were done in western Europe, 162 in North America, 14 in north Africa and the Middle East, 20 in Australasia, five in southeast Asia, seven in south Asia, two in eastern Europe, three in central Europe, one in east Asia, and one in central Asia. 1 040 827 participants were included in these primary studies; however, gender was only reported for 572 111 participants, of whom 377 991 (66·1%) were male and 194 120 (33·9%) were female. Mean age was 37·1 years (SD 6·0). At timepoints beyond 1 month, retention was better for methadone than for buprenorphine: for example, at 6 months, the pooled effect favoured methadone in RCTs (risk ratio 0·76 [95% CI 0·67-0·85]; I·=74·2%; 16 studies, N=3151) and in observational studies (0·77 [0·68-0·86]; I·=98·5%; 21 studies, N=155 111). Retention was generally higher in RCTs than observational studies. There was no evidence suggesting that adherence to treatment differed with buprenorphine compared with methadone. There was some evidence that extra-medical opioid use was lower in those receiving buprenorphine in RCTs that measured this outcome by urinalysis and reported proportion of positive urine samples (over various time frames; standardised mean difference -0·20 [-0·29 to -0·11]; I·=0·0%; three studies, N=841), but no differences were found when using other measures. Some statistically significant differences were found between buprenorphine and methadone among secondary outcomes. There was evidence of reduced cocaine use, cravings, anxiety, and cardiac dysfunction, as well as increased treatment satisfaction among people receiving buprenorphine compared with methadone; and evidence of reduced hospitalisation and alcohol use in people receiving methadone. These differences in secondary outcomes were based on small numbers of studies (maximum five), and were often not consistent across study types or different measures of the same constructs (eg, cocaine use).

INTERPRETATION

Evidence from trials and observational studies suggest that treatment retention is better for methadone than for sublingual buprenorphine. Comparative evidence on other outcomes examined showed few statistically significant differences and was generally based on small numbers of studies. These findings highlight the imperative for interventions to improve retention, consideration of client-centred factors (such as client preference) when selecting between methadone and buprenorphine, and harmonisation of data collection and reporting to strengthen future syntheses.

FUNDING

Australian National Health and Medical Research Council.

Text Messages Exchanged Between Individuals With Opioid Use Disorder and Their mHealth e-Coaches: Content Analysis Study

BACKGROUND

Opioid use disorder (OUD) has affected 2.2 million people in the United States. About 7.2 million people reported using illicit drugs in 2019, which contributed to over 70,000 overdose deaths. SMS text messaging interventions have been shown to be effective in OUD recovery. However, the interpersonal communication between individuals in OUD treatment and a support team on digital platforms has not been well examined.

OBJECTIVE

This study aims to understand the communication between participants undergoing OUD recovery and their e-coaches by examining the SMS text messages exchanged from the lens of social support and the issues related to OUD treatment.

METHODS

A content analysis of messages exchanged between individuals recovering from OUD and members of a support team was conducted. Participants were enrolled in a mobile health intervention titled "uMAT-R," a primary feature of which is the ability for patients to instantly connect with a recovery support staff or an "e-coach" via in-app messaging. Our team analyzed dyadic text-based messages of over 12 months. In total, 70 participants' messages and 1196 unique messages were analyzed using a social support framework and OUD recovery topics.

RESULTS

Out of 70 participants, 44 (63%) were between the ages of 31 and 50 years, 47 (67%) were female, 41 (59%) were Caucasian, and 42 (60%) reported living in unstable housing conditions. An average of 17 (SD 16.05) messages were exchanged between each participant and their e-coach. Out of 1196 messages, 64% (n=766) messages were sent by e-coaches and 36% (n=430) by participants. Messages of emotional support occurred the most, with 196 occurrences (n=9, 0.8%) and e-coaches (n=187, 15.6%). Messages of material support had 110 occurrences (participants: n=8, 0.7%; e-coaches: n=102, 8.5%). With OUD recovery topics, opioid use risk factors appeared in most (n=72) occurrences (patient: n=66, 5.5%; e-coach: n=6, 0.5%), followed by a message of avoidance of drug use 3.9% (n=47), which occurred mainly from participants. Depression was correlated with messages of social support (r=0.27; P=.02).

CONCLUSIONS

Individuals with OUD who had mobile health needs tended to engage in instant messaging with the recovery support staff. Participants who are engaged in messaging often engage in conversations around risk factors and avoidance of drug use. Instant messaging services can be instrumental in providing the social and educational support needs of individuals recovering from OUD.

Using ecological momentary assessments of negative affect and craving during residential opioid use disorder treatment to predict patients' relapse to substance use

BACKGROUND

Negative affect (NA) and craving are often independently examined as precipitators of relapse among individuals with substance use disorders, including opioid use disorder (OUD). Recent ecological momentary assessment (EMA) research has revealed that NA and craving frequently co-occur within individuals. Yet we know little about the general patterns of, and variability in, within-person associations between NA and craving, as well as whether the nature and degree of within-person NA-craving coupling predicts post-treatment time-to-relapse.

METHODS

Seventy-three patients (77 % male, Mage = 30.10, Range = 19-61) in residential treatment for OUD took part in a 12-day, 4× daily smartphone-based EMA study. Linear mixed-effects models tested within-person, day-level associations between self-reported NA and craving during treatment. The study used Person-specific slopes (i.e., average within-person NA-craving coupling for each participant) estimated from the mixed-effects model in survival analyses with Cox proportional hazards regression models to determine if between-person differences in the within-person coupling predicted post-treatment time-to-relapse (operationalized as the return to problematic use of any substance except tobacco), and whether this prediction was similar across patients' average levels of NA and craving intensity. The study monitored relapse through a combination of hair samples and reports from patients or alternative contacts via a voice response system twice a month for up to 120 days or more following discharge.

RESULTS

Among the 61 participants with time-to-relapse data, those with stronger positive within-person NA-craving coupling on average during residential OUD treatment had a lower hazard of relapsing (slower time to relapse) post-treatment than participants with weaker NA-craving slopes. The significant association held after controlling for interindividual differences in age, sex, and average levels of NA and craving intensity. Average NA and craving intensity did not moderate the association between NA-craving coupling and time-to-relapse.

CONCLUSIONS

Interindividual differences in average within-person, day-level NA-craving coupling during residential treatment predict OUD patients' post-treatment time-to-relapse.

