Stigma from the Viewpoint of the Patient

Lived experiences of Oxford House residents prescribed medication-assisted treatment

Qualitative studies have examined the recovery experiences of individuals prescribed medication-assisted treatment (MAT), including their experiences within treatment facilities. However, the literature lacks qualitative studies exploring the recovery process of individuals prescribed MAT while living in recovery housing, such as Oxford House (OH). The purpose of this study was to explore how OH residents, who are prescribed MAT, make sense of recovery. The fact that OHs are drug-free recovery housing is what makes the issue of using MATs potentially contentious in these settings. Interpretative phenomenological analysis (IPA) was used to document the lived experiences of individuals prescribed MAT in OH. The sample included: five women and three men, prescribed either methadone or Suboxone, that were living in an OH in the United States. Participants were interviewed on four topics: their recovery process, their transition to OH, and their experience living in and outside of an OH. Analysis of results followed the recommendations for IPA from Smith, Flowers, and Larkin. Four general themes emerged from the data: Recovery Process, Managing Logistics of MAT Utilization, Personal Development, and Familial Values. In conclusion, individuals prescribed MAT did benefit from living in an OH to manage their recovery as well as stay compliant with their medication.

Nurses' experiences of ethical and legal issues in post-resuscitation care: A qualitative content analysis

BACKGROUND

Cardiopulmonary resuscitation and subsequent care are subject to various ethical and legal issues. Few studies have addressed ethical and legal issues in post-resuscitation care.

OBJECTIVE

To explore nurses' experiences of ethical and legal issues in post-resuscitation care.

RESEARCH DESIGN

This qualitative study adopted an exploratory descriptive qualitative design using conventional content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

In-depth, semi-structured interviews were conducted in three educational hospital centers in northwestern Iran. Using purposive sampling, 17 nurses participated. Data were analyzed by conventional content analysis.

ETHICAL CONSIDERATIONS

The study was approved by Research Ethics Committees at Tabriz University of Medical Sciences. Participation was voluntary and written informed consent was obtained. For each interview, the ethical principles including data confidentiality and social distance were respected.

FINDINGS

Five main categories emerged: Pressure to provide unprincipled care, unprofessional interactions, ignoring the patient, falsifying documents, and specific ethical challenges. Pressures in the post-resuscitation period can cause nurses to provide care that is not consistent with guidelines, and to avoid communicating with physicians, patients and their families. Patients can also be labeled negatively, with early judgments made about their condition. Medical records can be written in a way to indicate that all necessary care has been provided. Disclosure, withdrawing, and withholding of therapy were also specific important ethical challenges in the field of post-resuscitation care.

CONCLUSION

There are many ethical and legal issues in post-resuscitation care. Developing evidence-based guidelines and training staff to provide ethical care can help to reduce these challenges.

Experiences of Healthcare and Substance Use Treatment Provider-based Stigma Among Patients Receiving Methadone

Background

Medications for Opioid Use Disorder (MOUD) are efficacious, however only one-third of individuals with an opioid use disorder (OUD) enter into treatment. Low rates of MOUD utilization are partially due to stigma. This study examines provider-based stigma toward MOUD and identifies factors associated with experiencing stigma related to MOUD from substance use treatment and healthcare providers among people receiving methadone.

Methods

Clients receiving MOUD at an opioid treatment program (N = 247) were recruited to complete a cross-sectional computer-based survey assessing socio-demographics, substance use, depression and anxiety symptoms, self-stigma, and recovery supports/barriers. Logistic regression was used to examine factors associated with hearing negative comments about MOUD from substance use treatment and healthcare providers.

Results

27.9% and 56.7% of respondents reported they sometimes/often hear negative comments about MOUD from substance use treatment and healthcare providers, respectively. Logistic regression results indicate that individuals who experience more negative consequences resulting from their OUD (OR=1.09, p=.019) had greater odds of hearing negative comments from substance use treatment providers. Age (OR=0.966, p=.017) and treatment stigma (OR=1.42, p=.030) were associated with greater odds of hearing negative comments from healthcare providers.

