Utilization of buprenorphine and methadone among opioid users who inject drugs

Characterizing Opioid Withdrawal Experiences and Consequences Among a Community Sample of People Who Use Opioids

BACKGROUND

Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA.

METHODS

Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27-63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data.

RESULTS

Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation.

CONCLUSION

Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm.

Estimated Clinical Outcomes and Cost-effectiveness Associated With Provision of Addiction Treatment in US Primary Care Clinics

Importance

US primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.

Objective

To estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.

Design, Setting, and Participants

In this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.

Main Outcomes and Measures

Life-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).

Results

The simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.

Conclusions and Relevance

This modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Community-, network-, and individual-level predictors of uptake of medication for opioid use disorder among young people who inject drugs and their networks: A multilevel analysis

BACKGROUND

Opioid use has been increasing at alarming rates over the past 15 years, yet uptake of medication for opioid use disorder (MOUD) remains low. Much of the research on individual characteristics predicting MOUD uptake is equivocal, and there is a dearth of research on setting-level and network-level characteristics that predict MOUD uptake. Towards a more holistic, multilevel understanding, we explore individual-level, network-level, and community-level characteristics associated with MOUD uptake.

METHODS

Baseline data from a longitudinal study of young people who inject drugs and their injection and support network members living in Chicago (N = 165) was used to conduct cross-sectional multilevel logistic regression analyses to examine associations between MOUD uptake and a set of potential predictors at the individual-, network-, and community-levels that were chosen based on theoretical relevance or support from previous empirical studies.

RESULTS

Stigma at both the individual and community levels was significantly associated with MOUD uptake (though in different directions). Greater individual-level stigma was associated with a higher likelihood of MOUD uptake, while having a more normatively stigmatizing community environment was associated with a lower likelihood of MOUD uptake. Using heroin and cocaine simultaneously and having a larger support network were associated with a greater likelihood of MOUD uptake.

CONCLUSIONS

The present study's holistic, multilevel approach identified three individual-level characteristics, one network-level characteristic, and one community-level characteristic associated with MOUD uptake. However, more research is needed examining multilevel predictors, to help with developing interventions addressing barriers to MOUD use at multiple levels of influence.

Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review

BACKGROUND

Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access.

METHODS

To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S.

RESULTS

In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD.

CONCLUSIONS

Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.

Substance Use Treatment Utilization Among Women With and Without Human Immunodeficiency Virus

Background

Substance use (SU) contributes to poor health outcomes, yet limited data exist to inform strategies to optimize SU treatment among persons with human immunodeficiency virus (HIV). We describe SU and SU treatment utilization among women with and without HIV in the Women's Interagency HIV Study (WIHS).

Methods

We included data from women enrolled in WIHS from 2013 to 2020. Current SU was self-reported, nonmedical use of drugs in the past year, excluding use of only marijuana. SU treatment utilization was self-reported use of a drug treatment program in the past year. Multivariable regression models were used to investigate associations between participant characteristics and SU treatment.

Results

Among 2559 women (1802 women living with HIV [WWH], 757 women without HIV), 14% reported current SU. Among those with current SU (n = 367), 71% reported crack/cocaine followed by 40% reporting opioids, and 42% reported any treatment in the past year. The most common treatments were methadone (64%), Narcotics Anonymous (29%), inpatient programs (28%), and outpatient programs (16%). Among women using opioids (n = 147), 67% reported methadone use in the past year compared to 5% using buprenorphine/naloxone. Multivariable analysis showed lower odds of treatment utilization among WWH with concurrent alcohol or marijuana use. Visiting a psychiatrist/counselor was associated with higher odds of treatment. Among WWH, SU treatment was not associated with HIV-related clinical outcomes.

Conclusions

Treatment utilization was high, especially for methadone use. Our results highlight opportunities for accessing SU treatment for WWH, such as the need to prioritize buprenorphine and comprehensive, wraparound services in HIV care settings.

Inpatient Opioid Use Disorder Treatment by Generalists is Associated With Linkage to Opioid Treatment Programs After Discharge

OBJECTIVES

Describe clinical and demographic associations with inpatient medication for opioid use disorder (MOUD) initiation on general medicine services and to examine associations between inpatient MOUD initiation by generalists and subsequent patient healthcare utilization.

METHODS

This is a retrospective study using medical record data from general medicine services at an urban safety-net hospital before an inpatient addiction consultation service. The patients were adults hospitalized for acute medical illness who had an opioid-related ICD-10 code associated with the visit. Associations with MOUD initiation were assessed using multivariable logistic regression. Hospital readmission, emergency department use, linkage to opioid treatment programs (OTP), and mortality at 30- and 90-days postdischarge were compared between those with and without hospital MOUD initiation using χ2 tests.

