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Saunders EC, Budney AJ, Cavazos-Rehg P, Scherer E, Bell K, John D, Marsch LA. Evaluating preferences for medication formulation and treatment model among people who use opioids non-medically: A web-based cross-sectional study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 163:209383. [PMID: 38670531 PMCID: PMC11180569 DOI: 10.1016/j.josat.2024.209383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 02/19/2024] [Accepted: 04/22/2024] [Indexed: 04/28/2024]
Abstract
INTRODUCTION Over the past decade, treatment for opioid use disorder has expanded to include long-acting injectable and implantable formulations of medication for opioid use disorder (MOUD), and integrated treatment models systematically addressing both behavioral and physical health. Patient preference for these treatment options has been underexplored. Gathering data on OUD treatment preferences is critical to guide the development of patient-centered treatment for OUD. This cross-sectional study assessed preferences for long-acting MOUD and integrated treatment using an online survey. METHODS An online Qualtrics survey assessed preferences for MOUD formulation and integrated treatment models. The study recruited participants (n = 851) in October and November 2019 through advertisements or posts on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (mTurk). Eligible participants scored a two or higher on the opioid pain reliever or heroin scales of the Tobacco, Alcohol Prescription Medication and other Substance Use (TAPS) Tool. Structured survey items obtained patient preference for MOUD formulation and treatment model. Using stated preference methods, the study assessed preference via comparison of preferred options for MOUD and treatment model. RESULTS In the past year, 824 (96.8 %) participants reported non-prescribed use of opioid pain relievers (mean TAPS score = 2.72, SD = 0.46) and 552 (64.9 %) reported heroin or fentanyl use (mean TAPS score = 2.73, SD = 0.51). Seventy-four percent of participants (n = 631) reported currently or previously receiving OUD treatment, with 407 (48.4 %) receiving MOUD. When asked about preferences for type of MOUD formulation, 452 (53.1 %) preferred a daily oral formulation, 115 (13.5 %) preferred an implant, 114 (13.4 %) preferred a monthly injection and 95 (11.2 %) preferred a weekly injection. Approximately 8.8 % (n = 75) would not consider MOUD regardless of formulation. The majority of participants (65.2 %, n = 555) preferred receiving treatment in a specialized substance use treatment program distinct from their medical care, compared with receiving care in an integrated model (n = 296, 34.8 %). CONCLUSIONS Though most participants expressed willingness to try long-acting MOUD formulations, the majority preferred short-acting formulations. Likewise, the majority preferred non-integrated treatment in specialty substance use settings. Reasons for these preferences provide insight on developing effective educational tools for patients and suggesting targets for intervention to develop a more acceptable treatment system.
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Affiliation(s)
- Elizabeth C Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA.
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA
| | - Kathleen Bell
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
| | | | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine at Dartmouth College, Lebanon, NH, USA.
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McLean K, Murphy J, Kruis N. "I think we're getting better but we're still not there": Provider-based stigma and perceived barriers to care for people who use opioids (PWUO). JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 159:209270. [PMID: 38103831 DOI: 10.1016/j.josat.2023.209270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 09/18/2023] [Accepted: 12/13/2023] [Indexed: 12/19/2023]
Abstract
BACKGROUND Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD - is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care. METHODS This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population. RESULTS Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO. CONCLUSIONS Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma - blameworthiness - in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma.
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Affiliation(s)
- Katherine McLean
- Penn State Greater Allegheny, 4000 University Dr., McKeesport, PA 15131, United States of America.
| | - Jennifer Murphy
- Penn State Berks, 1801 Broadcasting Rd, Reading, PA 19610, United States of America.
| | - Nathan Kruis
- Penn State Altoona, 3000 Ivyside Park, Altoona, PA 16601, United States of America.
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Khail JW, Rawal S, Young HN, Caballero J. Addressing buprenorphine supply barriers: A guidance commentary. J Am Pharm Assoc (2003) 2024; 64:377-379. [PMID: 38272311 DOI: 10.1016/j.japh.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 01/27/2024]
Abstract
The current supply-side constraints limiting buprenorphine availability at pharmacies may reduce the potential impact of recent initiatives to improve medications for opioid use disorder (MOUD) access. The recent opioid litigation combined with existing federal regulation and enforcement has resulted in significant restrictions to the distribution and dispensing practices of pharmaceutical wholesalers and pharmacies countrywide. Previously discussed solutions to these problems do not seem to have produced actionable improvements to the current landscape. However, a novel solution to this problem may exist in the form of a Drug Enforcement Administration (DEA) guidance letter. These guidance letters allow the DEA to communicate directly to registrants, providing detailed interpretation and clarity regarding the DEA's expectations and enforcement realities. Recently, the DEA guidance letter portal was used to remind registrants that the DEA does not create quantitative thresholds or volume limits on controlled substance distribution. An additional guidance letter could be issued to ease the concerns about liability connected to the distribution and dispensing of buprenorphine. In particular, this guidance could acknowledge certain terms of the distributor settlement agreement as legal precedent and clarify that buprenorphine is not subject to the same restriction as other defined "highly diverted" controlled substances. Such guidance may also serve to provide both pharmaceutical wholesalers and pharmacies with assurance that an increase in buprenorphine distribution would not directly result in increased DEA scrutiny. This strategy represents an actionable step toward the goal of providing better access to MOUD by reducing existing supply-side limitations.
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Feder KA, Byrne L, Miller SM, Sodder S, Saloner B. Beliefs and Attitudes about Vermont's Buprenorphine Decriminalization Law among Clinicians Who Prescribe Buprenorphine. Subst Use Misuse 2023; 59:150-153. [PMID: 37752786 DOI: 10.1080/10826084.2023.2262014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND On June 1, 2021, Vermont repealed all criminal penalties for possessing 224 milligrams or less of buprenorphine. We examined the potential impact of decriminalization with a survey of Vermont clinicians who prescribed buprenorphine within the past year. METHODS All 638 Vermont clinicians with a waiver to prescribe buprenorphine were emailed the survey by Vermont Department of Health; 117 responded. We estimated the prevalence of the following four outcomes, for all responding clinicians and stratified by clinician demographics and practice characteristics: awareness of decriminalization, beliefs about the effects of decriminalization, support for decriminalization, and changes in practice resulting from decriminalization. RESULTS 72 (62%) prescribers correctly stated that Vermont does not have criminal penalties for buprenorphine possession. 107 (91%) support decriminalization. 56 (48%) believe that, because buprenorphine is decriminalized, their patients are more likely to give, sell, or trade the buprenorphine that is prescribed to them to someone else. However, only 5 providers (4%) said they now prescribe to fewer patients. CONCLUSION The great majority of Vermont clinicians who prescribe buprenorphine support its decriminalization and have not changed their prescribing practices because of decriminalization.
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Affiliation(s)
- Kenneth A Feder
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Lauren Byrne
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Samantha M Miller
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Shereen Sodder
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Feder KA, Harris SJ, Byrne L, Miller SM, Sodder S, Berman V, Livingston A, Edwards J, Hartman S, Sugarman OK, Shah H, Xu J, Raikes J, Gattine S, Saloner B. Attitudes and beliefs about Vermont's 2021 buprenorphine decriminalization law among residents who use illicit opioids. Drug Alcohol Depend 2023; 250:110879. [PMID: 37473698 DOI: 10.1016/j.drugalcdep.2023.110879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/20/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND In July 2021, Vermont removed all criminal penalties for possessing 224mg or less of buprenorphine. METHODS Vermont residents (N=474) who used illicit opioid drugs or received treatment for opioid use disorder in the past 90 days were recruited for a mixed-methods survey on the health and criminal legal effects of decriminalization. Topics assessed included: motivations for using non-prescribed buprenorphine, awareness of and support for decriminalization, and criminal legal system experiences involving buprenorphine. We examined the frequencies of quantitative measures and qualitatively summarized themes from free-response questions. RESULTS Three-quarters of respondents (76%) reported lifetime use of non-prescribed buprenorphine. 80% supported decriminalization, but only 28% were aware buprenorphine was decriminalized in Vermont. Respondents described using non-prescribed buprenorphine to alleviate withdrawal symptoms and avoid use of other illicit drugs. 18% had been arrested while in buprenorphine, with non-White respondents significantly more likely to report such arrests (15% v 33%, p<0.001). CONCLUSION Decriminalization of buprenorphine may reduce unnecessary criminal legal system involvement, but its health impact was limited by low awareness at the time of our study.
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Affiliation(s)
- Kenneth A Feder
- Johns Hopkins Bloomberg School of Public Health, Department of Mental Health, United States.
| | - Samantha J Harris
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Lauren Byrne
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Samantha M Miller
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Shereen Sodder
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Vanessa Berman
- Pacific Institute for Research and Evaluation, United States
| | - Amy Livingston
- Pacific Institute for Research and Evaluation, United States
| | - Jessica Edwards
- Pacific Institute for Research and Evaluation, United States
| | - Shane Hartman
- Pacific Institute for Research and Evaluation, United States
| | - Olivia K Sugarman
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Hridika Shah
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Justin Xu
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Jewyl Raikes
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Sabrina Gattine
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
| | - Brendan Saloner
- Johns Hopkins Bloomberg School of Public Health, Department of Health Policy and Management, United States
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Jakubowski A, Fowler S, Fox AD. Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature. Addict Sci Clin Pract 2023; 18:40. [PMID: 37301953 PMCID: PMC10256972 DOI: 10.1186/s13722-023-00394-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD. METHODS We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs. RESULTS SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs. CONCLUSIONS SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.
