Perceptions and preferences for long-acting injectable and implantable medications in comparison to short-acting medications for opioid use disorders

Evaluating preferences for medication formulation and treatment model among people who use opioids non-medically: A web-based cross-sectional study

INTRODUCTION

Over the past decade, treatment for opioid use disorder has expanded to include long-acting injectable and implantable formulations of medication for opioid use disorder (MOUD), and integrated treatment models systematically addressing both behavioral and physical health. Patient preference for these treatment options has been underexplored. Gathering data on OUD treatment preferences is critical to guide the development of patient-centered treatment for OUD. This cross-sectional study assessed preferences for long-acting MOUD and integrated treatment using an online survey.

METHODS

An online Qualtrics survey assessed preferences for MOUD formulation and integrated treatment models. The study recruited participants (n = 851) in October and November 2019 through advertisements or posts on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (mTurk). Eligible participants scored a two or higher on the opioid pain reliever or heroin scales of the Tobacco, Alcohol Prescription Medication and other Substance Use (TAPS) Tool. Structured survey items obtained patient preference for MOUD formulation and treatment model. Using stated preference methods, the study assessed preference via comparison of preferred options for MOUD and treatment model.

RESULTS

In the past year, 824 (96.8 %) participants reported non-prescribed use of opioid pain relievers (mean TAPS score = 2.72, SD = 0.46) and 552 (64.9 %) reported heroin or fentanyl use (mean TAPS score = 2.73, SD = 0.51). Seventy-four percent of participants (n = 631) reported currently or previously receiving OUD treatment, with 407 (48.4 %) receiving MOUD. When asked about preferences for type of MOUD formulation, 452 (53.1 %) preferred a daily oral formulation, 115 (13.5 %) preferred an implant, 114 (13.4 %) preferred a monthly injection and 95 (11.2 %) preferred a weekly injection. Approximately 8.8 % (n = 75) would not consider MOUD regardless of formulation. The majority of participants (65.2 %, n = 555) preferred receiving treatment in a specialized substance use treatment program distinct from their medical care, compared with receiving care in an integrated model (n = 296, 34.8 %).

CONCLUSIONS

Though most participants expressed willingness to try long-acting MOUD formulations, the majority preferred short-acting formulations. Likewise, the majority preferred non-integrated treatment in specialty substance use settings. Reasons for these preferences provide insight on developing effective educational tools for patients and suggesting targets for intervention to develop a more acceptable treatment system.

Evaluation of an injectable monthly extended-release buprenorphine program in a low-barrier specialty addiction medicine clinic

INTRODUCTION

Monthly injectable extended-release buprenorphine (XR-BUP) can address several systemic and individual barriers to consistent sublingual buprenorphine treatment for patients with opioid use disorder (OUD). Real-world evaluations of XR-BUP in the outpatient addiction treatment setting are limited. The purpose of this study was to compare 6-month treatment retention and urine drug tests between patients who initiated XR-BUP compared to those who were prescribed but did not initiate XR-BUP in a low-barrier addiction medicine specialty clinic.

METHODS

We conducted a retrospective cohort study of adults with OUD prescribed XR-BUP between 12/1/2018 and 12/31/2020 in a low-barrier addiction medicine specialty clinic to compare 6-month treatment retention between patients who initiated XR-BUP and those who were prescribed but did not initiate XR-BUP (comparison group). Secondary outcomes included percent of urine toxicology tests negative for non-prescribed opioids. Multivariable logistic regression models evaluated factors associated with 6-month treatment retention and XR-BUP initiation.

