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Crisanti AS, Page K, Saavedra JL, Kincaid T, Caswell CM, Waldorf VA. A combined intervention strategy to increase linkage to and retention in substance use treatment for individuals accessing hospital-based services: study protocol. Front Psychiatry 2024; 15:1330436. [PMID: 38855640 PMCID: PMC11160486 DOI: 10.3389/fpsyt.2024.1330436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 05/06/2024] [Indexed: 06/11/2024] Open
Abstract
Background In 2020, New Mexico had the highest alcohol related death and the 11th highest drug overdose rate in the U.S. Towards the long-term goal of addressing this public health problem, we are implementing and evaluating an multi-level intervention designed to identify adults at risk of substance use disorder (SUD) and encourage linkage to and retention in treatment. The first level includes equipping the ED and medical inpatient units of a safety-net hospital with a method to screen individuals at risk of a SUD. The second level includes Seeking Safety (SS), a trauma-specific treatment for PTSD and SUD; and pharmacotherapy for SUD. Motivational Interviewing (MI) is used throughout both levels. Using the SPIRIT guidelines and checklist, this study protocol describes the multi-level intervention and the methodology we are using to assess feasibility and effectiveness. Methods We are using a Type 1 hybrid implementation design with a non-randomized approach (ISRCTN registration # ISRCTN33100750). We aim to enroll 110 adults ( ≧ 18 ) who screen positive for unhealthy use of alcohol, prescription medications (used nonmedically) and/or illicit drugs. Peer support workers are responsible for screening, using MI to increase engagement in screening and treatment and delivery of SS. Pharmacotherapy is provided by addiction clinical specialists. Treatment is provided post hospital discharge via telehealth to increase access to care. Participants are identified through (1) review of electronic health records for individuals with a chief or secondary complaint or mental health condition relating to alcohol and/or other drug use, (2) referrals from clinical staff and (3) screening in the ED and medical inpatient units. Feasibility is being measured through process data. Effectiveness will be determined by changes in two primary outcomes: (i) PTSD symptom severity; and (ii) substance use. Discussion Our study will expand on research related to the implementation of treatment strategies for patients presenting at EDs and admitted to medical inpatients units wherein there is a significant window of opportunity to link patients with follow-up behavioral and clinical services for alcohol and/or drug misuse. The challenges associated with implementation and strategies that have been helpful to address these challenges will further inform the field.
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Affiliation(s)
- A. S. Crisanti
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - K. Page
- Department of Internal Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - J. L. Saavedra
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - T. Kincaid
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - C. M. Caswell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
| | - V. A. Waldorf
- Department of Psychiatry and Behavioral Sciences, University of New Mexico Health Sciences Center, Albuquerque, NM, United States
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McLean K, Murphy J, Kruis N. "I think we're getting better but we're still not there": Provider-based stigma and perceived barriers to care for people who use opioids (PWUO). JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 159:209270. [PMID: 38103831 DOI: 10.1016/j.josat.2023.209270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/18/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD - is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care. METHODS This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population. RESULTS Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO. CONCLUSIONS Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma - blameworthiness - in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma.
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Affiliation(s)
- Katherine McLean
- Penn State Greater Allegheny, 4000 University Dr., McKeesport, PA 15131, United States of America.
| | - Jennifer Murphy
- Penn State Berks, 1801 Broadcasting Rd, Reading, PA 19610, United States of America.
| | - Nathan Kruis
- Penn State Altoona, 3000 Ivyside Park, Altoona, PA 16601, United States of America.
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Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [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: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
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Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
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Hsu M, Jung OS, Kwan LT, Jegede O, Martin B, Malhotra A, Suzuki J. Access challenges to opioid use disorder treatment among individuals experiencing homelessness: Voices from the streets. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 157:209216. [PMID: 37981243 DOI: 10.1016/j.josat.2023.209216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/25/2023] [Accepted: 11/13/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Achieving equitable access to medications for opioid use disorder (MOUD) such as buprenorphine is a pressing issue. Evidence suggests disparities in MOUD access based on race and socioeconomic status, further exacerbated by the COVID-19 pandemic. However, the drivers behind this access gap remain poorly understood. This study explores barriers to treatment access among individuals with opioid use disorder (OUD) experiencing homelessness. METHODS We interviewed 28 individuals in and around the Boston Public Health Commission (BPHC) Engagement Center, an area known for its high density of active substance use and homelessness. We asked about people's experiences, perceptions, and attitudes toward OUD treatment. We conducted a thematic analysis of our interview data. RESULTS Fifty-four percent of participants sampled were not prescribed MOUD. None of the participants reported having an active prescription of sublingual buprenorphine or buprenorphine/naloxone. White participants were more likely to have been prescribed buprenorphine in the past compared to participants of other races even in this socioeconomically homogeneous sample. Themes that emerged in our data included challenges to accessing MOUD due to reduced services during the COVID-19 pandemic, lost or stolen medications, fewer inpatient withdrawal management beds for women, transportation challenges, fear of adverse effects of MOUD, the perception that taking MOUD replaces one addiction for another, and community disapproval of MOUD. Participants also reported stigma and discrimination based on race, gender, and socioeconomic status. CONCLUSION Systems and individual-level factors contribute to the MOUD treatment gap across race and socioeconomic status. The COVID-19 pandemic posed additional access challenges. This study provides important, actionable insights about the barriers faced by a particularly vulnerable population of individuals with OUD experiencing homelessness.
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Affiliation(s)
- Michael Hsu
- Department of Psychiatry, Greater Los Angeles VA Medical Center, Los Angeles, CA, USA.
| | - Olivia S Jung
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, California, USA
| | - Li Ting Kwan
- Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Oluwole Jegede
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Bianca Martin
- Division of Addiction Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
| | - Aniket Malhotra
- Department of Psychiatry, Emory University School of Medicine, Atlanta, GA, USA
| | - Joji Suzuki
- Division of Addiction Psychiatry, Brigham and Women's Hospital, Boston, MA, USA
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Apsley HB, Brant K, Brothers S, Harrison E, Skogseth E, Schwartz RP, Jones AA. Pregnancy- and parenting-related barriers to receiving medication for opioid use disorder: A multi-paneled qualitative study of women in treatment, women who terminated treatment, and the professionals who serve them. WOMEN'S HEALTH (LONDON, ENGLAND) 2024; 20:17455057231224181. [PMID: 38362719 PMCID: PMC10874161 DOI: 10.1177/17455057231224181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/14/2023] [Accepted: 12/15/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Women face unique barriers when seeking treatment for substance use disorders, often related to pregnancy and parenting. OBJECTIVES This study adds to the extant literature by elucidating the pregnancy- and parenting-related barriers women face when initiating or continuing medication for opioid use disorder, specifically. DESIGN This study is based on qualitative semi-structured interviews. METHODS Three subgroups participated in semi-structured interviews regarding their experiences (N = 42): women with current or past opioid use disorders who have used or were presently using medication for opioid use disorder, professionals working in substance use disorder treatment programs, and criminal justice professionals. RESULTS Three parenting-related subthemes were identified: (1) insufficient access to childcare to navigate appointments and meetings, (2) fear of losing custody of, or access to, one's children, and (3) prioritizing one's children's needs before one's own. Three subthemes were identified with regard to pregnancy as a barrier: (1) hesitancy among physicians to prescribe medication for opioid use disorder for pregnant patients, (2) limited access to resources in rural areas, and (3) difficulty navigating a complex, decentralized health system. CONCLUSION Systemic changes are needed to reduce pregnant and parenting women's barriers to seeking medication for opioid use disorder. These include improved childcare support at both in-patient and outpatient treatment programs, which would assuage women's barriers related to childcare, as well as their fears of losing access to their children if they spend time away from their children for treatment. An additional systemic improvement that may reduce barriers for these women is access to comprehensive, integrated care for their prenatal care, postpartum care, pediatric appointments, and appropriate substance use disorder treatment.
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Affiliation(s)
- Hannah B Apsley
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Kristina Brant
- Department of Agricultural Economics, Sociology, and Education, The Pennsylvania State University, University Park, PA, USA
| | - Sarah Brothers
- Department of Sociology and Criminology, The Pennsylvania State University, University Park, PA, USA
| | - Eric Harrison
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | - Emma Skogseth
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | | | - Abenaa A Jones
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
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Lihi R, Yael D, Silviu B, Anat S, Marsha W, Stacy S, Shaul S, Miriam A, Einat P. Stigma and level of familiarity with opioid maintenance treatment (OMT) among specialist physicians in Israel. Harm Reduct J 2023; 20:134. [PMID: 37715237 PMCID: PMC10503015 DOI: 10.1186/s12954-023-00869-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/07/2023] [Indexed: 09/17/2023] Open
Abstract
CONTEXT Opioid use disorder (OUD) poses significant public health problems that have increased dramatically, resulting in high rates of morbidity and mortality. OBJECTIVES To minimize the risk of an opioid epidemic in Israel and be prepared, we evaluated physicians' objective knowledge, level of stigma, and approach to prescribing opioids, risk factors, and identification of patients with substance use disorder (SUD), as well as their knowledge about opioid maintenance treatment (OMT) for OUD. METHODS Anonymous computerized questionnaires were distributed nationally to physicians by the Israel Medical Association. Knowledge, stigma, and approach were scored. RESULTS Of only 249 responders, 58.6% prescribe opioids, 32.1% prescribe cannabis, and 18.5% daily encounter patients with SUD. Logistic regression found the high knowledge group had daily encounters with SUD (Odds Ratio (OR) = 3.5, 95% CI 1.7-7.1) and were familiar with OMT (OR = 10.1, 95% CI 3.5-29.0). The high stigma group was characterized by physicians who prescribe opioids (OR = 1.7, 95% CI 1.0-2.9), but who self-reported having limited knowledge regarding OMT (OR = 2, 95% CI 1.1-3.7). The high approach group was characterized by those who prescribe opioids (OR = 11.7, 95% CI 4.9-28), prescribe cannabis (OR = 2.1, 95% CI 1.0-4.3), self-report having limited knowledge regarding OMT (OR = 11.2, 95% CI 1.4-89) and self-report identifying SUD (OR = 32.5, 95% CI 4.1-260). CONCLUSION High stigma was most evident among physicians who prescribe opioids but, importantly, who had limited knowledge specifically regarding OMT. Gaps in knowledge and approach were observed. An educational intervention is highly recommended to reduce stigma and increase referrals of patients for OMT, the most effective treatment for opioid use disorder.
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Affiliation(s)
- Rozner Lihi
- Department of Psychiatry, Maayenei Hayeshua Medical Center, Bnei Brak, Israel
| | - Delayahu Yael
- Psychiatry, Abarbanel Mental Health Center, Bat Yam, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Brill Silviu
- Pain Institute, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Sason Anat
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel
| | - Weinstein Marsha
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel
| | - Shoshan Stacy
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel
| | - Schreiber Shaul
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel
- Division of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Adelson Miriam
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel
| | - Peles Einat
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
- Adelson Clinic for Drug Abuse Treatment and Research, Tel Aviv Sourasky Medical Center, 10 Dafna Street, 6492805, Tel Aviv, Israel.
