A Systematic Review on the Use of Psychosocial Interventions in Conjunction With Medications for the Treatment of Opioid Addiction

Effectiveness of Psychosocial Interventions in Alcohol and Substance Use Disorders: A Meta-Analysis Study

Alcohol and substance use disorders (ASUD), are increasing worldwide, and these psychiatric disorders are difficult to treat. The search for new treatments for these disorders continues. Psychosocial interventions (PI) are among them, and it is important to evaluate their effectiveness. This study aimed to assess the effectiveness of PI applied to individuals with ASUD. This meta-analysis was conducted by searching PubMed, Web of Science, EBSCOhost, Google Scholar, and YOK Thesis Center databases without year restrictions between October and December 2023. After reviewing the studies, 18 research articles were included in the analysis. The meta-analysis revealed that PI applied to individuals with ASUD were effective in reducing depression (SMD: -0.753, 95% CI: -1.215 to -2.91; I2 = 94.515; p < 0.05) and enhancing self-efficacy (SMD: 0.709, 95% CI: 0.096-1.321; I2 = 93.34; p < 0.05). However, these interventions were not found to be effective in improving self-esteem (SMD: 0.655, 95% CI: -1.641 to 0.331).

Patent review of novel compounds targeting opioid use disorder (2018-2024)

INTRODUCTION

Opioids have served as a cornerstone in pain management for decades. However, the emergence of increasingly potent synthetic analogs brings forth a range of side effects, including respiratory depression, tolerance, dependence, constipation, and, more importantly, the development of severe and debilitating opioid use disorder (OUD). Search for therapeutics to mitigate OUD has been challenging, and this has called for novel approaches that include the design of small molecules targeting neuronal circuits involved in addiction (opioid, dopamine, serotonin, norepinephrine, and glutamate receptors, etc.).

AREAS COVERED

In this review, we retrieve and discuss two dozen (24) relevant patents filed in the past six (6) years that focus on novel small-molecule therapeutics for OUD. The chemical entities disclosed were highlighted, and specific examples were provided where necessary.

EXPERT OPINION

Several chemical entities targeting both opioid and non-opioid targets are under consideration for treating OUD. Our search for patents covering such compounds revealed embodiments with diverse chemistry. Understanding the public impact of OUD and the rapidly evolving landscape of substance abuse underscores the urgent need for a thorough reevaluation of strategies to address these challenges. This includes the development of small molecules with unique mechanisms of action for OUD treatment.

Self-reported experiences and perspectives on using psychedelics to manage opioid use among participants of two Reddit communities

BACKGROUND AND AIMS

The opioid crisis continues to exert a tremendous toll in North America, with existing interventions often falling short of addressing ongoing needs. Psychedelics are emerging as a possible alternative therapy for mental health and substance use disorders. This study aimed to gather insights on how people use or are considering using psychedelics to manage opioid use disorder (OUD), how these experiences are perceived to impact opioid use and what these lessons imply for future research and practice.

METHODS

We conducted a qualitative study using the Reddit online community platform. We extracted posts that contained key psychedelic terms from the two most subscribed-to subreddits dedicated to discussions of OUD treatment (r/OpiatesRecovery and r/Methadone) from 2018 to 2021. We thematically analyzed content from 151 relevant posts and their respective comments.

RESULTS

Two prominent themes identified in discussions were perspectives on the effectiveness of psychedelics in treating OUD, and mechanisms through which psychedelics were thought to impact use and desire to use opioids. For many, psychedelics were deemed to have a strong impact on opioid use via multiple mechanisms, including alleviating physical symptoms of dependence, shifting motivations around desire to use opioids and addressing underlying mental health problems and reasons for use. Others saw the potential promise around psychedelics as exaggerated, acknowledging many people eventually return to use, or even considered psychedelics dangerous.

CONCLUSIONS

There appear to be diverse perspectives on the effects of using psychedelics to treat opioid use disorder and an urgent need for controlled studies to better understand the impact of different psychedelics on opioid use, how they may be used in the context of existing treatments and what strategies they must be combined with to ensure safety and effectiveness. Integrating the experiences of people who use drugs will help guide psychedelics research toward effective person-centered interventions to enhance health and wellness.

Hospital and physician-based mental healthcare during 12 months of opioid agonist treatment for opioid use disorder: Exploring costs and factors associated with acute care

BACKGROUND

Individuals with opioid use disorder (OUD) have a high prevalence of co-occurring mental health disorders; however, there exists little information on mental health service use for this population. We aimed to determine the prevalence of non-substance use-related mental health emergency department (ED) visits, hospitalizations, and outpatient physician visits for individuals receiving treatment for OUD over one year. We also explored individual-level characteristics associated with mental health care service use and estimated the costs of this care.

METHODS

We linked observational cohort data collected from 3,430 individuals receiving treatment for OUD in Ontario, Canada, with health administrative records available for all individuals enrolled in Ontario's public health insurance program. Eligible participants were receiving medication treatment for OUD and were recruited between 2011 and 2021 Starting on the day of cohort enrolment, we included health service data for up to 12 months. We identified ED visits and hospitalizations for non-substance use-related mental health disorders using ICD-10-CA diagnostic codes. Outpatient mental health visits to primary care providers and psychiatrists were ascertained by examining the diagnostic codes of physician billing claims. We used logistic regression to explore the association between demographic and clinical factors of interest and mental health-related ED visits or hospitalizations. Mean one-year mental healthcare costs, calculated in 2022 Canadian dollars, were estimated. We fit a two-part zero-inflated negative binomial model to explore the association between factors of interest and healthcare costs.

FINDINGS

Altogether, 14.9% of individuals had mental health-related acute care ED visits or hospitalizations and 37.3% had outpatient mental health visits during the follow up period. For participants with at least one visit, we determined the mean number of ED visits (1.93, standard deviation [SD] = 2.15), hospitalizations (1.46, SD = 1.05), primary care visits (3.51, SD = 4.31), and psychiatry visits (4.04, SD = 4.73). Lower odds of ED use and hospitalization were associated with older age (46+ compared to less than 25 years: odds ratio [OR] 0.43, 95% confidence interval [CI]: 0.29, 0.63) and being employed (OR 0.48, 95% CI 0.37, 0.61). Higher odds of ED use and hospitalization was associated with positive opioid urine drug screens (50% positive urine drug screens compared to 0%: OR 1.45, 95% CI 1.05, 2.01), having more comorbid conditions (7+ health conditions compared to 0-2 health conditions: OR 3.76, 95% CI 2.60, 5.44), and receipt of outpatient mental healthcare (OR 2.38, 95% CI 1.95, 2.92) were associated with higher odds of ED visits or hospitalizations. Mean one-year mental healthcare costs for individuals receiving ED visits or hospitalizations totaled $9,117.80 (95% CI 7,372.90, 10,862.70) per person. Mean one-year costs for individuals with outpatient mental healthcare alone totaled $382.30 (95% CI 343.20, 421.30) per person.

CONCLUSIONS

Individuals receiving treatment for OUD receive care in EDs, inpatient units, and outpatient clinics for mental health conditions other than substance use-related diagnoses. Healthcare costs were considerably higher for those receiving acute care treatment for mental health conditions. Studying integrated mental health and substance use disorder treatment in the outpatient setting should be a priority to bolster care for this population.

Factors affecting problem-solving court team decisions about medications for opioid use disorder

BACKGROUND

Problem-solving courts (PSCs) provide alternatives to prosecution and incarceration for drug-related crimes and offer integrated support for people who have lost custody of children due to drug use. Methadone and buprenorphine are lifesaving medications for opioid use disorder (MOUD) but are underused by PSC clients. Even when PSCs lack a court-level prohibition against MOUD, court staff still make individualized decisions about whether a court client can use MOUD. Therefore, we sought to identify factors involved in such individualized PSC court decisions about clients' use of MOUD.

METHODS

We conducted semi-structured interviews and focus groups between Summer and Fall 2022 with a convenience sample of 54 PSC staff members from 33 courts across four states. Data were analyzed using iterative categorization.

RESULTS

Interviewees indicated that their courts had eliminated blanket prohibitions against MOUD due to federal and state policy funding requirements, widespread dissemination of voluntary best practice standards, fear of lawsuits, and MOUD education targeting courts. Courts allowed MOUD if the court client accessed it through a treatment provider with whom the court collaborates. Some courts only allowed court clients to access MOUD from non-partnering treatment providers after a court-led "vetting" process of the proposed MOUD provider. MOUD provider characteristics considered during the vetting process included the provider's willingness to communicate with the court, frequent drug testing, adjustments of medication or dosage in response to aberrant results, offering of counseling, and acceptance of Medicaid or sliding scale payments. PSC staff were least comfortable with court clients using methadone treatment.