Using Machine Learning to Predict Treatment Adherence in Patients on Medication for Opioid Use Disorder

OBJECTIVE

Patients receiving medication for opioid use disorder (MOUD) may continue using nonprescribed drugs or have trouble with medication adherence, and it is difficult to predict which patients will continue to do so. In this study, we develop and validate an automated risk-modeling framework to predict opioid abstinence and medication adherence at a patient's next attended appointment and evaluate the predictive performance of machine-learning algorithms versus logistic regression.

METHODS

Urine drug screen and attendance records from 40,005 appointments drawn from 2742 patients at a multilocation office-based MOUD program were used to train logistic regression, logistic ridge regression, and XGBoost models to predict a composite indicator of treatment adherence (opioid-negative and norbuprenorphine-positive urine, no evidence of urine adulteration) at next attended appointment.

RESULTS

The XGBoost model had similar accuracy and discriminative ability (accuracy, 88%; area under the receiver operating curve, 0.87) to the two logistic regression models (accuracy, 88%; area under the receiver operating curve, 0.87). The XGBoost model had nearly perfect calibration in independent validation data; the logistic and ridge regression models slightly overestimated adherence likelihood. Historical treatment adherence, attendance rate, and fentanyl-positive urine at current appointment were the strongest contributors to treatment adherence at next attended appointment.

DISCUSSION

There is a need for risk prediction tools to improve delivery of MOUD. This study presents an automated and portable risk-modeling framework to predict treatment adherence at each patient's next attended appointment. The XGBoost algorithm appears to provide similar classification accuracy to logistic regression models; however, XGBoost may offer improved calibration of risk estimates compared with logistic regression.

Evaluation of real-world outcomes associated with use of a prescription digital therapeutic to treat substance use disorders

BACKGROUND AND OBJECTIVES

Digital therapeutics can expand the reach and fidelity of behavioral treatment for substance use disorders (SUDs). This analysis evaluated real-world engagement and clinical outcomes in patients diagnosed with SUD who were prescribed reSET®, an FDA-authorized prescription digital therapeutic (PDT).

METHODS

Patients were prescribed a 12-week PDT comprising 61 therapy lessons (31 "core" and 30 "keep learning" lessons) and contingency management rewards (positive reinforcement message or monetary gift cards) based on lesson completion and negative urine drug screens. Engagement (defined as any activity in the PDT), retention (any activity in Weeks 9-12), and substance use data were collected automatically by the PDT and analyzed descriptively. Associations between early lesson completion and end-of-treatment outcomes were assessed.

RESULTS

Six hundred and fifty-eight patients filled their prescription. Evaluated were 602 patients who were exposed to therapeutic content by completing at least one lesson (median age 37 years, 33% female, 41% male, 26% unreported sex). Median lessons completed was 33 (out of 61 possible), and 52% of patients completed all core modules. Retention in treatment during the last 4 weeks of treatment was 74%, and 62% were abstinent (missing data considered positive). [Correction added on 13 December 2022, after first online publication: In the preceding sentence, the treatment percentage values were revised from 74.6% to 74%.] DISCUSSION AND CONCLUSIONS: Patients with SUD exhibited robust engagement with a PDT, high rates of retention through 12 weeks, and substantial rates of abstinence at end of treatment when the therapeutic was used in a real-world setting. PDT's hold promise as a new way to access effective SUD treatment.

SCIENTIFIC SIGNIFICANCE

This study is the first to report real-world PDT engagement and clinical outcomes data from a large, geographically diverse population of patients with SUDs.

Long-term recovery from opioid use disorder: recovery subgroups, transition states and their association with substance use, treatment and quality of life

BACKGROUND AND AIMS

Limited information exists regarding individual subgroups of recovery from opioid use disorder (OUD) following treatment and how these subgroups may relate to recovery trajectories. We used multi-dimensional criteria to identify OUD recovery subgroups and longitudinal transitions across subgroups.

DESIGN, SETTING AND PARTICIPANTS

In a national longitudinal observational study in the United States, individuals who previously participated in a clinical trial for subcutaneous buprenorphine injections for treatment of OUD were enrolled and followed for an average of 4.2 years after participation in the clinical trial.

MEASUREMENTS

We identified recovery subgroups based on psychosocial outcomes including depression, opioid withdrawal and pain. We compared opioid use, treatment utilization and quality of life among these subgroups.

FINDINGS

Three dimensions of the recovery process were identified: depression, opioid withdrawal and pain. Using these three dimensions, participants were classified into four recovery subgroups: high-functioning (minimal depression, mild withdrawal and no/mild pain), pain/physical health (minimal depression, mild withdrawal and moderate pain), depression (moderate depression, mild withdrawal and mild/moderate pain) and low-functioning (moderate/severe withdrawal, moderate depression and moderate/severe pain). Significant differences among subgroups were observed for DSM-5 criteria (P < 0.001) and remission status (P < 0.001), as well as with opioid use (P < 0.001), treatment utilization (P < 0.001) and quality of life domains (physical health, psychological, environment and social relationships; Ps < 0.001, Cohen's fs ≥ 0.62). Recovery subgroup assignments were dynamic, with individuals transitioning across subgroups during the observational period. Moreover, the initial recovery subgroup assignment was minimally predictive of long-term outcomes.

CONCLUSIONS

There appear to be four distinct subgroups among individuals in recovery from OUD. Recovery subgroup assignments are dynamic and predictive of contemporaneous, but not long-term, substance use, substance use treatment utilization or quality of life outcomes.

Struggling With Recovery From Opioids: Who Is at Risk During COVID-19?

OBJECTIVES

Individuals in recovery from opioid use disorder (OUD) are vulnerable to the impacts of the COVID-19 pandemic. Recent findings suggest increased relapse risk and overdose linked to COVID-19-related stressors. We aimed to identify individual-level factors associated with COVID-19-related impacts on recovery.

METHODS

This observational study (NCT04577144) enrolled 216 participants who previously partook in long-acting buprenorphine subcutaneous injection clinical trials (2015-2017) for OUD. Participants indicated how COVID-19 affected their recovery from substance use. A machine learning approach Classification and Regression Tree analysis examined the association of 28 variables with the impact of COVID-19 on recovery, including demographics, substance use, and psychosocial factors. Tenfold cross-validation was used to minimize overfitting.