RESULTS

Of the 233 patients prescribed XR-BUP, 148 (63.8 %) identified as non-Hispanic white, 218 (93.6 %) were insured by public insurance (Medicare/Medicaid), and nearly two-thirds were prescribed XR-BUP due to unstable OUD. Approximately 50 % of patients initiated XR-BUP treatment (mean number of injections = 3.7). About 60 % of XR-BUP-treated patients received supplemental sublingual buprenorphine and nearly two-thirds received a 300 mg maintenance dose. Six-month treatment retention was greater in the XR-BUP treatment versus comparison group (70.3 % vs. 36.5 %, p < 0.001). The XR-BUP treatment group had a higher percentage of opioid-negative urine toxicology tests versus the comparison group (67.2 % vs. 36.3 %, p < 0.001). Receipt of XR-BUP was an independent predictor of 6-month treatment retention (OR 5.40, 95 % CI 2.18-13.38). Those prescribed XR-BUP due to unstable OUD had lower odds of treatment retention (OR 0.41, 95 % CI 0.24-0.98) after controlling for receipt of XR-BUP and other variables known to impact retention.

CONCLUSIONS

XR-BUP improved 6-month treatment retention and resulted in a greater proportion of opioid-negative urine toxicology tests compared to a comparison group of patients who were prescribed but did not initiate XR-BUP. Patients with unstable OUD had lower odds of XR-BUP initiation, suggesting the need for targeted interventions to increase XR-BUP uptake in this high-risk population.

Medications for opioid use disorder in rural primary care practices: Patient and provider experiences

INTRODUCTION

The opioid epidemic has exacted a significant toll in rural areas, yet adoption of medications for opioid use disorder (MOUD) lags. The Rural Access to Medication Assisted Treatment in Pennsylvania (RAMP) Project facilitated adoption of MOUD in rural primary care clinics. The purpose of this study was to gain a better understanding of the barriers and facilitators operating at multiple levels to access or provide MOUD in rural Pennsylvania.

METHODS

In total, the study conducted 35 semi-structured interviews with MOUD patients and MOUD providers participating in RAMP. Qualitative analysis incorporated both deductive and inductive approaches. The study team coded interviews and performed thematic analysis. Using a modified social-ecological framework, themes from the qualitative interviews are organized in five nested levels: individual, interpersonal, health care setting, community, and public policy.

RESULTS

Patients and providers agreed on many barriers (e.g., lack of providers, lack of transportation, insufficient rapport and trust in patient-provider relationship, and cost, etc.); however, their interpretation of the barrier, or indicated solution, diverged in meaningful ways. Patients described their experiences in broad terms pointing to the social determinants of health, as they highlighted their lives outside of the therapeutic encounter in the clinic. Providers focused on their professional roles, responsibilities, and operations within the primary care setting.

CONCLUSIONS

Providers may want to discuss barriers to treatment related to social determinants of health with patients, and pursue partnerships with organizations that seek to address those barriers. The findings from these interviews point to potential opportunities to enhance patient experience, increase access to and optimize processes for MOUD in rural areas, and reduce stigma against people with opioid use disorder (OUD) in the wider community.

Preferences in medications for patients seeking treatment for opioid use disorder: A conjoint analysis

INTRODUCTION

The opioid epidemic continues to be a public health crisis that has worsened during the COVID-19 pandemic. Medications for opioid use disorder (MOUD) are the most effective way to reduce complications from opioid use disorder (OUD), but uptake is limited by both structural and individual factors. To inform strategies addressing individual factors, we evaluated patients' preferences and trade-offs in treatment decisions using conjoint analysis.

METHOD

We developed a conjoint analysis survey evaluating patients' preferences for FDA-approved MOUDs. We recruited patients with OUD presenting to initiate treatment. This survey included five attributes: induction, location and route of administration, impact on mortality, side effects, and withdrawal symptoms with cessation. Participants performed 12 choice sets, each with two hypothetical profiles and a "none" option. We used Hierarchical Bayes to identify relative importance of each attribute and part-worth utility scores of levels, which we compared using chi-squared analysis. We used the STROBE checklist to guide our reporting of this cross-sectional observational study.

RESULTS

Five-hundred and thirty participants completed the study. Location with route of administration was the most important attribute. Symptom relief during induction and withdrawal was a second priority. Mortality followed by side effects had lowest relative importance. Attribute levels with highest part-worth utilities showed patients preferred monthly pick-up from a pharmacy rather than daily supervised dosing; and oral medications more than injection/implants, despite the latter's infrequency.