RESULTS

Of 1,284 hospitalized patients with an opioid-related code, 59.81% received MOUD and 31.38% of these were newly initiated in-hospital. In multivariable logistic regression, Black race, mood disorder, psychotic disorder, and alcohol use disorder were negatively associated with MOUD initiation, while being aged 25-34, having a moderate hospital severity of illness score, and experiencing homelessness were positively associated. There were no bivariate associations between MOUD initiation and postdischarge emergency department use, hospital readmission, or mortality at 30- and 90-days, but those initiated on MOUD were more likely to present to an OTP within 90 days (30.57% vs 12.80%, P < 0.001).

CONCLUSIONS

MOUD prescribing by inpatient generalists may help to increase the number of patients on treatment for opioid use disorder after hospital discharge. More research is needed to understand the impact of inpatient MOUD treatment without addiction specialty consultation.

Socio-ecological and pharmacy-level factors associated with buprenorphine stocking at pharmacies in New York City

BACKGROUND

Research is lacking on community and pharmacy-level factors that are associated with stocking buprenorphine. To address these gaps, this study applied a socio-ecological framework to estimate the association between community- and pharmacy-level factors and buprenorphine stocking among a sample of pharmacies in New York City.

METHODS

A telephone survey recruitment strategy was used to administer surveys to 662 pharmacies on the New York City Naloxone Standing Order Pharmacy list in 2018. The survey assessed pharmacy-level factors of private spaces to consult with pharmacists, type of pharmacy (chain/independent), size of pharmacy, having buprenorphine in stock and being open on nights and weekends. Socio-ecological variables drawn from census tract and public health data consisted of racial and ethnic composition, rates of poverty, rates of people without insurance, and rates of overdose. Mixed effects logistic regression estimated odds ratios (OR) of carrying buprenorphine in stock after adjusting for socio-ecological and pharmacy-level factors.

RESULTS

Fewer than half of the pharmacies reported having buprenorphine in stock (43.81% n = 290). Logistic regression analyses indicate that several pharmacy-level factors - the number of private spaces (aOR=1.67 95% CI=1.20, 2.32 p=.002), large size of the pharmacy (aOR=1.52 95% CI=1.04, 2.22, p=.032), having naloxone in stock (aOR=1.54, 95%CI=1.03, 2.32 p=.037), as well as neighborhood-level factors of higher rates of poverty (aOR=2.07 95%CI=1.07, 4.02 p<.001) and higher rates of uninsured residents were associated with carrying buprenorphine (aOR=0.23 95%CI=0.14,.38).

CONCLUSIONS

Using a socio-ecological framework, this study identified inequities in pharmacy stocking of buprenorphine by neighborhood rates of health insurance. At the pharmacy level, increasing private spaces for consultation and encouraging co-stocking of naloxone with buprenorphine stocking may reduce inequalities in buprenorphine availability.

'Treat my whole person, not just my condition': qualitative explorations of hepatitis C care delivery preferences among people who inject drugs

Background

The advent of direct-acting antivirals (DAAs)—a form of hepatitis C (HCV) treatment associated with shorter treatment course and greater efficacy—offers an unprecedented opportunity to eliminate HCV, but only if care delivery systems are developed to extend treatment to people who inject drugs (PWID). To support the design of a community-pharmacy program, we explored perspectives of PWID with chronic HCV with regard to barriers, motivators, preferences, and prior experiences related to HCV treatment and pharmacists.

Methods

We conducted semi-structured interviews with people living with HCV who reported active injection drug use. Participants were recruited from local community service and clinical organizations in the Seattle, Washington region, and focus groups and interviews were conducted in-person or via phone/video-conference. Rapid Assessment Process was used to analyze qualitative data. Dual coders used structured templates to summarize findings and engaged in iterative review to identify themes.

Results

Among the 40 participants, 65% were male, 52.5% were white, and 80% were not stably housed. On average, participants had been injecting drugs for 14 years and living with HCV for 6 years. Analyses revealed 3 themes: (1) limited knowledge regarding HCV and DAA treatments; (2) barriers/motivators for receiving treatment included fear of side effects, prior stigmatizing behaviors from physicians, and desire to protect relatives and the PWID community from HCV transmission; and (3) preferences for HCV care delivery, including a need for person-centered, low-barrier, and collaborative treatment integrated with other care (e.g. primary care and addiction treatment) for PWID. Participants were generally receptive to a community-pharmacy model for HCV treatment, but prior interactions with pharmacists were mixed and there were some concerns expressed that care delivered by pharmacists would not be equivalent to that of physicians.