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Affiliation(s)
- Andrea Jakubowski
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
| | - Sabrina Fowler
- Present Address: Ascension St. John Hospital, 22101 Moross Road, Detroit, MI 48236 USA
- Albert Einstein College of Medicine, 1300 Morris Park Avenue, Bronx, NY 10461 USA
| | - Aaron D. Fox
- Department of Medicine, Division of General Internal Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, 3300 Kossuth Avenue, Bronx, NY 10467 USA
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Hospital-initiated Extended-release Injectable Buprenorphine Using a Novel Reallocation Initiative From an Outpatient Addiction Medicine Clinic. J Addict Med 2023; 17:108-110. [PMID: 36166670 DOI: 10.1097/adm.0000000000001038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Novel strategies for initiation and continuation of buprenorphine are critical, especially during a pandemic when traditional opioid use disorder treatment pathways may be disrupted. We describe an innovative outpatient to inpatient reallocation initiative for extended-release buprenorphine (XR-BUP) designed to repurpose an expensive medication for use in hospitalized patients facing treatment barriers upon discharge and pilot the feasibility of XR-BUP use in the inpatient setting. METHODS We collaborated with our institution's inpatient pharmacy and a New Jersey Medicaid managed care organization to create an alternate pathway to make XR-BUP available to hospitalized patients insured by the same payor. In this process, XR-BUP doses were deidentified and transferred to the inpatient controlled substance inventory for administration to hospitalized patients at no charge by our Addiction Medicine Consult Service after a period of sublingual buprenorphine stabilization. Our reallocation pathway bypassed several existing XR-BUP regulatory barriers to allow for inpatient administration. RESULTS To date, we have transferred approximately 85 XR-BUP 300 mg doses to the inpatient controlled substance inventory. This equates to a cost savings of nearly $145,000. CONCLUSIONS Reallocation of XR-BUP from an outpatient to inpatient setting increased postdischarge buprenorphine treatment access while also reducing health care costs by repurposing an expensive medication that would otherwise go to waste. Use of reallocated XR-BUP in the inpatient setting may pave the way for addition of XR-BUP to the hospital's formulary to minimize treatment gaps after discharge.
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Corneli A, Perry B, Des Marais A, Choi Y, Chen H, Lilly R, Ayers D, Bennett J, Kestner L, Meade CS, Sachdeva N, McKellar MS. Participant perceptions on the acceptability and feasibility of a telemedicine-based HIV PrEP and buprenorphine/naloxone program embedded within syringe services programs: a qualitative descriptive evaluation. Harm Reduct J 2022; 19:132. [PMID: 36463214 PMCID: PMC9719634 DOI: 10.1186/s12954-022-00718-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/19/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are at risk for HIV and opioid overdose. We piloted PARTNER UP, a telemedicine-based program to provide PWID with access to both oral pre-exposure prophylaxis (PrEP) for HIV prevention and medication for opioid use disorder (MOUD) through two syringe services programs (SSPs) in North Carolina. We conducted a qualitative evaluation to assess the acceptability and feasibility of PARTNER UP from the participant perspective. METHODS PARTNER UP participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly telemedicine visits until program end at month 6. Using a qualitative descriptive study design, we conducted in-depth interviews with a subsample of PARTNER UP participants at 1 month and 4 months. Informed by the technology acceptance model, we assessed participant perceptions of the usefulness and ease of use of PARTNER UP, as well as their intent to continue to use the program's components. We audio-recorded all interviews with participants' permission and used applied thematic analysis to analyze the verbatim transcripts. RESULTS We interviewed 11 of 17 people who participated in PARTNER UP-10 in the month 1 interview and 8 in the month 4 interview. Nearly all participants were motivated to join for consistent and easy access to buprenorphine/naloxone (i.e., MOUD); only a few joined to access PrEP. Most were comfortable accessing healthcare at the SSP because of their relationship with and trust toward SSP staff, and accessing services at the SSP was preferred compared with other healthcare centers. Some participants described that telemedicine allowed them to be honest and share more information because the visits were not in-person and they chose the location, although the initial in-person meeting was helpful to build provider trust and rapport. Most participants found the visit schedule to be feasible, although half described needing to reschedule at least once. Nearly all participants who were interviewed intended to continue with MOUD after the program ended, whereas none were interested in continuing with PrEP. CONCLUSIONS Participant narratives suggest that the PARTNER UP telemedicine program was acceptable and feasible. Future studies should continue to explore the benefits of embedding both PrEP and MOUD into SSPs with larger numbers of participants. Trial registration Clinicaltrials.gov Identifier: NCT04521920.
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Affiliation(s)
- Amy Corneli
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - Brian Perry
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Andrea Des Marais
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Yujung Choi
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Hillary Chen
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Rebecca Lilly
- North Carolina Harm Reduction Coalition, Wilmington, NC USA ,Present Address: Port City Harm Reduction, Wilmington, NC USA
| | - Denae Ayers
- Queen City Harm Reduction, Charlotte, NC USA
| | - Jesse Bennett
- North Carolina Harm Reduction Coalition, Wilmington, NC USA
| | | | - Christina S. Meade
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Nidhi Sachdeva
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.10698.360000000122483208Present Address: North Carolina Association of County Commissioners, Raleigh, NC USA
| | - Mehri S. McKellar
- grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
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Filteau MR, Green B, Kim F, McBride KA. 'It's the same thing as giving them CPR training': rural first responders' perspectives on naloxone. Harm Reduct J 2022; 19:111. [PMID: 36192736 PMCID: PMC9531424 DOI: 10.1186/s12954-022-00688-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 09/13/2022] [Indexed: 12/03/2022] Open
Abstract
The Substance Abuse and Mental Health Services Administration's (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders' inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area's overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents' best chance for surviving an opioid overdose.
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Affiliation(s)
| | | | - Frances Kim
- JG Research and Evaluation, Bozeman, MT, USA
| | - Ki-Ai McBride
- Montana Department of Health and Human Services, Behavioral Health and Disabilities Disorders Division, Helena, MT, USA
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Adams JW, Savinkina A, Fox A, Behrends CN, Madushani RWMA, Wang J, Chatterjee A, Walley AY, Barocas JA, Linas BP. Modeling the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine-naloxone treatment at syringe service programs. Addiction 2022; 117:2635-2648. [PMID: 35315148 PMCID: PMC9951221 DOI: 10.1111/add.15883] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 03/06/2022] [Indexed: 12/25/2022]
Abstract
AIM To estimate the number of treatment initiations, averted fatal opioid overdoses and the cost-effectiveness associated with offering buprenorphine-naloxone (buprenorphine) treatment on-site within existing syringe service programs (SSPs) in Massachusetts, USA. DESIGN, SETTING AND PARTICIPANTS This was a cohort-based mathematical model and cost-effectiveness analysis. We derived model inputs from state and national surveillance data, clinical trials and observational cohort studies. We compared an intervention scenario where 30% of SSP clients initiated buprenorphine treatment on-site at least once annually to a status quo scenario where no buprenorphine was available on-site among community treatment providers in Massachusetts, 2020-30. In individuals with opioid use disorder (OUD) we assumed that 80% of SSP clients had recently injected drugs and that treatment within SSPs would have similar or improved retention compared with standard-of-care buprenorphine programs, but higher rates of active opioid use while in treatment. MEASUREMENTS Number of treatment initiations (i.e. individuals began treatment on a medication for opioid use disorder or entered medically managed withdrawal), averted fatal opioid overdoses, quality-adjusted life-years (QALYs) and life-time discounted costs from a health sector and a limited societal perspective. FINDINGS The status quo scenario resulted in 23 051 fatal overdoses and 1 511 613 treatment initiations over a 10-year simulation period. An intervention scenario with on-site SSP buprenorphine treatment averted 4797 (-20.8%) fatal opioid overdoses and resulted in 129 359 (+8.6%) additional treatment initiations compared with the status quo. The intervention scenario was the dominating scenario: providing OUD treatment through Massachusetts SSPs cost less (-$3612 per person) with patients accumulating more QALYs (0.2 per person) compared with the status quo scenario. CONCLUSIONS Offering buprenorphine treatment on-site within syringe service programs has the potential to decrease fatal overdoses substantially, improve treatment engagement and save on costs.
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Affiliation(s)
- Joëlla W. Adams
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
- RTI International, Research Triangle, NC, USA
| | - Alexandra Savinkina
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
| | - Aaron Fox
- Montefiore Medical Center and Albert Einstein College of Medicine, New York, NY, USA
| | - Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York City, NY, USA
| | | | - Jianing Wang
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
| | - Avik Chatterjee
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Joshua A. Barocas
- Divisions of General Internal Medicine and Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, USA
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center (BMC), Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
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Winstanley EL, Thacker EP, Choo LY, Lander LR, Berry JH, Tofighi B. Patient-reported problems filling buprenorphine prescriptions and motivations for illicit use. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100091. [PMID: 36844166 PMCID: PMC9949336 DOI: 10.1016/j.dadr.2022.100091] [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: 06/11/2022] [Revised: 08/04/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022]
Abstract
Background While barriers to accessing buprenorphine (BUP) therapy have been well described, little is known about pharmacy-related barriers. The objective of this study was to estimate the prevalence of patient-reported problems filling BUP prescriptions and determine whether these problems were associated with illicit use of BUP. The secondary objectives included identifying motivations for illicit BUP use and the prevalence of naloxone acquisition among patients prescribed BUP. Methods Between July 2019 and March 2020, 139 participants receiving treatment for an opioid use disorder (OUD) at two sites within a rurally-located health system, completed an anonymous 33-item survey. A multivariable model was used to assess the association between pharmacy-related problems filling BUP prescriptions and illicit substance use. Results More than a third of participants reported having problems filling their BUP prescription (34.1%, n = 47) with the most commonly reported problems being insufficient pharmacy stock of BUP (37.8%, n = 17), pharmacist refusal to dispense BUP (37.8%, n = 17), and insurance problems (34.0%, n = 16). Of those who reported illicit BUP use (41.5%, n = 56), the most common motivations were to avoid/ease withdrawal symptoms (n = 39), prevent/reduce cravings (n = 39), maintain abstinence (n = 30), and treat pain (n = 19). In the multivariable model, participants who reported a pharmacy-related problems were significantly more likely to use illicitly obtained BUP (OR=8.93, 95% CI: 3.12, 25.52, p < 0.0001). Conclusion Efforts to improve BUP access have primarily focused on increasing the number of clinicians waivered to prescribe; however, challenges persist with BUP dispensing and coordinated efforts may be needed to systematically reduce pharmacy-related barriers.
