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Todd-Kvam J, Clausen T. Practitioner perspectives on working with older patients in opioid agonist treatment (OAT) in Norway: opportunities and challenges. Addict Sci Clin Pract 2024; 19:44. [PMID: 38783382 PMCID: PMC11118995 DOI: 10.1186/s13722-024-00473-7] [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: 08/01/2023] [Accepted: 05/08/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Norway has a growing proportion of ageing opioid agonist treatment (OAT) patients, with 42% of the 8300 Norwegian OAT patients aged over 50 in 2022. This study aims to explore practitioners' views and experiences from treatment of ageing OAT patients. METHODS Data were collected as a series of semi-structured interviews with treatment staff (roles interviewed: doctor, psychologist, social worker, nurse, and learning disability nurse). Participants were recruited from three OAT outpatient clinics, one with an urban catchment area and two with a mix of urban and rural. The interviews incorporated questions on patients' somatic and mental health, strengths and weaknesses of the service for this group, and patients' quality of life. RESULTS Older patients were perceived to be more often stable in terms of substance use and housing situation, but also experiencing some key challenges in terms of cognitive impairment, loneliness and isolation, and comorbidities. Both the practitioner-patient relationship and healthcare interactions outside OAT had the potential to impact treatment quality positively or negatively depending on how they were managed. CONCLUSIONS Treating older patients in a way that respects and enhances their dignity is important. We argue that this requires better services for those whose functioning is impacted by cognitive impairment/dementia, an age-informed treatment model for this patient group, along with urgent work to improve municipal-level services given practitioners describe them as unacceptable in certain areas.
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Affiliation(s)
- John Todd-Kvam
- Norwegian Centre for Addiction Research, University of Oslo, Blindern, Postboks 1039, 0315, Oslo, Norway.
- Sørlandet Sykehus HF, Lundsiden, Postboks 416, 4604, Kristiansand, Norway.
| | - Thomas Clausen
- Norwegian Centre for Addiction Research, University of Oslo, Blindern, Postboks 1039, 0315, Oslo, Norway
- Sørlandet Sykehus HF, Lundsiden, Postboks 416, 4604, Kristiansand, Norway
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2
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Bardwell G, Ivsins A, Wallace JR, Mansoor M, Kerr T. "The machine doesn't judge": Counternarratives on surveillance among people accessing a safer opioid supply via biometric machines. Soc Sci Med 2024; 345:116683. [PMID: 38364722 DOI: 10.1016/j.socscimed.2024.116683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/16/2024] [Accepted: 02/08/2024] [Indexed: 02/18/2024]
Abstract
People who use illegal drugs experience routine surveillance, including in healthcare and harm reduction settings. The MySafe Project - a safer supply pilot project that dispenses prescription opioids via a biometric vending machine - exists in the Canadian province of British Columbia. The machine scans a participant's palmprint and has a built-in camera that records every machine interaction. The aim of this paper is to understand participants' experiences of surveillance, privacy, and personal security when accessing this novel program. An integrative case study and grounded theory methodology was employed. Qualitative one-to-one interviews were conducted with 46 MySafe participants across three different program sites in Vancouver. We used a team-based approach to code interview transcripts and utilized directed and conventional content analyses for deductive and inductive analyses. While participants described negative experiences of surveillance in other public and harm reduction settings, they did not have concerns regarding cameras, collection of personal information, tracking, nor staff issues associated with MySafe. Similarly, while some participants had privacy concerns in other settings, very few privacy and confidentiality concerns were expressed regarding accessing the machine in front of others. Lastly, while some participants reported being targeted by others when accessing the machines, most participants described how cameras, staff, and machine locations helped ensure a sense of safety. Despite negative experiences of surveillance and privacy issues elsewhere, participants largely lacked concern regarding the MySafe program and machines. The machine-human interaction was characterized as different than some human-human interactions as the machine is completing tasks in a manner that is acceptable and comfortable to participants, leading to a social preference toward the machines in comparison to other surveilled means of accessing medications. These findings provide an opportunity to rethink how we conceptualize surveillance, medication access, and harm reduction programs targeting people who use drugs.
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Affiliation(s)
- Geoff Bardwell
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada; British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - Andrew Ivsins
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
| | - James R Wallace
- School of Public Health Sciences, Faculty of Health, University of Waterloo, 200 University Avenue West, Waterloo, ON, N2L 3G1, Canada.
| | - Manal Mansoor
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada.
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, V6Z 2A9, Canada; Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, BC, V6Z 1Y6, Canada.
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3
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Witcraft SM, Johnson C, Guille C. The Psychiatrist's Role in Treating Perinatal Opioid Use Disorder and Reducing Maternal Mortality. FOCUS (AMERICAN PSYCHIATRIC PUBLISHING) 2024; 22:25-34. [PMID: 38694152 PMCID: PMC11058912 DOI: 10.1176/appi.focus.20230018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2024]
Abstract
Drug overdose is a leading cause of maternal mortality. Psychiatrists can play a critical role in reducing these deaths by delivering effective evidence-based treatments for perinatal opioid use disorder (POUD), including the use of buprenorphine. Medications for POUD (i.e., buprenorphine, methadone) are life-saving treatments, but only half of those who are diagnosed as having POUD will receive this treatment, which can result in an increased risk for return to opioid use, overdose, and death. Psychiatrists are well positioned to prescribe buprenorphine given the Drug Enforcement Administration's (DEA) removal of the requirement to submit a Notice of Intent to prescribe buprenorphine for the treatment of opioid use disorders. Psychiatrists who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorders; the training requirements to do so are outlined herein. This article reviews the standard of care for screening, diagnosis, and treatment of POUD, and prescribing buprenorphine for POUD, as well as shared decision-making for medication selection, induction, and maintenance of buprenorphine during pregnancy, labor and delivery, and the postpartum year.
