Treatment outcome disparities for opioid users: Are there racial and ethnic differences in treatment completion across large US metropolitan areas?

Adapting a Behavioral Activation Intervention for Opioid Use Disorder and Methadone Treatment Retention for Peer Delivery in a Low-Resource Setting: A Case Series

While methadone treatment (MT) is effective in treating opioid use disorder (OUD), retention remains an issue nationwide, especially among low-income, minoritized populations. Peer recovery specialists (PRSs), individuals with lived substance use experience, are particularly well suited to support vulnerable populations, though often are not trained in delivering evidence-based interventions. Thus, our team developed a Type 1 hybrid effectiveness-implementation open-label pilot trial to evaluate the effectiveness of PRS-delivered BA (Peer Activate) in improving MT retention and establish feasibility, acceptability and PRS fidelity of the intervention. In this case series, we provide a more in-depth depiction of the adaption of Peer Activate and present three cases to illustrate how Peer Activate can be implemented among patients in routine MT care and adapted to meet the needs of varying clinical presentations. We include descriptive data on participant substance use and MT outcomes to supplement the narrative discussion. While varying participant presentations and needs presented challenges to the PRS interventionist, the PRS utilized his shared, lived substance use and recovery experiences and met participants where they were at, as well as successfully used BA techniques, ultimately leading to intervention success.

Exogenous Opioids and the Human Endocrine System: An Endocrine Society Scientific Statement

The use and misuse of opioids are a growing global problem. Although the effects of these drugs on the human endocrine system have been studied for decades, attention on their related clinical consequences, particularly on the hypothalamic-pituitary system and bone health, has intensified over recent years. This Statement appraises research data related to the impact of opioids on the gonadal and adrenal function. Whereas hypogonadism is well recognized as a side effect of opioids, the significance of their inhibitory actions on the hypothalamic-pituitary-adrenal system and the occurrence of clinically relevant adrenal insufficiency is not fully elucidated. The often-inconsistent results of studies investigating how opioids affect the secretion of GH, prolactin, arginine vasopressin, and oxytocin are assessed. The accumulating evidence of opioid actions on bone metabolism and their negative sequelae on bone mineral density and risk of fracture are also reviewed. In each section, available data on diagnostic and management approaches for opioid endocrine sequelae are described. This Statement highlights a plethora of gaps in research associated with the effects and clinical consequences of opioids on the endocrine system. It is anticipated that addressing these gaps will improve the care of people using or misusing opioids worldwide. The Statement is not intended to serve as a guideline or dictate treatment decisions.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative study

Question

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders, in "real world" settings.

Goal

To determine sex disparities in non-medical opioid use (NMOU) at the end of outpatient medication-assisted treatment (MAT), using nationally representative data.

Design

Observational epidemiological study of publicly funded outpatient MAT programs in the national "Treatment episode data set-discharges" (TEDS-D) for 2019.

Participants

Persons aged ≥18 in their first treatment episode, in outpatient MAT for use of heroin or other opioids (N=11,549). The binary outcome was presence/absence of NMOU.

Results

In univariate analyses, males had significantly higher odds of NMOU, compared to females (odds ratio=1.27; Chi2 [df:1]=39.08; uncorrected p<0.0001; p=0.0041 after Bonferroni correction). A multivariable logistic regression detected a male>female odds ratio of 1.19 (95%CI=1.09-1.29; p<0.0001), adjusting for socio-demographic/clinical variables. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., at ages 18-29 and 30-39; corrected p=0.012, or if they used opioids by inhalation; corrected p=0.0041).

Conclusions

This nationally representative study indicates that males have greater odds of NMOU in their first episode of MAT, indicating more unfavorable outcomes. The study reveals specific socio-demographic and clinical variables under which this sex disparity is most prominent.

Worsening trends in the frequency of methamphetamine and other stimulant use between treatment admission and discharge

BACKGROUND

Treatment for methamphetamine and other stimulants can be effective but treatment attrition and continued use are very high. Abstinence is the conventional outcome used to evaluate treatment success, but defining treatment success in this way misses opportunities to promote improved health even when abstinence is not achieved. Reducing methamphetamine and stimulant use without abstinence is associated with many positive outcomes. However, little is known about drug use patterns during treatment or trends in use over time.

METHODS

We used the Treatment Episode Dataset-Discharges (TEDS-D) to identify treatment episodes that had a stimulant drug indicated as the primary substance of use (2017-2021; N=251,841; methamphetamine, cocaine, other amphetamines, or other stimulants). Our outcome was the change in the frequency of drug use between admission and discharge (decreased use with abstinence, decreased use without abstinence, increased use). We used multiple logistic regression to model a change in drug use frequency, predicted by year, stimulant type, and their interaction.

RESULTS

Nearly two-thirds of the sample (60 %) had methamphetamine indicated as the primary stimulant of use. There was a decrease in the predicted rate of abstinence over time and worsening trends were strongest among those using methamphetamine. Daily and periodic drug use at both admission and discharge (no change in use) became worse over time, particularly for those using methamphetamine.

CONCLUSION

Treatment outcomes worsened over time and declined fastest among those reporting methamphetamine. Abstinence was rare and most treatment clients did not change their drug use behavior. We recommend a renewed focus on evidence-based harm reduction while the nation's treatment systems continue grappling with the stimulant crises.

Exploring predictors of substance use disorder treatment engagement with machine learning: The impact of social determinants of health in the therapeutic landscape

BACKGROUND

Improved knowledge of factors that influence treatment engagement could help treatment providers and systems better engage patients. The present study used machine learning to explore associations between individual- and neighborhood-level factors, and SUD treatment engagement.

METHODS

This was a secondary analysis of the Global Appraisal of Individual Needs (GAIN) dataset and United States Census Bureau data utilizing random forest machine learning and generalized linear mixed modelling. Our sample (N = 15,873) included all people entering SUD treatment at GAIN sites from 2006 to 2012. Predictors included an array of demographic, psychosocial, treatment-specific, and clinical measures, as well as environment-level measures for the neighborhood in which patients received treatment.

RESULTS

Greater odds of treatment engagement were predicted by adolescent age and psychiatric comorbidity, and at the neighborhood-level, by low unemployment and high population density. Lower odds of treatment engagement were predicted by Black/African American race, and at the neighborhood-level by high rate of public assistance and high income inequality. Regardless of the degree of treatment engagement, individuals receiving treatment in areas with high unemployment, alcohol sale outlet concentration, and poverty had greater substance use and related problems at baseline. Although these differences reduced with treatment and over time, disparities remained.

CONCLUSIONS

Neighborhood-level factors appear to play an important role in SUD treatment engagement. Regardless of whether individuals engage with treatment, greater loading on social determinants of health such as unemployment, alcohol sale outlet density, and poverty in the therapeutic landscape are associated with worse SUD treatment outcomes.

Lost in transition: A protocol for a retrospective, longitudinal cohort study for addressing challenges in opioid treatment for transition-age adults

BACKGROUND

In the United States, there has been a concerning rise in the prevalence of opioid use disorders (OUD) among transition-age (TA) adults, 18 to 25-years old, with a disproportionate impact on individuals and families covered by Medicaid. Of equal concern, the treatment system continues to underperform for many young people, emphasizing the need to address the treatment challenges faced by this vulnerable population at a pivotal juncture in their life course. Pharmacotherapy is the most effective treatment for OUD, yet notably, observational studies reveal gaps in the receipt of and retention in medications for opioid use disorder (MOUD), resulting in poor outcomes for many TA adults in treatment. Few current studies on OUD treatment quality explicitly consider the influence of individual, organizational, and contextual factors, especially for young people whose social roles and institutional ties remain in flux.