CONCLUSION

We measured treatment preferences among patients seeking to initiate OUD treatment to inform strategies to scale MOUD treatment uptake. Patients prioritize the route of administration in treatment preference-less frequent pick up, but also injections and implants were less preferred despite their convenience. Second, patients prioritize symptom relief during the induction and withdrawal procedures of medication. These transition periods influence the sustainability of treatment. Although health professionals prioritize mortality, it did not drive decision-making for patients. To our knowledge, this is the largest study on patients' preferences for MOUD among treatment-seeking people with OUD to date. Future analysis will evaluate patient preference heterogeneity to further target program planning, counseling, and decision aid development.

Patients' goals when initiating long-acting injectable buprenorphine treatment for opioid use disorder: findings from a longitudinal qualitative study

BACKGROUND

Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that has been introduced against an international policy backdrop of recovery and person-centred care. This paper explores the goals that people want to achieve from LAIB to identify potential implications for policy and practice.

METHODS

Data derive from longitudinal qualitative interviews conducted with 26 people (18 male; 8 female) initiating LAIB in England and Wales, UK (June 2021-March 2022). Participants were interviewed up to five times by telephone over six months (107 interviews in total). Transcribed interview data relating to each participant's treatment goals were coded, summarised in Excel, and then analysed via a process of Iterative Categorization.

RESULTS

Participants often articulated a desire to be abstinent without defining exactly what they meant by this. Most intended to reduce their dosage of LAIB but did not want to rush. Although participants seldom used the term 'recovery', almost all identified objectives consistent with current definitions of this concept. Participants articulated broadly consistent goals over time, although some extended the timeframes for achieving treatment-related goals at later interviews. At their last interview, most participants remained on LAIB, and there were reports that the medication was enabling positive outcomes. Despite this, participants were aware of the complex personal, service-level, and situational factors that hindered their treatment progress, understood the additional support they needed to achieve their goals, and voiced frustrations when services failed them.

CONCLUSIONS

There is a need for wider debate regarding the goals people initiating LAIB are seeking and the diverse range of positive treatment outcomes LAIB could potentially generate. Those providing LAIB should offer regular on-going contact and other forms of non-medical support so that patients have the best opportunity to succeed. Policies relating to recovery and person-centred care have previously been criticised for responsibilising patients and service users to take better care of themselves and to change their own lives. In contrast, our findings suggest that these policies may, in fact, be empowering people to expect a greater range of support as part of the package of care they receive from service providers.

'I just thought that was the best thing for me to do at this point': Exploring patient experiences with depot buprenorphine and their motivations to discontinue

INTRODUCTION

Long-acting injectable depot buprenorphine is a recent addition to the suite of opioid agonist therapies (OAT) used to treat opioid use disorder (OUD). However, there has been little research that focuses on the lived experience of people receiving depot buprenorphine treatment and reasons for why people decide to discontinue. The aim of this study was to explore what it is like to receive depot buprenorphine and to understand the motivations behind why people discontinue.

METHODS

Open-ended, semi-structured interviews were conducted between November 2021 and January 2022 with individuals who were either currently receiving depot buprenorphine or had discontinued or were in the process of discontinuing depot buprenorphine. Liberati, et al.'s (2022) adaptation of Dixon-Woods's (2006) candidacy framework was used to analyse the participant experiences.

RESULTS

40 participants (26 male, 13 female, 1 undisclosed; mean age 42 years) were interviewed about their experience with depot buprenorphine. At the time of the interview, 21 were currently receiving depot buprenorphine and 19 had discontinued this treatment or were in the process of discontinuing. Participants cited 4 key reasons why they decided to discontinue depot buprenorphine:1) feeling forced into the program, 2) experiencing negative side-effects, 3) finding the treatment ineffective, and 4) wanting to stop depot buprenorphine/OAT to use opioids again or feeling 'cured' and no longer in need of OAT. Participants were ultimately discussing issues related to clinician-patient power relations, agency and bodily autonomy, and the pursuit of well-being.