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Affiliation(s)
- Sara M Witcraft
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
| | - Claire Johnson
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
| | - Constance Guille
- Department of Psychiatry and Behavioral Sciences (all authors) and Department of Obstetrics and Gynecology (Guille), Medical University of South Carolina, Charleston
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4
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Lepley J. President's message. J Addict Dis 2023; 41:263-265. [PMID: 37466366 DOI: 10.1080/10550887.2023.2237394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Jon Lepley
- Addiction Medicine, Penn Medicine Lancaster General Health, Lancaster, PA, USA
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5
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Conway A, Krawczyk N, McGaffey F, Doyle S, Baaklini V, Marshall AD, Treloar C, Davis CS, Colledge-Frisby S, Grebely J, Cerdá M. Typology of laws restricting access to methadone treatment in the United States: A latent class analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104141. [PMID: 37540917 DOI: 10.1016/j.drugpo.2023.104141] [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: 02/10/2023] [Revised: 07/09/2023] [Accepted: 07/14/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND In the United States, methadone treatment for opioid use disorder is only available at opioid treatment programs (OTPs). In addition to federal regulations, states can enact laws which shape access to OTPs. We aimed to define classes of states according to restrictiveness of state OTP laws and examine population characteristics associated with class membership. METHODS A set of laws was extracted from a database of statutes and regulations governing OTPs in 49 states and the District of Columbia as of June 2021. Latent class analysis of laws was used to estimate the probability of class membership for each state. Class-weighted multinomial logistic regression analysis assessed state-level correlates of class membership and adjusted Relative Risk Ratio (aRRR) and 95% confidence intervals (95%CI) were generated. RESULTS States (n = 50) were assigned to three classes; Class 1) High restrictiveness on patient experience, low restrictiveness on access to service (n = 13); Class 2) Medium restrictiveness on patient experience, high restrictiveness on access to service (n = 14); Class 3) Low restrictiveness on patient experience, low restrictiveness on access to service (n = 23). States with a higher probability of membership in Classes with higher restrictiveness had higher rates of unemployment (Class 1 vs Class 3, aRRR:1.24; 95%CI:1.06-1.45), and Black residents (Class 2 vs Class 3, aRRR:1.10; 95%CI:1.04-1.15), and lower likelihood of Medicaid coverage of methadone (Class 1 vs Class 3, aRRR:0.25; 95%CI:0.07-0.88). States with a higher probability of membership in Classes with higher restrictiveness also had higher rates of potential indicators for opioid use disorder treatment need, including rates of opioid dispensing (Class 1 vs Class 3, aRRR:1.06; 95%CI:1.02-1.10, Class 2 vs Class 3, aRRR:1.07; 95%CI:1.03-1.11) and HIV diagnoses attributed to injection (Class 1 vs Class 3, aRRR:3.92; 95%CI:1.25-12.22). CONCLUSIONS States with indicators of greater potential need for opioid use disorder treatment have the most restrictions, raising concerns about unmet treatment need.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW, Sydney, Australia; Centre for Social Research in Health, UNSW, Sydney, Australia.
| | - Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
| | | | - Sheri Doyle
- The Pew Charitable Trusts, Philadelphia, United States
| | | | - Alison D Marshall
- The Kirby Institute, UNSW, Sydney, Australia; Centre for Social Research in Health, UNSW, Sydney, Australia
| | - Carla Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | - Corey S Davis
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States; Network for Public Health Law, Los Angeles, United States
| | - Samantha Colledge-Frisby
- National Drug Research Institute, Curtin University, Melbourne, Australia; National Drug and Alcohol Research Centre, Burnet Institute, Melbourne, Australia
| | | | - Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, NY, United States
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Conway A, Marshall AD, Crawford S, Hayllar J, Grebely J, Treloar C. Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study. Implement Sci 2023; 18:22. [PMID: 37296448 DOI: 10.1186/s13012-023-01281-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 06/02/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic. METHODS Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access. RESULTS We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses. CONCLUSIONS The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.
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Affiliation(s)
- Anna Conway
- The Kirby Institute, UNSW, Sydney, Australia.
- Centre for Social Research in Health, UNSW, Sydney, Australia.