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Affiliation(s)
- Erin L. Winstanley
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States,Corresponding author at: Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States.
| | - Emily P. Thacker
- Department of Pharmacy, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lyn Yuen Choo
- West Virginia Clinical and Translational Science Institute, West Virginia University, Morgantown, WV, United States
| | - Laura R. Lander
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - James H. Berry
- Department of Behavioral Medicine and Psychiatry, School of Medicine and Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV, United States,Department of Neuroscience, West Virginia University, Morgantown, WV, United States
| | - Babak Tofighi
- Department of Population Health, New York University School of Medicine, United States
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12
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Initiation of Low-threshold Buprenorphine in Nontreatment Seeking Patients With Opioid Use Disorder Engaged in Hepatitis C Treatment. J Addict Med 2022; 16:10-17. [PMID: 33560694 PMCID: PMC8923533 DOI: 10.1097/adm.0000000000000807] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE The ANCHOR program offered buprenorphine treatment to people who inject drugs engaged in hepatitis C (HCV) treatment at a Washington, DC harm reduction organization. This analysis describes the program model and outcomes of the opioid care continuum at 1 year. METHODS Primary outcomes were initiation of buprenorphine and retention in care, defined by an active buprenorphine prescription at given time points. Secondary outcomes included treatment interruptions, reasons for treatment noninitiation and termination, buprenorphine and opiate use, and HIV risk behaviors. Buprenorphine and opiate use were measured by urine toxicology screens and HIV risk behavior was quantified using a validated survey. RESULTS Of 67 patients receiving HCV treatment not on opioid agonist therapy at baseline, 96% (n = 64) were interested and 73% (n = 49) initiated buprenorphine. Retention was 82% (n = 40), 65% (n = 32), and 59% (n = 29) at months 1, 6, and 12, respectively. Retention at 12 months was associated with self-reported engagement in routine medical care (P < 0.01), but was not associated with gender, stable housing, past opioid agonist therapy, or past overdose. Among retained patients, urine screens positive for opioids were 73% (n = 29), 56% (n = 18), and 79% (n = 23) at months 1, 6, and 12. There was a significant mean decrease in HIV risk-taking behavior scores over the treatment period, primarily driven by reduced injection frequency. CONCLUSIONS Patients engaged in HCV treatment at a harm reduction organization showed a high rate of initiation of buprenorphine treatment, with retention comparable to other treatment settings. Although most patients continued using opioids on treatment, there was a reduced frequency of injection drug use, a significant driver of OUD-related risk. These data support the use of low-threshold buprenorphine access alongside HCV treatment to reduce morbidity and mortality in people with OUD.
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13
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McLean K, Kavanaugh PR. "I'm Not a Good Drug Dealer": Styles of Buprenorphine Diversion in a Multisite Qualitative Study. Subst Use Misuse 2022; 57:452-460. [PMID: 35067160 DOI: 10.1080/10826084.2021.2019775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Against the backdrop of the U.S. opioid epidemic, there has been a concerted movement to improve access to buprenorphine maintenance therapy (BMT). In Pennsylvania, where overdose mortality increased 65% between 2015 and 2017, over $75 million has been appropriated toward BMT since 2016. Concurrently, efforts to increase BMT availability while lowering barriers to entry have given way to fears of increased diversion and illegitimate patients. Little is known about the circumstances and motivations that surround buprenorphine diversion, particularly within the context of treatment expansion. METHOD Drawing on 27 in-depth interviews with individuals who reported sharing or selling buprenorphine in the past year, in this study we consider the relationship between treatment access, treatment experiences, and individuals' decision to divert buprenorphine, while further comparing motivations for buprenorphine diversion across two Pennsylvania counties with disparate levels of BMT availability. RESULTS We identify four styles of buprenorphine diversion ("ad hoc sellers," "concerned suppliers," "social sharers," "professional dealers"), with different levels of representation by county. Overall, our analysis found the explicit economic exploitation of BMT was rare, while a plurality of participants reported selling unwanted or unneeded buprenorphine only when presented with an opportunity. CONCLUSIONS Across our typology, market demand in the form of unmet need for buprenorphine was the major driver of diversion, suggesting that "supply-side interventions" intended to again limit access to BMT may be counterproductive.
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Affiliation(s)
- Katherine McLean
- Administration of Justice, Penn State Greater Allegheny, McKeesport, Pennsylvania, USA
| | - Philip R Kavanaugh
- School of Public Affairs, Penn State Harrisburg, Middletown, Pennsylvania, USA
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14
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Low-threshold Buprenorphine Treatment in a Syringe Services Program: Program Description and Outcomes. J Addict Med 2022; 16:447-453. [PMID: 34775441 PMCID: PMC9095762 DOI: 10.1097/adm.0000000000000934] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVES Low-threshold buprenorphine treatment aims to reduce barriers to evidence-based opioid use disorder treatment. We aimed to describe the treatment philosophy, practices, and outcomes of a low-threshold syringe services program (SSP)-based buprenorphine program developed through an SSP-academic medical center partnership. METHODS We included all SSP participants who received 1 or more buprenorphine prescription from Feb 5, 2019 to October 9, 2020. We collected data on patient characteristics, substance use, buprenorphine prescriptions, and urine drug tests (UDTs). We evaluated buprenorphine treatment retention using prescription data and buprenorphine adherence using UDTs. We used 2 retention definitions: (1) percentage of patients with buprenorphine prescriptions at 30, 90, and 180 days; and (2) total percentage of days "covered" with buprenorphine prescriptions through 180 days. RESULTS One-hundred and eighteen patients received 1 or more buprenorphine prescriptions. Patients were largely middle-aged (mean age 44, standard deviation 11), male (68%), Hispanic (31%) or Non-Hispanic Black (32%), with heroin (90%) and crack/cocaine (62%) use, and injection drug use (59%). Retention was 62%, 43%, and 31% at 30, 90, and 180 days, respectively. The median percentage of days covered with buprenorphine prescriptions through 180 days was 43% (interquartile range 8%-92%). Of the 82 patients who completed 2 or more UDTs, the median percentage of buprenorphine-positive UDTs was 71% (interquartile range 40%-100%). CONCLUSIONS In an SSP-based low-threshold buprenorphine treatment program, approximately one-third of patients continued buprenorphine treatment for 180 days or more, and buprenorphine adherence was high. SSPs can be a pathway to buprenorphine treatment for patients at high risk for opioid-related harms.
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15
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Hudgins A, Uzwiak B, Pizzicato L, Viner K. Barriers to effective care: Specialty drug treatment in Philadelphia. J Subst Abuse Treat 2021; 131:108639. [PMID: 34728133 DOI: 10.1016/j.jsat.2021.108639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 09/23/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION In Philadelphia, the poorest big city in the United States, an estimated 60,000 people misuse opioids and more than 3500 have died of overdose in the past three years. In 2019, fentanyl was detected in 76% of drug-related deaths and 94% of opioid-involved deaths. While much attention has been directed at the public face of the city's drug problem, more than 75% of drug deaths in 2017 took place in a private residence. METHOD Based on qualitative research to understand the vulnerabilities of this hidden population of drug users, we interviewed kin of 35 people who had died of opioid overdose in 2017 to learn whether their loved one had interacted with any social services or harm-reduction interventions. RESULTS In our demographically and geographically representative sample of decedents, we found that while most had received treatment at least once, many faced barriers to getting treatment when they needed it, including barriers related to stigma, structural racism, gender inequities, bureaucracy, insurance requirements, and cost. CONCLUSION We argue that these barriers place an undue burden on people with substance use disorder and their kin during particularly fraught moments of heightened vulnerability. The failure of state and federal policies, practices, and infrastructure to address these barriers, and the failure to require that evidence-based care be provided during treatment have deleterious effects on people affected by the opioid epidemic in the United States.
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Affiliation(s)
| | - Beth Uzwiak
- Ethnologica, 4732 Stenton Ave., Philadelphia, PA 19144, USA
| | - Lia Pizzicato
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, 123 S. Broad Street, Suite 1120, Philadelphia, PA 19109, USA
| | - Kendra Viner
- Division of Substance Use Prevention and Harm Reduction, Philadelphia Department of Public Health, 123 S. Broad Street, Suite 1120, Philadelphia, PA 19109, USA
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16
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Wenger LD, Kral AH, Bluthenthal RN, Morris T, Ongais L, Lambdin BH. Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises. Transl Res 2021; 234:159-173. [PMID: 33746108 PMCID: PMC8217165 DOI: 10.1016/j.trsl.2021.03.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/25/2021] [Accepted: 03/15/2021] [Indexed: 12/09/2022]
Abstract
As COVID-19 accelerated throughout 2020, syringe service programs (SSPs) faced challenges necessitating programmatic adaptations to prevent overdose deaths while simultaneously keeping workers and participants safe from COVID-19. We used qualitative methods to gain an understanding of the social context within which SSPs are operating during the COVID-19 pandemic. We conducted 36 in-depth interviews with program representatives from 18 programs and used the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation framework to guide data analysis. We focused on 3 of the 4 EPIS constructs: Outer context, inner context, and innovation factors. Our data indicate that responding to the pandemic led to innovations in service delivery such as secondary and mail-based distribution, adoption of telemedicine for enrolling participants in medications for opioid use disorder (MOUD) and use of virtual training platforms for overdose prevention. We found high levels of staff and volunteer commitment, which was a cornerstone to the success of these innovations. We observed that many SSPs were short-staffed because of their commitment to safety, and some lost current funding as well as opportunities for future funding. Despite minimal staffing and diminished funding, SSPs innovated at an accelerated pace. To ensure the sustainability of these new approaches, a supportive external context (federal, state, and local policies and funding) is needed to support the development of SSPs' inner contexts (organizational characteristics, characteristics of individuals) and sustainment of the innovations achieved regarding delivery of naloxone and MOUD.
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Affiliation(s)
| | | | - Ricky N Bluthenthal
- University of Southern California, Keck School of Medicine, Los Angeles, California
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17
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Armoon B, SoleimanvandiAzar N, Rostami M, Higgs P, Bayani A, Bayat AH, Mohammadi R, Ahounbar E, Fattah Moghaddam L. Drug type and risk behaviors associated with non-fatal overdose among people who use drugs: a systematic review and meta-analysis. J Addict Dis 2021; 40:114-125. [PMID: 34286664 DOI: 10.1080/10550887.2021.1950262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The present study aimed to determine the association between drug type, risk behaviors and non-fatal overdose among people who use drugs (PWUD). We searched for studies in English published before February 1, 2021, on PubMed, Scopus, Cochrane, and Web of Science to identify primary studies on the factors associated with non-fatal overdose among PWUD. After reviewing for study duplicates, the full-text of selected articles were assessed for eligibility using Population, Intervention, Comparator, Outcomes (PICO) criteria. After a detailed assessment of over 13,845 articles, a total of 49 studies met the eligibility criteria. We found that non-injection opioid use, heroin injection, cocaine use, concurrent use of buprenorphine and benzodiazepines, benzodiazepine use, incarceration, injecting drugs, and duration of injecting were associated with greater odds of non-fatal overdose among PWUD. The findings of the current meta-analysis support the requirement to improve suitable harm reduction strategies for drug users, such as peer-based overdose management, and further focusing on the need to balance the current emphasis on enforcement-based responses to illegal drug use with health-related interventions.