Conclusions

Even in the direct-acting antivirals era, people who inject drugs still face major barriers to hepatitis C treatment which may be reduced by providing low-barrier points of access for care through pharmacists. Key recommendations for community-pharmacy design included providing care team training to reduce stigma and ensuring care team structures and culture target PWID-specific needs for education and engagement.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00260-8.

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.

The Abuse Characteristics of Amphetamine-Type Stimulants in Patients Receiving Methadone Maintenance Treatment and Buprenorphine Maintenance Treatment

Objective

The purpose of this study was to retrospectively investigate the abuse characteristics of amphetamine-type stimulants (ATS) in patients receiving methadone maintenance treatment (MMT) and buprenorphine maintenance treatment (BMT).

Methods

A total of 58 MMT and 51 BMT patients abusing ATS were recruited from the drug maintenance treatment clinic of Ningbo Addiction Research and Treatment Center from January 2018 to December 2019. They were assessed using the amphetamine abuse questionnaire (AAQ), addiction severity index (ASI) and Barratt impulsiveness scale (BIS). Moreover, 40 MMT control patients, 40 BMT control patients and 20 healthy controls were also assessed using the BIS. All information was collected using the amphetamine abuse questionnaire (AAQ), Chinese version of addiction severity index (ASI-C) and Chinese version of Barratt impulsiveness scale (BIS-C) conducted by qualified psychologists.

Results

The interval of amphetamine use in the MMT group was shorter than the BMT group (P < 0.05). The drug use subscale score of ASI was higher in the MMT group than the BMT group (P < 0.05). The respective and total scores of attentional impulsiveness, motor impulsiveness and non-planning impulsiveness in BIS in the MMT group were all higher than the MMT control group (P < 0.05). The scores of motor impulsiveness and non-planning impulsiveness in the BMT group were higher than the BMT control group (P < 0.05). The respective and total scores in BIS in the MMT control group and the BMT control group were all higher than those in the healthy controls.

Conclusion

The patients showing amphetamine abuse in maintenance therapy had a greater impulsiveness than those having other simple maintenance treatments, and patients under MMT may be more addicted to amphetamines in comparison with those having BMT.

Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV

BACKGROUND

Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV.

OBJECTIVE

To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV.

DESIGN

Retrospective observational cohort study using electronic health record and insurance data.

PARTICIPANTS

Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN).

MAIN MEASURES

The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site.

KEY RESULTS

The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72).

CONCLUSIONS

Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.

Familial perceptions of appropriate treatment types and goals for a family member who has opioid use disorder

BACKGROUND

Despite effective, evidence-based medications for opioid use disorder (MOUD), these treatments remain underutilized. This may be due to multiple reasons. Family members may impact patient decision-making when choosing an opioid use disorder (OUD) treatment. While there has been work on patient preferences and attitudes towards opioid use disorder (OUD) treatment, to date, there has been minimal work assessing the attitudes of family member towards OUD treatment and recovery.

METHODS

Participants were ≥ 18 years of age and endorsed having a first-degree family member with past-year treatment for OUD. Participants were recruited via online crowdsourcing and were asked a number of questions regarding their desired outcomes for OUD treatment, and their familiarity, approval, and perceived effectiveness of various OUD treatment options.

RESULTS

The most commonly reported desired treatment outcome (50 %) was for family members to never use any kind of opioid, including maintenance therapies or opioid analgesics. Mean familiarity ratings for MOUD (rated 0-100) were relatively low, with naltrexone being the least familiar (32.3). Among those who endorsed a familiarity rating of at least 30 for a given treatment, mean approval and effectiveness ratings were relatively low-buprenorphine (approve 55.1; effective 54.1), methadone (approve 51.9; effective 49.3), naltrexone (approve 61.6; effective 55.9). These were lower than approval and effectiveness ratings for all non-MOUD treatments queried.

CONCLUSIONS

These findings highlight a need for clinicians and researchers to engage with family members' regarding their preferences and understanding of treatment, and to better understand how this might impact patient engagement with treatment.

Increased utilization of buprenorphine and methadone in 2018 compared to 2015 among Seattle-area persons who inject drugs

OBJECTIVE

To describe utilization patterns of methadone and buprenorphine among persons who inject drugs (PWID) in the Seattle area in 2018, compared to 2015.