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Britz JB, O'Loughlin KM, Henry TL, Richards A, Sabo RT, Saunders HG, Tong ST, Brooks EM, Lowe J, Harrell A, Bethune C, Moeller FG, Krist AH. Rising Racial Disparities in Opioid Mortality and Undertreatment of Opioid Use Disorder and Mental Health Comorbidities in Virginia. AJPM FOCUS 2023; 2:100102. [PMID: 37790667 PMCID: PMC10546578 DOI: 10.1016/j.focus.2023.100102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
Introduction There were more than 100,000 fatal drug overdoses in the U.S. in 2021 alone. In recent years, there has been a shift in opioid mortality from predominantly White rural communities to Black urban communities. This study aimed to identify the Virginia communities disproportionately affected by the overdose crisis and to better understand the systemic factors contributing to disparities in opioid mortality. Methods Using the state all-payer claims database, state mortality records, and census data, we created a multivariate model to examine the community-level factors contributing to racial disparities in opioid mortality. We used generalized linear mixed models to examine the associations between socioecologic factors and fatal opioid overdoses, opioid use disorder diagnoses, opioid-related emergency department visits, and mental health diagnoses. Results Between 2015 and 2020, racial disparities in mortality widened. In 2020, Black males were 1.5 times more likely to die of an opioid overdose than White males (47.3 vs 31.6 per 100,000; p<0.001). The rate of mental health disorders strongly correlated with mortality (β=0.53, p<0.001). Black individuals are not more likely to be diagnosed with opioid use disorder (β=0.01, p=0.002) or with mental health disorders (β= -0.12, p<0.001), despite higher fatal opioid overdoses. Conclusions There are widening racial disparities in opioid mortality. Untreated mental health disorders are a major risk factor for opioid mortality. Findings show pathways to address inequities, including early linkage to care for mental health and opioid use disorders. This analysis shows the use of comprehensive socioecologic data to identify the precursors to fatal overdoses, which could allow earlier intervention and reallocation of resources in high-risk communities.
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Affiliation(s)
- Jacqueline B. Britz
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Kristen M. O'Loughlin
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Tracey L. Henry
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alicia Richards
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Roy T. Sabo
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Heather G. Saunders
- Department of Health Behavior and Policy, Virginia Commonwealth University, Richmond, Virginia
| | - Sebastian T. Tong
- Department of Family Medicine, University of Washington, Seattle, Washington
| | - E. Marshall Brooks
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Jason Lowe
- Division of Behavioral Health, Virginia Department of Medical Assistance (DMAS), Richmond, Virginia
| | - Ashley Harrell
- Division of Behavioral Health, Virginia Department of Medical Assistance (DMAS), Richmond, Virginia
| | - Christine Bethune
- Division of Behavioral Health, Virginia Department of Medical Assistance (DMAS), Richmond, Virginia
| | - F. Gerard Moeller
- C. Kenneth and Dianne Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, Virginia
| | - Alex H. Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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Waite MR, Heslin K, Cook J, Kim A, Simpson M. Predicting substance use disorder treatment follow-ups and relapse across the continuum of care at a single behavioral health center. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 147:208933. [PMID: 36805798 DOI: 10.1016/j.josat.2022.208933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Substance use disorder is often a chronic condition, and its treatment requires patient access to a continuum of care, including inpatient, residential, partial hospitalization, intensive outpatient, and outpatient programs. Ideally, patients complete treatment at the most suitable level for their immediate individual needs, then transition to the next appropriate level. In practice, however, attrition rates are high, as many patients discharge before successfully completing a treatment program or struggle to transition to follow-up care after program discharge. Previous studies analyzed up to two programs at a time in single-center datasets, meaning no studies have assessed patient attrition and follow-up behavior across all five levels of substance use treatment programs in parallel. METHODS To address this major gap, this retrospective study collected patient demographics, enrollment, discharge, and outcomes data across five substance use treatment levels at a large Midwestern psychiatric hospital from 2017 to 2019. Data analyses used descriptive statistics and regression analyses. RESULTS Analyses found several differences in treatment engagement based on patient-level variables. Inpatients were more likely to identify as Black or female compared to lower-acuity programs. Patients were less likely to step down in care if they were younger, Black, had Medicare coverage were discharging from inpatient treatment, or had specific behavioral health diagnoses. Patients were more likely to relapse if they were male or did not engage in follow-up SUD treatment. CONCLUSIONS Future studies should assess mechanisms by which these variables influence treatment access, develop programmatic interventions that encourage appropriate transitions between programs, and determine best practices for increasing access to treatment.
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Affiliation(s)
- Mindy R Waite
- Advocate Aurora Behavioral Health Services, Advocate Aurora Health, 1220 Dewey Ave, Wauwatosa, WI 53213, USA; Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Kayla Heslin
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Jonathan Cook
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
| | - Aengela Kim
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA; Chicago Medical School, Rosalind Franklin University, 3333 Green Bay Rd, North Chicago, IL 60064, USA.
| | - Michelle Simpson
- Advocate Aurora Research Institute, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA; AAH Ed Howe Center for Health Care Transformation, Advocate Aurora Health, 960 N 12th St, Milwaukee, WI 53233, USA.
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Nong T, Hodgkin D, Trang NT, Shoptaw SJ, Li MJ, Hai Van HT, Le G. A review of factors associated with methadone maintenance treatment adherence and retention in Vietnam. Drug Alcohol Depend 2023; 243:109699. [PMID: 36603363 PMCID: PMC9851667 DOI: 10.1016/j.drugalcdep.2022.109699] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Starting in 2008, Vietnam's national MMT program expanded quickly, but it is struggling with increasing attrition rates and poor adherence among patients. Several studies have reported on MMT retention and adherence, but no overview has yet been published. The objective of this study is to fill that gap and to review factors associated with retention and adherence in MMT in Vietnam. METHODS A systematic search was conducted using databases of literature - Pubmed, Cochrane, Scopus, Academic search premiere, and SoINDEX. Peer-reviewed empirical studies with full text in English discussing retention attrition and adherence regarding MMT in Vietnam were selected. The results were synthesized using qualitative methods. RESULTS Adherence and retention rates varied among the 11 included studies. In general, patients in mountainous provinces had lower adherence and retention rates than those in big cities. Retention rates decreased with the studies' follow-up period and had a downward trend over time. Factors associated with adherence and retention can be classified into three groups: individual, community, and institutional factors. Important individual factors areage, education, awareness of MMT and HIV, and co-occurring disorders and comorbidities. Stigma is the major community risk factor, and methadone daily dose, the distance between home and clinic, and clinic's service hours are the three most important institutional factors. CONCLUSIONS The literature reviewed identifies important factors associated with MMT adherence and retention in Vietnam. The findings suggest further research exploring both subjective and objective factors and more policies to remove social and structural barriers to enhance treatment outcomes.
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Affiliation(s)
- Thuong Nong
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA 02453, the United States of America.
| | - Dominic Hodgkin
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA 02453, the United States of America
| | - Nguyen Thu Trang
- Center for Training and Research on Substance Abuse and HIV, Hanoi Medical University, Hanoi, Viet Nam
| | - Steven J Shoptaw
- Center for Behavioral and Addiction Medicine, Department of Family Medicine, University of California, Los Angeles, the United States of America
| | - Michael J Li
- Center for Behavioral and Addiction Medicine, Department of Family Medicine, University of California, Los Angeles, the United States of America
| | | | - Giang Le
- Center for Training and Research on Substance Abuse and HIV, Hanoi Medical University, Hanoi, Viet Nam
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Grieb SM, Harris R, Rosecrans A, Zook K, Sherman SG, Greenbaum A, Lucas GM, Page KR. Awareness, perception and utilization of a mobile health clinic by people who use drugs. Ann Med 2022; 54:138-149. [PMID: 36799361 PMCID: PMC8741230 DOI: 10.1080/07853890.2021.2022188] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION People who use drugs (PWUD) face a multitude of barriers to accessing healthcare and other services. Mobile health clinics (MHC) are an innovative, cost-effective health care delivery approach that increases healthcare access to vulnerable populations and medically underserved areas. There is limited understanding, however, of how PWUD perceive and experience MHCs. METHODS Semi-structured interviews were conducted with 31 PWUD - 16 who had received care (clients) on an MHC (The Spot) and 15 who had not (non-clients) - to explore their perceptions and utilization of an MHC partnered with a mobile syringe services program in Baltimore, Maryland. Data analysis of the text was conducted using an iterative thematic constant comparison process informed by grounded theory. RESULTS Clients and non-clients, once aware of the MHC, had positive perceptions of The Spot and its benefits for their individual health as well as for the wellbeing of their community. These sentiments among clients were largely driven by access to low-barrier buprenorphine and service delivery without stigma around drug use. However, lack of general awareness of the spot and specific service offering were barriers to its use among non-clients. DISCUSSION MHCs provide an important opportunity to engage PWUD in healthcare and to expand buprenorphine use; however, even with accessibility near where PWUD access injection equipment, barriers to its use remain. Peer dissemination may be able to facilitate program information sharing and recruitment.KEY MESSAGESPeople who use drugs perceive a mobile health clinic in their neighbourhood as a benefit to their communities and themselves by improving access to healthcare services, providing access to low-threshold buprenorphine dispensation, and offering services without drug use stigma.People who use drugs learned about a mobile health clinic in their neighbourhood largely through word-of-mouth. As a result, people received limited information about the mobile health clinic services creating a barrier to its use.
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Affiliation(s)
- Suzanne M Grieb
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert Harris
- Baltimore City Health Department, Baltimore, MD, USA
| | - Amanda Rosecrans
- Baltimore City Health Department, Baltimore, MD, USA.,Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Katie Zook
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Gregory M Lucas
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen R Page
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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11
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Carswell N, Angermaier G, Castaneda C, Delgado F. Management of opioid withdrawal and initiation of medications for opioid use disorder in the hospital setting. Hosp Pract (1995) 2022; 50:251-258. [PMID: 35837678 DOI: 10.1080/21548331.2022.2102776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Opioid use disorder (OUD) has become increasingly prevalent among hospitalized patients in the United States and globally. As its prevalence increases, this provides a valuable opportunity for clinicians in the hospital setting to engage and initiate management and treatment of OUD. This article aims to provide hospitalists and other clinicians working in the hospital with a narrative review of the management of opioid withdrawal and the initiation of medications for opioid use disorder (MOUD) in the hospital and provide an update on a novel low dose approach to buprenorphine induction (also commonly referred to as the "microinduction" method). Management can initially include treating withdrawal symptoms with opioids as well as with a combination of non-opioid medications such as alpha 2 agonists, benzodiazepines, and/or antiemetics as needed. Besides simply managing withdrawal symptoms, clinicians can further improve the care of patients with OUD through initiating maintenance treatment with MOUD, ideally with opioids used in the initial management of withdrawal. Opioid detoxification is an inferior method of primary treatment and is associated with relapse and poor outcomes. In contrast, treatment with MOUD using methadone or buprenorphine is associated with superior treatment outcomes and reduced relapse compared to detoxification alone. Treatment with MOUD using methadone or buprenorphine can be successfully used in the hospital setting. A novel low dose approach to buprenorphine induction may be useful in minimizing precipitated withdrawals in patients who have recently used or received opioids, which makes this an attractive option in the hospital where patients are frequently on opioids for acutely painful conditions. The hospital setting also provides a valuable opportunity for clinicians to address harm reduction in patients with OUD. Finally, clinicians can improve the long-term outcomes of patients with OUD by ensuring a smooth discharge with adequate and timely follow-up.