METHODS

We introduce a retrospective, longitudinal cohort design to study treatment quality practices and outcomes among approximately 65,000 TA adults entering treatment for OUD between 2012 and 2025 in New York. We propose to combine data from multiple sources, including Medicaid claims and encounter data and a state registry of substance use disorder (SUD) treatment episodes, to examine three aspects of OUD treatment quality: 1) MOUD use, including MOUD option (e.g., buprenorphine, methadone, or extended-release [XR] naltrexone); 2) adherence to pharmacotherapy and retention in treatment; and 3) adverse events (e.g., overdoses). Using rigorous analytical methods, we will provide insights into how variation in treatment practices and outcomes are structured more broadly by multilevel processes related to communities, treatment programs, and characteristics of the patient, as well as their complex interplay.

DISCUSSION

Our findings will inform clinical decision making by patients and providers as well as public health responses to the rising number of young adults seeking treatment for OUD amidst the opioid and polysubstance overdose crisis in the U.S.

Multiple marginalized identities: A qualitative exploration of intersectional perinatal experiences of birthing people of color with substance use disorder in Massachusetts

INTRODUCTION

Racial and ethnic inequities persist in receipt of prenatal care, mental health services, and addiction treatment for pregnant and postpartum individuals with substance use disorder (SUD). Further qualitative work is needed to understand the intersectionality of racial and ethnic discrimination, stigma related to substance use, and gender bias on perinatal SUD care from the perspectives of affected individuals.

METHODS

Peer interviewers conducted semi-structured qualitative interviews with recently pregnant people of color with SUD in Massachusetts to explore the impact of internalized, interpersonal, and structural racism on prenatal, birthing, and postpartum experiences. The study used a thematic analysis to generate the codebook and double coded transcripts, with an overall kappa coefficient of 0.89. Preliminary themes were triangulated with five participants to inform final theme development.

RESULTS

The study includes 23 participants of diverse racial/ethnic backgrounds: 39% mixed race/ethnicity (including 9% with Native American ancestry), 30% Hispanic or Latinx, 26% Black/African American, 4% Asian. While participants frequently names racial and ethnic discrimination, both interpersonal and structural, as barriers to care, some participants attributed poor experiences to other marginalized identities and experiences, such as having a SUD. Three unique themes emerged from the participants' experiences: 1) Participants of color faced increased scrutiny and mistrust from clinicians and treatment programs; 2) Greater self-advocacy was required from individuals of color to counteract stereotypes and stigma; 3) Experiences related to SUD history and pregnancy status intersected with racism and gender bias to create distinct forms of discrimination.

CONCLUSION

Pregnant and postpartum people of color affected by perinatal SUD faced pervasive mistrust and unequal standards of care from mostly white healthcare staff and treatment spaces, which negatively impacted their treatment access, addiction medication receipt, postpartum pain management, and ability to retain custody of their children. Key clinical interventions and policy changes identified by participants for antiracist action include personalizing anesthetic plans for adequate peripartum pain control, minimizing reproductive injustices in contraceptive counseling, and addressing misuse of toxicology testing to mitigate inequitable Child Protective Services (CPS) involvement and custody loss.

Reduction in substance use stigma following a peer-recovery specialist behavioral activation intervention

BACKGROUND

Patients' perceptions and experiences of stigma related to substance use and methadone treatment are barriers to successful treatment of opioid use disorder, particularly among low-income and medically underserved populations. Interventions led by peer recovery specialists (PRSs) may shift stigma-related barriers. This study sought to evaluate shifts in substance use and methadone treatment stigma in the context of an evidence-based behavioral intervention adapted for PRS delivery to support methadone treatment outcomes.

METHODS

We recruited patients who had recently started methadone treatment or demonstrated difficulty with adherence from a community-based program (N = 37) for an open-label pilot study of a 12-session behavioral activation intervention led by a PRS interventionist. Participants completed substance use and methadone treatment stigma assessments and the SIP-R, a brief measure of problems related to substance use, at baseline, mid-point (approximately six weeks), and post-treatment (approximately 12 weeks). Generalized estimating equations assessed change in total stigma scores between baseline and post-treatment as well as change in stigma scores associated with change in SIP-R responses.

RESULTS

There was a statistically significant decrease in substance use stigma (b(SE)=-0.0304 (0.0149); p = 0.042) from baseline to post-treatment, but not methadone treatment stigma (b(SE)=-0.00531 (0.0131); p = 0.68). Decreases in both substance use stigma (b(SE)=0.5564 (0.0842); p < 0.001) and methadone treatment stigma (b(SE)=0.3744 (0.1098); p < 0.001) were associated with a decrease in SIP-R scores.

CONCLUSIONS

PRS-led interventions have potential to shift substance use stigma, which may be associated with decrease in problems related to substance use, and therefore merit further testing in the context of randomized controlled trials.

How Does Telehealth Expansion Change Access to Healthcare for Patients With Different Types of Substance Use Disorders?

BACKGROUND

Patients with substance use disorders (SUDs) exhibit low healthcare utilization despite high medical need. Telehealth could boost utilization, but variation in uptake across SUDs is unknown.

METHODS

Using Wisconsin Medicaid enrollment and claims data from December 1, 2018, to December 31, 2020, we conducted a cohort study of telemedicine uptake in the all-ambulatory and the primary care setting during telehealth expansion following the COVID-19 public health emergency (PHE) onset (March 14, 2020). The sample included continuously enrolled (19 months), nonpregnant, nondisabled adults aged 19 to 64 years with opioid (OUD), alcohol (AUD), stimulant (StimUD), or cannabis (CannUD) use disorder or polysubstance use (PSU). Outcomes: total and telehealth visits in the week, and fraction of visits in the week completed by telehealth. Linear and fractional regression estimated changes in in-person and telemedicine utilization. We used regression coefficients to calculate the change in telemedicine utilization, the proportion of in-person decline offset by telemedicine uptake ("offset"), and the share of visits completed by telemedicine ("share").

RESULTS

The cohort (n = 16 756) included individuals with OUD (34.8%), AUD (30.1%), StimUD (9.5%), CannUD (9.5%), and PSU (19.7%). Total and telemedicine utilization varied by group post-PHE. All-ambulatory: total visits dropped for all, then rose above baseline for OUD, PSU, and AUD. Telehealth expansion was associated with visit increases: OUD: 0.489, P < .001; PSU: 0.341, P < .001; StimUD: 0.160, P < .001; AUD: 0.132, P < .001; CannUD: 0.115, P < .001. StimUD exhibited the greatest telemedicine share. Primary care: total visits dropped for all, then recovered for OUD and CannUD. Telemedicine visits rose most for PSU: 0.021, P < .001; OUD: 0.019, P < .001; CannUD: 0.011, P < .001; AUD: 0.010, P < .001; StimUD: 0.009, P < .001. PSU and OUD exhibited the greatest telemedicine share, while StimUD exhibited the lowest. Telemedicine fully offset declines for OUD only.

CONCLUSIONS

Telehealth expansion helped maintain utilization for OUD and PSU; StimUD and CannUD showed less responsiveness. Telehealth expansion could widen gaps in utilization by SUD type.

Exploring racial and secondary substance use differences in route of administration of opioid drugs: Analysis of the 2015-2019 treatment admission data

INTRODUCTION

The opioid crisis continues to evolve with increasing opioid-related overdose deaths among under-represented minorities. A better understanding of substance use differences in the route of administration for people using heroin and other opioids can lead to targeted strategies and interventions.

METHODS

Using the 2015-2019 Treatment Episode Data Set - Admissions (TEDS-A), a multinomial logistic regression model examined the relationship between race/ethnicity and secondary substance use with route of administration in a subset of 591,078 admissions.

