Increased distance was associated with lower daily attendance to an opioid treatment program in Spokane County Washington

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

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

Retention of people who inject drugs enrolled in a 'medications for opioid use disorder' (MOUD) programme in Uganda

BACKGROUND

Injection Drug use is associated with increased HIV risk behaviour that may result in the transmission of HIV and poor access to HIV prevention and treatment. In 2020, Uganda introduced the 'medication for opioid use disorder (MOUD) treatment' for People who inject drugs (PWID). We analysed the 12-month retention and associated factors among PWID enrolled on MOUD treatment in Kampala, Uganda.

METHODS

We conducted a retrospective analysis of 343 PWID with OUD who completed 14 days of methadone induction from September 2020 to July 2022. Retention was defined as the number of individuals still in the programme divided by the total number enrolled, computed at 3-, 6-, 9-, and 12 months using lifetable and Kaplan-Meier survival analyses. Cox proportional regression analyses were conducted to assess factors associated with retention in the programme in the first 12 months.

RESULTS

Overall, 243 (71%) of 343 participants stabilized at a methadone dose of 60 mg or more. The majority of participants were males (n = 284, 82.8%), and the median (interquartile range, IQR) age was 31 (26-38) years. Most participants (n = 276, 80.5%) lived 5 km or more away from the MOUD clinic. Thirty (8.8%) were HIV-positive, 52 (15.7%) had a major mental illness and 96 (27.9%) had a history of taking alcohol three months before enrollment. The cumulative retention significantly declined from 83.4% (95%CI = 79.0-87.0) at 3months to 71.9% (95%CI = 67.2-76.6) at 6months, 64% 95%CI = 58.7-68.9) at 9months, and 55.2%; 95% CI (49.8-60.3% at 12months. The 12-month retention was significantly higher for participants on methadone doses of 60 mg or more (adj.HR = 2.1, 95%CI = 1.41-3.22), while participants resident within 5 km of the MOUD clinic were 4.9 times more likely to be retained at 12 months, compared to those residing 5 km or more, (adj. HR = 4.81, 95%CI = 1.54-15). Other factors, including predisposing, need, and enabling factors, were not associated with retention.

CONCLUSION

Our study demonstrates acceptable 12-month retention rates for people who inject drugs, comparable to previous studies done in both developing and developed countries. Sustaining and improving retention may require enhanced scaling up of MOUD dose to an optimal level in the first 14 days and reducing the distance between participant locale and MOUD clinics.

An Exploration of Geographic Access to Substance Use Treatment Programs and Violence Against Women

Violence against women (VAW) is a significant public health and human rights issue, with an estimated 736 million women globally experiencing VAW. Consistent evidence demonstrates that substance use is associated with VAW and that participation in substance use treatment programs is associated with reduction in substance use-related violence. While evidence demonstrates the ability to address VAW through substance use treatment programs, less attention has been paid to geographic access to substance use programs. If these programs are geographically inaccessible, particularly to marginalized populations, many people will not get the help they need. This study seeks to explore the relationship between geographic access to substance use treatment programs on VAW. Using data from the HIV Prevention Trials Network (HPTN) 064 study, longitudinal multilevel models were used to assess the relationship between neighborhood-level social determinants, with a specific focus on geographic access to Substance Abuse and Mental Health Services Administration (SAMHSA) certified drug and alcohol treatment programs and VAW. The study included 1910 women, ages 18 to 44, living in select geographic areas with high-ranked prevalence of HIV and poverty. The findings of this study indicate that among women who reside in census tracts with high prevalence rates of HIV: (1) substance use increases VAW; (2) VAW decreases as geographic access to SAMHSA-certified drug and alcohol treatment facilities increases; and (3) when looking at specific types of VAW, emotional and physical abuse decreases as geographic access to substance use treatment increases. Policies and programs to increase access to substance use treatment should be explored and evaluated, and more programs are needed that address the intersectionality of substance use and VAW.

Centring the health of women across the HIV research continuum

Despite tremendous advances in HIV research, women and gender diverse people-particularly women from racial and ethnic groups under-represented in research, transgender women, and young women-remain disproportionately affected by HIV. Women and gender diverse people face unique challenges and have been under-represented in HIV research. The National Institutes of Health (NIH) is tasked to apply fundamental knowledge about the nature and behaviour of living systems to enhance health, lengthen life, and reduce disability. Rigorous exploration of-and interventions for-the individual, social, biological, structural, and environmental factors that influence HIV prevention, transmission, treatment, and cure is crucial to advance research for women, girls, and gender diverse people across the lifespan. In this Position Paper, we introduce a framework for an intersectional, equity-informed, data-driven approach to research on HIV and women and highlight selected issues for women and gender diverse people, including HIV prevention, HIV cure, ageing with HIV, substance use and misuse, violence, pregnancy, and breastfeeding or chestfeeding. This framework underlines a new HIV and Women Signature Programme from the NIH Office of AIDS Research and Office of Research on Women's Health that advances the NIH vision for women's health, in which all women receive evidence-based HIV prevention, treatment, and care across their lifespan tailored to their unique needs, circumstances, and goals. The time is now to centre the health of women, girls, and gender diverse people across the HIV research continuum.

A case study on variations in network structure and cross-sector alignment in two local systems serving pregnant and parenting women in recovery

OBJECTIVE

To describe network structure and alignment across organizations in healthcare, public health, and social services sectors that serve pregnant and parenting women with substance use disorder (SUD) in an urban and a rural community.

DATA SOURCES AND STUDY SETTINGS

Two community networks, one urban and one rural with each including a residential substance use treatment program, in Kentucky during 2021.

STUDY DESIGN

Social network analysis measured system collaboration and cross-sector alignment between healthcare, public health, and social services organizations, applying the Framework for Aligning Sectors. To understand the alignment and structure of each network, we measured network density overall and between sectors, network centralization, and each organization's degree centrality and effective size.

DATA COLLECTION/EXTRACTION METHODS

Computer-assisted telephone interviews were conducted to document alignment around shared purpose, data, financing, and governance.

PRINCIPAL FINDINGS

On average, overall and cross-sector network densities in both communities were similar. However, alignment was highest for data sharing and financing in the urban community and for shared purpose and governance in the rural community. Cross-sector partnerships involving healthcare organizations were more prevalent in the rural county (44% vs. 38% for healthcare/public health, 44% vs. 29% for healthcare/social services), but more prevalent for those involving public health/social services organizations in the urban county (42% vs. 24%). A single healthcare organization had the highest degree centrality (Mdn [IQR] = 26 [26-9.5]) and effective size (Mdn [IQR] = 15.9 [20.6-8.7]) within the rural county. Social services organizations held more central positions in the urban county (degree centrality Mdn [IQR] = 13 [14.8-9.5]; effective size Mdn [IQR] = 10.4 [11.4-7.9]).

CONCLUSIONS

Cross-sector alignment may strengthen local capacity for comprehensive SUD care for pregnant and parenting women. Healthcare organizations are key players in cross-sector partnerships in the rural community, where one healthcare facility holds the central brokerage role. In contrast, public health agencies are key to cross-sector collaboration with social services in the urban community.

Simulated impact of mobile opioid treatment program units on increasing access to methadone for opioid use disorder

OBJECTIVE

To model the potential impact of mobile methadone unit implementation in Louisiana on net medication for opioid use disorder (MOUD) treatment rates.

DATA SOURCES/STUDY SETTING

We use secondary Louisiana Medicaid claims data between 2020 and 2021.