Conclusions

Stigma can be a deterrent to seeking substance use treatment, healthcare, and recovery support. Understanding factors associated with experiencing stigma from substance use treatment providers and healthcare providers is important as these individuals may act as advocates for those with OUD. This study highlights individual factors associated with hearing negative comments about methadone and other MOUD and point to areas for targeted education.

Patient-centered quality measurement for opioid use disorder: Development of a taxonomy to address gaps in research and practice

Background: Evidence-based treatment is provided infrequently and inconsistently to patients with opioid use disorder (OUD). Treatment guidelines call for high-quality, patient-centered care that meets individual preferences and needs, but it is unclear whether current quality measures address individualized aspects of care and whether measures of patient-centered OUD care are supported by evidence. Methods: We conducted an environmental scan of OUD care quality to (1) evaluate patient-centeredness in current OUD quality measures endorsed by national agencies and in national OUD treatment guidelines; and (2) review literature evidence for patient-centered care in OUD diagnosis and management, including gaps in current guidelines, performance data, and quality measures. We then synthesized these findings to develop a new quality measurement taxonomy that incorporates patient-centered aspects of care and identifies priority areas for future research and quality measure development. Results: Across 31 endorsed OUD quality measures, only two measures of patient experience incorporated patient preferences and needs, while national guidelines emphasized providing patient-centered care. Among 689 articles reviewed, evidence varied for practices of patient-centered care. Many practices were supported by guidelines and substantial evidence, while others lacked evidence despite guideline support. Our synthesis of findings resulted in EQuIITable Care, a taxonomy comprised of six classifications: (1) patient Experience and engagement, (2) Quality of life; (3) Identification of patient risks; (4) Interventions to mitigate patient risks; (5) Treatment; and (6) Care coordination and navigation. Conclusions: Current quality measurement for OUD lacks patient-centeredness. EQuIITable Care for OUD provides a roadmap to develop measures of patient-centered care for OUD.

Buprenorphine and its formulations: a comprehensive review

Buprenorphine, a novel long-acting analgesic, was developed with the intention of two purposes: analgesia and opioid use disorder. Regarding its pharmacodynamics, it is a partial agonist at mu receptors, an inverse agonist at kappa receptors, and an antagonist at delta receptors. For the purpose of analgesia, three formulations of buprenorphine were developed: IV/IM injectable formulation (Buprenex®), transdermal patch formulation (Butrans®), and buccal film formulation (Belbuca®). Related to opioid dependence, the formulations developed were subcutaneous extended release (Sublocade®), subdermal implant (Probuphine®), and sublingual tablets (Subutex®). Lastly, in order to avoid misuse of buprenorphine for opioid dependence, two combination formulations paired with naloxone were developed: film formulation (Suboxone®) and tablet formulation (Zubsolv®). In this review, we present details of each formulation along with their similarities and differences between each other and clinical considerations.

Mifepristone (RU-486®) as a Schedule IV Controlled Drug-Implications for a Misleading Drug Policy on Women's Health Care

BACKGROUND

Mifepristone (RU-486) has been approved for abortion in Taiwan since 2000. Mifepristone was the first non-addictive medicine to be classified as a schedule IV controlled drug. As a case of the "misuse" of "misuse of drugs laws," the policy and consequences of mifepristone-assisted abortion for pregnant women could be compared with those of illicit drug use for drug addicts.

METHODS

The rule-making process of mifepristone regulation was analyzed from various aspects of legitimacy, social stigma, women's human rights, and access to health care.

RESULTS AND DISCUSSION

The restriction policy on mifepristone regulation in Taiwan has raised concerns over the legitimacy of listing a non-addictive substance as a controlled drug, which may produce stigma and negatively affect women's reproductive and privacy rights. Such a restriction policy and social stigma may lead to the unwillingness of pregnant women to utilize safe abortion services. Under the threat of the COVID-19 pandemic, the US FDA's action on mifepristone prescription and dispensing reminds us it is time to consider a change of policy.