RESULTS

For individuals reporting heroin as their primary substance, minoritized clients were both more likely to smoke (NH Blacks RR: 2.28, 95 % CI 2.16-2.41; Hispanic RR: 1.80, 95 % CI: 1.74, 1.87; Other RR: 2.09, 95 % CI: 2.00, 2.20) or inhale heroin (Hispanic RR: 1.82, 95 % CI 1.78-1.85; Other RR: 1.30, 95 % CI 1.25, 1.34) compared to non-Hispanic (NH) Whites. NH Black clients were nearly seven and a half times more likely to report inhaling (RR: 7.45, 95 % CI 7.28, 7.62) heroin over injecting it. Clients were more likely to smoke heroin compared to injection if they reported secondary drug use of methamphetamines (RR: 2.28, 95 % CI 2.21, 2.35) and other opioids (RR: 1.21, 95 % CI 1.15, 1.28). For clients reporting other opioids as their primary substance, Hispanic (RR: 1.33, 95 % CI 1.19, 1.47) and other racial/ethnic minority clients (RR: 2.50, 95 % CI 2.23, 2.79) were more likely to smoke opioids vs take it orally compared to their NH White counterparts. Individuals who reported methamphetamine use as a secondary substance were significantly more than three times as likely to smoke (RR: 3.07, 95 % CI 2.74, 3.45) or inject (RR: 3.36, 95 % CI 3.17, 3.57) compared to orally ingesting opioids, while those who reported cocaine or crack cocaine use were more than twice as likely to inject (RR: 2.22, 95 % CI 2.09-2.36) opioids than taking them orally.

CONCLUSION

Findings demonstrate significant racial and ethnic differences in the route of administration. This work expands on the understanding of the complex nature of polysubstance use in the evolving opioid crisis and the secondary substance use of clients on routes of administration of opioids and heroin, highlighting the need for tailored interventions to address the treatment needs of under-represented minorities.

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

CONTEXT

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A thematic analysis of stress, substance-cue, and neutral/relaxing events to inform approaches for improving treatment among Black adults who use substances

INTRODUCTION

To inform approaches for adapting substance use treatment for Black adults, the aim of this study was to thematically analyze the stressors, triggers for substance use, and neutral/relaxing events reported among Black adults who participated in a lab paradigm.

METHODS

The sample included 36 Black adults (mean age [years] = 37.47, SD = 7.30; 53 % male, 12 (33 %) with alcohol use disorder, 12 (33 %) with cocaine use disorder, and 12 (33 %) healthy controls). All participants provided detailed stimulus and response context information on the most stressful event they experienced in the past year, an event that involved substance use, and a neutral/relaxing event in a structured interview using a scene development questionnaire, and this information was utilized to generate a personalized imagery script for each event using standardized procedures. Thematic analyses identified the key themes reported within scripts.

RESULTS

Consistent with a prior thematic analysis on a majority White sample, we found the following themes for the stress scripts: Relational (Violation, Loss, Parenting, Betrayal, Isolation vs. support), Environmental (Housing, Legal), and Achievement (Employment, Role in household). However, our analyses also resulted in new stress themes: Relational (Violation-Racial Microaggressions) and Institutional (Time Wasted). The substance use scripts consisted of the following trigger themes: Social (Social Facilitation, Socially-Sanctioned Substance Use Event, Exposure to Substance Use Friends/Associates), Internal (Free Time, Boredom, Thoughts of Using Substance, Frustration, Reward), and Environment (Availability of Substance, Celebration, Party Environment, Food, Hot Day, Money/Payday). The neutral/relaxing scripts themes were: Outdoor Activities (Admiring Nature, People Watching, Observing Surroundings, Enjoying the Sun, Playing in the Sand, Walking), Quiet Activities (Silence/Quiet, Prayer, Reading), and Indoor Activities (Radio, Television, Bath/Shower, Bed/Chair, Observing from a Window). We found sex differences across scripts.

CONCLUSIONS

The results suggest that Black people experience unique stressors (e.g., institutional and racial stressors) that are important to consider when modifying treatment to improve outcomes among this group. In addition to stressors, this study also identified high-risk situations involving triggers for use. Taken together these findings suggest targets for the tailoring of coping strategies that could be incorporated for the development of culturally relevant behavioral treatment for SUD.

Receipt and duration of buprenorphine treatment during pregnancy and postpartum periods in a national privately-insured cohort

Background

Research gaps exist on the use of medications for opioid use disorder (OUD) among birthing people.

Methods

This retrospective cohort study included people who underwent childbirth deliveries during 2017-2020 and had a diagnosis of OUD identified from a national private insurance claims database. Buprenorphine prescriptions received during the year before childbirth and the year after childbirth were obtained from pharmacy claims. Logistic regressions were used to estimate associations between receipt of buprenorphine and individual and state-level factors.

Results

Among a sample of 1,523 birthing people diagnosed with OUD, 540 (35.5 %) received buprenorphine during the pregnancy or postpartum periods. About half (51.5 %) of new recipients of buprenorphine received treatment for at least six months and, of those, one-third experienced a treatment interruption. The buprenorphine receipt rate differed significantly by race and ethnicity: 28.8 % of non-Hispanic Black birthing people with OUD and 22.8 % of Hispanic birthing people with OUD received buprenorphine treatment in contrast to 37.7 % of non-Hispanic white birthing people (aOR 0.53 [95 % CI 0.35-0.81] and 0.59 [95 % CI 0.37-0.96], respectively). The buprenorphine use rate increased over time from 29.7 % in 2017 to 42.9 % in 2020. Birthing people living in states with punitive policies related to substance use in pregnancy had the lowest buprenorphine use rate of 22.7 % as compared to 43.0 % in states with least restrictive policies.

Conclusion

In this national sample of privately-insured individuals, by 2020, 42.9 % of birthing people with OUD received buprenorphine treatment. Treatment discontinuation and interruptions were common in the period surrounding childbirth.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Higher perceived stress during admission is associated with shorter retention in short-term residential substance use disorder treatment

Introduction

Over one million people in the U.S. received residential treatment for a substance use disorder (SUD) in 2020. Longer treatment retention is associated with better outcomes (e.g., reduced substance use). Entering treatment with higher stress may be associated with shorter retention. This paper examines the impact of perceived stress at admission on SUD treatment retention in short-term residential treatment.

Methods

A sample of 271 treatment episodes with admissions between October 2019 and February 2020 were collected from de-identified records of an urban mid-Atlantic adult 28-day short-term residential SUD treatment facility. Treatment completion involved finishing 28 days. Sociodemographic, substance use, perceived stress, and treatment discharge variables were analyzed. Bivariate analyses examined differences between treatment completion and early discharge, and Cox regression investigated the effect of perceived stress on treatment retention with covariates.

Results

The sample was primarily male (73.8%) and non-Hispanic Black (71.6%). A majority used heroin as their primary substance (54.6%) and reported polysubstance use (72.3%). About half (51.3%) completed treatment, and completed an average of 18.7 (SD = 10.7) days. Those who prematurely discharged from treatment stayed an average of 8.9 (SD = 7.0) days. The Cox regression model found that higher perceived stress (adjusted hazard ratio (AHR) = 1.028; 95% CI = [1.005, 1.053], p =.019) and a race/ethnicity other than non-Hispanic Black (AHR = 1.546, 95% CI = [1.037, 2.305], p =.033) predicted premature discharge.

Conclusions

Perceived stress at admission is associated with shorter treatment retention. Early stress management interventions may help increase treatment retention.

Inequities in the treatment of opioid use disorder: A scoping review

BACKGROUND

Given the lack of access to evidenced-based OUD treatment and the corresponding overdose crisis, researchers must evaluate and report health care inequities involving the treatment of OUD. Additionally, clinicians should be aware of these inequities in the treatment of patients.

METHODS

We carried out a scoping review of the literature regarding health inequities in treatment for OUD in July 2022. The study team retrieved articles published between 2016 and 2021 from MEDLINE and Ovid Embase. After authors received training, screening and data extraction were performed in masked, duplicate fashion. The team screened a total of 3673 titles and abstracts, followed by 172 articles for full-text review. The inequities that we examined were race/ethnicity, sex or gender, income, under-resourced/rural, occupational status, education level, and LGBTQ+. We used Stata 17.0 (StataCorp, LLC, College Station, TX) to summarize data and statistics of the studies within our sample.

RESULTS

A total of 44 studies evaluating inequities in OUD treatment met inclusion criteria. The most common inequity that studies examined was race/ethnicity (34/44 [77.27 %] studies), followed by under-resourced/rural (19/44 [43.18 %] studies), and sex or gender (18/44 [40.91 %] studies). LGBTQ+ (0/44 [0.0 %] studies) was not reported in the included studies. Our results indicate that many historically marginalized populations experience inequities related to access and outcomes in OUD treatment. The included studies in our scoping review occasionally demonstrated inconsistent findings.

