The mixed message behind “Medication-Assisted Treatment” for substance use disorder

Development of an Educational Brochure about Treatment Options for Pregnant Women with Opioid Use Disorders

The goal of this study was to describe the development of an educational brochure for pregnant women with opioid use disorders (OUDs) about treatment options. Based on findings from a preliminary review of the literature, we drafted a brochure that addressed the following questions: (1) What are your options (Medication-Assisted Treatment (MAT) versus no treatment)? (2) What are the benefits of MAT? (3) What are the risks of MAT? (4) Can I take buprenorphine or methadone while breastfeeding? (5) Which medication should I choose? Clinicians and doulas (n = 19) who provide care to pregnant women with OUDs were recruited. Semi-structured interviews elicited participants' feedback on brochure content and their perceptions about brochure use for patient education. Thematic data analyses were performed. Three emergent themes were identified (suggested uses and settings of use, content revisions, and perceptions about the brochure) and used to refine the final brochure. This study provides valuable insights into the desired content of an educational brochure describing treatment options for pregnant women with OUDs from the provider's standpoint. Research is needed to assess the use of the brochure in shared decision-making conversations with providers about treatment.

Workplace Supported Recovery from Substance Use Disorders: Defining the Construct, Developing a Model, and Proposing an Agenda for Future Research

Substance use disorders (SUDs) represent a critical public and occupational health issue. Therefore, understanding the process of SUD recovery has become an issue of growing importance among substance use and recovery professionals. Nonetheless, despite the acknowledged importance of employment for SUD recovery, little conceptual or empirical work exists on how the workplace might support or undermine SUD recovery. In this article, we address this limitation in several ways. First, to promote a better understanding of SUD recovery for occupational health researchers, we provide a brief overview of the nature of a SUD, prior definitions of SUD recovery, and general themes associated with the recovery process. Second, we develop a working definition of workplace supported recovery. Third, we present a heuristic conceptual model showing how the workplace might impact the SUD recovery process. Fourth, using this model and research from the substance use and occupational health literatures, we develop a series of general research propositions. These propositions highlight broad directions requiring more detailed conceptualization and empirical research to understand better how work conditions may support or undermine the process of employee SUD recovery. Our overarching goal is to motivate innovative conceptualization and research on workplace supported recovery from SUDs. Such research may inform the development and evaluation of workplace interventions and policies supporting SUD recovery and highlight the benefits of workplace supported SUD recovery for employees, employers, and communities. Research on this issue may allow occupational health researchers to impact a significant societal and occupational health issue.

Care Experiences of Persons With Perinatal Opioid Use: A Qualitative Study

Opioid use in the perinatal period has escalated rapidly, with potentially devastating outcomes for perinatal persons and infants. Substance use treatment is effective and has the potential to greatly improve clinical outcomes; however, characteristics of care received from providers including nurses have been described as a barrier to treatment. Our purpose was to describe supportive perinatal care experiences of persons with opioid use disorder. A qualitative descriptive study design was used to examine experiences of 11 postpartum persons (ages 22-36 years) in medication-assisted treatment for opioid use disorder at an academic medical center in the southern region of the United States. Participants were interviewed about experiences with perinatal and neonatal care during the child's hospitalization for neonatal abstinence syndrome surveillance and/or treatment. Four themes of supportive care experiences emerged: informing, relating, accepting, and holistic supporting. Participants reported a range of positive and negative perinatal care experiences, with examples and counterexamples provided. This fuller understanding of perceptions and lived experiences of care can inform practice changes and educational/training priorities. Future research is needed to facilitate development of comprehensive care models geared to address perinatal care needs of persons with opioid use disorder.

Examination of Correlates of OUD Outcomes in Young Adults: Secondary Analysis From the XBOT Trial

BACKGROUND AND OBJECTIVES

Opioid use disorder (OUD) treatment outcomes are poorer for young adults than older adults. Developmental differences are broadly implicated, but particular vulnerability factor interactions are poorly understood. This study sought to identify moderators of OUD relapse between age groups.

METHODS

This secondary analysis compared young adults (18-25) to older adults (26+) from a comparative effectiveness trial ("XBOT") that randomized (N = 570) participants to extended-release naltrexone or sublingual buprenorphine-naloxone. We explored the relationship between 25 prespecified patient baseline characteristics and relapse to regular opioid use by age group and treatment condition, using logistic regression.

