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Carroll JJ, Dasgupta N, Ostrach B, El-Sabawi T, Dixon S, Morrissey B, Saucier R. Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 167:209474. [PMID: 39179208 DOI: 10.1016/j.josat.2024.209474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 07/11/2024] [Accepted: 07/29/2024] [Indexed: 08/26/2024]
Abstract
INTRODUCTION Opioid agonist treatment (OAT) is the only treatment for opioid use disorder (OUD) proven to reduce overdose mortality, yet access to this evidence-based treatment remains poor. The purpose of this cross-sectional audit study was to assess OAT availability at residential substance use services in North Carolina. METHODS We conducted a state-wide inventory of residential substance use service providers in North Carolina and subsequently called all providers identified, posing as uninsured persons who use heroin, seeking treatment services. Program characteristics, as reported in phone calls, were systematically recorded. We used Fisher's exact tests to assess what program characteristics were associated with OAT availability and with staff making discouraging comments about OAT. We used unsupervised agglomerative clustering to identify facilities with similar characteristics. RESULTS Of the 94 treatment providers identified, we successfully contacted and collected data from 66. Of those, only 7 (10.6 %) provide OAT on site; an additional 9 (13.6 %) allow OAT through an outside or community-based prescriber. Only 8 (12.1 %) providers were licensed to provide residential substance use treatment. Staff from 33 (50.0 %) providers made negative, discouraging, or stigmatizing remarks about OAT-for example, that OAT substitutes one addiction for another or does not constitute "true recovery." OAT availability was positively associated with a provider holding a state license for any substance use-related service (41.9 % vs 8.6 %, p = 0.002) and offering 12-step programming (36.1 % vs. 10/0 %, p = 0.020). OAT availability was negatively associated with faith-based programming (6.1 % vs 42.4 %, p = 0.001), dress codes (5.3 % vs 50.0 %, p < 0.001), and mandates that residents work in a provider-owned and -operated commercial enterprise (5.0 % vs 32.6 %, p = 0.026). Cluster analysis revealed that the most common (n = 21) type of service provider in North Carolina is an unlicensed, faith-based organization that prohibits OAT, imposes a dress code, and mandates that residents work, often in provider-owned and -operated commercial enterprises. CONCLUSION Evidence-based treatments for OUD are largely unavailable at providers of residential substance use services in North Carolina. The prohibition of OAT occurs most often among providers who are unlicensed and impose labor and/or 12-step mandates on residents. Changes to state licensure requirements and exemptions may help improve OAT availability.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, North Carolina State University, United States of America.
| | - Nabarun Dasgupta
- Injury Prevention Research Center, University of North Carolina Chapel Hill, United States of America
| | - Bayla Ostrach
- Medical Anthropology, Department of Family Medicine, Boston University, United States of America; Fruit of Labor Action Research and Technical Assistance, LLC, United States of America
| | - Taleed El-Sabawi
- Florida International University School of Law, United States of America
| | - Sarah Dixon
- Department of Sociology and Anthropology, North Carolina State University, United States of America
| | - Brandon Morrissey
- Department of Sociology and Anthropology, North Carolina State University, United States of America
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D'Onofrio G, Herring AA, Perrone J, Hawk K, Samuels EA, Cowan E, Anderson E, McCormack R, Huntley K, Owens P, Martel S, Schactman M, Lofwall MR, Walsh SL, Dziura J, Fiellin DA. Extended-Release 7-Day Injectable Buprenorphine for Patients With Minimal to Mild Opioid Withdrawal. JAMA Netw Open 2024; 7:e2420702. [PMID: 38976265 PMCID: PMC11231806 DOI: 10.1001/jamanetworkopen.2024.20702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 05/05/2024] [Indexed: 07/09/2024] Open
Abstract
Importance Buprenorphine is an effective yet underused treatment for opioid use disorder (OUD). Objective To evaluate the feasibility (acceptability, tolerability, and safety) of 7-day injectable extended-release buprenorphine in patients with minimal to mild opioid withdrawal. Design, Setting, and Participants This nonrandomized trial comprising 4 emergency departments in the Northeast, mid-Atlantic, and Pacific geographic areas of the US included adults aged 18 years or older with moderate to severe OUD and Clinical Opiate Withdrawal Scale (COWS) scores less than 8 (minimal to mild), in which scores range from 0 to 7, with higher scores indicating increasing withdrawal. Exclusion criteria included methadone-positive urine, pregnancy, overdose, or required admission. Outcomes were assessed at baseline, daily for 7 days by telephone surveys, and in person at 7 days. Patient recruitment occurred between July 13, 2020, and May 25, 2023. Intervention Injection of a 24-mg dose of a weekly extended-release formulation of buprenorphine (CAM2038) and referral for ongoing OUD care. Main Outcomes and Measures Primary feasibility outcomes included the number of patients who (1) experienced a 5-point or greater increase in the COWS score or (2) transitioned to moderate or greater withdrawal (COWS score ≥13) within 4 hours of extended-release buprenorphine or (3) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. Secondary outcomes included injection pain, satisfaction, craving, use of nonprescribed opioids, adverse events, and engagement in OUD treatment. Results A total of 100 adult patients were enrolled (mean [SD] age, 36.5 [8.7] years; 72% male). Among the patients, 10 (10.0% [95% CI, 4.9%-17.6%]) experienced a 5-point or greater increase in COWS and 7 (7.0% [95% CI, 2.9%-13.9%]) transitioned to moderate or greater withdrawal within 4 hours, and 2 (2.0% [95% CI, 0.2%-7.0%]) experienced precipitated withdrawal within 1 hour of extended-release buprenorphine. A total of 7 patients (7.0% [95% CI, 2.9%-13.9%]) experienced precipitated withdrawal within 4 hours of extended-release buprenorphine, which included 2 of 63 (3.2%) with a COWS score of 4 to 7 and 5 of 37 (13.5%) with a COWS score of 0 to 3. Site pain scores (based on a total pain score of 10, in which 0 indicated no pain and 10 was the worst possible pain) after injection were low immediately (median, 2.0; range, 0-10.0) and after 4 hours (median, 0; range, 0-10.0). On any given day among those who responded, between 29 (33%) and 31 (43%) patients reported no cravings and between 59 (78%) and 75 (85%) reported no use of opioids; 57 patients (60%) reported no days of opioid use. Improving privacy (62%) and not requiring daily medication (67%) were deemed extremely important. Seventy-three patients (73%) were engaged in OUD treatment on day 7. Five serious adverse events occurred that required hospitalization, of which 2 were associated with medication. Conclusions and Relevance This nonrandomized trial of the feasibility of a 7-day buprenorphine injectable in patients with minimal to mild opioid withdrawal (COWS scores, 0-7) found the formulation to be acceptable, well tolerated, and safe in those with COWS scores of 4 to 7. This new medication formulation could substantially increase the number of patients with OUD receiving buprenorphine. Trial Registration ClinicalTrials.gov Identifier: NCT04225598.
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Affiliation(s)
- Gail D'Onofrio
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - Andrew A Herring
- Department of Emergency Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Addiction Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Emergency Medicine, University of California, San Francisco
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Kathryn Hawk
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, Connecticut
| | - Elizabeth A Samuels
- Department of Emergency Medicine, David Geffen School of Medicine at the University of California, Los Angeles
- Department of Emergency Medicine, the Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Ethan Cowan
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Erik Anderson
- Department of Emergency Medicine, Highland General Hospital-Alameda Health System, Oakland, California
- Department of Addiction Medicine, Highland General Hospital-Alameda Health System, Oakland, California
| | - Ryan McCormack
- Ronald O. Perelman Department of Emergency Medicine at New York University Langone Health, New York
| | - Kristen Huntley
- Center for Clinical Trials, Clinical Trials Network, National Institute on Drug Abuse, Rockville, Maryland
| | - Patricia Owens
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Shara Martel
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Michele R Lofwall
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington
| | - Sharon L Walsh
- Department of Behavioral Science, University of Kentucky College of Medicine, Lexington
- Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington
| | - James Dziura
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A Fiellin
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
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Morin KA, Tatangelo M, Marsh D. Canadian Addiction Treatment Centre (CATC) opioid agonist treatment cohort in Ontario, Canada. BMJ Open 2024; 14:e080790. [PMID: 38401902 PMCID: PMC10895228 DOI: 10.1136/bmjopen-2023-080790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/14/2024] [Indexed: 02/26/2024] Open
Abstract
PURPOSE The Canadian Addiction Treatment Centre (CATC) cohort was established during a period of increased provision of opioid agonist treatment (OAT), to study patient outcomes and trends related to the treatment of opioid use disorder (OUD) in Canada. The CATC cohort's strengths lie in its unique physician network, shared care model and event-level data, making it valuable for validation and integration studies. The CATC cohort is a valuable resource for examining OAT outcomes, providing insights into substance use trends and the impact of service-level factors. PARTICIPANTS The CATC cohort comprises 32 246 people who received OAT prescriptions between April 2014 and February 2021, with ongoing tri-annual updates planned until 2027. The cohort includes data from all CATC clinics' electronic medical records and includes demographic information and OAT clinical indicators. FINDINGS TO DATE This cohort profile describes the demographic and clinical characteristics of patients being treated in a large OAT physician network. As well, we report the longitudinal OAT retention by treatment type during a time of increasing exposure to a contaminated dangerous drug supply. Notable findings also include retention differences between methadone (32% of patients at 1 year) and buprenorphine (20% at 1 year). Previously published research from this cohort indicated that patient-level factors associated with retention include geographic location, concurrent substance use and prior treatment attempts. Service-level factors such as telemedicine delivery and frequency of urine drug screenings also influence retention. Additionally, the cohort identified rising OAT participation and a substantial increase in fentanyl use during the COVID-19 pandemic. FUTURE PLANS Future research objectives are the longitudinal evaluation of retention and flexible modelling techniques that account for the changes as patients are treated with OAT. Furthermore, future research aims are the use of conditional models, and linkage with provincial-level administrative datasets.
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Affiliation(s)
- Kristen A Morin
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
| | - Mark Tatangelo
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
| | - David Marsh
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
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