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Affiliation(s)
- Nico Carswell
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Giselle Angermaier
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Christopher Castaneda
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Fabrizzio Delgado
- Department of Psychiatry, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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12
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Dorgay CE, Bromberg DJ, Doltu S, Litz T, Galvez S, Polonsky M, Dvoryak S, Altice FL. A pilot implementation study to scale-up methadone in incarcerated persons with opioid use disorder and retain them on treatment after release in Moldova. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 104:103683. [PMID: 35417790 PMCID: PMC9827420 DOI: 10.1016/j.drugpo.2022.103683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Eastern Europe and Central Asia have intertwined HIV and incarceration epidemics, concentrated in people who inject drugs. Moldova is one of the few countries in this region that offers methadone within prisons, but uptake and post-release retention remains suboptimal. Screening, brief intervention, and referral to treatment (SBIRT) procedures are a potential implementation strategy to address this problem. METHODS From June 1, 2017 to March 3, 2018, we conducted a 2-stage SBIRT strategy in nine prisons and four pre-trial detention facilities in Moldova among incarcerated persons with opioid use disorder (OUD; N = 121) and within 90 days of release. Survey results were analyzed to evaluate the effect of the SBIRT strategy on the uptake of and post-release retention on methadone maintenance treatment (MMT). RESULTS Among the 121 screened with OUD, 27 were on MMT at baseline within the prison and this number increased to 41 after the two-step SBIRT intervention, reflecting a 51.9% increase over baseline. Eleven (78.6%) of the 14 participants that newly started MMT did so only after completing both SBIRT sessions. The brief intervention did not significantly improve knowledge about methadone but did improve attitudes towards it. Among the 41 participants who received methadone during this trial, 40 (97.6%) were retained 6 months after release; the one participant not retained was on methadone at the time of the intervention and had planned to taper off. CONCLUSION The SBIRT strategy significantly improved participant attitudes, but treatment initiation mostly occurred after completing both sessions, including soon after release, but remained low overall. Work within the Moldovan prison subculture to dispel negative myths and misinformation is needed to further scale-up OAT in Moldova.
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Affiliation(s)
- Coriann E Dorgay
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States
| | - Daniel J Bromberg
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Svetlana Doltu
- Act For Involvement, 7A Varșovia street, Chișinău, 2060, Republic of Moldova
| | - Taylor Litz
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Samy Galvez
- Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Maxim Polonsky
- Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States
| | - Sergey Dvoryak
- Ukrainian Institute on Public Health Policy, 5 Biloruska Str. Office 20, 27, Kyiv, 04050 Ukraine
| | - Frederick L Altice
- Yale School of Public Health, Yale University, 60 College Street, New Haven, Connecticut, 06510, United States; Yale Center for Interdisciplinary Research on AIDS, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; Yale School of Medicine, Yale University, 135 College Street, New Haven, Connecticut, 06510, United States; University of Malaya, 50603 Kuala Lumpur, Malaysia.
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13
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Andersson L. A transition of power in opioid substitution treatment: Clinic managers' views on the consequences of a patient choice reform. NORDIC STUDIES ON ALCOHOL AND DRUGS 2022; 39:279-300. [PMID: 35720521 PMCID: PMC9152230 DOI: 10.1177/14550725221075003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives: Opioid substitution treatment (OST) is often described as a strict and highly regulated treatment method, in which patients have limited influence over their treatment. In 2014, a reform was introduced by the regional council of Skåne in southern Sweden, which allowed OST patients to choose their treatment provider, thus transferring power from care providers to patients. The aim of this study was to examine what this increase in patient influence has meant for the clinics that provide OST in Skåne, and how these clinics have dealt with the new competitive situation that has arisen following the introduction of the reform. Methods: The study is based on two waves of semi-structured interviews with clinic managers at all OST clinics in Skåne. Results: The clinic managers described the increase in patient influence as a positive change, which had led to the patients being treated with more respect. The competition among clinics was expressed, among other things, in the form of differing views on the prescription of benzodiazepines, which initially gave rise to dissatisfaction among clinics with a more restrictive approach to such prescriptions. The reform did not lead to any clear diversity between clinics, apart from different approaches to the prescription of benzodiazepines. The incentive for competition-based diversity is, however, limited by the strict national regulatory system and by the reimbursement system, which restricts the ways in which clinics can conduct treatment activities. Conclusion: OST-clinic managers were largely positive about the increased patient empowerment and the shift in power balance associated with the patient choice reform. The introduction of the reform did not lead to any clear diversity between treatment providers, apart from differing views on the prescription of benzodiazepines, which by some managers was regarded as unfair competition.
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14
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Walters SM, Perlman DC, Guarino H, Mateu-Gelabert P, Frank D. Lessons from the First Wave of COVID-19 for Improved Medications for Opioid Use Disorder (MOUD) Treatment: Benefits of Easier Access, Extended Take Homes, and New Delivery Modalities. Subst Use Misuse 2022; 57:1144-1153. [PMID: 35443862 PMCID: PMC9709780 DOI: 10.1080/10826084.2022.2064509] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Medications for Opioid Use Disorder (MOUD) are associated with important public health benefits. Program changes implemented in response to COVID-19 hold promise as ongoing strategies to improve MOUD treatment. Methods: MOUD patients on buprenorphine or methadone, providers, government regulators, and persons who use drugs not in MOUD were recruited in the Northeast region of the United States between June and October of 2020 via advertisements, fliers, and word of mouth. Semi-structured qualitative interviews were conducted. Interviews were professionally transcribed and thematically coded by two independent coders. Results: We conducted interviews with 13 people currently on buprenorphine, 11 currently on methadone, 3 previously on buprenorphine, 4 previously on methadone, and 6 who used drugs but had never been on MOUD. In addition, we interviewed MOUD providers, clinic staff, and government officials at agencies that regulate MOUD. Most participants found increased take-home doses, home medication delivery, and telehealth implemented during COVID-19 to be favorable, reporting that these program changes reduced travel time to clinics, facilitated retention in care, and reduced stigma associated with clinic attendance. However, some participants reported negative consequences of COVID-19, most notably, decreased access to basic resources, such as food, clothing, and harm reduction materials that had previously been distributed at some MOUD clinics. Conclusion: Access to and retention in MOUD can be lifesaving for persons using drugs. COVID-19-impelled program changes, including increased take-home doses, home medication delivery, and telehealth generally improved participants' experiences with MOUD. Making these permanent could improve retention in care.
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Affiliation(s)
- Suzan M Walters
- New York University, School of Global Public Health
- Center for Drug Use and HIV/HCV Research, NYU School of Global Public Health
| | - David C. Perlman
- Center for Drug Use and HIV/HCV Research, NYU School of Global Public Health
- Icahn School of Medicine at Mount Sinai; New York, NY
| | - Honoria Guarino
- City University of New York, Graduate School of Public Health & Health Policy
| | | | - David Frank
- Center for Drug Use and HIV/HCV Research, NYU School of Global Public Health
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15
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Mitchell SG, Nordeck CD, Lertch E, Ross TE, Welsh C, Schwartz RP, Gryczynski J. Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization. Subst Abus 2022; 43:848-854. [PMID: 35179452 PMCID: PMC9793431 DOI: 10.1080/08897077.2021.2007512] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.
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Affiliation(s)
| | - Courtney D. Nordeck
- Friends Research Institute, Inc., Baltimore, MD,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD
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Rostam-Abadi Y, Gholami J, Noroozi A, Ansari M, Baheshmat S, Hamzehzadeh M, Ghadirzadeh MR, Vahdani B, Ekhtiari H, Mojtabai R, Rahimi-Movaghar A. Public health risks associated with methadone in Iran: A systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 100:103529. [PMID: 34826790 DOI: 10.1016/j.drugpo.2021.103529] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 09/25/2021] [Accepted: 10/30/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been a marked growth in methadone maintenance treatment (MMT) in Iran in the past two decades with positive health outcomes. We conducted a systematic review of studies on the prevalence of non-prescribed methadone use, methadone use disorder, and methadone-related poisoning and mortality in Iran. METHODS We searched International and Iranian databases up to May 2020 and contacted relevant experts. The pooled proportions were estimated through random-effects model. Methadone-related adverse outcomes were evaluated over time. RESULTS Sixty-five studies were included. The pooled estimates of non-prescribed methadone use in the last 12-month were 2.7% (95%CI: 0.9-5.4) and 0.1% (95%CI: 0.03-0.2) in the male and female general population, respectively. Among people who use drugs, 8.4% reported daily non-prescribed use in 2018. Four heterogeneous studies in drug treatment centers reported the existence of treatment-seeking for methadone use disorder. Methadone was responsible for 10.4% (95%CI: 4.5-18.3) of cases of acute poisoning in adults and 16.0% (95%CI: 9.3-24.1) in children. Methadone was reported as a cause of death in 53.5% of substance-related deaths referred to the Legal Medicine Organization while being the only cause in 35.8% of all cases. CONCLUSION Non-prescribed use of methadone in the general population is much less than opiates and some other available prescription opioids, like tramadol. However, notwithstanding the large and successful MMT program in Iran, increasing trends in methadone-related poisoning and deaths pose serious public health concerns. There is an urgent need to explore these fatal and non-fatal poisoning cases and implement policies to curb the harms associated with methadone use.
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Affiliation(s)
- Yasna Rostam-Abadi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Jaleh Gholami
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Alireza Noroozi
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Mina Ansari
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran
| | - Shahab Baheshmat
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran
| | - Marziyeh Hamzehzadeh
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran; Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine (SATiM), Tehran University of Medical Sciences, Tehran, Iran
| | | | - Bita Vahdani
- Center for Disease Affairs and Transplant, Ministry of Health, Tehran, Iran
| | - Hamed Ekhtiari
- Laureate Institute for Brain Research, Tulsa, Oklahoma, USA
| | - Ramin Mojtabai
- Department of Mental Health, Bloomberg School of Public Health and Department of Psychiatry, Johns Hopkins University, Baltimore, Maryland, USA
| | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Tehran University of Medical Sciences, Tehran, Iran.
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Hall N, Le L, Majmudar I, Teesson M, Mihalopoulos C. Treatment-seeking behaviour among people with opioid use disorder in the high-income countries: A systematic review and meta-analysis. PLoS One 2021; 16:e0258620. [PMID: 34653220 PMCID: PMC8519451 DOI: 10.1371/journal.pone.0258620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 09/01/2021] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To determine treatment seeking behaviour in those with opioid use disorder (OUD) in the high-income countries. METHODS Five databases were searched in November 2019 for quantitative studies that reported OUD treatment seeking behaviour. Data analysis involved determining an overall pooled proportion estimate of treatment seeking behaviour for the two base groups, lifetime treatment and past 12-month or less treatment using the IVhet effect model. Subgroup analysis included heroin OUD, prescription OUD and general OUD. The sensitivity analysis included removal of outliers, separating adults and adolescents and the metaXL sensitivity analysis (studies are excluded if outside the pooled proportion confidence interval of the base case). Systematic review Prospero database registration number [CRD42020159531]. RESULTS There were 13 quantitative studies included in the systematic review, with all studies being from the United States of America (USA). IVhet models showed that 40% (95% CI: 23%, 58%) and 21% (95% CI: 16%, 26%) sought treatment in their lifetime and past 12 months respectively. Sub-group analysis found that lifetime treatment seeking for prescription OUD, 29% (95% CI: 27%, 31%), was less than for heroin plus combined OUD, 54% (95% CI: 26%, 82%). Most of the pooled results had high heterogeneity statistics except for results of lifetime treatment seeking for prescription OUD and past 12-month treatment seeking for prescription OUD. CONCLUSION All included studies in this meta-analysis were from the USA and indicate modest levels of treatment seeking for those with OUD. In particular, this review found that in the USA one in five people with OUD sought OUD treatment in the previous 12 months and two in five people with OUD sought OUD treatment in their lifetime. Further research is urgently required to explore the barriers and facilitators that can improve this low treatment seeking in those with OUD.
