Recovery Goals and Long-term Treatment Preference in Persons Who Engage in Nonmedical Opioid Use

Evidence-based treatment for opioid use disorder is widely unavailable and often discouraged by providers of residential substance use services in North Carolina

INTRODUCTION

Opioid agonist treatment (OAT) is the only treatment for opioid use disorder (OUD) proven to reduce overdose mortality, yet access to this evidence-based treatment remains poor. The purpose of this cross-sectional audit study was to assess OAT availability at residential substance use services in North Carolina.

METHODS

We conducted a state-wide inventory of residential substance use service providers in North Carolina and subsequently called all providers identified, posing as uninsured persons who use heroin, seeking treatment services. Program characteristics, as reported in phone calls, were systematically recorded. We used Fisher's exact tests to assess what program characteristics were associated with OAT availability and with staff making discouraging comments about OAT. We used unsupervised agglomerative clustering to identify facilities with similar characteristics.

RESULTS

Of the 94 treatment providers identified, we successfully contacted and collected data from 66. Of those, only 7 (10.6 %) provide OAT on site; an additional 9 (13.6 %) allow OAT through an outside or community-based prescriber. Only 8 (12.1 %) providers were licensed to provide residential substance use treatment. Staff from 33 (50.0 %) providers made negative, discouraging, or stigmatizing remarks about OAT-for example, that OAT substitutes one addiction for another or does not constitute "true recovery." OAT availability was positively associated with a provider holding a state license for any substance use-related service (41.9 % vs 8.6 %, p = 0.002) and offering 12-step programming (36.1 % vs. 10/0 %, p = 0.020). OAT availability was negatively associated with faith-based programming (6.1 % vs 42.4 %, p = 0.001), dress codes (5.3 % vs 50.0 %, p < 0.001), and mandates that residents work in a provider-owned and -operated commercial enterprise (5.0 % vs 32.6 %, p = 0.026). Cluster analysis revealed that the most common (n = 21) type of service provider in North Carolina is an unlicensed, faith-based organization that prohibits OAT, imposes a dress code, and mandates that residents work, often in provider-owned and -operated commercial enterprises.

CONCLUSION

Evidence-based treatments for OUD are largely unavailable at providers of residential substance use services in North Carolina. The prohibition of OAT occurs most often among providers who are unlicensed and impose labor and/or 12-step mandates on residents. Changes to state licensure requirements and exemptions may help improve OAT availability.

Electronic harm reduction interventions for drug overdose monitoring and prevention: A scoping review

BACKGROUND

Novel strategies are required to address rising overdose deaths across the globe. We sought to identify the breadth and depth of the existing evidence around electronic harm reduction (e-harm reduction) interventions that aimed to reduce the harms associated with substance use.

METHODS

We conducted a scoping review according to the PRISMA-ScR and PRISMA for Searching guidelines. A health sciences librarian systematically searched seven health databases from inception until January 20, 2023. Citation chaining and reference lists of included studies were searched to identify additional articles. Two reviewers independently screened, extracted and charted the data. Additionally, we conducted a gray literature search and environmental scan to supplement the findings.

RESULTS

A total of 51 studies met the criteria for inclusion (30 peer-reviewed articles and 21 non-peer reviewed). Most peer-reviewed studies were conducted in Western countries (USA = 23, Canada = 3, Europe = 3, China = 1) and among adult samples (adult = 27, youth/adults =1, unspecified = 2). Study designs were predominantly quantitative (n = 24), with a minority using qualitative (n = 4) or mixed methods (n = 2). Most e-harm reduction interventions were harm reduction (n = 15), followed by education (n = 6), treatment (n = 2), and combined/other approaches (n = 7). Interventions utilized web-based/mobile applications (n = 15), telephone/telehealth (n = 10), and other technology (n = 5).

CONCLUSIONS

While e-harm reduction technology is promising, further research is required to establish the efficacy and effectiveness of these novel interventions.

Patient-Concerned Other Dyads' 12-Step Involvement and Patients' Substance Use: A Latent Class Growth Model Analysis

OBJECTIVE

This study aimed to inform clinical practice by identifying subgroups of patient-concerned other (CO) dyads. Patients with alcohol use disorders (AUDs) were characterized on Alcoholics Anonymous (AA) involvement and substance use together with COs' Al-Anon involvement. Predictors and recovery maintenance outcomes of subgroup membership were examined.

METHOD

Participants were 279 patient-CO dyads. Patients were in residential treatment for AUD. Parallel latent class growth model analysis characterized 12-step involvement and substance use at treatment entry and 3-, 6-, and 12-month follow-ups.

