Factors associated with methadone maintenance therapy discontinuation among people who inject drugs

Opioid agonist therapy discontinuation in British Columbia: a cross-sectional study of people who access harm reduction services

OBJECTIVES

This study evaluates the prevalence and correlates of opioid agonist therapy (OAT) discontinuation across British Columbia (BC), using a sample of individuals who used substances and accessed harm reduction sites.

DESIGN

This study uses data from the 2019 cross-sectional Harm Reduction Client Survey (HRCS).

SETTING

The 2019 survey was administered from October to December at 22 harm reduction supply distribution sites across the 5 Regional Health Authorities of BC.

PARTICIPANTS

The 2019 HRCS was administered among individuals who used illicit substances in the past 6 months and were aged 19 years and above.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was defined as self-reported discontinuation of OAT in the past 6 months. Measures of association (χ2 and Fisher's exact tests) and logistic regression models were used to assess the strength of association between OAT discontinuation and demographic, socioeconomic, accessibility, drug use and harm reduction correlates.

RESULTS

Of the 194 participants included, 59.8% self-identified as cis man, 37.6% self-identified as Indigenous, 38.1% were aged 30-39 years and 43.8% had discontinued OAT in the past 6 months. Multivariable logistic regression analyses identified that those aged ≥50 years (AOR=0.12, 95% CI (0.03 to 0.45)) and those who took the survey in medium/large urban areas (AOR=0.27, 95% CI (0.07 to 0.98)) were significantly less likely to discontinue OAT, while those who experienced an overdose in the past 6 months were significantly more likely (AOR=3.77, 95% CI (1.57 to 9.03)) to have discontinued OAT in the past 6 months. Substance use, including opioids and stimulants, was similar among those who continued and discontinued OAT. Of the 73 participants who discontinued OAT and provided a reason, one-third reported discontinuing OAT because treatment was not effective, 27.4% could not get to the pharmacy during open hours, 23.3% could not make their clinic appointment and 15.1% reported challenges with transportation/travel.

CONCLUSIONS

OAT discontinuation prevention efforts for individuals using substances in BC need to address disparities in healthcare accessibility, especially in rural areas and among younger individuals. Continued access to harm reduction services can allow for safer consumption of substances for individuals enrolled in OAT programs.

Provision of medications to treat opioid use disorder via a mobile health unit: A scoping review

INTRODUCTION

Mobile health units (MHUs) provide a variety of low-barrier services to populations that face systemic barriers to healthcare access. However, MHUs are not a common delivery method for medications to treat opioid use disorder (MOUD), and, of these, there is no consensus regarding MHU targeted objectives and outcomes. This scoping review seeks to summarize the state of the literature examining the delivery of MOUD by MHUs in the United States.

METHODS

A search of PubMed, PsycInfo, and CINAHL on February 21, 2023, found 223 articles. Two authors completed title and abstract and full text reviews and extracted data relevant to intervention and study design, program objectives, and study outcomes. Ten articles fit the study's inclusion criteria (nine total interventions).

RESULTS

Of the 10 studies, six were cohort designs, three were cross-sectional (one with qualitative interviews), and one study conducted qualitative interviews only. Most studies were located in the Northeastern United States. MHU interventions primarily aimed to provide MOUD and to retain populations in treatment. Two interventions aimed to engage patients and then transfer them to fixed-site MOUD providers. Across four interventions that provided buprenorphine, 1- and 3-month retention rates varied from 31.6 % to 72.3 % and 26.2 % to 58.5 %, respectively. Qualitative interviews found that MOUD delivery from the MHU was characterized by less stigma/judgment and greater privacy compared to fixed-site, and it was flexible and low-barrier. MHUs were reportedly underutilized by the target populations, suggesting a lack of awareness from community members with opioid use disorder.

CONCLUSIONS

MHUs that deliver MOUD are both under-provided and -utilized. Future research should continue to assess MOUD provision from MHUs with an emphasis on robust study design, application to other formulations of MOUD, and evaluation of outcomes such as participant satisfaction and key informant perceived challenges.

REGISTRATION

Submitted to Open Science Framework (OSF) Repository on February 6, 2023.

An ecological study of the correlation between COVID-19 support payments and overdose events in British Columbia, Canada

BACKGROUND

Pandemic income support payments have been speculatively linked to an increased incidence of illicit drug poisoning (overdose). However, existing research is limited.

METHODS

Collating Canadian Emergency Response Benefit (CERB) payment data with data on paramedic attended overdose and illicit drug toxicity deaths for the province of British Columbia at the Local Health Area (LHA) level, we conducted a correlation analysis to compare overdose rates before, during and after active CERB disbursement.

RESULTS

There were 20,014,270 CERB-entitled weeks identified among residents of British Columbia for the duration of the pandemic response program. Approximately 52 % of all CERB entitled weeks in the study were among females and approximately 48 % were among males. Paramedic-attended overdoses increased uniformly across the pre-CERB, CERB and post-CERB periods, while illicit drug toxicity deaths sharply increased and then remained high over the period of the study. Correlation analyses between overdose and CERB-entitled weeks approached zero for both paramedic-attended overdoses and illicit drug toxicity deaths.

CONCLUSIONS

These findings suggest that attributing the pandemic increase in overdose to income support payments is unfounded. Sustained levels of unacceptably high non-fatal and fatal drug poisonings that further increased at the start of the pandemic are reflective of complex pre-existing and pandemic-driven changes to overdose risk.

Outcome in methadone maintenance treatment of immigrants from the former Union of Soviet Socialist Republics

CONTEXT

Immigrants from the former Union of Soviet Socialist Republics (USSR) are more prevalent in Methadone maintenance treatment (MMT) in Israel than their percentage in the general population.

AIMS

To compare their characteristics and outcomes to those of Israeli-born and other immigrant patients.

METHODS

Retention and survival since admission (June/1993-Dec/2022) until leaving treatment (for retention), or at the end of follow-up were analyzed. Vital data was taken from a national registry. Predictors were estimated using Kaplan-Meier and Cox regression models.

RESULTS

The USSR patients (N = 262) compared with other immigrants (N = 132) and Israeli-born (N = 696) were more educated (≥ 12y) (p < 0.001), admitted to MMT at a younger age (p < 0.001), following a shorter duration of opioid usage (p < 0.001). More of them ever injected drugs (p < 0.001) and ever drank alcohol (p < 0.001). One-year retention was comparable (77.2% vs. 75.6% and 72%, p = 0.2) as did opioid discontinuation in those who stayed (p = 0.2). Former USSR patients had longer cumulative retention of their first admission (p = 0.05) with comparable overall retention since first admission, and survival, although the age of death was younger. Specific origin within the former USSR found immigrants from the Russian Federation with the best outcome, and those from Ukraine as having high HIV seropositive and shorter retention.