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Affiliation(s)
- Bahram Armoon
- Douglas Hospital Research Centre, Douglas Mental Health University Institute, Montreal, QC, Canada.,Department of Psychiatry, McGill University, Montreal, QC, Canada
| | - Neda SoleimanvandiAzar
- Preventive Medicine and Public Health Research Center, Psychosocial Health Research Institute, Iran University of Medical Sciences, Tehran, Iran
| | - Mohammad Rostami
- Department of Counseling, Faculty of Humanities and Social Sciences, University of Kurdistan, Kurdistan, Iran
| | - Peter Higgs
- Department of Public Health, School of Psychology and Public Health, La Trobe University, Melbourne, VIC, Australia
| | - Azadeh Bayani
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Amir-Hossein Bayat
- Social Determinants of Health Research Center, Saveh University of Medical Sciences, Saveh, Iran
| | - Rasool Mohammadi
- Department of Biostatistics and Epidemiology, School of Public Health and Nutrition, Lorestan University of Medical Sciences, Khorramabad, Iran
| | - Elahe Ahounbar
- Substance Abuse and Dependence Research Center, The University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Ladan Fattah Moghaddam
- Department of Nursing, Faculty of Nursing and Midwifery, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
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18
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Hall NY, Le L, Majmudar I, Mihalopoulos C. Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective. Drug Alcohol Depend 2021; 221:108651. [PMID: 33667783 DOI: 10.1016/j.drugalcdep.2021.108651] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD). METHODS The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes. RESULTS There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility. CONCLUSION This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.
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Affiliation(s)
- Natasha Yvonne Hall
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Long Le
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Ishani Majmudar
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin University, 221 Burwood Highway, Burwood, Victoria, 3125, Australia.
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19
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Morse E, Binswanger IA, Taylor E, Gray C, Stimmel M, Timko C, Harris AHS, Smelson D, Finlay AK. Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study. J Subst Abuse Treat 2021; 129:108353. [PMID: 34080564 DOI: 10.1016/j.jsat.2021.108353] [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: 09/19/2020] [Revised: 12/07/2020] [Accepted: 02/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD). METHODS Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD. RESULTS The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans. CONCLUSIONS Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.
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Affiliation(s)
- Erica Morse
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 10065 E Harvard Ave #300, Denver, CO 80231, USA; Colorado Permanente Medical Group, 1835 Franklin St, Denver, CO 80218, USA; Division of General Internal Medicine, University of Colorado School of Medicine, 12631 East 17th Avenue, Aurora, CO 80045, USA.
| | - Emmeline Taylor
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Clinical Psychology, University of Colorado, 1420 Austin Bluffs Pkwy, Colorado Springs, CO 80918, USA.
| | - Caroline Gray
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Matthew Stimmel
- Veterans Justice Programs, U.S. Department of Veterans Affairs (MS), 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
| | - Christine Timko
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, 1199 Welch Road, Stanford, CA 94304, USA.
| | - Alex H S Harris
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; Department of Surgery, Stanford University School of Medicine, Always Building, Suite M121, 300 Pasteur Drive, Stanford, CA 94305-2200, USA.
| | - David Smelson
- Center for Organization and Implementation Science, Edith Nourse Rogers VA Medical Center, 200 Springs Road, Bedford, MA 01730, USA.
| | - Andrea K Finlay
- Center for Innovation to Implementation (Ci2i), VA Palo Alto Health Care System, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA; National Center on Homelessness Among Veterans, Department of Veterans Affairs, 795 Willow Road (152-MPD), Menlo Park, CA 94025, USA.
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20
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Saunders EC, Moore SK, Walsh O, Metcalf SA, Budney AJ, Cavazos-Rehg P, Scherer E, Marsch LA. "It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder. Addict Sci Clin Pract 2021; 16:8. [PMID: 33499938 PMCID: PMC7839299 DOI: 10.1186/s13722-021-00213-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 01/06/2021] [Indexed: 01/17/2023] Open
Abstract
Background Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences. Methods This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed. Results While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma). Conclusions Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.
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Affiliation(s)
- Elizabeth C Saunders
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA.
| | - Sarah K Moore
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Olivia Walsh
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Stephen A Metcalf
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Alan J Budney
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Patricia Cavazos-Rehg
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Emily Scherer
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
| | - Lisa A Marsch
- Center for Technology and Behavioral Health, Geisel School of Medicine At Dartmouth College, 46 Centerra Parkway, Suite 301, Lebanon, NH, 03766, USA
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21
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Carroll JJ, Mital S, Wolff J, Noonan RK, Martinez P, Podolsky MC, Killorin JC, Green TC. Knowledge, preparedness, and compassion fatigue among law enforcement officers who respond to opioid overdose. Drug Alcohol Depend 2020; 217:108257. [PMID: 32947173 PMCID: PMC7475730 DOI: 10.1016/j.drugalcdep.2020.108257] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Revised: 08/20/2020] [Accepted: 08/23/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND Rates of fatal overdose (OD) from synthetic opioids rose nearly 60 % from 2016 to 2018. 911 Good Samaritan Laws (GSLs) are an evidenced-based strategy for preventing OD fatality. This study describes patrol officers' knowledge of their state's GSL, experience with OD response, and their perspectives on strategies to prevent and respond to opioid OD. METHODS An electronic survey assessed officers' knowledge of state GSLs and experiences responding to OD. Descriptive statistics and hierarchical linear modeling were generated to examine differences in knowledge, preparedness, and endorsement of OD response efforts by experience with OD response. RESULTS 2,829 officers responded to the survey. Among those who had responded to an OD call in the past six months (n = 1,946), 37 % reported administering naloxone on scene and 36 % reported making an arrest. Most (91 %) correctly reported whether their state had a GSL in effect. Only 26 % correctly reported whether that law provides limited immunity from arrest. Fifteen percent of officers who had responded to an OD work in departments that do not carry naloxone. Compared with officers who had not responded to any OD calls, those who reported responding OD calls at least monthly and at least weekly, were significantly less likely to endorse OD response efforts. CONCLUSION Officers who respond to OD calls are generally receiving training and naloxone supplies to respond, but knowledge gaps and additional training needs persist. Additional training and strategies to relieve compassion fatigue among those who have more experience with OD response efforts may be indicated.
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Affiliation(s)
- Jennifer J. Carroll
- Department of Sociology & Anthropology, Elon University, Elon, NC, United States,Department of Medicine, Brown University, Providence, RI, United States,Corresponding author at: Elon University, 100 Campus Drive, 2035 Campus Box, Elon, NC, United States
| | - Sasha Mital
- National Center for Injury Control and Prevention, Centers for Disease Control & Prevention, Atlanta, GA, United States
| | - Jessica Wolff
- National Center for Injury Control and Prevention, Centers for Disease Control & Prevention, Atlanta, GA, United States
| | - Rita K. Noonan
- National Center for Injury Control and Prevention, Centers for Disease Control & Prevention, Atlanta, GA, United States
| | - Pedro Martinez
- National Center for Injury Control and Prevention, Centers for Disease Control & Prevention, Atlanta, GA, United States
| | - Melissa C. Podolsky
- National Center for Injury Control and Prevention, Centers for Disease Control & Prevention, Atlanta, GA, United States
| | - John C. Killorin
- Atlanta-Carolinas High Intensity Drug Trafficking Areas, Peachtree Corners, GA, United States
| | - Traci C. Green
- Heller School for Social Policy and Development, Brandeis University, Waltham, MA, United States,Departments of Emergency Medicine and Epidemiology, Brown University, Providence, RI, United States
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22
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Barriers and Facilitators to the Use of Medications for Opioid Use Disorder: a Rapid Review. J Gen Intern Med 2020; 35:954-963. [PMID: 33145687 PMCID: PMC7728943 DOI: 10.1007/s11606-020-06257-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 09/18/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Despite evidence that medications to treat opioid use disorder (OUD) are effective, most people who could benefit from this treatment do not receive it. This rapid review synthesizes evidence on current barriers and facilitators to buprenorphine/naloxone and naltrexone at the patient, provider, and system levels to inform future interventions aimed at expanding treatment. METHODS We systematically searched numerous bibliographic databases through May 2020 and selected studies published since 2014. Study selection, data abstraction, coding of barriers and facilitators, and quality assessment were first completed by one reviewer and checked by a second. RESULTS We included 40 studies of buprenorphine (5 also discussed naltrexone). Four types of patient and provider-level barriers to OUD medication use emerged-stigma related to OUD medications, treatment experiences and beliefs (positive or negative), logistical issues (time and costs as well as insurance and regulatory requirements), and knowledge (high or low) of OUD and the role of medications. Stigma was the most common barrier among patients, while logistical issues were the most common barriers among providers. Facilitators for both patients and providers included peer supports. Most administrator-identified or system-level barriers and facilitators fit into the category of logistical issues. We have moderate confidence in buprenorphine findings but low confidence in naltrexone findings due to the small number of studies. DISCUSSION Stigma, treatment experiences, logistical issues, and knowledge gaps are the main barriers associated with low utilization of OUD medications. These barriers can overlap and mutually reinforce each other, but given that, it is plausible that reducing one barrier may lead to reductions in others. The highest priority for future research is to evaluate interventions to reduce stigma. Other priorities for future research include better identification of barriers and facilitators for specific populations, such as those with OUD related to prescription opioids, and for naltrexone use. PROTOCOL REGISTRATION PROSPERO; CRD42019133394.
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23
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McMahan VM, Kingston S, Newman A, Stekler JD, Glick SN, Banta-Green CJ. Interest in reducing methamphetamine and opioid use among syringe services program participants in Washington State. Drug Alcohol Depend 2020; 216:108243. [PMID: 32911134 PMCID: PMC9632690 DOI: 10.1016/j.drugalcdep.2020.108243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/13/2020] [Accepted: 08/15/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Methamphetamine use is increasing, and opioid use remains elevated in the US. Understanding interest in reducing/stopping substance use among people who inject drugs (PWID), as well as types of help wanted, can inform interventions. METHODS Data from the 2019 Washington State Syringe Exchange Survey were used in logistic regression analyses to assess if demographics, substance use, and concern about anxiety or depression were associated with interest in reducing/stopping substance use among people whose main drug was methamphetamine or opioids. Types of help wanted to reduce/stop use are reported. RESULTS Of 583 participants included, 76 % reported opioids were their main drug, of whom 82 % were interested in reducing/stopping their opioid use. 24 % reported methamphetamine as their main drug, of whom 46 % were interested in reducing/stopping their methamphetamine use. Among those whose main drug was an opioid, female gender (AOR:2.19, p = .023) and concern about depression (AOR:3.04, p = .002) were associated with interest in reducing/stopping opioid use. Among participants whose main drug was methamphetamine, being in jail in the past year and having an infection likely related to injection (e.g., abscess) in the past year were associated with over twice the odds of interest in reducing/stopping methamphetamine use (AOR:2.14, p = .056 and 2.43, p = .052, respectively); however, these findings were not significant. Several types of help to reduce/stop use were endorsed. CONCLUSION There were high, though differing, levels of interest in reducing/stopping opioid or methamphetamine use and in a range of support services. PWID should be asked about interest in reducing/stopping use and provided appropriate support.
