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Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
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Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
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Costa GPA, Nunes JC, Heringer DL, Anand A, De Aquino JP. The impact of cannabis on non-medical opioid use among individuals receiving pharmacotherapies for opioid use disorder: a systematic review and meta-analysis of longitudinal studies. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:12-26. [PMID: 38225727 DOI: 10.1080/00952990.2023.2287406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/17/2024]
Abstract
Background: The relationship between cannabis use and the risk of returning to using opioids non-medically during treatment for opioid use disorder (OUD) remains unclear.Objective: We sought to quantify the impact of cannabis use on the risk of non-medical opioid use among people receiving pharmacotherapies for OUD.Methods: A comprehensive search was performed using multiple databases from March 1 to April 5 of 2023. Eligible studies longitudinally assessed the association between cannabis use and non-medical opioid use among people with OUD receiving treatment with buprenorphine, methadone, or naltrexone. We utilized a random-effects model employing the restricted maximum likelihood method. A sensitivity analysis was conducted to understand potential differences between each OUD treatment modality.Results: A total of 10 studies were included in the final meta-analysis. There were 8,367 participants (38% female). The average follow-up time across these studies was 9.7 months (SD = 3.77), ranging from 4 to 15 months. The pharmacotherapies involved were methadone (76.3%) buprenorphine (21.3%), and naltrexone (2.4%). The pooled odds ratio did not indicate that cannabis use significantly influenced non-medical opioid use (OR: 1.00, 95% CI: 0.97-1.04, p = .98). There is evidence of moderate heterogeneity and publication bias.Conclusion: There was no significant association between cannabis use and non-medical opioid use among patients receiving pharmacotherapies for OUD. These findings neither confirm concerns about cannabis increasing non-medical opioid use during MOUD, nor do they endorse its efficacy in decreasing non-medical opioid use with MOUD. This indicates a need for individualized approaches for cannabis use and challenges the requirement of cannabis abstinence to maintain OUD pharmacotherapies.
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Affiliation(s)
- Gabriel P A Costa
- Faculty of Medicine, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Julio C Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel L Heringer
- Faculty of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Akhil Anand
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Medical Center, Cleveland, OH, USA
| | - Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Lake S, Buxton J, Walsh Z, Cooper ZD, Socías ME, Fairbairn N, Hayashi K, Milloy MJ. Methadone Dose, Cannabis Use, and Treatment Retention: Findings From a Community-based Sample of People Who Use Unregulated Drugs. J Addict Med 2023; 17:e18-e26. [PMID: 35914028 PMCID: PMC9889569 DOI: 10.1097/adm.0000000000001032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Stephanie Lake
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA, 90025
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, USA, 90025
| | - Jane Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall Vancouver, BC, CANADA, V6T 1Z3
| | - Zach Walsh
- Department of Psychology, University of British Columbia, 3187 University Way, Kelowna, BC, CANADA, V1V 1V7
| | - Ziva D. Cooper
- UCLA Cannabis Research Initiative, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, 760 Westwood Plaza, Los Angeles, CA, USA, 90025
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 757 Westwood Plaza, Los Angeles, CA, USA, 90025
| | - M. Eugenia Socías
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1080 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Nadia Fairbairn
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1080 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
| | - Kanna Hayashi
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- Faculty of Health Sciences, Simon Fraser University, 8888 University Drive, Burnaby, BC, CANADA, V5A 1S6
| | - M-J Milloy
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, BC, Canada, V6Z 2A9
- Division of Social Medicine, Department of Medicine, University of British Columbia, St. Paul’s Hospital, 1080 Burrard Street, Vancouver, BC, CANADA, V6Z 1Y6
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Krawczyk N, Allen ST, Schneider KE, Solomon K, Shah H, Morris M, Harris SJ, Sherman SG, Saloner B. Intersecting substance use treatment and harm reduction services: exploring the characteristics and service needs of a community-based sample of people who use drugs. Harm Reduct J 2022; 19:95. [PMID: 36002850 PMCID: PMC9400571 DOI: 10.1186/s12954-022-00676-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/15/2022] [Indexed: 11/29/2022] Open
Abstract
Background Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. Methods We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. Results We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. Conclusions In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.
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Affiliation(s)
- Noa Krawczyk
- Center for Opioid Epidemiology and Policy, Department of Population Health, NYU Grossman School of Medicine, New York, USA.
| | - Sean T Allen
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kristin E Schneider
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Keisha Solomon
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Hridika Shah
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Miles Morris
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Samantha J Harris
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Susan G Sherman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Andersson L. A transition of power in opioid substitution treatment: Clinic managers' views on the consequences of a patient choice reform. NORDIC STUDIES ON ALCOHOL AND DRUGS 2022; 39:279-300. [PMID: 35720521 PMCID: PMC9152230 DOI: 10.1177/14550725221075003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 01/05/2022] [Indexed: 11/23/2022] Open
Abstract
Objectives: Opioid substitution treatment (OST) is often described as a strict and highly regulated treatment method, in which patients have limited influence over their treatment. In 2014, a reform was introduced by the regional council of Skåne in southern Sweden, which allowed OST patients to choose their treatment provider, thus transferring power from care providers to patients. The aim of this study was to examine what this increase in patient influence has meant for the clinics that provide OST in Skåne, and how these clinics have dealt with the new competitive situation that has arisen following the introduction of the reform. Methods: The study is based on two waves of semi-structured interviews with clinic managers at all OST clinics in Skåne. Results: The clinic managers described the increase in patient influence as a positive change, which had led to the patients being treated with more respect. The competition among clinics was expressed, among other things, in the form of differing views on the prescription of benzodiazepines, which initially gave rise to dissatisfaction among clinics with a more restrictive approach to such prescriptions. The reform did not lead to any clear diversity between clinics, apart from different approaches to the prescription of benzodiazepines. The incentive for competition-based diversity is, however, limited by the strict national regulatory system and by the reimbursement system, which restricts the ways in which clinics can conduct treatment activities. Conclusion: OST-clinic managers were largely positive about the increased patient empowerment and the shift in power balance associated with the patient choice reform. The introduction of the reform did not lead to any clear diversity between treatment providers, apart from differing views on the prescription of benzodiazepines, which by some managers was regarded as unfair competition.
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