Patterns in admission delays to outpatient methadone treatment in the United States

Mobile addiction treatment and harm reduction services as tools to address health inequities: a community case study of the Brockton Neighborhood Health Center mobile unit

Opioid overdose deaths continue to increase in the US. Recent data show disproportionately high and increasing overdose death rates among Black, Latine, and Indigenous individuals, and people experiencing homelessness. Medications for opioid use disorder (MOUD) can be lifesaving; however, only a fraction of eligible individuals receive them. Our goal was to describe our experience promoting equitable MOUD access using a mobile delivery model. We implemented a mobile MOUD unit aiming to improve equitable access in Brockton, a racially diverse, medium-sized city in Massachusetts. Brockton has a relatively high opioid overdose death rate with increasingly disproportionate death rates among Black residents. Brockton Neighborhood Health Center (BNHC), a community health center, provides brick-and-mortar MOUD access. Through the Communities That HEAL intervention as part of the HEALing Communities Study (HCS), Brockton convened a community coalition with the aim of selecting evidence-based practices to decrease overdose deaths. BNHC leadership and coalition members recognized that traditional brick-and-mortar treatment locations were inaccessible to marginalized populations, and that a mobile program could increase MOUD access. In September 2021, with support from the HCS coalition, BNHC launched its mobile initiative - Community Care-in-Reach® - to bring low-threshold buprenorphine, harm reduction, and preventive care to high-risk populations. During implementation, the team encountered several challenges including: securing local buy-in; navigating a complex licensure process; maintaining operations throughout the COVID-19 pandemic; and finally, planning for sustainability. In two years of operation, the mobile team cared for 297 unique patients during 1,286 total visits. More than one-third (36%) of patients received buprenorphine prescriptions. In contrast to BNHC's brick-and-mortar clinics, patients with OUD seen on the mobile unit were more representative of historically marginalized racial and ethnic groups, and people experiencing homelessness, evidencing improved, equitable addiction care access for these historically disadvantaged populations. Offering varied services on the mobile unit, such as wound care, syringe and safer smoking supplies, naloxone, and other basic medical care, was a key engagement strategy. This on-demand mobile model helped redress systemic disadvantages in access to addiction treatment and harm reduction services, reaching diverse individuals to offer lifesaving MOUD at a time of inequitable increases in overdose deaths.

Spatial inequities in access to medications for treatment of opioid use disorder highlight scarcity of methadone providers under counterfactual scenarios

Access to treatment and medication for opioid use disorder (MOUD) is essential in reducing opioid use and associated behavioral risks, such as syringe sharing among persons who inject drugs (PWID). Syringe sharing among PWID carries high risk of transmission of serious infections such as hepatitis C and HIV. MOUD resources, such as methadone provider clinics, however, are often unavailable to PWID due to barriers like long travel distance to the nearest methadone provider and the required frequency of clinic visits. The goal of this study is to examine the uncertainty in the effects of travel distance in initiating and continuing methadone treatment and how these interact with different spatial distributions of methadone providers to impact co-injection (syringe sharing) risks. A baseline scenario of spatial access was established using the existing locations of methadone providers in a geographical area of metropolitan Chicago, Illinois, USA. Next, different counterfactual scenarios redistributed the locations of methadone providers in this geographic area according to the densities of both the general adult population and according to the PWID population per zip code. We define different reasonable methadone access assumptions as the combinations of short, medium, and long travel distance preferences combined with three urban/suburban travel distance preference. Our modeling results show that when there is a low travel distance preference for accessing methadone providers, distributing providers near areas that have the greatest need (defined by density of PWID) is best at reducing syringe sharing behaviors. However, this strategy also decreases access across suburban locales, posing even greater difficulty in regions with fewer transit options and providers. As such, without an adequate number of providers to give equitable coverage across the region, spatial distribution cannot be optimized to provide equitable access to all PWID. Our study has important implications for increasing interest in methadone as a resurgent treatment for MOUD in the United States and for guiding policy toward improving access to MOUD among PWID.

Typology of laws restricting access to methadone treatment in the United States: A latent class analysis

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.

Methadone Treatment Gap in Tennessee and How Medication Units Could Bridge the Gap: A Review

The opioid epidemic has been an ongoing public health concern in the United States (US) for the last few decades. The number of overdose deaths involving opioids, hereafter referred to as overdose deaths, has increased yearly since the mid-1990s. One treatment modality for opioid use disorder (OUD) is medication-assisted treatment (MAT). As of 2022, only three pharmacotherapy options have been approved by the Food and Drug Administration (FDA) for treating OUD: buprenorphine, methadone, and naltrexone. Unlike buprenorphine and naltrexone, methadone dispensing and administrating are restricted to opioid treatment programs (OTPs). To date, Tennessee has no medication units, and administration and dispensing of methadone is limited to licensed OTPs. This review details the research process used to develop a policy draft for medication units in Tennessee. This review is comprised of three parts: (1) a rapid review aimed at identifying obstacles and facilitators to OTP access in the US, (2) a descriptive analysis of Tennessee's geographic availability of OTPs, pharmacies, and federally qualified health centers (FQHCs), and (3) policy mapping of 21 US states' OTP regulations. In the rapid review, a total of 486 articles were imported into EndNote from PubMed and Embase. After removing 152 duplicates, 357 articles were screened based on their title and abstract. Thus, 34 articles underwent a full-text review to identify articles that addressed the accessibility of methadone treatment for OUD. A total of 18 articles were identified and analyzed. A descriptive analysis of Tennessee's availability of OTP showed that the state has 22 OTPs. All 22 OTPs were matched to a county and a region based on their address resulting in 15 counties (16%) and all three regions having at least one OTP. A total of 260 FQHCs and 2294 pharmacies are in Tennessee. Each facility was matched to a county based on its address resulting in 70 counties (74%) having at least one FQHC and 94 counties (99%) having at least one pharmacy. As of 31 December 2022, 17 states mentioned medication units in their state-level OTP regulations. Utilizing the regulations for the eleven states with medication units and federal guidelines, a policy draft was created for Tennessee's medication units.

Correlates of Perceived Discrimination Related to Substance Use Disorders Among Patients in Methadone Maintenance Treatment

This study sought to examine demographic, treatment-related, and diagnosis-related correlates of substance use disorder (SUD)-related perceived discrimination among patients receiving methadone maintenance treatment (MMT). Participants were 164 patients at nonprofit, low-barrier-to-treatment-access MMT programs. Participants completed measures of demographics, diagnosis-related characteristics (Brief Symptom Inventory (BSI-18) and Depressive Experiences Questionnaire (DEQ)), and treatment-related characteristics. Perceived discrimination was measured on a seven-point Likert-type scale ranging from 1 ("Not at all") to 7 ("Extremely") in response to the item: "I often feel discriminated against because of my substance abuse." Given the variable's distribution, a median split was used to categorize participants into "high" and "low" discrimination groups. Correlates of high and low discrimination were analyzed with bivariate and logistic regression models. Ninety-four participants (57%) reported high SUD-related perceived discrimination. Bivariate analyses identified six statistically significant correlates of SUD-related perceived discrimination (P < .05): age, race, age of onset of opioid use disorder, BSI-18 Depression, DEQ Dependency, and DEQ Self-Criticism. In the final logistic regression model, those with high (versus low) SUD-related perceived discrimination were more likely to report depressive symptoms and be self-critical. Patients in MMT with high compared to low SUD-related perceived discrimination may be more likely to report being depressed and self-critical.