CONCLUSIONS

Despite several characteristics known to be associated with poor outcomes, former USSR immigrants showed better adherence to MMT, reflected by their longer cumulative retention in their first admission, lower rate of readmissions, and a comparable survival and overall retention in treatment. An in depth study is needed in order to understand why they decease at a younger age.

Dysregulation of the endogenous cannabinoid system following opioid exposure

Rates of opioid-related deaths and overdoses in the United States are at record-high levels. Thus, novel neurobiological targets for the treatment of OUD are greatly needed. Given the close interaction between the endogenous opioid system and the endocannabinoid system (ECS), targeting the ECS may have therapeutic potential in OUD. The various components of the ECS, including cannabinoid receptors, their lipid-derived endogenous ligands (endocannabinoids [eCBs]), and the related enzymes, present potential targets for developing new medications in OUD treatment. The purpose of this paper is to review the clinical and preclinical literature on the dysregulation of the ECS after exposure to opioids. We review the evidence of ECS dysregulation across various study types, exposure protocols, and measurement protocols and summarize the evidence for dysregulation of ECS components at specific brain regions. Preclinical research has shown that opioids disrupt various ECS components that are region-specific. However, the results in the literature are highly heterogenous and sometimes contradictory, possibly due to variety of different methods used. Further research is needed before a confident conclusion could be made on how exposure to opioids can affect ECS components in various brain regions.

"You rise up and then you start pulling people up with you": Patient experiences with a peer-delivered behavioral activation intervention to support methadone treatment

BACKGROUND

Although medications for opioid use disorder (MOUD) are efficacious treatments for opioid use disorder, retention remains low. Peer recovery specialists (PRSs), individuals with lived substance use and recovery experience, may be particularly well-suited to support patients receiving MOUD. While PRSs are rarely trained in evidence-based behavioral interventions other than motivational interviewing, preliminary evidence suggests that peers can deliver brief behavioral interventions, such as behavioral activation, with efficacy and fidelity. This qualitative study sought to explore patient perspectives on receiving an adapted PRS-delivered behavioral activation intervention (Peer Activate) to support patients receiving methadone treatment.

METHODS

The sample (N = 26) included patients recently starting or demonstrating challenges with adherence at a community-based methadone treatment program who received the Peer Activate intervention in a pilot trial. Participants were invited to participate in in-depth, semi-structured interviews at study completion or discontinuation, assessing perceived acceptability and feasibility of Peer Activate, and stigma-related barriers. Interview transcripts were coded using codebook/template thematic analysis.

RESULTS

Analysis revealed the importance of two areas to promote intervention acceptability: 1) connection with intervention content and skill building, and 2) valued PRS-specific qualities. Intervention flexibility was found to promote feasibility of the intervention in the context of chaotic and challenging life circumstances. Additionally, participants described stigma towards substance use and methadone treatment as potential barriers to engaging in methadone treatment.

CONCLUSION

Results support the acceptability and feasibility to patients of this PRS-delivered behavioral activation intervention in the context of outpatient MOUD treatment among a low-income, majority racially minoritized patient population. Future intervention adaptation and implementation should focus on incorporating content related to relationships and interpersonal skills; balancing behavioral intervention content with system navigation support; maintaining flexibility; and further investigation of the impact of individual PRS attributes, including shared lived experiences, on intervention acceptability and shifts in stigma.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

INTRODUCTION

People experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals.

METHODS

The Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid.

RESULTS

Medicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, -18.6 to -5.07) percentage points less likely to have MOUD-inclusive treatment plans.

CONCLUSIONS

Medicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

The impact of methamphetamine use on medications for opioid use disorder (MOUD) treatment retention: a scoping review

BACKGROUND

An emerging public health threat of methamphetamine/opioid co-use is occurring in North America, including increases in overdoses related to concomitant methamphetamine/opioid use. This presents a potential risk to established treatments for opioid use disorder (i.e., medications for opioid use disorder [MOUD]). To date, few studies have examined the impact of methamphetamine use on MOUD-related outcomes, and no studies have synthesized data on MOUD retention.

METHODS

A scoping review was undertaken to examine the impact of methamphetamine use on MOUD retention. All original published research articles were searched in Embase, MEDLINE, PsychINFO, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Protocols, and Google scholar databases. Data were extracted into a standardized data extraction chart. Findings were presented narratively.

RESULTS

All eight included studies demonstrated an increased likelihood of treatment discontinuation or dropout among patients enrolled in MOUD who used methamphetamine. The frequency of methamphetamine use was also associated with MOUD dropout, in that those who used methamphetamine more often were more likely to discontinue MOUD. The definitions and measurements of MOUD retention varied considerably, as did the magnitude of effect size.

CONCLUSIONS

Results indicate that methamphetamine use has an undesirable impact on MOUD retention and results in an increased risk of treatment discontinuation or dropout. Strategies to identify concurrent methamphetamine use among individuals engaging in MOUD and educate them on the increased risk for dropout should be undertaken. Further research is needed to understand how MOUD retention among patients with concomitant opioid and methamphetamine use can be improved.

Psychosocial challenges affecting patient-defined medication for opioid use disorder treatment outcomes in a low-income, underserved population: Application of the social-ecological framework

INTRODUCTION

Successful engagement with medication treatment for opioid use disorder is an important focus in reducing mortality associated with the opioid crisis. Mortality remains at unacceptably high levels, pointing to a need for improved understanding of factors that affect medication for opioid use disorder outcomes. This study aims to understand how barriers co-occur and interact to interfere with outcomes in methadone treatment for a low-income, underserved patient population with opioid use disorder.

METHODS

This study was conducted at a community-based drug treatment center that serves a predominately low-income, racially diverse population. Guided by the social-ecological framework, we analyzed semi-structured interviews and focus groups with patients and providers working in opioid use disorder care and recovery across Baltimore City (N = 32) to assess factors that influence methadone treatment outcomes, and how barriers co-occur and interact to worsen treatment outcomes. The study used patient-centered definitions to describe successful treatment outcomes.

RESULTS

Barriers described by both patients and providers fit into several broad levels: individual, interpersonal, institutional, community, and stigma. Participants described co-occurrence of many barriers. Further, the study identified potential interactive effects, such that interrelated barriers were seen as fueling one another and having a deleterious effect on treatment outcomes. Specifically, interrelationships between barriers were described for 1) unstable housing with social influences and mental health factors; 2) transportation with poor physical health and other competing responsibilities; 3) treatment program policies and schedule with competing responsibilities; and 4) stigma with poor physical and mental health.