CONCLUSIONS

Gaps exist within the literature on health inequities in treatment for OUD. The most examined inequities were race/ethnicity, under-resourced/rural and sex or gender, while studies did not examine LGBTQ+ status. Future research should aim to advance and supplement literature investigating health inequities in OUD treatment to ensure inclusive, patient-centered care.

Association of Medication-Assisted Therapy and Risk of Drug Overdose-Related Hospitalization or Emergency Room Visits in Patients With Opioid Use Disorder

Objective To examine the differential impacts of medication-assisted therapy (MAT) medications (naltrexone, methadone, and buprenorphine) on drug overdose-related hospitalizations or emergency room (ER) visits in patients with opioid use disorder (OUD). Patients and methods A retrospective cohort study was performed on patients 18 years or older diagnosed with OUD, using Optum's de-identified Clinformatics® Data Mart database. To ensure a new diagnosis of OUD from 2018 to 2019, each patient required one year of continuous enrollment before OUD diagnosis. The primary outcome was the incidence of drug overdose-related hospitalization or ER visits in the follow-up period. Patients were censored at loss of coverage or end of the study (9/30/2020). A multivariable Cox proportional hazard model was built to compare the outcomes across three MAT medications (buprenorphine, methadone, and naltrexone). Results Only 10.38% of the 145,317 OUD patients received MAT prescriptions in the 12 months after diagnosis. The majority of MAT users (77.8%) received buprenorphine. At one year of follow-up, the incidence of drug overdose-related hospitalization or ER visits varied by MAT drug type: naltrexone (14.26%), methadone (12.26%), and buprenorphine (10.23%). Compared to methadone drug users, buprenorphine users had a lower risk of negative outcomes (adjusted hazard ratio: 0.84; 95% confidence interval: 0.73-0.97). Conclusion Buprenorphine was associated with the lowest risk of drug overdose-related hospitalization or ER visits among the MAT drugs. However, only 10.38% of OUD patients received MAT. Increasing MAT availability to patients with OUD is a key step toward preventing relapse and reducing adverse health outcomes.

Exploring Gender and Ethnoracial Differences and Trends in Methamphetamine Treatment

Introduction

Given the significant rise in methamphetamine use and related mortality in the United States, it is critical to explore differences in treatment trends with particular attention to women and ethnoracial groups in hard-hit areas like Los Angeles County.

Methods

We analyzed a large sample across 4 waves: 2011 (105 programs, 10 895 clients), 2013 (104 programs, 17 865 clients), 2015 (96 programs, 16 584 clients), and 2017 (82 programs, 15 388 clients). We completed a comparative analysis to identify differences across subgroups and a trend analysis of treatment episodes by gender and ethnoracial group to differentiate users of methamphetamine and users of other drugs.

Results

Treatment clients using methamphetamine increased over time for each gender and race. There were also significant differences across age groups. Women comprised a greater proportion of treatment episodes involving methamphetamine use (43.3%) compared to all other drugs combined (33.6%). Latinas represented 45.5% of methadone-related admissions. Compared with other drug users, methamphetamine users had a lower successful treatment completion rate and were served by programs with less financial and culturally responsive capacity.

Conclusions

Findings highlight a sharp increase in treatment admissions for methamphetamine users of all gender and ethnocultural groups. Women, especially Latinas, saw the most significant increases, with a widening gender gap over time. All subgroups of methamphetamine users had a lower treatment completion rate compared with users of other drugs, and critical differences existed in the programs where they received services.

Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework

INTRODUCTION

Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder.

METHODS

This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes.

RESULTS

Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health.

CONCLUSIONS

Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

Racial/ethnic differences in medication for addiction treatment for opioid use disorders among pregnant women in treatment facilities supported by state funds

INTRODUCTION

Medication for addiction treatment (MAT) for opioid use disorder (OUD) in pregnant women is known to improve neonatal health outcomes. Despite the benefits of this evidence-based treatment for OUD, MAT has been underutilized during pregnancy among certain racial/ethnic groups of women in the United States. The purpose of this study was to examine racial/ethnic differences and factors that affect MAT administration among pregnant women with OUD seeking treatment at publicly funded facilities.

METHODS

We used data from the 2010-2019 Treatment Episode Data Set system. The analytic sample included 15,777 pregnant women with OUD. We built logistic regression models to examine associations between race/ethnicity and MAT and determine differences and similarities in factors that may influence the use of MAT across racial/ethnic groups of pregnant women with OUD.

RESULTS

Although in this sample only 31.6 % received MAT, an increasing trend of MAT receipt has been observed during 2010-2019. Approximately 44 % of the Hispanic pregnant women received MAT, and this was significantly higher than non-Hispanic Black (27.1 %) and White (31.3 %) women. Even after adjusting for potential confounders, the adjusted odds of receiving MAT during pregnancy were lower for Black (AOR = 0.57, 95 % CI 0.44, 0.75) and White (AOR = 0.75, 95 % CI 0.61, 0.91) women compared to Hispanic women. Not being in the labor force increased the odds of receiving MAT in Hispanic women relative to their employed counterparts while homelessness or dependent living decreased the odds of MAT for White women compared to those living independently. Regardless of their racial/ethnic background, pregnant women younger than 29 years old were less likely to receive MAT relative to older women; however, if they were arrested once prior to admission to treatment, they had significantly higher odds of receiving MAT than those with no arrests. Treatment of at least 7 months was associated with a higher likelihood of MAT across all racial/ethnic groups.

CONCLUSIONS

This study highlights the underutilization of MAT, particularly among pregnant Black and White women who seek treatment for OUD in publicly funded treatment facilities. A multi-dimensional approach to MAT intervention programs is needed to increase MAT for all pregnant women and reduce racial/ethnic inequities.

Treatment outcomes among pregnant women with cannabis use disorder

Cannabis use disorder (CUD) among pregnant women is on the rise in the United States. The American College of Obstetricians and Gynecologists have recommended against the use of cannabis during pregnancy and breastfeeding. However, limited research exists on CUD treatment in this vulnerable population. The purpose of this study was to examine factors that influence CUD treatment completion in pregnant women. Data from the 2010-2019 Treatment Episode Data Set-Discharges (TEDS-D) were used (n = 7,319 pregnant women who reported CUD and had no prior treatment history). Descriptive statistics, logistic regression, and classification tree analyses were conducted to assess treatment outcomes. Only 30.3% of the sample completed CUD treatment. Length of stay between 4 and 12 months was associated with a higher likelihood of CUD treatment completion. The odds of treatment completion were higher if the referral source was alcohol/drug use care provider (AOR = 1.60, 95% CI [1.01, 2.54]), other community referral (AOR = 1.65, 95% CI [1.38, 1.97]), and the court/criminal justice (AOR = 2.29, 95% CI [1.92, 2.72]) relative to being referred by individual/self. A relatively high proportion of CUD treatment completion (52%) was observed among pregnant women who had > 1 month of CUD treatment and were referred to the treatment program by the criminal justice system. For pregnant women, referrals from the justice system, community, and healthcare providers can increase the likelihood of successful CUD treatment outcomes. Developing targeted CUD treatments for pregnant populations is crucial due to increasing CUD rates, cannabis accessibility, and potency.

Patient experiences of COVID-19-induced changes to methadone treatment in a large community-based opioid treatment program in Baltimore

INTRODUCTION

Following the March 2020 federal declaration of a COVID-19 public health emergency, in line with recommendations for social distancing and decreased congregation, federal agencies issued sweeping regulation changes to facilitate access to medications for opioid use disorder (MOUD) treatment. These changes allowed patients new to treatment to receive multiple days of take-home medications (THM) and to use remote technology for treatment encounters-allowances that previously had been reserved exclusively for "stable" patients who met minimum adherence and time-in-treatment criteria. The impact of these changes on low-income, minoritized patients (frequently the largest recipients of opioid treatment program [OTP]-based addiction care), however, is not well characterized. We aimed to explore the experiences of patients who were enrolled in treatment prior to COVID-19 OTP regulation changes, with the goal of understanding patients' perceptions of the impact of these changes on treatment.