STUDY DESIGN

We simulate the impact of mobile methadone units in Louisiana using two approaches: (1) a "Poisson regression approach," which predicts the number of opioid use disorder (OUD) patients that might use methadone at mobile locations based on the underlying association between methadone use and proximity to a brick-and-mortar methadone clinic; (2) a "policy approach," which leverages local treatment uptake rates following the expansion of methadone coverage to Louisiana Medicaid beneficiaries in 2020 to estimate methadone use following mobile unit implementation. Models were run in cases where mobile methadone operators could choose their operation locations freely and in a separate instance where they were restricted to serving rural locations.

DATA COLLECTION

Our analytic sample includes 43,341 Louisiana Medicaid beneficiaries with one or more primary or secondary diagnoses for opioid dependence.

PRINCIPAL FINDINGS

We predict that 10 new mobile methadone units in Louisiana would increase the net MOUD treatment rate in the state by 0.54-2.39 percentage points. If these mobile units delivered Methadone exclusively to rural areas, they could increase rural MOUD treatment by 8.54-13.67 percentage points. Further, roughly 20% of all beneficiaries residing in rural areas being treated with methadone would be an average of 24 miles closer to a methadone treatment provider following mobile unit implementation.

CONCLUSIONS

Mobile methadone units represent a promising innovation in the delivery of methadone that is likely to increase methadone use, especially in underserved rural locations. However, we find significant variation in their impact conditional on where they choose to operate, and so careful location planning will be required to maximize their benefit.

Utilization of Medications for Opioid Use Disorder Among West Virginia Medicaid Enrollees Following Medicaid Coverage of Methadone

BACKGROUND

West Virginia entered an institution for mental disease Section 1115 waiver with the Centers for Medicare & Medicaid Services in 2018, which allowed Medicaid to cover methadone at West Virginia's nine opioid treatment programs (OTPs) for the first time.

METHODS

We conducted time trend and geospatial analyses of Medicaid enrollees between 2016 and 2019 to examine medications for opioid use disorder utilization patterns following Medicaid coverage of methadone, focusing on distance to an OTP as a predictor of initiating methadone and conditional on receiving any, longer treatment duration.

RESULTS

Following Medicaid coverage of methadone in 2018, patients receiving methadone comprised 9.5% of all Medicaid enrollees with an opioid use disorder (OUD) diagnosis and 10.6% in 2019 (P < 0.01). In 2018, two-thirds of methadone patients either had no prior OUD diagnosis or were not previously enrolled in Medicaid in our observation period. Patients residing within 20 miles of an OTP were more likely to receive methadone (marginal effect [ME]: -0.041, P < 0.001). Similarly, patients residing in metropolitan areas were more likely to receive treatment than those residing in nonmetropolitan areas (ME: -0.019, P < 0.05). Metropolitan patients traveled an average of 15 miles to an OTP; nonmetropolitan patients traveled more than twice as far (P < 0.001). We found no significant association between distance and treatment duration.

CONCLUSIONS

West Virginia Medicaid's new methadone coverage was associated with an influx of new enrollees with OUD, many of whom had no previous OUD diagnosis or prior Medicaid enrollment. Methadone patients frequently traveled far distances for treatment, suggesting that the state needs additional OTPs and innovative methadone delivery models to improve availability.

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

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

Analysis of Wastewater Samples to Explore Community Substance Use in the United States: Pilot Correlative and Machine Learning Study

BACKGROUND

Substance use disorder and associated deaths have increased in the United States, but methods for detecting and monitoring substance use using rapid and unbiased techniques are lacking. Wastewater-based surveillance is a cost-effective method for monitoring community drug use. However, the examination of the results often focuses on descriptive analysis.

OBJECTIVE

The objective of this study was to explore community substance use in the United States by analyzing wastewater samples. Geographic differences and commonalities of substance use were explored.

METHODS

Wastewater was sampled across the United States (n=12). Selected drugs with misuse potential, prescriptions, and over-the-counter drugs and their metabolites were tested across geographic locations for 7 days. Methods used included wastewater assessment of substances and metabolites paired with machine learning, specifically discriminant analysis and cluster analysis, to explore similarities and differences in wastewater measures.

RESULTS

Geographic variations in the wastewater drug or metabolite levels were found. Results revealed a higher use of methamphetamine (z=-2.27, P=.02) and opioids-to-methadone ratios (oxycodone-to-methadone: z=-1.95, P=.05; hydrocodone-to-methadone: z=-1.95, P=.05) in states west of the Mississippi River compared to the east. Discriminant analysis suggested temazepam and methadone were significant predictors of geographical locations. Precision, sensitivity, specificity, and F1-scores were 0.88, 1, 0.80, and 0.93, respectively. Finally, cluster analysis revealed similarities in substance use among communities.

CONCLUSIONS

These findings suggest that wastewater-based surveillance has the potential to become an effective form of surveillance for substance use. Further, advanced analytical techniques may help uncover geographical patterns and detect communities with similar needs for resources to address substance use disorders. Using automated analytics, these advanced surveillance techniques may help communities develop timely, tailored treatment and prevention efforts.

Pharmacy-based methadone treatment in the US: views of pharmacists and opioid treatment program staff

BACKGROUND

The US federal regulations allow pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) to increase the capability of opioid treatment programs (OTPs) in providing methadone maintenance treatment (MMT) for opioid use disorder (OUD) as part of a medication unit. However, there is a lack of research data from both pharmacy and OTP staff to inform the implementation of PADMOUD.

METHODS

Staff of a pharmacy (n = 8) and an OTP (n = 9) that participated in the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were recruited to participate in this qualitative interview study to explore implementation-related factors for PADMOUD. Each interview was recorded and transcribed verbatim. NVivo was used to help identify themes of qualitative interview data. The Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to guide the coding and interpretation of data.

RESULTS

Six pharmacy staff and eight OTP staff (n = 14) completed the interview. Results based on PARIHS domains were summarized, including evidence, context, and facilitation domains. Participants perceived benefits of PADMOUD for patients, pharmacies, OTPs, and payers. PADMOUD was considered to increase access for stable patients, provide additional patient service opportunities and revenues for pharmacies/pharmacists, enhance the capability of OTPs to treat more new patients, and reduce patients' cost when receiving medication at a pharmacy relative to an OTP. Both pharmacy and OTP staff were perceived to be supportive of the implementation of PADMOUD. Pharmacy staff/pharmacists were perceived to need proper training on addiction and methadone as well as a protocol of PADMOUD to conduct PADMOUD. Facilitators include having thought leaders to guide the operation, a certification program to ensure proper training of pharmacy staff/pharmacist, having updated pharmacy service software or technology to streamline the workflow of delivering PADMOUD and inventory management, and reimbursement for pharmacists.

CONCLUSION

This study presents the first findings on perspectives of PADMOUD from both staff of a community pharmacy and an OTP in the US. Finding on barriers and facilitators are useful data to guide the development of strategies to implement PADMOUD to help address the US opioid crisis.

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

BACKGROUND

In the United States, methadone treatment for opioid use disorder is only available at opioid treatment programs (OTPs). In addition to federal regulations, states can enact laws which shape access to OTPs. We aimed to define classes of states according to restrictiveness of state OTP laws and examine population characteristics associated with class membership.

METHODS

A set of laws was extracted from a database of statutes and regulations governing OTPs in 49 states and the District of Columbia as of June 2021. Latent class analysis of laws was used to estimate the probability of class membership for each state. Class-weighted multinomial logistic regression analysis assessed state-level correlates of class membership and adjusted Relative Risk Ratio (aRRR) and 95% confidence intervals (95%CI) were generated.