RESULTS

Young adults (n = 111) had higher rates of 24-week relapse than older adults (n = 459) (70.3% vs 58.8%) and differed on a number of specific characteristics, including more smokers, more intravenous opioid use, and more cannabis use. No significant moderators predicted relapse, in either three-way or two-way interactions.

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

No baseline factors were identified as moderating the relationship between age group and opioid relapse, nor any interactions between baseline characteristics, age group, and treatment condition to predict opioid relapse. Poorer treatment outcomes for young adults are likely associated with multiple developmental vulnerabilities rather than any single predominant factor. Although not reaching significance, several characteristics (using heroin, smoking tobacco, high levels of depression/anxiety, or treatment because of family/friends) showed higher odds ratio point estimates for relapse in young adults than older adults. This is the first study to explore moderators of worse OUD treatment outcomes in young adults, highlighting the need to identify predictor variables that could inform treatment enhancements. (Am J Addict 2021;00:1-12).

Pre-arrest diversion to addiction treatment by law enforcement: protocol for the community-level policing initiative to reduce addiction-related harm, including crime

BACKGROUND

Despite evidence that treatment reduces addiction-related harms, including crime and overdose, only a minority of addiction-affected individuals receive it. Linking individuals who committed an addiction-related crime to addiction treatment could improve outcomes.

METHODS

The aim of this city-wide, pre-arrest diversion program, Madison Addiction Recovery Initiative (MARI) is to reduce crime and improve health (i.e., reduce the overdose deaths) among adults who committed a minor, non-violent, drug use-related offense by offering them a referral to treatment in lieu of arrest and prosecution of criminal charges. This manuscript outlines the protocol and methods for the MARI program development and implementation. MARI requires its participants to engage in the recommended treatment, without reoffending, during the six-month program, after which the initial criminal charges are "voided" by the law enforcement agency. The project, implemented in a mid-size U.S. city, has involved numerous partners, including law enforcement, criminal justice, public health, and academia. It includes training of the police officer workforce and collaboration with clinical partners for treatment need assessment, treatment placement, and peer support. Program evaluation includes formative, process, outcome (participant-level) and exploratory impact (community-level) assessments. For outcome evaluation, we will compare crime (primary outcome), overdose-related offenses, and incarceration-related data 12 months before and 12 months after the index crime between participants who completed (Group 1), started but not completed (Group 2), and were offered but did not start (Group 3) the program, and adults who would have been eligible should MARI existed (Historical Comparison, Group 4). Clinical characteristics will be compared at baseline between Groups 1-2, and pre-post the program within Group 1. Participant baseline data will be assessed as potential covariates. Surveys of police officers and program completers, and community-level indicators of crime and overdose pre- versus post-program will provide additional data on the program impact.

DISCUSSION

By offering addiction treatment in lieu of arrest and prosecution of criminal charges, this pre-arrest diversion program has the potential to disrupt the cycle of crime, reduce the likelihood of future offenses, and promote public health and safety.

A pilot randomized controlled trial of assertive treatment including family involvement and home delivery of medication for young adults with opioid use disorder

BACKGROUND AND AIMS

Although medications for opioid use disorder (OUD), including extended-release naltrexone (XR-NTX), have demonstrated effectiveness, adherence is often low. We tested the preliminary efficacy of youth opioid recovery support (YORS), a multi-component intervention designed to improve engagement and medication adherence for young adults with OUD.

DESIGN

Single-site randomized controlled trial with 24-week follow-up.

SETTING

Community substance use disorder treatment program in Baltimore, MD, USA.

PARTICIPANTS

Young adults aged 18-26 years enrolled in inpatient/residential OUD treatment intending to pursue outpatient OUD treatment with XR-NTX. Twenty-one participants were randomized to YORS and 20 to treatment as usual (TAU). The analyzed sample was 65.8% male.

INTERVENTION AND COMPARATOR

Components of YORS include: (1) home delivery of XR-NTX; (2) family engagement; (3) assertive outreach; and (4) contingency management for receipt of XR-NTX doses. The comparator was TAU, which consisted of a standard referral to outpatient care following an inpatient stay.

MEASUREMENTS

Primary outcomes were number of XR-NTX doses received over 24 weeks and relapse to opioid use (defined as ≥ 10 days of use within 28 days) at 24 weeks.