CONCLUSION

Depot buprenorphine remains a promising treatment for OUD and offers potential to improve treatment adherence. Instances of restricted OAT choice and consumer concerns regarding a lack of agency must be addressed in order to enhance therapeutic relationships. Clinicians and other healthcare workers in this field also need greater access to information about depot buprenorphine to better address issues patients face during treatment. More research is required to understand patient and treatment choice given the options of these new treatment formulations.

Iteration is not solving the opioid crisis, it's time for transformation

Opioid use disorder (OUD) produces exceedingly high rates of morbidity and mortality in the United States and throughout the world. Almost 90% of persons qualifying for treatment do not enter treatment and 72% of those who initiate treatment leave within 60 days. This Perspective posits that over the past decade our OUD treatment system has produced only small iterative gains in treatment access because, in part, it is founded in a series of top-down regulatory policies dating back more than 100 years. These policies prioritized restricting persons with OUD from having access to opioid agonists over empirical discovery of treatment best practice. It further suggests that for persons who are not already responding positively to our existing treatments, we may need to fundamentally transform care to enact true, meaningful change. Four potential considerations are outlined: expanding beyond long-acting opioids for treatment, embracing safe use as a viable therapeutic target, ending closed medication distribution systems, and partnering with our patients. The overarching aim of this discussion is to motivate broader thinking about new solutions for the patients for whom the existing strategies are not working and who may benefit from more transformative approaches. Though efforts to-date to expand existing treatment systems and find new ways to promote existing MOUDs have been important, these efforts have represented iterative changes. For us to meet our goal of substantially reducing opioid-related harms, it may be time to consider strategies that represent true transformation.

Enhancing Use of Medications for Opioid Use Disorder Through External Coaching

OBJECTIVE

This randomized controlled trial tested whether external coaching influences addiction treatment providers' utilization of medications to treat opioid use disorder (MOUDs).

METHODS

This study recruited 75 unique clinical sites in Florida, Ohio, and Wisconsin, including 61 sites in specialty treatment agencies and 14 behavioral health sites within health systems. The trial used external coaching to increase use of MOUDs in the context of a learning collaborative and compared it with no coaching and no learning collaborative (control condition). Outcome measures of MOUD capacity and utilization were monthly tabulations of licensed buprenorphine slots (i.e., the number of patients who could be treated based on the buprenorphine waiver limits of the site's providers), buprenorphine use, and injectable naltrexone administration.

RESULTS

The coaching and control arms showed no significant difference at baseline. Although buprenorphine slots increased in both arms during the 30-month trial, growth increased twice as fast at the coaching sites, compared with the control sites (average monthly rate of 6.1% vs. 3.0%, respectively, p<0.001). Buprenorphine use showed a similar pattern; the monthly growth rate in the coaching arm was more than twice the rate in the control arm (5.3% vs. 2.4%, p<0.001). Coaching did not have an impact on injectable naltrexone, which grew less than 1% in both arms over the trial period.

CONCLUSIONS

External coaching can increase organizational capacity for and growth of buprenorphine use. Future research should explore the dimensions of coaching practice, dose, and delivery modality to better understand and enhance the coaching function.

How do patients feel during the first 72 h after initiating long-acting injectable buprenorphine? An embodied qualitative analysis

BACKGROUND AND AIMS

Long-acting injectable buprenorphine (LAIB) is a new treatment for opioid use disorder that is generating positive outcomes. Negative effects are typically mild and transient, but can occasionally be serious, resulting in treatment discontinuation/non-adherence. This paper aims to analyse patients' accounts of how they felt during the first 72 h after initiating LAIB.

METHODS

Semi-structured interviews were conducted (June 2021-March 2022) with 26 people (18 males and 8 females) who had started LAIB within the previous 72 h. Participants were recruited from treatment services in England and Wales and were interviewed by telephone using a topic guide. Interviews were audio-recorded, transcribed and coded. The concepts of embodiment and embodied cognition framed the analyses. Data on participants' substance use, initiation onto LAIB and feelings were tabulated. Next, participants' accounts of how they felt were analysed following the stages of Iterative Categorization.