RESULTS

Twenty-six percent of the sample reported that COVID-19 had made recovery somewhat or much harder. Past-month opioid use was higher among those who reported that recovery was harder compared with those who did not (51% vs 24%, respectively; P < 0.001). The final classification tree (overall accuracy, 80%) identified the Beck Depression Inventory (BDI-II) as the strongest independent risk factor associated with reporting COVID-19 impact. Individuals with a BDI-II score ≥10 had 6.45 times greater odds of negative impact (95% confidence interval, 3.29-13.30) relative to those who scored <10. Among individuals with higher BDI-II scores, less progress in managing substance use and treatment of OUD within the past 2 to 3 years were also associated with negative impacts.

CONCLUSIONS

These findings underscore the importance of monitoring depressive symptoms and perceived progress in managing substance use among those in recovery from OUD, particularly during large-magnitude crises.

Prefrontal cortical response to natural rewards and self-reported anhedonia are associated with greater craving among recently withdrawn patients in residential treatment for opioid use disorder

Both anhedonia and craving are common among patients with opioid use disorder (OUD), and are associated with vulnerability to relapse. Although these constructs are theoretically linked relatively few studies have examined them together. In the current study, recently withdrawn patients (N = 71) in residential treatment for prescription OUD underwent a cue reactivity paradigm while being monitored with functional near-infrared spectroscopy (fNIRS). Patients also self-reported symptoms of anhedonia via the Snaith-Hamilton Pleasure Scale (SHAPS), while smartphone-based ecological momentary assessments (EMA) were used to measure craving levels. On average, lower right prefrontal cortex (PFC) activity in response to positive social stimuli was associated with higher craving (β = - 2.87; S.E. = 1.23; p = 0.02). Self-reported anhedonia moderated the association between PFC activity and craving (β = - 1.02; S.E. = 0.48; p = 0.04), such that patients with two or more anhedonic symptoms had a significant and stronger negative association between PFC activation to hedonically positive images and craving, compared to patients with fewer than two anhedonic symptoms, among whom the association was not significant. This finding provides evidence that higher levels of anhedonia among patients in residential treatment for OUD are associated with a stronger link between lower PFC response to positive social experiences and higher levels of craving, potentially increasing overall vulnerability to relapse.

Opioid agonist treatment for people who are dependent on pharmaceutical opioids

BACKGROUND

There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin.  OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence.

SEARCH METHODS

We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms.

AUTHORS' CONCLUSIONS

There is  very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

Racial and ethnic differences in alcohol, cannabis, and illicit substance use treatment: a systematic review and narrative synthesis of studies done in the USA

Reports from uncontrolled trials and surveys suggest that there are disparities in substance-use outcomes for minoritised racial and ethnic populations, yet few of these disparities have emerged from randomised clinical trials (RCTs). We conducted a systematic review of RCTs published in English of Black or Latinx adults with any non-nicotine substance use disorder that reported rates of treatment initiation, engagement, or substance-use outcome by race or ethnicity. Study quality was assessed by the Joanna Briggs Institute appraisal tool and a Yale internally validated quality assessment. Of the 5204 studies, 50 RCTs met the inclusion criteria, all done in the USA, 24 compared treatment initiation, engagement, or outcome across races or ethnicities and 26 compared these same factors within a race. Few RCTs have reported outcomes specifically for Black or Latinx populations, with nine reporting significant differences by race or ethnicity. Significant differences were found in all studies that evaluated the baseline differences in social determinants. This Review explains the need for optimisation of RCTs to inform the design, delivery, and dissemination of treatment to historically excluded communities.

Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis

Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.

Recovery from opioid use disorder: A 4-year post-clinical trial outcomes study

BACKGROUND

Opioid use disorder (OUD) seriously impacts public health in the United States. However, few investigations of long-term outcomes following treatment with medication for OUD exist. Additionally, these studies have prioritized opioid use and treatment utilization outcomes, and a gap in knowledge regarding long-term, multidimensional trajectories of OUD recovery exists. This study investigated a diverse array of outcomes for individuals with OUD at an average of 4.2 years post clinical trial participation.

METHODS

Individuals who previously participated in long-acting buprenorphine subcutaneous injection clinical trials (NCT023579011; NCT025100142; NCT02896296) and enrolled in The Remission from Chronic Opioid Use-Studying Environmental and SocioEconomic Factors on Recovery (RECOVER; NCT03604861) Study participated in a follow up assessment (n = 216). Substance use, psychosocial, opioid dependence, and delay discounting outcomes were assessed. Regression analyses were conducted to determine significant associations between psychosocial/opioid dependence variables and both recent opioid use and delay discounting.

RESULTS

The majority of participants reported abstinence from opioids since the last RECOVER study assessment (mean 2.26 years; 55%) and in the past 30 days (69%). Participants reported low levels of depression and psychological distress. Positive associations between depression and opioid craving with past 30-day opioid misuse and delay discounting, and negative associations between quality of life and treatment effectiveness with these outcomes were observed.

CONCLUSIONS

This study examined longer term OUD recovery outcomes. Participants reported high levels of abstinence from opioids and psychosocial functioning. These encouraging results highlight the multidimensional nature of recovery from OUD, and further support the effectiveness of buprenorphine as an OUD treatment.

Trajectories of craving during medication-assisted treatment for opioid-use disorder: Subtyping for early identification of higher risk

AIMS

To examine evidence for subtypes of opioid craving trajectories during medication for opioid use disorder (MOUD), and to (a) test whether these subtypes differed on MOUD-related outcomes, and (b) determine whether nonresponders could be identified before treatment initiation.

DESIGN, SETTING, AND PARTICIPANTS

Outpatients (n = 211) being treated with buprenorphine or methadone for up to 16 weeks. Growth mixture modeling was used to identify unobserved craving-trajectory subtypes. Support Vector Machines (SVM) were trained to predict subtype membership from pretreatment data.

MEASUREMENTS

Self-reported opioid craving (Ecological Momentary Assessment - EMA - three random moments per day). Participant-initiated EMA reports of drug use or higher-than-usual stress. Addiction Severity Index (ASI) pretreatment.