CONCLUSIONS

Listing mifepristone as a controlled drug could impede the acceptability and accessibility of safe mifepristone use and violates women's right to health care.

Addressing Bias and Stigma in the Language We Use With Persons With Opioid Use Disorder: A Narrative Review

BACKGROUND: Despite an increase in access to medications for opioid use disorder, less than 20% of individuals with opioid use disorder (OUD) receive treatment. Stigmatizing language has been identified as a potential trigger for explicit and implicit biases that may adversely affect treatment enrollment and quality of care for persons with OUD. AIMS: To conduct a narrative review of the literature on stigmatizing language and OUD, examine how treatment outcomes are affected, and present strategies to reduce bias and promote OUD treatment. METHOD: A narrative review of the literature between 2010 and 2019 was conducted using CINAHL, PubMed, and PsycINFO. Key search terms were opioid use disorder (or substance use disorder), stigma, and language. Fifty-two articles were screened for inclusion, and 17 articles were included in this review. RESULTS: The articles reviewed provide consensus that stigmatizing language toward persons with OUD fosters explicit and implicit bias and impedes engagement in treatment. Four themes emerged: (1) stigma and language, (2) stigma and language used by health care professionals, (3) stigma and language used by the general public, and (4) stigma and language used by people with OUD. CONCLUSIONS: Stigmatizing language is dehumanizing and plays a pivotal role in bias and discrimination that may contribute to unsatisfactory treatment outcomes among persons with OUD. Health care professionals, nursing in particular, must assume an intentional stance against stigma perpetuated toward persons with OUD through advocacy in education, practice, policy, and the media.

Buprenorphine Waiver Attitudes Among Primary Care Providers

BACKGROUND

Despite efforts to improve access to Medications for Opioid Use Disorder (MOUD), such as buprenorphine, the number of opioid overdoses in the United States continues to rise. In April 2021, the Department of Health and Human Services removed the mandatory training requirement to obtain a buprenorphine waiver; the goal was to encourage more providers to prescribe buprenorphine, thus improving access. Little is known about the attitudes on buprenorphine prescribing after this policy change.

OBJECTIVE

The primary objective was to assess attitudes among primary care providers toward the removal of the buprenorphine waiver training requirement. A secondary objective was to identify other barriers to prescribing buprenorphine.

METHODS

We conducted a survey between September 15 and October 13, 2021 to assess the overall beliefs on the effectiveness of MOUD and attitudes toward the removal of the waiver training, current knowledge of buprenorphine, current practice styles related to screening for and treating OUD, and attitudes toward prescribing buprenorphine in the future. This survey was sent to 890 Mayo Clinic primary care providers in 5 US states.

RESULTS

One hundred twenty-three respondents (13.8%) completed the survey; 35.8% respondents agreed that the removal of the waiver training was a positive step. These respondents expressed a greater familiarity with the different formulations, pharmacology, and titration of buprenorphine. This group was also more likely to prescribe (or continue to prescribe) buprenorphine in the future. Approximately one-third (34.4%) of respondents reported perceived institutional support in prescribing buprenorphine. This group expressed greater confidence in diagnosing OUD, had greater familiarity with the different formulations, pharmacology, and titration of buprenorphine, and was more likely to prescribe (or continue to prescribe) buprenorphine in the future. Respondents who have been in practice for 11 to 20 years since completion of training were most likely to refer all OUD patients to specialists.

CONCLUSIONS

Results of our survey suggests that simply removing the mandatory waiver training requirement is insufficient in positively changing attitudes toward buprenorphine prescribing. A key barrier is the perceived lack of institutional support. Future studies investigating effective ways to provide such support may help improve providers' willingness to prescribe buprenorphine.