RESULTS

Three classes were as follows: 38% Low AA/Low Al-Anon (patients' low AA and COs' low Al-Anon involvement, and patients' high-to-moderate substance use), 10% High AA/High Al-Anon (patients' high AA and COs' high Al-Anon involvement, and patients' moderate-to-low substance use), and 52% High AA/Low Al-Anon (patients' high AA and COs' low Al-Anon involvement, and patients' moderate-to-low substance use). At follow-up, the Low AA/Low Al-Anon classes' patients were less likely to have spirituality as recovery support, confidence about staying abstinent, and satisfaction with recovery progress. The High AA classes' COs had less concern about patients' drinking and scored higher on positive aspects of relationships with patients.

CONCLUSIONS

Clinicians should encourage patients' and COs' 12-step group involvement (12-step practices' engagement). Among patients treated for AUD, AA involvement was related to better outcomes, and to COs' lessened concern about the patients' drinking. COs' Al-Anon involvement was associated with having a more positive view of their relationship with the patient. That more than one third of dyads had low 12-step group involvement suggests that treatment programs may need to facilitate involvement in non-12-step mutual-help groups.

Delta-9-tetrahydrocannabinol modulates pain sensitivity among persons receiving opioid agonist therapy for opioid use disorder: A within-subject, randomized, placebo-controlled laboratory study

The opioid and cannabinoid receptor systems are inextricably linked-overlapping at the anatomical, functional and behavioural levels. Preclinical studies have reported that cannabinoid and opioid agonists produce synergistic antinociceptive effects. Still, there are no experimental data on the effects of cannabinoid agonists among humans who receive opioid agonist therapies for opioid use disorder (OUD). We conducted an experimental study to investigate the acute effects of the delta-9-tetrahydrocannabinol (THC) among persons receiving methadone therapy for OUD. Using a within-subject, crossover, human laboratory design, 25 persons on methadone therapy for OUD (24% women) were randomly assigned to receive single oral doses of THC (10 or 20 mg, administered as dronabinol) or placebo, during three separate 5-h test sessions. Measures of experimental and self-reported pain sensitivity, abuse potential, cognitive performance and physiological effects were collected. Mixed-effects models examined the main effects of THC dose and interactions between THC (10 and 20 mg) and methadone doses (low-dose methadone defined as <90 mg/day; high dose defined as >90 mg/day). Results demonstrated that, for self-reported rather than experimental pain sensitivity measures, 10 mg THC provided greater relief than 20 mg THC, with no substantial evidence of abuse potential, and inconsistent dose-dependent cognitive adverse effects. There was no indication of any interaction between THC and methadone doses. Collectively, these results provide valuable insights for future studies aiming to evaluate the risk-benefit profile of cannabinoids to relieve pain among individuals receiving opioid agonist therapy for OUD, a timely endeavour amidst the opioid crisis.

Can initial experiences with drugs predict future drug abuse risks?

Initial experiences with drugs may influence an individual's motivations for continued use. This study evaluated the relationship between subjective effects elicited by an individual's first use of alcohol or cannabis, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) alcohol use disorder (AUD) or cannabis use disorder (CUD) severity, and behavioral economic demand for alcohol or cannabis. Self-reports of initial subjective effects associated with drugs were analyzed for N = 463 participants whose first substance use was either alcohol or cannabis. The likelihood that a particular subjective effect at the time of first use was associated with current AUD/CUD was assessed using ordinal logistic regression with subjective effects as predictors of DSM-5 severity. Behavioral economic demand was assessed using a hypothetical purchase task in which participants indicated their hypothetical consumption of alcohol or cannabis as a function of price. Significant associations were observed for initial subjective effects elicited by alcohol or cannabis and increased DSM-5 severity: (alcohol) relief (OR = 2.52 [95% CI 1.51-4.25], p = .0005) and (cannabis) energetic (OR = 2.31 [95% CI 3.27-55.5], p = .0004). The mean (± SEM) Pmax value for the alcohol subgroup endorsing relief ($96.22 ± $26.48) was significantly greater than the Pmax value for the alcohol subgroup not endorsing relief ($33.81 ± $12.93), t(237) = 2.276, p = .0237. These results suggest that the initial subjective effects associated with a given substance may predict the development and/or severity of substance misuse and substance use disorders (SUDs). These findings are consistent with anecdotal reports that persons with SUD feel energized by the use of substances whereas persons without SUD do not report experiencing such subjective effects upon first use. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sleep disturbance as a therapeutic target to improve opioid use disorder treatment