CONCLUSIONS

Understanding barriers to successful medication for opioid use disorder outcomes and considering their co-occurrence may help to identify and promote interventions to mitigate their impact. This work is intended to guide future research to adapt conceptual frameworks for understanding psychosocial and structural barriers affecting opioid use disorder treatment and ultimately intervention efforts to improve treatment outcomes.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States

BACKGROUND

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement.

METHODS

Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates.

RESULTS

There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates.

CONCLUSIONS

Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Methadone Dose, Cannabis Use, and Treatment Retention: Findings From a Community-based Sample of People Who Use Unregulated Drugs

OBJECTIVES

Lower daily methadone dose is negatively associated with retention in methadone maintenance treatment (MMT). Cannabis use during MMT is common, with many patients reporting its use for opioid withdrawal mitigation. We sought to test whether the association between lower MMT dose and treatment retention differs by concurrent high-frequency cannabis use in a community sample of people on MMT.

METHODS

We obtained data from participants initiating MMT in 2 community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. We built multivariable Cox frailty models to estimate the relationships between MMT dose (<90 mg/d vs ≥90 mg/d) and time to treatment discontinuation. We included an interaction term to test whether high-frequency (≥daily) cannabis use modified the measured effect of lower treatment dose on treatment retention.

RESULTS

Between December 2005 and December 2018, 829 participants (54.1%) initiated at least 1 MMT episode and were included in the analysis. Lower MMT dose was strongly positively associated with treatment discontinuation regardless of concurrent high-frequency cannabis use (interaction P > 0.05). Structural factors including homelessness and incarceration were significantly and positively associated with treatment discontinuation.

CONCLUSIONS

Although we previously found the magnitude and strength of the relationship between lower MMT dose and high-frequency unregulated opioid use to be tempered during high-frequency cannabis use periods, this effect measure modification does not appear to translate to time retained in treatment. Cannabis-based interventions to promote retention in MMT are unlikely to produce long-term benefit without addressing external factors that place MMT patients at increased risk of treatment discontinuation.

Discontinuation of opioid agonist treatment following release from prison in a cohort of men who injected drugs prior to imprisonment in Victoria, Australia: A discrete-time survival analysis

BACKGROUND

Retention in opioid agonist treatment (OAT) following release from prison is associated with improved outcomes, however factors associated with post-release OAT discontinuation in Australia are poorly understood. We examined post-release OAT discontinuation in a cohort of men who engaged in approximately monthly injecting drug use (IDU) prior to imprisonment in Victoria, Australia.

METHODS

Longitudinal data were used to calculate incidence of first-event post-release OAT discontinuation among men released from prison receiving OAT, and single-event discrete-time survival methods were used to estimate associations with post-release OAT discontinuation.

RESULTS

Among 110 participants, 55 OAT discontinuations were observed in the two years post-release, an overall crude incidence rate (IR) of 46 per 100 person-years (PY) (95 % confidence interval [95 %CI]: 36-60 per 100PY). Incidence was greatest between release from prison and first follow-up (IR: 84 per 100PY, 95 %CI: 62-116 per 100PY). Initiating OAT during index imprisonment (versus transitioning from community OAT; adjusted hazard rate [AHR]: 2.17, 95 %CI: 1.14-4.13) and identifying as Aboriginal and/or Torres Strait Islander (AHR: 4.95, 95 %CI: 2.00-12.25) were associated with an increased hazard of OAT discontinuation.

CONCLUSION

In a cohort of men with recent histories of IDU released from prison receiving OAT, half reported OAT discontinuation within two years of release from prison, with incidence of discontinuation greatest soon after prison-release. Targeted support for men who initiate OAT during episodes of imprisonment and Aboriginal and/or Torres Strait Islander peoples is necessary to reduce incidence of OAT discontinuation among people at greatest risk of discontinuation.

Inability to contact opioid agonist therapy prescribers during the COVID-19 pandemic in a Canadian setting: a cross-sectional analysis among people on opioid agonist therapy

BACKGROUND

The COVID-19 pandemic and consequent public health response may have undermined key responses to the protracted drug poisoning crisis, including reduced access to opioid agonist therapy (OAT) among people with opioid use disorder. Our study objectives were to estimate the prevalence of and identify factors associated with inability to contact OAT prescribers when in need among people on OAT in a Canadian setting during the dual public health crises.

METHODS

Survey data were collected from three prospective cohort studies of community-recruited people who use drugs between July and November 2020, in Vancouver, Canada. A multivariable logistic regression analysis was used to identify potential factors associated with inability to contact OAT prescribers among patients who accessed OAT in the past 6 months.

RESULTS

Among 448 respondents who reported accessing OAT in the past 6 months, including 231 (54.9%) men, 85 (19.0%) reported having been unable to contact OAT prescribers when needed, whereas 268 (59.8%) reported being able to talk to their prescriber when needed, and 95 (21.2%) reported that they did not want to talk to their medication prescriber in the previous 6 months. Among those who reported inability to contact prescribers, 45 (53.6%) reported that their overall ability to contact prescribers decreased since the start of the pandemic. In multivariable analyses, factors independently associated with inability to talk to OAT prescribers included: chronic pain (Adjusted Odds Ratio [AOR] = 1.82; 95% Confidence Interval [CI] 1.02, 3.27), moderate to severe symptoms of depression or anxiety (AOR = 4.74; 95% CI 2.30, 9.76), inability to access health/social services (AOR = 2.66; 95% CI 1.41, 5.02), and inability to self-isolate or socially distance most or all of the time (AOR = 2.13; 95% CI 1.10, 4.14).

CONCLUSIONS

Overall, approximately one fifth of the sample reported inability to contact their OAT prescribers when needed, and those people were more likely to have co-occurring vulnerabilities (i.e., co-morbidities, inability to access health/social services) and higher vulnerability to COVID-19. Interventions are needed to ensure optimal access to OAT and mitigate the deepening health inequities resulting from the COVID-19 pandemic and the escalating drug poisoning crisis.

Treatment History and Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among People Who Inject Drugs

OBJECTIVES

Injectable opioid agonist treatment (iOAT) is a novel approach to treating opioid use disorder (OUD) that is typically reserved for treatment-experienced persons who inject drugs (PWID) with long-standing OUD. This study examined PWID's past OUD treatment histories and their attitudes toward iOAT with hydromorphone.

METHODS

This cross-sectional study recruited syringe services program participants with OUD in New York City. Participants self-reported past OUD care episodes (detoxification; outpatient, inpatient, or medication treatment; or mutual aid groups) and current interest in iOAT with hydromorphone (assessed on a 4-point scale with 3 or 4 considered "interested"). Participants with 2 or more treatment episodes in the past 5 years were considered treatment-experienced. We examined whether the number of past care episodes was associated with interest in iOAT.