FINDINGS

Four craving trajectories were identified: Low (73%); High and Increasing (HIC) (10.9%); Increasing and Decreasing (8.5%); and Rapidly Declining (7.6%). The HIC subgroup reported the highest use of heroin, any opiate, and cannabis during treatment. The Low Craving subgroup reported the lowest use of heroin or any opiate use, and the lowest levels of stress and drug-cue exposure during treatment. SVM models predicting HIC membership before treatment initiation had a sensitivity of 0.70, specificity of 0.78, and accuracy of 0.77. Including 3 weeks of EMA reports increased sensitivity to 0.78, specificity to 0.84, and accuracy to 0.85.

CONCLUSIONS

Subgroups of MOUD patients show distinct patterns of opioid craving during treatment. Subgroups differ on critical outcomes including drug-use lapse, stress, and exposure to drug cues. Data from enrollment and early in treatment may help focus clinical attention.

Sex Differences in Injection Drug Risk Behaviors Among Hospitalized Persons

OBJECTIVES

As opioid use increases, it remains important to assess factors that contribute to injection drug risk behaviors, as sharing needles and other drug use equipment contributes to the spread of human immunodeficiency virus and hepatitis C virus. Such risks may differ by sex and injecting with others. The current study examined factors that contribute to increased injection drug risk separately for men and women.

METHODS

People who inject drugs were recruited at an academic safety-net hospital that reported recent injection drug use. Two main injection outcomes were assessed: (1) human immunodeficiency virus drug risk behaviors as assessed by the Risk Assessment Battery and (2) the number of times participants injected drugs with a needle used by someone else. For each outcome, different models for women and men were conducted to detect differences by sex.

RESULTS

Both men and women were more likely to inject with a needle used by someone else if they used drugs within a sexual relationship (incidence rate ratio (IRR) = 14.61, P < 0.01; IRR = 7.17, P < 0.05). Being employed was associated with lower risk assessment battery scores among men, and lower mean rates of using a needle used by someone else among women (IRR = 0.22, P < 0.05). Women with post-traumatic stress disorder (PTSD) and men with higher depression scores had higher rates of injecting with a needle used by someone else.

CONCLUSIONS

People who inject drugs who are in intimate relationships report higher injection drug risk behaviors. We found benefits to employment among both men and women. Identifying factors associated with increased injection risk behaviors can be useful for creating interventions tailored by sex.

Patient Characteristics Associated with Opioid Abstinence after Participation in a Trial of Buprenorphine versus Injectable Naltrexone

Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.

The Public Health Approach to the Worsening Opioid Crisis in the United States Calls for Harm Reduction Strategies to Mitigate the Harm From Opioid Addiction and Overdose Deaths

The opioid crisis has devastated the U.S. more than any other country, and the epidemic is getting worse. While opioid prescriptions have decreased by more than 40% from its peak in 2010, unfortunately, opioid-related overdose deaths have not declined but continued to increase. With greater scrutiny on prescription opioids, many users switched to the cheaper and more readily available heroin that drove up heroin-related overdose deaths from 2010 to peak in 2016, being overtaken by the spike in synthetic opioid (mostly fentanyl)-related overdose deaths. The surge in fentanyl-related overdose deaths since 2013 is alarming as fentanyl is more potent and deadly. One thing is certain the opioid crisis is not improving but has become dire with the surge in fentanyl-related overdose deaths. Evidence-based strategies have to be implemented in the U.S. to control this epidemic before it destroys more lives. Other countries, including European countries and Canada, have invested more in harm reduction strategies than the U.S. even though they (especially Europe) do not face anywhere near the level of crisis as the U.S. In the long-run, upstream measures (tackling the social determinants of health) are more effective public health strategies to control the epidemic. In the meantime, however, harm reduction strategies have to be employed to mitigate the harm from addiction and overdose deaths.

Is the relapse concept in studies of substance use disorders a 'one size fits all' concept? A systematic review of relapse operationalisations

ISSUES

Relapse is a theoretical construct and empirical object of inquiry. It is unclear how relapse is operationalised with regard to the various phases in substance use disorders (SUD). The aim was to investigate relapse operationalisations in SUDs studies after short- and long-term abstinence and remission, recovery and slip/lapse.

APPROACH

Systematic review using the following databases: Epistemonikos, Cochrane Central Register of Controlled Trials (CENTRAL and DARE), MEDLINE, EMBASE, Google Scholar, CINAHL, Web of Science and PsycINFO. Search returned 3426 articles, with 276 meeting the following inclusion criteria: empirical study published in English in a peer-reviewed journal; samples meet diagnostic criteria for dependence syndrome or moderate-severe drug use disorder or alcohol use disorder; reports relapse, abstinence, recovery, remission, slip or lapse. Review protocol registration: PROSPERO (CRD42020154062).

KEY FINDINGS

Thirty-two percent of the studies had no definition of 'relapse'. Most relapse operationalisations were defined according to measure (26%), time (17%), use (26%) and amount and frequency (27%). Of the 16 studies with a follow-up duration of up to 2 years, one (6%) contained a definition of 'long-term abstinence'. Of the 64 studies with a follow-up duration of more than 2 years, four (6%) contained a definition of 'long-term abstinence'. Of those, one (2%) mentioned 'early relapse' and one (2%) mentioned 'late relapse'.

IMPLICATIONS

Future research is needed to explore the possible difference between early and late relapse. Moreover, working to increase consensus on relapse operationalisations in SUD research is warranted.

CONCLUSIONS

We identified no consensus on relapse operationalisations nor agreement on the differentiation between early and late relapse. The clinical utility of current relapse operationalisations seems low and may compromise knowledge accumulation about relapse and implementation of research into treatment.

Buprenorphine/naloxone associated with a reduced odds of fentanyl exposure among a cohort of people who use drugs in Vancouver, Canada

BACKGROUND

Little is known about the relationship between opioid agonist therapy (OAT) and fentanyl use, specifically. This study aimed to estimate the association between current use of different forms of OAT, including methadone, buprenorphine/naloxone (BUP/NX), slow release oral morphine (SROM), or injectable opioid agonist treatment (iOAT), and the likelihood of a fentanyl-positive urine drug test (UDT) as compared to no OAT.

METHODS

Data were obtained from three community-recruited prospective cohort studies of people who use drugs in Vancouver, Canada from December 2016 through November 2018. Using multivariable Generalized Estimating Equations (GEE), we examined the association between current use of each form of OAT, as compared to no OAT, and fentanyl-positive UDT among participants who use opioids.