CONCLUSIONS

The presence (or lack of) a PSC-MOUD partnership is a key factor involved in court staff decisions when a court client desires MOUD. Therefore, increasing the number of partnerships between PSCs and MOUD providers could lead to higher rates of MOUD utilization. It is unclear whether court-led vetting processes for non-partnering MOUD treatment providers are necessary or appropriate, and such vetting processes could reduce treatment choice or access in communities with few MOUD providers.

Relationship of hub and treatment characteristics with client outcomes in the initial Washington State hub and spoke cohort

INTRODUCTION

Washington State's Hub and Spoke (HS) approach aims to improve availability of opioid use disorder (OUD) treatment. Washington initially funded six hubs with expertise in medications for opioid use disorder (MOUD) that built care networks with referral and treatment partners (spokes). We assessed outcomes for the initial HS cohort, considering the role of HS and treatment characteristics.

METHODS

We conducted a cohort-based observational study using 2017-2019 Medicaid claims data for 2841 HS participants aged 18-64, excluding those with past-month MOUD, in an intent-to-treat analysis. We describe treatment characteristics (MOUD type, treatment setting, and hub type at the initial HS visit, number of outpatient services in their first HS month), and six-month outcomes (MOUD continuity, emergency department (ED) utilization, hospitalization, and intensive SUD treatment). We used multivariable regressions to assess associations with six-month outcomes, adjusting for client characteristics.

RESULTS

Two-thirds (68 %) of participants received buprenorphine, 22 % methadone, 5 % naltrexone, and 5 % outpatient without MOUD for their initial visit. Within six months, 45 % had an ED visit, 14 % any hospitalization, and 18 % entered intensive SUD treatment. Only 24 % remained on MOUD for six months. Compared to buprenorphine, the methadone sample had higher odds of MOUD continuity (aOR = 2.81, 95%CI 2.21-3.55), and the naltrexone sample had lower odds (aOR = 0.36, 95%CI 0.19-0.66). FQHC/public health treatment settings had higher odds of MOUD continuity (aOR = 1.70, 95%CI 1.17-2.47) but hub type was not significant. MOUD continuity increased with 2+ outpatient services for the buprenorphine sample (aOR range 2.55-4.73). Odds of intensive SUD treatment were lower for the methadone sample, compared to buprenorphine (aOR = 0.16, 95%CI 0.11-0.23), all settings compared to SUD settings (aOR range 0.32-0.58), and SUD + MH and medical/hospital hubs compared to SUD only hubs (aOR range 0.28-0.41).

CONCLUSIONS

Most participants did not attain six-month MOUD continuity, despite the HS approach, with variations by MOUD type and treatment setting. The number of outpatient services in the first month for buprenorphine clients was associated with greater odds of MOUD continuity and reduced odds of intensive SUD treatment. More work is needed to improve MOUD continuity for people with OUD within the HS model.

Association of Opioid Use Disorder-Related Service Trajectories during Pregnancy and Postpartum Health Service Use: A Group-Based Multitrajectory Modeling Study

OBJECTIVE

The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations.

METHODS

We used the Merative MarketScan Commercial Claims and Encounters Database (2013-2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization.

RESULTS

Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits (HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered ≥80%) alone, both throughout or in the latter half of pregnancy (HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services (HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy (HRHOS = 2.33), or in the latter half, with or without services (HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services (HRHOS = 1.73).

CONCLUSIONS

Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

Sustainability of Treatment Programs Utilizing Medications for Opioid Use Disorders in Incarcerated Young Adults

The epidemic of opioid overdose brought a major health crisis to the front line of public health in the United States. Early efforts have focused on the prevention of production, distribution, and consumption of the drugs. However, there is little information about youth populations at risk for opioid overdose and their response to targeted treatment plans. The San Bernardino County Youth Opioid Response (SBCYOR) coalition in collaboration with the San Bernadino County (SBC) Probation Department organized a safety net system for at-risk youth by improving communication among county resources. This program mainly focused on individuals aged 12 to 24 years in the county's detention centers along with educational and prevention projects such as naloxone programs for first responders in the region. To describe the impact of the SBCYOR program on at-risk youth, we compare the frequencies of patients referred and treated with medications for opioid use disorder (MOUD) at the SBC Probation Department, which was responsible for individuals from age 12 to less than 18 years, with those from the West Valley Detention Center (WVDC), which was responsible for adults (18 to 24 years of age), from September 2020 through June 2022. Similar proportions of youths were referred for treatment of opioid use disorder (OUD) at the respective sites (3.7% SBC Probation Department, 3.6% WVDC). Of these, however, 78.0% were treated with MOUD at SBC Probation Department compared with only 7.1% at WVDC. SBCYOR coalition partners were able to transform their services into a comprehensive medical and behavioral health program for the incarcerated youth population at risk for OUD.

Virtual reality-based Mindfulness-Oriented Recovery Enhancement (MORE-VR) as an adjunct to medications for opioid use disorder: a Phase 1 trial

INTRODUCTION

Medications for opioid use disorder (MOUD) are the most effective interventions for this condition, yet many patients discontinue treatment. Though adjunct psychosocial treatments are recommended to increase retention and reduce relapse, the scarcity of trained providers hinders access to and utilization of evidence-based interventions. We conducted a Phase 1 study to assess the feasibility of a virtual reality-delivered Mindfulness-Oriented Recovery Enhancement (MORE-VR) intervention for patients receiving MOUD.

PATIENTS AND METHODS

Patients receiving buprenorphine or methadone for OUD (N = 34) were scheduled for 8 weekly sessions of MORE-VR. Enrollment and retention rates were analyzed. Participants reported on the usability and acceptability of MORE-VR, opioid use, and craving and affect before and after each VR session. Heart rate was monitored during one session of MORE-VR.

RESULTS

Twenty-three participants completed four or more MORE-VR sessions (minimum recommended intervention dose). Participants reported high usability and acceptability of MORE-VR, which had an excellent safety profile. Illicit opioid use decreased significantly from pre- to post-treatment (F = 4.44, p=.04). We observed a significant within-session decrease in opioid craving (F = 39.3, p<.001) and negative affect (F = 36.3, p<.001), and a significant within-session increase in positive affect (F = 23.6, p<.001). Heart rate shifted during cue-exposure and mindfulness practices (F = 6.79, p<.001).

CONCLUSIONS

High retention, usability and acceptability rates and low adverse events demonstrated that MORE-VR is a feasible, engaging, and safe intervention. Our findings show that MORE-VR can be delivered as an adjunctive intervention to MOUD and suggest that MORE-VR may improve OUD treatment outcomes and modulate autonomic responses. MORE-VR's efficacy will be tested in a subsequent Phase 2 trial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05034276; https://classic.clinicaltrials.gov/ct2/show/NCT05034276.

Immediate Effects of Mindful Awareness in Body-Oriented Therapy as an Adjunct to Medication for Opioid Use Disorder

The need for improve medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring polysubstance use, mental health, and chronic pain conditions. Interoceptive training may facilitate well-being and support medication treatment for MOUD.

Objectives

While effective, medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring polysubstance use, mental health, and chronic pain conditions. Interoceptive training may facilitate well-being and support medication treatment for MOUD. This study examined the pre-post effects of the mindfulness-based intervention Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to MOUD. MABT teaches interoceptive awareness skills to promote self-care and emotion regulation.

Method

Participants stabilized on medication for opioid use disorder (OUD) (n = 303) from six community clinics in North-western United States were recruited and randomly assigned to MABT plus MOUD or MOUD only. In a mixed-methods study, we used an intent-to-treat approach (analyzing participants based on their assigned group, regardless of adherence) to examine the proportion of days abstinent from non-prescribed opioids, and other substance use (primary outcomes) at baseline and 3 months post-intervention. Secondary outcomes included symptoms of mental health distress, emotional regulation difficulties, pain and physical symptom indicators, interoceptive awareness, and mindfulness skills. Participant experience of MABT was collected through post-intervention surveys. Changes in outcomes were assessed using linear mixed models; content analysis was used to analyze the qualitative data.

Results

Levels of overall substance use were low and did not differ between groups. Significant improvements in PTSD symptoms, interoceptive awareness, pain severity, pain activity interference, and physical symptom frequency were found for those who received MABT compared to MOUD only.

Conclusions

In this stable MOUD population, substance use outcomes were not improved; however, MABT demonstrated significant positive changes across multiple health outcomes critical for improving MOUD treatment.

Preregistration

ClinicalTrials.gov identifer: NCT04082637.