The interaction of race and age in methadone treatment retention outcomes: A single-center analysis

OBJECTIVES

Early treatment drop-out is due to the unique interplay of the individual and their context, and is associated with overdose death. The objective of this project was to determine if age or race is associated with 6-month treatment retention outcome differences at a single-center opioid treatment program.

METHODS

The study team performed a retrospective administrative database study from January 2014 to January 2017 using admission data with age and race as predictors of 6-month treatment retention outcomes.

RESULTS

Of the 457 admissions, 114 were under the age of 30; however, only 4 % of these young adults were Black, Indigenous, and/or People of Color (BIPOC). While retention for BIPOC patients (62 %) was slightly higher than for White patients (57 %), this difference did not reach traditional levels of significance.

CONCLUSIONS

Once BIPOC enter treatment, their treatment retention is similar to their White counterparts. Young adult BIPOC were less represented in the admission data, but treatment retention across racial groups was similar. An urgent need exists to determine the barriers and facilitators to treatment access among BIPOC young adults.

Comparative Safety Analysis of Opioid Agonist Treatment in Pregnant Women with Opioid Use Disorder: A Population-Based Study

INTRODUCTION AND OBJECTIVE

Receipt of opioid agonist treatment during early and late pregnancy for opioid use disorder may relate to varying perinatal risks. We aimed to assess the effect of time-varying prenatal exposure to opioid agonist treatment using buprenorphine or methadone on adverse neonatal and pregnancy outcomes.

METHODS

We conducted a retrospective cohort study of pregnant women with opioid use disorder using Rhode Island Medicaid claims data and vital statistics during 2008-16. Time-varying exposure was evaluated in early (0-20 weeks) and late (≥ 21 weeks) pregnancy. Marginal structural models with inverse probability of treatment weighting were applied.

RESULTS

Of 400 eligible pregnancies, 85 and 137 individuals received buprenorphine and methadone, respectively, during early pregnancy. Compared with 152 untreated pregnancies with opioid use disorders, methadone exposure in both periods was associated with an increased risk of preterm birth (adjusted odds ratio [aOR]: 2.52; 95% confidence interval [CI] 1.07-5.95), low birth weight (aOR: 2.99; 95% CI 1.34-6.66), neonatal intensive care unit admission (aOR, 5.04; 95% CI 2.49-10.21), neonatal abstinence syndrome (aOR: 11.36; 95% CI 5.65-22.82), respiratory symptoms (aOR, 2.71; 95% CI 1.17-6.24), and maternal hospital stay > 7 days (aOR, 14.51; 95% CI 7.23-29.12). Similar patterns emerged for buprenorphine regarding neonatal abstinence syndrome (aOR: 10.27; 95% CI 4.91-21.47) and extended maternal hospital stay (aOR: 3.84; 95% CI 1.83-8.07). However, differences were found favoring the use of buprenorphine for preterm birth versus untreated pregnancies (aOR: 0.17; 95% CI 0.04-0.77), and for several outcomes versus methadone.

CONCLUSIONS

Methadone and buprenorphine prescribed for the treatment of opioid use disorder during pregnancy are associated with varying perinatal risks. However, buprenorphine may be preferred in the setting of pregnancy opioid agonist treatment. Further research is necessary to confirm our findings and minimize residual confounding.

Anticipated Barriers to Sustained Engagement in Treatment With Medications for Opioid Use Disorder After Release From Incarceration

BACKGROUND

Although the burden of opioid use disorder is disproportionately high among persons who are incarcerated, medications for opioid use disorder are often unavailable in correctional settings. The Rhode Island Department of Corrections provides all 3 classes of medications for opioid use disorder to clinically eligible persons who are incarcerated. Despite a decrease in fatal overdoses among persons with recent criminal legal system involvement since the program's implementation, barriers to continued engagement in treatment after release from incarceration still exist.

METHODS

We conducted 40 semistructured, qualitative interviews with people who were incarcerated and enrolled in the comprehensive medications for opioid use disorder program at the Rhode Island Department of Corrections. Analysis applied a general, inductive approach using NVivo 12.

RESULTS

Participants discussed barriers to treatment engagement before incarceration, as well as anticipated barriers to medications to treat opioid use disorder continuation after release from incarceration. Structural factors including housing, health insurance, transportation, and the treatment program structure, as well as social factors such as social support networks were perceived to influence retention in medications to treat opioid use disorder post-release.

CONCLUSION

Our findings suggest that people with opioid use disorder who are incarcerated encounter unique challenges upon community reentry. Addressing structural factors that pose barriers to post-release engagement is essential to sustaining retention. We recommend utilization of peer recovery specialists to alleviate some of the stress of navigating the structural barriers identified by participants.

History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder

Buprenorphine-based medications were first approved by the United States Food and Drug Administration in 2002 for the treatment of opioid dependence, or opioid use disorder (OUD) as the condition is presently known. This regulatory milestone was the outcome of 36 years of research and development, which also led to the development and approval of several other new buprenorphine-based medications. In this short review, we first describe the discovery and early development stages of buprenorphine. Second, we review key steps that led to the development of buprenorphine as a drug product. Third, we explain the regulatory approval of several buprenorphine-based medications for the treatment of OUD. We also discuss these developments in the context of the evolution of regulations and policies that have progressively improved OUD treatment availability and efficacy, although challenges remain in removing system-level, provider-level, and local-level barriers to quality treatment, to integrating OUD treatment into routine care and other settings, to reducing disparities in access to treatment, and to optimizing person-centered outcomes.

County-level sociodemographic differences in availability of two medications for opioid use disorder: United States, 2019

BACKGROUND

Differences in availability of medications for opioid use disorder (MOUD) buprenorphine and methadone exist. Factors that may influence such differences in availability include sociodemographic characteristics but research in this area is limited. We explore the association between county-level sociodemographic factors and MOUD treatment availability.

METHODS

County-level Drug Enforcement Administration (DEA) data were used to determine the presence or absence of buprenorphine treatment or opioid treatment programs (OTPs) and the level of availability of these types of treatment in a county. Hurdle models were used to examine the associations of our covariates with any MOUD treatment availability and level of available treatment.

RESULTS

The odds of a county having OTP availability were higher for counties with higher percentages of non-Hispanic Black and Hispanic populations and higher drug overdose death rates. Counties with higher percentages of persons in poverty and drug overdose death rates had higher odds of maximum potential buprenorphine treatment capacity, while counties with high percentages of persons without health insurance, with disability, and rural counties had lower odds.

CONCLUSIONS

There are significant differences in the county-level availability of OTPs and buprenorphine treatment. Our findings expand on prior studies illustrating that barriers to accessing treatment persist and are not evenly distributed among sociodemographic groups, further study is needed to examine if barriers of availability translate to barriers in receiving treatment. Given the escalating overdose crisis in the U.S., expanding equitable availability of MOUD is critical. Informed strategies are needed to reach areas and populations in greatest need.