RESULTS

Participants reported complex combinations of changing negative and positive feelings. Bodily experiences included withdrawal symptoms, poor sleep, injection-site pain/soreness, lethargy and heightened senses inducing nausea ('distressed bodies'), but also enhanced somatic wellbeing, improved sleep, better skin, increased appetite, reduced constipation and heightened senses inducing pleasure ('returning body functions'). Cognitive responses included anxiety, uncertainties and low mood/depression ('the mind in crisis') and improved mood, greater positivity and reduced craving ('feeling psychologically better'). Whereas most negative effects reported are widely recognized, the early benefits of treatment described are less well-documented and may be an overlooked distinctive feature of LAIB.

CONCLUSIONS

During the first 72 h after initiating long-acting injectable buprenorphine, new patients report experiencing a range of interconnected positive and negative short-term effects. Providing new patients with information about the range and nature of these effects can prepare them for what to expect and help them manage feelings and reduce anxiety. In turn, this may increase medication adherence.

Application of the COM-B model to patient barriers and facilitators of retention in medication treatment for opioid use disorder in rural Northeastern United States: A qualitative study

Introduction

Medications for opioid use disorder (MOUD) reduce illicit opioid use and overdose mortality, but effectiveness remains limited by poor treatment retention. Understanding multilevel barriers and facilitators to retention from the patient perspective can guide intervention strategies to improve retention.

Methods

We conducted semi-structured telephone interviews to elicit perspectives of individuals with opioid use disorder (OUD) currently (n = 19) and formerly (n = 16) receiving treatment from a multi-clinic outpatient MOUD program in Pennsylvania in July 2020 to January 2021. The Capability, Opportunity, Motivation, Behavior model provided a theoretical framework for analysis.

Results

Based on interview themes, physical, rather than psychological, capability was more salient to MOUD engagement, and pertained to individual-level factors such as side effects, withdrawal, and the degree to which MOUD addressed participants' need for pain management. Co-existing mental health conditions also challenged participants' physical ability to attend appointments. The opportunity domain contained both physical and social aspects. Physical opportunity for MOUD engagement centered on community-level factors related to MOUD access (e.g., distance, transportation) and clinical-level factors including program policies. Themes related to social opportunity included interpersonal influences-such as therapeutic and social support-and stigma associated with OUD and MOUD. Motivation emerged as the dominant domain for patients. Reflective motivation factors included individual-level factors such as participants' recognition of their addiction and "readiness" to quit illicit opioid use, attitudes toward MOUD, future treatment expectations, motivation to engage in MOUD, and perceived consequences of disengagement. Automatic motivation factors included the degree to which MOUD created a sense of normalcy for participants and the use of illicit drugs to numb emotions.

Conclusions

Factors at the individual, interpersonal, clinical, community, and societal levels influenced patients' capability, opportunity, and motivation to engage in MOUD. Understanding such factors can inform implementation strategies to improve retention.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Variation in Initiation, Engagement, and Retention on Medications for Opioid Use Disorder Based on Health Insurance Plan Design

BACKGROUND

The association between cost-sharing and receipt of medication for opioid use disorder (MOUD) is unknown.

METHODS

We constructed a cohort of 10,513 commercially insured individuals with a new diagnosis of opioid use disorder and information on insurance cost-sharing in a large national deidentified claims database. We examined 4 cost-sharing measures: (1) pharmacy deductible; (2) medical service deductible; (3) pharmacy medication copay; and (4) medical office copay. We measured MOUD (naltrexone, buprenorphine, or methadone) initiation (within 14 d of diagnosis), engagement (second receipt within 34 d of first), and 6-month retention (continuous receipt without 14-d gap). We used multivariable logistic regression to assess the association between cost-sharing and MOUD initiation, engagement, and retention. We calculated total out-of-pocket costs in the 30 days following MOUD initiation for each type of MOUD.