METHODS

Data from the 2018 National HIV Behavioral Surveillance (NHBS) system were used to compare the proportions of PWID reporting treatment with buprenorphine or methadone to survey responses in 2015. Temporal trends were assessed by calculating adjusted prevalence ratios (aPR) using Poisson regression.

RESULTS

The sample included 498 PWID, of whom 39.2% (95% CI: 34.8-43.6%) reported past-year treatment with methadone and 21.9% (95% CI: 18.3-25.8%) reported buprenorphine. Participants in 2018 were significantly more likely to report past year receipt of buprenorphine (aPR = 4.43, 95% CI: 2.81-7.01) or methadone (aPR = 1.38, 95% CI: 1.02-1.87) compared to 2015. Most buprenorphine treated participants (67.6%) reported that they had received buprenorphine through low-barrier, community, or nonprofit programs.

CONCLUSIONS

Among PWID who use opioids in the Seattle area, methadone use increased 38%, and buprenorphine use more than quadrupled from 2015 to 2018. Approximately half of surveyed PWID who use opioids still reported no treatment with either medication, highlighting remaining treatment gaps.

Increasing Heroin-Methamphetamine (Goofball) Use and Related Morbidity Among Seattle Area People Who Inject Drugs

BACKGROUND AND OBJECTIVES

Methamphetamine use is increasing in the United States, potentially including the simultaneous injection of methamphetamine with heroin (goofball). We compared demographic, behavioral, contextual, and health factors among people who inject drugs (PWID) in the Seattle area and who reported that their main drug was goofball, heroin, or methamphetamine.

METHODS

We used data from 2017 and 2019 cross-sectional surveys of clients at Public Health-Seattle & King County's syringe services program (N = 792).

RESULTS

Among PWID participants, 55.3% reported using goofball in the last 3 months, and the proportion reporting goofball as their main drug doubled between 2017 (10.3%) and 2019 (20.1%, P < .001). The goofball group had the highest proportions of people who were aged less than 30, women, homeless or unstably housed, and recently incarcerated. PWID whose main drug was goofball reported considerable health risks and morbidity. Witnessing an opioid overdose was most commonly reported by participants whose main drug was goofball. This group also reported naloxone possession and use in an overdose situation more than other participants. The majority of participants were interested in reducing or stopping their opioid and stimulant use.

DISCUSSION AND CONCLUSIONS

Among PWID, using goofball as a main drug doubled over 2 years and was characterized by contextual and individual factors that increase the risk of morbidity and mortality.

SCIENTIFIC SIGNIFICANCE

This is the first study to characterize goofball use as a main drug. Clinical and public health efforts to diminish morbidity associated with opioid use need to integrate interventions that address the co-use of methamphetamine. (Am J Addict 2020;00:00-00).

Brief Training on Medication-Assisted Treatment Improves Community Mental Health Clinicians' Confidence and Readiness to Address Substance Use Disorders

Despite the availability and effectiveness of medication-assisted treatment (MAT) for substance use disorders (SUDs), utilization of these medications remains suboptimal, especially in public sector settings. A key limitation is clinicians' reluctance to include MAT in their routine practice due, in part, to low confidence about managing SUDs and limited awareness of the disease model of addiction. This study evaluates the impact of a 1-day MAT training for community mental health clinicians using a 30-item pre- and post-training questionnaire. Of the 109 clinicians who attended the training, 107 completed the pre- and post-training questionnaires. Factor analysis of the questionnaire identified two domains: readiness to address SUDs among patients (factor 1) and understanding SUDs as diseases (factor 2). Post training, there was a significant change in both factor 1 (p = .00001) and factor 2 (p = .00003), indicating that a brief MAT training can increase clinicians' confidence and readiness to address SUDs and improve their understanding of the disease model of addiction.

Healthcare Access and Utilization Among Persons Who Inject Drugs in Medicaid Expansion and Nonexpansion States: 22 United States Cities, 2018

BACKGROUND

Medicaid expansion under the Affordable Care Act increased insurance coverage, access to healthcare, and substance use disorder treatment, for many Americans. We assessed differences in healthcare access and utilization among persons who inject drugs (PWID) by state Medicaid expansion status.

METHODS

In 2018, PWID were interviewed in 22 US cities for National HIV Behavioral Surveillance. We analyzed data from PWID aged 18-64 years who reported illicit use of opioids (n = 9957) in the past 12 months. Poisson regression models with robust standard errors were used to estimate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) were used to examine differences by Medicaid expansion status in indicators of healthcare access and utilization.