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Affiliation(s)
- Natasha Hall
- School of Health and Social Development, Deakin University, Burwood, Australia
| | - Long Le
- School of Health and Social Development, Deakin University, Burwood, Australia
| | - Ishani Majmudar
- School of Health and Social Development, Deakin University, Burwood, Australia
| | - Maree Teesson
- Director Matilda Centre for Research in Mental Health and Substance Use, Sydney University, Sydney, Australia
| | - Cathy Mihalopoulos
- School of Health and Social Development, Deakin University, Burwood, Australia
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18
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Taylor EN, Timko C, Binswanger IA, Harris AHS, Stimmel M, Smelson D, Finlay AK. A national survey of barriers and facilitators to medications for opioid use disorder among legal-involved veterans in the Veterans Health Administration. Subst Abus 2021; 43:556-563. [PMID: 34586978 PMCID: PMC9423124 DOI: 10.1080/08897077.2021.1975867] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents' current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents' current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.
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Affiliation(s)
- Emmeline N. Taylor
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA
- Department of Psychology, University of Colorado Colorado Springs, Colorado Springs, CO, USA
| | - Christine Timko
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Ingrid A. Binswanger
- Kaiser Permanente Colorado, Institute for Health Research, Denver, CO, USA
- Colorado Permanente Medical Group, Denver, CO, USA
- Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Alex H. S. Harris
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Matthew Stimmel
- U.S. Department of Veterans Affairs, Veterans Justice Programs, Menlo Park, CA, USA
| | - David Smelson
- U.S. Department of Veterans Affairs, Edith Nourse Rodgers VA Medical Center, Center for Organization and Implementation Science, Bedford, MA, USA
| | - Andrea K. Finlay
- U.S. Department of Veterans Affairs, VA Palo Alto Health Care System, Center for Innovation to Implementation, Palo Alto, CA, USA
- U.S. Department of Veterans Affairs, National Center on Homelessness Among Veterans, Menlo Park, CA, USA
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Sulzer SH, Prevedel S, Barrett T, Voss MW, Manning C, Madden EF. Professional education to reduce provider stigma toward harm reduction and pharmacotherapy. DRUGS: EDUCATION, PREVENTION AND POLICY 2021. [DOI: 10.1080/09687637.2021.1936457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Sandra H. Sulzer
- Kinesiology and Health Science, Utah State University, Logan, UT, USA
| | | | | | | | - Cassandra Manning
- Painted Horse Diabetes Prevention Program, Ute Indian Tribe, UT, USA
| | - Erin Fanning Madden
- Family Medicine and Public Health Services, Wayne State University, Detroit, MI, USA
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Cernasev A, Hohmeier KC, Frederick K, Jasmin H, Gatwood J. A systematic literature review of patient perspectives of barriers and facilitators to access, adherence, stigma, and persistence to treatment for substance use disorder. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2021; 2:100029. [PMID: 35481114 PMCID: PMC9029901 DOI: 10.1016/j.rcsop.2021.100029] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 11/21/2022] Open
Abstract
Introduction The opioid crisis has left a devastating impact on the United States (U.S.) for over 20 years. The over-prescribing of opioid medications and availability of illicit opioids have contributed to the U.S. opioid epidemic. Given the complexity of the epidemic, substance use disorder, and its treatment, there is an urgent need for a thorough review of the qualitative literature which has captured the patient's experiences Such patient-derived qualitative data on lived experiences and perspectives may allow researchers, clinicians, and policy makers to glean new insights into addressing this epidemic. Objectives The objective of this paper is to present a systematic literature review of the existing U.S. qualitative research and provide a patient perspective on medications for opioid use disorder (MOUD), including barriers and facilitators to MOUD use. Methods In November 2019, four electronic databases (PubMed, CINAHL, Scopus, and Web of Science) were searched by a medical librarian using a combination of keywords, Medical Subject Headings (MeSH), and/or CINAHL subject headings. 8766 results were imported into EndNote, then duplicate records were removed, leaving a total of 4722 articles. The unique records were imported into Rayyan QCRI an online platform designed to expedite screening. Blinded screening was undertaken in duplicate by four reviewers. Two researchers abstracted all the articles and used thematic analysis. Results The screening in the abstract phase excluded 4681 results, leaving 41 studies for full-text screening to determine their eligibility for inclusion in the review. After screening, 21 articles were included in the study and the analysis is based on these articles Common themes across studies included stigmatization, perceived barriers to MOUD, and MOUD treatment deserts and provider shortages. Conclusions Qualitative research studies conducted to date have uncovered substantial MOUD treatment barriers which are both social and structural in nature. Such barriers to treatment may serve to exacerbate the current epidemic and must be taken into consideration in designing policy and treatment solutions for patients with OUD.
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Affiliation(s)
- Alina Cernasev
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Kenneth C. Hohmeier
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Kelsey Frederick
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Sciences Center, Nashville, TN, USA
| | - Hilary Jasmin
- Health Sciences Library, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Justin Gatwood
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Sciences Center, Nashville, TN, USA
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21
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Frank D. A chance to do it better: Methadone maintenance treatment in the age of Covid-19. J Subst Abuse Treat 2021; 123:108246. [PMID: 33612189 PMCID: PMC7834469 DOI: 10.1016/j.jsat.2020.108246] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 12/01/2020] [Accepted: 12/05/2020] [Indexed: 11/30/2022]
Abstract
Methadone maintenance treatment (MMT) in the United States, and particularly the clinic system of distribution, is often criticized as punitive, over-regulated, and misaligned to the needs of many patients. However, changes to the regulations that COVID-19 caused may have provided an opportunity for improving service. This commentary uses literature and my own experience to provide a brief description of how MMT programs responded to the threat of Covid-19 and how such responses fit into the larger context of attempts to reform treatment. It discusses, in particular, opportunities for liberalizing "take-home" doses and implementing office-based MMT.
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Affiliation(s)
- David Frank
- New York University, United States of America.
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22
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Hall NY, Le L, Majmudar I, Mihalopoulos C. Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective. Drug Alcohol Depend 2021; 221:108651. [PMID: 33667783 DOI: 10.1016/j.drugalcdep.2021.108651] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD). METHODS The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes. RESULTS There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility. CONCLUSION This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.
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Affiliation(s)
- Natasha Yvonne Hall
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Long Le
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Ishani Majmudar
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
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23
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Transporting to treatment: Evaluating the effectiveness of a mobile engagement unit. J Subst Abuse Treat 2021; 129:108377. [PMID: 34080548 DOI: 10.1016/j.jsat.2021.108377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Substance use treatment providers have increasingly developed novel engagement and low-threshold treatment services (such as mobile treatment units) to meet the needs of people with opioid use disorder (OUD). Use of these service models has outpaced the research on their effectiveness. The current study examines the effectiveness of a mobile engagement unit in connecting individuals with OUD to a treatment program. METHODS This retrospective cohort study included 468 Medicaid-enrolled individuals served through a managed care behavioral health system. Analyses used administrative data from 2018 to 2019 to compare the characteristics and service use of individuals transported to an intake appointment by a mobile engagement unit with individuals who arrived through typical referral routes such as walk-in, other providers, and court order. The authors employed a difference-in-differences analysis to adjust for prior service history. The outcomes of interest were any utilization of substance use treatment services. RESULTS The groups were virtually identical in age and gender, prior to matching, except for race where there was a lower proportion of Black individuals (17% versus 44%) and lower pre-service utilization of outpatient and methadone services by the mobile group. Following intake, mobile participants used significantly more outpatient substance use treatment services (23 percentage point relative increase) and methadone maintenance (32 percentage point relative increase) than the comparison group. CONCLUSIONS The results of this study suggest that mobile engagement units designed to identify and serve individuals with OUD in the community hold promise for reaching underserved high-risk populations and reduce barriers to treatment entry and recovery.
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24
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Abadie R, McLean K, Habecker P, Dombrowski K. Treatment trajectories and barriers in opioid agonist therapy for people who inject drugs in rural Puerto Rico. J Subst Abuse Treat 2021; 127:108347. [PMID: 34134865 DOI: 10.1016/j.jsat.2021.108347] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 01/18/2021] [Accepted: 02/15/2021] [Indexed: 01/01/2023]
Abstract
BACKGROUND Research has shown medication for opioid use disorder (MOUD) to have positive effects, including reducing HIV and HCV transmission, but important barriers to access remain among people who inject drugs (PWID). Barriers include lack of social and familial support, bureaucracy, distance to treatment, poverty, and homelessness. However, we know little about how these barriers interact with each other to shape PWID's drug treatment access and retention. METHODS We used qualitative methods with a dataset from a study conducted during 2019 with 31 active PWID residing in rural Puerto Rico. The study gathered ethnographic data and narratives about treatment trajectories to document the lived experiences of PWID as they moved in and out of treatment. RESULTS Participants were at least 18 years old; 87.7% were male, the mean age was 44.1 years, and the mean age at first injection was 22 years. Participants identified homelessness, lack of proper ID or other identifying documents, and previous negative experiences with MOUD as the main barriers to treatment entry and retention. In addition, PWID's belief that MOUD simply substitutes an illegal drug for a legal one, while furthering drug dependence by chronically subjecting patients to treatment, constitutes an additional barrier to entry. Findings from this study demonstrate that MOUD barriers to access and retention compound and are severely affected by poverty and other forms of vulnerability among PWID in rural Puerto Rico. CONCLUSION Policies to increase access and retention should consider barriers not in isolation but as an assemblage of many factors.
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Affiliation(s)
- Roberto Abadie
- Department of Anthropology, University of Nebraska-Lincoln, 839 Old Father Hall, Lincoln, NE 68588, United States of America.
| | - Katherine McLean
- Department of Administration of Justice, Penn State Greater Allegheny, 400 University Drive, McKeesport, PA 15216, United States of America
| | - Patrick Habecker
- Department of Sociology, University of Nebraska-Lincoln, 430 Old Father Hall, Lincoln, NE 68588, United States of America
| | - Kirk Dombrowski
- Department of Anthropology, University of Vermont, 72 University Place, VT 05405, United States of America
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25
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Madden EF, Prevedel S, Light T, Sulzer SH. Intervention Stigma toward Medications for Opioid Use Disorder: A Systematic Review. Subst Use Misuse 2021; 56:2181-2201. [PMID: 34538213 DOI: 10.1080/10826084.2021.1975749] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Medications for opioid use disorder (MOUD) are evidence-based treatments, yet can be controversial among some populations. This study provides a systematic review of prejudice and discrimination toward MOUD, a form of "intervention stigma," or stigma associated with a particular medical treatment. A systematic search strategy was used in PsychInfo and PubMed to identify studies published between 1998 and 2018. Studies that empirically examined stigma toward MOUD were included if the manuscript was of moderate or high quality. Studies were analyzed using thematic synthesis. The search yielded 972 studies, of which 28 were included. Most studies utilized qualitative methods to examine intervention stigma toward methadone or buprenorphine, with one including naltrexone. Studies demonstrated that intervention stigma among healthcare providers was influenced by lack of training and abstinent treatment preferences. Providers equated MOUD with illicit substance use and at times refused to care for MOUD patients. Stigma among peer patients seeking treatment was also influenced by abstinent treatment preferences, and among the general public stigma was influenced by lack of MOUD knowledge. Intervention stigma was also driven at the policy level by high regulation of methadone, which fueled diversion and hindered social functioning among patients. Few studies indicated how to reduce intervention stigma toward MOUD. Intervention stigma affects both provision and perceptions of methadone and buprenorphine, decreasing access and utilization of MOUD. Future research should further develop and test MOUD stigma reduction interventions in a variety of social contexts to improve access to care and reduce patient barriers.
