Medication-assisted treatment of opioid use disorder: review of the evidence and future directions

Comparing outcomes of extended-release naltrexone in adolescents and young adults with opioid use disorder

INTRODUCTION

Opioid use among youth is a public health concern in the United States, with >3300 overdose deaths occurring nationally each year. Unfortunately, youth in the United States are still prescribed medication for opioid use disorder (OUD) at a lower rate than their adult counterparts.

METHODS

From 10/2013 to 01/2018, adolescents (ages 15-17; n = 25) and young adults (ages 18-21; n = 263) with moderate to severe OUD enrolled in the parent trial of extended-release naltrexone (XR-NTX; n = 82) versus treatment-as-usual (TAU; either buprenorphine maintenance [n = 94] or counseling without buprenorphine maintenance [n = 112]). The study assessed opioid use outcomes for adolescents vs. young adults using timeline follow-back self-report procedures at baseline and 3-/6-month follow-up assessments. Mixed-effects longitudinal and clustered panel regression models compared treatment effects over time of XR-NTX and TAU on opioid use outcomes in this secondary analysis.

RESULTS

Though adolescent participants reported significantly less opioid use at baseline relative to their young adult counterparts (p < 0.05), the two age groups reported similar rates of opioid use throughout the intervention period. Additionally, both adolescents and young adults receiving XR-NTX evidenced lower rates of opioid use than those receiving TAU at all time points, and adolescents on XR-NTX were the only group who reduced their opioid use at all time points. Mixed-effects models indicated adolescents receiving XR-NTX demonstrated a 48 % lower rate of opioid use days [Incidence Rate Ratio (IRR) = 0.52; p = 0.020], while young adults receiving XR-NTX reported an estimated 26 % lower rate (IRR = 0.74; p = 0.009).

CONCLUSIONS

Results indicate that adolescents respond favorably to XR-NTX relative to TAU for treatment of OUD, demonstrating similar outcomes to young adults.

Evolution of an epidemic: Understanding the opioid epidemic in the United States and the impact of the COVID-19 pandemic on opioid-related mortality

We conduct this research with a two-fold aim: providing a quantitative analysis of the opioid epidemic in the United States (U.S.), and exploring the impact of the COVID-19 pandemic on opioid-related mortality. The duration and persistence of the opioid epidemic lends itself to the need for an overarching analysis with extensive scope. Additionally, studying the ramifications of these concurrent severe public health crises is vital for informing policies to avoid preventable mortality. Using data from CDC WONDER, we consider opioid-related deaths grouped by Census Region spanning January 1999 to October 2022 inclusive, and later add on a demographic component with gender-stratification. Through the lens of key events in the opioid epidemic, we build an interrupted time series model to reveal statistically significant drivers of opioid-related mortality. We then employ a counterfactual to approximate trends in the absence of COVID-19, and estimate excess opioid-related deaths (defined as observed opioid-related deaths minus projected opioid-related deaths) associated with the pandemic. According to our model, the proliferation of fentanyl contributed to sustained increases in opioid-related death rates across three of the four U.S. census regions, corroborating existing knowledge in the field. Critically, each region has an immediate increase to its opioid-related monthly death rate of at least 0.31 deaths per 100,000 persons at the start of the pandemic, highlighting the nationwide knock-on effects of COVID-19. There are consistent positive deviations from the expected monthly opioid-related death rate and a sizable burden from cumulative excess opioid-related deaths, surpassing 60,000 additional deaths nationally from March 2020 to October 2022, ∼70% of which were male. These results suggest that robust, multi-faceted measures are even more important in light of the COVID-19 pandemic to prevent overdoses and educate users on the risks associated with potent synthetic opioids such as fentanyl.

Medicare Payment for Opioid Treatment Programs

Importance

Medicare began paying for medications for opioid use disorder (MOUD) at opioid treatment programs (OTPs) that dispense methadone and other MOUD in January 2020. There has been little research describing the response to this payment change and whether it resulted in more patients receiving MOUD or just a shift in who pays for this care.