Qualitative characterizations of misinformed disclosure reactions to medications for opioid use disorders and their consequences

INTRODUCTION

Methadone and buprenorphine/naloxone medications are among the most effective treatment options for opioid use disorders, yet many people remain misinformed about their benefits and hold negative perceptions about the use of medications to treat opioid use disorders. Such perceptions, especially negative perceptions based on misinformation, may be especially harmful or stigmatizing within the context of disclosure (i.e., telling another about one's opioid use disorder history or treatment), inhibiting important recovery outcomes and sources of social support.

METHODS

Therefore, using the Disclosure Process Model as a framework, the current study seeks to characterize and compare participants' perceptions of stigmatizing reactions to their disclosures of MOUD use that stem from misinformation about methadone or buprenorphine/naloxone. Participants included people who are actively receiving MOUD as treatment.

RESULTS

Results suggest that participants (N = 52) receiving both types of medications experienced similar stigmatizing reactions to disclosures. Participants also reported treatment consequences of misinformed reactions to their disclosure, such as dropping out of support groups (e.g., Narcotics Anonymous) or prematurely ending their medication use. Further, the paper provides participants' recommendations for avoiding or managing misinformed disclosure reactions.

CONCLUSIONS

Short-term intervention efforts may promote strategies to manage misinformation, equipping individuals to respond to misinformation surrounding their medication use. Long-term interventions may target misinformation about methadone and buprenorphine/naloxone medications to increase health literacy, reduce stigma, and combat cultural ambivalence within communities, as well as promote recovery among people receiving medications for opioid use disorder.

Factors associated with obtaining employment among opioid use disorder patients enrolled in a therapeutic workplace intervention

BACKGROUND

Unemployment is a common problem among adults who have substance use disorder that often persists during treatment and recovery. We identified patient characteristics that were associated with obtaining employment among unemployed adults in opioid use disorder treatment.

METHODS

This analysis used data from participants (N = 91) who were enrolled in a randomized controlled trial evaluating the effectiveness of a therapeutic workplace in promoting drug abstinence and employment. After a 3-month training period (Phase 1), participants were randomly assigned to a study group and could work for 12 months with an employment specialist who assisted participants in obtaining employment (Phase 2). A logistic regression model was used to identify patient characteristics that were associated with obtaining employment.

RESULTS

Of the 91 participants, 39 (42.9 %) obtained employment. Compared to participants who did not obtain employment, participants who obtained employment worked more days in the therapeutic workplace during the training period (Phase 1) [OR (95 % CI) = 1.072 (1.015-1.132), p = .014], provided more opiate- and cocaine-negative urine samples while seeking employment [OR (95 % CI) = 1.015 (1.002-1.027), p = .025], and reported not usually being unemployed at study intake [OR (95 % CI) = 0.229 (0.080-0.652), p = .007].

CONCLUSIONS

Our analyses suggest that among unemployed adults in opioid use disorder treatment, those with the lowest rates of therapeutic workplace attendance, lowest rates of drug abstinence while seeking employment, and relatively long histories of unemployment are the least likely to obtain employment. These relations are potentially addressable at a practical level, and future research could build on these findings to improve the effectiveness of employment-based interventions.

"Don't Label Them as Addicts!" Student Pharmacists' Views on the Stigma Associated with Opioid use Disorder

Background:

Student pharmacists represent an important potential population for targeted educational interventions focused on skill and confidence development in order to improve interactions with opioid users and to decrease stigma. The objective of this study was to understand student pharmacists’ perceptions of opioid users.

Methods:

Focus groups were conducted with student pharmacists across Tennessee over two months in 2020. Concepts from the Transtheoretical Mode, Social Cognitive Theory, stigma, and results from a survey sent to student pharmacists were used to develop the open-ended questions. Thematic analysis was conducted to inductively identify main themes. The recruitment of student pharmacists continued until thematic saturation was obtained.

Results:

Three focus groups were conducted with a total of 16 student pharmacists in second, third, and fourth professional years. Thematic analysis revealed two themes: Don’t label them as addicts, Student Insight into OUD-Associated Stigma and five sub-themes: developing a judgment-free environment; unconscious bias; a possible connection between physical appearance and addiction; socio-cultural factors, addiction, and isolation; and motivators to decrease stigma. This study not only presents the pharmacy students experiences and their significance, but also reports their recommendations for addressing the stigma associated with OUD in the pharmacy curriculum.