RESULTS

Of 108 PWID, most participants were male (68.5%) and Hispanic (68.5%) with a mean age of 43 years (±10.8). Nearly all (98.1%) had severe OUD and had received past OUD care (96.3%), with the mean number of care episodes being 17.4 (SD, ±15.9). Most participants (59.8%) were treatment-experienced. Interest in iOAT with hydromorphone was high (64.8%), but there was no significant association between total past care episodes and expressing interest in iOAT (odds ratio, 1.02; 95% confidence interval, 0.99-1.05).

CONCLUSION

Participants were highly treatment-experienced, and iOAT interest was high regardless of prior OUD treatment. New OUD treatment options, such as iOAT with hydromorphone, would be welcomed by PWID whose OUD has not remitted with conventional treatment as well as other PWID.

GAWMerge expands GWAS sample size and diversity by combining array-based genotyping and whole-genome sequencing

Genome-wide association studies (GWAS) have made impactful discoveries for complex diseases, often by amassing very large sample sizes. Yet, GWAS of many diseases remain underpowered, especially for non-European ancestries. One cost-effective approach to increase sample size is to combine existing cohorts, which may have limited sample size or be case-only, with public controls, but this approach is limited by the need for a large overlap in variants across genotyping arrays and the scarcity of non-European controls. We developed and validated a protocol, Genotyping Array-WGS Merge (GAWMerge), for combining genotypes from arrays and whole-genome sequencing, ensuring complete variant overlap, and allowing for diverse samples like Trans-Omics for Precision Medicine to be used. Our protocol involves phasing, imputation, and filtering. We illustrated its ability to control technology driven artifacts and type-I error, as well as recover known disease-associated signals across technologies, independent datasets, and ancestries in smoking-related cohorts. GAWMerge enables genetic studies to leverage existing cohorts to validly increase sample size and enhance discovery for understudied traits and ancestries.

Factors associated with 60-day adherence to "safer supply" opioids prescribed under British Columbia's interim clinical guidance for health care providers to support people who use drugs during COVID-19 and the ongoing overdose emergency

AIMS

In March 2020, British Columbia issued Risk Mitigation Guidance (RMG) to support prescribing of pharmaceutical alternatives to illicit drugs, in order to reduce risk for COVID-19, overdose, and withdrawal among people who use drugs. This study evaluated factors associated with 60-day adherence to novel opioid alternatives prescribed at an inner-city health centre in Victoria, Canada.

METHODS

A chart review was conducted to collect data on sociodemographic information, medical histories, and follow-up services among all clients prescribed novel opioid alternatives from March 2020-August 2020 (n = 286). Bivariable and multivariable regression were used to identify independent and adjusted factors associated with 60-day adherence.

RESULTS

Overall, 77% of 286 clients were still receiving opioids after 60 days of follow-up. Medications included hydromorphone (n = 274), sustained-release oral morphine (n = 2), and oxycodone (n = 9). The adjusted odds of 60-day adherence to novel opioid alternatives were significantly higher for those receiving a mental health medication (aOR = 3.49, 95%CI = 1.26, 11.00), a higher maximum daily dosage of RMG prescriptions (aOR = 1.03 per mg increase, 95%CI = 1.01, 1.04), and those with continuous receipt of OAT (aOR = 6.25, 95%CI = 2.67, 15.90).

CONCLUSIONS

Higher dosages and co-prescription of mental health medications and OAT may help support better adherence to this form of prescriber-based "safer supply". Further work is needed to identify optimal prescribing practices and the longer term impacts of differing implementation scenarios.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Stepping up to the Canadian opioid crisis: a longitudinal analysis of the correlation between socioeconomic status and population rates of opioid-related mortality, hospitalization and emergency department visits (2000-2017)

INTRODUCTION

High levels of income inequality and increased opioid-related harm across Canada bring into question the role of socioeconomic status (SES) in the opioid epidemic. Only a few studies have examined this association, and most of those have analyzed this issue on a provincial level. This study examined the association between opioid-related health outcomes and SES, and investigated rate ratios over time.

METHODS

Administrative databases were used to identify opioid-related mortality, hospitalization and emergency department visits between 2000 and 2017. Patient's postal code was linked to the quintile of median household income at the forward sortation area level. Crude rates and age- and sex-adjusted rates in each quintile were calculated, as well as the adjusted rate ratio of average annual rates between the lowest and highest quintiles. The significance of the time trend of rate ratios for all outcomes was examined using linear regression.

RESULTS

A stepped gradient of opioid-related outcomes across all income quintiles emerged from these data. For mortality, hospitalization and emergency department visits, the average annual rate ratio between lowest quintile and highest quintile was 3.8, 4.3 and 4.9, respectively. These ratios were generally stable and consistent over the study period, albeit the opioid-related mortality SES gap decreased gradually (p < 0.01).

CONCLUSION

Area income quintile was found to be highly associated with opioid outcomes. Psychosocial factors (stress, unemployment, housing insecurity) that are typically concentrated in low SES areas may play a significant role in the opioid epidemic. Health policies should address these factors in order to provide effective solutions.

Modeling the population-level impact of opioid agonist treatment on mortality among people accessing treatment between 2001 and 2020 in New South Wales, Australia

BACKGROUND AND AIMS

The individual-level effectiveness of opioid agonist treatment (OAT) in reducing mortality is well established, but there is less evidence on population-level benefits. We use modeling informed with linked data from the OAT program in New South Wales (NSW), Australia, to estimate the impact of OAT provision in the community and prisons on mortality and the impact of eliminating excess mortality during OAT initiation/discontinuation.

DESIGN

Dynamic modeling.

SETTING AND PARTICIPANTS

A cohort of 49 359 individuals who ever received OAT in NSW from 2001 to 2018.

MEASUREMENTS

Receipt of OAT was represented through five stages: (i) first month on OAT, (ii) short (1-9 months) and (iii) longer (9+ months) duration on OAT, (iv) first month following OAT discontinuation and (v) rest of time following OAT discontinuation. Incarceration was represented as four strata: (i) never or not incarcerated in the past year, (ii) currently incarcerated, (iii) released from prison within the past month and (iv) released from prison 1-12 months ago. The model incorporated elevated mortality post-release from prison and OAT impact on reducing mortality and incarceration.

FINDINGS

Among the cohort, mortality was 0.9 per 100 person-years, OAT coverage and retention remained high (> 50%, 1.74 years/episode). During 2001-20, we estimate that OAT provision reduced overdose and other cause mortality among the cohort by 52.8% [95% credible interval (CrI) = 49.4-56.9%] and 26.6% (95% CrI =22.1-30.5%), respectively. We estimate 1.2 deaths averted and 9.7 life-years gained per 100 person-years on OAT. Prison OAT with post-release OAT-linkage accounted for 12.4% (95% CrI = 11.5-13.5%) of all deaths averted by the OAT program, primarily through preventing deaths in the first month post-release. Preventing elevated mortality during OAT initiation and discontinuation could have averted up to 1.4% (95% CrI =  0.8-2.0%) and 3.0% (95% CrI = 2.1-5.3%) of deaths, respectively.