METHODS

This study included semistructured, qualitative interviews with 28 patients. We used a purposeful sampling method to recruit individuals who were active in treatment just before COVID-19-related policy changes went into effect, and who were still in treatment several months later. To ensure a diverse array of perspectives, we interviewed individuals who either had or had not experienced challenges with methadone medication adherence from 3/24/21 to 6/8/21, approximately 12-15 months following the onset of COVID-19. Interviews were transcribed and coded using thematic analysis.

RESULTS

Participants were majority male (57 %), Black/African American (57 %), with a mean age of 50.1 (SD = 9.3). Fifty percent received THM prior to COVID-19, which increased to 93 % during the pandemic. COVID-19 program changes had mixed effects on treatment and recovery experiences. Themes identified convenience, safety, and employment as reasons for preferring THM. Challenges included difficulty with managing/storing medications, experiencing isolation, and concern about relapse. Furthermore, some participants reported that telebehavioral health encounters felt less personal.

CONCLUSIONS

Policymakers should consider patients' perspectives to foster a more patient-centered approach to methadone dosing that is safe, flexible, and accommodating to a diverse array of patients' needs. Additionally, technical support should be provided to OTPs to ensure interpersonal connections are maintained in the patient-provider relationship beyond the pandemic.

An evaluation of the association between specific post-overdose care services in emergency departments and subsequent treatment engagement

Objective

The objective of this study was to estimate the association between receipt of specific post-overdose care services in the emergency department (ED) and subsequent engagement in treatment for opioid use disorder (OUD) after discharge.

Methods

This was a retrospective cohort study of Rhode Island residents treated at 1 of 4 EDs for opioid overdose who were not engaged in OUD treatment and were discharged home (May 2016-April 2021). Electronic health record data were used to identify ED services received, and state administrative data were used to define subsequent engagement in OUD treatment within 30 days. Multivariable conditional logistic regression was used to estimate the association between ED services received and subsequent treatment engagement.

Results

Overall, 1008 people not engaged in OUD treatment were treated at study EDs for opioid overdose and discharged home, of whom 146 (14%) subsequently engaged in OUD treatment within 30 days. Most patients were aged 25 to 44 years (59%) and non-Hispanic White (69%). Receipt of behavioral counseling in the ED (adjusted odds ratio [aOR] = 1.79, 95% confidence interval [CI] = 1.18-2.71) and initiation of buprenorphine treatment in/from the ED (aOR = 5.86, 95% CI = 2.70-12.71) were associated with treatment engagement. Receipt of a take-home naloxone kit or naloxone prescription and referral to treatment at discharge were not associated with treatment engagement. Overall, 49% of patients received behavioral counseling in the ED, and 3% initiated buprenorphine in/from the ED.

Conclusion

Strategies for increasing provision of behavioral counseling and initiation of buprenorphine in the ED may be useful for improving subsequent engagement in OUD treatment after discharge.

Contraception claims by medication for opioid use disorder prescription status among insured women with opioid use disorder, United States, 2018

OBJECTIVE(S)

To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid-insured women.

STUDY DESIGN

IBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the (1) crude prevalence, and (2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for ≥6 years. Claims data was used to define contraception use. Fisher exact test or χ² test with a P-value ≤ 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively.

RESULTS

Only 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06-1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method.

CONCLUSIONS

Among women with ≥ 6 years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care.

IMPLICATIONS

Only two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.

Clinical Trial Design Challenges and Opportunities for Emerging Treatments for Opioid Use Disorder: A Review

Importance

Novel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines.

Observations

Consensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications.

Conclusions and Relevance

Applying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.

Peer recovery specialist-delivered, behavioral activation intervention to improve retention in methadone treatment: Results from an open-label, Type 1 hybrid effectiveness-implementation pilot trial

BACKGROUND

Despite the efficacy of methadone to treat opioid use disorder (OUD), retention is an urgent priority, particularly among low-income, minoritized populations. Peer recovery specialists are well-positioned to engage vulnerable patients, particularly when trained in an evidence-based intervention to promote retention. This hybrid effectiveness-implementation pilot trial aimed to demonstrate the proof of concept of a peer recovery specialist-delivered behavioral activation and problem solving-based approach (Peer Activate) to improve methadone retention.

METHODS

Implementation outcomes included feasibility, acceptability, and fidelity. Feasibility and acceptability were defined by the percentage of participants who initiated the intervention (≥75%) and completed ≥75% of core sessions, respectively. Fidelity was assessed via independent rating of a randomly selected 20% of sessions. The primary effectiveness outcome was methadone retention at three-months post-intervention vs. a comparison cohort initiating methadone during the same time period. Secondary outcomes included methadone adherence, substance use frequency, and substance use-related problems.

RESULTS

Benchmarks for feasibility and acceptability were surpassed: 86.5% (32/37) initiated the intervention, and 81.3% of participants who initiated attended ≥75% of core sessions. The mean independent rater fidelity score was 87.9%, indicating high peer fidelity. For effectiveness outcomes, 88.6% of participants in Peer Activate were retained in methadone treatment at three-months post-intervention-28.9% higher than individuals initiating methadone treatment alone in the same time period [χ2(1) = 10.10, p = 0.001]. Among Peer Activate participants, urine-verified methadone adherence reached 97% at post-intervention, and there was a significant reduction in substance use frequency from 48% of past two-week days used at baseline to 31.9% at post-intervention [t(25) = 1.82, p = .041]. Among participants who completed the core Peer Activate sessions (n = 26), there was a significant reduction in substance use-related problems [t(21) = 1.84, p = 0.040].

CONCLUSION

Given the rapid scale-up of peer recovery specialist programs nationwide and the urgent need to promote methadone retention, these results, although preliminary, have important potential clinical significance. The next steps are to conduct a Type 1 hybrid effectiveness-implementation randomized trial with a larger sample size and longer-term follow-up to further establish the implementation and effectiveness of the Peer Activate approach.

The association between medication for opioid use disorder and employment outcomes in the U.S.: The relevance of race and ethnicity

•White admissions given MOUD were less likely to become unemployed at discharge.•Blacks and Hispanics given MOUD were more likely to remain unemployed at discharge.•Racial disparities associated with MOUD have notable implications for policy.

Demographic and geographic shifts in the preferred route of methamphetamine administration among treatment cases in the US, 2010-2019

BACKGROUND

Methamphetamine use disorder has increased rapidly in the past decade. Injecting is also increasing and has multifaceted implications for disease severity, overall health, and treatment outcomes, but less is known about where or among whom injecting has shifted the most. This national study assessed temporal changes in the preferred route of methamphetamine administration by race/ethnicity and within urban/rural geographies.

METHODS

We used the Treatment Episode Dataset-Discharges (2010-2019) to identify outpatient treatment cases who reported methamphetamine as their primary drug of choice at admission (N = 531,799; 2010 n = 33,744; 2019 n = 81,885). We created a combined variable indicating race/ethnicity and the rural/urban location of treatment, and used logistic regression to model the predicted probability of cases reporting injection, smoking, or snorting as their preferred route of administration. We included an interaction term to determine differences over time (race/ethnicity/rurality*year).

RESULTS

Across all years, smoking methamphetamine was the most common route of administration (66%), followed by injection (24%) and snorting (10%). Over time and among most sub-groups, the rates of injection increased while the rates of smoking decreased. Compared to 2010, the odds of injecting methamphetamine in 2019 were highest among Black cases in urban areas (aOR = 2.30, 95% CI = 1.76-3.00, p < 0.0001).

CONCLUSION

Increasing methamphetamine injection was most pronounced among Black treatment cases in more urban areas, which is in contrast to the longstanding narrative that methamphetamine is a White and rural drug. Methamphetamine prevention, treatment, and harm reduction should target populations with high injection prevalence and growing incidence.