| | - Alison D Marshall
- The Kirby Institute, UNSW, Sydney, Australia
- Centre for Social Research in Health, UNSW, Sydney, Australia
| | | | - Jeremy Hayllar
- Alcohol and Drug Service, Metro North Mental Health, Metro North Hospital and Health Service, Brisbane, Australia
| | | | - Carla Treloar
- Centre for Social Research in Health, UNSW, Sydney, Australia
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7
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Guerra-Alejos BC, Kurz M, Min JE, Dale LM, Piske M, Bach P, Bruneau J, Gustafson P, Hu XJ, Kampman K, Korthuis PT, Loughin T, Maclure M, Platt RW, Siebert U, Socías ME, Wood E, Nosyk B. Comparative effectiveness of urine drug screening strategies alongside opioid agonist treatment in British Columbia, Canada: a population-based observational study protocol. BMJ Open 2023; 13:e068729. [PMID: 37258082 PMCID: PMC10255039 DOI: 10.1136/bmjopen-2022-068729] [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: 09/29/2022] [Accepted: 04/26/2023] [Indexed: 06/02/2023] Open
Abstract
INTRODUCTION Urine drug tests (UDTs) are commonly used for monitoring opioid agonist treatment (OAT) responses, supporting the clinical decision for take-home doses and monitoring potential diversion. However, there is limited evidence supporting the utility of mandatory UDTs-particularly the impact of UDT frequency on OAT retention. Real-world evidence can inform patient-centred approaches to OAT and improve current strategies to address the ongoing opioid public health emergency. Our objective is to determine the safety and comparative effectiveness of alternative UDT monitoring strategies as observed in clinical practice among OAT clients in British Columbia, Canada from 2010 to 2020. METHODS AND ANALYSIS We propose a population-level retrospective cohort study of all individuals 18 years of age or older who initiated OAT from 1 January 2010 to 17 March 2020. The study will draw on eight linked health administrative databases from British Columbia. Our primary outcomes include OAT discontinuation and all-cause mortality. To determine the effectiveness of the intervention, we will emulate a 'per-protocol' target trial using a clone censoring approach to compare fixed and dynamic UDT monitoring strategies. A range of sensitivity analyses will be executed to determine the robustness of our results. ETHICS AND DISSEMINATION The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
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Affiliation(s)
- B Carolina Guerra-Alejos
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Laura M Dale
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, University of Montreal, Montreal, Québec, Canada
- Research Center, Centre hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Paul Gustafson
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - X Joan Hu
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kyle Kampman
- Department of Psychiatry, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - P Todd Korthuis
- School of Public Health, OHSU-PSU, Portland, Oregon, USA
- Section of Addiction Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Tom Loughin
- Department of Statistics and Actuarial Science, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert W Platt
- Departments of Epidemiology, Biostatistics, and Occupational Health and of Pediatrics, McGill University, Montreal, Québec, Canada
| | - U Siebert
- Center for Health Decision Science, Department of Health Policy and Management, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
- Department of Public Health, Health Services Research and Health Technology Assessment, Private University of Health Sciences Medical Informatics and Technology Hall/Tyrol Institute for Health Information Systems, Hall in Tirol, Austria
| | - M Eugenia Socías
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Evan Wood
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Michaud L, van der Meulen E, Guta A. Between Care and Control: Examining Surveillance Practices in Harm Reduction. CONTEMPORARY DRUG PROBLEMS 2023; 50:3-24. [PMID: 36733491 PMCID: PMC9885017 DOI: 10.1177/00914509221128598] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/08/2022] [Indexed: 02/05/2023]
Abstract
As harm reduction programs and services proliferate, people who use drugs (PWUD) are increasingly subjected to surveillance through the collection of their personal information, systematic observation, and other means. The data generated from these practices are frequently repurposed across various institutional sites for clinical, evaluative, epidemiological, and administrative uses. Rationales provided for increased surveillance include the more effective provision of care, service optimization, risk stratification, and efficiency in resource allocation. With this in mind, our reflective essay draws on empirical analysis of work within harm reduction services and movements to reflect critically on the impacts and implications of surveillance expansion. While we argue that many surveillance practices are not inherently problematic or harmful, the unchecked expansion of surveillance under a banner of health and harm reduction may contribute to decreased uptake of services, rationing and conditionalities tied to service access, the potential deepening of health disparities amongst some PWUD, and an overlay of health and criminal-legal systems. In this context, surveillance relies on the enlistment of a range of therapeutic actors and reflects the permeable boundary between care and control. We thus call for a broader critical dialogue within harm reduction on the problems and potential impacts posed by surveillance in service settings, the end to data sharing of health information with law enforcement and other criminal legal actors, and deference to the stated need among PWUD for meaningful anonymity when accessing harm reduction and health services.
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Affiliation(s)
- Liam Michaud
- Socio-Legal Studies Graduate Program, York University, Toronto,
Ontario, Canada,Liam Michaud, Socio-Legal Studies Graduate
Program, York University, 4700 Keele St, Toronto, Ontario M3J 1P3, Canada.
| | - Emily van der Meulen
- Department of Criminology, Toronto Metropolitan University, Toronto,
Ontario, Canada
| | - Adrian Guta
- School of Social Work, University of Windsor, Windsor, Ontario,
Canada,Australian Research Centre in Sex, Health and Society, La Trobe
University, Melbourne, Victoria, Australia
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9
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Buprenorphine Program Evaluation in a Private Psychiatric Office-Based Practice. J Addict Nurs 2023; 34:89-95. [PMID: 36857552 DOI: 10.1097/jan.0000000000000516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
PURPOSE The opioid crisis has contributed to the mortality, morbidity, and rising healthcare costs in the United States. Buprenorphine (BUP) is an effective medication for opioid use disorder. The aims of this quality assurance evaluation of a BUP program were to (a) evaluate the clinic's performance in illicit opioid abstinence and (b) identify patient risk and resilience characteristics to improve patient success in recovery with BUP. METHODS A retrospective chart review of open (n = 35) and closed (n = 21) cases and a cross-sectional survey in open cases were completed. Adults (aged ≥18 years) who completed 6 months of BUP treatment at a psychiatric clinic were included. Clinical performance was measured with percentages of opioid-negative urine and completed monthly urine drug tests (UDTs) for the first 6 months. Open cases were surveyed regarding risk and resilience characteristics (frequency of opioid cravings and triggers, therapy participation, and coping skills). Descriptive statistics, t test, and chi-square test were used to analyze data. RESULTS Average opioid-negative urine was significantly higher in open cases than closed cases (88.57% vs. 74.82%; t = 2.885, p = .004). There was no significant association between open cases (61.4%) and closed cases (73.8%) in completed monthly UDT. Opening and closing of cases stabilized with mandatory monthly UDT. Most individuals reported therapy participation, minimal opioid cravings, and use of distraction to cope with chronic-pain-induced cravings. CONCLUSIONS/IMPLICATIONS This clinic met benchmarks leading to improved substance recovery. Recommendations include regular evaluations of UDT, cravings, and chronic pain; therapy participation; and continuous quality assurance activities.