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Affiliation(s)
- Vanessa M McMahan
- Department of Medicine, University of Washington, 325 9(th)Avenue, Seattle, WA, 98104, USA; Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA.
| | - Susan Kingston
- Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th St, Suite 120, Seattle, WA, 98105, USA
| | - Alison Newman
- Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th St, Suite 120, Seattle, WA, 98105, USA
| | - Joanne D. Stekler
- Department of Medicine, University of Washington, 325 9Avenue, Seattle, WA, 98104, USA,Department of Global Health, University of Washington, 1510 San Juan Road, Seattle, WA, 98195, USA,Department of Epidemiology, University of Washington, 1959 NE Pacific St, Seattle, WA, USA
| | - Sara N. Glick
- Department of Medicine, University of Washington, 325 9Avenue, Seattle, WA, 98104, USA,HIV/STD Program, Public Health – Seattle & King County, Seattle, WA, USA
| | - Caleb J. Banta-Green
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Seattle, WA, 98195, USA,Alcohol and Drug Abuse Institute, University of Washington, 1107 NE 45th St, Suite 120, Seattle, WA, 98105, USA
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24
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Cooper HL, Cloud DH, Freeman PR, Fadanelli M, Green T, Van Meter C, Beane S, Ibragimov U, Young AM. Buprenorphine dispensing in an epicenter of the U.S. opioid epidemic: A case study of the rural risk environment in Appalachian Kentucky. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102701. [PMID: 32223985 PMCID: PMC7529684 DOI: 10.1016/j.drugpo.2020.102701] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 01/24/2020] [Accepted: 02/16/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Buprenorphine is a cornerstone to curbing opioid epidemics, but emerging data suggest that rural pharmacists in the US sometimes refuse to dispense this medication. We conducted a case study to explore buprenorphine dispensing practices in 12 rural Appalachian Kentucky counties, and analyze whether and how they were shaped by features of the rural risk environment. METHODS In this case study, we conducted one-on-one semi-structured interviews with 14 pharmacists operating 15 pharmacies in these counties to explore buprenorphine dispensing practices and perceived influences on these practices. Thematic analyses of the resulting transcripts revealed three features of the rural risk environment that shaped dispensing. To explore these three risk environment features, we analyzed policy documents (e.g., Attorney General lawsuits) and administrative databases (e.g., incarceration data). Textual documents were analyzed using thematic analyses and administrative data were analyzed using descriptive statistics; memoes explored relationships among risk environment features and dispensing practices. RESULTS Twelve of the 15 pharmacies limited dispensing, by refusing to serve new patients; limiting dispensing to known patients or prescribers; or refusing to dispense buprenorphine altogether. Concerns about exceeding a "Drug Enforcement Administration (DEA) cap" on opioid dispensing stifled dispensing. A legacy of aggressive and fraudulent marketing of opioid analgesics (OAs) by pharmaceutical companies and physician OA overprescribing undermined pharmacist trust in buprenorphine and in its prescribers. The escalating local war on drugs may have undermined dispensing by reinforcing stigma against people who use drugs. CONCLUSIONS Initiatives to increase buprenorphine prescribing must be accompanied by policy changes to increase dispensing. Specifically, buprenorphine should be removed from opioid monitoring systems; efforts to de-escalate the war on drugs should be extended to encompass rural areas; initiatives to dismantle aggressive OA marketing should be strengthened; and efforts to re-build pharmacist trust in physicians are needed.
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Affiliation(s)
| | - David H Cloud
- Emory University Rollins School of Public Health, Atlanta GA
| | | | | | - Travis Green
- University of Kentucky College of Public Health, Lexington KY
| | | | - Stephanie Beane
- Emory University Rollins School of Public Health, Atlanta GA
| | | | - April M Young
- University of Kentucky College of Public Health, Lexington KY
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25
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Valente PK, Bazzi AR, Childs E, Salhaney P, Earlywine J, Olson J, Biancarelli DL, Marshall BDL, Biello KB. Patterns, contexts, and motivations for polysubstance use among people who inject drugs in non-urban settings in the U.S. Northeast. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2020; 85:102934. [PMID: 32911318 PMCID: PMC7770041 DOI: 10.1016/j.drugpo.2020.102934] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 08/12/2020] [Accepted: 08/20/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Polysubstance use (i.e., using ≥2 psychoactive substances concomitantly) is associated with increased morbidity and mortality and complicates drug treatment needs among people who inject drugs (PWID). We explored patterns, contexts, motivations, and perceived consequences of polysubstance use among PWID in small cities and towns in the U.S. Northeast. METHODS Between October 2018 and March 2019, we conducted semi-structured interviews with 45 PWID living outside of the capital cities of Rhode Island and Massachusetts recruited online and through community-based organizations. Written transcripts were coded inductively and deductively using a team-based approach and analyzed thematically. RESULTS All participants reported recent polysubstance use, with most using five or more classes of substances in the past three months. Polysubstance use often followed long personal drug use histories (i.e., years or decades of occasional drug use). Reasons for polysubstance use included obtaining synergistic psychoactive effects as a result of mixing drugs (i.e., using drugs to potentiate effects of other drugs) and managing undesirable effects of particular drugs (e.g., offsetting the depressant effects of opioids with stimulants or vice-versa). Polysubstance use to self-medicate poorly managed physical and mental health conditions (e.g., chronic pain, anxiety, and depression) was also reported. Inadequately managed cravings and withdrawal symptoms prompted concomitant use of heroin and medications for opioid use disorder, including among individuals reporting cocaine or crack as their primary "issue" drugs. Polysubstance use was perceived to increase overdose risks and to be a barrier to accessing healthcare and drug treatment services. CONCLUSION Healthcare services and clinicians should acknowledge, assess, and account for polysubstance use among patients and promote harm reduction approaches for individuals who may be using multiple drugs. Comprehensive healthcare that meets the social, physical, mental health, and drug treatment needs of PWID may decrease the perceived need for polysubstance use to self-medicate poorly managed health conditions and symptoms.
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Affiliation(s)
- Pablo K Valente
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, 4th Floor, Providence, RI 02912, USA
| | - Angela R Bazzi
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, USA
| | - Ellen Childs
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Peter Salhaney
- Center for Health Promotion and Health Equity, Brown University School of Public Health, 121 South Main Street, 8th Floor, Providence, RI 02912, USA
| | - Joel Earlywine
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, 4th Floor, Boston, MA 02118, USA
| | - Jennifer Olson
- Center for Health Promotion and Health Equity, Brown University School of Public Health, 121 South Main Street, 8th Floor, Providence, RI 02912, USA
| | - Dea L Biancarelli
- Department of Health Law, Policy, and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA 02118, USA
| | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, 2nd Floor, Providence, RI 02912, USA
| | - Katie B Biello
- Department of Behavioral and Social Sciences, Brown University School of Public Health, 121 South Main Street, 4th Floor, Providence, RI 02912, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, 2nd Floor, Providence, RI 02912, USA; The Fenway Institute, Fenway Health, 1340 Boylston Street, Boston, MA 02215, USA.
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26
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Kavanaugh PR, McLean K. Motivations for Diverted Buprenorphine Use in a Multisite Qualitative Study. JOURNAL OF DRUG ISSUES 2020. [DOI: 10.1177/0022042620941796] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Drawing on a multisite sample of 40 persons who sell, share, or use diverted buprenorphine to manage opioid use disorder, in this study we describe why individuals seek to obtain buprenorphine outside of formal treatment contexts, and between-site variation regarding their motives and means. Findings indicate that both the provision and purchase of diverted buprenorphine support user-defined risk minimization strategies to avoid withdrawal, reduce heroin use, and satiate opioid cravings in periods of lowered tolerance. We also found that a subset of the sample used buprenorphine recreationally, and that it functioned to extend or augment illicit drug use careers. Implications of the findings are discussed in light of federal and state drug control and treatment policies.
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27
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Blanco C, Wiley TRA, Lloyd JJ, Lopez MF, Volkow ND. America's opioid crisis: the need for an integrated public health approach. Transl Psychiatry 2020; 10:167. [PMID: 32522999 PMCID: PMC7286889 DOI: 10.1038/s41398-020-0847-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 02/28/2020] [Accepted: 05/13/2020] [Indexed: 12/12/2022] Open
Abstract
Continued increases in overdose deaths and recent declines in life expectancy call for need to adopt comprehensive public health approaches to the United States opioid crisis and to establish an infrastructure to avert future crises. Successfully addressing the challenges posed by the crisis requires a translational, integrated approach that combines the contribution of neuroscience, pharmacology, epidemiology, treatment services and prevention. It also is critical to integrate interventions across settings, including healthcare, justice, education and social service systems. This review highlights four interconnected themes: (1) social determinants of health and disease; (2) person-centered approaches for prevention and treatment; (3) bridging the gap between implementation science and practice; and (4) using data to build learning systems of care, relevant to public health approaches to address the opioid crisis. We discuss how across these four themes taking into account the influence of developmental factors on brain function and sensitivity to environmental stimuli including drugs, addressing the complex interactions between biological and social factors, and promoting an ongoing dialogue across disciplines and settings will help accelerate public health advances that are evidenced based and sustainable to address the current opioid crisis and avert future ones.
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Affiliation(s)
- Carlos Blanco
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA.
| | | | | | - Marsha F Lopez
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA
| | - Nora D Volkow
- National Institute on Drug Abuse, Bethesda, MD, 20892, USA
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28
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Miles J, Howell J, Sheridan D, Braucht G, Mericle A. Supporting individuals using medications for opioid use disorder in recovery residences: challenges and opportunities for addressing the opioid epidemic. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2020; 46:266-272. [PMID: 32091262 DOI: 10.1080/00952990.2020.1719410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Full and partial opioid agonists and opioid antagonist medications play an important role in containing the opioid epidemic. However, these medications have not been used to their full extent. Recovery support services, such as recovery residences (RRs), also play a key role. RRs may increase an individual's recovery capital, facilitate social support for abstinence, and foster a sense of community among residents. These processes may be critical for individuals with opioid use disorder (OUD). In combination these two recovery pathways have the potential to enhance one another and improve outcomes among residents with OUD. Barriers to doing so have resulted in a limited supply of residences that can support residents using opioid agonist and antagonist medications. This perspective describes key interpersonal and structural barriers to medication use among individuals with an OUD seeking support from a recovery residence and discusses measures for reducing these barriers. These measures include workforce development to address stigma and attitudinal barriers and enhancing residence capability to ensure resident safety and reduce potential diversion. The perspective also highlights the need for additional research to facilitate the identification of best practices to improve outcomes among residents treated with medications living in recovery residences.