"In their mind, they always felt less than": The role of peers in shifting stigma as a barrier to opioid use disorder treatment retention

INTRODUCTION

A substantial, national need exists for culturally acceptable, accessible opioid use disorder (OUD) treatment. Medication for opioid use disorder (MOUD) is regarded as effective in treating OUD; however, retention in MOUD programs remains low nationally. One known barrier to MOUD retention is stigma, particularly within ethno-racial minority communities. Peer recovery specialists (PRSs), individuals with shared experience in substance use and recovery, may be particularly well suited to support patients in MOUD treatment, and may have capacity to play a key role in decreasing stigma-related barriers to MOUD retention.

METHODS

This study used qualitative methods to solicit feedback on how patients receiving methadone treatment (MT) experience stigma (i.e., toward substance use [SU] and MT). Study staff also gathered information regarding how a PRS role may reduce stigma and improve retention in care, including barriers and facilitators to the PRS role shifting stigma. Study staff conducted semi-structured qualitative interviews and focus groups (N = 32) with staff and patients receiving MT at an opioid treatment program as well as PRSs in Baltimore.

RESULTS

Participants identified experiences of internalized, as well as enacted and anticipated, MT and SU stigma, and described these as barriers to treatment. Participants also identified opportunities for PRSs to shift stigma-related barriers for patients receiving MT through unique aspects of the PRS role, such as their shared lived experience.

CONCLUSIONS

Reducing stigma surrounding SUD and MT is critical for improving MOUD outcomes, and future research may consider how the PRS role can support this effort.

Treatment outcomes associated with medications for opioid use disorder (MOUD) among criminal justice-referred admissions to residential treatment in the U.S., 2015-2018

AIMS

To examine the use and association of medications for opioid use disorder (MOUD) with treatment completion and retention for criminal justice referred (CJR) admissions to residential treatment.

METHODS

A retrospective analysis of the Treatment Episode Dataset-Discharge (TEDS-D; 2015-2018) for adults (N = 205,348) admitted to short-term (ST) (< 30 days) or long-term (LT) (>30 days) residential treatment for OUD. Outcomes were MOUD in treatment plans, and treatment completion and retention (ST >10 days; LT > 90 days). Logistic regression analyses were conducted separately for ST and LT settings.

RESULTS

CJR admissions were less likely to have MOUD than non-CJR admissions (ST, 11% vs. 21%; LT, 10% vs. 24%, respectively) and were more likely to complete and be retained in treatment. In ST settings, MOUD was associated with higher likelihood of treatment completion and retention. In LT settings, MOUD was associated with higher likelihood of treatment retention and lower likelihood of treatment completion. These associations tended to be slightly weaker for CJR admissions, with the exception of treatment completion in LT settings, but the moderating effect size of CJR status in all models was very small. Small differences in the moderating effect of CJR status by race and ethnicity were observed in LT settings.

CONCLUSIONS

MOUD is greatly under-utilized for CJR patients, and given that MOUD was associated with positive outcomes, there is a critical need to find ways to increase access to MOUD for CJR patients in residential treatment. Race and ethnicity appear to have relatively little impact on outcomes.

Technology-Based Interventions in Substance Use Treatment to Promote Health Equity Among People Who Identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native: Protocol for a Scoping Review

BACKGROUND

Technology-based interventions (TBIs; ie, web-based and mobile interventions) have the potential to promote health equity in substance use treatment (SUTx) for underrepresented groups (people who identify as African American/Black, Hispanic/Latinx, and American Indian/Alaskan Native) by removing barriers and increasing access to culturally relevant effective treatments. However, technologies (emergent and more long-standing) may have unintended consequences that could perpetuate health care disparities among people who identify as a member of one of the underrepresented groups. Health care research, and SUTx research specifically, is infrequently conducted with people who identify with these groups as the main focus. Therefore, an improved understanding of the literature at the intersection of SUTx, TBIs, and underrepresented groups is warranted to avoid exacerbating inequities and to promote health equity.

OBJECTIVE

This study aims to explore peer-reviewed literature (January 2000-March 2021) that includes people who identify as a member of one of the underrepresented groups in SUTx research using TBIs. We further seek to explore whether this subset of research is race/ethnicity conscious (does the research consider members of underrepresented groups beyond their inclusion as study participants in the introduction, methods, results, or discussion).

METHODS

Five electronic databases (MEDLINE, Scopus, Cochrane Library, CINAHL, and PsycInfo) were searched to identify SUTx research using TBIs, and studies were screened for eligibility at the title/abstract and full-text levels. Studies were included if their sample comprised of people who identify as a member of one of the underrepresented groups at 50% or more when combined.

RESULTS

Title/abstract and full-text reviews were completed in 2021. These efforts netted a sample of 185 studies that appear to meet inclusionary criteria. Due to the uniqueness of tobacco relative to other substances in the SUTx space, as well as the large number of studies netted, we plan to separately publish a scoping review on tobacco-focused studies that meet all other criteria. Filtering for tobacco-focused studies (n=31) netted a final full-text sample for a main scoping review of 154 studies. The tobacco-focused scoping review manuscript is expected to be submitted for peer review in Spring 2022. The main scoping review data extraction and data validation to confirm the accuracy and consistency of data extraction across records was completed in March 2022. We expect to publish the main scoping review findings by the end of 2022.

CONCLUSIONS

Research is needed to increase our understanding of the range and nature of TBIs being used in SUTx research studies with members of underrepresented groups. The planned scoping review will highlight research at this intersection to promote health equity.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/34508.

Disparities in expected driving time to opioid treatment and treatment completion: findings from an exploratory study

BACKGROUND

Commuting time to treatment has been shown to affect healthcare outcomes such as engagement and initiation. The purpose of this study is to extend this line of research to investigate the effects of driving time to opioid programs on treatment outcomes.

METHODS

We analyzed discharge survey data from 22,587 outpatient opioid use disorder treatment episodes (mainly methadone) in Los Angeles County and estimated the associated driving time to each episode using Google Maps. We used multivariable logistic regressions to examine the association between estimated driving time and odds of treatment completion after adjusting for possible confounders.

RESULTS

Findings show an average driving time of 11.32 min and an average distance of 11.18 km. We observed differences in estimated driving time across age, gender, and socioeconomic status. Young, male, less formally educated, and Medi-Cal-ineligible clients drove longer to treatment. A 10-min drive was associated with a 33% reduction in the completion of methadone treatment plans (p < .01).

CONCLUSION

This systemwide analysis provides novel time estimates of driving-based experiences and a strong relationship with completion rates in methadone treatment. Specifically, the result showing reduced treatment completion rates for drive times longer than 10 min may inform policies regarding the ideal geographic placement of methadone-based treatment programs and service expansion initiatives.

Characterizing the social support and functioning of a low-threshold medication for opioid use disorder treatment cohort at intake

BACKGROUND

Despite the growing morbidity and mortality rates associated with opioid use disorder, a large gap still exists between treatment need and capacity. Low-threshold clinics utilizing medication for opioid use disorder (MOUD) treatment can increase treatment access but are understudied, and little is known about how patient demographic characteristics are associated with their social support and functioning in these settings.

METHODS

We used multivariate regression to estimate associations between demographic characteristics and self-reported social support or functioning indicators among patients receiving MOUD in a low-threshold clinic using several validated instruments administered at intake: Behavior and Symptom Identification Scale, Brief Pain Inventory, and Life Events Checklist for DSM-5. Patients initiating MOUD treatment between April 1 and December 31, 2017, with complete surveys were included (N=582).

RESULTS

Patients were primarily male (62%), aged 34 or older (53%), non-Hispanic White (79%), separated or not married (86%), and unemployed (64%). Over 20% did not live in a house or apartment in the past month. Women were more likely to "get along" with people outside their family or in social situations and to identify their partner as their source of support. Women, non-White, and older patients were at higher risk of social functioning-disrupting events (physical/sexual assaults or experiencing chronic pain), while employment and housing were protective against exposure to these trauma-related events. However, employment and housing also decreased the odds of talking with others about substance use. The aforementioned results were obtained from multivariate logistic regression models and were significant to p<0.05.