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Morin KA, Dabous JR, Vojtesek F, Marsh D. Evaluating the association between urine drug screening frequency and retention in opioid agonist treatment in Ontario, Canada: a retrospective cohort study. BMJ Open 2022; 12:e060857. [PMID: 36223960 PMCID: PMC9562722 DOI: 10.1136/bmjopen-2022-060857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The objective of this study was to evaluate how urine drug screening (UDS) frequency is associated with retention in opioid agonist treatment (OAT). METHODS Data for this retrospective cohort study of 55 921 adults in OAT in Ontario, Canada, were derived from administrative sources between 1 January 2011 and 31 December 2015. All patient information was linked anonymously across databases using encrypted health card numbers. Descriptive statistics were calculated for comparing UDS frequency groups using standardised differences (d) where d less than 10% indicated a statistically significant difference. A logistic regression model was then used to calculate ORs adjusting for baseline covariates, including sex, age, location of residence, income quintile, mental disorders, HIV status and deep tissue infections. RESULTS Over 70% of the cohort had four or more UDS tests per month (weekly or more UDS). Significant associations were observed between UDS frequency and 1-year treatment retention in OAT biweekly (adjusted OR (aOR)=3.20, 95% CI 2.75 to 3.75); weekly UDS (aOR=6.86, 95% CI 5.88 to 8.00) and more than weekly (aOR=8.03, 95% CI 6.87 to 9.38) using the monthly or less groups as the reference. CONCLUSION This study identified an association between weekly UDS and 1-year treatment retention in OAT. There is an active discussion within Canada about the utility of UDS. The lack of evidence for the impact of UDS on retention has left it open to some to argue they simply provide a barrier to patient engagement. Therefore, it is timely of this study to demonstrate that more frequent urine testing is not associated with a reduction in treatment retention.
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Affiliation(s)
- Kristen A Morin
- ICES North, Sudbury, Ontario, Canada
- Health Sciences North Research Institute, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - John R Dabous
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - Frank Vojtesek
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
| | - David Marsh
- ICES North, Sudbury, Ontario, Canada
- Northern Ontario School of Medicine-East Campus, Sudbury, Ontario, Canada
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11
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Kamran H, Piske M, Min JE, Pearce LA, Zhou H, Homayra F, Wang L, Small W, Nosyk B. Validation and endorsement of health system performance measures for opioid use disorder in British Columbia, Canada: A Delphi panel study. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100095. [PMID: 36844158 PMCID: PMC9948861 DOI: 10.1016/j.dadr.2022.100095] [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: 03/21/2022] [Revised: 08/16/2022] [Accepted: 08/30/2022] [Indexed: 11/30/2022]
Abstract
Background Limited data exists on the performance of the healthcare system in opioid use disorder (OUD). We evaluated the face validity and potential risks of a set of health system performance measures for OUD collaboratively with clinicians, policymakers and people with lived experience of opioid use (PWLE) in the interest of establishing an endorsed set of measures for public reporting. Methods Through a two-stage Delphi-panel approach, a panel of clinical and policy experts validated and considered 102 previously constructed OUD performance measures for endorsement using information on measurement construction, sensitivity analyses, quality of evidence, predictive validity, and feedback from local PWLE. We collected quantitative and qualitative survey responses from 49 clinicians and policymakers, and 11 PWLE. We conducted inductive and deductive thematic analysis to present qualitative responses. Results A total of 37 measures of 102 were strongly endorsed (9/13 cascade of care, 2/27 clinical guideline compliance, 17/44 healthcare integration, and 9/18 healthcare utilization measures). Thematic analysis of responses revealed several themes regarding measurement validity, unintended consequences, and key contextual considerations. Overall, measures related to the cascade of care (excluding opioid agonist treatment dose tapering) received strong endorsements. PWLE highlighted barriers to accessing treatment, undignified aspects of treatment, and lack of a full continuum of care as their concerns. Conclusion We defined 37 endorsed health system performance measures for OUD and presented a range of perspectives on their validity and use. These measures provide critical considerations for health system improvement in the care of people with OUD.
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Affiliation(s)
- Hasham Kamran
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Micah Piske
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Lindsay A Pearce
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Haoxuan Zhou
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Linwei Wang
- BC Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Will Small
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Centre for Applied Research in Mental Health and Addiction, SFU Faculty of Health Sciences, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
- Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
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12
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Russell C, Lange S, Kouyoumdjian F, Butler A, Ali F. Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA? Harm Reduct J 2022; 19:89. [PMID: 35948961 PMCID: PMC9363267 DOI: 10.1186/s12954-022-00671-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/02/2022] [Indexed: 11/12/2022] Open
Abstract
Opioid agonist treatment (OAT) is the primary intervention for opioid use disorder (OUD) in Canada and the USA. Yet, a number of barriers contribute to sub-optimal treatment uptake and retention, including daily-supervised medication administration. Thus, clients are eventually granted access to take-home OAT doses (i.e., ‘carries’) to reduce this burden. However, this decision is based on physician discretion and whether patients can demonstrate stability in various life domains, many of which are inextricably linked to the social determinants of health (SDOH). Current Canadian and USA OAT carry guidance documents are not standardized and do not take the SDOH into consideration, resulting in the potential for inequitable access to OAT carries, which may be the case particularly among marginalized populations such as individuals with OUD who have been released from custody. This perspective article posits that current OAT guidelines contribute to inequities in access to OAT carries, and that these inequities likely result in disproportionately low coverage for OUD treatment among some high-risk groups, including individuals on release from incarceration in particular. Relevant impacts of COVID-19 and related policy changes are considered, and suggestions and recommendations to amend current OAT guidance documents are provided.