Bridge clinic implementation of "72-hour rule" methadone for opioid withdrawal management: Impact on opioid treatment program linkage and retention in care

BACKGROUND

Methadone for opioid use disorder (OUD) treatment is restricted to licensed opioid treatment programs (OTPs) with substantial barriers to entry. Underutilized regulations allow non-OTP providers to administer methadone for opioid withdrawal for up to 72 h while arranging ongoing care. Our low-barrier bridge clinic implemented a new pathway to treat opioid withdrawal and facilitate OTP linkage utilizing the "72-hour rule."

METHODS

Patients presenting to a hospital-based bridge clinic were evaluated for OUD, opioid withdrawal, and treatment goals. Eligible patients were offered methadone opioid withdrawal management with rapid OTP referral. OTPs accepted patients as direct admissions. We described bridge clinic patients who received at least one dose of methadone between March-August 2021 and key clinical outcomes including OTP referral completion within 72 h. For the subset of patients referred to our two primary OTP partners, we described OTP linkage (i.e., attended at least one OTP visit within one month) and OTP retention at one month.

RESULTS

Methadone was administered during 150 episodes of care for 142 unique patients, the majority of whom were male (73%), white (67%), and used fentanyl (85%). In 92% of episodes (138/150), a plan for ongoing care was in place within 72 h. Among 121 referrals to two primary OTP partners, 87% (105/121) linked and 58% (70/121) were retained at one month.

CONCLUSIONS

Methadone administration for opioid withdrawal with direct OTP admission under the "72-hour rule" is feasible in an outpatient bridge clinic and resulted in high OTP linkage and 1-month retention rates. This model has the potential to improve methadone access.

Group-based medical mistrust and care expectations among black patients seeking addiction treatment

Background

Black patients seeking addiction care experience poorer treatment access, retention, and outcomes when compared to White counterparts. Black patients may have elevated group-based medical mistrust, which has been associated with poorer health outcomes and increased experiences of racism across multiple healthcare contexts. The relationship between group-based medical mistrust and expectations for addiction treatment among Black individuals remains untested.

Methods

A total of 143 Black participants were recruited from two addiction treatment centers in Columbus, Ohio. Participants completed the Group Based Medical Mistrust Scale (GBMMS) and answered questions related to expectations of addiction treatment. Descriptive analysis and Spearman's rho correlations were performed to assess for relationships between group-based medical mistrust and expectations of care.

Results

Group-based medical mistrust in Black patients was associated with self-reported delay in accessing addiction treatment, anticipation of racism during addiction treatment, non-adherence and discrimination-precipitated relapse. However, non-adherence to treatment was least strongly correlated with group-based medical mistrust demonstrating an opportunity for engagement.

Conclusion

Group-based medical mistrust is associated with Black patients' care expectations when seeking addiction treatment. Use of the GBMMS within addiction medicine to address themes of mistrust in patients, and potential biases in providers, may improve treatment access and outcomes.

Association Between Assistance With Medicaid Enrollment and Use of Health Care After Incarceration Among Adults With a History of Substance Use

IMPORTANCE

The transition from prison to community is characterized by elevated morbidity and mortality, particularly owing to drug overdose. However, most formerly incarcerated adults with substance use disorders do not use any health care, including treatment for substance use disorders, during the initial months after incarceration.

OBJECTIVE

To evaluate whether a prerelease Medicaid enrollment assistance program is associated with increased health care use within 30 days after release from prison.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study included 16 307 adults aged 19 to 64 years with a history of substance use who were released from state prison between April 1, 2014, and December 31, 2016. The Wisconsin Department of Corrections implemented prerelease Medicaid enrollment assistance in January 2015. Statistical analysis was performed from January 1 to August 31, 2021.

EXPOSURE

A statewide Medicaid prerelease enrollment assistance program.

MAIN OUTCOMES AND MEASURES

The main outcome was Medicaid-reimbursed health care, associated with substance use disorders and for any cause, within 30 days of prison release, including outpatient, emergency department, and inpatient care. Mean outcomes were compared for those released before and after implementation of prerelease Medicaid enrollment assistance using an intention-to-treat analysis and person-level data from the Wisconsin Department of Corrections and Medicaid.

RESULTS

The sample included 16 307 individuals with 18 265 eligible releases (men accounted for 16 320 of 18 265 total releases, and 6213 of 18 265 releases were among Black individuals; mean [SD] age at release, 35.5 [10.7] years). The likelihood of outpatient care use within 30 days of release increased after implementation of enrollment assistance relative to baseline by 7.7 percentage points for any visit (95% CI, 6.4-8.9 percentage points; P < .001), by 0.7 percentage points for an opioid use disorder visit (95% CI, 0.4-1.0 percentage points; P < .001), by 1.0 percentage point for any substance use disorder visit (95% CI, 0.5-1.6 percentage points; P < .001), and by 0.4 percentage points for receipt of medication for opioid use disorder (95% CI, 0.2-0.6 percentage points; P < .001). There was no significant change in use of the emergency department (0.7 percentage points [95% CI, -0.15 to 1.4 percentage points]). The probability of an inpatient stay increased by 0.4 percentage points (95% CI, 0.03-0.7 percentage points; P = .03).

CONCLUSIONS AND RELEVANCE

The results of this cohort study suggest that prerelease Medicaid enrollment assistance was associated with increased use of outpatient health care after incarceration and highlights the value of making this assistance universally available within correctional settings. More tailored interventions may be needed to increase the receipt of treatment for substance use disorders.

Differences in the delivery of medications for opioid use disorder during hospitalization by racial categories: A retrospective cohort analysis

Background: As the drug-related overdose crisis and COVID-19 pandemic continue, communities need increased access to medications for opioid use disorder (MOUD) (i.e., buprenorphine and methadone). Disparities in the type of MOUD prescribed or administered by racial and ethnic categories are well described in the outpatient clinical environment. It is unknown, however, if these disparities persist when MOUD is provided in acute care hospitals. Methods: This study assessed differences in the delivery of buprenorphine versus methadone during acute medical or surgical hospitalizations for veterans with opioid use disorder (OUD) by racial categories (Black Non-Hispanic or Latino vs. White Non-Hispanic or Latino). Data were obtained retrospectively from the Veterans Health Administration (VHA) for federal fiscal year 2017. We built logistic regression models, adjusted for individual and hospital-related covariates, and calculated the predicted probabilities of MOUD delivery by racial categories. Results: The study cohort (n = 1,313 unique patients; N = 107 VHA hospitals) had a mean age of 57 (range 23 to 87 years), was predominantly male (96%), and composed entirely of Black (29%) or White (71%) patients. White patients were 11% more likely than Black patients to receive buprenorphine than methadone during hospitalization (p = 0.010; 95% CI: 2.7%, 20.0%). Among patients on MOUD prior to hospitalization, White patients were 21% more likely than Black patients to receive buprenorphine (p = 0.000; 95% CI: 9.8%, 31.5%). Among patients newly initiated on MOUD during hospitalization, there were no differences by racial categories. Conclusion: We observed disparities in the delivery of buprenorphine versus methadone during hospitalization by racial categories. The observed differences in hospital-based MOUD delivery may be influenced by MOUD received prior to hospitalization within the racialized outpatient addiction treatment system. The VHA and health systems more broadly must address all aspects of racism that contribute to inequitable MOUD access throughout all clinical contexts.