CONCLUSIONS

Variation in support and functioning by demographic characteristics suggests that treatment facilities may benefit from adopting strategies that take baseline disparities in support and functioning into account.

Opioid Use Disorder Diagnosis and Management

Opioid Use Disorder Diagnosis and ManagementThe last 20 years have seen a staggering increase in opioid-related morbidity and mortality. Although the consequences of untreated OUDs are significant, OUD is a treatable illness. This article reviews the epidemiology of OUD and its complications, screening, diagnosis, treatment, and harm reduction interventions.

Individual and Health Policy Factors Associated With Positive Heroin and Opioid Treatment Response: United States, 2018

Objectives. To identify client- and state-level factors associated with positive treatment response among heroin and opioid treatment episodes in the United States. Methods. We used national data from 46 states using the Treatment Episode Dataset‒Discharges (2018) to identify heroin and opioid treatment episodes (n = 162 846). We defined positive treatment response as a decrease in use between admission and discharge. We used multivariable regression, stratified by race/ethnicity, to identify demographic, pain-related, and state-level factors associated with positive treatment response. Results. Lower community distress was the strongest predictor of better treatment outcomes across all racial/ethnic groups, particularly among White and American Indian/Alaska Native episodes. A primary opioid of heroin was associated with worse outcomes among White and Hispanic episodes. Legislation limiting opioid dispensing was associated with better outcomes among Hispanic episodes. Buprenorphine availability was strongly associated with better outcomes among Black episodes. Conclusions. State-level variables, particularly community distress, had greater associations with positive treatment outcomes than client-level variables. Public Health Implications. Changes in state-level policies and increased resources directed toward areas of high community distress have the potential to improve opioid use disorder treatment and reduce racial/ethnic disparities in treatment outcomes. (Am J Public Health. 2022;112(S1):S66-S76. https://doi.org/10.2105/AJPH.2021.306503).

Barriers to retention in substance use treatment: Validation of a new, theory-based scale

PURPOSE

Few studies and no theory-based scales have addressed specific barriers to substance use disorder (SUD) treatment retention. The current study, building on the Theory of Planned Behavior (TPB), sought to (a) identify those barriers that are most strongly associated with treatment retention, and most common, and (b) develop and validate a new scale of retention barriers, focusing on TPB attitude and perceived control components.

METHODS

The study administered surveys to 200 participants initiating SUD treatment at a public, outpatient program in Northern California; the analytic sample (N = 156) included only those not strongly coerced into treatment. Surveys included TPB-based measures of treatment barriers; other motivational readiness measures; treatment coercion and social desirability measures; and clinical severity variables and demographics. Discharge status was collected from program records.

RESULTS

Item and scale analyses identified three dimensions of attitudinal barriers (i.e., Low Perceived Treatment Need/Value, Social Concerns, and Concerns about Missing Substances) and two dimensions of perceived control barriers (i.e., Personal Limitations and Basic Logistic Barriers). Results informed creation of a 19-item Barriers to Retention Scale (BRS) with 5 subscales and very good internal reliability (alpha = 0.88). While all subscale scores were correlated with treatment completion, only Concerns about Missing Substances and total BRS scores predicted treatment completion in multivariate analyses.

CONCLUSIONS

The present study identified core dimensions of treatment retention barriers and developed a new scale predictive of treatment completion and potentially useful as a screener and in future research. Results suggest that interventions to improve retention should focus strongly on concerns about the negative impacts of abstaining from alcohol and drugs on craving and quality of life.

Connecting and disconnecting: Experiences of people with opioid use disorder in intensive outpatient treatment

INTRODUCTION

Opioid use disorder (OUD) is a public health crisis affecting 2 million Americans. Approximately 80% of people with OUD do not receive treatment, and attrition rates in treatment programs are as high as 80%. Previous research has shown intensive outpatient treatment (IOT) has positive outcomes, but enrollment and retention in programs are problematic. To improve outcomes and increase engagement, more information is needed about how persons experience IOT programs. The purpose of this study is to describe processes that people with OUD undergo as they participate in IOT programs.

METHODS

The research team conducted a constructivist grounded theory study in IOT programs at two adult academic health centers within a large Midwest health care system. Study staff conducted interviews with 14 persons to elicit narratives about their experiences in the IOT programs. The team transcribed and analyzed interviews using a four-step process consistent with grounded theory methods.

RESULTS

Participants described the process of connecting and disconnecting as central to their IOT experience. The process included eight stages: (1) connecting with drugs, (2) disconnecting from everyday life, (3) connecting with the IOT program, (4) connecting with others in the IOT program, (5) disconnecting from drugs, (6) reconnecting with others, (7) reconnecting with self, and (8) disconnecting from the IOT program.

CONCLUSIONS

Connections with the IOT program, other patients, and IOT staff are central to beginning sobriety. Findings indicate that clinicians should foster connections and provide a multi-dimensional experience that enables patients to begin recovery.

Impact of Medicaid expansion and methadone coverage as a medication for opioid use disorder on foster care entries during the opioid crisis

Between 2012 and 2018, incidents of opioid-involved injuries surged and the number of children in foster care due to parental drug use disorder increased. Treatments for opioid use disorder (OUD) might prevent or reduce the amount of time that children spend in the child welfare system. Using administrative data, we examined the impact of Medicaid expansion and state support for methadone as a medication for opioid use disorder (MOUD) on first-time foster care placements. Results show that first-time foster care entries due to parental drug use disorder experienced a reduction of 28 per 100,000 children in Medicaid expansion states with methadone MOUD covered by their state Medicaid programs. The largest reduction was found among non-Hispanic Black children and the youngest children (age 0-1 years). Policies that increase OUD treatment access may reduce foster care placements by reducing parents' drug use, a risk factor for child abuse/neglect and subsequent home removal.

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.

Treatment Outcomes Among Black Adults Receiving Medication for Opioid Use Disorder

Largely due to structural racism, Black people with substance use disorder have worse outcomes than their White counterparts. The opioid epidemic has amplified these racial disparities. Little is known about strengths that buffer against the systemic issues that disproportionately impact Black adults with opioid use disorder (OUD), particularly those receiving buprenorphine for OUD. The objectives of this study are to (1) assess psychosocial and clinical predictors of OUD outcomes and (2) explore differences in OUD outcomes by gender among a sample of Black adults receiving buprenorphine. This is a secondary data analysis of a cross-sectional survey and medical record review with a convenience sample recruited from an addiction medicine clinic. Analyses included Black participants who provided at least one urine drug test during the study period (n = 98). Prospective 6-month OUD outcomes (treatment retention, substance use recurrence, and buprenorphine continuation) were abstracted from the medical record. Univariate analyses explored differences by gender. Multivariate regressions assessed predictors of OUD outcomes. Participants were 53% women and middle-aged (47 ± 12 years). The majority (59%) had been in treatment for at least 1 year at study enrollment. Substance use recurrence was common, but many individuals remained in treatment. OUD outcomes did not differ by gender. Older age and absence of injection opioid use history were significant predictors of treatment retention and buprenorphine continuation. When provided access to high-quality treatment, Black adults with OUD demonstrate positive outcomes. Addressing structural racism and developing culturally informed treatment interventions are necessary to improve access to high-quality care for this community.

Gender disparities in opioid treatment progress in methadone versus counseling

BACKGROUND

In the United States, the high dropout rate (75%) in opioid use disorder (OUD) treatment among women and racial/ethnic minorities calls for understanding factors that contribute to making progress in treatment. Whereas counseling and medication for OUD (MOUD, e.g. methadone, buprenorphine, naltrexone) is considered the gold standard of care in substance use disorder (SUD) treatment, many individuals with OUD receive either counseling or methadone-only services. This study evaluates gender disparities in treatment plan progress in methadone- compared to counseling-based programs in one of the largest SUD treatment systems in the United States.