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Affiliation(s)
- Cayley Russell
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada. .,Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St, ON, M5S 2S1, Toronto, Canada.
| | - Shannon Lange
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada.,Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health (CAMH), ON, Toronto, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Fiona Kouyoumdjian
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Amanda Butler
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada
| | - Farihah Ali
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health (CAMH), 33 Ursula Franklin St, Toronto, ON, M5S 2S1, Canada.,Ontario Node, Canadian Research Initiative in Substance Misuse (CRISM), 33 Ursula Franklin St, ON, M5S 2S1, Toronto, Canada
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13
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Mattocks KM, Moore DT, Wischik DL, Lazar CM, Rosen MI. Understanding opportunities and challenges with telemedicine-delivered buprenorphine during the COVID-19 pandemic. J Subst Abuse Treat 2022; 139:108777. [PMID: 35346533 PMCID: PMC8949846 DOI: 10.1016/j.jsat.2022.108777] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 02/14/2022] [Accepted: 03/22/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is a debilitating illness that remains a serious public health issue in the United States. Use of telemedicine to deliver medications for the treatment of OUD (MOUD) was limited until the confluence of the COVID-19 and opioid addiction epidemics in spring 2020. Starting in spring 2020, the Department of Veterans Health Affairs (VHA) transitioned from in-person to mostly telemedicine-delivered OUD care to reduce COVID-19 transmission among veterans and providers. To gain a nuanced understanding of provider perspectives on MOUD care delivery using telemedicine, we conducted semi-structured interviews with VHA providers who were using telehealth to deliver MOUD care. METHODS We conducted semi-structed Zoom interviews with VA clinicians at nine VA Medical Centers (VAMCs) in eight states. Potential study participants were identified as providers who were involved in referrals and provision of buprenorphine treatment for chronic pain and opioid addiction. Audio-recordings of all interviews were transcribed and entered into Atlas. Ti qualitative analysis software. The study team analyzed the transcripts for major themes related to tele-prescribing practices for buprenorphine. RESULTS Twenty-three VA providers participated in the study, representing 32% of all providers invited to participate in the study. The research team identified the following four themes: (1) COVID-19 spurred a seismic shift in OUD treatment; (2) Video calls provided a rare window into veterans' lives; (3) Providers experienced numerous challenges to virtual visits; and (4) Providers wrestled with paternalism and trust. CONCLUSIONS The pandemic accelerated the movement toward harm reduction approaches. Prior to the pandemic, stringent requirements existed for patients receiving MOUD care. Providers in this study reflected on the need for these requirements (e.g., in-person visits, toxicology screens) and how reducing this monitoring implied more trust in patients' autonomous decisions. Providers' observation that videoconferencing offered them a window into patients' lives may offer some ways to improve rapport, and research should explore how best to incorporate the additional information conveyed in virtual visits.
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Affiliation(s)
- Kristin M Mattocks
- VA Central Western Massachusetts Healthcare System, Leeds, MA, United States of America; University of Massachusetts Medical School, Worcester, MA, United States of America.
| | - David T Moore
- Yale University School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Dora Lendvai Wischik
- VA Connecticut Healthcare System, West Haven, CT, United States of America; Yale University School of Nursing, New Haven, CT, United States of America
| | - Christina M Lazar
- Yale University School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
| | - Marc I Rosen
- Yale University School of Medicine, New Haven, CT, United States of America; VA Connecticut Healthcare System, West Haven, CT, United States of America
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14
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Durand L, Keenan E, Boland F, Harnedy N, Delargy Í, Scully M, Mayock P, Ebbitt W, Vázquez MO, Corrigan N, Killeen N, Pate M, Byrne P, Cousins G. Consensus recommendations for opioid agonist treatment following the introduction of emergency clinical guidelines in Ireland during the COVID-19 pandemic: A national Delphi study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2022; 106:103768. [PMID: 35738029 PMCID: PMC9212711 DOI: 10.1016/j.drugpo.2022.103768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 10/30/2022]
Abstract
BACKGROUND Emergency contingency guidelines for opioid agonist treatment (OAT) were introduced in Ireland in March 2020, to ensure rapid and uninterrupted access to treatment while mitigating COVID-19 risk. The contingency guidelines deviated, across multiple clinical domains, from pre-pandemic clinical guidelines published in 2016. The objectives of this study are to (1) identify changes introduced to OAT clinical guidelines in Ireland during the pandemic; and (2) develop consensus on whether the new recommendations should be retained beyond the pandemic, using a national Delphi consensus methodology. METHODS Clinical guidance recommendations ('statements') were generated by comparing the newly established contingency guidelines with the national 2016 Clinical Guidelines for OAT. Over two rounds of on-line Delphi testing, a panel of experts (people currently accessing OAT, psychiatrists, general practitioners, community pharmacists, a nurse, a psychologist and support/key workers) independently rated their agreement with each statement and provided comments. Statements with a median score of 4 or 5 and a lower quartile of ≥4 were classified as having reached consensus. RESULTS Forty-eight panel members were recruited, with a high participation level at Round 2 (90%, n=43). Consensus was achieved for 12 of the 19 statements at Round 1. The 7 remaining statements were revised, with 2 new statements, resulting in 9 statements at Round 2. Four statements reached consensus at Round 2. The final list includes 16 clinical guidance statements; 9 relating to assessment, 3 to OAT drug choice and dosing, 1 to take-away doses, 2 to overdose prevention and 1 to the continuation of e-prescriptions. CONCLUSIONS A wide range of stakeholders involved in the delivery and receipt of OAT agreed on 16 clinical guidance statements for inclusion in OAT clinical guidelines as we move beyond the pandemic, rather than reverting to pre-pandemic guidelines. The agreed statements relate to facilitating safe access to OAT with minimal waiting time, supporting patient-centred care to promote health and well-being, and preventing drug overdose. Notably, consensus was not achieved for OAT drug dosage and frequency of urine testing during the stabilisation and maintenance phase of care.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular Science, Royal College of Surgeons in Ireland, First Floor, Ardilaun House (Block B), 111 St Stephen's Green, Dublin 2, D02 VN51, Ireland