Opioid reward and deep brain stimulation of the lateral hypothalamic area

Opioid use disorder (OUD) is considered a global health issue that affects various aspects of patients' lives and poses a considerable burden on society. Due to the high prevalence of remissions and relapses, novel therapeutic approaches are required to manage OUD. Deep brain stimulation (DBS) is one of the most promising clinical breakthroughs in translational neuroscience. It involves stereotactically implanting electrodes inside the brain and transmitting electrical pulses to targeted areas. To date, the nucleus accumbens has been recognized as the most successful DBS target for treating different types of drug addiction. Nevertheless, further preclinical research is required to determine the optimal brain target and stimulation parameters. On the other hand, the lateral hypothalamic area (LHA) plays a crucial role in many motivated behaviors including food intake and drug-seeking. Additionally, it projects widely throughout the brain to reward-related areas like the ventral tegmental area. Therefore, this chapter reviews studies investigating the potential positive effects of DBS administration in the LHA in animal models of opioid dependence and other pathological conditions. Findings reveal that LHA has the potential to be targeted for DBS application to treat a wide variety of disorders such as opioid dependence, obesity, and sleep disorders without significant adverse events. However, in the context of opioid dependence, more studies are needed, based on more valid animal models of addiction, including self-administration paradigms and varying stimulation patterns, to indicate that LHA is a safe and effective target for DBS in subjects with refractory opioid dependence.

A systematic review and meta-analysis of psychosocial interventions for persons with comorbid anxiety and substance use disorders

BACKGROUND & AIMS

Anxiety and substance use disorders are highly comorbid and represent two of the leading causes of disease burden globally. Psychosocial interventions are important treatment options for people with co-occurring anxiety and substance use (A-SUD). To date, few reviews have assessed the efficacy of psychosocial treatments for patients with A-SUD. This systematic review and meta-analysis aims to synthesize this literature and assess the efficacy of psychosocial interventions among patients with A-SUD.

METHODS

We searched all relevant records published until March 2023 in Medline, EMBASE, PsycINFO, CINAHL and Google Scholar. Two authors extracted and reconciled relevant data and assessed risk of bias. Random effects models were used to calculate effect sizes using Hedges' g for post treatment and follow-up time points. Main outcomes of the review were anxiety, alcohol use, and use of other substances. We examined effects on depression as a secondary outcome since it commonly co-occurs with A-SUD.

RESULTS

Psychosocial interventions for co-occurring A-SUD showed moderate effects on anxiety (g = 0.44), alcohol (Hedges' g = 0.29), and other substance use (g = 0.38) at post intervention. Large effects were observed on depression (g = 0.88) at post intervention with high heterogeneity. These effects were maintained at follow-up for anxiety (Hedges' g = 0.38), other substances (g = 0.44), and depression (g = 0.50). Moderation analyses for demographic factors, intervention characteristics, community level factors, anxiety reduction, and alcohol use reduction, were non-significant.

CONCLUSIONS

The current meta-analysis investigated the effects of psychosocial interventions on patients with anxiety and co-occurring SUD. The analyses indicated promising moderate-sized effects of treatment on anxiety, alcohol, all other drug use, and depression. The findings point to important avenues for psychosocial treatment while highlighting critical gaps in knowledge to be addressed in future research.

Self-help groups and opioid use disorder treatment: An investigation using a machine learning-assisted robust causal inference framework

OBJECTIVES

This study investigates the impact of participation in self-help groups on treatment completion among individuals undergoing medication for opioid use disorder (MOUD) treatment. Given the suboptimal adherence and retention rates for MOUD, this research seeks to examine the association between treatment completion and patient-level factors. Specifically, we evaluated the causal relationship between self-help group participation and treatment completion for patients undergoing MOUD.

METHODS

We used the Substance Abuse and Mental Health Services Administration's (SAMHSA) Treatment Episode Data Set: Discharges (TEDS-D) from 2015 to 2019. The data are filtered by the patient's opioid use history, demographics, treatment modality, and other relevant information. In this observational study, machine learning models (Lasso Regression, Decision Trees, Random Forest, and XGBoost) were developed to predict treatment completion. Outcome Adaptive Elastic Net (OAENet) was used to select confounders and outcome predictors, and the robust McNemars test was used to evaluate the causal relationship between self-help group participation and MOUD treatment completion.

RESULTS

The machine-learning models showed a strong association between participation in self-help groups and treatment completion. Our causal analysis demonstrated an average treatment effect on treated (ATT) of 0.260 and a p-value < 0.0001 for the robust McNemars test.

CONCLUSIONS

Our study demonstrates the importance of participation in self-help groups for MOUD treatment recipients. We found that participation in MOUD along with self-help groups caused higher chances of treatment completion than MOUD alone. This suggests that policymakers should consider further integrating self-help groups into the treatment for OUD to improve the adherence and completion rate.

Linkage facilitation for opioid use disorder in criminal legal system contexts: a primer for researchers, clinicians, and legal practitioners

At the intersection of drug policy, the opioid crisis, and fragmented care systems, persons with opioid use disorder (OUD) in the United States are significantly vulnerable to contact with the criminal legal system (CLS). In CLS settings, provision of evidence-based treatment for OUD is variable and often secondary to punitive approaches. Linkage facilitation at every touch point along the CLS Sequential Intercept Model has potential to redirect persons with OUD into recovery-oriented systems of care, increase evidence-based OUD treatment connections, and therefore reduce CLS re-exposure risk. Research in this area is still nascent. Thus, this narrative review explores the state of the science on linkage facilitation across the varied CLS contexts, including general barriers, facilitators, and opportunities for using linkage facilitation for OUD treatment and related services. Following the CLS Sequential Intercept Model, the specific CLS contexts examined include community services, police encounters, the courts (pre- and post-disposition), incarceration (pre-trial detention, jail, and prison), reentry (from jails, prisons, and unified systems), and community supervision (probation and parole). Examples of innovative linkage facilitation interventions are drawn from the Justice Community Opioid Innovation Network (JCOIN). Areas for future research and policy change are highlighted to advance the science of linkage facilitation for OUD services in the CLS.

Predictors of urine toxicology and other biologic specimen missingness in randomized trials of substance use disorders

BACKGROUND

High levels of missing outcome data for biologically confirmed substance use (BCSU) threaten the validity of substance use disorder (SUD) clinical trials. Underlying attributes of clinical trials could explain BCSU missingness and identify targets for improved trial design.

METHODS

We reviewed 21 clinical trials funded by the NIDA National Drug Abuse Treatment Clinical Trials Network (CTN) and published from 2005 to 2018 that examined pharmacologic and psychosocial interventions for SUD. We used configurational analysis-a Boolean algebra approach that identifies an attribute or combination of attributes predictive of an outcome-to identify trial design features and participant characteristics associated with high levels of BCSU missingness. Associations were identified by configuration complexity, consistency, coverage, and robustness. We limited results using a consistency threshold of 0.75 and summarized model fit using the product of consistency and coverage.

RESULTS

For trial design features, the final solution consisted of two pathways: psychosocial treatment as a trial intervention OR larger trial arm size (complexity=2, consistency=0.79, coverage=0.93, robustness score=0.71). For participant characteristics, the final solution consisted of two pathways: interventions targeting individuals with poly- or nonspecific substance use OR younger age (complexity=2, consistency=0.75, coverage=0.86, robustness score=1.00).

CONCLUSIONS

Psychosocial treatments, larger trial arm size, interventions targeting individuals with poly- or nonspecific substance use, and younger age among trial participants were predictive of missing BCSU data in SUD clinical trials. Interventions to mitigate missing data that focus on these attributes may reduce threats to validity and improve utility of SUD clinical trials.

Immediate Effects of Mindful Awareness in Body-oriented Therapy as an Adjunct to Medication for Opioid Use Disorder

Objective

While effective, medication for opioid use disorder (MOUD) treatment outcomes can be limited by co-occurring polysubstance use, mental health and chronic pain conditions. Interoceptive training may facilitate well-being and support medication treatment for MOUD. This study examined the pre-post effects of the mindfulness-based intervention Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to MOUD. MABT teaches interoceptive awareness skills to promote self-care and emotion regulation.

Methods

People stabilized on medication for OUD (N = 303) from 6 community clinics in Northwestern United States were recruited and randomly assigned to MABT plus MOUD or MOUD only. In a mixed-methods study, we used an intent-to-treat approach to examine the proportion of days abstinent from non-prescribed opioids, and other substance use (primary outcomes) at baseline and 3 months post-intervention. Secondary outcomes included symptoms of mental health distress; emotional regulation difficulties; pain and physical symptom indicators; interoceptive awareness and mindfulness skills. Participant experience of MABT was collected through post-intervention surveys. Changes in outcomes were assessed using linear mixed models; content analysis was used to analyze the qualitative data.