RESULTS

Of 10,513 individuals with incident opioid use disorder, 1202 (11%) initiated MOUD, 742 (7%) engaged, and 253 (2%) were retained in MOUD at 6 months. A high ($1000+) medical deductible was associated with a lower odds of initiation compared with no deductible (odds ratio: 0.85, 95% confidence interval: 0.74-0.98). We found no significant associations between other cost-sharing measures for initiation, engagement, or retention. Median initial 30-day out-of-pocket costs ranged from $100 for methadone to $710 for extended-release naltrexone.

CONCLUSIONS

Among insurance plan cost-sharing measures, only medical services deductible showed an association with decreased MOUD initiation. Policy and benefit design should consider ways to reduce cost barriers to initiation and retention in MOUD.

Comparing the feasibility of four web-based recruitment strategies to evaluate the treatment preferences of rural and urban adults who misuse non-prescribed opioids

This cross-sectional study examined the feasibility of using four different web-based strategies to recruit rural and urban adults who use opioids non-medically for a survey on opioid use disorder (OUD) treatment preferences, and compared the treatment preferences of rural versus urban participants. Preferences for medication for opioid use disorder (MOUD) formulation and OUD treatment models were assessed through an online survey. Recruitment advertisements were shown on Facebook, Google AdWords, Reddit, and Amazon Mechanical Turk (MTurk). Participants were categorized by zip code into urban versus rural residence using the Centers for Medicaid and Medicaid Health Resources and Services Administration definitions. OUD treatment preferences were compared using chi-square and t-tests. Among the 851 participants recruited, 815 provided zip codes and were classified as residing in rural (n = 200, 24.5%) or urban (n = 615, 75.4%) regions. A crowdsourcing service (MTurk) recruited the most rural participants, while posts on a social news website (Reddit) recruited the most urban participants (χ²₃ = 17.0, p < 0.01). While preferred MOUD formulation and OUD treatment model did not differ by rurality, rural participants were more likely to report a willingness to receive OUD treatment integrated with general medical care (χ²₁ = 18.9, p < 0.0001). This study demonstrated that web-based strategies are feasible for recruiting rural adults who misuse opioids. Results suggest OUD treatment preferences largely did not differ by rural residence, and highlight the importance of enhancing the availability and increasing education about MOUD formulations in rural regions.

Tracing the affordances of long-acting injectable depot buprenorphine: A qualitative study of patients' experiences in Australia

BACKGROUND

Long-acting injectable depot buprenorphine is an important new treatment option for the management of opioid dependence, delivering therapeutic doses in weekly or monthly formulations. Depot buprenorphine aims to overcome challenges associated with traditional opioid agonist therapy (OAT), including: poor patient adherence; inconvenience of regular attendance for dosing; and, risk of non-medical use of takeaway doses. However, little is known about patients' experiences of depot buprenorphine. This qualitative study aimed to explore patients' experiences of the practical and social affordances of depot buprenorphine.

METHODS

Participants were recruited from sites in Sydney, regional New South Wales, and Melbourne, Victoria, Australia. Thirty participants (16 men, 14 women; mean age 47.3 years) participated in semi-structured interviews. Participants had histories of both heroin and prescription opioid use, and previous OAT including daily dosing of buprenorphine and methadone.

FINDINGS

Depot buprenorphine afforded positive benefits for many participants, including: opportunities to avoid stigma experienced at pharmacies/clinics; time to engage in activities (e.g., travel, work) by releasing participants from previous OAT treatment regimens; and, cost savings by not having to pay pharmacy fees associated with daily dosing. However, for some participants, moving to depot buprenorphine: disrupted engagements with important social/practical supports available at pharmacies/clinics; constrained their control over dosing; and, constrained their ability to generate income via the sale of takeaway doses.

CONCLUSIONS

While generally experienced as affording benefits, depot buprenorphine can have differing social and practical impacts. Clinicians should monitor patients receiving depot buprenorphine to reduce the risk of unintended consequences including disruption to clinical supports.