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Affiliation(s)
- Jennifer Miles
- The Heller School for Social Policy and Management, Brandeis University , Waltham, MA, USA
| | - Jason Howell
- National Alliance for Recovery Residences , St. Paul, MN, USA
| | - Dave Sheridan
- National Alliance for Recovery Residences , St. Paul, MN, USA
| | - George Braucht
- National Alliance for Recovery Residences , St. Paul, MN, USA
| | - Amy Mericle
- Public Health Institute, Alcohol Research Group , Emeryville, CA, USA
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29
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Banta-Green C, Williams J, Sears J, Floyd A, Tsui J, Hoeft T. Impact of a jail-based treatment decision-making intervention on post-release initiation of medications for opioid use disorder. Drug Alcohol Depend 2020; 207:107799. [PMID: 31865058 PMCID: PMC8085903 DOI: 10.1016/j.drugalcdep.2019.107799] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/29/2019] [Accepted: 11/28/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Opioid use disorder (OUD) is common among people in jail and is effectively treated with medications for OUD (MOUD). People with OUD may have an incomplete or inaccurate understanding of OUD and MOUD, and of how to access care. We evaluated an OUD treatment decision making (TDM) intervention to determine whether the intervention increased MOUD initiation post-release. METHODS We conducted an observational retrospective cohort study of the TDM intervention on initiation of MOUD, individuals with records data indicating confirmed or suspected OUD incarcerated in four eligible jails were eligible to receive the intervention. Time-to-event analyses of the TDM intervention were conducted using Cox proportional hazard modeling with MOUD as the outcome. RESULTS Cox proportional hazard modeling, with the intervention modeled as having a time-varying effect due to violation of the proportionality assumption, indicated that those receiving the TDM intervention (n = 568) were significantly more likely to initiate MOUD during the first month after release from jail (adjusted hazard ratio 6.27, 95 % C.I. 4.20-9.37), but not in subsequent months (AHR 1.33 95 % C.I. 0.94-1.89), adjusting for demographics, prior MOUD, or felony or gross misdemeanor arrest in the prior year compared to those not receiving the intervention (n = 3174). CONCLUSION The TDM intervention was associated with a significantly higher relative hazard of starting MOUD, specifically during the first month after incarceration. However, a minority of all eligible people received any MOUD. Future research should examine ways to increase initiation on MOUD immediately after (or ideally during) incarceration.
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Affiliation(s)
- C.J. Banta-Green
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA,Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA,Corresponding author. (C.J. Banta-Green)
| | - J.R. Williams
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - J.M. Sears
- Department of Health Services, School of Public Health, University of Washington, Seattle, WA, USA,Department of Environmental and Occupational Health Sciences, University of Washington, Seattle, WA, USA,Harborview Injury Prevention and Research Center, Seattle, WA, USA,Institute for Work and Health, Toronto, Ontario, Canada
| | - A.S. Floyd
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA,Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
| | - J.I. Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - T.J. Hoeft
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Daniulaityte R, Nahhas RW, Silverstein S, Martins S, Zaragoza A, Moeller A, Carlson RG. Patterns of non-prescribed buprenorphine and other opioid use among individuals with opioid use disorder: A latent class analysis. Drug Alcohol Depend 2019; 204:107574. [PMID: 31568934 PMCID: PMC6886684 DOI: 10.1016/j.drugalcdep.2019.107574] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/08/2019] [Accepted: 08/13/2019] [Indexed: 11/28/2022]
Abstract
AIM Non-prescribed buprenorphine (NPB) use increased in the US. This study aims to characterize heterogeneity in patterns of NPB and other opioid use among individuals with current opioid use disorder. METHODS The study recruited 356 participants in Dayton (Montgomery County), Ohio, area in 2017-2018 using targeted and Respondent Driven Sampling. Participants met the following criteria: 1) 18 years or older, 2) current moderate/severe opioid use disorder (DSM-5), 3) past 6-month NPB use. Latent class analysis (LCA) was conducted to identify subgroups based on past 6-month (days of NPB and heroin/fentanyl use; use of NPB to get high; use of non-prescribed and prescribed pharmaceutical opioids; participation in formal treatment) and lifetime (years since first NPB and other illicit opioid use) characteristics. Selected auxiliary variables were compared across classes using Asparouhov and Muthén's 3-step approach. RESULTS 49.7% were female, and 88.8% were non-Hispanic whites. 89% used NPB to self-treat withdrawal. LCA resulted in three classes: "Heavy Heroin/Fentanyl Use" (61%), "More Formal Treatment Use" (29%) and "Intense NPB Use" (10%). After adjusting for multiple testing, the following past 6-month variables differed significantly between classes: injection as a primary route of heroin/fentanyl administration (p < 0.001), cocaine use (p = 0.044), unintentional drug overdose (p = 0.023), and homelessness (p = 0.044), with the "Intense NPB Use" class having the lowest prevalences. CONCLUSION Predominance of self-treatment goals and the association between more intense NPB use and lower risks of adverse consequences suggest potential harm minimization benefits of NPB use. More research is needed to understand consequences of NPB use over time.
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Affiliation(s)
- Raminta Daniulaityte
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, United States.
| | - Ramzi W. Nahhas
- Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University, Dayton,Department of Psychiatry, Boonshoft School of Medicine, Wright State University
| | - Sydney Silverstein
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University
| | - Silvia Martins
- Department of Epidemiology Columbia University Mailman School of Public Health
| | - Angela Zaragoza
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University
| | - Avery Moeller
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University
| | - Robert G. Carlson
- Center for Interventions, Treatment, and Addictions Research, Department of Population and Public Health Sciences, Boonshoft School of Medicine, Wright State University
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Banta-Green CJ, Floyd AS, Vick K, Arthur J, Hoeft TJ, Tsui JI. Opioid Use Disorder Treatment Decision Making And Care Navigation Upon Release From Prison: A Feasibility Study. Subst Abuse Rehabil 2019; 10:57-67. [PMID: 31695555 PMCID: PMC6815213 DOI: 10.2147/sar.s192045] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 10/08/2019] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Opioid use disorder (OUD) is a medical condition that is effectively treated with medications. A major challenge in breaking the cycle of OUD and related illegal activity is seamlessly introducing medications for opioid use disorder (MOUD) as individuals leave jail or prison. We examined the feasibility of a pilot intervention to link participants to ongoing MOUD and psychosocial supports following release from custody. METHODS The study enrolled adults with a history of OUD released from Washington State prisons to Department of Corrections (DOC) community supervision. Participants were randomized to the study intervention or comparison group. The intervention consisted of education on OUD and available treatments, support with individualized treatment decision making, and continued care navigation for 6 months to facilitate linkage to chosen treatments. Participants randomized to the control condition received referral to services in the community from their community corrections officers. A care navigation activity log documented intervention participants' intervention engagement, service utilization, and needs. Follow-up interviews were conducted at 1 and 6 months to assess satisfaction with the intervention. RESULTS Fifteen participants were enrolled. All were male, most were white (86.6%) and the average age was 36.9 years. The majority (14 of 15 participants) were near-daily heroin users with severe OUD prior to incarceration. Of the seven intervention participants, two wished to start medications immediately. Three participants reported starting buprenorphine or methadone in the subsequent follow-up period, with or without social support and/or outpatient counseling, and three reported enrolling in social support and/or outpatient counseling without medications. Participants who received the intervention reported high satisfaction. We discuss barriers and facilitators to study implementation. CONCLUSION An intervention to link participants to ongoing MOUD and psychosocial supports following release from prison had broad acceptability among participants and was feasible to implement among those recruited; however, enrollment was much lower than anticipated and the study intervention did not demonstrate the intended effect to facilitate use of MOUD immediately post-release in this small sample of participants. Given recent research showing benefits of pre-release medication initiation, the potential added benefits of this two-part intervention should be studied in systems that initiate MOUD prior to release.
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Affiliation(s)
- Caleb J Banta-Green
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
- School of Public Health, Department of Health Services, University of Washington, Seattle, WA, USA
| | - Anthony S Floyd
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
- School of Public Health, Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Kristin Vick
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Jen Arthur
- Alcohol and Drug Abuse Institute, University of Washington, Seattle, WA, USA
| | - Theresa J Hoeft
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Judith I Tsui
- Department of Medicine, University of Washington, Seattle, WA, USA
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“They're making it so hard for people to get help:” Motivations for non-prescribed buprenorphine use in a time of treatment expansion. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 71:118-124. [DOI: 10.1016/j.drugpo.2019.06.019] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 06/19/2019] [Accepted: 06/23/2019] [Indexed: 01/22/2023]
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Buprenorphine in the United States: Motives for abuse, misuse, and diversion. J Subst Abuse Treat 2019; 104:148-157. [PMID: 31370979 DOI: 10.1016/j.jsat.2019.07.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 07/11/2019] [Accepted: 07/11/2019] [Indexed: 12/25/2022]
Abstract
Opioid use disorder (OUD) and its consequences are a major public health concern. The partial agonist buprenorphine is a safe and effective treatment for OUD, but concerns about abuse, misuse, and diversion of buprenorphine have been raised. This narrative review examined the rates and motives for use of illicit buprenorphine in the United States. Findings from the 17 included studies suggest the majority of study participants using illicit buprenorphine do so for reasons related to misuse (to manage opioid withdrawal symptoms or achieve or maintain abstinence from other opioids). A smaller percentage of study respondents reported using buprenorphine for reasons related to abuse (to get high). There appears to be a gap between need for buprenorphine and access to adequate treatment. Attenuation of policy-related barriers and adoption of appropriate buprenorphine use by the treatment community are critical tools in the continued effort to reduce the burdens associated with OUD.