RESULTS

States (n = 50) were assigned to three classes; Class 1) High restrictiveness on patient experience, low restrictiveness on access to service (n = 13); Class 2) Medium restrictiveness on patient experience, high restrictiveness on access to service (n = 14); Class 3) Low restrictiveness on patient experience, low restrictiveness on access to service (n = 23). States with a higher probability of membership in Classes with higher restrictiveness had higher rates of unemployment (Class 1 vs Class 3, aRRR:1.24; 95%CI:1.06-1.45), and Black residents (Class 2 vs Class 3, aRRR:1.10; 95%CI:1.04-1.15), and lower likelihood of Medicaid coverage of methadone (Class 1 vs Class 3, aRRR:0.25; 95%CI:0.07-0.88). States with a higher probability of membership in Classes with higher restrictiveness also had higher rates of potential indicators for opioid use disorder treatment need, including rates of opioid dispensing (Class 1 vs Class 3, aRRR:1.06; 95%CI:1.02-1.10, Class 2 vs Class 3, aRRR:1.07; 95%CI:1.03-1.11) and HIV diagnoses attributed to injection (Class 1 vs Class 3, aRRR:3.92; 95%CI:1.25-12.22).

CONCLUSIONS

States with indicators of greater potential need for opioid use disorder treatment have the most restrictions, raising concerns about unmet treatment need.

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

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

Patient perspectives on community pharmacy administered and dispensing of methadone treatment for opioid use disorder: a qualitative study in the U.S

BACKGROUND

Pharmacy administration and dispensing of methadone treatment for opioid use disorder (PADMOUD) may address inadequate capability of opioid treatment programs (OTPs) in the US by expanding access to methadone at community pharmacies nationally. PADMOUD is vastly underutilized in the US. There is no published US study on OUD patients' perspectives on PADMOUD. Data are timely and needed to inform the implementation of PADMOUD in the US to address its serious opioid overdose crisis.

METHODS

Patient participants of the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were interviewed to explore implementation-related factors for PADMOUD. All 20 participants of the parent study were invited to participate in this interview study. Each interview was recorded and transcribed verbatim. Thematic analysis was conducted to identify emergent themes.

RESULTS

Seventeen participants completed the interview. Patients' perspectives on PADMOUD were grouped into five areas. Participants reported feasibility of taking the tablet formulation of methadone at the pharmacy and identified benefits from PADMOUD (e.g., better access, efficiency, convenience) compared with usual care at the OTP. Participants perceived support for PADMOUD from their family/friends, OTP staff, and pharmacy staff. PADMOUD was perceived to be a great option for stable patients with take-home doses and those with transportation barriers. The distance (convenience), office hours, and the cost were considered factors most influencing their decision to receive methadone from a pharmacy. Nonjudgmental communication, pharmacists' training on methadone treatment, selection of patients (stable status), workflow of PADMOUD, and protection of privacy were considered key factors for improving operations of PADMOUD.

CONCLUSION

This study presents the first findings on patient perspectives on PADMOUD. Participants considered pharmacies more accessible than OTPs, which could encourage more people to receive methadone treatment earlier and help transition stable patients from an OTP into a local pharmacy. The findings have timely implications for informing implementation strategies of PADMOUD that consider patients' views and needs.

Internal and Environmental Predictors of Physician Practice Use of Screening and Medications for Opioid Use Disorders

Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.

Access to Medications for Opioid Use Disorder in Rural Versus Urban Veterans Health Administration Facilities

BACKGROUND

For patients with opioid use disorder (OUD), medications for OUD (MOUD) reduce morbidity, mortality, and return to use. Nevertheless, a minority of patients receive MOUD, and underutilization is pronounced among rural patients.

OBJECTIVE

While Veterans Health Administration (VHA) initiatives have improved MOUD access overall, it is unknown whether access has improved in rural VA health systems specifically. How "Community Care," healthcare paid for by VHA but received from non-VA providers, has affected rural access is also unknown.

DESIGN

Data for this observational study were drawn from the VHA Corporate Data Warehouse. Facility rurality was defined by rural-urban commuting area code of the primary medical center. International Classification of Diseases codes identified patients with OUD within each year, 2015-2020. We included MOUD (buprenorphine, methadone, extended-release naltrexone) received from VHA or paid for by VHA but received at non-VA facilities through Community Care. We calculated average yearly MOUD receipt; linear regression of outcomes on study years identified trends; an interaction between year and rural status evaluated trend differences over time.

PARTICIPANTS

All 129 VHA Health Systems, a designation that encompasses one or more medical centers and their affiliated community-based outpatient clinics MAIN MEASURES: The average proportion of patients diagnosed with OUD that receive MOUD within rural versus urban VHA health care systems.

KEY RESULTS

From 2015 to 2020, MOUD access increased substantially: the average proportion of patients receiving MOUD increased from 34.6 to 48.9%, with a similar proportion of patients treated with MOUD in rural and urban systems in all years. Overall, a small proportion (1.8%) of MOUD was provided via Community Care, and Community Care did not disproportionately benefit rural health systems.

CONCLUSIONS

Strategies utilized by VHA could inform other health care systems seeking to ensure that, regardless of geographic location, all patients are able to access MOUD.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Changes in buprenorphine visits in frontier and remote locations: Effects of the SARS-CoV-2 pandemic

Background

The pandemic has changed many aspects of healthcare, including the treatment of people with opioid use disorder with buprenorphine. Prior to the pandemic, rural health disparities existed in the accessibility of this treatment. Rural and frontier areas of the United States, particularly the Great Plains, had few or no providers of this evidence-based treatment. This study aimed to investigate how access to buprenorphine changed in the Great Plains during the pandemic.

Methods

This retrospective observational study compared the number of weekly patient appointments resulting in a buprenorphine prescription for 55 weeks before the start of the SARS-CoV-2 pandemic and 55 weeks after. Electronic health records of the largest rural health provider in the Great Plains were queried. Patients were categorized as coming from a frontier location or a non-frontier location based on the home address provided at the visit. The USDA defines frontier as communities that are small and distant from urban centers. Time series analysis was utilized to understand changes in weekly visits during this period.

Results

A significant increase in weekly buprenorphine visits occurred after the pandemic's start. Further, females and people from frontier locations had significantly higher numbers of buprenorphine visits.

Conclusions

In an area of the country with low pre-existing access to buprenorphine treatment for opioid use disorder, increases in buprenorphine visits were found after the pandemic began. This was particularly true of females who reside in frontier areas. Pandemic-related changes may have reduced barriers to this critical treatment, especially among rural populations.

Clients' experiences on North America's first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study

BACKGROUND

To support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients' quality of life and continuity of care in real-life settings.

METHODS

Three rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach.

RESULTS

Participants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service.

CONCLUSIONS

Reducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.

Did Access to Ambulatory Care Moderate the Associations Between Visit Mode and Ancillary Services Utilization Across the COVID-19 Pandemic Period?

BACKGROUND/OBJECTIVE

In recent years, 2 circumstances changed provider-patient interactions in primary care: the substitution of virtual (eg, video) for in-person visits and the COVID-19 pandemic. We studied whether access to care might affect patient fulfillment of ancillary services orders for ambulatory diagnosis and management of incident neck or back pain (NBP) and incident urinary tract infection (UTI) for virtual versus in-person visits.

METHODS

Data were extracted from the electronic health records of 3 Kaiser Permanente Regions to identify incident NBP and UTI visits from January 2016 through June 2021. Visit modes were classified as virtual (Internet-mediated synchronous chats, telephone visits, or video visits) or in-person. Periods were classified as prepandemic [before the beginning of the national emergency (April 2020)] or recovery (after June 2020). Percentages of patient fulfillment of ancillary services orders were measured for 5 service classes each for NBP and UTI. Differences in percentages of fulfillments were compared between modes within periods and between periods within the mode to assess the possible impact of 3 moderators: distance from residence to primary care clinic, high deductible health plan (HDHP) enrollment, and prior use of a mail-order pharmacy program.