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Affiliation(s)
- Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, School of Medicine, Wayne State University, Detroit, Michigan, USA
| | - Suzanne Prevedel
- Utah State University Extension, Utah State University, Logan, Utah, USA
| | - Timothy Light
- College of Osteopathic Medicine, Rocky Vista University-Southern Utah, Ivins, Utah, USA
| | - Sandra H Sulzer
- Utah State University Extension, Utah State University, Logan, Utah, USA
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Kumar N, Mancino MJ, Thostenson JD, McGaugh J, Oliveto AH. Feasibility and Preliminary Efficacy of Isradipine During Outpatient Buprenorphine Stabilization and Detoxification: A Pilot Randomized, Placebo-Controlled Trial. SUBSTANCE ABUSE-RESEARCH AND TREATMENT 2020; 14:1178221820970926. [PMID: 33281447 PMCID: PMC7686602 DOI: 10.1177/1178221820970926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022]
Abstract
Background: Given the immense burden of the widespread use of opioids around the world,
exploring treatments that improve drug use outcomes, and craving and
withdrawal measures in individuals with opioid use disorder is crucial. This
pilot study examined the feasibility and preliminary efficacy of the L-type
calcium-channel blocker isradipine (ISR) to improve drug use outcomes, and
craving and withdrawal measures during buprenorphine (BUP)/ISR stabilization
and subsequent taper in opioid-dependent individuals. Methods: Participants were stabilized on BUP sublingual tablets within the first 2
days of week 1, were then randomized and inducted on either ISR or placebo,
gradually increasing the dose over the next 2 weeks, followed by a 10-day
BUP taper during weeks 5-6, and ISR/placebo taper during weeks 7 to 8.
Assessments included thrice-weekly measures of craving and withdrawal, as
well as vital signs and urine drug screens. Medication compliance was
assessed by monitoring number of missed clinic visit days. Results: Baseline characteristics of participants (n = 25; 60% male, 96% Caucasian,
48% employed, mean age 32.8 years) did not differ significantly between
treatment groups (isradipine, n = 11; placebo, n = 14). During the
stabilization phase (n = 19), ISR participants had significantly lower rates
of illicit opioid-positive urines (treatment × visit:
t = -2.16, P = 0.03), as well as reduction
in craving intensity (t = –2.50,
P = 0.01), frequency (t = –3.43,
P < 0.01) and duration (t = –2.51,
P = 0.01). ISR was well tolerated with mild adverse
effects. Conclusions: This study was likely underpowered due to being a pilot trial. Although
preliminary results suggest ISR may improve BUP-assisted treatment outcomes,
concerns about high number of exclusions (n = 11 during taper phase) based
on cardiovascular measures as well as ISR-induced changes in vital signs
with the immediate release formulation may limit the feasibility of this
approach. Trial Registration: Clinicaltrials.gov identifier NCT01895270. Registered 10 July 2013, https://clinicaltrials.gov/ct2/show/NCT01895270?id=NCT01895270&draw=2&rank=1
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Affiliation(s)
- Nihit Kumar
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Michael J Mancino
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeff D Thostenson
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Janette McGaugh
- Ouachita Behavioral Health and Wellness, Hot Springs, AR, USA
| | - Alison H Oliveto
- Department of Psychiatry and Behavioral Sciences, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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27
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Cioe K, Biondi BE, Easly R, Simard A, Zheng X, Springer SA. A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder. J Subst Abuse Treat 2020; 119:108146. [PMID: 33138929 PMCID: PMC7609980 DOI: 10.1016/j.jsat.2020.108146] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 07/02/2020] [Accepted: 09/10/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery. METHODS This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review. RESULTS There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD. CONCLUSION This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.
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Affiliation(s)
- Katharine Cioe
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Breanne E Biondi
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America
| | - Rebecca Easly
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Amanda Simard
- Frank H. Netter MD School of Medicine, 370 Bassett Road, North Haven, CT 06473, United States of America
| | - Xiao Zheng
- Yale University, New Haven, CT 06520, United States of America
| | - Sandra A Springer
- Yale School of Medicine, Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, United States of America; Center for Interdisciplinary Research on AIDS, Yale University School of Public Health, New Haven, CT, United States of America.
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28
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Deng Q, Hu M, Yu F, Liu Q, Hao W, Wu Q, Luo T. A Community-Based Investigation of Stigma Toward Individuals Receiving Methadone Maintenance Treatment in China: A Randomized Case Vignette Study. Front Psychiatry 2020; 11:601266. [PMID: 33324264 PMCID: PMC7723969 DOI: 10.3389/fpsyt.2020.601266] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 10/23/2020] [Indexed: 01/16/2023] Open
Abstract
Background: Even though methadone maintenance treatment (MMT) is effective and widely recommended, it is widely misunderstood and stigmatized. This study aimed to explore people's attitudes and beliefs toward MMT, and stigmatization of MMT patients in China. Methods: This randomized, vignette-based study enrolled 1,066 household respondents (552 males and 514 females, response rate is 88.83%, 86.00% in vignette 1 and 91.66% in vignette 2) from two communities in China. Respondents initially completed questionnaires on sociodemographic characteristics and their knowledge about methadone and MMT. They were then randomly assigned to vignette 1 (described a patient receiving MMT) or vignette 2 (described a patient receiving amlodipine treatment). The labeling, stereotyping, and social distance toward the individual described in the vignettes were evaluated. Results: In these two vignettes, respondents showed a significantly higher level of stigma and discrimination toward the patient receiving MMT than the patient receiving amlodipine treatment. Approximately 60% of respondents believed that methadone is a type of addictive drug and that participating in MMT is a way to get high. Over 60% of respondents labeled the heroin-dependent patient who is receiving MMT as an addict even though the patient has not used heroin for several years; about 80% of them believed that the patient has undesirable characteristics and expressed a strong desire for social distance. Conclusions: People's misunderstanding of MMT, and stigmatization of MMT patients were very common among populations in the communities in China. To maximize MMT patients benefiting from MMT programs, more efforts are needed to minimize the impact of MMT-related stigma.
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Affiliation(s)
- Qijian Deng
- Department of Psychiatry, Second Xiangya Hospital, Central South University, Changsha, China
| | - Maorong Hu
- Department of Psychiatry, The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Fang Yu
- Department of Psychology, Jiangxi Mental Hospital, Nanchang, China
| | - Qiaosheng Liu
- Department of Psychology, Jiangxi Mental Hospital, Nanchang, China
| | - Wei Hao
- Department of Psychiatry, Second Xiangya Hospital, Central South University, Changsha, China
| | - Qiuxia Wu
- Department of Psychiatry, Second Xiangya Hospital, Central South University, Changsha, China
| | - Tao Luo
- Department of Psychology, Jiangxi Mental Hospital, Nanchang, China
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, Changsha, China
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Winhusen T, Wilder C, Lyons MS, Theobald J, Kropp F, Lewis D. Evaluation of a personally-tailored opioid overdose prevention education and naloxone distribution intervention to promote harm reduction and treatment readiness in individuals actively using illicit opioids. Drug Alcohol Depend 2020; 216:108265. [PMID: 32919098 PMCID: PMC7458095 DOI: 10.1016/j.drugalcdep.2020.108265] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/21/2020] [Accepted: 08/24/2020] [Indexed: 10/28/2022]
Abstract
BACKGROUND Opioid overdose prevention education and naloxone distribution (OEND) programs include information on general risk factors, overdose recognition, and naloxone utilization. This study evaluated a personally-tailored OEND (PTOEND) intervention designed to promote harm reduction and treatment readiness for illicit opioid users by also including education about personal overdose-risk factors and medication for opioid use disorder (MOUD). METHOD A secondary analysis of a randomized controlled trial testing a Peer recovery support service (PRSS) intervention, relative to Control, in adult illicit opioid users reporting treatment for an overdose in the prior 6 months. PTOEND, a 30-minute computer-guided intervention, was administered by a research assistant at the randomization visit to all participants (N = 80). Participants completed a telephone visit 3 weeks post-randomization (n = 74) to assess changes in opioid overdose/MOUD knowledge and treatment readiness. Participants completed in-person visits at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization to assess illicit opioid use and naloxone utilization (all time points) and overdose-risk behaviors (12 months). We conducted pre-post analyses of the impact of PTOEND controlling for the PRSS effect. RESULTS PTOEND increased knowledge of overdose (79.8% to 81.5%, p < 0.05) and MOUD (66.9% to 75.0%, p < 0.01) and decreased perceived treatment barriers (2.1 to 1.9, p < 0.01); desire to quit all substances increased (7.2 to 7.8, p = 0.05). Self-reported opioid use was significantly decreased at each follow-up (all p < 0.01). Self-reported overdose-risk behaviors decreased significantly (6.2 to 2.4, p < 0.01). A majority of participants (65 %) reported naloxone utilization. CONCLUSIONS PTOEND may be effective for promoting harm reduction and treatment readiness.
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Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.
| | - Christine Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Michael S Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine 231, Albert Sabin Way, Cincinnati, OH 45267, USA
| | - Jeff Theobald
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Frankie Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Daniel Lewis
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
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30
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Winhusen T, Wilder C, Kropp F, Theobald J, Lyons MS, Lewis D. A brief telephone-delivered peer intervention to encourage enrollment in medication for opioid use disorder in individuals surviving an opioid overdose: Results from a randomized pilot trial. Drug Alcohol Depend 2020; 216:108270. [PMID: 32911132 PMCID: PMC7462596 DOI: 10.1016/j.drugalcdep.2020.108270] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 08/20/2020] [Accepted: 08/24/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) can decrease the risk of opioid overdose (OOD) in individuals with opioid use disorder. Peer recovery support services (PRSS) are increasingly used to promote MOUD engagement but evidence of their efficacy is limited. This study's objective was to evaluate a single 20-minute telephone-delivered PRSS intervention for increasing MOUD enrollment and decreasing recurring OODs. METHOD This single-site, randomized controlled pilot trial enrolled adults, primarily recruited from a syringe service program, with an opioid-positive urine drug screen (UDS) reporting having been treated for an OOD within the past 6 months. Participants (N = 80) were randomized to PRSS (n = 40) or Control (n = 40) condition with all participants receiving personally-tailored OOD education and naloxone. Outcome measures obtained at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization included verified MOUD enrollment (primary), self-reported OOD, and opioid use assessed by self-report and UDS. RESULTS Through 12-month follow-up, 32.5 % of PRSS, compared to 17.5 % of Control participants enrolled in MOUD (X2 = 2.4, p = 0.12; odds ratio = 2.27 (0.79-6.49)). PRSS participants were significantly less likely to have experienced an OOD through 12-month follow-up (12.5 % of PRSS participants, 32.5 % of Control, p = 0.03). No significant treatment effect was found for opioid use through 12-month follow-up as measured by either opioid-positive UDSs or self-reported past month opioid use days. Based on self-report, PRSS had good acceptability for both the interventionists and participants. CONCLUSIONS The results suggest that further development and testing of this PRSS telephone intervention to encourage MOUD enrollment and reduce OOD may be warranted.
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Affiliation(s)
- Theresa Winhusen
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA; Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA.
| | - Christine Wilder
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA,Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Frankie Kropp
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA,Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Jeff Theobald
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA,Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
| | - Michael S. Lyons
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA
| | - Daniel Lewis
- Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH, 45229, USA,Center for Addiction Research, University of Cincinnati College of Medicine, 3230 Eden Ave, Cincinnati, OH 45267, USA
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Frank D. "That's No Longer Tolerated": Policing Patients' Use of Non-opioid Substances in Methadone Maintenance Treatment. J Psychoactive Drugs 2020; 53:10-17. [PMID: 32996399 DOI: 10.1080/02791072.2020.1824046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The current overdose crisis in the United States emphasizes the importance of providing substance use treatment programs that are not only effective but tailored to meet the specific needs of the populations they serve. While Methadone Maintenance Treatment (MMT) is considered to be among the best strategies for reducing rates of opioid-involved overdose, its ability to attract and maintain patients may be hindered by a recent focus on policing the non-opioid substance use of people on the program. This paper uses interview data from treatment providers to examine how clinicians conceptualize and organize MMT in regards to patients' use of non-opioid drugs. Responses demonstrate that some treatment providers are increasingly monitoring their patients' use of non-opioid substances and punishing them for infractions, up to and including discharge from treatment. This approach will likely result in increasing rates of patient dropout and a lack of new admissions among people who use non-opioid substances. This article argues that including non-opioid substances in MMT's mandate restricts its ability to improve public health, including by preventing overdoses, and recommends instead that MMT adopt a more individualized approach, shaped by the needs and goals of the patient rather than those of the clinician.