Characterizing initiation, use, and discontinuation of extended-release buprenorphine in a nationally representative United States commercially insured cohort

BACKGROUND AND AIMS

While the United States is in the midst of an overdose epidemic, effective treatments are underutilized and commonly discontinued. Innovations in medication delivery, including an extended-release formulations, have the potential to improve treatment access and reduce discontinuation. We sought to assess extended-release buprenorphine discontinuation among individuals with opioid use disorder (OUD) in a real-world, nationally representative cohort.

SETTING

United States PARTICIPANTS: Commercially insured individuals initiating one of four FDA-approved medications for opioid use disorder (MOUD) in 2018: extended-release buprenorphine, extended-release naltrexone, mucosal buprenorphine (mono- or co-formulated with naloxone), or methadone.

MEASUREMENTS

Our primary outcome was medication discontinuation, defined as a gap of more than 14 days between the end of one prescription or administration and the subsequent dose.

FINDINGS

We identified 14,358 individuals initiating MOUD in 2018, including 204 (1%) extended-release buprenorphine, 1,173 (8%) extended-release naltrexone, 12,171 (85%) mucosal buprenorphine, and 810 (6%) methadone initiations. Three months after initiation, 50% (95% confidence interval [CI] 40%-60%) of extended-release buprenorphine, 64% (95% CI 61%-69%) of extended-release naltrexone, 34% (95% CI 33%-35%) of mucosal buprenorphine, and 58% (95% CI 54%-62%) of methadone initiators had discontinued treatment.

CONCLUSIONS

Across all treatment groups, medication discontinuation was high, and in this sample of early adopters with limited follow-up time, we found no evidence that extended-release buprenorphine offered a retention advantage compared to other MOUD in real-world settings. Retention continues to represent a major obstacle to treatment effectiveness, and interventions are needed to address this challenge even as new MOUD formulations become available.

Patterns of clinic switching and continuity of medication for opioid use disorder in a Medicaid-enrolled population

BACKGROUND

Many persons with opioid use disorder (OUD) initiate medication for opioid use disorder (MOUD) with one clinic and switch to another clinic during their course of treatment. These switches may occur for referrals or for unplanned reasons. It is unknown, however, what effect switching MOUD clinics has on continuity of MOUD treatment or on overdoses.

OBJECTIVE

To examine patterns of switching MOUD clinics and its association with the proportion of days covered (PDC) by MOUD, and opioid-related overdose.

DESIGN

Cross-sectional retrospective analysis of Pennsylvania Medicaid claims data.

MAIN MEASURES

MOUD clinic switches (i.e., filling a MOUD prescription from a prescriber located in a different clinic than the previous prescriber), PDC, and opioid-related overdose.

RESULTS

Among 14,107 enrollees, 43.2 % switched clinics for MOUD at least once during the 270 day period. In multivariate regression results, enrollees who were Non-Hispanic black (IRR = 1.43; 95 % CI = 1.24-1.65; p < 0.001), had previous methadone use (IRR = 1.32; 95 % CI = 1.13-1.55; p < 0.001), and a higher total number of office visits (IRR = 1.01; CI = 1.01-1.01; p < 0.001) had more switches. The number of clinic switches was positively associated with PDC (OR = 1.12; 95 % CI = 1.10-1.13). In secondary analyses, we found that switches for only one MOUD fill were associated with lower PDC (OR = 0.97; 95 % CI = 0.95-0.99), while switches for more than one MOUD fill were associated with higher PDC (OR = 1.40; 95 % CI = 1.36-1.44). We did not observe a relationship between opioid-related overdose and clinic switches.

CONCLUSIONS

Lack of prescriber continuity for receiving MOUD may not be problematic as it is for other conditions, insofar as it is related to overdose and PDC.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

BACKGROUND

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

METHODS

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

RESULTS

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

CONCLUSIONS

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Determinants of interest in extended-released buprenorphine: A survey among 366 French patients treated with buprenorphine or methadone

AIM

To explore the factors determining the interest in extended-release buprenorphine (XR-BUP) injections among patients receiving opioid agonist treatment (OAT) in France.