CONCLUSION

The community and prison opioid agonist treatment program in New South Wales, Australia appears to have substantially reduced population-level overdose and all-cause mortality in the past 20 years, partially due to high retention.

Factors associated with retention on medications for opioid use disorder among a cohort of adults seeking treatment in the community

BACKGROUND

Medication treatment for opioid use disorder (OUD) (MOUD; buprenorphine and methadone) reduces opioid use and overdose. Discontinuation of MOUD can quickly lead to relapse, overdose and death. Few persons who initiate MOUD are retained on treatment, thus it is critical to identify factors associated with retention.

METHODS

Evaluated data was from an ongoing prospective cohort study of adults aged 18 or older with DSM-5 moderate to severe OUD seeking MOUD in the community and followed for 6 months. Participants were considered retained on MOUD through 6 months if they reported taking MOUD at every study interview without discontinuation. A high dose of MOUD was defined as a methadone dose > 85 mg or buprenorphine dose ≥ 16 mg. Multivariable logistic regression was conducted to assess factors associated with 6-month MOUD retention.

RESULTS

A total of 118 participants (73% male, 58% white, 36% with HIV) were included. Buprenorphine was initiated by 58% and 42% started methadone. MOUD retention was 49% and 58% among buprenorphine and methadone, respectively, at 6-months. In adjusted models, a high MOUD dose (OR = 4.71, 95% CI 2.05-10.84) and higher pain interference (OR = 1.59, 95% CI 1.15-2.19) was associated with MOUD retention.

CONCLUSIONS

Adequate dosing of MOUD leads to improved retention on MOUD. Further, persons with high pain interference at baseline had higher odds of retention on MOUD. Both methadone and buprenorphine have analgesic effects, thus those with high pain interference could have dual benefits of MOUD for treating OUD and pain. Interventions should be tailored to improve adequate MOUD dosing to improve retention on MOUD.

Crystal methamphetamine use subgroups and associated addiction care access and overdose risk in a Canadian urban setting

OBJECTIVES

Methamphetamine use is rising globally and we have limited treatments for this. Subgroups within the diverse methamphetamine-using population may have distinct treatment needs. Among a community-recruited sample of people who use crystal methamphetamine, we aimed to identify subgroups and characterize their overdose risk and access to addiction care.

METHODS

Data from prospective cohorts of people who use drugs in Vancouver, Canada from 2014 to 2018 were used to conduct a repeated measures latent class analysis among participants who used crystal methamphetamine. Multivariable generalized estimating equations models were fit to determine the associated factors.

RESULTS

Among 824 eligible participants, a five-class model was identified as the best fit: (1) primary stimulant use (15.7%); (2) women engaged in sex work and opioid use (21.4%); (3) street income generation and opioid use (31.6%); (4) opioid agonist therapy (OAT) patients (22.3%); and (5) men who have sex with men (9.0%). In multivariable analyses, compared to the primary stimulant use group, non-fatal overdose was positively associated with street income generation (adjusted odds ratio [AOR] = 1.49, 95% confidence interval [95% CI]=1.30-1.71), sex work (AOR = 1.38, 95% CI=1.20-1.59) and OAT (AOR = 1.22, 95% CI=1.06-1.41) subgroups; engagement in non-OAT addiction care was negatively associated with street income generation (AOR = 0.81, 95% CI=0.68-0.97) and sex work (AOR = 0.78, 95% CI=0.63-0.98) subgroups.

DISCUSSION

Socioeconomically marginalized subgroups with opioid and crystal methamphetamine co-use were at highest risk of non-fatal overdose and had poorer access to addiction care, highlighting the need for tailored interventions.

Opioid Use Disorder

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

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

Background

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

Case presentation

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

Conclusions

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

The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review

Background

Methamphetamine/amphetamine use has sharply increased among people with opioid use disorder (OUD). It is therefore important to understand whether and how use of these substances may impact receipt of, and outcomes associated with, medications for OUD (MOUD). This systematic review identified studies that examined associations between methamphetamine/amphetamine use or use disorder and 3 classes of outcomes: (1) receipt of MOUD, (2) retention in MOUD, and (3) opioid abstinence during MOUD.

Methods

We searched 3 databases (PubMed/MEDLINE, PsycINFO, CINAHL Complete) from 1/1/2000 to 7/28/2020 using key words and subject headings, and hand-searched reference lists of included articles. English-language studies of people with documented OUD/opioid use that reported a quantitative association between methamphetamine/amphetamine use or use disorder and an outcome of interest were included. Study data were extracted using a standardized template, and risk of bias was assessed for each study. Screening, inclusion, data extraction and bias assessment were conducted independently by 2 authors. Study characteristics and findings were summarized for each class of outcomes.

Results

Thirty-nine studies met inclusion criteria. Studies generally found that methamphetamine/amphetamine use or use disorder was negatively associated with receiving methadone and buprenorphine; 2 studies suggested positive associations with receiving naltrexone. Studies generally found negative associations with retention; most studies finding no association had small samples, and these studies tended to examine shorter retention timeframes and describe provision of adjunctive services to address substance use. Studies generally found negative associations with opioid abstinence during treatment among patients receiving methadone or sustained-release naltrexone implants, though observed associations may have been confounded by other polysubstance use. Most studies examining opioid abstinence during other types of MOUD treatment had small samples.

Conclusions

Overall, existing research suggests people who use methamphetamine/amphetamines may have lower receipt of MOUD, retention in MOUD, and opioid abstinence during MOUD. Future research should examine how specific policies and treatment models impact MOUD outcomes for these patients, and seek to understand the perspectives of MOUD providers and people who use both opioids and methamphetamine/amphetamines. Efforts to improve MOUD care and overdose prevention strategies are needed for this population.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

BACKGROUND

The postpartum year is a vulnerable period for women with opioid use disorder, with increased rates of fatal and nonfatal overdose; however, data on the continuation of medications for opioid use disorder on a population level are limited.

OBJECTIVE

This study aimed to examine the effect of discontinuing methadone and buprenorphine in women with opioid use disorder in the year following delivery and determine the extent to which maternal and infant characteristics are associated with time to discontinuation of medications for opioid use disorder.

STUDY DESIGN

This population-based retrospective cohort study used linked administrative data of 211,096 deliveries in Massachusetts between 2011 and 2014 to examine the adherence to medications for opioid use disorder. Individuals receiving medications for opioid use disorder after delivery were included in the study. Here, demographic, psychosocial, prenatal, and delivery characteristics are described. Kaplan-Meier survival analysis and Cox regression modeling were used to examine factors associated with medication discontinuation.