Conclusions:

These findings highlight the need to normalize appropriate language when describing patients with OUD and avoid negative labels such as “addict.” The findings also indicate where the roots of stigma lie and provide some of the tools to fight stigma on different fronts. Future research should explore and address potential implicit biases throughout pharmacy curriculum.

Political frames of public health crises: Discussing the opioid epidemic in the US Congress

When and how do politicians talk about public health crises? Using evidence from the opioid crisis in the United States, this paper assembles and analyzes novel data on Congressional statements to explore the conditions under which politicians (1) issue public statements about opioids and (2) frame the opioid crisis as a predominantly public health or law enforcement problem. We examined 3.8 million Congressional floor speeches and 111,000 public statements to identify (1) floor speeches about drug crises in the 97th to 114th Congresses (1981-2017) and (2) public statements about the opioid crisis in the 116th Congress (2019-2020). Moderate ideology, women, greater overdose deaths, and larger white populations are associated with significantly higher frequencies of opioid statements. Using a dictionary-based text analysis approach, we find that ideologically liberal and African American legislators are more likely to use public health framing, while ideologically conservative members are more likely to use law enforcement framing and refer to national borders or foreign countries in opioid statements. Democrats/liberals more often referenced medication treatment for opioids. These findings imply two broader conclusions about the nature of political discourse in public health crises. First, that political extremists are least likely to talk about opioids suggests that increasing partisan polarization may result in less discussion, emphasis, and expertise in public health issues. Second, the tenor of discourse about opioids and other public health crises is likely to change with partisan electoral waves, potentially hindering long term planning of public health capacity.

Recovery opioid overdose team (ROOT) pilot program evaluation: A community-wide post-overdose response strategy

BACKGROUND

Effective interventions for overdose survivors are needed in the emergency departments (EDs). One promising model is the use of peer recovery coaches to engage with survivors in EDs, followed by partnering with community case management navigators to connect survivors to recovery support and treatment services. This paper describes the evaluation of a pilot program, the Recovery Opioid Overdose Team (ROOT), a warm hand-off system that links survivors to treatment services post-ED discharge. Methods: The ROOT program is composed of a peer recovery coach who is in long-term recovery, and a case management navigator who specializes in mental health care and provides guidance for accessing community services. After an overdose reversal, law enforcement contacts a county 24/7 Crisis Team, who then notifies ROOT. The peer recovery coach engages with the survivor in the ED, and then follow up continues with the case management navigator and the peer recovery coach for up to 90 days post-ED discharge. Retrospective chart reviews were conducted to evaluate ROOT in two Midwest EDs from September 2017 through March 2019. Results: Of the 122 referrals, 77.0% (n = 94) of the survivors initially engaged with ROOT in the ED or in the community. The remaining 23.0% (n = 28) left the ED against medical advice or were unengaged. The majority of overdose survivors were male (63.9%; n = 78), White (43.4%; n = 53), had housing (80.2%; n = 48), and access to transportation (48.4%; n = 59). From the 122 referrals, 33.6% (n = 41) received ongoing treatment services (n = 20 outpatient, n = 17 residential, n = 2 detoxification facility, n = 1 recovery housing, n = 1 medication treatment for opioid use disorder), 2.5% (n = 3) were incarcerated, 2.5% (n = 3) died, and 61.5% (n = 75) declined services. Conclusions: The ROOT, a community-wide coordinated program in the EDs, shows promise in linking overdose survivors to recovery support and treatment services post-overdose.