Opioid Agonist Treatment Recipients within Criminal Justice-Involved Populations

Background: In 2014, nearly 2.5 million Americans had a substance use disorder for opioids (e.g., prescription pain medication or heroin) with over half estimated to have had prior contact with the criminal justice system. Despite strong evidence that opioid agonist treatment (OAT) is effective in reducing overdose, increasing treatment retention, and improving physical health and well-being outcomes, the use of OAT among justice-involved individuals is relatively rare. Methods: The current study uses national data of publicly funded admissions to substance abuse treatment to assess the extent to which OAT is used for cases referred to treatment by the criminal justice system. We explore the relationship between demographics, substance use severity, and access to treatment and OAT receipt. Results: Findings indicate that fewer than 6% of criminal justice cases received OAT as part of the treatment plan. Those with daily substance use, comorbid psychiatric problems, prior treatment, females, Latinos, and those who were older and those who were living independently were more likely to receive OAT, as were those living in the Northeast and with government health insurance. Conclusions: Improving the integration of the criminal justice system with substance use treatment programs would improve access to care and potentially reduce multiple health disparities faced by those in the justice system. As criminal justice responses to substance use disorder move toward a public health approach, it is imperative that the criminal justice system consider mechanisms for improving access and referrals to OAT.

Opioid Use Disorder

Opioid use disorder (OUD) is a treatable chronic disorder with episodes of remission and recurrence characterized by loss of control of opioid use, compulsive use, and continued use despite harms. If untreated, OUD is associated with significant morbidity and mortality. Buprenorphine and methadone reduce fatal and nonfatal opioid overdose and infectious complications of OUD and are the first-line treatment options. Physicians have an important role to play in diagnosing OUD and its comorbidities, offering evidence-based treatment, and delivering overdose prevention and other harm reduction services to people who continue to use opioids. Interdisciplinary office-based addiction treatment programs support high-quality OUD care.

Methadone initiation in a bridge clinic for opioid withdrawal and opioid treatment program linkage: a case report applying the 72-hour rule

Background

In the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h.

Case presentation

A 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later.

Conclusions

While patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.

Understanding Polarizing Community Perspectives on Harm Reduction Strategies: Challenges to Addressing the Opioid Crisis in Appalachian Pennsylvania

Introduction

Rural communities face barriers to opioid treatment and overdose prevention including concerns about stigma and lack of harm reduction services.

Purpose

The aim of this study was to explore community perspectives and understanding of harm reduction approaches to opioid use and overdose in a high-risk Northern Appalachian case community in Pennsylvania.

Methods

A small town approximately 10 miles from Pittsburgh was identified as the community with the greatest predicted probabilities of epidemic outbreak using posteriors from spatial models of hospitalizations for opioid use disorders. We interviewed 20 key stakeholders in the case community in using a semi-structured interview guide and analyzed the qualitative data using an inductive grounded theory approach.

Results

Our findings illustrate how conflicting perspectives about opioid dependence lay the foundation for the polarizing community perspectives on addressing opioid use and overdose and general disagreement regarding the legitimacy of harm reduction approaches versus abstinence-based recovery plans. Community members shared varying perspectives on multiple aspects of the opioid epidemic, including appropriate strategies, treatment, and overdose prevention methods and how community leaders and organizations should respond.

Implications

Opinions, coupled with a general lack of education regarding opioid use and harm reduction options, make it challenging for small communities with limited resources to create comprehensive plans to address the opioid crisis.

Experiences of racial discrimination in the medical setting and associations with medical mistrust and expectations of care among black patients seeking addiction treatment

INTRODUCTION

Experiences of racial discrimination in the medical setting are common among Black patients and may be linked to mistrust in medical recommendations and poorer clinical outcomes. However, little is known about the prevalence of experiences of racial mistreatment by healthcare workers among Black patients seeking addiction treatment, or how these experiences might influence Black patients' medical mistrust or expectations of care.

METHODS

Participants were 143 Black adults recruited consecutively from two university addiction treatment facilities in Columbus, Ohio. All participants completed validated surveys assessing perceptions of prior racial discrimination in the medical setting and group-based medical mistrust. Participants were also asked a series of questions about their expectations of care with regard to racial discrimination and addiction treatment. Descriptive analyses were used to characterize the sample with regard to demographics, perceived racial discrimination and medical mistrust. Kendall tau-b correlations assessed relationships between racial discrimination, mistrust and expectations of care.

RESULTS

Seventy-nine percent (n = 113) of participants reported prior experiences of racial discrimination during healthcare. Racial discrimination in the medical setting was associated with greater mistrust in the medical system and worse expectations regarding racial discrimination in addiction treatment including delays in care-seeking due to concern for discrimination, projected non-adherence and fears of discrimination-precipitated relapse.

CONCLUSIONS

Black patients seeking addiction treatment commonly report experiencing racial discrimination by healthcare workers which may be associated with mistrust in the medical system and expectations of care. Strategies to eliminate and mitigate experiences of racial discrimination may improve addiction treatment receptivity and engagement.

U.S. student pharmacist perceptions of the pharmacist's role in methadone for opioid use disorder: A qualitative study

BACKGROUND

Of the over 20 million Americans reporting an opioid use disorder, only around 3 million report receiving treatment of any kind. The gold standard for opioid use disorder treatment is medication in combination with psychosocial support, but despite robust evidence supporting treatment, barriers are substantial and include limited insurance coverage, patient beliefs, ease of access, regulatory hurdles, and stigma. Although trained as medication experts, U.S. pharmacists are not routinely involved in opioid use disorder treatment and may represent an underutilized care team member.

OBJECTIVE

To explore U.S. pharmacy students' perspectives on pharmacists as providers of methadone-based medications for opioid use disorder treatment.

METHODS

A qualitative design with focus groups of student pharmacists in a U.S. college of pharmacy in the Southeastern United States.

RESULTS

Over 2 months in 2020, three focus groups were conducted with 15 students in each group participating, and including second-, third-, and fourth-year student pharmacists. Three overarching themes emerged from the data: (1) student pharmacists desire exposure to therapeutic knowledge and lived experiences related to opioid use disorder and methadone treatment, (2) students perceive stigmatizing views held by practicing pharmacists toward opioid use disorder and methadone treatment, (3) pharmacists should play a role in methadone treatment.

CONCLUSION

Student pharmacists desire an active and larger role in the care of patients managing opioid use disorder. Findings indicate these students perceive less stigma toward opioid use disorder than currently practicing pharmacists. Pharmacy curricula should emphasize stories of lived experiences of patients with opioid use disorder, therapeutic knowledge and guidelines related to medications for opioid use disorder, and the regulatory environment surrounding opioid use disorder treatment.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

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.

A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder

OBJECTIVE

To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500.

METHODS

Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported.

RESULTS

Counselors described perceived advantages of the open-access model for clients (e.g., "individualized to client needs"), clinicians (e.g., "fewer demands"), and the community (e.g., "crime reduced"). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., "uneven workload") and clients (e.g., "need for more intensive services for some clients"), as well as program-level concerns (e.g., "perceived lack of structure").

CONCLUSIONS

Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.