RESULTS

A total of 2314 women who received medications for opioid use disorder at delivery were included in our study. Overall, 1484 women (64.1%) continued receiving medications for opioid use disorder for a full 12 months following delivery. The rate of continued medication use varied from 34% if women started on medications for opioid use disorder the month before delivery to 80% if the medications were used throughout pregnancy. Kaplan-Meier survival curves differed by maternal race and ethnicity (the 12-month continuation probability was .65 for White non-Hispanic women and .51 for non-White women; P<.001) and duration of use of prenatal medications for opioid use disorder (12-month continuation probability was .78 for women with full prenatal engagement and .60 and .44 for those receiving medications for opioid use disorder ≥5 months [but not throughout pregnancy] and ≤4 months prenatally, respectively; P<.001). In all multivariable models, duration of receipt of prenatal medications for opioid use disorder (≤4 months vs throughout pregnancy: adjusted hazard ratio, 3.26; 95% confidence interval, 2.72-3.91) and incarceration (incarceration during pregnancy or after delivery vs none: adjusted hazard ratio, 1.79; 95% confidence interval, 1.52-2.12) were most strongly associated with the discontinuation of medications for opioid use disorder.

CONCLUSION

Almost two-thirds of women with opioid use disorder continued using medications for opioid use disorder for a full year after delivery; however, the rates of medication continuation varied significantly by race and ethnicity, degree of use of prenatal medications for opioid use disorder, and incarceration status. Prioritizing medication continuation across the perinatal continuum, enhancing sex-specific and family-friendly recovery supports, and expanding access to medications for opioid use disorder despite being incarcerated can help improve postpartum medication adherence.

Racial inequity in medication treatment for opioid use disorder: Exploring potential facilitators and barriers to use

BACKGROUND

Despite evidence that individuals with opioid use disorder (OUD) have a lower risk of mortality when using evidence-based medications for OUD (MOUD), only 20 % of people with OUD receive MOUD. Black patients are significantly less likely than White patients to initiate MOUD. We measured the association between various facilitators and barriers to initiation, including criminal justice, human services, and health care factors, and variation in initiation of MOUD by race.

METHODS

We used data from a comprehensive, linked data set of health care, human services, and criminal justice programs from Allegheny County in Western Pennsylvania to measure disparities in MOUD initiation by race in the first 180 days after an OUD diagnosis, as well as mediation by potential facilitators and barriers to treatment, among Medicaid enrollees. This is a cross-sectional analysis.

RESULTS

Among 6374 Medicaid enrollees who met study criteria, Black enrollees were 18.2 percentage points less likely than White enrollees to start MOUD after controlling for gender, age, and Medicaid eligibility (95 % CI: -21.5 % - -14.8 %). Each day in the emergency department or county jail was associated with a decrease in the likelihood of initiation, as was the presence of a non-OUD substance use disorder diagnosis or participation in intensive non-MOUD treatment. Mediators accounted for approximately one-fifth of the variation in initiation related to race.

CONCLUSIONS

Acute care facilities and settings in which people with OUD are incarcerated may have an opportunity to increase the use of MOUD overall and close the racial gap in initiation.

Predictors of Opioid and Alcohol Pharmacotherapy Initiation at Hospital Discharge Among Patients Seen by an Inpatient Addiction Consult Service

BACKGROUND

Medications for opioid use disorder (MOUD) and alcohol use disorder (MAUD) are effective and under-prescribed. Hospital-based addiction consult services can engage out-of-treatment adults in addictions care. Understanding which patients are most likely to initiate MOUD and MAUD can inform interventions and deepen understanding of hospitals' role in addressing substance use disorders (SUD).

OBJECTIVE

Determine patient- and consult-service level characteristics associated with MOUD/MAUD initiation during hospitalization.

METHODS

We analyzed data from a study of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction consult service at an academic medical center. Researchers collected patient surveys and clinical data from September 2015 to May 2018. We used logistic regression to identify characteristics associated with medication initiation among participants with OUD, AUD, or both. Candidate variables included patient demographics, social determinants, and treatment-related factors.

RESULTS

Three hundred thirty-nine participants had moderate to severe OUD, AUD, or both and were not engaged in MOUD/MAUD care at admission. Past methadone maintenance treatment (aOR 2.07, 95%CI (1.17, 3.66)), homelessness (aOR 2.63, 95%CI (1.52, 4.53)), and partner substance use (aOR 2.05, 95%CI (1.12, 3.76) were associated with MOUD/MAUD initiation. Concurrent methamphetamine use disorder (aOR 0.32, 95%CI (0.18, 0.56)) was negatively associated with MOUD/MAUD initiation.

CONCLUSIONS

The association of MOUD/MAUD initiation with homelessness and partner substance use suggests that hospitalization may be an opportunity to reach highly-vulnerable people, further underscoring the need to provide hospital-based addictions care as a health-system strategy. Methamphetamine's negative association with MOUD/MAUD warrants further study.

Drug-related harm coinciding with income assistance payments: results from a community-based cohort of people who use drugs

BACKGROUND AND AIMS

Income assistance is critical to the health and wellbeing of socio-economically marginalized people who use illicit drugs (PWUD). However, past literature paradoxically identifies unintended increases in drug-related harm coinciding with synchronized payments that may magnify signals for drug use. The scope of such harm has not been fully characterized among non-institutionalized populations. This study examined socio-demographic, health and drug use-related correlates of payment-coincident drug-related harm.

DESIGN

This observational study uses data from prospective community-based longitudinal cohorts of PWUD between December 2013 and May 2018.

SETTING

Vancouver, British Columbia, Canada.

PARTICIPANTS

A total of 1604 PWUD receiving monthly income assistance. Our sample included 586 (36.5%) women, 861 (53.7%) non-white participants and 685 (42.7%) people living with HIV.

MEASUREMENTS

The primary outcome was a self-reported composite measure of drug-related harm in the past 6 months coinciding with income assistance, including higher-frequency substance use, non-fatal overdose and service barriers or interruptions. Subanalyses disaggregated this outcome.

FINDINGS

Payment-coincident drug-related harm was reported among 77.7% of participants during the study period. In multivariable models, key correlates positively and significantly associated with payment-coincident harm included: street-based income generation [adjusted odds ratio (aOR) = 1.48, 95% confidence interval (CI) = 1.26-1.74, P < 0.001], sex work (aOR = 1.66, 95% CI = 1.35-2.04, P < 0.001), illegal income generation (aOR = 1.57, 95% CI = 1.35-1.83 P < 0.001), homelessness (aOR = 1.34, 95% CI = 1.13-1.58, P < 0.001), exposure to violence (aOR = 1.31, 95% CI = 1.03-1.66, P = 0.032), daily crack cocaine use (aOR = 1.99, 95% CI = 1.59-2.50, P <  0.001), heavy alcohol use (aOR = 1.64, 95% CI = 1.37-1.97, P < 0.001) and injection drug use (aOR = 2.55, 95% CI = 2.01-3.23, P < 0.001). In subanalyses, specific harms were more likely among individuals reporting social, structural and health vulnerabilities.