Sleep health is an important factor across several physical and mental health disorders, and a growing scientific consensus has identified sleep as a critical component of opioid use disorder (OUD), both in the active disease state and during OUD recovery. The goal of this narrative review is to collate the literature on sleep, opioid use, and OUD as a means of identifying therapeutic targets to improve OUD treatment outcomes. Sleep disturbance is common and often severe in persons with OUD, especially during opioid withdrawal, but also in persons on opioid maintenance therapies. There is ample evidence that sleep disturbances including reduced total sleep time, disrupted sleep continuity, and poor sleep quality often accompany negative OUD treatment outcomes. Sleep disturbances are bidirectionally associated with several other factors related to negative treatment outcomes, including chronic stress, stress reactivity, low positive affect, high negative affect, chronic pain, and drug craving. This constellation of outcome variables represents a more comprehensive appraisal of the quality of life and quality of recovery than is typically assessed in OUD clinical trials. To date, there are very few clinical trials or experimental studies aimed at improving sleep health in OUD patients, either as a means of improving stress, affect, and craving outcomes, or as a potential mechanistic target to reduce opioid withdrawal and drug use behaviors. As such, the direct impact of sleep improvement in OUD patients is largely unknown, yet mechanistic and clinical research suggests that therapeutic interventions that target sleep are a promising avenue to improve OUD treatment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

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

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

Technology-assisted opioid education for out-of-treatment adults with opioid use disorder

OBJECTIVE

To evaluate the feasibility and potential efficacy of a technology-assisted education program in teaching adults at a high risk of opioid overdose about opioids; opioid overdose; and opioid use disorder medications.

METHOD

A within-subject, repeated-measures design was used to evaluate effects of the novel technology-assisted education program. Participants (N = 40) were out-of-treatment adults with opioid use disorder, recruited in Baltimore, Maryland from May 2019 to January 2020. The education program was self-paced and contained three courses. Each course presented information and required answers to multiple-choice questions. The education program was evaluated using a 50-item test, delivered before and after participants completed each course. Tests were divided into three subtests that contained questions from each course. We measured accuracy on each subtest before and after completion of each course and used a mixed-effects model to analyze changes in accuracy across tests.

RESULTS

The technology-assisted education program required a median time of 91 min of activity to complete. Most participants completed the program in a single day. Accuracy on each subtest increased only after completion of the course that corresponded to that subtest, and learning comparisons were significant at the p < .001 level for all subtests. Accuracy on each subtest was unchanged before completion of the relevant course, and increases in accuracy were retained across subsequent tests. Learning occurred similarly independent of participant education, employment, and poverty.

CONCLUSIONS

Technology-assisted education programs can provide at-risk adults with access to effective education on opioids, opioid overdose, and opioid use disorder medications. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Pills to Powder: A 17-Year Transition From Prescription Opioids to Heroin Among US Adolescents Followed Into Adulthood

OBJECTIVES

To examine the longitudinal relationships between US adolescents' prescription opioid use and misuse and any subsequent heroin use in adulthood.

METHODS

Nationally representative samples of adolescents from 25 independent cohorts were surveyed via self-administered questionnaires and followed from ages 18 to 35 (n = 11,012). Adolescents were divided into 5 subgroups based on survey responses at age 18: no lifetime exposure to prescription opioids (population controls), medical prescription opioid use without a history of nonmedical misuse (medical use only), medical use followed by nonmedical misuse, nonmedical misuse followed by medical use, and nonmedical misuse only. These 5 subgroups were compared on their risk for any heroin use through age 35 (1993-2017). Adolescents who reported lifetime heroin use at age 18 were excluded.

RESULTS

Adolescents who reported nonmedical prescription opioid misuse followed by medical use or nonmedical misuse only had greater odds of any heroin use in adulthood than population controls. More recent cohorts of adolescents who reported nonmedical misuse or medical use only (compared to older cohorts) had greater odds of any heroin use in adulthood relative to population controls. Nearly 1 in 3 adolescents in recent cohorts who reported nonmedical prescription opioid misuse transitioned to any heroin use.

CONCLUSIONS

There is increased risk for heroin use among adolescents who initiated nonmedical misuse or adolescents prescribed opioids in more recent cohorts. These findings indicate historical variation and reinforce the critical role of vigilant monitoring and drug screening to detect high-risk individuals who would benefit from an intervention to reduce later heroin use.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Treatment Disruption and Childcare Responsibility as Risk Factors for Drug and Alcohol Use in Persons in Treatment for Substance Use Disorders During the COVID-19 Crisis

The novel 2019 coronavirus (COVID-19) crisis has caused considerable upheaval in the U.S. healthcare system. The current study examined patient-reported experiences in substance use disorder (SUD) treatment during the early stages of the COVID-19 crisis.

Differences in Availability and Use of Medications for Opioid Use Disorder in Residential Treatment Settings in the United States

Importance

While many individuals with opioid use disorder seek treatment at residential facilities to initiate long-term recovery, the availability and use of medications for opioid use disorder (MOUDs) in these facilities is unclear.