| | - Eamon Keenan
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Fiona Boland
- RCSI Data Science Centre and Department of General practice, Royal College of Surgeons in Ireland, Beaux Lane House, Mercer Street Lower, Dublin 2, D02 DH60, Ireland
| | - Norma Harnedy
- HSE Addiction Services, PO Box 486, Corporate House, Mungret Street, Limerick, V94 PV34, Ireland
| | - Íde Delargy
- Irish College of General Practitioners, Lincoln Place, Dublin 2, D02 XR68, Ireland
| | - Mike Scully
- National Drug Treatment Centre, 30/31 Pearse street, Dublin 2, D02 NY26, Ireland
| | - Paula Mayock
- School of Social Work and Social Policy, 3/4 Foster place, Trinity College Dublin Dublin 2, Ireland
| | - William Ebbitt
- National Drug Treatment Centre, 30/31 Pearse street, Dublin 2, D02 NY26, Ireland
| | - María Otero Vázquez
- UISCE, National Advocacy Service for People who use Drugs in Ireland, 8 Cabra road, Dublin 7, D07 T1W2, Ireland
| | - Nicola Corrigan
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Nicki Killeen
- Health Service Executive, National Social Inclusion Office, Mill Lane, Palmerstown, Dublin 20, D20 KH63, Ireland
| | - Muriel Pate
- Health Service Executive, National Quality and Patient Safety Directorate, Dr. Steeven's Hospital, Dublin 8, D08 W2A8, Ireland
| | - Paula Byrne
- Merchants Quay Ireland Head Office, Merchants Court, 24 Merchants Quay, Dublin 8, D08 × 7YK, Ireland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular Science, Royal College of Surgeons in Ireland, First Floor, Ardilaun House (Block B), 111 St Stephen's Green, Dublin 2, D02 VN51, Ireland.
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15
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Hoffman KA, Foot C, Levander XA, Cook R, Terashima JP, McIlveen JW, Korthuis PT, McCarty D. Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis. J Subst Abuse Treat 2022; 141:108801. [PMID: 35589443 PMCID: PMC9080674 DOI: 10.1016/j.jsat.2022.108801] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/21/2022] [Accepted: 05/04/2022] [Indexed: 11/25/2022]
Abstract
Objectives In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties. Methods We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings. Results The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = −0.12, CI [−0.21, −0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers. Conclusions Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.
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16
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Suen LW, Castellanos S, Joshi N, Satterwhite S, Knight KR. "The idea is to help people achieve greater success and liberty": A qualitative study of expanded methadone take-home access in opioid use disorder treatment. Subst Abuse 2022; 43:1143-1150. [PMID: 35499469 PMCID: PMC9710250 DOI: 10.1080/08897077.2022.2060438] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Prior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California. Methods: We interviewed 10 providers (including two physicians, five social worker associates, and three nurse practitioners) and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes. Results: Patient participants were middle-aged (median age 51 years) and were predominantly men (53%). Providers discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making. Conclusion: Federal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.
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Affiliation(s)
- Leslie W. Suen
- UCSF National Clinician Scholars Program, Philip R. Lee Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA, United States,San Francisco Veterans Affairs Medical Center, San Francisco, CA, United States
| | - Stacy Castellanos
- UCSF Center for Vulnerable Populations, San Francisco General Hospital, San Francisco, CA, United States,Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Neena Joshi
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Shannon Satterwhite
- Department of Family and Community Medicine, University of California, Davis, Davis, CA, United States
| | - Kelly R. Knight
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
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17
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Sobel HG, Warrington JS, Francis-Fath S, Crocker AM, Berger CA. A Descriptive analysis of urine drug screen results in patients with opioid use disorder managed in a primary care setting. Addict Sci Clin Pract 2021; 16:59. [PMID: 34593036 PMCID: PMC8482571 DOI: 10.1186/s13722-021-00264-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 09/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Urine drug screening (UDS) is commonly used as part of treatment for opioid use disorder (OUD), including treatment with buprenorphine-naloxone for OUD in a primary care setting. Very little is known about the value of UDS, the optimum screening frequency in general, or its specific use for buprenorphine treatment in primary care. To address this question, we thought that in a stable population receiving buprenorphine-naloxone in the primary care setting it would be useful to know how often UDS yielded expected and unexpected results. METHODS We present a descriptive analysis of UDS results in patients treated with buprenorphine-naloxone for OUD in a primary care setting over a two-year period. An unexpected test result is: 1. A negative test for buprenorphine and/or 2. A positive test for opioids, methadone, cocaine and/or heroin. RESULTS A total of 161 patients received care during the study period and a total of 2588 test results were analyzed from this population. We found that 64.4% of the patient population (n = 104 patients) demonstrated both treatment adherence (as measured by buprenorphine positive test results) and no apparent unexpected test findings, as defined by negative tests for opioids, methadone, cocaine and heroin. Of the 161 patients, 20 results were positive for opioids, 5 for methadone, 39 for heroin and 2 for cocaine. Analysis at the UDS level demonstrated that, of the 2588 test results, 38 (1.5%) results did not have buprenorphine. Of the 2588, 28 (1.1%) test results were positive for opioids, 8 (0.3%) were positive for methadone, 39 (1.5%) for cocaine and 2 (0.1%) for heroin. CONCLUSION Given that the majority of patients in our study had expected urine results, it may be reasonable for less frequent urine testing in certain patients.