RESULTS

Persons who inject drugs in Medicaid expansion states were more likely to have insurance (87% vs 36%; aPR, 2.3; 95% CI, 2.0-2.6), a usual source of healthcare (53% vs 34%; aPR, 1.5; 95% CI, 1.3-1.9), and have used medication-assisted treatment (61% vs 36%; aPR, 1.4; 95% CI, 1.1-1.7), and they were less likely to have an unmet need for care (21% vs 39%; aPR, 0.6; 95% CI, 0.4-0.7) than those in nonexpansion states.

CONCLUSIONS

Low insurance coverage, healthcare access, and medication-assisted treatment utilization among PWID in some areas could hinder efforts to end the intertwined human immunodeficiency virus and opioid overdose epidemics.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

Correlates of death during outpatient treatment for opioid use disorder: A national study

BACKGROUND

As the burden of opioid use disorder (OUD) increases in the United States, manifold federal and state initiatives have sought to increase access to treatment for OUD, which includes behavioral and pharmaceutical treatment modalities. Although the evidence base for outpatient treatment for OUD-including medications for opioid use disorder-is substantial, few studies have examined the risk factors for fatality during treatment for OUD.

METHODS

Treatment Episode Data Set-Discharges (TEDS-D) data were used to evaluate correlates of death during outpatient treatment for OUD in 2016. To determine the correlates of mortality during an outpatient treatment for OUD, we constructed a pooled logistic regression model, stratified by use of medication for opioid use disorder (MOUD), to control for the duration of time in treatment and to identify the independent characteristics that may lead to differences in the odds of mortality during treatment.

FINDINGS

1861 (0.8%) of 235,745 outpatient treatment episodes for OUD included in our analysis resulted in fatality. Many factors correlated with death during treatment were similar for individuals who did and did not receive MOUD. However, non-White race was only significantly associated with decreases in fatality in non-MOUD treatment episodes. Male sex and reported intravenous drug use at admission were associated with fatality only for treatment episodes that did not involve MOUD.

CONCLUSIONS

In this national study of outpatient treatment episodes for OUD, we found differences in age, sex, region, drug use history, treatment setting, and treatment history significantly affected the risk of death during treatment. As more people become engaged with treatment, facilities should work toward delivering optimal treatment for all patients regardless of personal characteristics.

Outcomes Associated With Medications for Opioid Use Disorder Among Persons Hospitalized for Infective Endocarditis

BACKGROUND

Endocarditis, once predominately found in older adults, is increasingly common among younger persons who inject drugs. Untreated opioid use disorder (OUD) complicates endocarditis management. We aimed to determine if rates of overdose and rehospitalization differ between persons with OUD with endocarditis who are initiated on medications for OUD (MOUDs) within 30 days of hospital discharge and those who are not.

METHODS

We performed a retrospective cohort study using a large commercial health insurance claims database of persons ≥18 years between July 1, 2010, and June 30, 2016. Primary outcomes included opioid-related overdoses and 1-year all-cause rehospitalization. We calculated incidence rates for the primary outcomes and developed Cox hazards models to predict time from discharge to each primary outcome as a function of receipt of MOUDs.

RESULTS

The cohort included 768 individuals (mean age 39 years, 51% male). Only 5.7% of people received MOUDs in the 30 days following hospitalization. The opioid-related overdose rate among those who did receive MOUDs in the 30 days following hospitalization was lower than among those who did not (5.8 per 100 person-years [95% confidence interval [CI], 5.1-6.4] vs 7.3 per 100-person years [95% CI, 7.1-7.5], respectively). The rate of 1-year rehospitalization among those who received MOUDs was also lower than those who did not (162.0 per 100 person-years [95% CI, 157.4-166.6] vs 255.4 per 100 person-years [95% CI, 254.0-256.8], respectively). In the Cox hazards models, the receipt of MOUDs was not associated with either of the outcomes.

CONCLUSIONS

MOUD receipt following endocarditis may improve important health-related outcomes in commercially insured persons with OUD.

Effect of lowering initiation thresholds in a primary care-based buprenorphine treatment program

BACKGROUND

Office-based buprenorphine treatment is effective for opioid use disorder. Scant research has examined programmatic factors impacting successful initiation of treatment. To increase initiation of eligible patients, our buprenorphine program implemented changes to lower treatment thresholds. Most notable among these was elimination of a requirement that patients demonstrate abstinence from stimulants prior to initiating buprenorphine.