RESULTS

The 915 participants contributed 2112 UDTs over a median of two follow-up visits. The majority of UDTs (74.9 %) were positive for fentanyl. After adjustment for a priori defined confounding factors, compared to no OAT, current use of BUP/NX was associated with lower odds of fentanyl-positive UDT (odds ratio [OR] = 0.36, 95 % confidence interval [CI]: 0.22-0.58) while current use of methadone (OR = 0.84, 95 % CI: 0.65-1.07), iOAT (OR = 1.30, 95 % CI: 0.75-2.28), and SROM (OR = 1.34, 95 % CI: 0.74-2.43) were not.

CONCLUSIONS

In this cohort of people who use opioids in Vancouver, only use of BUP/NX was associated with lower odds of fentanyl-positive UDT. Our findings highlight high rates of ongoing fentanyl use despite the use of OAT and support the expansion of BUP/NX for the treatment of people who use fentanyl.

Psychiatric comorbidity and treatment outcomes in patients with opioid use disorder: Results from a multisite trial of buprenorphine-naloxone and methadone

BACKGROUND

Individuals treated for opioid use disorder (OUD) have high rates of psychiatric disorders potentially diminishing treatment outcomes. We examined long-term treatment experiences and outcomes by type of psychiatric disorder among participants who participated in the Starting Treatment with Agonist Replacement Therapies (START) study and its follow-up study.

METHODS

We categorized the 593 participants who completed the Mini-International Neuropsychiatric Interview (MINI) during the START follow-up study into four mutually exclusive groups to indicate current psychiatric diagnosis: 1) bipolar disorder (BPD; n = 51), 2) major depressive disorder (MDD; n = 85), 3) anxiety disorder (AXD; n = 121), and 4) no comorbid mental disorder (NMD; n = 336). We compared participants' baseline characteristics and treatment outcomes.

RESULTS

Groups with mental disorders had worse substance use outcomes and poorer psychosocial functioning than the NMD group. Participants with BPD had significantly more self-reported days using opioids (Mean: 8.6 for BPD vs. 3.4 days for NMD, p < 0.01) and heroin (Mean: 6.4 for BPD vs. 2.0 for MDD, 3.1 days for NMD, p < 0.05) in the 30 days prior to the final interview. Compared to patients without mental disorders, patients with MDD spent more time engaged with OUD pharmacotherapy during the ∼16-month period between MINI and final interview (mean: 71.6 % vs. 50.6 %; p < 0.001).

CONCLUSIONS

Our results show that treatment outcomes in individuals with OUD vary by psychiatric comorbidity groups, which supports the need for mental health assessment and treatment for psychiatric conditions in the context of pharmacotherapy for patients with OUD.

I feel good? Anhedonia might not mean "without pleasure" for people treated for opioid use disorder

Anhedonia is usually defined as partial or total loss of the capacity for pleasure. People with anhedonia in the context of major depressive disorder may have an unexpected capacity for event-related mood brightening, observable when mood is assessed dynamically (with smartphone-based ecological momentary assessment [EMA]) rather than only statically via questionnaire. We used EMA to monitor mood and pleasant events for 4 weeks in 54 people being treated with opioid agonist medication for opioid-use disorder (OUD), which is also associated with anhedonia, said to manifest especially as loss of pleasure from nondrug reward. We compared OUD patients' EMA reports with those of 47 demographically similar controls. Background positive mood was lower in OUD patients than in controls, as we hypothesized (Cohen ds = .85 to 1.32, 95% CIs [.66, 1.55]), although, contrary to our hypothesis, background negative mood was also lower (ds = .82 to .85, 95% CIs [.73, .94]). As hypothesized, instances of nondrug pleasure were as frequent in OUD patients as in controls-and were not rated much less pleasurable (d = .18, 95% CI [-.03, .35]). Event-related mood brightening occurred in both abstinent and nonabstinent OUD patients (ds = .18 to .37, CIs [-.01, .57]) and controls (ds = .04 to .60, CIs [-.17, .79]), brightening before each event began earlier for controls than OUD patients, but faded similarly postevent across groups. Our findings add to the evidence that anhedonia does not rule out reactive mood brightening, which, for people with OUD being treated on opioid agonist medication, can be elicited by nondrug activities. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) and their effects on residential drug treatment outcomes in the US

BACKGROUND

This study examines racial/ethnic disparities in the use of medications for opioid use disorder (MOUD) in residential treatment and the influence of race/ethnicity on the association between MOUD use and treatment retention and completion.

METHODS

Data were extracted from SAMHSA's 2015-2017 Treatment Episode Dataset-Discharge (TEDS-D) datasets for adult opioid admissions/discharges to short-term (ST) (30 days or less) (N = 83,032) or long-term (LT) (> 30 days) residential treatment settings (N=61,626). Logistic regression estimated the likelihood of MOUD use among racial/ethnic groups and the moderation of race/ethnicity on the probability of treatment completion and retention, controlling for background factors.

RESULTS

After adjusting for covariates, compared to Whites, MOUD use was less likely for Blacks in ST (OR = 0.728) and LT settings (OR = 0.725) and slightly less likely for Hispanics in ST settings (OR = 0.859) but slightly more likely for Hispanics in LT settings (OR = 1.107). In ST settings, compared to Whites, the positive effect of MOUD on retention was enhanced for Blacks (OR = 1.191) and Hispanics (OR = 1.234), and the positive effect on treatment completion was enhanced for Hispanics (OR = 1.144). In LT settings, the negative association between MOUD and treatment completion was enhanced for Hispanics (OR = 0.776).

CONCLUSIONS

Access to medications for opioid use disorder in short term residential treatment is particularly beneficial for Blacks and Hispanics, though adjusted models indicate they are less likely to receive it compared to Whites. Results are mixed for long-term residential treatment. Residential addiction treatment may represent an important setting for mitigating low rates of medication initiation and early discontinuation for minority patients.

Sublingual Buprenorphine-Naloxone Compared With Injection Naltrexone for Opioid Use Disorder: Potential Utility of Patient Characteristics in Guiding Choice of Treatment

OBJECTIVE

Sublingual buprenorphine-naloxone and extended-release injection naltrexone are effective treatments, with distinct mechanisms, for opioid use disorder. The authors examined whether patients' demographic and clinical characteristics were associated with better response to one medication or the other.