CONCLUSIONS

In Vancouver, Canada, people who use illicit drugs who receive income assistance report high prevalence of payment-coincident drug-related harm, particularly people experiencing socioeconomic and structural marginalization or engaging in high-intensity drug use.

Trajectories of Retention in Opioid Agonist Therapy and Overdose Risk During a Community-Wide Overdose Epidemic in a Canadian Setting

INTRODUCTION

Retention in opioid agonist therapy consistently has been linked with improved outcomes among people with opioid use disorder. However, less is known about the links between patterns of engagement in opioid agonist therapy over the long term and overdose risk. This study assesses the association of opioid agonist therapy retention trajectories with nonfatal overdose.

METHODS

Data were drawn from 2 community-recruited prospective cohorts of people who use drugs in Vancouver, Canada. Latent class growth analysis was used to identify trajectories of opioid agonist therapy retention among people with opioid use disorder initiating therapy, and generalized estimating equations assessed the association of these trajectories with nonfatal overdose events after opioid agonist therapy initiation.

RESULTS

Between 2005 and 2018, among 438 opioid agonist therapy initiators, 4 retention trajectories were identified: consistently high (35.6%), increasing (26.0%), consistently low (23.3%), and decreasing (15.1%) opioid agonist therapy engagement. During the study period, there were 371 nonfatal overdose events, with 179 (40.1%) participants reporting ≥1. In adjusted analysis, the consistently low (AOR=1.73, 95% CI=1.10, 2.71) and decreasing (AOR=1.87, 95% CI=1.18, 2.95) retention trajectories were positively associated with increased odds of nonfatal overdose compared with the consistently high opioid agonist therapy retention class.

CONCLUSIONS

Suboptimal trajectories of opioid agonist therapy retention were associated with an increased likelihood of nonfatal overdose. These findings suggest that reducing the barriers to sustained engagement in opioid agonist therapy will be critical to address North America's overdose epidemic.

Awareness of and interest in oral pre-exposure prophylaxis (PrEP) for HIV prevention and interest in hypothetical forms of PrEP among people who inject drugs in rural West Virginia

Injection drug use-associated HIV outbreaks have occurred in rural communities throughout the United States, which often have limited HIV prevention services for people who inject drugs (PWID). Pre-exposure prophylaxis (PrEP) is one tool that may help fill gaps in HIV prevention programing in rural settings. Oral PrEP has been approved for use, and new PrEP formulations are under development. Research is needed to better understand interest in oral and possible forthcoming PrEP formulations among PWID. We used survey data from 407 PWID in rural West Virginia. We asked if participants had heard of, taken, and were interested in taking PrEP, and about interest in several hypothetical forms of PrEP (arm injections, abdomen injections, implants, intravenous infusions). We estimated the prevalence of interest in each formulation and assessed correlates using Chi-squared tests. A minority had heard of oral PrEP (32.6%), and few had used it (3.7%). Many were interested in using oral PrEP (58.3%). Half were interested in arm injections (55.7%). Common correlates of interest across PrEP formulations were sexual minority status, comfort talking to a doctor about sex, sex work, and sharing injection equipment. Oral and injectable PrEP have the potential to fill HIV prevention gaps for rural PWID.

Correlates of Homelessness Among Patients in Methadone Maintenance Treatment

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Shifting the Paradigm for Opioid Use Disorder: Changing the Language

Morbidity and mortality associated from opioid use have been on the rise, exemplifying a major public health epidemic. Despite public health interventions, opioid-related morbidity and mortality have yet to plateau or decrease. One explanation for this phenomenon is the presence of barriers to evidence-based pharmacotherapies. Stigma has only recently been identified as a barrier to treatment. The purpose of this report is to evaluate language utilized to describe opioid use disorder and associated pharmacological treatment. Nurse practitioners must emerge as leaders in assuring that patient-centered and non-stigmatizing language is utilized, in order to improve patient outcomes.

A review of the pharmacogenomics of buprenorphine for the treatment of opioid use disorder

As the opioid epidemic continues to grow across the United States, the number of patients requiring treatment for opioid use disorder continues to climb. Although medication-assisted treatment presents a highly effective tool that can help address this epidemic, its use has been limited. Nonetheless, with easier dosing protocols (compared to the more complex dosing required of methadone due to its long and variable half-life) and fewer prescribing limitations (may be prescribed outside the setting of federally approved clinics), the increase in buprenorphine use in the United States has been dramatic in recent years. Despite buprenorphine's demonstrated efficacy, patient-specific factors can alter the response to the medications, which may lead to treatment failure in some patients. Clinical characteristics (sex, concurrent medications, and mental health comorbidities) as well as social determinants of health (housing status, involvement with the criminal justice system, and socioeconomic status) may impact treatment outcomes. Furthermore, a growing body of data suggests that genetic variations can alter pharmacological effects and influence therapeutic response. This review will cover the available pharmacogenomic data for the use of buprenorphine in the management of opioid use disorders. Pharmacogenomic determinants that affect opioid receptors, the dopaminergic system, metabolism of buprenorphine, and adverse events are discussed. Although much of the existing data comes from observational studies, clinical research is ongoing. Nevertheless, the development of pharmacogenomic-guided strategies has the potential to reduce opioid misuse, improve clinical outcomes, and save healthcare resources.

High retention in an opioid agonist therapy project in Durban, South Africa: the role of best practice and social cohesion

BACKGROUND

Moral conservatism within government and communities has resulted in a reluctance to support the provision of opioid agonist therapy for people with opioid use disorders in South Africa. In April 2017, South Africa's first low-threshold opioid agonist therapy demonstration project was launched in Durban. The project provided 54 low-income people with heroin use disorders methadone and voluntary access to psychosocial services for 18 months. At 12 months, retention was 74%, notably higher than the global average. In this paper, we aim to make sense of this outcome.

METHODS

Thirty semi-structured interviews, two focus groups, ten oral histories and ethnographic observations were done at various project time points. These activities explored participants' pathways into drug use and the project, their meaning attributed to methadone, the factors contributing to project success and changes they experienced. Recordings, transcripts, notes and feedback were reviewed and triangulated. Key factors contributing to retention were identified and analysed in light of the existing literature.