Results

Levels of overall substance use were low and did not differ between groups. Significant improvements in PTSD symptoms, interoceptive awareness, pain severity, pain activity interference, and physical symptom frequency were found for those who received MABT compared to MOUD only.

Conclusion

In this stable MOUD population, substance use outcomes were not improved, however MABT demonstrated significant positive changes across multiple health outcomes critical for improving MOUD treatment. Clinical Trials Registration: NCT04082637 on 9/3/2019.

Mediating effect of craving on the impact of buprenorphine/naloxone and methadone treatment on opioid use: Results from a randomized controlled trial

BACKGROUND

The relationship between opioid craving and opioid use is unclear. We sought to determine to what extent craving mediated the relationship between opioid agonist therapy and changes in opioid use.

METHODS

Data came from a pragmatic, 24-week, pan-Canadian, multi-centric, open-label, randomized controlled trial comparing flexible buprenorphine/naloxone take-home doses to standard supervised methadone models of care for the treatment of prescription-type opioid use disorder. Participants were randomly allocated to buprenorphine/naloxone or methadone models of care. 270 people with prescription-type opioid use disorder were included in analyses. There were 93 women (34.4%) and 2 transgender (0.7%) participants. Most participants were white (67.4%), 45.9% reported unstable living conditions, and 44.8% had psychiatric comorbidities. Generalized linear mixed models followed by mediation analysis estimated the direct effect of treatment group on Timeline Followback-reported next-week opioid use and the indirect effect through past 24-hour opioid craving measured using the Brief Substance Craving Scale at week 2, 6, 10, 14, 18 and 22.

RESULTS

Upon mediation analysis, the average direct effect of treatment on opioid use was 0.465 (95 % CI = 0.183 to 0.751, p < 0.001). The average causal mediated effect was 0.144 (95 % CI = 0.021 to 0.110; p < 0.001). Craving accounted for 23.6 % of the effect of treatment on opioid use (p < 0.001).

CONCLUSIONS

Past 24-hour craving was associated with increased next-week opioid use; however, craving only partially mediated the effect of buprenorphine/naloxone and methadone on next-week opioid use. Research is needed to develop a comprehensive understanding of factors mediating opioid use during opioid agonist therapy.

Attitudinal barriers to buprenorphine prescription and former waiver training

OBJECTIVE

Opioid use disorder (OUD) can be effectively treated with buprenorphine maintenance. Recent changes in federal policy have removed the requirement for physicians to complete additional training to apply for a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. At that time, few primary care providers (PCPs) had completed the training for a DEA waiver to prescribe buprenorphine. Our goal was to identify addressable barriers that may persist despite updates to federal legislation.

DESIGN

A 42-item survey was distributed to 662 physicians and nurse practitioners at two academic medical centers with 100 respondents.

SETTING

The survey was sent via email and administered anonymously through SurveyMonkey.

PATIENTS AND PARTICIPANTS

All participants were PCPs, and all PCPs at the two academic medical centers were eligible to participate.

INTERVENTIONS

PCPs responded to the survey by answering questions online.

MAIN OUTCOME MEASURES

PCPs answered questions regarding previous buprenorphine waiver training status, local OUD prevalence, the effectiveness of OUD treatment modalities, and previous barriers to training.

RESULTS

Respondents were compared using descriptive statistics and logistic regression. Of the 100 respondents (response rate: 15 percent), 69 percent had not completed the training. Ninety-nine percent of PCPs agreed that OUD was an issue in their area, 94 percent saw patients with OUD, and 91 percent rated buprenorphine maintenance as a very effective treatment for OUD. Previously waivered and nonwaivered providers did not differ in their responses to these questions. Those who had been waivered were less likely to say they did not see enough patients with OUD to justify training (odds ratio [OR] 0.267, p = 0.005) and were less likely to express concern about allowing patients with OUD into their practice (OR 0.348, p = 0.020) than PCPs who had applied for the DEA waiver.

CONCLUSIONS

Despite nonwaivered PCPs recognizing OUD's prevalence, they were concerned about allowing patients with OUD into their practice and said there were not enough patients to justify training. This suggests that attitudinal barriers are the most appropriate target for current intervention.

Is peer support a tipping point for the opioid use disorder crisis in Appalachia? Research holds the answer

BACKGROUND

The present commentary highlights the pressing need for systematic research to assess the implementation and effectiveness of medications for opioid use disorder, used in conjunction with peer recovery support services, to improve treatment outcomes for individuals with opioid use disorder in Central Appalachia. This region, encompassing West Virginia, Eastern Kentucky, Southwest Virginia, East Tennessee, and Western North Carolina, has long grappled with a disproportionate burden of the opioid crisis. Due to a complex interplay of cultural, socioeconomic, medical, and geographic factors, individuals in Central Appalachia face challenges in maintaining treatment and recovery efforts, leading to lower success rates.

APPROACH

To address the issue, we apply an exploratory approach, looking at the intersection of unique regional factors with the utilization of medications for opioid use disorder, in conjunction with peer recovery support services. This combined treatment strategy shows promise in addressing crucial needs in opioid use disorder treatment and enhancing the recovery journey. However, there are significant evidence gaps that need to be addressed to validate the expected value of incorporating peer support into this treatment strategy.

CONCLUSION

We identify nine obstacles and offer recommendations to address the gaps and advance peer recovery support services research. These recommendations include the establishment of specific partnerships and infrastructure for community-engaged, peer recovery support research; improved allocation of funding and resources to implement evidence-based practices such as peer support and medication-assisted treatment; developing a more precise definition of peer roles and their integration across the treatment and recovery spectrum; and proactive efforts to combat stigma through outreach and education.

Access to treatment before and after Medicare coverage of opioid treatment programs

Since January 2020, Medicare has covered opioid use disorder (OUD) treatment services at opioid treatment programs (OTPs), the only outpatient settings allowed to dispense methadone for treating OUD. This study examined policy-associated changes in Medicare acceptance and the availability of four OUD treatment services (ongoing buprenorphine, HIV/AIDS education, employment services, and comprehensive mental health assessment), by for-profit status, and county-level changes in Medicare-accepting-OTPs access, by sociodemographic characteristics (racial composition, poverty rate, and rurality). Using data from the 2019-2022 National Directory of Drug and Alcohol Abuse Treatment Facilities, we found Medicare acceptance increased from 21.31% in 2018 to 80.76% in 2021. The availability of the four treatment services increased, but no increases were significantly associated with Medicare coverage. While county-level OTP access significantly improved, counties with higher rates of non-White residents experienced an additional average increase of 0.86 Medicare-accepting-OTPs (95% CI, 0.05-1.67) compared to those without higher rates of non-White populations. Overall, Medicare coverage was associated with improved OTP access, not ancillary services.

Cost-effectiveness of full and partial opioid agonists for opioid use disorder in outpatient settings: United States healthcare sector perspective

INTRODUCTION

Studies show that medications for opioid use disorder (MOUD) reduce illicit opioid use, emergency healthcare services, opioid-related overdose, and death. However, few studies have investigated the long-term cost-effectiveness of MOUD in office-based opioid treatment (OBOT) and opioid treatment program (OTP) settings. We aimed to estimate the cost, utility, quality-adjusted life years gained (QALYs), and incremental cost-effectiveness ratios (ICERs) of three MOUD compared to each other and counseling without medication from a US healthcare sector perspective.

METHODS

Our study developed a Markov model to conduct a cost-effectiveness analysis of counseling and three MOUD in the OBOT and OTP settings: sublingual buprenorphine/naloxone (BUPNX), buprenorphine extended-release (XR-BUP) injection, and oral methadone. The model included five health states representing combinations of receiving or off treatment while either using or not actively using illicit opioids, and death. The cycle length was one month; the time-horizon was ten years. The study obtained model inputs from systematic reviews of published literature and public data. A 3 % annual discount rate was applied to cost and utility calculation. The primary outcomes included total costs, life-years (LYs), QALYs, and ICERs. We also conducted a scenario analysis using a hypothetical OBOT outpatient setting with methadone.

RESULTS

In the base-case OBOT setting, the total costs and QALYs, respectively, were counseling $22,848, 5.60; BUPNX $29,875, 5.82; and XR-BUP $63,936, 5.87. ICERs were $32,345/QALY (BUPNX vs. counseling) and $625,858/QALY (XR-BUP vs BUPNX). In the OTP setting, the total costs of counseling, methadone, BUPNX, and XR-BUP were $20,124, $27,000, $33,500, and $75,272, respectively. QALYs of methadone were 5.86. QALYs of counseling, BUPNX, and XR-BUP remained the same as in the OBOT setting. Incremental ICERs were $26,714/QALY (methadone vs counseling) and $3,337,623/QALY (XR-BUP vs methadone). BUPNX was dominated by methadone. In the scenario analysis, BUPNX was also dominated by methadone.