Cognitive-behavioral therapy and buprenorphine for opioid use disorder: A systematic review and meta-analysis of randomized controlled trials

Background: Recent systematic reviews have questioned the ability of psychosocial intervention to add substantive benefit to buprenorphine therapy. Objectives: The purpose of the present meta-analysis was to test the random effects model (REM) null hypothesis that, for opioid use disorder (OUD) and opioid biological sample outcomes, the summary effect of cognitive-behavioral therapy (CBT) + buprenorphine randomized controlled trials (RCTs) = 0. Methods: A systematic review was conducted searching electronic databases and the reference lists of included studies. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria were used to guide this review and the REM meta-analysis. Results: The initial meta-analytic model (k = 4) was insignificant (REM Hedges' g =.22, Z = 1.27, p =.206, 95% CI: -0.12-0.56) and heterogeneous (I2 = 53.47). A pre-specified categorical moderator analysis explained the heterogeneity via CBT modality. Categorical moderator analysis (k = 4) showed non-individual CBT RCTs (k = 2) to have a REM Hedges' g summary effect of.598 (p =.006) and individual-CBT RCTs (k = 2) to have a REM Hedges' g summary effect of -0.010 (p = .936). The difference between these two subgroups was significant (Q = 5.85, df = 1, p = .016). Conclusion: The evidence cautiously suggests that for OUD, there may be some benefit to adding non-individual CBT to buprenorphine therapy.

Stigma of Opioid Use Disorder and Its Indirect Effects on Student Pharmacists' Perceptions and Attitudes

OBJECTIVES

Pharmacists play a vital role in serving patients during the ongoing nationwide opioid epidemic, and so it is also critical to educate the next generation of pharmacists on opioids and opioid use disorder (OUD). The primary objective of this study was to quantitatively characterize student perceptions of opioid use and the stigma associated with OUD. Secondary aims were to determine whether differences in perceptions exist based upon the student's year in the Doctor of Pharmacy program or employment in a community pharmacy.

METHODS

First-, second-, third-, and fourth-year student pharmacists voluntarily completed an electronic survey regarding perceptions of opioid use and stigma associated with OUD.

RESULTS

Of the 9 survey items, students were most uncomfortable referring patients to community resources for addiction support and/or treatment (25.3% comfortable or very comfortable). Students working in a community pharmacy were significantly more comfortable talking to patients attempting to refill opioids early and providing opioid counseling as compared to their peers not working in community pharmacy. Fourth-year students reported a higher level of comfort talking to a patient attempting to refill an opioid prescription early, counseling a patient on an opioid prescription, and providing information about alternatives to opioids. Third-year students responded most favorably to the items regarding how well the curriculum has prepared them to interact with patients taking opioids and those with OUD.

CONCLUSIONS

These findings reveal that students are comfortable counseling on opioids and discussing alternative options. Differences in perceptions were observed based upon the student's year in the program and whether or not they were employed in a community pharmacy setting.

Association between prescription opioid misuse and dimensions of suicidality among college students

Suicide rates among young adults have increased in recent years. Prescription opioid misuse is not only associated with depression onset but misuse has also been reported as means to manage existing depressive symptoms. College students are at increased risk for psychological distress compared to other populations. The current cross-sectional study aimed to fill a literature gap by examining a relationship between prescription opioid misuse and 3 dimensions of suicidality among a large sample of college students (n = 889). Binomial logistic regression examined relationships between prescription opioid misuse and suicidality while adjusting for the effect of important demographic and substance use covariates. Among this sample 38.8% reported suicidal ideation, 11.6% reported making a plan to kill themselves, and 7.8% reported at least one suicide attempt in the past 12 months. Past year prescription opioid misuse was common (21.6% of participants) and significantly associated with each dimension of suicidality. Though the relationships were attenuated, past year prescription opioid misuse remained significantly associated with suicidal ideation, planning, and attempts following covariate adjustment. At a local level, University health promotion specialists should give particular consideration to individuals exhibiting prescription opioid misuse as this may serve as an indicator of underlying psychological distress and possible suicidality.