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Affiliation(s)
- Halle G Sobel
- University of Vermont, Robert Larner College of Medicine, VT, Burlington, USA. .,Department of General Internal Medicine, Larner College of Medicine University of Vermont, VT, Burlington, USA.
| | - Jill S Warrington
- University of Vermont, Robert Larner College of Medicine, VT, Burlington, USA.,Department of Pathology, Larner College of Medicine University of Vermont, VT, Burlington, USA
| | - Samuel Francis-Fath
- University of Vermont, Robert Larner College of Medicine, VT, Burlington, USA.,, South Burlington, VT, Averheatlh, USA
| | - Abigail M Crocker
- University of Vermont, Robert Larner College of Medicine, VT, Burlington, USA.,Department of Mathetmatics and Statistics College of Engineering and Mathematical Sciences, University of Vermont, VT, Burlington, USA
| | - Claudia A Berger
- University of Vermont, Robert Larner College of Medicine, VT, Burlington, USA.,Department of General Internal Medicine, Larner College of Medicine University of Vermont, VT, Burlington, USA
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18
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Lachapelle É, Archambault L, Blouin C, Perreault M. Perspectives of people with opioid use disorder on improving addiction treatments and services. DRUGS: EDUCATION, PREVENTION AND POLICY 2021. [DOI: 10.1080/09687637.2020.1833837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | | | | | - Michel Perreault
- Douglas Hospital Research Centre, Montreal, Canada
- Department of Psychiatry, McGill University, Montreal, Canada
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19
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Jin H, Marshall BDL, Degenhardt L, Strang J, Hickman M, Fiellin DA, Ali R, Bruneau J, Larney S. Global opioid agonist treatment: a review of clinical practices by country. Addiction 2020; 115:2243-2254. [PMID: 32289189 PMCID: PMC7554123 DOI: 10.1111/add.15087] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 11/28/2019] [Accepted: 04/03/2020] [Indexed: 01/30/2023]
Abstract
AIMS We assessed how opioid agonist treatment (OAT) for opioid use disorder (OUD), specifically methadone and buprenorphine, including buprenorphine-naloxone, is delivered in routine clinical practice, with a focus on factors that affect access to and delivery of these services. The aims of this review were to summarize eligibility criteria for entry to OAT, doses in routine clinical practice, access to and eligibility for unsupervised dosing and urine drug screening practices in OAT programs globally. METHODS We completed searches of PubMed, Embase, and grey literature databases for cross-sectional or observational cohort studies of OAT using either methadone or buprenorphine. Dose data extracted from eligible studies were compared with guidelines provided by WHO. RESULTS We found 140 reports from 41 countries that contained data for at least one of the relevant indicators. A diagnosis of opioid dependence or opioid use disorder was the most common eligibility requirement for OAT (13 or 17 countries). Reported mean or median doses for methadone ranged from 16-131 mg whereas range for buprenorphine was 2.5-19 mg. Access to unsupervised dosing under some conditions was reported in 18 of 27 countries. Frequency of regular urine drug screenings (UDS) ranged from several times a week to eight times per year (methadone) or as clinically indicated. CONCLUSIONS Opioid agonist treatment practices, including doses prescribed, vary greatly both within and across countries. Of particular concern is the persistence of lower dose prescribing practices, in which patients may be prescribed doses below those proven to yield significant clinical benefits.
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Affiliation(s)
- Harry Jin
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, United States
| | | | - Louisa Degenhardt
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - John Strang
- South London and Maudsley NHS Foundation Trust, Maudsley Hospital, London, United Kingdom
| | - Matt Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom
| | - David A. Fiellin
- Yale Schools of Medicine and Public Health, New Haven, Connecticut, United States
| | - Robert Ali
- School of Medicine, University of Adelaide, Adelaide, Australia
| | - Julie Bruneau
- Department of Family and Emergency Medicine, Université de Montréal, Québec, Canada
| | - Sarah Larney
- Centre Hospitalier de l’Université de Montréal Research Center, Quebec, Canada
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20
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Warfield SC, Pack RP, Degenhardt L, Larney S, Bharat C, Ashrafioun L, Marshall BDL, Bossarte RM. The next wave? Mental health comorbidities and patients with substance use disorders in under-resourced and rural areas. J Subst Abuse Treat 2020; 121:108189. [PMID: 33162261 DOI: 10.1016/j.jsat.2020.108189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/10/2020] [Accepted: 10/22/2020] [Indexed: 01/30/2023]
Abstract
The rapid spread of the coronavirus disease (COVID-19) has impacted the lives of millions around the globe. The COVID-19 pandemic has caused increasing concern among treatment professionals about mental health and risky substance use, especially among those who are struggling with a substance use disorder (SUD). The pandemic's impact on those with an SUD may be heightened in vulnerable communities, such as those living in under-resourced and rural areas. Despite policies loosening restrictions on treatment requirements, unintended mental health consequences may arise among this population. We discuss challenges that under-resourced areas face and propose strategies that may improve outcomes for those seeking treatment for SUDs in these areas.