CONCLUSIONS

Outpatient MOUD resulted in important gains in quality of life and life expectancy. In both OBOT and OTP settings, XR-BUP was not cost-effective. BUPNX was cost-effective in the OBOT setting, while it was dominated by methadone in the OTP setting. The cost-effectiveness of BUPNX and XR-BUP could be enhanced if the costs of these medications were reduced.

Reasons for not entering opioid agonist treatment: A survey among high-risk opioid users in Finland

Aims: To characterise and understand the untreated high-risk opioid user population in Finland, and to determine the reasons why these people do not enter treatment. Methods: The study setting was a half-year cross-sectional survey in Finland during 2021-2022. An electronic questionnaire with 24 structured questions was concluded in 16 needle exchange units. Participants were opioid-dependent people without opioid agonist treatment (OAT), and they answered the survey voluntarily and anonymously. Results: Of the 167 respondents, 62% were men, 53% were aged ≤34 years, 66% had used opioids for >6 years, and 78% used drugs intravenously (IV) daily. The most used opioid (95%) was buprenorphine. Most respondents used opioids as self-medication for withdrawal symptoms (75%), or to treat psychological symptoms (59%) or pain (43%). Of them, 70% also used other substances for recreational purposes. The most common named reasons to stay outside OAT were as follows: seeking treatment is too difficult (37%); treatment is too binding (36%); and fear of actions from authorities (23%). Conclusions: For opioid-dependent respondents who would be eligible for OAT in Finland, treatment awareness is limited. These high-risk opioid users also think that the treatment would be too binding. In conclusion, there is a need for increase in general information about, accessibility to, acceptance for and individualisation of OAT.

Psychosocial combined with methadone maintenance treatments versus methadone maintenance treatments alone for treatment of opioid use disorder: A meta-analysis

BACKGROUND

Psychosocial combined with methadone maintenance treatment aimed at opioid use disorder is effective, but the efficacy of the psychosocial intervention in such treatment is questionable.

OBJECTIVES

This study aims to evaluate the effectiveness of psychosocial plus methadone maintenance treatment versus methadone maintenance treatment alone for opioid use disorder in improving treatment retention and reducing drug use.

METHODS

An exhaustive literature search was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure database, "the Wan Fang database, the VIP database, and the Chinese Biomedical Literature Database", and randomized controlled trials were identified from their inception to February 2021.

RESULTS

Twenty-four studies were included. The results of this meta-analysis showed that adding any psychosocial treatment to standard methadone maintenance treatment significantly improved the illicit drug use during the treatment relative risk (RR) 0.62 (95% CI 0.48 to 0.79), and retention in treatment RR 1.18 (95% CI 1.11 to 1.25). No statistically significant additional benefit was detected in terms of retention at follow-up RR 1.08 (95% CI 0.95 to 1.22).

CONCLUSIONS

The present evidence suggests that adding psychosocial intervention to methadone maintenance treatment significantly improves the nonuse of opioids and retention in treatment. It should be noted that psychosocial treatment is only beneficial for methadone treatment when methadone is provided in subtherapeutic doses. Additionally, the finding about the improvement effect of retention at follow-up did not achieve statistical significance. Due to the diversity of outcome indicators in relevant original studies, the included studies are limited.

Efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT) in Individuals With Chronic Pain and Opioid Use Disorder: Protocol for a Randomized Clinical Trial of a Digital Cognitive Behavioral Treatment

BACKGROUND

Chronic pain is common among individuals with opioid use disorder (OUD) who are maintained on medications for OUD (MOUD; eg, buprenorphine or methadone). Chronic pain is associated with worse retention and higher levels of substance use. Treatment of individuals with chronic pain receiving MOUD can be challenging due to their increased clinical complexity. Given the acute and growing nature of the opioid crisis, MOUD is increasingly offered in a wide range of settings, where high-quality, clinician-delivered, empirically validated behavioral treatment for chronic pain may not be available. Therefore, digital treatments that support patient self-management of chronic pain and OUD have the potential for wider implementation to fill this gap.

OBJECTIVE

This study aims to evaluate the efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT), an interactive digital treatment program with asynchronous coach feedback, compared to treatment as usual (TAU) in individuals with chronic pain and OUD receiving MOUD.

METHODS

Adult participants (n=160) receiving MOUD and reporting bothersome or high-impact chronic pain will be recruited from outpatient opioid treatment programs in Connecticut (United States) and randomized 1:1 to either IMPACT+TAU or TAU only. Participants randomized to IMPACT+TAU will complete an interactive digital treatment that includes 9 modules promoting training in pain and addiction coping skills and a progressive walking program. The program is augmented with a weekly personalized voice message from a trained coach based on daily participant-reported pain intensity and interference, craving to use opioids, sleep quality, daily steps, pain self-efficacy, MOUD adherence, and engagement with IMPACT collected through digital surveys. Outcomes will be assessed at 3, 6, and 9 months post randomization. The primary outcome is MOUD retention at 3 months post randomization (ie, post treatment). Secondary outcomes include pain interference, physical functioning, MOUD adherence, substance use, craving, pain intensity, sleep disturbance, pain catastrophizing, and pain self-efficacy. Semistructured qualitative interviews with study participants (n=34) randomized to IMPACT (completers and noncompleters) will be conducted to evaluate the usability and quality of the program and its outcomes.

RESULTS

The study has received institutional review board approval and began recruitment at 1 site in July 2022. Recruitment at a second site started in January 2023, with a third and final site anticipated to begin recruitment in January 2024. Data collection is expected to continue through June 2025.

CONCLUSIONS

Establishing efficacy for a digital treatment for addiction and chronic pain that can be integrated into MOUD clinics will provide options for individuals with OUD, which reduce barriers to behavioral treatment. Participant feedback on the intervention will inform updates or modifications to improve engagement and efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05204576; https://clinicaltrials.gov/ct2/show/NCT05204576.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54342.

Navigating the Complex Intersection of Substance Use and Psychiatric Disorders: A Comprehensive Review

The co-occurrence of substance use disorders (SUDs) and psychiatric conditions, often referred to as comorbidity or concurrent disorders, presents intricate challenges in both diagnosis and treatment. This comprehensive narrative review aims to synthesize and critically evaluate the existing evidence surrounding the management of individuals with comorbid SUDs and psychiatric disorders. Comorbidity in these domains carries profound implications for clinical practice, research, and policymaking, emphasizing the need for a holistic understanding of the intricate dynamics that arise when these conditions coexist. This review explores recent research findings, evidence-based guidelines, and emerging trends within the field, offering valuable insights for clinicians, researchers, and policymakers seeking to navigate the complex terrain of comorbidity in substance use and psychiatric disorders.

IUPHAR-review: The integration of classic psychedelics into current substance use disorder treatment models

Substance use disorders (SUDs) have an enormous impact on public health. With classic psychedelic-assisted therapies showing initial promise in treating multiple SUDs, it is possible that these treatments will become legally available options for patients with SUDs in the future. This article highlights how classic psychedelic-assisted therapies might be integrated into current clinical practice. We first describe contemporary evidence-based treatments for SUDs and highlight how classic psychedelic-assisted therapies might fit within each treatment. We suggest that classic psychedelic-assisted therapies can be integrated into most mainstream evidence-based SUD treatments that are currently used in clinical settings, indicating broad compatibility of classic psychedelics with contemporary SUD treatment paradigms.

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

INTRODUCTION

The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma.

METHODS

The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation.

RESULTS

Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation.

CONCLUSIONS

NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.

Synthetic Anti-Cocaine Nanoaccine Successfully Prevents Cocaine-Induced Hyperlocomotion

Cocaine is one of the most widely used and increasingly popular illicit psychoactive drugs. Unlike other commonly used substances of abuse, cocaine has no pharmacological therapies to treat addiction or aid in rehabilitation. Immunopharmacology has long been touted as a possible avenue to develop effective anticocaine therapies; however, lack of efficacy and designs which are not consistent with simple large-scale production have hindered vaccine translation. We have designed and synthesized a peptide-based anti-cocaine immunogen which we have shown is capable of inducing physiologically relevant immune responses in mice as part of a self-adjuvanting delivery system or in combination with the human-approved commercial adjuvant MF59. We have demonstrated that immunization with the reported vaccine elicits high titers of anti-cocaine IgG and prevents cocaine-induced hyperlocomotion in an in vivo murine model. This peptide-hapten immunogen along with self-adjuvanting liposomal-based delivery system provides a platform for the development of effective anti-drug vaccines.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Nonopioid Substance Use among Patients Who Recently Initiated Office-based Buprenorphine Treatment

OBJECTIVES

Medications for opioid use disorder (MOUDs) like buprenorphine are a first-line treatment for individuals who have opioid use disorder (OUD); however, these medications are not designed to impact the use of other classes of drugs. This descriptive study provides up-to-date information about nonopioid substance use among patients who recently initiated office-based buprenorphine treatment for OUD using data from 2 ongoing clinical trials.