Objective

To examine differences in MOUD availability and use in residential facilities as a function of Medicaid policy, facility-level factors associated with MOUD availability, and admissions-level factors associated with MOUD use.

Design, Setting, and Participants

This cross-sectional study used deidentified facility-level and admissions-level data from 2863 residential treatment facilities and 232 414 admissions in the United States in 2017. Facility-level data were extracted from the 2017 National Survey of Substance Abuse Treatment Services, and admissions-level data were extracted from the 2017 Treatment Episode Data Set-Admissions. Statistical analyses were conducted from June to November 2019.

Exposures

Admissions for opioid use disorder at residential treatment facilities in the United States that identified opioids as the patient's primary drug of choice.

Main Outcomes and Measures

Availability and use of 3 MOUDs (ie, extended-release naltrexone, buprenorphine, and methadone).

Results

Of 232 414 admissions, 205 612 (88.5%) contained complete demographic data (166 213 [80.8%] aged 25-54 years; 136 854 [66.6%] men; 151 867 [73.9%] white). Among all admissions, MOUDs were used in only 34 058 of 192 336 (17.7%) in states that expanded Medicaid and 775 of 40 078 (1.9%) in states that did not expand Medicaid (P < .001). A relatively low percentage of the 2863 residential treatment facilities in this study offered extended-release naltrexone (854 [29.8%]), buprenorphine (953 [33.3%]), or methadone (60 [2.1%]). Compared with residential facilities that offered at least 1 MOUD, those that offered no MOUDs had lower odds of also offering psychiatric medications (odds ratio [OR], 0.06; 95% CI, 0.05-0.08; Wald χ21 = 542.09; P < .001), being licensed by a state or hospital authority (OR, 0.39; 95% CI, 0.27-0.57; Wald χ21 = 24.28; P < .001), or being accredited by a health organization (OR, 0.28; 95% CI, 0.23-0.33; Wald χ21 = 180.91; P < .001). Residential facilities that did not offer any MOUDs had higher odds of accepting cash-only payments than those that offered at least 1 MOUD (OR, 4.80; 95% CI, 3.47-6.64; Wald χ21 = 89.65; P < .001).

Conclusions and Relevance

In this cross-sectional study of residential addiction treatment facilities in the United States, MOUD availability and use were sparse. Public health and policy efforts to improve access to and use of MOUDs in residential treatment facilities could improve treatment outcomes for individuals with opioid use disorder who are initiating recovery.

Subtypes in patients with opioid misuse: A prognostic enrichment strategy using electronic health record data in hospitalized patients

BACKGROUND

Approaches are needed to better delineate the continuum of opioid misuse that occurs in hospitalized patients. A prognostic enrichment strategy with latent class analysis (LCA) may facilitate treatment strategies in subtypes of opioid misuse. We aim to identify subtypes of patients with opioid misuse and examine the distinctions between the subtypes by examining patient characteristics, topic models from clinical notes, and clinical outcomes.

METHODS

This was an observational study of inpatient hospitalizations at a tertiary care center between 2007 and 2017. Patients with opioid misuse were identified using an operational definition applied to all inpatient encounters. LCA with eight class-defining variables from the electronic health record (EHR) was applied to identify subtypes in the cohort of patients with opioid misuse. Comparisons between subtypes were made using the following approaches: (1) descriptive statistics on patient characteristics and healthcare utilization using EHR data and census-level data; (2) topic models with natural language processing (NLP) from clinical notes; (3) association with hospital outcomes.

FINDINGS

The analysis cohort was 6,224 (2.7% of all hospitalizations) patient encounters with opioid misuse with a data corpus of 422,147 clinical notes. LCA identified four subtypes with differing patient characteristics, topics from the clinical notes, and hospital outcomes. Class 1 was categorized by high hospital utilization with known opioid-related conditions (36.5%); Class 2 included patients with illicit use, low socioeconomic status, and psychoses (12.8%); Class 3 contained patients with alcohol use disorders with complications (39.2%); and class 4 consisted of those with low hospital utilization and incidental opioid misuse (11.5%). The following hospital outcomes were the highest for each subtype when compared against the other subtypes: readmission for class 1 (13.9% vs. 10.5%, p<0.01); discharge against medical advice for class 2 (12.3% vs. 5.3%, p<0.01); and in-hospital death for classes 3 and 4 (3.2% vs. 1.9%, p<0.01).

CONCLUSIONS

A 4-class latent model was the most parsimonious model that defined clinically interpretable and relevant subtypes for opioid misuse. Distinct subtypes were delineated after examining multiple domains of EHR data and applying methods in artificial intelligence. The approach with LCA and readily available class-defining substance use variables from the EHR may be applied as a prognostic enrichment strategy for targeted interventions.