RESULTS

For diagnostic radiology, laboratory, and pharmacy services, percentages of fulfilled orders were generally >70-80%. Given an incident NBP or UTI visit, longer distance to the clinic and higher cost-sharing due to HDHP enrollment did not significantly suppress patients' fulfillment of ancillary services orders. Prior use of mail-order prescriptions significantly promoted medication order fulfillments on virtual NBP visits compared with in-person NBP visits in the prepandemic period (5.9% vs. 2.0%, P=0.01) and in the recovery period (5.2% vs. 1.6%, P=0.02).

CONCLUSIONS

Distance to the clinic or HDHP enrollment had minimal impact on the fulfillment of diagnostic or prescribed medication services associated with incident NBP or UTI visits delivered virtually or in-person; however, prior use of mail-order pharmacy option promoted fulfillment of prescribed medication orders associated with NBP visits.

"You'll come in and dose even in a global pandemic": A qualitative study of adaptive opioid agonist treatment provision during the COVID-19 pandemic

BACKGROUND

Opioid agonist treatment (OAT) improves multiple health and social outcomes, yet requirements to attend for supervised dosing can be burdensome and stigmatising. The COVID-19 pandemic and associated restrictions threatened continuity of care and the wellbeing of people receiving OAT, risking a parallel health crisis. This study sought to understand how adaptations in the complex system of OAT provision impacted and responded to risk environments of people receiving OAT during the COVID-19 pandemic.

METHODS

The analysis draws on semi-structured interviews with 40 people receiving and 29 people providing OAT located across Australia. The study considered the risk environments that produce COVID-19 transmission, treatment (non-)adherence, and adverse events for people receiving OAT. Drawing on theories of risk environments and complex adaptive systems, data were coded and analysed to understand how adaptations to the typically rigid system of OAT provision impacted and responded to risk environments during the COVID-19 pandemic.

RESULTS

During COVID-19, the complex system of OAT provision demonstrated possibilities for responsive adaptation to the entangled features of risk environments of people receiving OAT. Structural stigma was evident in the services which stayed rigid during the pandemic, requiring people to attend for daily supervised dosing and risking fracturing therapeutic relationships. In parallel, there were several examples of services developing enabling environments by offering flexible care through increased takeaways, treatment subsidies, and home delivery.

CONCLUSIONS

Rigidity in the delivery of OAT has been an impediment to achieving health and wellbeing over past decades. To sustain health-promoting environments for people receiving OAT, the wider impacts of the complex system should be acknowledged beyond narrowly defined outcomes relating solely to the medication. Centring people receiving OAT in their own care plans will ensure adaptations in the complex system of OAT provision are responsive to the individual's risk environment.

Critical access medication for opioid use disorder (MOUD) treatment facilities in the continental United States

Research objective

Medication opioid use disorder (MOUD) treatment is the first-line approach to the treatment of opioid use disorder (OUD). This analysis seeks to identify "critical access" MOUD facilities that ensure geographic access for MOUD patients. Using public-source data and spatial analysis, we identify the top 100 "critical access" MOUD units across the continental U.S.

Study design

We use locational data from SAMHSA's Behavioral Health Treatment Services Locator and DATA 2000 waiver buprenorphine providers. We identify the closest MOUDs to each ZIP Code Tabulation Area (ZCTA)'s geographic centroid. We then construct a difference-in-distance metric by computing the difference in this distance measure between closest and second-closest MOUD, multiplied by ZCTA population, ranking MOUDs by difference-distance scores.

Population studied

All listed MOUD treatment facilities and all listed ZCTA's across the continental U.S., and all listed MOUD providers proximate to these areas.

Principal findings

We identified the top 100 critical access MOUD units in the continental United States. Many critical providers were in rural areas in the central United States, as well as a band extending east from Texas to Georgia. Twenty-three of the top 100 critical access providers were identified as providing naltrexone. Seventy-seven were identified as providing buprenorphine. Three were identified as providing methadone.

Conclusions

Significant areas of the United States are dependent on a single critical access MOUD provider.

Implications for policy or practice

Place-based supports may be warranted to support MOUD treatment access in areas dependent upon critical access providers.

Cost-effectiveness of office-based buprenorphine treatment for opioid use disorder

AIM

To assess the effectiveness and cost-effectiveness of office-based buprenorphine treatment (OBBT) in the U.S.

DESIGN SETTING AND PARTICIPANTS

We performed a model-based analysis of buprenorphine treatment provided in a primary care setting for the U.S. population with OUD.

INTERVENTION

Buprenorphine treatment provided in a primary care setting.

MEASUREMENTS

Fatal and nonfatal overdoses and deaths over five years, discounted lifetime quality-adjusted life years (QALYs), costs.

FINDINGS

For a cohort of 100,000 untreated individuals who enter OBBT, approximately 9350 overdoses would be averted over five years; of these, approximately 900 would have been fatal. OBBT compared to no treatment would yield 1.07 incremental lifetime QALYs per person at an incremental cost of $17,000 per QALY gained when using a healthcare perspective. If OBBT is half as effective and twice as expensive as assumed in the base case, the incremental cost when using a healthcare perspective is $25,500 per QALY gained. Using a limited societal perspective that additionally includes patient costs and criminal justice costs, OBBT is cost-saving compared to no treatment even under pessimistic assumptions about efficacy and cost.

CONCLUSIONS

Expansion of OBBT would be highly cost-effective compared to no treatment when considered from a healthcare perspective, and cost-saving when reduced criminal justice costs are included. Given the continuing opioid crisis in the U.S., expansion of this care option should be a high priority.

Geographic information science and the United States opioid overdose crisis: A scoping review of methods, scales, and application areas

BACKGROUND

The Opioid Overdose Crisis (OOC) continues to generate morbidity and mortality in the United States, outpacing other prominent accident-related reasons. Multiple disciplines have applied geographic information science (GIScience) to understand geographical patterns in opioid-related health measures. However, there are limited reviews that assess how GIScience has been used.

OBJECTIVES

This scoping review investigates how GIScience has been used to conduct research on the OOC. Specific sub-objectives involve identifying bibliometric trends, the location and scale of studies, the frequency of use of various GIScience methodologies, and what direction future research can take to address existing gaps.

METHODS

The review was pre-registered with the Open Science Framework ((https://osf.io/h3mfx/) and followed the PRISMA-ScR guidelines. Scholarly research was gathered from the Web of Science Core Collection, PubMed, IEEE Xplore, ACM Digital Library. Inclusion criteria was defined as having a publication date between January 1999 and August 2021, using GIScience as a central part of the research, and investigating an opioid-related health measure.

RESULTS

231 studies met the inclusion criteria. Most studies were published from 2017 onward. While many (41.6%) of studies were conducted using nationwide data, the majority (58.4%) occurred at the sub-national level. California, New York, Ohio, and Appalachia were most frequently studied, while the Midwest, north Rocky Mountains, Alaska, and Hawaii lacked studies. The most common GIScience methodology used was descriptive mapping, and county-level data was the most common unit of analysis across methodologies.

CONCLUSIONS

Future research of GIScience on the OOC can address gaps by developing use cases for machine learning, conducting analyses at the sub-county level, and applying GIScience to questions involving illicit fentanyl. Research using GIScience is expected to continue to increase, and multidisciplinary research efforts amongst GIScientists, epidemiologists, and other medical professionals can improve the rigor of research.