METHODS

The study sample was composed of 257 patients from 6 federally qualified health centers in the mid-Atlantic region who recently (i.e., within the past 28 days) initiated office-based buprenorphine treatment between July 2020 and May 2022. After the screening and informed consent processes, participants completed a urine drug screen and psychosocial interview as a part of the study baseline assessment. Descriptive analyses were performed on urine drug screen results to identify the prevalence and types of substances detected.

RESULTS

More than half of participants provided urine specimens that were positive for nonopioid substances, with marijuana (37%, n = 95), cocaine (22%, n = 56), and benzodiazepines (11%, n = 28) detected with the highest frequencies.

CONCLUSIONS

A significant number of participants used nonopioid substances after initiating buprenorphine treatment, suggesting that some patients receiving MOUDs could potentially benefit from adjunctive psychosocial treatment and supports to address their nonopioid substance use.

Substance Use Disorders: Basic Overview for the Anesthesiologist

Substance use disorders (SUDs) represent a current major public health concern in the United States and around the world. Social and economic stressors secondary to the coronavirus disease 2019 (COVID-19) pandemic have likely led to an increase in SUDs around the world. This chronic, debilitating disease is a prevalent health problem, and yet many clinicians do not have adequate training or clinical experience diagnosing and treating SUDs. Anesthesiologists and other perioperative medical staff frequently encounter patients with co-occurring SUDs. By such, through increased awareness and education, physicians and other health care providers have a unique opportunity to positively impact the lives and improve the perioperative outcomes of patients with SUDs. Understanding commonly used terms, potentially effective perioperative screening tools, diagnostic criteria, basics of treatment, and the perioperative implications of SUDs is essential to providing adequate care to patients experiencing this illness.

Long-Acting Buprenorphine Formulations as a New Strategy for the Treatment of Opioid Use Disorder

Long-acting buprenorphine formulations have been recently marketed for the Opioid Agonist Treatment (OAT) of opioid use disorder (OUD) associated with medical, social, and psychological support. Their duration of action ranges from one week up to 6 months. The non-medical use of opioids is increasing with a parallel rise in lethal overdoses. Methadone and buprenorphine are the standard treatment for opioid dependence. Methadone Maintenance Treatment (MMT) is widely recognized as one of the most effective ways of reducing the risks of overdose, crime, and transmission of HIV (Human Immunodeficiency Virus) in people who use opioids; however, its effectiveness has been hindered by low rates of uptake and retention in treatment. Furthermore, both methadone and buprenorphine are widely diverted and misused. Thus, a crucial aspect of treating OUD is facilitating patients' access to treatment while minimizing substance-related harm and improving quality of life. The newly developed long-acting buprenorphine formulations represent a significant change in the paradigm of OUD treatment, allowing an approach individualized to patients' needs. Strengths of this individualized approach are improved adherence (lack of peaks and troughs in blood concentrations) and a reduced stigma since the patient doesn't need to attend their clinic daily or nearly daily, thus facilitating social and occupational integrations as the quality of life. However, less frequent attendance at the clinic should not affect the patient-physician relationship. Therefore, teleconsulting or digital therapeutic services should be developed in parallel. In addition, diversion and intravenous misuse of buprenorphine are unlikely due to the characteristics of these formulations. These features make this approach of interest for treating OUD in particular settings, such as subjects staying or when released from prison or those receiving long-term residential treatment for OUD in the therapeutic communities. The long-lasting formulations of buprenorphine can positively impact the OUD treatment and suggest future medical and logistic developments to maximize their personalized management and impact.

Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment

Background

Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial.

Methods

Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens.

Results

137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder.

Conclusion

Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

Sudarshan Kriya Meditation Reduces Substance Abuse Cravings and Improves Physical and Emotional Well-Being of Individuals With Opioid Use Disorder: A Pilot Study

Opioid use disorder (OUD) is widely prevalent in the United States and there are high levels of comorbidity between OUD and mental illnesses, such as depression, anxiety, and posttraumatic stress disorder. Psychotherapy, in addition to medication-assisted therapy, are considered important components of long-term OUD treatment. Sudarshan Kriya Yoga (SKY) is a breathing-based mind-body intervention that has been demonstrated to have multiple physiological and psychological benefits. In the current study, participants (N = 8) recruited from a rural community were offered SKY in addition to treatment-as-usual. Physical and psychological well-being were measured using the Behavior and Symptom Identification Scale-24, Short Form-36, Perceived Stress Scale, and participant logs and journals. Of eight participants, seven (87.5%) successfully completed the SKY intervention. Compared to baseline, there was a significant decrease in substance use cravings (p = 0.04) and depression (p = 0.01). In addition, physical functioning and emotional well-being significantly increased after SKY. SKY demonstrated efficacy in improving physical and social functioning along with enhancing mental and emotional well-being. Larger-scale trials should be performed to validate these findings. [Journal of Psychosocial Nursing and Mental Health Services, 61(8), 51-59.].

An Automatically Adaptive Digital Health Intervention to Decrease Opioid-Related Risk While Conserving Counselor Time: Quantitative Analysis of Treatment Decisions Based on Artificial Intelligence and Patient-Reported Risk Measures

BACKGROUND

Some patients prescribed opioid analgesic (OA) medications for pain experience serious side effects, including dependence, sedation, and overdose. As most patients are at low risk for OA-related harms, risk reduction interventions requiring multiple counseling sessions are impractical on a large scale.

OBJECTIVE

This study evaluates whether an intervention based on reinforcement learning (RL), a field of artificial intelligence, learned through experience to personalize interactions with patients with pain discharged from the emergency department (ED) and decreased self-reported OA misuse behaviors while conserving counselors' time.

METHODS

We used data representing 2439 weekly interactions between a digital health intervention ("Prescription Opioid Wellness and Engagement Research in the ED" [PowerED]) and 228 patients with pain discharged from 2 EDs who reported recent opioid misuse. During each patient's 12 weeks of intervention, PowerED used RL to select from 3 treatment options: a brief motivational message delivered via an interactive voice response (IVR) call, a longer motivational IVR call, or a live call from a counselor. The algorithm selected session types for each patient each week, with the goal of minimizing OA risk, defined in terms of a dynamic score reflecting patient reports during IVR monitoring calls. When a live counseling call was predicted to have a similar impact on future risk as an IVR message, the algorithm favored IVR to conserve counselor time. We used logit models to estimate changes in the relative frequency of each session type as PowerED gained experience. Poisson regression was used to examine the changes in self-reported OA risk scores over calendar time, controlling for the ordinal session number (1st to 12th).

RESULTS

Participants on average were 40 (SD 12.7) years of age; 66.7% (152/228) were women and 51.3% (117/228) were unemployed. Most participants (175/228, 76.8%) reported chronic pain, and 46.2% (104/225) had moderate to severe depressive symptoms. As PowerED gained experience through interactions over a period of 142 weeks, it delivered fewer live counseling sessions than brief IVR sessions (P=.006) and extended IVR sessions (P<.001). Live counseling sessions were selected 33.5% of the time in the first 5 weeks of interactions (95% CI 27.4%-39.7%) but only for 16.4% of sessions (95% CI 12.7%-20%) after 125 weeks. Controlling for each patient's changes during the course of treatment, this adaptation of treatment-type allocation led to progressively greater improvements in self-reported OA risk scores (P<.001) over calendar time, as measured by the number of weeks since enrollment began. Improvement in risk behaviors over time was especially pronounced among patients with the highest risk at baseline (P=.02).

CONCLUSIONS

The RL-supported program learned which treatment modalities worked best to improve self-reported OA risk behaviors while conserving counselors' time. RL-supported interventions represent a scalable solution for patients with pain receiving OA prescriptions.

TRIAL REGISTRATION

Clinicaltrials.gov NCT02990377; https://classic.clinicaltrials.gov/ct2/show/NCT02990377.