Assessing public behavioral health services data: a mixed method analysis

Background

Measuring behavioral health treatment accessibility requires timely, comprehensive and accurate data collection. Existing public sources of data have inconsistent metrics, delayed times to publication and do not measure all factors related to accessibility. This study seeks to capture this additional information and determine its importance for informing accessibility and care coordination.

Methods

The 2018 National Survey for Substance Abuse and Treatment Services (N-SSATS) data were used to identify behavioral health facilities in Indiana and gather baseline information. A telephone survey was administered to facilities with questions parallel to the N-SSATS and additional questions regarding capacity and patient intake. Quantitative analysis includes chi-square tests. A standard qualitative analysis was used for theming answers to open-ended questions.

Results

About 20% of behavioral health facilities responded to the study survey, and non-response bias was identified by geographic region. Among respondents, statistically significant differences were found in several questions asked in both the study survey and N-SSATS. Data gathered from the additional questions revealed many facilities to have wait times to intake longer than 2 weeks, inconsistency in intake assessment tools used, limited capacity for walk-ins and numerous requirements for engaging in treatment.

Conclusion

Despite the low response rate to this study survey, results demonstrate that multiple factors not currently captured in public data sources can influence coordination of care. The questions included in this study survey could serve as a framework for routinely gathering these data and can facilitate efforts for successful coordination of care and clinical decision-making.

Correlates of Homelessness Among Patients in Methadone Maintenance Treatment

BACKGROUND

Although homelessness and opioid use disorder (OUD) are important public health issues, few studies have examined their cooccurrence.

OBJECTIVES

The aim of this study was to evaluate the correlates of homelessness among patients enrolled in low-barrier-to-treatment-access methadone maintenance treatment (MMT) programs for OUD.

METHODS

Demographic, diagnosis-related, and treatment-related correlates were assessed by self-report for 164 patients in MMT. Correlates of past-month homelessness were investigated with logistic regression.

RESULTS

Twenty-four percent of patients reported homelessness in the past month. Bivariate analyses initially identified 7 statistically significant (P<0.05) correlates of homelessness: gender; Latinx ethnicity; symptoms of depression, anxiety, and somatization; self-criticism; and duration of MMT. In the final logistic regression model, which included significant independent variables from the bivariate logistic regressions, patients in MMT who were homeless (vs. domiciled) were more likely to be male (odds ratio 2.54; confidence interval, 1.01-6.36) and report higher symptoms of depression (odds ratio 1.07; confidence interval, 1.01-1.15).

CONCLUSIONS

Low-barrier-to-treatment-access programs can attract people who are homeless with OUD into MMT. These programs also have an important public health role in addressing both depression and OUD among people who are homeless.

Assessment of Racial and Ethnic Disparities in the Use of Medication to Treat Opioid Use Disorder Among Pregnant Women in Massachusetts

IMPORTANCE

Racial and ethnic disparities persist across key health and substance use treatment outcomes for mothers and infants. The use of medications, such as methadone or buprenorphine, for the treatment of opioid use disorder (OUD) has been associated with improvements in the outcomes of mothers and infants; however, only half of all pregnant women with OUD receive these medications. The extent to which maternal race or ethnicity is associated with the use of medication to treat OUD, the duration of the use of medication to treat OUD, and the type of medication used to treat OUD during pregnancy are unknown.

OBJECTIVE

To examine the extent to which maternal race and ethnicity is associated with the use of medications for the treatment of OUD in the year before delivery among pregnant women with OUD.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study used a linked population-level statewide data set of pregnant women with OUD who delivered a live infant in Massachusetts between October 1, 2011, and December 31, 2015. Of 274 234 total deliveries identified, 5247 deliveries among women with indicators of having OUD were included in the analysis. Maternal race and ethnicity were defined as white non-Hispanic, black non-Hispanic, or Hispanic based on self-reported data on birth certificates.

MAIN OUTCOMES AND MEASURES

Main outcomes were the receipt of any medication for OUD, the consistency of the use of medication (at least 6 continuous months of use before delivery, inconsistent use, or no use) for the treatment of OUD, and the type of medication (methadone or buprenorphine) used to treat OUD. Multivariable models were adjusted for maternal sociodemographic characteristics, comorbidities, and any significant interactions between the covariates and race and ethnicity.

RESULTS

The sample included 5247 pregnant women with OUD who delivered a live infant in Massachusetts during the study period. The mean (SD) maternal age at delivery was 28.7 (5.0) years; 4551 women (86.7%) were white non-Hispanic, 462 women (8.8%) were Hispanic, and 234 women (4.5%) were black non-Hispanic. A total of 3181 white non-Hispanic women (69.9%) received any type of medication for the treatment of OUD in the year before delivery compared with 228 Hispanic women (49.4%) and 108 black non-Hispanic women (46.2%). Compared with white non-Hispanic women, black non-Hispanic and Hispanic women had a substantially lower likelihood (adjusted odds ratio [aOR], 0.37; 95% CI, 0.28-0.49 and aOR, 0.42; 95% CI, 0.35-0.52, respectively) of receiving any medication for the treatment of OUD. Stratification by maternal age identified greater disparities among younger women. Black non-Hispanic and Hispanic women also had a lower likelihood (aOR, 0.24; 95% CI, 0.17-0.35 and aOR, 0.34; 95% CI, 0.27-0.44, respectively) of consistent use of medication for the treatment of OUD compared with white non-Hispanic women. With respect to the type of medication used to treat OUD, black non-Hispanic and Hispanic women had a lower likelihood (aOR, 0.60; 95% CI, 0.40-0.90 and aOR, 0.77; 95% CI, 0.58-1.01, respectively) than white non-Hispanic women of receiving buprenorphine treatment compared with methadone treatment.

CONCLUSIONS AND RELEVANCE

This study found racial and ethnic disparities in the use of medications to treat OUD during pregnancy, with black non-Hispanic and Hispanic women significantly less likely to use medications consistently or at all compared with white non-Hispanic women. Further investigation of patient, clinician, treatment program, and system-level factors associated with these findings is warranted.

Differences in receipt of opioid agonist treatment and time to enter treatment for opioid use disorder among specialty addiction programs in the United States, 2014-17

Background

Access to adequate treatment for opioid use disorder (OUD) has been a high priority among American policymakers. Elucidation of the sociodemographic and institutional differences associated with the use, or lack thereof, of opioid agonist therapy (OAT) provides greater clarity on who receives OAT. Timely access to care is a further consideration and bears scrutiny as well.

Methods

We draw upon data from the Treatment Episode Data Set—Admissions (TEDS-A) to analyse the relationship between sociodemographic and institutional characteristics and the receipt of opioid agonist treatments and time waiting to enter treatment.

Results

Estimates from logistic regression models highlight certain groups which show lower odds of receipt of OAT, including those in precarious housing arrangements, those unemployed or not otherwise in the labor force, and those referred by drug abuse care providers, educational institutions, employers, and the criminal justice system. Groups which showed higher odds of waiting over a week to enter treatment included those who were separated, divorced, or widowed, those working part-time, and those referred by drug abuse care providers, employers, and the criminal justice system.

Conclusion

Given the efficacy of OAT and the adverse outcomes associated with long waiting times, coordinated effort is needed to understand why these differences persist and how they may be addressed through appropriate policy responses.