Relationships between places of residence, injury, and death: Spatial and statistical analysis of fatal opioid overdoses across Massachusetts

Understanding the factors associated with where people who use opioids live, where their fatal overdoses occur, and where deaths are recorded can improve our knowledge of local risk environments and inform intervention planning. Through geospatial analyses of death certificate data between 2015 and 2017, we found that a majority of opioid-involved fatal overdoses in Massachusetts occurred at home. Age (adjusted odds ratio [AOR], 1.03; 95% confidence interval [CI], 1.02-1.04), living in a census tract with a higher percentage of crowded households (AOR, 1.04; 95% CI, 1.01-1.08), households without vehicles (AOR, 1.01; 95% CI, 1.00-1.02), and Hispanic ethnicity (AOR, 0.56; 95% CI, 0.42-0.74) were independently associated with fatal overdose at home. Using geographically weighted regression, we identified locations where these associations were stronger and could benefit most from home-based and culturally sensitive overdose prevention efforts, including expanded overdose education and naloxone distribution.

Opioid-Involved Overdose Vulnerability in Wyoming: Measuring Risk in a Rural Environment

BACKGROUND

Between 2009 and 2019 opioid-involved fatal overdose rates increased by 45% and the average opioid dispensing rate in Wyoming was higher than the national average. The opioid crisis is shaped by a complex set of socioeconomic, geopolitical, and health-related variables. We conducted a vulnerability assessment to identify Wyoming counties at higher risk of opioid-related harm, factors associated with this risk, and areas in need of overdose treatment access to inform priority responses.

METHODS

We compiled 2016 to 2018 county-level aggregated and de-identified data. We created risk maps and ran spatial analyses in a geographic information system to depict the spatial distribution of overdose-related measures. We used addresses of opioid treatment programs and buprenorphine providers to develop drive-time maps and ran 2-step floating catchment area analyses to measure accessibility to treatment. We used a straightforward and replicable weighted ranks approach to calculate final county vulnerability scores and rankings from most to least vulnerable.

FINDINGS

We found Hot Springs, Carbon, Natrona, Fremont, and Sweetwater Counties to be most vulnerable to opioid-involved overdose fatalities. Opioid prescribing rates were highest in Hot Springs County (97 per 100 persons), almost two times the national average (51 per 100 persons). Statewide, there were over 90 buprenorphine-waivered providers, however accessibility to these clinicians was limited to urban centers. Most individuals lived further than a four-hour round-trip drive to the nearest methadone treatment program.

CONCLUSIONS

Identifying Wyoming counties with high opioid overdose vulnerabilities and limited access to overdose treatment can inform public health and harm reduction responses.

Cumulative barriers to retention in methadone treatment among adults from rural and small urban communities

Background

Though methadone has been shown to effectively treat opioid use disorder, many barriers prevent individuals from accessing and maintaining treatment. Barriers are prevalent in less populated areas where treatment options are limited. This study examines barriers to retention in methadone treatment in a small Midwest community and identifies factors associated with greater endorsement of barriers.

Methods

Patients at an opioid treatment program (N = 267) were recruited to complete a computer-based survey onsite. Surveys assessed demographics, opioid misuse, depression and anxiety symptoms, trauma history and symptoms, social support, and barriers to retention in treatment (e.g., childcare, work, housing, transportation, legal obligations, cost, health). Descriptive statistics were used to examine individual barriers and multiple regression was calculated to identify demographic and psychosocial factors associated with greater cumulative barriers.

Results

Most participants reported at least one barrier to retention in treatment and more than half reported multiple barriers. Travel hardships and work conflicts were the most highly endorsed barriers. Past year return to use (B = 2.31, p = 0.004) and more severe mental health symptomology (B = 0.20, p = 0.038) were associated with greater cumulative barriers. Greater levels of social support were associated with fewer barriers (B = − 0.23, p < 0.001).

Conclusion

This study adds to the limited research on barriers to retention in methadone treatment among patients in rural and small urban communities. Findings suggest flexible regulations for dispensing methadone, co-location or care coordination, and family or peer support programs may further reduce opioid use and related harms in small communities. Individuals with past year return to use reported a greater number of barriers, highlighting the time following return to use as critical for wraparound services and support. Those with co-occurring mental health issues may be vulnerable to poor treatment outcomes, as evidenced by greater endorsement of barriers. As social support emerged as a protective factor, efforts to strengthen informal support networks should be explored as adjunctive services to methadone treatment.

Twelve-month Treatment Retention and Associated Factors: A Comparison of 2 Medically Assisted Therapy Clinics in Dar es Salaam, Tanzania

OBJECTIVES

Retention in methadone maintenance treatment is instrumental in achieving better treatment outcomes. In this study, we compared 2 medication-assisted treatment (MAT) clinics in Dar es Salaam, Tanzania with respect to patient characteristics, outcomes, and factors that predict 12-month treatment retention.

METHODS

This retrospective registry-based cohort study utilized data collected for routine clinical and program monitoring at 2 sites, Mwananyamala and Muhimbili MAT clinics. Cumulative retention in treatment was calculated using life tables. The analysis of treatment retention predictor variables used both Kaplan-Meier and Cox proportional hazard analyses.

RESULTS

We examined the socio-demographic and program-related characteristics of 362 (181 from each clinic) patients. Twelve-month treatment retention was higher at Mwananyamala (73%) than Muhimbili (64%) MAT clinic, but the difference was not significant. In both clinics, a higher methadone dose (>60 mg) significantly predicted treatment retention (P < 0.05). Being employed and traveling an average short distance (<5 km) from home to clinic significantly increased the likelihood of remaining in treatment in Muhimbili MAT clinic (P  < 0.05) only.

CONCLUSIONS

A methadone dose of 60 mg and above was associated with longer retention in treatment. At 1 clinic in a denser and more central location, employment and a short travel distance from home to clinic were associated with longer tenure in treatment. These findings have potential implications for clinical practice, research, and scaling up MAT services in Tanzania.

A bridge too far? Distance to waivered physicians and utilization of buprenorphine treatment for opioid use disorder in West Virginia Medicaid

Background: Travel distance to medication treatment for opioid use disorder (OUD) is a challenge for many patients, but little is known about how distance is associated with medication treatment utilization. This study examines the association between distance to the nearest physician waivered to prescribe buprenorphine and patient-level buprenorphine treatment among West Virginia Medicaid expansion enrollees with diagnosed OUD. Methods: We conducted a cross-sectional spatial analysis with 2016 Medicaid claims data, separately examining individuals living in metropolitan and non-metropolitan areas. We calculated the driving distance from the centroid of patients' residential ZIP codes to the street address of the nearest waivered physician derived from the 2015 Drug Enforcement Administration listing. Regression models examined the association between distance and initiation and duration of buprenorphine (among those initiating). Results: We focused on 8,008 individuals with OUD in 2016. The nearest waivered prescriber in metropolitan areas was an average of 7.13 miles away from patients' residential ZIP codes and 14.54 miles in non-metropolitan areas. The providers they actually visited were a mean of 33.63 miles away in metro areas and 46.36 in non-metropolitan areas. In multivariable analyses, compared to those living <10 miles from a waivered physician, living >20 miles from a waivered physician was associated with -32.13 fewer days of treatment (95% CI: -57.86, -6.40) in metro areas and -16.70 fewer days in non-metro areas (95% CI: -32.32, -1.08). Conclusions: Longer travel distance to buprenorphine treatment is associated with a shorter duration of care that is likely to be clinically meaningful.

Medicaid expansion and opioid overdose mortality among socioeconomically disadvantaged populations in the US: A difference in differences analysis

BACKGROUND

Opioid-related overdoses are a major cause of mortality in the US. Medicaid Expansion is posited to reduce opioid overdose-related mortality (OORM), and may have a particularly strong effect among people of lower socioeconomic status. This study assessed the association between state Medicaid Expansion and county-level OORM rates among individuals with low educational attainment.