METHODS

This observational, retrospective study included patients screened for primary care-based buprenorphine treatment under high- and low-threshold conditions from 2015 to 2017. Background characteristics and treatment data were extracted from the electronic medical record and clinical registry. Chi-squared tests were used to compare proportions of patients initiated within 90 days of screening and retained to 60 days after initiation, under both conditions. Multivariate logistic regression was employed to compare relative odds of buprenorphine initiation after adjustment for several covariates. All analyses were stratified by recent stimulant use.

RESULTS

The sample of 168 patients included 96 in the high-threshold group and 72 in the low-threshold group. Among patients with recent stimulant use, low-threshold conditions were associated with a higher proportion of patients initiated (69% versus 35%, p = 0.002) and higher relative odds of initiation (aOR = 7.01, 95% CI = 2.26-21.80) but also with a lower proportion of patients retained (63% versus 100%, p = 0.004). Among patients without recent stimulant use, low-threshold conditions did not change these measures by a statistically significant margin.

CONCLUSIONS

Lower-threshold policies may increase buprenorphine treatment initiation for patients with co-occurring stimulant use. However, patients using stimulants may require additional supports to remain engaged.

Targeting opioid dysregulation in depression for the development of novel therapeutics

Since the serendipitous discovery of the first class of modern antidepressants in the 1950's, all pharmacotherapies approved by the Food and Drug Administration for major depressive disorder (MDD) have shared a common mechanism of action, increased monoaminergic neurotransmission. Despite the widespread availability of antidepressants, as many as 50% of depressed patients are resistant to these conventional therapies. The significant length of time required to produce meaningful symptom relief with these medications, 4-6 weeks, indicates that other mechanisms are likely involved in the pathophysiology of depression which may yield more viable targets for drug development. For decades, no viable candidate target with a different mechanism of action to that of conventional therapies proved successful in clinical studies. Now several exciting avenues for drug development are under intense investigation. One of these emerging targets is modulation of endogenous opioid tone. This review will evaluate preclinical and clinical evidence pertaining to opioid dysregulation in depression, focusing on the role of the endogenous ligands endorphin, enkephalin, dynorphin, and nociceptin/orphanin FQ (N/OFQ) and their respective receptors, mu (MOR), delta (DOR), kappa (KOR), and the N/OFQ receptor (NOP) in mediating behaviors relevant to depression and anxiety. Finally, putative opioid based antidepressants that are under investigation in clinical trials, ALKS5461, JNJ-67953964 (formerly LY2456302 and CERC-501) and BTRX-246040 (formerly LY-2940094) will be discussed. This review will illustrate the potential therapeutic value of targeting opioid dysregulation in developing novel therapies for MDD.

Provider and patient perspectives on barriers to buprenorphine adherence and the acceptability of video directly observed therapy to enhance adherence

Background

Buprenorphine effectively reduces opioid craving and illicit opioid use. However, some patients may not take their medication as prescribed and thus experience suboptimal outcomes. The study aim was to qualitatively explore buprenorphine adherence and the acceptability of utilizing video directly observed therapy (VDOT) among patients and their providers in an office-based program.

Methods

Clinical providers (physicians and staff; n = 9) as well as patients (n = 11) were recruited from an office-based opioid treatment program at an urban academic medical center in the northwestern United States. Using a semi-structured guide, interviewers conducted individual interviews and focus group discussions. Interviews were digitally recorded and transcribed verbatim. Transcripts were independently coded to identify key themes related to non-adherence and then jointly reviewed in an iterative fashion to develop a set of content codes.

Results

Among providers and patients, perceived reasons for buprenorphine non-adherence generally fell into several thematic categories: social and structural factors that prevented patients from consistently accessing medications or taking them reliably (e.g., homelessness, transportation difficulties, chaotic lifestyles, and mental illness); refraining from taking medication in order to use illicit drugs or divert; and forgetting to take medication, especially in the setting of taking split-doses. Some participants perceived non-adherence to be less of a problem for buprenorphine than for other medications. VDOT was viewed as potentially enhancing patient accountability, leading to more trust from providers who are concerned about diversion. On the other hand, some participants expressed concern that VDOT would place undue burden on patients, which could have the opposite effect of eroding patient-provider trust. Others questioned the clinical indication.

Conclusions

Findings suggest potential arenas for enhancing buprenorphine adherence, although structural barriers will likely be most challenging to ameliorate. Providers as well as patients indicated mixed attitudes toward VDOT, suggesting it would need to be thoughtfully implemented.