Characteristics and current clinical practices of opioid treatment programs in the United States

BACKGROUND

Given rising rates of opioid use disorder (OUD) and related consequences, opioid treatment programs (OTPs) can play a pivotal role in the U.S. opioid crisis. There is a paucity of recent research to guide how best to leverage OTPs in the opioid response.

METHODS

We conducted a national survey of U.S. OTPs using a 46-question electronic survey instrument covering three domains: 1) OTP characteristics; 2) services offered; and 3) current clinical practices. Descriptive statistics and multivariable logistic regression examined variables in these domains.

RESULTS

Among responding OTPs, 32.4% reported using all three medications for OUD treatment; 95.8% used methadone, 61.8% used buprenorphine, and 43.9% used naltrexone. The mean (SD) number of patients currently receiving methadone was 383 (20.4), buprenorphine 51 (7.0), extended-release naltrexone 6 (1.0). Viral hepatitis testing was provided by 60.9% of OTPs, 15.3% provided hepatitis B vaccination, 14.9% provided hepatitis A vaccination, and 12.6% provided medication treatment for hepatitis C virus infection. HIV testing was provided by 60.7% of OTPs, 9.5% provided pre-exposure prophylaxis, and 8.4% provided medication treatment for HIV. OTP characteristics associated with using all three forms of medications for OUD included: providing medication for alcohol use disorder (aOR = 5.24, 95% CI:2.99-9.16), providing telemedicine services (aOR = 3.82, 95% CI:2.14-6.84), and directly providing naloxone to patients (aOR = 2.57, 95% CI:1.53-4.29). Multiple barriers to providing buprenorphine and extended-release naltrexone were identified.

CONCLUSIONS

Efforts are needed to increase availability of all medications approved to treat OUD in OTPs, integrate infectious disease-related services, and expand the reach of OTPs in the U.S.

Understanding the reasons for using methamphetamine by sexual minority people in Dhaka, Bangladesh

BACKGROUND

Internationally, methamphetamine use is prevalent among males who have sex with males (MSM) and transgender women (hijra), with studies showing its association with risky sexual behaviours leading to HIV transmission. This study aimed to explore the underlying reasons for methamphetamine use among MSM and hijra in Bangladesh.

METHODS

We conducted 30 in-depth interviews with MSM and hijra and six focus groups with MSM, hijra and service providers. Data were thematically analysed using manual data analysis procedures.

FINDING

Reasons cited for using methamphetamine varied across feminized MSM (i.e. kothis), masculine MSM (i.e. panthis), male sex workers and hijra. For sex workers, increased sexual pleasure and consequent ability to take more clients increased their income. For panthis, methamphetamine enhanced feelings of masculinity and sexual prowess. Kothis were able to feel more feminine due to their ability to receive multiple partners each night. For all participants, methamphetamine restored self-esteem and relieved the stress resulting from stigma.

CONCLUSIONS

Findings indicate that reasons for using methamphetamine are not only rooted in the individual's psyche but also grounded in the socio-cultural expectations about masculinities and femininities in Bangladeshi society. Limited knowledge about the complexities concerning methamphetamine use mean that appropriate counselling and treatment services are non-existent in Bangladesh. The study findings can be used to refine national and international harm reduction policies so as to incorporate and address methamphetamine use.

Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program

BACKGROUND

Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine.

METHODS

This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use.

RESULTS

The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26-21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin.

CONCLUSIONS

Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

The Role of Patient Payment Method in Premature Discharge from Methadone Maintenance Treatment

BACKGROUND

Premature discharge is a pervasive problem in methadone maintenance treatment (MMT), and is associated with numerous adverse outcomes. Although a number of demographic variables have consistently been found to impact MMT retention, method of payment has received considerably less attention. A notable limitation of prior work is that most studies classify all patients who leave treatment early, irrespective of reason, as treatment dropouts and fail to account for specific reasons.

OBJECTIVE

This study sought to determine whether method of payment for MMT services was associated with differential reasons for premature discharge.

METHODS

The sample was comprised of 4158 patients prematurely discharged from 33 MMT facilities located throughout the U.S. from 2009 to 2012. Patients were classified into two groups based on their method of payment: self-pay and insurance (largely Medicaid). Patients were studied through retrospective electronic chart review.

RESULTS

Binary logistic regression indicated that insurance patients who were prematurely discharged were significantly more likely to be discharged due to a program-initiated reason (administrative), while self-pay patients were more likely to be discharged due to a patient-initiated reason (against medical advice) after controlling for significant intake demographic and clinical covariates.

CONCLUSIONS

Further research is needed to determine whether insurance patients may require different supports in place compared to self-pay patients in order to improve compliance with program guidelines (e.g. behavioral contracts providing a detailed description of rules both at admission and throughout treatment with an emphasis on the potential consequences of noncompliance), and whether self-pay patients may benefit from motivational incentives and interventions to remain engaged in treatment.

Pharmacotherapy for opioid addiction in community corrections

Pharmacotherapy for opioid addiction with methadone, buprenorphine, and naltrexone has proven efficacy in reducing illicit opioid use. These treatments are under-utilized among opioid-addicted individuals on parole, probation, or in drug courts. This paper examines the peer-reviewed literature on the effectiveness of pharmacotherapy for opioid addiction of adults under community-based criminal justice supervision in the US. Compared to general populations, there are relatively few papers addressing the separate impact of pharmacotherapy on individuals under community supervision. Tentative conclusions can be drawn from the extant literature. Reasonable evidence exists that illicit opioid use and self-reported criminal behaviour decline after treatment entry, and that these outcomes are as favourable among individuals under criminal justice supervision as the general treatment population. Surprisingly, there is no conclusive evidence regarding the extent to which pharmacotherapy impacts the likelihood of arrest and incarceration among individuals under supervision. However, given the proven efficacy of these three medications in reducing illicit opioid use and the evidence that, in the general population, methadone and buprenorphine treatment are associated with reduction in overdose mortality, the use of all three pharmacotherapies among patients under criminal justice supervision should be expanded while more data are collected on their impact on arrest and incarceration.

An investigation of an open-access model for scaling up methadone maintenance treatment

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.

A population-based examination of trends and disparities in medication treatment for opioid use disorders among Medicaid enrollees

BACKGROUND

Medication treatment (MT) with methadone and buprenorphine are effective treatments for opioid use disorders, but little information is available regarding the extent to which buprenorphine's approval resulted in more individuals receiving MT nor to what extent receipt of such treatment was equitable across communities.

METHODS

To examine changes in MT utilization and the association between MT utilization and county-level indicators of poverty, race/ethnicity, and urbanicity, we used Medicaid claims of non-dually eligible Medicaid enrollees aged 18-64 from 14 states for 2002-2009. We generated county-level aggregate counts of MT (methadone, buprenorphine, and any MT) by year (N = 7760 county-years). We estimated count data models to identify associations between MT and county characteristics, including levels of poverty and racial/ethnic concentration.