METHODS

This quasi-experimental study used lagged multilevel difference-in-difference models to test the relationship of state Medicaid Expansion to county-level OORM rates among people with a high-school diploma or less. Longitudinal (2008-2018) OORM data on 2978 counties nested in 48 states and the District of Columbia (DC) were drawn from the National Center for Health Statistics. The state-level exposure was a time-varying binary-coded variable capturing pre- and post-Medicaid Expansion under the Affordable Care Act (an "on switch"-type variable). The main outcome was annual county-level OORM rates among low-education adults adjusted for potential underreporting of OORM.

FINDINGS

The adjusted county-level OORM rates per 100,000 among the study population rose on average from 10.26 (SD = 13.56) in 2008-14.51 (SD = 18.20) in 2018. In the 1-year lagged multivariable model that controlled for policy and sociodemographic covariates, the association between state Medicaid Expansion and county-level OORM rates was statistically insignificant.

CONCLUSIONS

We found no evidence that expanding Medicaid eligibility reduced OORM rates among adults with lower educational attainment. Future work should seek to corroborate our findings and also identify - and repair - breakdowns in mechanisms that should link Medicaid Expansion to reduced overdoses.

Opioid treatment program and community pharmacy collaboration for methadone maintenance treatment: results from a feasibility clinical trial

BACKGROUND AND AIMS

Pharmacy administration and dispensing of methadone for methadone maintenance treatment (MMT) can expand treatment access for opioid use disorder (OUD). This study investigated the feasibility and acceptability of a novel model permitting an opioid treatment program (OTP) physician to prescribe methadone for OUD treatment through collaboration with a partnered pharmacy.

DESIGN

Non-randomized, single-arm, open-label feasibility trial.

SETTING

One OTP and one community pharmacy in the United States.

PARTICIPANTS

One OTP physician, two pharmacists and 20 MMT patients receiving between six and 13 take-home methadone doses at 5-160 mg/day.

INTERVENTION

Patients' methadone administration and dispensing of take-home doses was transferred from the OTP to the pharmacy for 3 months.

MEASUREMENTS

Primary outcome was medication adherence. Secondary outcomes were recruitment, treatment retention, substance use, counseling attendance at the OTP, pharmacist prescription drug monitoring program (PDMP) use, safety and satisfaction.

FINDINGS

Of 29 patients eligible at pre-screen, 20 patients (69%) enrolled into the study. Recruitment occurred from 6 August 2020 to 10 October 2020. Treatment retention rate at month 3 was 80% (16 of 20). Two participants returned early to the OTP because of a work/schedule change, one due to pregnancy and one following a non-study-related hospitalization. Medication adherence among 16 patients who were retained was 100%. Intervention fidelity was 100%. All participants attended random call-back visits. None showed evidence of tampering/diversion of methadone. Pharmacists checked the PDMP at all visits. All participants attended psychosocial counseling as planned. There were no positive urine screens for illicit opioid use and no study-related adverse events. All participants endorsed 'pharmacy is the right location for receiving methadone for MMT', 88% endorsed 'convenient or very convenient to receive methadone at the pharmacy' and 88% were satisfied or very satisfied with the quality of treatment offered.

CONCLUSIONS

This feasibility trial has found pharmacy administration and dispensing of physician-prescribed methadone for methadone maintenance treatment to be feasible and acceptable.

"Tackling the Substance Use Disorder Crisis: The Role of Access to Treatment Facilities"

The continuing drug overdose crisis in the U.S. has highlighted the urgent need for greater access to treatment. This paper examines the impact of openings and closings of substance use disorder treatment facilities in New Jersey on emergency room visits for substance use disorder issues among nearby residents. We find that drug-related ER visits increase by 7.4% after a facility closure and decrease by 6.5% after an opening. The effects are smaller for the middle aged than for either younger or older people, and are also somewhat larger for Black residents, and for those on Medicaid. The results suggest that expanding access to treatment results in significant reductions in morbidity related to drugs.

Methadone Exposures Reported to Poison Control Centers in the United States Following the COVID-19-Related Loosening of Federal Methadone Regulations

Background

Methods

Results

Conclusions

Spatial and Nonspatial Factors Associated with Access to Medication for Opioid Use Disorder among Pregnant Women in Massachusetts

INTRODUCTION

In Massachusetts, one-third of pregnant women with opioid use disorder (OUD) do not receive medications for OUD (MOUD), such as buprenorphine and methadone. Research has demonstrated that broadly, access to medications differs by location and by socioeconomic and geographic characteristics of communities, but a comprehensive understanding at the micro-level is lacking. This study aims to identify and characterize access to MOUD treatment among pregnant women in Massachusetts.

METHODS

We used enhanced two-step floating catchment area analyses, which incorporated supply and demand measures, as well as local drive-time, to determine spatial accessibility to MOUD. We used four publicly available data sources to calculate geographic accessibility to MOUD. We then merged the resulting accessibility indices with data from the American Community Survey to statistically analyze ZIP Code Tabulation Area (ZCTA) characteristics that were associated with geographic accessibility to MOUD among the study population.

RESULTS

We calculated access to 258 opioid (methadone and/or buprenorphine) treatment programs and 2,585 buprenorphine-waivered prescribers among 74,969 pregnant women during the period 2016-2020 in 448 ZCTAs (N = 537 ZCTAs). ZCTAs with lower accessibility to both types of MOUD were concentrated in Western Massachusetts. Central Massachusetts had poor accessibility to buprenorphine providers. Accessibility was greater in ZCTAs that were nonmetropolitan, that had higher minority status and langauge vulnerability, and that had less extreme concentration of privilege.

CONCLUSIONS

There is a need to improve MOUD access overall, and to enhance access to both types of medications, so pregnant women can choose the one that works best for them.

Identifying barriers to emergency department-initiated buprenorphine: A spatial analysis of treatment facility access in Michigan

STUDY OBJECTIVES

Emergency department (ED)-initiated buprenorphine/naloxone has been shown to improve treatment retention and reduce illicit opioid use; however, its potential may be limited by a lack of accessible community-based facilities. This study compared one state's geographic distribution of EDs to outpatient treatment facilities that provide buprenorphine treatment and identified ED and geographic factors associated with treatment access.

METHODS

Treatment facility data were obtained from the SAMHSA 2018 National Directory of Drug and Alcohol Abuse Treatment Facilities, and ED data were obtained from the Michigan College of Emergency Physician's 2018 ED directory. Geospatial analysis compared EDs to buprenorphine treatment facilities using 5-, 10-, and 20-mile network buffers.

RESULTS

Among 131 non-exclusively pediatric EDs in Michigan, 57 (43.5%) had a buprenorphine treatment facility within 5 miles, and 66 (50.4%) had a facility within 10 miles. EDs within 10 miles of a Medicaid-accepting, outpatient buprenorphine treatment facility had higher average numbers of beds (41 vs. 15; p < 0.0001) and annual patient volumes (58,616 vs. 17,484; p < 0.0001) compared to those without. Among Michigan counties with EDs, those with at least one buprenorphine facility had larger average populations (286,957 vs. 44,757; p = 0.005) and higher annual rates of opioid overdose deaths (mean 18.3 vs. 13.0 per 100,000; p = 0.02) but were similar in terms of opioid-related hospitalizations and socioeconomic distress.

CONCLUSION

Only half of Michigan EDs are within 10 miles of a buprenorphine treatment facility. Given these limitations, expanding access to ED-initiated buprenorphine in states similar to Michigan may require developing alternative models of care.