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Affiliation(s)
- David Frank
- Rory Meyers College of Nursing, New York University, New York, NY, USA
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Kavanaugh PR, McLean K. Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study. JOURNAL OF DRUG ISSUES 2020. [DOI: 10.1177/0022042620941796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.
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Frank D. Methadone maintenance treatment is swapping one drug for another, and that's why it works: Towards a treatment-based critique of the war on drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 83:102844. [PMID: 32653670 DOI: 10.1016/j.drugpo.2020.102844] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Revised: 06/16/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
The claim that methadone maintenance treatment (MMT) is 'just swapping one drug for another' has typically been used to de-legitimize the treatment and attack those who use it. However, this commentary re-positions that argument as a way of bringing analytic focus to the role of structural forces, like criminalization and the war on drugs, in the treatment decisions of people who use illegal drugs. Specifically, I use my experience as a qualitative sociologist who studies MMT as well as my own experience on MMT to demonstrate how criminalization functions as source of harm in the lives of people who use illegal drugs, that drives them towards the legal, and thus comparatively safer, style of substance use made available by MMT. Moreover, I argue that the dominance of individually-focused theories based on addiction and recovery to understand MMT is related to its punitive organizational structure and lack of popularity among people who use illegal opioids. Ultimately, I argue for a paradigm shift, both in policy and scholarship, that acknowledges the pragmatic value of MMT within the structural context of criminalization.
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Affiliation(s)
- David Frank
- New York University, Behavioral Science Training in Drug Abuse Research program, United States.
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Silverstein SM, Daniulaityte R, Miller SC, Martins SS, Carlson RG. On my own terms: Motivations for self-treating opioid-use disorder with non-prescribed buprenorphine. Drug Alcohol Depend 2020; 210:107958. [PMID: 32203863 PMCID: PMC7190448 DOI: 10.1016/j.drugalcdep.2020.107958] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/05/2020] [Accepted: 03/07/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The opioid overdose crisis in the United States has prompted an expansion of treatment services, including pharmacotherapy with buprenorphine. However, many people who use illicit opioids (PWUIO) self-treat their opioid-use disorder (OUD) with non-prescribed buprenorphine (NPB) in lieu of attending formal treatment. The present study aims to qualitatively understand motivations of people who are self-treating their OUD with NPB. METHODS Qualitative study designed to supplement and contextualize quantitative findings from natural history study of buprenorphine diversion, self-treatment, and use of substance use disorder treatment services. Interviews were audio-recorded, transcribed, systematically coded and analyzed via Iterative Categorization. STUDY SETTING The Dayton, Ohio metropolitan area in the midwestern United States; a site previously characterized as high impact in the national opioid overdose crisis. PARTICIPANTS Sixty-five individuals (35 men and 30 women) who met the DSM-5 criteria for OUD (moderate or severe) and had used NPB at least one time in the six months prior to their intake interview. RESULTS Participants described four key motivators for self-treating with NPB: perceived demands of formal treatment, the desire to utilize non-prescribed buprenorphine in combination with a geographic relocation, to self-initiate treatment while preparing for formal services, and to bolster a sense of self-determination and agency in their recovery trajectory. CONCLUSIONS Use of NPB is a recognized self-treatment modality among PWUIO, with some PWUIO transitioning into sustained recovery episodes or enrollment in formal treatment. Understanding the motivations for opting out of treatment is crucial for improving forms of care for people with OUD.
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Affiliation(s)
- Sydney M. Silverstein
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University; 3171 Research Blvd, Kettering, OH, USA
| | - Raminta Daniulaityte
- College of Health Solutions, Arizona State University, 425 N 5(th)Street, Arizona Biomedical Collaborative 121, Phoenix, AZ, 85004, USA.
| | - Shannon C. Miller
- Dayton VA Medical Center/Middletown CBOC; 4337 Union Road, Middletown, OH 45005,Departments of Psychiatry & Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University; 3171 Research Blvd, Kettering, OH, USA
| | - Silvia S. Martins
- Columbia University Mailman School of Public Health, 722 West 168th Street 5th Floor Room 509, New York, NY, USA
| | - Robert G. Carlson
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University; 3171 Research Blvd, Kettering, OH, USA
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Morozova O, Crawford FW, Cohen T, Paltiel AD, Altice FL. Cost-effectiveness of expanding the capacity of opioid agonist treatment in Ukraine: dynamic modeling analysis. Addiction 2020; 115:437-450. [PMID: 31478285 PMCID: PMC7015766 DOI: 10.1111/add.14797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 06/24/2019] [Accepted: 08/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although opioid agonist treatment (OAT) for opioid use disorder (OUD) is cost-effective in settings where the HIV epidemic is concentrated among people who inject drugs, OAT coverage in Ukraine remains far below internationally recommended targets. Scale-up is limited by both OAT availability and demand. This study aimed to evaluate the cost-effectiveness of a range of plausible OAT scale-up strategies in Ukraine incorporating the potential impact of treatment spillover and the real-world demand for addiction treatment. DESIGN, SETTING AND PARTICIPANTS Ten-year horizon (2016-25) modeling study of opioid addiction epidemic and treatment that accommodated potential peer effects in opioid use initiation and supply-induced treatment demand in three Ukrainian cities: Kyiv, Mykolaiv and Lviv, comprising a simulated population of people at risk of and with OUD. MEASUREMENTS Incremental cost per quality-adjusted life-year gained in the simulated population. FINDINGS An estimated 12.2-, 2.4- and 13.4-fold OAT capacity increase over 2016 baseline capacity in Kyiv, Mykolaiv and Lviv, respectively, would be cost-effective at a willingness-to-pay of one per-capita gross domestic product (GDP) per quality-adjusted life-year gained. This result is robust to parametric and structural uncertainty. Even under the most ambitious capacity increase, OAT coverage (i.e. the proportion of people with OUD receiving OAT) over a 10-year modeling horizon would be 20, 11 and 17% in Kyiv, Mykolaiv and Lviv, respectively, owing to limited demand. CONCLUSIONS It is estimated that a substantial increase in opioid agonist treatment (OAT) capacity in three Ukrainian cities would be cost-effective for a wide range of willingness-to-pay thresholds. Even a very ambitious capacity increase, however, is unlikely to reach internationally recommended coverage levels. Further increases in coverage may be limited by demand and would require addressing existing structural barriers to OAT access.
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Affiliation(s)
- Olga Morozova
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Forrest W Crawford
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
- Department of Statistics and Data Science, Yale University, New Haven, CT, USA
- Yale School of Management, New Haven, CT, USA
| | - Ted Cohen
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - A David Paltiel
- Yale School of Management, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Frederick L Altice
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- University of Malaya, Kuala Lumpur, Malaysia
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Smith LR, Mittal ML, Wagner K, Copenhaver MM, Cunningham CO, Earnshaw VA. Factor structure, internal reliability and construct validity of the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS). Addiction 2020; 115:354-367. [PMID: 31478272 PMCID: PMC7089617 DOI: 10.1111/add.14799] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 05/07/2019] [Accepted: 08/23/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIM Experience of stigma towards methadone maintenance treatment (MMT) may be a barrier to the use of this treatment by people with opioid use disorder. We evaluated the factor structure, internal reliability, construct and criterion validity of a theory-based stigma measure, the Methadone Maintenance Treatment Stigma Mechanisms Scale (MMT-SMS) and compared this with the Substance Use Stigma Mechanism Scale (SU-SMS). DESIGN Surveys at the beginning and end of a prospective study together with records of drug use and treatment attendance during that study. SETTING Community methadone clinic in the Northeastern USA. PARTICIPANTS Ninety-three participants who were receiving MMT; the average daily methadone dose was 84.8 mg/day (standard deviation = 28.39 mg/day). MEASUREMENTS The MMT-SMS uses a self-report questionnaire to assess three dimensions reflecting experiences of anticipated (nine items), enacted (nine items) and internalized stigma (seven items) specifically related to receiving MMT. Anticipated and enacted scales include three stigma source subscales (family, employers, health care workers; three items each). Responses are recorded on a five-point Likert-type scale, then averaged to produce the MMT-SMS scale/subscale scores. The SU-SMS is a self-report questionnaire to assess experiences of anticipated, enacted and internalized stigma regarding substance use history. Both scales were administered at the final parent study visit. Other measures included were assessed in the parent study and used to assess life-time and recent MMT (e.g. current MMT dose) and drug use experiences (e.g. past 30-day heroin injection). FINDINGS The MMT-SMS demonstrated good internal reliability (α = 0.806-0.952 for components). Confirmatory factor analysis supported the seven-factor scale structure, distinguishing between experiences of anticipated, enacted and internalized stigma, and anticipated and enacted stigma source subscales (family, employers, health care workers) [root mean square error of approximation (RMSEA) = 0.076, 90% confidence interval (CI) = 0.061-0.090, P-close = 0.003; confirmatory fit index (CFI) = 0.974; Tucker-Lewis index (TLI) = 0.971]. Construct validity helped to distinguish the MMT-SMS from established substance use stigma constructs. Criterion validity observed associations with substance use experiences while on MMT, likely to predict future MMT success. Internalized MMT stigma was uniquely associated with daily MMT dose. Regarding criterion validity: anticipated MMT and enacted substance use stigma were associated with past 30-day heroin injection, MMT stigma uniquely associated with opioid use behaviors while receiving MMT, and substance use stigma broadly associated with injection-related behaviors. CONCLUSIONS The Methadone Maintenance Treatment Stigma Mechanisms Scale appears to be a reliable measure of methadone maintenance treatment stigma with robust validity in a sample of people with opioid use disorders receiving methadone maintenance treatment.
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Affiliation(s)
- Laramie R Smith
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, USA
| | - Maria Luisa Mittal
- Division of Infectious Diseases and Global Public Health, University of California San Diego, La Jolla, CA, USA
| | - Karla Wagner
- School of Community Health Sciences, University of Nevada, Reno, NV, USA
| | | | - Chinazo O Cunningham
- Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, University of Delaware, Newark, DE, USA
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Abstract
OBJECTIVES The demand for substance use disorder treatment is increasing, fueled by the opioid epidemic and the Affordable Care Act mandate to treat substance use disorders. The increased demand for treatment, however, is not being met by a corresponding increase in access to or availability of treatment. This report focuses specifically on the treatment referral process, which we have identified as 1 of the key barriers to timely and effective treatment. Difficulties in referral to substance use disorder treatment are examined through the lens of providers who make referrals (ie, referral source) and individuals who work in substance use disorder facilities (ie, referral recipient). METHODS Administrative officials, emergency department physicians, addiction physicians, government officials, providers, insurance officials, and mental health advocates (n = 59) were interviewed on the referral process protocol, challenges for providers and others making referrals, and issues with substance use treatment facility intake procedures. RESULTS Several main themes were identified as barriers in the process: difficulties in determining patient eligibility, lack of transparency regarding treatment capacity, referral source knowledge/understanding of options, and issues with communication between referral source and recipient. We then proposed several solutions to address specific barriers. CONCLUSIONS Current gaps in the referral process cause delays to care. Improving systems would involve addressing these themes and expanding the use of appropriate treatments for the many patients in need.