METHODS

In a multisite 24-week randomized comparative-effectiveness trial of assignment to buprenorphine-naloxone (N=287) compared with extended-release naltrexone (N=283) comprising inpatients planning to initiate medication treatment for opioid use disorder, 50 demographic and clinical characteristics were examined as moderators of the effect of medication assignment on relapse to regular opioid use and failure to initiate medication. Moderator-by-medication interactions were estimated using logistic regression with correction for multiple testing.

RESULTS

In the intent-to-treat sample, patients who reported being homeless had a lower relapse rate if they were assigned to receive extended-release naltrexone (51.6%) compared with buprenorphine-naloxone (70.4%) (odds ratio=0.45, 95% CI=0.22, 0.90); patients who were not homeless had a higher relapse rate if they were assigned to extended-release naltrexone (70.9%) compared with buprenorphine-naloxone (53.1%) (odds ratio=2.15, 95% CI=1.44, 3.21). In the subsample of patients who initiated medication, the interaction was not significant, with a similar pattern of lower relapse with extended-release naltrexone (41.4%) compared with buprenorphine (68.6%) among homeless patients (odds ratio=0.32, 95% CI=0.15, 0.68) but less difference among those not homeless (extended-release naltrexone, 57.2%; buprenorphine, 52.0%; odds ratio=1.24, 95% CI=0.80, 1.90). For failure to initiate medication, moderators were stated preference for medication (failure was less likely if the patient was assigned to the medication preferred), parole and probation status (fewer failures with extended-release naltrexone for those on parole or probation), and presence of pain and timing of randomization (more failure with extended-release naltrexone for patients endorsing moderate to severe pain and randomized early while still undergoing medically managed withdrawal).

CONCLUSIONS

Among patients with opioid use disorder admitted to inpatient treatment, homelessness, parole and probation status, medication preference, and factors likely to influence tolerability of medication initiation may be important in matching patients to buprenorphine or extended-release naltrexone.

Perceived social support in patients with chronic pain with and without opioid use disorder and role of medication for opioid use disorder

BACKGROUND

A significant predictor of treatment outcomes for patients with chronic non-cancer pain (CNCP) and opioid use disorder (OUD) is the degree and quality of social support they receive. Specifically, in patients with CNCP and on long-term opioid therapy, the development of OUD tends to be associated with losses in social support, while engagement in treatment for OUD improves support networks. Delivery of the evidence-based OUD treatment medications, methadone and buprenorphine, occurs in clinical environments which patently differ with respect to social support resources. The aims of this study were to describe perceived social support in patients with CNCP without OUD (no-OUD), with OUD and on buprenorphine (OUD-BP), and with OUD and on methadone (OUD-methadone).

METHODS

Using the Duke Social Support Index (DSSI), perceived social support in a sample of Caucasian patients with CNCP and on opioid therapy was compared between no-OUDs (n = 834), OUD-methadone (n = 83) and OUD-BP (n = 99) therapy. Average DSSI scores were compared across groups and a linear regression model computed to describe association between group and perceived social support.

RESULTS

No difference was observed in DSSI scores between no-OUDs and OUD-methadone, however scores were lower among OUD-BP participants than those receiving methadone (x = -5.2; 95% CI: -7.5, -2.9) and (x = -6.5, 95% CI: -8.2, -4.9).

CONCLUSIONS

Patients with CNCP and OUD on methadone therapy endorse levels of social support comparable to those without OUD, however those on buprenorphine therapy report significantly less support, bringing implications for OUD treatment outcomes.

Real-world evidence for a prescription digital therapeutic to treat opioid use disorder

OBJECTIVES

To evaluate patient engagement and usage of a prescription digital therapeutic (PDT) and associated outcomes of opioid use and treatment retention in a large real-world dataset of patients with opioid use disorder (OUD) treated with buprenorphine medication for opioid use disorder (MOUD). PDTs are software-based disease treatments evaluated for safety and effectiveness in randomized clinical trials (RCTs), and authorized by the U.S. Food and Drug Administration (FDA) to treat disease with approved directions for use (label).

METHODS

A real-world observational evaluation of an all-comer population of patients who redeemed a 12-week prescription for the reSET-O PDT. Engagement and therapeutic use data were collected and analysed on a population level. Substance use was evaluated as a composite of self-reports recorded with reSET-O and urine drug screens (UDS).

RESULTS

Data from 3144 individuals with OUD were evaluated. 45.5% were between ages 30 and 39 years. 80% completed at least 8 of the 67 possible therapeutic modules, 66% completed half of all modules, and 49% completed all modules. Abstinence during the last 4 weeks of treatment was calculated with two imputation methodologies: 66% abstinent using "missing data excluded (patients with no data as positive)", and 91% abstinent with "missing data removed (patients with no data excluded)". 91% of patients met the responder definition of ≥80% of self-report or UDS negative. 74.2% of patients were retained through the last 4 weeks of treatment. Subgroup analysis of patients using reSET-O appropriately (4 or more modules per week for the first 4 weeks) showed 88.1% abstinence using "missing data excluded (patients with no data as positive)", and retention at weeks 9-12 of 85.8%.

CONCLUSIONS

Results demonstrate that reSET-O is readily and broadly used by patients with OUD and that high real-world engagement with the therapeutic is positively associated with abstinence and retention in treatment. ReSET-O is a potentially valuable adjunct to buprenorphine MOUD therapy for patients with OUD.

Beyond abstinence and relapse: cluster analysis of drug-use patterns during treatment as an outcome measure for clinical trials

RATIONALE

Many people being treated for opioid use disorder continue to use drugs during treatment. This use occurs in patterns that rarely conform to well-defined cycles of abstinence and relapse. Systematic identification and evaluation of these patterns could enhance analysis of clinical trials and provide insight into drug use.

OBJECTIVES

To evaluate such an approach, we analyzed patterns of opioid and cocaine use from three randomized clinical trials of contingency management in methadone-treated participants.

METHODS

Sequences of drug test results were analyzed with unsupervised machine-learning techniques, including hierarchical clustering of categorical results (i.e., whether any samples were positive during each week) and K-means longitudinal clustering of quantitative results (i.e., the proportion positive each week). The sensitivity of cluster membership as an experimental outcome was assessed based on the effects of contingency management. External validation of clusters was based on drug craving and other symptoms of substance use disorder.