Robustness of estimated access to opioid use disorder treatment providers in rural vs. urban areas of the United States

BACKGROUND

Effective, evidence-based treatments for opioid use disorder are not equally accessible to Americans. Recent studies have found urban/rural disparities in the driving times to the nearest opioid treatment providers. These disparities may be even worse than currently reported in the literature because patients may not be able to obtain appointments with their nearest provider. We examine the robustness of the opioid treatment infrastructure by estimating how driving times to treatment change as provider availability decreases.

METHODS

We used public data from the federal government to estimate the driving time from each census tract centroid to the nearest 15 treatment providers. We summarized the median and interquartile range of driving times to increasingly distant providers (i.e., nearest, second nearest, etc.), stratified by urban/rural classification.

RESULTS

The median driving time to the nearest provider was greater in rural areas than urban areas for both opioid treatment programs (12 min vs 61 min) and buprenorphine-waivered prescribers (5 min vs 21 min). Importantly, driving times in rural areas increased more steeply as nearer providers became unavailable. For example, the increase in driving time between the nearest provider and the fifth nearest provider was much greater in rural areas than in urban areas for both buprenorphine-waivered prescribers (23 min vs 4 min) and for opioid treatment programs (54 min vs 22 min).

CONCLUSIONS

Access to treatment for opioid use disorder is more robust in urban areas compared with rural areas. This disparity must be eliminated if the opioid overdose crisis is to be resolved.

The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era

BACKGROUND

Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020.

OBJECTIVE

To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes.

METHODS

A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes.

RESULTS

Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes.

CONCLUSIONS

Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.

Relationship between choice of opioid agonist therapy and distance from patients' residences in Taiwan, 2012-2014

BACKGROUND

Choice of opioid agonist therapy (OAT) for opioid use disorder (OUD) can be impacted by variables such as age, sex, and socioeconomic status. However, it remains unknown whether accessibility of treatment affects patient choice of OAT.

OBJECTIVES

To investigate the association between distance to the treatment site and choice of OAT.

METHODS

Electronic records were collected for the last outpatient visits of individuals with OUD between January 1, 2012 and December 31, 2014. The address of each patient was processed using the Geographic Information System to obtain the distance between place of residence and the hospital. Multivariate logistic regression was used to assess the correlation between individual drug selection and distance of residence. Among the study population of 2804 patients (81.5% male), 74.1% were receiving methadone while 25.8% were receiving buprenorphine. The vast majority (95%) of all patients lived within 50 km of the hospital, so regression analysis was limited to this distance. Sensitivity analysis was estimated using robust Poisson regression.

RESULTS

Logistic regression revealed that every 1-km increase in distance from home to hospital increased the odds ratio of choosing sublingual buprenorphine tablets over methadone by 1.05 (p = .02, 95% confidence interval (CI) = 1.02-1.08).

CONCLUSIONS

Patients living closer to the treatment center were more likely to choose methadone as treatment, while patients living farther away were more likely to choose sublingual buprenorphine tablets. To mitigate the influence of travel distance on therapy choice, we recommend that more medical institutions participate in OAT services.

"It's like 'liquid handcuffs": The effects of take-home dosing policies on Methadone Maintenance Treatment (MMT) patients' lives

BACKGROUND

Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing risk of overdose, arrest, and transmission of blood-borne viruses like HIV and HCV among people that use opioids. Yet, MMT's use of restrictive take-home dose policies that force most patients to attend their clinic on a daily, or near-daily, basis may be unpopular with many patients and lead to low rates of treatment uptake and retention. In response, this article examines how clinics' take-home dosing policies have affected patients' experiences of treatment and lives in general.

METHODS

This article is based on semi-structured, qualitative interviews with a variety of stakeholders in MMT. Interviews explored: reasons for engaging with, or not engaging with MMT; how MMT is conceptualized by patients and treatment providers (e.g., as harm reduction or route to abstinence and/or recovery); experiences with MMT; perception of barriers to MMT (e.g., organizational/regulatory, social) and how MMT might be improved to support peoples' substance use treatment needs and goals.

RESULTS

Nearly all of the patients with past or present MMT use were highly critical of the limited access to take-home doses and consequent need for daily or near daily clinic attendance. Participants described how the use of restrictive take-home dose policies negatively impacted their ability to meet day-to-day responsibilities and also cited the need for daily attendance as a reason for quitting or avoiding OAT. Responses also demonstrate how such policies contribute to an environment of cruelty and stigma within many clinics that exposes this already-stigmatized population to additional trauma.

CONCLUSIONS

Take-home dose policies in MMT are not working for a substantial number of patients and are reasonably seen by participants as degrading and dehumanizing. Revision of MMT regulations and policies regarding take home doses are essential to improve patient satisfaction and the quality and effectiveness of MMT as a key evidence-based treatment and harm reduction strategy.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Access to medication-assisted treatment in the United States: Comparison of travel time to opioid treatment programs and office-based buprenorphine treatment

OBJECTIVES

Disparities in access to medication-assisted treatment are a major problem. This study estimated and compared drive time to the nearest opioid treatment program (OTP) and office-based buprenorphine treatment (OBBT) across the urban-rural continuum in the U.S.

METHODS

Drive time was calculated between the longitude and latitude of population weighted block group centroids and the longitude and latitude of the nearest OTP and OBBT. Rural-Urban Commuting Area (RUCA) codes were used for defining rurality. The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

The mean travel time to the nearest OBBT compared to OTP decreased by 7.18 min (95 % CI = 7.23-7.14) in metropolitan cores, 36.63 min (95 % CI = 37.12-36.15) in micropolitan cores, 38.84 min (95 % CI = 39.57-38.10) in small town cores, and 40.16 min (95 % CI = 40.81-39.50) in rural areas. Additionally, travel burden to the nearest OTP would be more than 60 min for 13,526,605 people and more than 90 min for 5,371,852 people. The travel burden to the nearest OBBT would be more than 60 min for 845,991 people and more than 90 min for 149,297 people.

CONCLUSIONS

The mean drive time to the closest OBBT was significantly smaller than the mean drive time to the closest OTP. Analysis of barriers to access is necessary to devising creative initiatives to improve access to critical opioid use disorder treatment services.

Changes in methadone take-home dosing before and after COVID-19

INTRODUCTION

In response to the COVID-19 pandemic, a federal exemption allowed stable and less stable patients greater take-home doses of methadone. We assessed the adoption of increased take-home medication during COVID-19 and whether increased take-home doses is associated with clients' characteristics.

METHODOLOGY

We completed a pre-post study of adults receiving methadone for OUD from an OTP in Spokane, Washington. Our outcome was the change in the number of take-home methadone doses three months before and three months after the March 2020 take-home medication exemption. Clients' characteristics included age, gender, ethnicity, education level, homelessness, spatial access to the clinic, and methamphetamine use.

RESULTS

The study included 194 clients in treatment for a median of three years. All study participants experienced an average increase in take-home medication of 41.4 in the three-month period after the COVID-19 exemption. In the final adjusted models, clients who reported using methamphetamine in the last 30 days experienced a significantly larger increase in take-home dosage (55.6 days) compare to clients who did not use methamphetamine (p ≤0.001). Most of the clients who reported using methamphetamine were also likely to be homeless. All other variables were not associated with a change in take-home doses.

CONCLUSION

These results suggest that the Spokane OTP quickly expanded take-home medication dosing in response to the COVID-19 exemption and broadly expanded take-home dosing among established clients. Clients with concurrent methamphetamine use were allowed fewer take-home doses prior to COVID-19, but after the exemption the clinic provided them the same number of take-home doses as clients who had not used methamphetamine.