RESULTS

The number of Medicaid enrollees receiving MT increased 62% from 2002 to 2009. The number of enrollees receiving methadone increased 20%, with the remaining increase resulting from buprenorphine. Urban county residents were significantly more likely to receive MT in both 2002 and 2009 than rural county residents. However, buprenorphine substantially increased MT in rural counties from 2002 to 2009. Receipt of MT increased at a much higher rate for residents of counties with lower poverty rates and lower concentrations of black and Hispanic individuals than for residents of counties without those characteristics.

CONCLUSIONS

The increase in Medicaid enrollees receiving MT in the years following buprenorphine's approval is encouraging. However, it is concerning that MT trends varied so dramatically by characteristics of the county population and that increases in utilization were substantially lower in counties with populations that historically have been disadvantaged with respect to health care access and quality. Concerted efforts are needed to ensure that MT benefits are equitably distributed across society and reach disadvantaged individuals who may be at higher risk of experiencing opioid use disorders.

Justice Involvement and Treatment Use Among Rural Veterans

Veterans in rural areas and veterans involved in the criminal justice system have experienced less access to, and use of, health care. However, there is limited information on the treatment needs and health care access of justice-involved veterans who live in rural areas. This study used national Veterans Health Administration data from fiscal year 2014 to examine the interactive effect of rural/urban residence and justice involvement on mental health and substance use disorder treatment entry among veterans diagnosed with mental health or substance use disorders. Of veterans residing in rural areas, 15,328 (2.5%) were justice-involved and 607,819 (97.5%) veterans had no known justice involvement. Among veterans in urban areas, 54,525 (4.3%) were justice-involved and 1,213,766 (95.7%) had no known justice involvement. Rural residence was associated with lower access to mental health or substance use disorder treatment in the non-justice-involved sample but not the justice-involved sample. Justice-involvement was associated with higher odds of entering mental health or substance use disorder treatment for veterans in rural and in urban areas. Substance use disorder treatment entry could be improved for all veterans, particularly rural veterans who are not justice-involved. Telehealth, outreach services, and integrated treatment may help address challenges to treatment entry experienced by rural veterans and justice-involved veterans.

Racial and ethnic differences in opioid agonist treatment for opioid use disorder in a U.S. national sample

BACKGROUND

Opioid Agonist Treatment (OAT) is the standard of care for the treatment of opioid use disorders. However, most people in treatment do not receive OAT. This study evaluated whether there are racial and/or ethnic differences in OAT receipt among adults entering specialty treatment for opioid use disorders in publicly-funded treatment programs across the U.S.

METHODS

Using data from the national Treatment: Episode Data Base, odds of OAT receipt were compared among black, Hispanic and white clients. Mediation analyses were used to explore whether any racial/ethnic differences in OAT receipt were explained by variation in clinical need or by other treatment, sociodemographic, or geographic characteristics. Interaction terms were used to assess whether this association was modified by primary opioid type.

RESULTS

Only 28.7% of clients received OAT. Odds of OAT receipt were significantly higher odds among blacks (OR: 2.27(2.14-2.41)) and Hispanics (OR: 1.98(1.88-2.09)), compared to whites. Differences in clinical need accounted for a substantial portion of this difference (76.79% and 49.74%, respectively). Differences persisted after accounting for other potential explanatory variables (adjusted OR: 1.37 (1.24-1.52); 1.21(1.11-1.32)), but were only evident for primary heroin users (adjusted OR: 1.50 (1.34-1.69); 1.29 (1.17-1.42)) and not other opioid users.

CONCLUSIONS

OAT receipt in treatment programs is low overall and particularly lacking among white heroin users. Differences in OAT receipt cannot be fully explained by differences in clinical need. More research is needed to understand and address barriers that underpin these differences so more patients with opioid use disorder can access evidenced-based treatment.

Failure to get into substance abuse treatment

Among substance abusers in the US, the discrepancy in the number who access substance abuse treatment and the number who need treatment is sizable. This results in a major public health problem of access to treatment. The purpose of this study was to examine characteristics of Persons Who Use Drugs (PWUDs) that either hinder or facilitate access to treatment. 2646 participants were administered the Risk Behavior Assessment (RBA) and the Barratt Impulsiveness Scale. The RBA included the dependent variable which was responses to the question "During the last year, have you ever tried, but been unable, to get into a drug treatment or detox program?" In multivariate analysis, factors associated with being unable to access treatment included: Previously been in drug treatment (OR=4.51), number of days taken amphetamines in the last 30days (OR=1.18), traded sex for drugs (OR=1.53), homeless (OR=1.73), Nonplanning subscale of the Barratt Impulsiveness Scale (OR=1.19), age at interview (OR=0.91), and sexual orientation, with bisexual men and women significantly more likely than heterosexuals to have tried but been unable to get into treatment. The answers to the question on "why were you unable to get into treatment" included: No room, waiting list; not enough money, did not qualify, got appointment but no follow through, still using drugs, and went to jail before program start. As expected, findings suggest that limiting organizational and financial obstacles to treatment may go a long way in increasing drug abuse treatment accessibility to individuals in need. Additionally, our study points to the importance of developing approaches for increasing personal planning skills/reducing Nonplanning impulsivity among PWUDs when they are in treatment as a key strategy to ensure access to additional substance abuse treatment in the future.

A review of a national training initiative to increase provider use of MAT to address the opioid epidemic

BACKGROUND AND OBJECTIVES

The Providers' Clinical Support System for Medication Assisted Treatment (PCSS-MAT) initiative focuses on training and mentoring health professionals in the treatment of opioid use disorders (OUD) using pharmacological strategies. Led by the American Academy of Addiction Psychiatry (AAAP), PCSS-MAT is a consortium representing four of the five national professional organizations authorized by DATA 2,000-AAAP, American Osteopathic Academy of Addiction Medicine, American Psychiatric Association, and American Society of Addiction Medicine. DATA organizations are authorized to train physicians to prescribe buprenorphine for OUD treatment. The primary aim of PCSS-MAT is to substantially increase evidence-based practices with medications for OUD.

METHODS

This review describes the development of PCSS-MAT, an ongoing national initiative funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), to address the training needs posed by this critical public health problem. Core initiatives include: (1) Training and mentoring activities for primary care physicians; (2) Outreach to multidisciplinary professional organizations, (3) Creating a resource portal for families, patients, and communities for OUD treatment.

RESULTS

Educational outreach to providers addresses the needs of patients with OUD and common co-occurring psychiatric and medical disorders.

DISCUSSION AND CONCLUSIONS

The overall scope of PCSS-MAT is to increase access to evidence-based treatment of substance use disorders as a public health priority. Recently enacted legislation requires office-based opioid treatment programs to offer all Food and Drug Administration-approved (FDA) forms of MAT.

SCIENTIFIC SIGNIFICANCE

Working with health care providers to effectively deliver MAT is key to integrating behavioral and physical medicine. (Am J Addict 2016;25:603-609).

Stratifying delays for assessment by type of substance to improve the probability of attendance in outpatient services

AIMS

1) To confirm the association between delay for assessment (DFA) and probability of first-time attendance in outpatient substance use disorder (SUD) treatment. 2) To evaluate whether this association varies by the type of primary substance for which the assessment was requested. 3) To assess the possibility of estimating differential DFAs to conform to equal probabilities of attendance across various types of primary substance.