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Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addict Sci Clin Pract 2019; 14:20. [PMID: 31060600 PMCID: PMC6501460 DOI: 10.1186/s13722-019-0149-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 04/29/2019] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Opioid overdose is a leading cause of death in persons experiencing homelessness (PEH), despite effective medications for opioid use disorder (OUD). In 2016, the San Francisco Street Medicine Team piloted a low barrier buprenorphine program with the primary goal of engaging and retaining PEH with OUD in care as a first step toward reducing opioid use and improving overall health. OBJECTIVE To characterize the patients; assess treatment retention, retention on buprenorphine, and opioid use; and to describe adverse events. METHODS Retrospective chart review of patients receiving at least one buprenorphine prescription from Street Medicine (November 2016-October 2017). We abstracted demographic, medical, substance use, prescription, and health care utilization data from medical records. We assessed retention in care at 1, 3, 6, 9 and 12 months, defined as a provider visit 1 week prior to or any time after each time point. We considered patients to be retained on buprenorphine if they had active buprenorphine prescriptions for more than 2 weeks of the month. We estimated opioid use by the percentage of patients with any opioid-negative, buprenorphine-positive urine toxicology test. We reviewed emergency department and hospital records for adverse events, including deaths and nonfatal opioid overdoses. RESULTS Among the 95 persons eligible for analysis, mean age was 39.2, and 100% reported injecting heroin and homelessness. Medical and psychiatric comorbidities and co-occurring substance use were common. The percentages of patients retained in care at 1, 3, 6, 9 and 12 months were 63%, 53%, 44%, 38%, and 26%, respectively. The percentages of patients retained on buprenorphine at 1, 3, 6, 9 and 12 months were 37%, 27%, 27%, 26%, and 18%, respectively. Twenty-three percent of patients had at least one opioid-negative, buprenorphine-positive test result. One patient died from fentanyl overdose, and four patients presented on six occasions for non-fatal overdoses requiring naloxone. CONCLUSIONS This program engaged and retained a subset of PEH with OUD in care and on buprenorphine over 12 months. While uninterrupted treatment and abstinence are reasonable outcomes for conventional treatment programs, intermittent treatment with buprenorphine and decreased opioid use were more common in this pilot and may confer important reductions in opioid and injection-related harms.
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Affiliation(s)
- Jamie Carter
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC 27707 USA
| | - Barry Zevin
- Street Medicine and Shelter Health, San Francisco Department of Public Health, 101 Grove St, San Francisco, CA 94102 USA
| | - Paula J. Lum
- UCSF Division of HIV, Infectious Disease and Global Medicine, Zuckerberg San Francisco General, 1001 Potrero Ave, San Francisco, CA 94110 USA
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Carter J, Zevin B, Lum PJ. Low barrier buprenorphine treatment for persons experiencing homelessness and injecting heroin in San Francisco. Addict Sci Clin Pract 2019. [PMID: 31060600 DOI: 10.1186/s13722-019-0149-1.pmid:31060600;pmcid:pmc6501460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/18/2023] Open
Abstract
BACKGROUND Opioid overdose is a leading cause of death in persons experiencing homelessness (PEH), despite effective medications for opioid use disorder (OUD). In 2016, the San Francisco Street Medicine Team piloted a low barrier buprenorphine program with the primary goal of engaging and retaining PEH with OUD in care as a first step toward reducing opioid use and improving overall health. OBJECTIVE To characterize the patients; assess treatment retention, retention on buprenorphine, and opioid use; and to describe adverse events. METHODS Retrospective chart review of patients receiving at least one buprenorphine prescription from Street Medicine (November 2016-October 2017). We abstracted demographic, medical, substance use, prescription, and health care utilization data from medical records. We assessed retention in care at 1, 3, 6, 9 and 12 months, defined as a provider visit 1 week prior to or any time after each time point. We considered patients to be retained on buprenorphine if they had active buprenorphine prescriptions for more than 2 weeks of the month. We estimated opioid use by the percentage of patients with any opioid-negative, buprenorphine-positive urine toxicology test. We reviewed emergency department and hospital records for adverse events, including deaths and nonfatal opioid overdoses. RESULTS Among the 95 persons eligible for analysis, mean age was 39.2, and 100% reported injecting heroin and homelessness. Medical and psychiatric comorbidities and co-occurring substance use were common. The percentages of patients retained in care at 1, 3, 6, 9 and 12 months were 63%, 53%, 44%, 38%, and 26%, respectively. The percentages of patients retained on buprenorphine at 1, 3, 6, 9 and 12 months were 37%, 27%, 27%, 26%, and 18%, respectively. Twenty-three percent of patients had at least one opioid-negative, buprenorphine-positive test result. One patient died from fentanyl overdose, and four patients presented on six occasions for non-fatal overdoses requiring naloxone. CONCLUSIONS This program engaged and retained a subset of PEH with OUD in care and on buprenorphine over 12 months. While uninterrupted treatment and abstinence are reasonable outcomes for conventional treatment programs, intermittent treatment with buprenorphine and decreased opioid use were more common in this pilot and may confer important reductions in opioid and injection-related harms.
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Affiliation(s)
- Jamie Carter
- Lincoln Community Health Center, 1301 Fayetteville St, Durham, NC, 27707, USA.
| | - Barry Zevin
- Street Medicine and Shelter Health, San Francisco Department of Public Health, 101 Grove St, San Francisco, CA, 94102, USA
| | - Paula J Lum
- UCSF Division of HIV, Infectious Disease and Global Medicine, Zuckerberg San Francisco General, 1001 Potrero Ave, San Francisco, CA, 94110, USA
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36
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Doernberg M, Krawczyk N, Agus D, Fingerhood M. Demystifying buprenorphine misuse: Has fear of diversion gotten in the way of addressing the opioid crisis? Subst Abus 2019; 40:148-153. [PMID: 31008694 DOI: 10.1080/08897077.2019.1572052] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Buprenorphine is considered one of the most effective treatments for opioid use disorder and significantly reduces risk of overdose death. However, concerns about its diversion and misuse have often taken center stage in public discourse and in the design of practices and policies regarding its use. This has been to the detriment of many vulnerable patient populations, especially those involved in the criminal justice system. Policies that restrict access to buprenorphine in criminal justice and other settings due to concerns of diversion do not accurately reflect the relative risks and safety profile associated with it, creating unnecessary barriers that drive an illicit market of this much-needed medication. Although proper regulation of all controlled medications should be a priority, in most instances the benefits of buprenorphine highly outweigh its risks. In the midst of a national crisis, efforts should be focused on expanding, and not restricting, access to this lifesaving treatment.
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Affiliation(s)
- Molly Doernberg
- Yale University School of Public Health , New Haven , Connecticut , USA
| | - Noa Krawczyk
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Behavioral Health Leadership Institute , Baltimore , Maryland , USA
| | - Deborah Agus
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Behavioral Health Leadership Institute , Baltimore , Maryland , USA
| | - Michael Fingerhood
- Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA.,Johns Hopkins School of Medicine , Baltimore , Maryland , USA
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Breen CT, Fiellin DA. Buprenorphine Supply, Access, and Quality: Where We Have Come and the Path Forward. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2018; 46:272-278. [PMID: 30147002 DOI: 10.1177/1073110518782934] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Buprenorphine is a form of opioid agonist treatment that has been demonstrated to be an effective medication for opioid addiction. It is available in different formulations and marketed under various trade names, including commonly as a buprenorphine/naloxone combination. This paper provides an overview of existing literature on the supply of buprenorphine treatment, the ability of people to access treatment with buprenorphine, and the quality of treatment received. We argue that better data for each of these aspects of treatment could inform policy to expand effective treatment with buprenorphine, and we suggest steps to obtain and act on such data.
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Affiliation(s)
- Christopher T Breen
- Christopher T. Breen is a medical student at Yale School of Medicine. He received an A.B. in Politics from Princeton University. David A. Fiellin, M.D., is a Professor of Medicine, Emergency Medicine and Public Health at Yale where he directs the Program in Addiction Medicine. His research is focused on implementing addiction treatment in general medical settings
| | - David A Fiellin
- Christopher T. Breen is a medical student at Yale School of Medicine. He received an A.B. in Politics from Princeton University. David A. Fiellin, M.D., is a Professor of Medicine, Emergency Medicine and Public Health at Yale where he directs the Program in Addiction Medicine. His research is focused on implementing addiction treatment in general medical settings
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Hunter K, Park JN, Allen ST, Chaulk P, Frost T, Weir BW, Sherman SG. Safe and unsafe spaces: Non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 57:25-31. [PMID: 29660732 DOI: 10.1016/j.drugpo.2018.03.026] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 03/01/2018] [Accepted: 03/27/2018] [Indexed: 01/15/2023]
Abstract
The spaces in which drug use occurs constitutes a key aspect of the "risk environment" of people who inject drugs (PWID). We aimed to add nuance to the characterization of "safe" and "unsafe" spaces in PWID's environments to further understand how these spaces amplify the risk of morbidities associated with injection drug use. PWID were recruited through the Baltimore City syringe service program and through peer referral. Participants completed a socio-behavioral survey. Multivariable logistic regression was used to identify associations between utilization of public, semi-public and private spaces with arrest, non-fatal overdose, and receptive syringe sharing. The sample of PWID (N = 283) was mostly 45 years and older (54%), male (69%), Black (55%), and heroin users (96%). Compared to PWID who primarily used private settings, the adjusted odds of recent overdose were greater among PWID who mostly used semi-public and public locations to inject drugs. We also found independent associations between arrest and semi-public spaces, and between receptive syringe sharing and public spaces (all p < 0.05). This study highlights the need for safe spaces where PWID can reduce their risk of overdose, likelihood of arrest and blood-borne diseases, and the dual potential of the environment in promoting health and risk.
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Affiliation(s)
- Kyle Hunter
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Ju Nyeong Park
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205, USA.
| | - Sean T Allen
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Patrick Chaulk
- Baltimore City Health Department, 1001 East Fayette Street, Baltimore, MD 21202, USA; Department of Health, Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA; Division of Infectious Diseases, School of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Taeko Frost
- Harm Reduction Coalition, 22 West 27th Street, 5th Floor, New York, NY 10001, USA
| | - Brian W Weir
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
| | - Susan G Sherman
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD 21205, USA.
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Wakeman SE, Raja AS. Case 37-2017: A Man with Unintentional Opioid Overdose. N Engl J Med 2018; 378:873. [PMID: 29490179 DOI: 10.1056/nejmc1800046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
| | - Ali S Raja
- Massachusetts General Hospital, Boston, MA
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40
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Sharma A, Kelly SM, Mitchell SG, Gryczynski J, O'Grady KE, Schwartz RP. Update on Barriers to Pharmacotherapy for Opioid Use Disorders. Curr Psychiatry Rep 2017; 19:35. [PMID: 28526967 PMCID: PMC7075636 DOI: 10.1007/s11920-017-0783-9] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW The recent heroin and prescription opioid misuse epidemic has led to a sharp increase in the number of opioid overdose deaths in the USA. Notwithstanding the availability of three FDA-approved medications (methadone, buprenorphine, and naltrexone) to treat opioid use disorder, these medications are underutilized. This paper provides an update from the recent peer-reviewed literature on barriers to the use of these medications. FINDINGS These barriers are interrelated and can be categorized as financial, regulatory, geographic, attitudinal, and logistic. While financial barriers are common to all three medications, other barriers are medication-specific. The adverse impact of the current opioid epidemic on public health can be reduced by increasing access to effective pharmacotherapy for opioid use disorder.