METHODS

Multi-year and multi-level (treatment program and client-level) data were analyzed using the Integrated Substance Abuse Treatment to Eliminate Disparities (iSATed) dataset collected in Los Angeles County, California. The sample consisted of 4 waves: 2011 (66 SUD programs, 1035 clients), 2013 (77 SUD programs, 3686 clients), 2015 (75 SUD programs, 4626 clients), and 2017 (69 SUD programs, 4106 clients). We conducted two multi-level negative binomial regressions, one per each outcome (1) making progress towards completing treatment plan, and (2) completing treatment plan. We included outpatient clients discharged on each of the years of the study (over 95% of all clients) and accounted for demographics, wave, homelessness and prior treatment episodes, as well as clients clustered within programs.

RESULTS

We detected gender differences in two treatment outcomes (progress and completion) considering two outpatient program service types (MOUD-methadone vs. counseling). Clients who received methadone vs. counseling had lower odds of completing their treatment plan (OR = 0.366; 95% CI = 0.163, 0.821). Female clients receiving methadone had lower odds of both making progress (OR = 0.668; 95% CI = 0.481, 0.929) and completing their treatment plan (OR = 0.666; 95% CI = 0.485, 0.916) compared to male clients and receiving counseling. Latina clients had lower odds of completing their treatment plan (OR = 0.617; 95% CI = 0.408, 0.934) compared with non-Latina clients.

CONCLUSIONS

Clients receiving methadone, the most common and highly effective MOUD in reducing opioid use, were less likely to make progress towards or complete their treatment plan than those receiving counseling. Women, and in particular those identified as Latinas, were least likely to benefit from methadone-based programs. These findings have implications for health policy and program design that consider the need for comprehensive and culturally responsive services in methadone-based programs to improve outpatient treatment outcomes among women.

An Evaluation of Opioid Use in Black Communities: A Rapid Review of the Literature

BACKGROUND

There are multiple aspects of the opioid crisis among Black people, who have been left out of the broader conversation. Despite evidence of increased opioid overdose deaths, less is known about opioid use among Black people. This review synthesizes research on Black people who use opioids; the goals are to advance knowledge, highlight research gaps, and inform clinical practice.

METHODS

This rapid review investigating opioid use among Black people utilized systematic review methods and was conducted according to a predefined protocol with clear inclusion criteria (PROSPERO ID: 177071). A comprehensive search strategy was used, including published and gray-literature sources (i.e., literature that has not been formally published). A narrative summary of the results is presented.

RESULTS

A total of 76 works were selected for inclusion and full text review. Sex, age, geographic location, and involvement in the carceral system were associated with the use of opioids among Black individuals. Non-epidemiologic factors included treatment-seeking patterns, disparate clinician prescribing, and social determinants.

CONCLUSIONS

Through this rapid review we suggest three main areas of focus: (1) including culturally informed collection methods in epidemiologic surveys to accurately reflect prevalences, (2) funding research that specifically addresses the importance of culture in accessing treatment, and (3) directly studying how social determinants can improve or exacerbate health outcomes. Focusing on the unique needs of Black people who use opioids is warranted to increase treatment initiation and adherence among a population less likely to engage with the traditional health care system.

Collaborative care in the treatment of opioid use disorder and mental health conditions in primary care: A clinical study protocol

BACKGROUND

People with opioid use disorder (OUD) often have a co-occurring psychiatric disorder, which elevates the risk of morbidity and mortality. Promising evidence supports the use of collaborative care for treating people with OUD in primary care. Whether collaborative care interventions that treat both OUD and psychiatric disorders will result in better outcomes is presently unknown.

METHODS

The Whole Health Study is a 3-arm randomized controlled trial designed to test collaborative care treatment for OUD and the psychiatric disorders that commonly accompany OUD. Approximately 1200 primary care patients aged ≥18 years with OUD and depression, anxiety, or PTSD will be randomized to one of three conditions: (1) Augmented Usual Care, which consists of a primary care physician (PCP) waivered to prescribe buprenorphine and an addiction psychiatrist to consult on medication-assisted treatment; (2) Collaborative Care, which consists of a waivered PCP, a mental health care manager trained in psychosocial treatments for OUD and psychiatric disorders, and an addiction psychiatrist who provides consultation for OUD and mental health; or (3) Collaborative Care Plus, which consists of all the elements of the Collaborative Care arm plus a Certified Recovery Specialist to help with treatment engagement and retention. Primary outcomes are six-month rates of opioid use and six-month rates of remission of co-occurring psychiatric disorders.

DISCUSSION

The Whole Health Study will investigate whether collaborative care models that address OUD and co-occurring depression, anxiety, or PTSD will result in better patient outcomes. The results will inform clinical care delivery during the current opioid crisis.

CLINICAL TRIALS REGISTRATION

www.clinicaltrials.gov registration: NCT04245423.

Treatment Retention in Opioid Dependent Clients Receiving Medication-Assisted Treatment: Six-Month Rate and Baseline Correlates

In the current opioid overdose epidemic, treatment retention among clients receiving medication-assisted treatment (MAT) for opioid dependence is a significant and growing concern among treatment providers, policymakers, and researchers. Methods: We examined a sample of clients enrolled in a federally funded MAT expansion program implemented in four sites in Connecticut. Program participants received MAT for their opioid use disorders (OUDs). All program sites utilized a person in recovery from OUD (a recovery support coach, RSC) as part of the treatment team. By performing bivariate analyses and multivariate logistic regression models, we evaluated the association of 6-month retention and program site, gender, age, race/ethnicity, and past month substance use. Results: At 6-month follow-up, 58.9% of participants were classified as "retained." Multivariate logistic regression analysis revealed that participants who were older, reported no past month cocaine/crack use, or reported any illegal drug use other than cocaine/crack, were significantly more likely to be retained in treatment at follow-up. Conclusions: Retention rates were relatively high in these Connecticut sites compared to those examined in previous literature. Findings suggest that efforts for enhancing retention and successful treatment outcomes need to consider and potentially address the unique needs, problems, and risks of younger clients and clients with crack/cocaine involvement. The importance of drug use screening for those entering MAT is underscored. Future research needs to explore how levels of client involvement in adjunctive therapies may impact their retention.

Racial and Ethnic Disparities in Maternal and Infant Outcomes Among Opioid-Exposed Mother-Infant Dyads in Massachusetts (2017-2019)

Objectives. To examine the extent to which differences in medication for opioid use disorder (MOUD) in pregnancy and infant neonatal opioid withdrawal syndrome (NOWS) outcomes are associated with maternal race/ethnicity.Methods. We performed a secondary analysis of a statewide quality improvement database of opioid-exposed deliveries from January 2017 to April 2019 from 24 hospitals in Massachusetts. We used multivariable mixed-effects logistic regression to model the association between maternal race/ethnicity (non-Hispanic White, non-Hispanic Black, or Hispanic) and prenatal receipt of MOUD, NOWS severity, early intervention referral, and biological parental custody at discharge.Results. Among 1710 deliveries to women with opioid use disorder, 89.3% (n = 1527) were non-Hispanic White. In adjusted models, non-Hispanic Black women (AOR = 0.34; 95% confidence interval [CI] = 0.18, 0.66) and Hispanic women (AOR = 0.43; 95% CI = 0.27, 0.68) were less likely to receive MOUD during pregnancy compared with non-Hispanic White women. We found no statistically significant associations between maternal race/ethnicity and infant outcomes.Conclusions. We identified significant racial/ethnic differences in MOUD prenatal receipt that persisted in adjusted models. Research should focus on the perspectives and treatment experiences of non-Hispanic Black and Hispanic women to ensure equitable care for all mother-infant dyads.

Opioid-related overdose deaths among African Americans: Implications for research, practice and policy

Opioid-related overdose deaths among African Americans have only recently received national attention despite evidence of increase in death rates among this population spanning the past decade. Numerous authors have highlighted how the 'opioid epidemic' has largely been portrayed as a problem mostly affecting White America. The purpose of this commentary is to provide a synthesis spotlighting the unique structural and cultural considerations involved in research, practice and policy related to opioid use and treatment for opioid use disorders among African Americans. The commentary concludes with considerations for future research and practice intended to reduce deaths among this group.