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“They're making it so hard for people to get help:” Motivations for non-prescribed buprenorphine use in a time of treatment expansion. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 71:118-124. [DOI: 10.1016/j.drugpo.2019.06.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/19/2019] [Accepted: 06/23/2019] [Indexed: 01/22/2023]
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Johnson B, Richert T. Non-prescribed use of methadone and buprenorphine prior to opioid substitution treatment: lifetime prevalence, motives, and drug sources among people with opioid dependence in five Swedish cities. Harm Reduct J 2019; 16:31. [PMID: 31046774 PMCID: PMC6498489 DOI: 10.1186/s12954-019-0301-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 04/15/2019] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Opioid substitution treatment (OST) with methadone or buprenorphine is the most effective means of treating opioid dependence. If these substances are used by people who are not undergoing OST, they can however carry serious risks. This article examines the lifetime prevalence, motives, and drug sources for such use, as well as geographical differences in these variables. METHODS Structured interviews were conducted with 411 patients from 11 OST clinics in five Swedish cities. The researchers carried out 280 interviews on-site, while 131 interviews were conducted by specially trained patients through privileged access interviewing. Data were analyzed by frequency and average calculations, cross-tabulations, and χ2 tests. RESULTS The lifetime prevalence of non-prescribed use was 87.8% for methadone, 80.5% for buprenorphine, and 50.6% for buprenorphine/naloxone. Pseudo-therapeutic motives-avoiding withdrawal symptoms, staying clean from heroin, detoxification, or taking care of one's own OST-were commonly cited as driving the use, while using the drugs for euphoric purposes was a less common motive. Most respondents had bought or received the substances from patients in OST, but dealers were also a significant source of non-prescribed methadone and buprenorphine. Geographical differences of use, motives, and sources suggest that prescription practices in OST have a great impact on which substances are used outside of the treatment. CONCLUSIONS Experiences of non-prescribed use of methadone and buprenorphine are extremely common among those in OST in southern Sweden. As the use is typically driven by pseudo-therapeutic motives, increased access to OST might decrease the illicit demand for these substances. Buprenorphine/naloxone has a lower abuse potential than buprenorphine and should therefore be prioritized as the prescribed drug. Supervised dosage and other control measures are important provisions in the prevention of drug diversion and non-prescribed use among people not undergoing OST.
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Affiliation(s)
- Björn Johnson
- Department of Social Work, Malmö University, Malmö, Sweden
| | - Torkel Richert
- Department of Social Work, Malmö University, Malmö, Sweden
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Ritter A, Mellor R, Chalmers J, Sunderland M, Lancaster K. Key Considerations in Planning for Substance Use Treatment: Estimating Treatment Need and Demand. J Stud Alcohol Drugs Suppl 2019; Sup 18:22-30. [PMID: 30681945 PMCID: PMC6377022 DOI: 10.15288/jsads.2019.s18.22] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 02/07/2018] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Estimates of the extent of treatment need (defined by the presence of a diagnosis for which there is an effective treatment available) and treatment demand (defined as treatment seeking) are essential parts of effective treatment planning, service provision, and treatment funding. This article reviews the existing literature on approaches to estimating need and demand and the use of models to inform such estimation, and then considers the implications for health planners. METHOD A thematic review of the literature was undertaken, with a focus on covering the key concepts and research methods that have been used to date. RESULTS Both need and demand are important estimates in planning for services but contain many difficulties in moving from the theory of measurement to the practicalities of establishing these figures. Furthermore, the simple quantum of need or demand is limited in its usefulness unless it is matched with consideration of different treatment types and their relative intensity, and/or explored as a function of geography and subpopulation. Modeling can assist with establishing more fine-tuned planning estimates, and is able to take into account both client severity and the various treatment types that might be available. CONCLUSIONS Moving from relatively simplistic estimates of need and demand for treatment, this review has shown that although such estimation can inform national or subnational treatment planning, more sophisticated models are required for alcohol and other drug treatment planning. These can help health planners to determine the appropriate amount and mix of treatments for substance use disorders.
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Affiliation(s)
- Alison Ritter
- Drug Policy Modelling Program, National
Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW,
Australia
| | - Richard Mellor
- Drug Policy Modelling Program, National
Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW,
Australia
| | - Jenny Chalmers
- Drug Policy Modelling Program, National
Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW,
Australia
| | - Matthew Sunderland
- Drug Policy Modelling Program, National
Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW,
Australia
| | - Kari Lancaster
- Drug Policy Modelling Program, National
Drug and Alcohol Research Centre, University of New South Wales, Randwick, NSW,
Australia
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Barak I, Adelson M, Sason A, Livnat Y, Schreiber S, Peles E. Educational lectures enhance knowledge about the human immunodeficiency virus (HIV) and reduce risky behavior and fear among methadone maintenance treatment patients. Subst Abus 2018; 41:14-18. [PMID: 30513276 DOI: 10.1080/08897077.2018.1528492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Background: The aim of this study was to characterize human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS)-related knowledge and stigma among methadone maintenance treatment (MMT) patients and evaluate the contribution of an educational lecture in reducing risky behavior and unjustified overprotective behavior due to fear and stigma among MMT patients. Methods: Patients from an MMT clinic within a tertiary medical center were invited to an educational lecture on HIV/AIDS. Seventy participants (of current 330) were chosen by a random sample (December 2015), plus at-risk patients and HIV patients. Attendee compliance and change in scores of questionnaires on knowledge (modified HIV-K-Q-22) and on sexual and injection behaviors were studied. Results: Forty-six patients (65.7% compliance) attended the lecture, and their knowledge and behavior scores improved 2 weeks post-lecture (knowledge: from 14.2 ± 3 to 19.0 ± 2.2 [P < .0005], sexual behavior: from 12.1 ± 2.9 to 8.8 ± 3.0 [P < .0005], and injection behavior: from 7.3 ± 6.2 to 0.2 ± 1.3 [P < .0005]). The unjustified fear of proximity to HIV carriers reported by 50% attendees fell to 35% post-lecture. Eight months post-lecture, the scores on knowledge and risky behavior of 21 randomly chosen attendees were still better than pre-lecture scores (knowledge: 15.4 ± 2.3 vs. 17.2 ± 1.8 [paired t test, P = .001], sexual behavior: 13.2 ± 2.3 vs. 9.7 ± 2.9 [P < .0005], and injection behavior: 9.3 ± 5.6 vs. 2.8 ± 3.1 [P < .0005]). Drug abuse and treatment adherence were not related to intervention and to risky behavior. Conclusions: More knowledge, less fear, and less risky behavior immediately and at 8 months post-lecture reflect the success and importance of the educational intervention. Future efforts are needed in order to reduce ignorance and fear associated with HIV/AIDS.
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Affiliation(s)
- Idan Barak
- Israel AIDS Task Force, Tel Aviv, Israel
| | - Miriam Adelson
- Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Anat Sason
- Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | | | - Shaul Schreiber
- Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
| | - Einat Peles
- Dr. Miriam and Sheldon G. Adelson Clinic for Drug Abuse, Treatment and Research, Department of Psychiatry, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Sagol School of Neuroscience, Tel Aviv University, Tel Aviv, Israel
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Moran L, Keenan E, Elmusharaf K. Barriers to progressing through a methadone maintenance treatment programme: perspectives of the clients in the Mid-West of Ireland's drug and alcohol services. BMC Health Serv Res 2018; 18:911. [PMID: 30497467 PMCID: PMC6267916 DOI: 10.1186/s12913-018-3717-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 11/15/2018] [Indexed: 11/24/2022] Open
Abstract
Background The ‘perfect’ journey through an Irish Methadone Maintenance Treatment Programme (MMTP) would have a client engage appropriately with all relevant services available to them, inclusive of psychiatry, counselling, out-reach support, nursing and psychology. Concurrently, a client would ideally adhere to their prescribed methadone-dosing regimen, until a client is stabilised allowing them to function optimally. At this point, a client should transfer to the GP community setting. Unfortunately, this fails to occur. To date, very few studies have specifically investigated the reasons why a cohort of clients remain ‘trapped’ in the high risk, specialist clinical setting. Methods Qualitative detailed semi-structured interviews were undertaken with 17 clients of one of Ireland’s Health Service Executive (HSE) Drug and Alcohol Services, entitled ‘HSE Mid-West Limerick Drug and Alcohol Service’. Each client had a severe Opioid Use Disorder (OUD) and clients had spent on average 7.5 years engaging with the MMTP. Results Participants’ life journey prior to an OUD included Adverse Childhood Experiences (ACEs) and early exposure to illicit drug use. Shared life events resulting in their initiating and sustaining an OUD involved continuous hardship into adulthood, mental illness and concurrent benzodiazepine use disorder, often resulting in harrowing accounts of participants’ loneliness and lack of life purpose. Their living environments, an erroneous understanding of their illness and poor communication with allied health professionals further perpetuated their OUD. Positive factors influencing periods of abstinence were familial incentives and a belief in the efficacy of methadone. Clients own suggestions for improving their journeys included employing a multi-sectorial approach to managing OUD and educating themselves and others on opioid agonist treatments. If clients were not progressing appropriately, they themselves suggested enforcing a ‘time-limit’ on clients to engage with the programme or indeed for their treatment to be postponed. Conclusions To optimise the functioning of the MMTP, three tasks need to be fulfilled: 1) Reduce the incidences of ACEs, 2) Diagnose and treat clients with a dual diagnosis 3) Educate clients, their families, the public and allied health care professionals on all aspects of OUD. A cross- departmental, inter-governmental approach is needed to address opioid misuse as a societal issue as a whole.
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Affiliation(s)
- Lisa Moran
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - Eamon Keenan
- HSE, Social Inclusion Office, Primary Care Division, Dublin, Ireland
| | - Khalifa Elmusharaf
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
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Interest in Getting Help to Reduce or Stop Substance Use Among Syringe Exchange Clients Who Use Opioids. J Addict Med 2018; 12:428-434. [DOI: 10.1097/adm.0000000000000426] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Madden LM, Farnum SO, Eggert KF, Quanbeck AR, Freeman RM, Ball SA, Schottenfeld RS, Shi JM, Savage ME, Barry DT. An investigation of an open-access model for scaling up methadone maintenance treatment. Addiction 2018; 113:1450-1458. [PMID: 29453891 DOI: 10.1111/add.14198] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/03/2017] [Accepted: 02/09/2018] [Indexed: 01/01/2023]
Abstract
AIMS To examine retrospectively patient and programmatic outcomes following the development and implementation of an 'open-access' model in which prospective patients were enrolled rapidly in methadone maintenance treatment, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. DESIGN Medical and administrative records were abstracted to compare data for 1 year before and 9 years after initiating the implementation of an open-access treatment model in May 2007. SETTING Methadone maintenance treatment center in Connecticut, USA. PARTICIPANTS Individuals with opioid use disorder entering treatment between July 2006 and June 2015. In June 2015, 64% (n = 2594) of the sample were men and 80% (n = 3133) reported that they were white. INTERVENTION The Network for the Improvement of Addiction Treatment-informed open-access treatment model uses process improvement strategies to improve treatment access and capacity. MEASUREMENTS Census, waiting time, retention, non-medical opioid use, patient mortality and financial sustainability (net income and state-block grants as proportions of revenue). FINDINGS In the 9 years following the initial implementation of the open-access model, patient census increased by 183% from 1431 to 4051, and average waiting-time days decreased from 21 to 0.3 (same day) without apparent deleterious effects on rates of retention, non-medical opioid use or mortality. Between fiscal years (FY) 06 and FY 15, net operating margin rose from 2 to 10%, while state-block grant revenues declined 14% and the proportion of total revenue from state-block grant revenue decreased from 49 to 24%. CONCLUSIONS An open-access model for rapid enrolment of people with opioid use disorder in methadone treatment appears to improve treatment access, capacity, and financial sustainability without evidence of deleterious effects on treatment outcomes.