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Affiliation(s)
- Anjalee Sharma
- Friends Research Institute, Inc, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Sharon M Kelly
- Friends Research Institute, Inc, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Shannon Gwin Mitchell
- Friends Research Institute, Inc, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Jan Gryczynski
- Friends Research Institute, Inc, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA
| | - Kevin E O'Grady
- Department of Psychology, University of Maryland, College Park, College Park, MD, USA
| | - Robert P Schwartz
- Friends Research Institute, Inc, 1040 Park Avenue, Suite 103, Baltimore, MD, 21201, USA.
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Fox AD, Sohler NL, Frost T, Lopez C, Cunningham CO. Development and evaluation of a community-based buprenorphine treatment intervention. Harm Reduct J 2017; 14:23. [PMID: 28499432 PMCID: PMC5427587 DOI: 10.1186/s12954-017-0149-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 04/18/2017] [Indexed: 11/12/2022] Open
Abstract
Background The majority of Americans with opioid use disorder remain out of treatment. Operating in 33 states, Washington DC, and Puerto Rico, harm reduction agencies, which provide sterile syringes and other health services to people who inject drugs, are a key venue to reach out-of-treatment opioid users. Aiming to link out-of-treatment individuals with opioid use disorder to buprenorphine treatment, we developed a community-based buprenorphine treatment (CBBT) intervention in collaboration with New York City harm reduction agencies. Methods Intervention development included formative data collection, feasibility testing at one harm reduction agency, and pilot testing for preliminary effectiveness at a second harm reduction agency. We used a pre-post design for both feasibility and pilot testing. In the CBBT intervention, we trained harm reduction agency staff to provide (1) buprenorphine education, (2) motivational interviewing, (3) referrals to buprenorphine-prescribing doctors, and (4) treatment retention support. We assessed feasibility by measuring staff satisfaction with the intervention and changes in knowledge about buprenorphine. We assessed preliminary effectiveness by comparing rates of buprenorphine initiation among groups of harm reduction agency clients before and after intervention implementation. Results Among staff members at the first harm reduction agency, knowledge increased from 52% correct answers pre-intervention to 79% correct post-intervention. Among clients at the second harm reduction agency, initiation of buprenorphine treatment was low and did not differ between pre- and post-intervention groups. Conclusions The CBBT intervention was feasible and well-received, but initiation of buprenorphine treatment among harm reduction agency clients was low. More robust interventions may be necessary to increase initiation of buprenorphine treatment.
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Affiliation(s)
- Aaron D Fox
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA. .,Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA.
| | - Nancy L Sohler
- City College of New York, Sophie Davis School of Biomedical Education, New York, NY, 10031, USA
| | - Taeko Frost
- Washington Heights CORNER Project, New York, NY, 10033, USA
| | - Carolina Lopez
- New York Harm Reduction Educators, New York, NY, 10035, USA
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Bronx, NY, 10461, USA.,Montefiore Medical Center, 111 E. 210th Street, Bronx, NY, 10467, USA
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Doorley SL, Ho CJ, Echeverria E, Preston C, Ngo H, Kamal A, Cunningham CO. Buprenorphine shared medical appointments for the treatment of opioid dependence in a homeless clinic. Subst Abus 2016; 38:26-30. [PMID: 27897918 DOI: 10.1080/08897077.2016.1264535] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Opioid misuse and dependence are prevalent and rising problems in the United States. Treatment with buprenorphine is a successful treatment option for individuals with opioid dependence. This study describes and preliminarily evaluates a unique delivery system that provides buprenorphine treatment via a shared medical appointment. METHODS A retrospective medical record review on all 77 opioid-dependent patients referred for a buprenorphine shared medical appointment in a homeless clinic from 2010 to 2012. RESULTS Most patients were currently homeless (61%), unemployed (92%), had an Axis I psychiatric diagnosis (81%), and had recent polysubstance use (53%). Of the 77 patients, 95% attended at least 1 shared medical appointment. Treatment retention at 12 and 24 weeks was 86% and 70%, respectively. CONCLUSIONS In a patient population with complex social and mental health histories, buprenorphine treatment via a shared medical appointment had high retention rates. Findings can help guide the development of unique delivery systems to serve real-world complex patients with opioid dependence.
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Affiliation(s)
- Sara L Doorley
- a Santa Clara Valley Medical Center , San Jose , California , USA
| | - Cheryl J Ho
- a Santa Clara Valley Medical Center , San Jose , California , USA
| | | | - Charles Preston
- a Santa Clara Valley Medical Center , San Jose , California , USA
| | - Huy Ngo
- a Santa Clara Valley Medical Center , San Jose , California , USA
| | - Ahmad Kamal
- a Santa Clara Valley Medical Center , San Jose , California , USA.,b Stanford Medical Center , Stanford , California , USA
| | - Chinazo O Cunningham
- c Albert Einstein College of Medicine and Montefiore Medical Center , Bronx , New York , USA
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Non-Prescribed Buprenorphine in New York City: Motivations for Use, Practices of Diversion, and Experiences of Stigma. J Subst Abuse Treat 2016; 70:81-86. [PMID: 27692193 DOI: 10.1016/j.jsat.2016.08.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 07/28/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Non-medical use of opioid analgesics (OAs) has increased in the United States over the past decade. Concurrently, access to opioid agonist therapies (OATs) such as buprenorphine has expanded. However, there has been little in-depth qualitative exploration into circumstances surrounding buprenorphine diversion and non-prescribed use. This study reports on qualitative data from in-depth interviews conducted with persons in New York City reporting non-medical OA use in the past 12 months. Participants (n=42) were aged between 18 and 49 years. The majority were male (n=29) and non-Hispanic White (n=35). All participants self-reported physical opioid dependence. Motivations for non-prescribed buprenorphine use included the abatement of withdrawal symptoms or a self-initiated detoxification or treatment plan. Few participants reported buprenorphine use for euphoric effect, and no participants reported using buprenorphine as a primary drug. Buprenorphine diversion primarily occurred as a means of supporting ongoing illicit drug use, and no participants reported selling buprenorphine as a primary source of income. Participants reported misinformation around some key areas of buprenorphine induction and use, as well as stigma within peer networks and from drug treatment providers. As access to buprenorphine treatment continues to expand in the United States, enhancing patient education is a critical step toward minimizing diversion and incidental harms from non-prescribed use.
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Paone D, Tuazon E, Stajic M, Sampson B, Allen B, Mantha S, Kunins H. Buprenorphine infrequently found in fatal overdose in New York City. Drug Alcohol Depend 2015; 155:298-301. [PMID: 26305073 DOI: 10.1016/j.drugalcdep.2015.08.007] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Revised: 08/05/2015] [Accepted: 08/06/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Buprenorphine is an opioid agonist medication that is both safe and effective in the treatment of opioid use disorders and the prevention of opioid overdoses. Despite this, media coverage has highlighted public concerns about the potential safety consequences of buprenorphine misuse and diversion. To address the possible contribution of buprenorphine to overdose mortality, we systematically tested post mortem blood specimens from decedents who had died of an unintentional drug overdoses in 2013. METHODS We retrospectively tested consecutive drug overdose cases that occurred from June through October 2013. Cases with available blood specimens were tested for buprenorphine and norbuprenorphine using liquid chromatography-tandem mass spectrometry. Toxicology results were linked to death certificates and case files from New York City Vital Statistics and New York City Office of the Chief Medical Examiner. RESULTS Of the 98 unintentional drug overdose fatalities tested, only 2 (2.0%) tested positive for buprenorphine metabolites. All 98 unintentional fatalities involved multiple substances. CONCLUSIONS Buprenorphine was infrequently found in drug overdose deaths in New York City. Since the safety and efficacy of buprenorphine are well documented, and overdoses resulting from buprenorphine treatment or diversion are very rare, facilitating access to buprenorphine treatment is strongly recommended.
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Affiliation(s)
- Denise Paone
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States.
| | - Ellenie Tuazon
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Marina Stajic
- New York City Office of the Chief Medical Examiner, 520 First Avenue, New York, NY 10016, United States
| | - Barbara Sampson
- New York City Office of the Chief Medical Examiner, 520 First Avenue, New York, NY 10016, United States
| | - Bennett Allen
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Shivani Mantha
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
| | - Hillary Kunins
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care, and Treatment, 42-09 28th Street, Queens, NY 11101, United States
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45
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Fox AD, Chamberlain A, Frost T, Cunningham CO. Harm Reduction Agencies as a Potential Site for Buprenorphine Treatment. Subst Abus 2015; 36:155-60. [PMID: 25837290 PMCID: PMC4706457 DOI: 10.1080/08897077.2015.1011820] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Harm reduction agencies complement addiction treatment by providing diverse services that improve the health of people who use drugs. Buprenorphine maintenance treatment (BMT) is an effective opioid addiction treatment that may be provided from flexible settings, potentially including harm reduction agencies. This study investigated attitudes toward different potential sites for BMT (harm reduction agencies, general medical clinics, and drug treatment programs) among harm reduction clients. METHODS Using computer-based interviews, participants indicated preferred potential site for BMT (harm reduction agency, drug treatment program, or general medical clinic), interest in BMT by potential site, motivation for treatment, and barriers to BMT. Multivariable logistic regression was used to determine factors associated with harm reduction agency preference. RESULTS Of 102 opioid users, the most preferred potential site for BMT was a harm reduction agency (51%), whereas fewer preferred general medical clinics (13%), drug treatment programs (12%), or were not interested in BMT (25%). In multivariable analysis, experiencing ≥1 barrier to BMT was strongly associated with preferring harm reduction agencies (adjusted odds ratio [aOR] = 3.39, 95% confidence interval [CI]: 1.00-11.43). CONCLUSIONS The potential to initiate BMT at harm reduction agencies is highly favorable among harm reduction clients, especially among those experiencing barriers to BMT. Offering BMT at harm reduction agencies could improve access to treatment, but studies are needed to determine safety and efficacy of this approach.
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Affiliation(s)
- Aaron D Fox
- a Department of Medicine , Albert Einstein College of Medicine , Bronx , New York , USA
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