METHODS

366 patients receiving OAT for opioid use disorder, recruited in 66 French centers, were interviewed from 12/2018 to 05/2019. A structured questionnaire assessed their interest in XR-BUP using a [1-10] Likert scale. 'More' vs. 'less' interested groups were defined using the median score of interest, and their characteristics were explored using adjusted odds ratios (aORs) and 95 % confidence interval (95 %CI). Independent variables were as follows: sociodemographic characteristics, OAT-related features (e.g., type of OAT and prescriber, dosing, or duration of treatment), OAT representations, and personal objectives of treatment.

RESULTS

The median interest in XR-BUP was 7 (interquartile range: 3-9) out of 10. The participants who were 'more interested' (i.e. those scoring ≥7) showed no substantial difference in sociodemographic characteristics, relative to the 'less interested' participants. However, they more frequently reported forgetting to take their OAT (OR = 1.81; CI95 % = 1.06-3.10) or reported experiencing situations where taking their OAT was impractical (aOR = 1.69; CI95 % = 1.05-2.73). Their treatment objective was more focused on stopping illicit drugs (aOR = 1.67; 95 %CI = 1.02-2.70), reducing health risks (aOR = 3.57; 95 %CI = 1.67-7.69) and craving (aOR = 2.38; 95 %CI = 1.39-4.02) or improving family (aOR = 1.81; 95 %CI = 1.03-3.13) or professional (aOR = 2.22; 95 %CI = 1.43-3.85) recovery.

CONCLUSIONS

In France, where the access to OAT is relatively unrestricted, the majority of participants were interested in XR-BUP formulations. Being interested was associated with treatment objectives focused on abstinence and recovery, and with experiencing constraints in taking a daily oral OAT.

Economic Evaluation in Opioid Modeling: Systematic Review

OBJECTIVES

The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature.

METHODS

A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study.

RESULTS

The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs.

CONCLUSION

The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.

"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Background

Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences.

Methods

This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed.

Results

While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma).

Conclusions

Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.

Can Extended-release Injectable Medications Help Curb United States and Canada's Opioid Overdose Epidemic?

Settings throughout the United States and Canada continue to face escalating overdose epidemics. Notably, history of overdose is associated with increased risk of fatal overdose. Unfortunately, despite frequent contact with health services and the well-known mortality benefits of medications for opioid use disorder (MOUD), only a fraction of overdose survivors is successfully linked to addiction care after leaving the emergency department. This may be partially explained by well-documented challenges of oral MOUD, including the need for frequent visits to the pharmacy to receive their medications, which may limit the flexibility to acquire or sustain employment, and therefore contribute to high rates of opioid addiction care discontinuation. This commentary discusses the potential fit of different extended-release injectable MOUD to circumvent limitations of oral formulations, and thereby improve linkage and retention in care of high-risk populations, such as opioid-overdose survivors.

A New Long-Term Composite Drug Delivery System Based on Thermo-Responsive Hydrogel and Nanoclay

Several problems and limitations faced in the treatment of many diseases can be overcome by using controlled drug delivery systems (DDS), where the active compound is transported to the target site, minimizing undesirable side effects. In situ-forming hydrogels that can be injected as viscous liquids and jellify under physiological conditions and biocompatible clay nanoparticles have been used in DDS development. In this work, polymer-clay composites based on Pluronics (F127 and F68) and nanoclays were developed, aiming at a biocompatible and injectable system for long-term controlled delivery of methylene blue (MB) as a model drug. MB release from the systems produced was carried out at 37 °C in a pH 7.4 medium. The Pluronic formulation selected (F127/F68 18/2 wt.%) displayed a sol/gel transition at approx. 30 °C, needing a 2.5 N force to be injected at 25 °C. The addition of 2 wt.% of Na116 clay decreased the sol/gel transition to 28 °C and significantly enhanced its viscoelastic modulus. The most suitable DDS for long-term application was the Na116-MB hybrid from which, after 15 days, only 3% of the encapsulated MB was released. The system developed in this work proved to be injectable, with a long-term drug delivery profile up to 45 days.