RESULTS

The philosophy and architecture of the project, and social cohesion were identified as the main factors contributing to retention. The use of a harm reduction approach enabled participants to set and be supported to achieve their treatment goals, and was shown to be important for the development of trusting therapeutic relationships. The employment of a restorative justice paradigm provided a sense of acceptance of humanity and flaws as well as an imperative to act responsibly towards others, fostering a culture of respect. Social cohesion was fostered through the facilitation of group sessions, a peace committee and group sport (soccer). In concert, these activities provided opportunities for participants to demonstrate care and interest in one another's life, leading to interdependence and care, contributing to them remaining in the project.

CONCLUSIONS

We believe that the high retention was achieved through attraction. We argue that opioid agonist therapy programmes should take the principles of harm reduction and restorative justice into consideration when designing low-threshold opioid agonist therapy services. Additionally, ways to support cohesion amongst people receiving agonist therapy should be explored to support their effective scale-up, both in low-middle income countries and in high-income countries.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa

BACKGROUND

Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa.

METHODS

We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency.

RESULTS

The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254).

CONCLUSIONS

Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

Trajectories of retention in opioid agonist therapy in a Canadian setting

BACKGROUND

Long-term engagement in opioid agonist therapy (OAT) has been consistently associated with reduced risk for morbidity and mortality in people with opioid use disorder (OUD). However, the dynamic nature of engagement/disengagement in OUD care for over time is poorly captured by traditional metrics. We characterized long-term longitudinal trajectories of engagement in OAT in Vancouver, Canada, between 2005 and 2018.

METHODS

Data were derived from two community-recruited prospective cohorts of people who use drugs. Retention in OAT was defined as self-reported enrolment in OAT for two consecutive follow-up periods (an approximately six-month retention interval). We used latent class growth analysis to identify OAT engagement trajectories during the first five years after OAT initiation and multivariable logistic regression to evaluate predictors of trajectory group membership.

RESULTS

We identified four OAT retention trajectories among 438 OAT initiators: "consistently high" (36%), "consistently low" (23%), "increasing" (23%), and "decreasing" (15%). Employment was a significant cross-cutting predictor of membership of all sub-optimal OAT engagement patterns compared to consistently high trajectories. We also found that initiating OAT after 2014 (when regulatory changes to the provincial OAT program were introduced) was associated with the "consistently low" engagement group relative to others.

CONCLUSIONS

We identified four distinct OAT engagement trajectories in Vancouver, Canada, with employment being a common predictor of sub-optimal care trajectories, suggesting the need to explore alternative OAT models to address employment-related barriers. Care trajectory analysis could help inform tailored interventions to specific populations of people with OUD at specific time points to improve engagement in OAT, and decrease opioid-related morbidity and mortality.

Associations between housing stability and injecting frequency fluctuations: findings from a cohort of people who inject drugs in Montréal, Canada

BACKGROUND

The relationship between housing stability and drug injecting is complex, as both outcomes fluctuate over time. The objectives were to identify short-term trajectories of housing stability and injecting frequency among people who inject drugs (PWID) and examine how patterns of injecting frequency relate to those of housing stability.

METHODS

At three-month intervals, PWID enrolled between 2011 and 2016 in the Hepatitis Cohort completed an interviewer-administered questionnaire and were tested for hepatitis C and HIV infections. At each visit, participants reported, for each of the past three months, the accommodation they lived in the longest (stable/unstable) and the number of injecting days (0-30). Group-based dual trajectory modeling was conducted to identify housing stability and injecting frequency trajectories evolving concomitantly over 12 months and estimate the probabilities of following injecting trajectories conditional upon housing trajectories.

RESULTS

386 participants were included (mean age 40.0, 82 % male). Three housing stability trajectories were identified: sustained (53 %), declining (20 %), and improving (27 %). Five injecting frequency trajectories were identified: sporadic (26 %), infrequent (34 %), increasing (15 %), decreasing (11 %), and frequent (13 %). PWID with improving housing were less likely to increase injecting (8 %) compared to those with sustained (17 %) or declining housing (17 %).

CONCLUSIONS

Improving housing was associated with a lower probability of increasing injecting compared to declining housing, while sustained housing stability was associated with a higher probability of increasing injecting compared to improving housing. Therefore, policies to improve PWID's access to stable housing are warranted and may reduce, to some extent, drug injecting and related harms.

What place for prolonged-release buprenorphine depot-formulation Buvidal® in the treatment arsenal of opioid dependence? Insights from the French experience on buprenorphine

Introduction: Since the 1990s, opioid maintenance treatments (OMTs), i.e. mostly methadone and buprenorphine, have represented the therapeutic cornerstone of opioid dependence. In France, the public health strategy on opioid dependence, identified here as the 'French model', has consisted of offering a facilitated access to buprenorphine, to reach a large treatment coverage and reduce opioid-related mortality. Areas covered: Recently, a new formulation of subcutaneous buprenorphine depot (Buvidal®) has been approved in Europe for treatment of opioid dependence. The place of Buvidal® among the pre-existing arsenal of OMTs is discussed in the light of the pharmacological specificities of this new formulation, and with the particular standpoint of the French model on opioid dependence. Expert opinion: Buvidal® could constitute a promising treatment option mainly in case of: 1) OMT initiation, including in non-specialized addiction medicine care; 2) Discharge from prison or hospital; Diversion/misuse of 3) buprenorphine or 4) methadone; 5) Clinically stabilized patients wishing to avoid daily oral taking of the medication. As such, this new formulation should be highly accessible, which will require specific pathways through care as the product is intended to be administered by a healthcare professional.

Determining spatial access to opioid use disorder treatment and emergency medical services in New Hampshire

This research presents an analysis of spatial access to both opioid use disorder treatment facilities and emergency medical services in New Hampshire during 2015-2016, a period during which there was a steep increase in unintentional overdoses involving fentanyl. For this research, spatial access was computed using the enhanced two-step floating catchment area model combined with the Huff model to assess access across New Hampshire and gives attention to supply-side parameters that can impact spatial access. The model is designed to measure access to healthcare services for opioid use disorder patients offered at treatment centers or from buprenorphine treatment practitioners, as well as from emergency medical services across New Hampshire. A composite index of accessibility is proposed to represent overall access to these different treatment services for opioid use disorder patients. Geospatial determinants of spatial access included street network distances, driving times and distance decay relationships, while other key factors were services availability and population demand. Among the towns with the highest composite access scores, approximately 40% were metropolitan locations while 16% were rural towns. The insights from this research showed that for this period, while the opioid crisis was impacting many towns in New Hampshire, high levels of access to treatment services were not uniform across the state. When comparing the access results with data on the towns of residence for individuals who died from unintentional overdoses involving fentanyl during 2015 and 2016, estimates found that approximately 40% of the towns were not estimated to be in the highest class of access to treatment services at the time. This research provides information for local public health officials to support planning strategies to address opioid use disorder treatment access in high-risk regions.