Buprenorphine After Nonfatal Opioid Overdose: Reduced Mortality Risk in Medicare Disability Beneficiaries

INTRODUCTION

Opioid-involved overdose mortality is a persistent public health challenge, yet limited evidence exists on the relationship between opioid use disorder treatment after a nonfatal overdose and subsequent overdose death.

METHODS

National Medicare data were used to identify adult (aged 18-64 years) disability beneficiaries who received inpatient or emergency treatment for nonfatal opioid-involved overdose in 2008-2016. Opioid use disorder treatment was defined as (1) buprenorphine, measured using medication days' supply, and (2) psychosocial services, measured as 30-day exposures from and including each service date. Opioid-involved overdose fatalities were identified in the year after nonfatal overdose using linked National Death Index data. Cox proportional hazards models estimated the associations between time-varying treatment exposures and overdose death. Analyses were conducted in 2022.

RESULTS

The sample (N=81,616) was mostly female (57.3%), aged ≥50 years (58.8%), and White (80.9%), with a significantly elevated overdose mortality rate, compared with the general U.S. population (standardized mortality ratio=132.4, 95% CI=129.9, 135.0). Only 6.5% of the sample (n=5,329) had opioid use disorder treatment after the index overdose. Buprenorphine (n=3,774, 4.6%) was associated with a significantly lower risk of opioid-involved overdose death (adjusted hazard ratio=0.38, 95% CI=0.23, 0.64), but opioid use disorder-related psychosocial treatment (n=2,405, 2.9%) was not associated with risk of death (adjusted hazard ratio=1.18, 95% CI=0.71, 1.95).

CONCLUSIONS

Buprenorphine treatment after nonfatal opioid-involved overdose was associated with a 62% reduction in the risk of opioid-involved overdose death. However, fewer than 1 in 20 individuals received buprenorphine in the subsequent year, highlighting a need to strengthen care connections after critical opioid-related events, particularly for vulnerable groups.

The four-factor personality model and its qualitative correlates among opioid agonist therapy clients

Background

The Four Factor Personality Vulnerability model identifies four specific personality traits (e.g., sensation seeking [SS], impulsivity [IMP], anxiety sensitivity [AS], and hopelessness [HOP]) as implicated in substance use behaviors, motives for substance use, and co-occurring psychiatric conditions. Although the relationship between these traits and polysubstance use in opioid agonist therapy (OAT) clients has been investigated quantitatively, no study has examined the qualitative expression of each trait using clients' voice.

Method

Nineteen Methadone Maintenance Therapy (MMT) clients (68.4% male, 84.2% white, mean age[SD] = 42.71 [10.18]) scoring high on one of the four personality traits measured by the Substance Use Risk Profile Scale [SURPS] completed a semi-structured qualitative interview designed to explore their lived experience of their respective trait. Thematic analysis was used to derive themes, which were further quantified using content analysis.

Results

Themes emerging from interviews reflected (1) internalizing and externalizing symptoms, (2) adversity experiences, and (3) polysubstance use. Internalizing symptoms subthemes included symptoms of anxiety, fear, stress, depression, and avoidance coping. Externalizing subthemes included anger, disinhibited cognitions, and anti-social and risk-taking behaviors. Adverse experiences subthemes included poor health, poverty, homelessness, unemployment, trauma, and conflict. Finally, polysubstance use subthemes include substance types, methods of use, and motives. Differences emerged between personality profiles in the relative endorsement of various subthemes, including those pertaining to polysubstance use, that were largely as theoretically expected.

Conclusion

Personality is associated with unique cognitive, affective, and behavioral lived experiences, suggesting that personality may be a novel intervention target in adjunctive psychosocial treatment for those undergoing OAT.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Importance

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective

To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, Setting, and Participants

This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure

Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main Outcomes and Measures

Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results

Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and Relevance

In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Principles of care for pregnant and parenting people with substance use disorder: the obstetrician gynecologist perspective

Substance use in pregnant and parenting persons is common, yet still underdiagnosed. Substance use disorder (SUD) is one of the most stigmatized and undertreated chronic medical conditions, and this is exacerbated in the perinatal period. Many providers are not sufficiently trained in screening or treatment for substance use, so gaps in care for this population persist. Punitive policies towards substance use in pregnancy have proliferated, lead to decreased prenatal care, do not improve birth outcomes, and disproportionately impact Black, Indigenous, and other families of color. We discuss the importance of understanding the unique barriers of pregnancy-capable persons and drug overdose as one of the leading causes of maternal death in the United States. We highlight the principles of care from the obstetrician-gynecologist perspective including care for the dyad, person-centered language, and current medical terminology. We then review treatment of the most common substances, discuss SUD during the birthing hospitalization, and highlight the high risk of mortality in the postpartum period.

Group Cognitive Behavioral Therapy for Substance Use Disorders Among Psychiatric Inpatients in a Medically Underserved Area: An Intervention for Opioid Misuse

OBJECTIVES

Opioid misuse is a serious public health concern, yet few people seek treatment for this condition. Hospitals may be one opportunity to identify those with opioid misuse and to teach them skills to help manage their opioid misuse upon discharge. We tested the relationship between opioid misuse status and motivation to change substance use among patients admitted with substance misuse to an inpatient psychiatric unit in a medically underserved area in Baton Rouge, Louisiana, who attended at least 1 group session of motivation enhancement therapy combined with cognitive behavioral therapy (MET-CBT) from January 29, 2020, through March 10, 2022.

METHODS

Of the 419 patients in our sample, 86 (20.5%) appeared to misuse opioids (62.5% male; mean age, 35.0 y; 57.7% non-Hispanic/Latin White). At the beginning of each session, patients completed 2 measures of motivation-importance and confidence to change substance use-from 0 (not at all) to 10 (most). At the end of each session, patients rated perceived session helpfulness from 1 (extremely hindering) to 9 (extremely helpful).

RESULTS

Opioid misuse was associated with greater importance (Cohen d = 0.12) and confidence (Cohen d = 0.13) to change substance use and with attending more MET-CBT sessions (Cohen d = 0.13). Patients with opioid misuse rated sessions as highly helpful (score of 8.3 of 9), and these ratings did not differ from patients who used other substances.

CONCLUSIONS

Inpatient psychiatry hospitalizations may provide an opportunity to identify patients with opioid misuse and introduce these patients to MET-CBT to learn skills to manage opioid misuse upon discharge.

Applications of isradipine in human addiction studies: A systematic literature review

Given the personal and public health burden of addictive disorders, innovative approaches to treatment are sorely needed. This systematic review examined the use of the pharmacological agent isradipine in the context of potential applications for addiction treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guided a comprehensive search of PubMed, Cochrane Library, and PsycINFO between the years 1985 to July 2022. Studies were included if isradipine was administered to adults with a current Diagnostic and Statistical Manual of Mental Disorders-5th edition diagnosis of a substance use disorder and/or to healthy volunteers alone and in conjunction with a substance (i.e, cocaine, methamphetamine, alcohol). A total of 16 studies with 252 participants were included in this review. Substantial variability was identified with study designs, isradipine dosages/dosing, and addictive substance of interest. Outcomes clustered in four categories: (a) cerebral blood flow (CBF), (b) hemodynamic effects, (c) subjective effects, and (d) cognitive effects. Isradipine was found to improve CBF in individuals with cocaine-induced hypoperfusion and in several studies was found to reduce parameters of blood pressure elevation after stimulant use. There were no significant findings on isradipine's effect on subjective reporting (i.e., craving, mood, drug affect) or cognition/attention. Given the limited number of studies identified in this review, there is insufficient data to draw clear conclusions. The direct effects of isradipine as a pharmacologic agent for addictive disorder treatment appear minimal, however, future work may benefit from examining the impact of isradipine as an augmentative agent within existing cue exposure paradigms for preventing cue-induced drug relapse. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The interaction of race and age in methadone treatment retention outcomes: A single-center analysis

OBJECTIVES

Early treatment drop-out is due to the unique interplay of the individual and their context, and is associated with overdose death. The objective of this project was to determine if age or race is associated with 6-month treatment retention outcome differences at a single-center opioid treatment program.

METHODS

The study team performed a retrospective administrative database study from January 2014 to January 2017 using admission data with age and race as predictors of 6-month treatment retention outcomes.

RESULTS

Of the 457 admissions, 114 were under the age of 30; however, only 4 % of these young adults were Black, Indigenous, and/or People of Color (BIPOC). While retention for BIPOC patients (62 %) was slightly higher than for White patients (57 %), this difference did not reach traditional levels of significance.

CONCLUSIONS

Once BIPOC enter treatment, their treatment retention is similar to their White counterparts. Young adult BIPOC were less represented in the admission data, but treatment retention across racial groups was similar. An urgent need exists to determine the barriers and facilitators to treatment access among BIPOC young adults.