RESULTS

In each clinical trial, we identified four clusters of use patterns, which can be described as opioid use, cocaine use, dual use (opioid and cocaine), and partial/complete abstinence. Different clustering techniques produced substantially similar classifications of individual participants, with strong above-chance agreement. Contingency management increased membership in clusters with lower levels of drug use and fewer symptoms of substance use disorder.

CONCLUSIONS

Cluster analysis provides person-level output that is more interpretable and actionable than traditional outcome measures, providing a concrete answer to the question of what clinicians can tell patients about the success rates of new treatments.

Improving translation of animal models of addiction and relapse by reverse translation

Critical features of human addiction are increasingly being incorporated into complementary animal models, including escalation of drug intake, punished drug seeking and taking, intermittent drug access, choice between drug and non-drug rewards, and assessment of individual differences based on criteria in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Combined with new technologies, these models advanced our understanding of brain mechanisms of drug self-administration and relapse, but these mechanistic gains have not led to improvements in addiction treatment. This problem is not unique to addiction neuroscience, but it is an increasing source of disappointment and calls to regroup. Here we first summarize behavioural and neurobiological results from the animal models mentioned above. We then propose a reverse translational approach, whose goal is to develop models that mimic successful treatments: opioid agonist maintenance, contingency management and the community-reinforcement approach. These reverse-translated 'treatments' may provide an ecologically relevant platform from which to discover new circuits, test new medications and improve translation.

Endogenous Opiates and Behavior: 2018

This paper is the forty-first consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2018 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (2), the roles of these opioid peptides and receptors in pain and analgesia in animals (3) and humans (4), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (5), opioid peptide and receptor involvement in tolerance and dependence (6), stress and social status (7), learning and memory (8), eating and drinking (9), drug abuse and alcohol (10), sexual activity and hormones, pregnancy, development and endocrinology (11), mental illness and mood (12), seizures and neurologic disorders (13), electrical-related activity and neurophysiology (14), general activity and locomotion (15), gastrointestinal, renal and hepatic functions (16), cardiovascular responses (17), respiration and thermoregulation (18), and immunological responses (19).

Barriers to Medications for Opioid Use Disorder Among Veterans Involved in the Legal System: a Qualitative Study

BACKGROUND

Veterans involved in the legal system are at high risk for overdose but have lower receipt of medications for opioid use disorder than other veterans.

OBJECTIVE

The study aimed to understand barriers to medication access from the perspective of legally involved veterans with opioid use disorder and people who work with these veterans in the Veterans Health Administration (VHA) and the legal system.

DESIGN

This national qualitative study interviewed veterans and stakeholders from 14 geographically diverse VHA facilities to explore perceptions of barriers to medications for opioid use disorder.

PARTICIPANTS

Participants included veterans with a history of opioid use disorder and legal involvement (n = 18), VHA Veterans Justice Programs Specialists (n = 15), VHA and community substance use disorder treatment providers (n = 5), and criminal justice staff (n = 12).

APPROACH

We conducted interviews based on the Consolidated Framework for Implementation Research. Interview transcripts were analyzed using a team-based approach.

KEY RESULTS

Four key barriers, noted by group, were identified: (1) a preference for counseling along with or instead of medications (veterans, Specialists, treatment providers, criminal justice staff); (2) concerns about veterans using medications without a prescription, selling them, or providing them to others (veterans, Specialists, treatment providers, criminal justice staff); (3) concerns about perceived stigma towards medication use (veterans, Specialists, treatment providers, criminal justice staff); and (4) concerns about medication discontinuation after recurrent opioid use (veterans, criminal justice staff). A fifth theme, education, was noted by all stakeholders except providers as important to facilitating use of medications for opioid use disorder. All five themes mapped to the framework construct of knowledge and beliefs about the intervention.

CONCLUSIONS

Based on identified barriers, interventions focused on enhancing medication knowledge, reducing stigma towards use of medications, and increasing knowledge that opioid use may recur during treatment may help increase access to medication for veterans with legal involvement.

Opioid knowledge and perceptions among Hispanic/Latino residents in Los Angeles

BACKGROUND

Most research and health education efforts to address the opioid crisis have focused on white populations. However, opioid use, opioid use disorder, and opioid overdose deaths also have increased among Hispanics. Methods: This study conducted four focus groups in a Hispanic community in Southern California (N = 45) to assess opioid-related knowledge, perceptions, and preventive behaviors among Hispanic residents. Focus group questions assessed medication storage, disposal, and sharing; opioid-related knowledge; how to recognize a drug problem; perceptions of the extent of the opioid use problem in the community; and sources of help for drug problems. Results: Qualitative analysis revealed that most participants were aware of the potential dangers of opioids and the importance of keeping them out of the reach of children. However, participants reported stockpiling, sharing, and borrowing prescription medications for financial reasons. They perceived marijuana use as a larger problem in the community than opioids. They were familiar with the behavioral indicators of opioid addiction, but they were unaware of the availability of naloxone to reverse overdoses. They were ambivalent about searching for information about opioids and treatment options because they lacked self-efficacy to find accurate information on the internet. Conclusions: Findings identify some knowledge gaps about opioids among Hispanics and suggest opportunities for culturally accessible health education to provide Hispanics with information about opioid use disorder, overdose reversal, and treatment options.

Medication-Assisted Treatment for Opioid Use Disorder in a Rural Family Medicine Practice

Opioid use disorder (OUD) is a cause of significant morbidity and mortality in the United States. Although efforts are being made to limit access to prescription opioids, the use of heroin and synthetic opioids as well as death due to opioid overdose has increased. Medication-assisted treatment (MAT) is the pairing of psychosocial intervention with a Food and Drug Administration (FDA)-approved medication (methadone, buprenorphine plus naltrexone) to treat OUD. MAT has resulted in reductions in overdose deaths, criminal activity, and infectious disease transmission. Access to MAT in rural areas is limited by shortages of addiction medicine-trained providers, lack of access to comprehensive addiction programs, transportation, and cost-related issues. Rural physicians express concern about lack of mentorship and drug diversion as reasons to avoid MAT. The prescribing of MAT with buprenorphine requires a Drug Enforcement Agency (DEA) waiver that can easily be obtained by Family Medicine providers. MAT can be incorporated into the outpatient practice, where patient follow-up rates and number needed to treat to effect change are similar to that of other chronic medical conditions. We describe a case of opioid overdose and a suggested protocol for the induction of MAT with buprenorphine/naloxone (Suboxone) for OUD in a rural family medicine outpatient practice. Treatment access is facilitated by utilizing the protocol, allowing office staff work to the extent allowed by their licensure, promoting teamwork and minimizing physician time commitment. We conclude that improved access to MAT can be accomplished in a rural family medicine outpatient clinic by staff that support and mentor one another through use of a MAT protocol.