Medication assisted treatment (MAT) in criminal justice settings as a double-edged sword: balancing novel addiction treatments and voluntary participation

Medication-Assisted Treatment (MAT) provides an opportunity to address opioid addiction among justice-involved individuals, an often difficult to reach population. This potential has been increasingly recognized by agencies, policymakers and pharmaceutical companies. The result has been a marked increase in the number of drug courts, prisons and agencies in which MAT, notably with long-acting injectable medications, is offered. While this is a positive development, ensuring that vulnerable individuals are in a position voluntarily participation within the complex criminal justice environment is necessary. The unequal authority and agency inherent in the nature of these environments should be recognized. Therefore, rigorous protections, mirroring the goals of the consent processes required for medical or sociobehavorial research, should be employed when MAT is offered to protect individual autonomy.

"You are not clean until you're not on anything": Perceptions of medication-assisted treatment in rural Appalachia

BACKGROUND

Medication-assisted treatment (MAT) is an evidence-based strategy to treat opioid use disorder (OUD). However, MAT-related stigma reduces MAT uptake, which is particularly low in rural areas. To date, perceptions and attitudes towards MAT in rural settings have not been described.

OBJECTIVE

This qualitative study aims to characterize perceptions and attitudes towards MAT and the environmental factors contributing to these views in Appalachian Ohio.

METHODS

From February to July 2018, semi-structured interviews were conducted with 34 stakeholders (12 healthcare professionals, 12 substance use treatment providers, 7 law enforcement agents and judicial officials, and 3 members of relevant organizations) in three rural counties in Appalachian Ohio. Interviews were transcribed, coded, and analyzed to characterize the risk environment and participants' perceptions and attitudes towards MAT.

RESULTS

Participants expressed or described pervasive MAT-related stigma in the region. Participants consistently described three elements of the environment affecting stigma: (1) a "conservative" culture in which abstinence is necessary to be in recovery successfully, (2) fear of medication diversion and abuse, and (3) drug court policies that keep MAT out of the criminal justice system.

CONCLUSION

MAT-related stigma will need to be addressed to tackle the opioid epidemic through evidence-based treatment effectively.

Intervention stigma: How medication-assisted treatment marginalizes patients and providers

Methadone and buprenorphine are drugs used to treat opioid use disorders, and are labeled the "gold standard" of treatment by the National Institutes of Health. Yet associating with these forms of medication-assisted treatment (MAT) subjects individuals to stigma from healthcare personnel both within and outside addiction treatment communities. This study uses the case of MAT to propose a new category of stigma: "intervention stigma." Unlike "condition stigmas" that mark individuals due to diagnosis, intervention stigma marks patients and health professionals due to involvement with a medical treatment or other form of intervention. In-depth interviews with 47 addiction treatment professionals explore how individuals working in MAT experience discrimination and prejudice from other healthcare professionals, especially abstinent treatment professionals who disagree with the use of medications to treat opioid use disorders. This discrimination and prejudice stems at times from stigma toward addiction diagnoses, and at other times toward unique features of MAT itself. The experiences of addiction treatment professionals illustrate how medical interventions can mark patients and professionals in ways that affect patient care, and thus must be added to the scope of destigmatization efforts operating in the health sector.

Use of Buprenorphine to Treat Opioid Use Disorder

As the opioid crisis continues to worsen in the United States, nurses must take on a central role of intervention, which includes use of the opioid agonist medication, buprenorphine. The current article addresses the need to understand opioid use disorder as a chronic condition and increase access to treatment with pharmacotherapies, particularly buprenorphine, in outpatient settings. The pharmacological activity of buprenorphine is discussed, as well as the reasons for its underutilization, specifically stigma. Nurses can be frontline leaders in the fight against the opioid crisis by addressing stigma and increasing access to the life-saving medication, buprenorphine. [Journal of Psychosocial Nursing and Mental Health Services, 56(11), 9-12.].