METHODS

A prospective observational cohort of consecutive patients (N=1015) who requested a first-time assessment appointment at a publicly funded outpatient SUD treatment center in France between January 2014 and December 2015 was conducted. Logistic regression analyses were performed to evaluate associations between DFA (after log-transformation) and attendance and to provide estimates of attendance probability over time by the type of primary substance.

FINDINGS

After adjusting for gender, age and referral status, the attendance rate was observed to decrease significantly with longer DFA (OR=0.54; 95%CI: 0.44-0.66). The strength of this association differed across types of primary substance (p for heterogeneity <0.0001), with the strongest association being found for opioids (adjusted OR=0.21; 95%CI: 0.10-0.45). DFA was also associated with attendance for alcohol (OR=0.51; 95%CI: 0.37-0.71) and cannabis (OR=0.60; 95%CI: 0.37-0.96), but not for tobacco (OR=0.95; 95%CI: 0.60-1.50). Differential DFAs reflecting equal probabilities of attendance across types of substance could be estimated.

CONCLUSION

Our study suggests that the approach of stratifying DFAs by the type of primary substance could be helpful to improve the probability of first-time attendance in outpatient SUD treatment services.

Adapting Screening, Brief Intervention, and Referral to Treatment for Alcohol and Drugs to Culturally Diverse Clinical Populations

OBJECTIVES

To review the literature on the screening, brief intervention, and referral to treatment (SBIRT) approach to alcohol and drug use with racial and ethnic subgroups in the United States and to develop recommendations for culturally competent SBIRT practice.

METHODS

Articles reporting on the use of SBIRT components (screening, brief intervention, referral to treatment) for alcohol and drug use were identified through a comprehensive literature search of PubMed from 1995 to 2015.

RESULTS

A synthesis of the published literature on racial and ethnic considerations regarding SBIRT components (including motivational interviewing techniques) was created using evidence-based findings. Recommendations on culturally competent use of SBIRT with specific ethnic groups are also described.

CONCLUSIONS

On the basis of the literature reviewed, SBIRT offers a useful set of tools to help reduce risky or problematic substance use. Special attention to validated screeners, appropriate use of language/literacy, trust building, and incorporation of patient and community health care preferences may enhance SBIRT acceptability and effectiveness.

PRACTICE IMPLICATIONS

Providers should consider the implications of previous research when adapting SBIRT for diverse populations, and use validated screening and brief intervention methods. The accompanying case illustration provides additional information relevant to clinical practice.

Correlates of cocaine use during methadone treatment: implications for screening and clinical management (ANRS Methaville study)

Background

Cocaine use is frequent in patients receiving methadone maintenance treatment (MMT) and can jeopardize their treatment response. Identifying clinical predictors of cocaine use during methadone treatment can potentially improve clinical management. We used longitudinal data from the ANRS Methaville trial both to describe self-reported occasional and regular cocaine use during MMT and to identify clinical predictors.

Methods

We selected 183 patients who had data on cocaine (or crack) use at months 0 (M0), M6, and/or M12, accounting for 483 visits. The outcome was “cocaine use” in three categories: “no,” “occasional,” and “regular” use. To identify factors associated with the outcome over time, we performed a mixed multinomial logistic regression.

Results

Time on methadone was significantly associated with a decrease in occasional but not in regular cocaine use from 14.7 % at M0 to 7.1 % at M12, and from 10.7 % at baseline to 6.5 % at M12, respectively. After multiple adjustments, opiate injection, individuals screening positive for attention deficit hyperactivity disorder (ADHD) symptoms, and those presenting depressive symptoms were more likely to regularly use cocaine.

Conclusions

Although time on MMT had a positive impact on occasional cocaine use, it had no impact on regular cocaine use. Moreover, regular cocaine users were more likely to report opiate injection and to present ADHD and depressive symptoms. Early screening of these disorders and prompt tailored pharmacological and behavioral interventions can potentially reduce cocaine use and improve response to MMT.

Trial registration

The trial is registered with the French Agency of Pharmaceutical Products (AFSSAPS) under the number 2008-A0277-48, the European Union Drug Regulating Authorities Clinical Trials, number Eudract 2008-001338-28, the ClinicalTrials.gov Identifier: NCT00657397, and the International Standard Randomised Controlled Trial Number Register ISRCTN31125511.

Receipt of pharmacotherapy for opioid use disorder by justice-involved U.S. Veterans Health Administration patients

BACKGROUND

Pharmacotherapy - methadone, buprenorphine, or naltrexone - is an evidence-based treatment for opioid use disorder, but little is known about receipt of these medications among veterans involved in the justice system. The current study examines receipt of pharmacotherapy for opioid use disorder among veterans with a history of justice involvement at U.S. Veterans Health Administration (VHA) facilities compared to veterans with no justice involvement.

METHODS

Using national VHA clinical and pharmacy records, we conducted a retrospective cohort study of veterans with an opioid use disorder diagnosis in fiscal year 2012. Using a mixed-effects logistic regression model, we examined receipt of pharmacotherapy in the 1-year period following diagnosis as a function of justice involvement, adjusting for patient and facility characteristics.

RESULTS

The 1-year rate of receipt for pharmacotherapy for opioid use disorder was 27% for prison-involved veterans, 34% for jail/court-involved veterans, and 33% for veterans not justice-involved. Compared to veterans not justice-involved, those prison-involved had 0.75 lower adjusted odds (95% confidence interval [CI]: 0.65-0.87) of receiving pharmacotherapy whereas jail/court-involved veterans did not have significantly different adjusted odds.

CONCLUSIONS

Targeted efforts to improve receipt of pharmacotherapy for opioid use disorder among veterans exiting prison is needed as they have lower odds of receiving these medications.

Policies related to opioid agonist therapy for opioid use disorders: The evolution of state policies from 2004 to 2013

BACKGROUND

State Medicaid policies play an important role in Medicaid enrollees' access to and use of opioid agonists, such as methadone and buprenorphine, in the treatment of opioid use disorders. Little information is available, however, regarding the evolution of state policies facilitating or hindering access to opioid agonists among Medicaid enrollees.

METHODS

During 2013-2014, we surveyed state Medicaid officials and other designated state substance abuse treatment specialists about their state's recent history of Medicaid coverage and policies pertaining to methadone and buprenorphine. We describe the evolution of such coverage and policies and present an overview of the Medicaid policy environment with respect to opioid agonist therapy from 2004 to 2013.

RESULTS

Among our sample of 45 states with information on buprenorphine and methadone coverage, we found a gradual trend toward adoption of coverage for opioid agonist therapies in state Medicaid agencies. In 2013, only 11% of states in our sample (n = 5) had Medicaid policies that excluded coverage for methadone and buprenorphine, whereas 71% (n = 32) had adopted or maintained policies to cover both buprenorphine and methadone among Medicaid enrollees. We also noted an increase in policies over the time period that may have hindered access to buprenorphine and/or methadone.

CONCLUSIONS

There appears to be a trend for states to enact policies increasing Medicaid coverage of opioid agonist therapies, while in recent years also enacting policies, such as prior authorization requirements, that potentially serve as barriers to opioid agonist therapy utilization. Greater empirical information about the potential benefits and potential unintended consequences of such policies can provide policymakers and others with a more informed understanding of their policy decisions.