Psychosocial intervention utilization and substance abuse treatment outcomes in a multisite sample of individuals who use opioids

BACKGROUND

There are several relatively safe and effective FDA-approved medications for Opioid Use Disorder (OUD). Despite the existence of these medications, the rate of returning to opioid use after treatment is relatively high, underscoring the need for continued enhancement of treatments. Adjunctive psychosocial interventions paired with medication have been shown to improve OUD treatment outcomes. However, studies have yet to conclusively examine the distinct effects of the most widely utilized psychosocial treatment modalities. The current study will investigate the relationship between individual counseling, group therapy, and 12-Step participation and illicit opioid abstinence at the end of treatment, 1 and 3 months after treatment.

METHOD

A secondary analysis was conducted with data from a sample of 570 individuals diagnosed with OUD who were recruited from eight substance abuse treatment centers in the United States. Participants were enrolled in a two-group randomized, controlled trial testing buprenorphine-naloxone versus extended-release naltrexone for OUD. A two-level hierarchical linear growth model was used to examine the effects of individual counseling, group therapy, and 12-Step participation on illicit opioid abstinence (urinanalyses) 1- and 3-months post-treatment.

RESULTS

Hours of individual counseling and 12-Step participation significantly predicted abstinence at follow-up (p < .001, b = -0.59, 95% CI [0.42, 0.74]; p < .01, b = -0.05, 95% CI [0.92, 0.98]). There was a significant interaction between individual counseling and 12-Step participation (p < .01, b = -0.06, 95% CI [1.02, 1.10]). Additionally, participant age and employment status were significant predictors of illicit opioid abstinence (p < .01, b = -0.02, 95% CI [0.97, 0.99]; p < .01, b = -0.38, 95% CI [0.52, 0.90]). Hours of group therapy was not found to significantly predict illicit opioid abstinence.

CONCLUSIONS

Findings suggest that greater levels of individual therapy and 12-Step participation may be beneficial for individuals receiving medication treatment for OUD.

Prediction of stress and drug craving ninety minutes in the future with passively collected GPS data

Just-in-time adaptive interventions (JITAIs), typically smartphone apps, learn to deliver therapeutic content when users need it. The challenge is to "push" content at algorithmically chosen moments without making users trigger it with effortful input. We trained a randomForest algorithm to predict heroin craving, cocaine craving, or stress (reported via smartphone app 3x/day) 90 min into the future, using 16 weeks of field data from 189 outpatients being treated for opioid-use disorder. We used only one form of continuous input (along with person-level demographic data), collected passively: an indicator of environmental exposures along the past 5 h of movement, as assessed by GPS. Our models achieved excellent overall accuracy-as high as 0.93 by the end of 16 weeks of tailoring-but this was driven mostly by correct predictions of absence. For predictions of presence, "believability" (positive predictive value, PPV) usually peaked in the high 0.70s toward the end of the 16 weeks. When the prediction target was more rare, PPV was lower. Our findings complement those of other investigators who use machine learning with more broadly based "digital phenotyping" inputs to predict or detect mental and behavioral events. When target events are comparatively subtle, like stress or drug craving, accurate detection or prediction probably needs effortful input from users, not passive monitoring alone. We discuss ways in which accuracy is difficult to achieve or even assess, and warn that high overall accuracy (including high specificity) can mask the abundance of false alarms that low PPV reveals.

Medication-assisted therapies for opioid use disorders in patients with chronic pain

Opioids have been used to treat pain and invoke pleasure for centuries. Modern scientific advancements have led to more potent, synthetic opioids. While certainly more effective in treating pain, they can also be much more addictive. Over the years the scientific community has developed a clearer understanding of the role opioid receptors play in causing and treating opioid use disorders (OUD) and we now know that OUD can develop in individuals taking opioids for "legitimate" pain. Current guidelines suggest that all prescribers (especially those prescribing opioids) be capable treating OUD. Pharmacological advances have led to a wide array of safe and effective treatment options to address OUDs. This paper will discuss the history of opioid development, what is known about the transition from analgesic uses to addiction and modern evidenced based treatment strategies to address OUDs.

Medication-Assisted Treatment for Opioid-Use Disorder

The United States is in the midst of a national opioid epidemic. Physicians are encouraged both to prevent and treat opioid-use disorders (OUDs). Although there are 3 Food and Drug Administration-approved medications to treat OUD (methadone, buprenorphine, and naltrexone) and there is ample evidence of their efficacy, they are not used as often as they should. We provide a brief review of the 3 primary medications used in the treatment of OUD. Using data from available medical literature, we synthesize existing knowledge and provide a framework for how to determine the optimal approach for outpatient management of OUD with medication-assisted treatments.

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

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

Editors' Commentary for Special Issue: The 2017 CALDAR Summer Institute and International Conference Promoting Global Health-Precision Research in Substance Abuse, HIV, and Care

This special issue contains 11 papers, including 3 Invited Reviews, one Brief Report and 6 Original Articles, which highlight the work by selected presenters at the third meeting of the biennial Conference Series to Promote Global Health held on August 15-17, 2017 in Los Angeles University City, California, USA. The Conference Series is sponsored by the National Institute on Drug Abuse, of the U.S. National Institutes of Health. A major goal of the conference is to promote international collaboration that will improve practices in the US and other countries, which is greatly needed to keep the scientific, treatment and service communities around the world abreast of the latest research findings and methods in substance abuse, HIV, and related areas, and to lead future directions in research. The papers in this special issue highlight current reseach in the areas of substance use disorders and HIV-infection, and related treatments to these disorders, as well as advancing the research of precision medicine in substance abuse, HIV, and care. Future research directions and unanswered questions are emphasized in each of these articles. ᅟ Graphical Abstract.