FINDINGS

Participants in the YORS condition received more XR-NTX doses [mean = 4.28; standard deviation (SD) = 2.3] compared with those in TAU (mean = 0.70; SD = 1.2), P < 0.01. Participants in the YORS group compared with TAU had lower rates of relapse (61 versus 95%; P < 0.01). Survival analyses revealed group differences on time to relapse with participants in TAU being more likely to relapse sooner compared with participants in the YORS condition [hazard ratio (HR) = 2.72, 95% confidence interval (CI) = 1.26-5.88, P < 0.01].

CONCLUSIONS

The youth opioid recovery support intervention for extended-release naltrexone adherence and opioid relapse prevention among young adults with opioid use disorder appeared to improve treatment and relapse outcomes compared with standard treatment.

Voice through the lens: Personal experience of those on methadone

With the rise of opioid deaths and methadone maintenance treatment (MMT) being the "gold standard," evidence lacks the quality of life for those on Methadone.

OBJECTIVE

This study aimed to develop educational materials for communities and clinics about MMT and abstinence, utilizing the PhotoVoice technique to represent the voice of those on Methadone treatment (MMT) and abstinence for recovery from opioid use disorder (OUD). Participants shared firsthand experiences of life on Methadone and abstinence, resulting in a short video clip and a poster.

DESIGN

Participants were recruited following meetings of Alcoholics Anonymous and Narcotics Anonymous. An introduction letter was handed out, and questions were answered. After COVID-19 Pandemic, further communications were delivered through Email. Five participants on Methadone and four who were abstinent were recruited. Participants were 18 years and over, male and female, were on MMT or abstinent for 6 months or more.

RESULTS

Common themes among participants were extracted and discussed with the participants and a short video clip and a poster were developed.

CONCLUSION

Further study in MMT from the patient's perspective need to be explored. The PhotoVoice project revealed personal barriers, while on Methadone, that impede a full and rich life spiritually, mentally, and physically.

Young Adults Have Worse Outcomes Than Older Adults: Secondary Analysis of a Medication Trial for Opioid Use Disorder

PURPOSE

Young adults are disproportionately affected by the current opioid crisis. Although medications for opioid use disorder are broadly effective, with reductions in morbidity and mortality, the particular effectiveness of medications for opioid use disorder among young adults is less well understood.

METHODS

This secondary analysis compared young adults (aged 18-25 years) with older adults (aged ≥26 years) in a large comparative effectiveness trial ("XBOT") that randomized subjects to extended-release naltrexone or sublingual buprenorphine-naloxone for 6 months. Opioid relapse was defined by opioid use over four consecutive weeks or seven consecutive days, using urine testing and self-report.

RESULTS

Among subjects in the intention-to-treat sample (n = 570, all randomized participants), a main effect of age group was found, with higher relapse rates among young adults (70.3%) compared with older adults (58.2%), with an odds ratio of 1.72 (95% confidence interval = 1.08-2.70), p = .02. In the per-protocol sample (n = 474, only participants who started medication), relapse rates were higher among young adults (66.3%) compared with older adults (50.8%), with an odds ratio of 1.91 (95% confidence interval = 1.19-3.06). Among the intention-to-treat sample, survival analysis revealed a significant time-by-age group interaction (p = .01) with more relapse over time in young adults. No significant interactions between age and medication group were detected.

CONCLUSIONS

Young adults have increased rates of relapse compared with older adults, perhaps because of vulnerabilities that increase their risk for treatment dropout and medication nonadherence, regardless of medication assignment. These results suggest that specialized, developmentally informed interventions may be needed to improve retention and successful treatment of opioid use disorder among young adults.

Rates of prescription orders for United States active duty service members diagnosed with alcohol use disorder

BACKGROUND

Alcohol-use disorders (AUD) pose a significant challenge for the United States (US) military. The US Department of Defense has strongly recommended several medications for use in the treatment of patients with diagnosed AUD. This study assessed the prescription of medications for active duty service members (ADSMs) diagnosed with AUD in the US Military Health System (MHS). Methods: Rates of prescription orders were retrospectively examined from 2010 to 2017 among ADSMs with an incident diagnosis of moderate-to-severe AUD. The rate of prescription orders was defined as the proportion of ADSMs with an ICD-9 or ICD-10 diagnosis code of alcohol dependence who received an order for acamprosate, disulfiram, naltrexone, and/or topiramate at a military treatment facility in the year following their incident diagnosis. Results: ADSMs receiving an order for at least one medication in the year following their incident AUD diagnosis increased from 8.8% in 2010 to 16.2% in 2017 (RR = 1.84, 95% CI, 1.76, 1.93). Oral naltrexone was ordered most frequently among this patient population, while injectable naltrexone, a medication option meant to ease and improve adherence, was ordered for a smaller proportion of patients. Conclusions: Most ADSMs who might benefit from prescriptions for AUD are not receiving them as part of their treatment despite strong clinical evidence and Department of Defense policy support for their use among this cohort.