Integrating Reproductive and Sexual Health Education and Services Into Opioid Use Disorder Treatment Programs: A Qualitative Study

OBJECTIVES

Women with opioid use disorder (OUD) in the USA are at risk for poor reproductive and sexual health (RSH) outcomes. The qualitative research presented here is part of a larger mixed methods study. The qualitative component used an implementation science framework to investigate provider and staff perspectives regarding the integration of RSH education and services for reproductive-age women in opioid treatment programs (OTPs) in North Carolina.

METHODS

Thirty-one semistructured interviews were conducted with providers and staff at 9 OTPs between November and December, 2017. The Consolidated Framework for Implementation Research (CFIR) was used to assess multilevel implementation contexts (eg, patient, provider, organizational) to identify barriers and facilitators that might influence effective intervention implementation. Interviews were audio-recorded, transcribed, coded, and analyzed to identify key themes. Deductive and inductive approaches were used.

RESULTS

Barriers included transportation, childcare, and time constraints (patient-level), lack of communication between providers (provider-level), lack of political will, competing priorities, and shortages of available resources (organizational-level). Facilitators included a group education approach (patient-level), strong communication (provider-level), and a culture of collaboration (organizational-level).

CONCLUSIONS

Assessing determinants of implementation is important to the development of RSH interventions. CFIR constructs were found to be important influences that could facilitate or hinder effective implementation. Integration of RSH education and services is a process, and, when addressed in stages, might be feasible. A broad range of RSH education and services has the potential to have a profound impact on the health of women with OUD and their children, their families, and their communities.

Facility Attractiveness and Social Vulnerability Impacts on Spatial Accessibility to Opioid Treatment Programs in South Carolina

Opioid dependence and opioid-related mortality have been increasing in recent years in the United States. Available and accessible treatments may result in a reduction of opioid-related mortality. This work describes the geographic variation of spatial accessibility to opioid treatment programs (OTPs) and identifies areas with poor access to care in South Carolina. The study develops a new index of access that builds on the two-step floating catchment area (2SFCA) method, and has three dimensions: a facility attractiveness index, defined by services rendered incorporated into the Huff Model; a facility catchment area, defined as a function of facility attractiveness to account for variable catchment size; and a Social Vulnerability Index (SVI) to account for nonspatial factors that mitigate or compound the impacts of spatial access to care. Results of the study indicate a significant variation in access to OTPs statewide. Spatial access to OTPs is low across the entire state except for in a limited number of metropolitan areas. The majority of the population with low access (85%) live in areas with a moderate-to-high levels of social vulnerability. This research provides more realistic estimates of access to care and aims to assist policymakers in better targeting disadvantaged areas for OTP program expansion and resource allocation.

Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder

Treatment with buprenorphine significantly reduces both all-cause and overdose mortality among individuals with opioid use disorder. Offering buprenorphine treatment to individuals who experience a nonfatal opioid overdose represents an opportunity to reduce opioid overdose fatalities. Although some emergency departments (EDs) initiate buprenorphine treatment, many individuals who experience an overdose either refuse transport to the ED or are transported to an ED that does not offer buprenorphine. Emergency medical services (EMS) professionals can help address this treatment gap. In this Concepts article, we describe the federal legal landscape that governs the ability of EMS professionals to administer buprenorphine treatment, and discuss state and local regulatory considerations relevant to this promising and emerging practice.

Expanding access to methadone treatment in Ohio through federally qualified health centers and a chain pharmacy: A geospatial modeling analysis

BACKGROUND

In the United States, methadone provision for opioid use disorder (OUD) occurs at opioid treatment programs (OTPs). Ohio recently enacted a policy to expand methadone administration to Federally Qualified Health Centers (FQHC). We compared how the provision of methadone at current OTPs or the proposed expansion to FQHCs and pharmacies meets the urban and rural need for OUD treatment.

METHODS

Cross-sectional geospatial analysis of zip codes within Ohio with at least one 2017 opioid overdose death stratified by Rural-Urban Commuting Area codes. Our primary outcome was the proportion of need by zip code (using opioid overdose deaths as a proxy for need) within a 15- or 30- minute drive time of an OTP.

RESULTS

Among 581 zip codes, sixty four percent of treatment need was within a 15-minute drive time and 81 %, within a 30-minute drive time. The proportion of need within a 15-minute drive decreased with increasing rural classification (urban 78 %, suburban 20 %, large rural 9%, and small rural 1%;p<.001). The portion of need within a 15-minute drive time increased with the addition of FQHCs (96 %) and the addition of chain pharmacies (99 %) relative to OTPs alone among all zip codes and for all urban-rural strata (p<.001).

CONCLUSION

Over one-third of OUD treatment need was not covered by existing OTPs and coverage decreased with rural classification of zip codes. Most of the gap between supply and need could be mitigated with FQHC methadone provision, which would expand both urban and rural access.

Disparities in Access to Opioid Treatment Programs and Office-Based Buprenorphine Treatment Across the Rural-Urban and Area Deprivation Continua: A US Nationwide Small Area Analysis

OBJECTIVES

To measure access to opioid treatment programs (OTPs) and office-based buprenorphine treatment (OBBTs) at the smallest geographic unit for which the Census Bureau publishes demographic and socioeconomic data (ie, block group) and to explore disparities in access to treatment across the rural-urban and area deprivation continua across the United States.

METHODS

Access to OTPs and OBBTs at the block group in 2019 was quantified using an innovative 2-step floating catchment area technique that accounts for the supply of treatment facilities relative to the population size, proximity of facilities relative to the location of population in block groups, and time as a barrier within catchments. Block groups were stratified into tertiles based on the rural-urban continuum codes (metropolitan, micropolitan, small town, or rural) and area deprivation index (least-deprived, middle-deprived, most-deprived). The Integrated Nested Laplace Approximation approach was used for statistical analysis.

RESULTS

Across the United States, 3329 block groups corresponding to 2 915 949 adults lacked access to OTPs within a 2-hour drive of their community and 130 block groups corresponding to 86 605 adults did not have access to OBBTs. Disparities in access to treatment were observed across the urban-rural and area deprivation continua including (1) lowest mean access score to OBBTs were found among most-deprived small towns, and (2) lower mean access score to OTPs were found among micropolitan and small towns.

CONCLUSIONS

The results of this study revealed disparities in access to medication-assisted treatment. The findings call for creative initiatives and local and regional policies to develop to mitigate access problems.

Using telehealth to improve buprenorphine access during and after COVID-19: A rapid response initiative in Rhode Island

Despite its proven efficacy, buprenorphine remains dramatically underutilized for management of opioid use disorder largely due to onerous barriers to treatment initiation. During the COVID-19 pandemic, many substance use disorder treatment facilities have reduced their hours and services, exacerbating existing barriers. To this end, the U.S. Drug Enforcement Administration and Substance Abuse Mental Health Services Administration adjusted their guidelines to allow for new buprenorphine prescriptions following audio-only telehealth encounters, no longer requiring an in-person evaluation prior to treatment initiation. Under this new guidance, we established a 24/7 telephone hotline to function as a "tele-bridge" clinic where people with opioid use disorder can be linked with a buprenorphine prescriber in real-time for OUD assessment and unobserved buprenorphine initiation with connection to follow-up if appropriate. Additionally, we developed an ED callback protocol to reach patients recently seen for opioid overdose and facilitate their entry into care if interested. In this commentary we describe our hotline and ED callback protocols, discuss theoretical and anecdotal benefits to this approach, and advocate for continuation of current regulatory changes post-COVID-19 to maintain expanded access to novel treatment approaches.