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Affiliation(s)
- Sara C Warfield
- Injury Control Research Center, West Virginia University, United States of America; Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Behavioral Medicine and Psychiatry, West Virginia University, United States of America.
| | - Robert P Pack
- Department of Community & Behavioral Health, College of Public Health, East Tennessee State University, United States of America; Addiction Science Center, East Tennessee State University, United States of America
| | | | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Sydney, Australia; Department of Family Medicine and Emergency Medicine, Université de Montréal, Canada; Université de Montréal Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Canada
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Australia
| | - Lisham Ashrafioun
- Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Psychiatry, University of Rochester, United States of America
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, United States of America
| | - Robert M Bossarte
- Injury Control Research Center, West Virginia University, United States of America; Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Behavioral Medicine and Psychiatry, West Virginia University, United States of America
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21
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Crowley D, Delargy I. A national model of remote care for assessing and providing opioid agonist treatment during the COVID-19 pandemic: a report. Harm Reduct J 2020; 17:49. [PMID: 32680520 PMCID: PMC7366558 DOI: 10.1186/s12954-020-00394-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/26/2020] [Indexed: 01/09/2023] Open
Abstract
Background Health services globally are struggling to manage the impact of COVID-19. The existing global disease burden related to opioid use is significant. Particularly challenging groups include older drug users who are more vulnerable to the effects of COVID-19. Increasing access to safe and effective opioid agonist treatment (OAT) and other harm reduction services during this pandemic is critical to reduce risk. In response to COVID-19, healthcare is increasingly being delivered by telephone and video consultation, and this report describes the development of a national model of remote care to eliminate waiting lists and increase access to OAT in Ireland. Purpose and findings The purpose of this initiative is to provide easy access to OAT by developing a model of remote assessment and ongoing care and eliminate existing national waiting lists. The Irish College of General Practitioners in conjunction with the National Health Service Executive office for Social Inclusion agreed a set of protocols to enable a system of remote consultation but still delivering OAT locally to people who use drugs. This model was targeted at OAT services with existing waiting lists due to a shortage of specialist medical staff. The model involves an initial telephone assessment with COVID-risk triage, a single-patient visit to local services to provide a point of care drug screen and complete necessary documentation and remote video assessment and ongoing management by a GP addiction specialist. A secure national electronic health link system allows for the safe and timely delivery of scripts to a designated local community pharmacy. Conclusion The development of a remote model of healthcare delivery allows for the reduction in transmission risks associated with COVID-19, increases access to OAT, reduces waiting times and minimises barriers to services. An evaluation of this model is ongoing and will be reported once completed. Fast adaptation of OAT delivery is critical to ensure access to and continuity of service delivery and minimise risk to our staff, patients and community. Innovative models of remote healthcare delivery adapted during the COVID-19 crisis may inform and have important benefits to our health system into the future.
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Affiliation(s)
- Des Crowley
- Irish College of General Practitioners, Lincoln Place, Dublin 2, Ireland. .,University College Dublin, Belfield, Dublin 4, Ireland.
| | - Ide Delargy
- Irish College of General Practitioners, Lincoln Place, Dublin 2, Ireland
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22
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Degenhardt L, Grebely J, Stone J, Hickman M, Vickerman P, Marshall BDL, Bruneau J, Altice FL, Henderson G, Rahimi-Movaghar A, Larney S. Global patterns of opioid use and dependence: harms to populations, interventions, and future action. Lancet 2019; 394:1560-1579. [PMID: 31657732 PMCID: PMC7068135 DOI: 10.1016/s0140-6736(19)32229-9] [Citation(s) in RCA: 386] [Impact Index Per Article: 77.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 08/15/2019] [Accepted: 09/06/2019] [Indexed: 12/15/2022]
Abstract
We summarise the evidence for medicinal uses of opioids, harms related to the extramedical use of, and dependence on, these drugs, and a wide range of interventions used to address these harms. The Global Burden of Diseases, Injuries, and Risk Factors Study estimated that in 2017, 40·5 million people were dependent on opioids (95% uncertainty interval 34·3-47·9 million) and 109 500 people (105 800-113 600) died from opioid overdose. Opioid agonist treatment (OAT) can be highly effective in reducing illicit opioid use and improving multiple health and social outcomes-eg, by reducing overall mortality and key causes of death, including overdose, suicide, HIV, hepatitis C virus, and other injuries. Mathematical modelling suggests that scaling up the use of OAT and retaining people in treatment, including in prison, could avert a median of 7·7% of deaths in Kentucky, 10·7% in Kiev, and 25·9% in Tehran over 20 years (compared with no OAT), with the greater effects in Tehran and Kiev being due to reductions in HIV mortality, given the higher prevalence of HIV among people who inject drugs in those settings. Other interventions have varied evidence for effectiveness and patient acceptability, and typically affect a narrower set of outcomes than OAT does. Other effective interventions focus on preventing harm related to opioids. Despite strong evidence for the effectiveness of a range of interventions to improve the health and wellbeing of people who are dependent on opioids, coverage is low, even in high-income countries. Treatment quality might be less than desirable, and considerable harm might be caused to individuals, society, and the economy by the criminalisation of extramedical opioid use and dependence. Alternative policy frameworks are recommended that adopt an approach based on human rights and public health, do not make drug use a criminal behaviour, and seek to reduce drug-related harm at the population level.
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Affiliation(s)
- Louisa Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, Australia.
| | - Jason Grebely
- Kirby Institute, University of New South Wales Sydney, Sydney, NSW, Australia
| | - Jack Stone
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Peter Vickerman
- Population Health Sciences, University of Bristol, Bristol, UK
| | | | - Julie Bruneau
- Research Center, Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada; Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Succursale Centre-Ville, Montreal, QC, Canada
| | | | | | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies, Tehran University of Medical Sciences, Tehran, Iran
| | - Sarah Larney
- National Drug and Alcohol Research Centre, University of New South Wales Sydney, Sydney, NSW, Australia
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