Patient experiences of methadone treatment changes during the first wave of COVID-19: a national community-driven survey

BACKGROUND

During COVID-19, the Substance Abuse and Mental Health Services Administration (SAMHSA) allowed Methadone Maintenance Treatment (MMT) programs to relax in-person MMT requirements to reduce COVID-19 exposure. This study examines patient-reported changes to in-person methadone clinic attendance requirements during COVID-19.

METHODS

From June 7, 2020, to July 15, 2020, a convenience sample of methadone patients (N = 392) were recruited in collaboration with National Survivors Union (NSU) in 43 states and Washington D.C. through social media (Facebook, Reddit, Twitter, and Web site pop-ups). The community-driven research (CDR) online survey collected information on how patient take-home methadone dosing and in-person drug testing, counseling, and clinic visit frequency changed prior to COVID-19 (before March 2020) to during COVID-19 (June and July 2020).

RESULTS

During the study time period, the percentage of respondents receiving at least 14 days of take-home doses increased from 22 to 53%, while the percentage receiving one or no take-home doses decreased from 22.4% before COVID-19 to 10.2% during COVID-19. In-person counseling attendance decreased from 82.9% to 19.4%. While only 3.3% of respondents accessed counseling through telehealth before COVID-19, this percentage increased to 61.7% during COVID-19. Many respondents (41.3%) reported visiting their clinics in person once a week or more during COVID-19.

CONCLUSIONS

During the first wave of COVID-19, methadone patients report decreased in-person clinic attendance and increased take-home doses and use of telehealth for counseling services. However, respondents reported considerable variations, and many were still required to make frequent in-person clinic visits, which put patients at risk of COVID-19 exposure. Relaxations of MMT in-person requirements during COVID-19 should be consistently implemented and made permanent, and patient experiences of these changes should be explored further.

Cannabis Use Disorder Treatment Preferences: A Pilot Survey in Current Users of Cannabis

OBJECTIVES

Highly effective treatments for cannabis use disorder (CUD) are lacking, and patient preferences have not been considered during treatment development. We therefore conducted an exploratory crowdsourced survey of individuals reporting current cannabis use and a willingness to cut down or quit their cannabis use, to determine their interest in various treatment aspects.

METHODS

Subjects (n = 63) were queried about their willingness to take medications as a function of type, route, and regimen and to participate in adherence monitoring. Subjects were also asked about their willingness to engage in behavioral/psychosocial interventions as a function of type, setting, and duration. Measures theorized to be associated with treatment preferences were also collected, including cannabis use variables, readiness to change, reduction or cessation goal, perceived cessation barriers, and medication use beliefs and behaviors.

RESULTS

Survey responses indicated that efforts to develop CUD medications should focus on nonsynthetic compounds administered orally or by mouth spray no more than once per day to maximize patient acceptance. Remote adherence monitoring and one-on-one outpatient behavioral treatment approaches, especially contingency management, are also anticipated to enhance participation. Most subjects indicated a preference to reduce their cannabis use rather than quit.

CONCLUSIONS

These data provide guidance for the development of CUD interventions based on the preferences of individuals interested in treatment for their cannabis use. Additional research is needed to confirm these results in a larger sample and determine if matching CUD patients with their preferred treatments improves success rates.

History of the discovery, development, and FDA-approval of buprenorphine medications for the treatment of opioid use disorder

Buprenorphine-based medications were first approved by the United States Food and Drug Administration in 2002 for the treatment of opioid dependence, or opioid use disorder (OUD) as the condition is presently known. This regulatory milestone was the outcome of 36 years of research and development, which also led to the development and approval of several other new buprenorphine-based medications. In this short review, we first describe the discovery and early development stages of buprenorphine. Second, we review key steps that led to the development of buprenorphine as a drug product. Third, we explain the regulatory approval of several buprenorphine-based medications for the treatment of OUD. We also discuss these developments in the context of the evolution of regulations and policies that have progressively improved OUD treatment availability and efficacy, although challenges remain in removing system-level, provider-level, and local-level barriers to quality treatment, to integrating OUD treatment into routine care and other settings, to reducing disparities in access to treatment, and to optimizing person-centered outcomes.

Digital interventions for opioid use disorder treatment: A systematic review of randomized controlled trials

INTRODUCTION

Opioid use disorders are associated with a high burden of disease and treatment gap. Digital interventions can be used to provide psycho-social treatment for opioid use disorders, as an alternative to or together with face-to-face interventions. This review aimed to assess the application and effectiveness of digital interventions to treat opioid use disorder globally.

METHODS

The study team searched four electronic databases (PubMed, Psych INFO, Web of Science and Cochrane Central register of controlled trials). The inclusion criteria were: randomized controlled trials, assessment for opioid use before and at least once following intervention, and use of digital interventions. The primary outcomes were opioid use and/or retention in treatment, with data being summarized in tables and a narrative review presented.

RESULTS

The initial database search yielded 3542 articles, of which this review includes 20. Nineteen were conducted among adults in the United States. The digital interventions used included web-based, computer-based, telephone calls, video conferencing, automated self-management system, mobile applications and text messaging. They were based on therapeutic education systems, community reinforcement approaches, cognitive behavior therapy, relapse prevention, brief interventions, supportive counselling and motivational interviewing. The studies had mixed findings; of the 20 studies, 10 had statistically significant differences between the treatment groups for opioid abstinence, and four had significant differences for treatment retention. Comparisons were difficult due to varying methodologies. Participants rated the interventions as acceptable and reported high rates of satisfaction.

CONCLUSION

The use of digital interventions for opioid use disorder treatment was acceptable, with varying levels of effectiveness for improving outcomes, which is influenced by participant and intervention delivery factors. Further studies in different parts of the world should compare these findings, specifically in low- and middle-income countries.

When a pandemic and epidemic collide: Lessons learned about how system barriers can interrupt implementation of addiction research

Background

Telehealth technologies are now featured more prominently in addiction treatment services than prior to the COVID-19 pandemic, but system barriers should be carefully considered for the successful implementation of innovative remote solutions for medication management and recovery coaching support for people with opioid use disorder (OUD).

Method

The Centers for Disease Control and Prevention funded a telehealth trial prior to the COVID-19 pandemic with a multi-institution team who attempted to implement an innovative protocol during the height of the pandemic in 2020 in Tampa, Florida. The study evaluated the effectiveness of a mobile device application, called MySafeRx, which integrated remote motivational recovery coaching with daily supervised dosing from secure pill dispensers via videoconference, on medication adherence during buprenorphine treatment. This paper provides a participant case example followed by a reflective evaluation of how the pandemic amplified both an existing research-to-practice gap and clinical system barriers during the implementation of telehealth clinical research intervention for patients with OUD.

Findings

Implementation challenges arose from academic institutional requirements, boundaries and role identity, clinical staff burnout and lack of buy-in, rigid clinical protocols, and limited clinical resources, which hampered recruitment and intervention engagement.

Conclusions

As the urgency for feasible and effective telehealth solutions continues to rise in response to the growing numbers of opioid-related deaths, the scientific community may use these lessons learned to re-envision the relationship between intervention implementation and the role of clinical research toward mitigating the opioid overdose epidemic.

Clinical Trial Design Challenges and Opportunities for Emerging Treatments for Opioid Use Disorder: A Review

Importance

Novel treatments for opioid use disorder (OUD) are needed to address both the ongoing opioid epidemic and long-standing barriers to existing OUD treatments that target the endogenous μ-opioid receptor (MOR) system. The goal of this review is to highlight unique clinical trial design considerations for the study of emerging treatments for OUD that address targets beyond the MOR system. In November 2019, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the US Food and Drug Administration sponsored a meeting to discuss the current evidence regarding potential treatments for OUD, including cannabinoids, psychedelics, sedative-hypnotics, and immunotherapeutics, such as vaccines.

Observations

Consensus recommendations are presented regarding the most critical elements of trial design for the evaluation of novel OUD treatments, such as: (1) stage of treatment that will be targeted (eg, seeking treatment, early abstinence/detoxification, long-term recovery); (2) role of treatment (adjunctive with or independent of existing OUD treatments); (3) primary outcomes informed by patient preferences that assess opioid use (including changes in patterns of use), treatment retention, and/or global functioning and quality of life; and (4) adverse events, including the potential for opioid-related relapse or overdose, especially if the patient is not simultaneously taking maintenance MOR agonist or antagonist medications.

Conclusions and Relevance

Applying the recommendations provided here as well as considering input from people with lived experience in the design phase will accelerate the development, translation, and uptake of effective and safe therapeutics for individuals struggling with OUD.