Effects of messaging on public support for drug consumption rooms in scotland, UK

BACKGROUND

There is evidence to suggest that medically supervised drug consumption rooms (DCRs) may form part of responses to reduce drug-related harm. Although DCRs have been established globally, they are perceived by some to be a controversial approach in the UK, and Government has repeatedly rejected proposals to establish one in Glasgow, Scotland. As public support is an important component of policy development and enactment, we sought to investigate the effects of different types of message framing on public support for DCR.

METHODS

We undertook a cross-sectional online study with a randomised design, conducted with a nationally representative sample. Participants were randomised to one of six message conditions comprising combinations of four components. All conditions included i) a basic description of a DCR, and conditions included combinations of ii) factual information; iii) pre-emptive refutation of common public concerns about DCR; and/or iv) a sympathetic narrative describing a mother whose son died from a heroin overdose. After reading each message, participants completed a bespoke measure assessing support for DCR. Data were analysed using ANCOVA.

RESULTS

Complete data were obtained from 1591 participants (50.3% Female; mean age 44.9 ± 16.1 years). Compared to reading a basic description of DCR alone, there was greater support for DCR in participants receiving the refutation (p < .001); sympathetic + factual (p < .05); and sympathetic + factual + refutation (p < .001) message conditions. Presenting factual or sympathetic messages alone were not associated with increased support.

CONCLUSION

Our findings suggest that public support for DCRs is not improved through communication of factual statements outlining potential benefits of the intervention alone. Advocates seeking to foster public support, and thus influence policy making, should also consider communication campaigns that address common concerns that the public might have about DCRs, and present the intervention in relation to potential benefits that they hold for people indirectly affected by drug-related harm.

Wearable and Wireless mHealth Technologies for Substance Use Disorder

Purpose of review

The goal of this scoping review is to evaluate the advances in wearable and other wireless mobile health (mHealth) technologies in the treatment of substance use disorders.

Recent findings

There are a variety of wireless technologies under investigation for the treatment of substance use disorder. Wearable sensors are the most commonly used technology. They can be used to decrease heavy substance use, mitigate factors related to relapse, and monitor for overdose. New technologies pose distinct advantages over traditional therapies by increasing geographic availability and continuously providing feedback and monitoring while remaining relatively non-invasive.

Summary

Wearable and novel technologies are important to the evolving landscape of substance use treatment. As technologies continue to develop and show efficacy, they should be incorporated into multifactorial treatment plans.

Nowhere to go? Examining facility acceptance levels for serving individuals using medications for opioid used disorder

Medications for opioid use disorder (OUD) are associated with better overall outcomes for individuals managing their OUD. While much attention has focused on expanding access to these medications, this study aimed to gain further clarity on how facility-level characteristics may be contributing to availability of complementary recovery-oriented and/or recovery support services for individuals diagnosed with OUD. We created a census of 410 facilities located within a Midwestern metropolitan area that provided services aligning with the substance use disorder (SUD) continuum of care between September 2017 and March 2018. Among facilities serving individuals with opioid-related needs (N = 360), we triangulated five sources of data to measure facility-reported acceptance for individuals who are using medications for OUD. We also obtained facility rationale for their acceptance level (N = 89). We used multinomial logistic regression to identify facility-level factors associated with acceptance for medication use, and we used content analysis to identify categories of common rationales. Compared to moderate acceptance facilities, zero and low acceptance facilities were more likely to provide recovery support services or less likely to provide more than one type of SUD service. In contrast, high acceptance facilities were more likely than moderate acceptance facilities to focus primarily on mental health needs or provide multiple types of SUD services. Qualitative feedback suggests that the factors contributing to these relationships are complex and varied, providing multiple points for intervention at a facility level to increase service availability for individuals using medications for OUD. We address implications for policy and practice, highlighting the need to build an infrastructure that promotes availability of complementary recovery-oriented and recovery support service for individuals once they are prescribed medications for OUD.