Future directions for medication assisted treatment for opioid use disorder with American Indian/Alaska Natives

The U.S. is experiencing an alarming opioid epidemic, and although American Indians and Alaska Natives (AI/ANs) are especially hard hit, there is a paucity of opioid-related treatment research with these communities. AI/ANs are second only to Whites in the U.S. for overdose mortality. Thus, the National Institute on Drug Abuse convened a meeting of key stakeholders to elicit feedback on the acceptability and uptake of medication assisted treatment (MAT) for opioid use disorders (OUDs) among AI/ANs. Five themes from this one-day meeting emerged: 1) the mismatch between Western secular and reductionistic medicine and the AI/AN holistic healing tradition; 2) the need to integrate MAT into AI/AN traditional healing; 3) the conflict between standardized MAT delivery and the traditional AI/AN desire for healing to include being medicine free; 4) systemic barriers; and 5) the need to improve research with AI/ANs using culturally relevant methods. Discussion is organized around key implementation strategies informed by these themes and necessary for the successful adoption of MAT in AI/AN communities: 1) type of medication; 2) educational interventions; 3) coordination of care; and 4) adjunctive psychosocial counseling. Using a community-based participatory research approach is consistent with a "two eyed seeing" approach that integrates Western and Indigenous worldviews. Such an approach is needed to develop impactful research in collaboration with AI/AN communities to address OUD health disparities.

Weekly and Monthly Subcutaneous Buprenorphine Depot Formulations vs Daily Sublingual Buprenorphine With Naloxone for Treatment of Opioid Use Disorder: A Randomized Clinical Trial

Importance

Buprenorphine treatment for opioid use disorder may be improved by sustained-release formulations.

Objective

To determine whether treatment involving novel weekly and monthly subcutaneous (SC) buprenorphine depot formulations is noninferior to a daily sublingual (SL) combination of buprenorphine hydrochloride and naloxone hydrochloride in the treatment of opioid use disorder.

Design, Setting, and Participants

This outpatient, double-blind, double-dummy randomized clinical trial was conducted at 35 sites in the United States from December 29, 2015, through October 19, 2016. Participants were treatment-seeking adults with moderate-to-severe opioid use disorder.

Interventions

Randomization to daily SL placebo and weekly (first 12 weeks; phase 1) and monthly (last 12 weeks; phase 2) SC buprenorphine (SC-BPN group) or to daily SL buprenorphine with naloxone (24 weeks) with matched weekly and monthly SC placebo injections (SL-BPN/NX group).

Main Outcomes and Measures

Primary end points tested for noninferiority were response rate (10% margin) and the mean proportion of opioid-negative urine samples for 24 weeks (11% margin). Responder status was defined as having no evidence of illicit opioid use for at least 8 of 10 prespecified points during weeks 9 to 24, with 2 of these at week 12 and during month 6 (weeks 21-24). The mean proportion of samples with no evidence of illicit opioid use (weeks 4-24) evaluated by a cumulative distribution function (CDF) was an a priori secondary outcome with planned superiority testing if the response rate demonstrated noninferiority.

Results

A total of 428 participants (263 men [61.4%] and 165 women [38.6%]; mean [SD] age, 38.4 [11.0] years) were randomized to the SL-BPN/NX group (n = 215) or the SC-BPN group (n = 213). The response rates were 31 of 215 (14.4%) for the SL-BPN/NX group and 37 of 213 (17.4%) for the SC-BPN group, a 3.0% difference (95% CI, -4.0% to 9.9%; P < .001). The proportion of opioid-negative urine samples was 1099 of 3870 (28.4%) for the SL-BPN/NX group and 1347 of 3834 (35.1%) for the SC-BPN group, a 6.7% difference (95% CI, -0.1% to 13.6%; P < .001). The CDF for the SC-BPN group (26.7%) was statistically superior to the CDF for the SL-BPN/NX group (0; P = .004). Injection site adverse events (none severe) occurred in 48 participants (22.3%) in the SL-BPN/NX group and 40 (18.8%) in the SC-BPN group.

Conclusions and Relevance

Compared with SL buprenorphine, depot buprenorphine did not result in an inferior likelihood of being a responder or having urine test results negative for opioids and produced superior results on the CDF of no illicit opioid use. These data suggest that depot buprenorphine is efficacious and may have advantages.

Trial Registration

ClinicalTrials.gov Identifier: NCT02651584.