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Affiliation(s)
- Lynn M Madden
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
| | | | | | | | | | - Samuel A Ball
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
| | - Richard S Schottenfeld
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
| | - Julia M Shi
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
| | - Mary Ellen Savage
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
| | - Declan T Barry
- Yale University School of Medicine, New Haven, CT, USA.,The APT Foundation, Inc., New Haven, CT, USA
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Weinstein ZM, Gryczynski G, Cheng DM, Quinn E, Hui D, Kim HW, Labelle C, Samet JH. Tapering off and returning to buprenorphine maintenance in a primary care Office Based Addiction Treatment (OBAT) program. Drug Alcohol Depend 2018; 189:166-171. [PMID: 29958128 PMCID: PMC6139651 DOI: 10.1016/j.drugalcdep.2018.05.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/13/2018] [Accepted: 05/04/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Guidelines recommend long-term treatment for opioid use disorder including the use of buprenorphine; however, many patients desire to eventually taper off. This study examines the prevalence and patient characteristics of patients that voluntarily taper off buprenorphine. METHODS This is a 12-year retrospective cohort study of adults on buprenorphine in a large urban safety-net primary care practice. The primary outcome was completion of a voluntary buprenorphine taper, which was further characterized as a medically supervised or unsupervised taper. The secondary outcome was re-engagement in care after taper. Descriptive statistics and estimated proportions of both taper completion and re-engagement in treatment were calculated using Kaplan-Meier estimates. RESULTS The study sample included 1308 patients with a median follow-up time of 316 days; 48 patients were observed to taper off buprenorphine during the study period, with an estimated proportion of 15% (95%CI: 10%-21%) based on Kaplan Meier analyses. Less than half of the tapers, 45.8% (22/48), were medically supervised. Thirteen of the 48 patients subsequently, re-engaged in buprenorphine treatment (estimated proportion 61%, 95%CI: 27%-96%), based on Kaplan-Meier analyses with median follow-up time of 490 days. DISCUSSION Despite the fact that many patients desire to discontinue buprenorphine, a minority had a documented taper. Among those who tapered, more than half did so unsupervised by the clinic and a majority of those who tapered off returned to buprenorphine treatment within two years. As many patients are unable to successfully taper off buprenorphine, the medical community must work to address any barriers to long-term maintenance.
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Affiliation(s)
- Zoe M Weinstein
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States.
| | | | - Debbie M Cheng
- Boston University School of Public Health, Department of Biostatistics, 801 Massachusetts Avenue, 3rd Floor, Boston, MA, 02118, United States
| | - Emily Quinn
- Boston University School of Public Health, Biostatistics and Epidemiology Data Analytics Center, 85 East Newton St, M921, Boston, MA, 02118, United States
| | - David Hui
- Boston University School of Medicine, 72 East Concord St., Boston, MA, 02118, United States
| | - Hyunjoong W Kim
- Boston University School of Medicine, 72 East Concord St., Boston, MA, 02118, United States
| | - Colleen Labelle
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States
| | - Jeffrey H Samet
- Boston University School of Medicine/Boston Medical Center, Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education (CARE) Unit, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States; Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Avenue, 2nd Floor, Boston, MA, 02118, United States
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47
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Park JN, Weir BW, Allen ST, Chaulk P, Sherman SG. Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD. Harm Reduct J 2018; 15:34. [PMID: 29976195 PMCID: PMC6034235 DOI: 10.1186/s12954-018-0240-z] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/15/2018] [Indexed: 01/06/2023] Open
Abstract
Background The opioid crisis remains a major public health issue in the US and beyond. Despite rapid rises in fentanyl-related mortality nationally, little is known about the role of fentanyl in the occurrence of non-fatal overdose among people who use drugs. We examined the prevalence of non-fatal overdose and perceived fentanyl exposure among syringe services program (SSP) clients and modeled the correlates of non-fatal overdose. Methods Data were drawn from a cross-sectional survey of 203 SSP clients in Baltimore, MD recruited in 2016. Logistic regression models were used to identify the correlates of experiencing non-fatal overdose in the past 12 months. Results The majority (65%) was male, 52% were black, 41% were white, and 37% were homeless. Almost all (97%) used heroin, 64% injected heroin with cocaine (i.e., speedball), and many used other types of drugs. Half (53%) perceived fentanyl presence in their drugs either half, most or all of the time. Lifetime and past 12 month prevalence of non-fatal overdose were 58 and 31%, respectively. Independent correlates of non-fatal overdose in the past 12 months were perceiving fentanyl in drugs more than half the time (aOR = 2.79; 95% CI = 1.00–4.68), speedball injection (aOR = 2.80, 95% CI = 1.26–6.23), non-prescription buprenorphine use (aOR = 6.37; 95% CI = 2.86–14.17), and homelessness (aOR = 3.07; 95% CI = 1.28–7.39). Conclusions These data demonstrate that SSP clients are at high-risk of overdose, some of which is likely attributable to fentanyl exposure. Addressing the rising fentanyl epidemic will require comprehensive and innovative strategies that attend to drug use patterns and structural factors such as homelessness.
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Affiliation(s)
- Ju Nyeong Park
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Ju Nyeong Park, 624 N Broadway, HH163, Baltimore, MD, 21205, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA.
| | - Brian W Weir
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Ju Nyeong Park, 624 N Broadway, HH163, Baltimore, MD, 21205, USA
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Ju Nyeong Park, 624 N Broadway, HH163, Baltimore, MD, 21205, USA
| | - Patrick Chaulk
- Baltimore City Health Department, 1001 E. Fayette St, Baltimore, MD, 21201, USA.,Department of Health, Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA.,Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, MD, 21205, USA
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Ju Nyeong Park, 624 N Broadway, HH163, Baltimore, MD, 21205, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD, 21205, USA
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48
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Russolillo A, Moniruzzaman A, Somers JM. Methadone maintenance treatment and mortality in people with criminal convictions: A population-based retrospective cohort study from Canada. PLoS Med 2018; 15:e1002625. [PMID: 30063699 PMCID: PMC6067717 DOI: 10.1371/journal.pmed.1002625] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 06/27/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Individuals with criminal histories have high rates of opioid dependence and mortality. Excess mortality is largely attributable to overdose deaths. Methadone maintenance treatment (MMT) is one of the best evidence-based opioid substitution treatments (OSTs), but there is uncertainty about whether methadone treatment reduces the risk of mortality among convicted offenders over extended follow-up periods. The objective of this study was to investigate the association between adherence to MMT and overdose fatality as well as other causes of mortality. METHODS AND FINDINGS We conducted a retrospective cohort study involving linked population-level administrative data among individuals in British Columbia (BC), Canada with a history of conviction and who filled a methadone prescription between January 1, 1998 and March 31, 2015. Participants were followed from the date of first-dispensed methadone prescription until censoring (date of death or March 31, 2015). Methadone was divided into medicated (methadone was dispensed) and nonmedicated (methadone was not dispensed) periods and analysed as a time-varying exposure. Hazard ratios (HRs) with 95% CIs were estimated using multivariable Cox regression to examine mortality during the study period. All-cause and cause-specific mortality rates were compared during medicated and nonmedicated methadone periods. Participants (n = 14,530) had a mean age of 34.5 years, were 71.4% male, and had a median follow-up of 6.9 years. A total of 1,275 participants died during the observation period. The overall all-cause mortality rate was 11.2 per 1,000 person-years (PYs). Participants were significantly less likely to die from both nonexternal (adjusted HR [AHR] 0.27 [95% CI 0.23-0.33]) and external (AHR 0.41 [95% CI 0.33-0.51]) causes during medicated periods, independent of sociodemographic, criminological, and health-related factors. Death due to infectious diseases was 5 times lower (AHR 0.20 [95% CI 0.13-0.30]), and accidental poisoning (overdose) deaths were nearly 3 times lower (AHR 0.39 [95% CI 0.30-0.50]) during medicated periods. A competing risk regression demonstrated a similar pattern of results. The use of a Canadian offender population may limit generalizability of results. Furthermore, our observation period represents community-based methadone prescribing and may omit prescriptions administered during hospital separations. Therefore, the magnitude of the protective effects of methadone from nonexternal causes of death should be interpreted with caution. CONCLUSIONS Adherence to methadone was associated with significantly lower rates of death in a population-level cohort of Canadian convicted offenders. Achieving higher rates of adherence may reduce overdose deaths and other causes of mortality among offenders and similarly marginalized populations. Our findings warrant examination in other study centres in response to the crisis of opiate-involved deaths.
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Affiliation(s)
- Angela Russolillo
- Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Akm Moniruzzaman
- Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Julian M. Somers
- Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Khazaee-Pool M, Moeeni M, Ponnet K, Fallahi A, Jahangiri L, Pashaei T. Perceived barriers to methadone maintenance treatment among Iranian opioid users. Int J Equity Health 2018; 17:75. [PMID: 29890990 PMCID: PMC5996552 DOI: 10.1186/s12939-018-0787-z] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 05/29/2018] [Indexed: 11/13/2022] Open
Abstract
Background Opioid use is a severe problem in Iran. Despite methadone maintenance treatment (MMT) programs being one of the most important treatment strategies for reducing individual and public harms associated with opioid use, a large proportion of Iranian patients refuse to participate in such treatment programs. Methods The present study aims to explore the beliefs and attitudes toward MMT programs of opioid-dependent patients who were participating or had participated in methadone therapy. In-depth interviews were conducted with 23 opioid users between 27 and 58 years of age from Kurdistan provinces. Results Overall, six themes were discovered to be key barriers relating to methadone treatment, including financial barriers related to methadone treatment, lack of awareness about methadone treatment, negative attitudes regarding using methadone, worries about methadone’s side effects, social stigma ascribed to methadone therapy, and systemic barriers to methadone treatment. Conclusion Our study revealed that the cost of treatment is a major obstacle to attending and continuing at MMT programs and that addicts and their families are not always accurately informed about the duration of MMT programs and the side effects of methadone treatment.
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Affiliation(s)
- Maryam Khazaee-Pool
- Department of Health Education and Promotion, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Maryam Moeeni
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Koen Ponnet
- Department of Communication Sciences, imec-mict-Ghent University, Ghent, Belgium
| | - Arezoo Fallahi
- Enviromental Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Science, Sanandaj, Iran
| | - Leila Jahangiri
- Research Center for Evidence Based Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Tahereh Pashaei
- Enviromental Health Research Center, Research Institute for Health Development, Kurdistan University of Medical Science, Sanandaj, Iran. .,Department of Public Health, Faculty of Health, Kurdistan University of Medical Sciences, Sanandaj, Iran.
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50
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Muller AE, Bjørnestad R, Clausen T. Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications. Drug Alcohol Depend 2018; 187:22-28. [PMID: 29626742 DOI: 10.1016/j.drugalcdep.2018.02.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 02/21/2018] [Accepted: 02/22/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications. AIM To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients. METHODS Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions. RESULTS High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication. CONCLUSIONS Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction.
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Affiliation(s)
- Ashley Elizabeth Muller
- Norwegian Centre for Addiction Research, Institute for Clinical Medicine, University of Oslo, Postboks 1039 Blindern, 0315 Oslo, Norway.
| | | | - Thomas Clausen
- Norwegian Centre for Addiction Research, Institute for Clinical Medicine, University of Oslo, Postboks 1039 Blindern, 0315 Oslo, Norway
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