Objective

To describe how many and which Medicare beneficiaries receive care from OTPs and how this compares to those receiving MOUD in other settings.

Design, Setting, and Participants

This cross-sectional study included all patients receiving MOUD care identified in 2019-2022 100% US Medicare Parts B and D claims. Patients receiving care in an OTP who were dually insured with Medicare and Medicaid in the 2019-2020 Transformed Medicaid Statistical Information System were also included.

Exposure

Receiving MOUD care in an OTP.

Main Outcomes and Measures

Comparisons of 2022 beneficiaries treated in OTPs vs other non-OTP settings in 2022.

Results

The share of Medicare beneficiaries treated by OTPs rose steadily from 4 per 10 000 (14 160 beneficiaries) in January 2020 to 7 per 10 000 (25 596 beneficiaries) in August 2020, then plateaued through December 2022; of 38 870 patients (23% ≥66 years; 35% female) treated at an OTP in 2022, 96% received methadone. Patients in OTPs, compared to those receiving MOUD in other settings, were more likely be 65 years and younger (65% vs 62%; P < .001), less likely to be White (72% vs 82%; P < .001), and more likely to be an urban resident (86% vs 74%; P < .001). When Medicare OTP coverage began, there was no associated drop in the number of dually insured patients with Medicaid with an OTP claim. Of the 1854 OTPs, 1115 (60%) billed Medicare in 2022, with the share billing Medicare ranging from 13% to 100% across states.

Conclusions and Relevance

This study showed that since the initiation of Medicare OTP coverage in 2020, there has been a rapid increase in the number of Medicare beneficiaries with claims for OTP services for MOUD, and most OTPs have begun billing Medicare. Patients in OTPs were more likely to be urban residents and members of racial or ethnic minority groups than the patients receiving other forms of MOUD.

Diagnosing and managing prescription opioid use disorder in patients prescribed opioids for chronic pain in Australian general practice settings: a qualitative study using the theory of Planned Behaviour

BACKGROUND

Chronic pain is a debilitating and common health issue. General Practitioners (GPs) often prescribe opioids to treat chronic pain, despite limited evidence of benefit and increasing evidence of harms, including prescription Opioid Use Disorder (pOUD). Australian GPs are worried about the harms of long-term opioids, but few are involved in the treatment of pOUD. There is little research on GPs' experiences diagnosing and managing pOUD in their chronic pain patients.

METHODS

This qualitative research used semi-structured interviews and a case study to investigate GPs' experiences through the lens of the Theory of Planned Behaviour (TPB). TPB describes three factors, an individual's perceived beliefs/attitudes, perceived social norms and perceived behavioural controls. Participants were interviewed via an online video conferencing platform. Interviews were transcribed verbatim and thematically analysed.

RESULTS

Twenty-four GPs took part. Participants were aware of the complex presentations for chronic pain patients and concerned about long-term opioid use. Their approach was holistic, but they had limited understanding of pOUD diagnosis and suggested that pOUD had only one treatment: Opioid Agonist Treatment (OAT). Participants felt uncomfortable prescribing opioids and were fearful of difficult, conflictual conversations with patients about the possibility of pOUD. This led to avoidance and negative attitudes towards diagnosing pOUD. There were few positive social norms, few colleagues diagnosed or managed pOUD. Participants reported that their colleagues only offered positive support as this would allow them to avoid managing pOUD themselves, while patients and other staff were often unsupportive. Negative behavioural controls were common with low levels of knowledge, skill, professional supports, inadequate time and remuneration described by many participants. They felt OAT was not core general practice and required specialist management. This dichotomous approach was reflected in their views that the health system only supported treatment for chronic pain or pOUD, not both conditions.

CONCLUSIONS

Negative beliefs, negative social norms and negative behavioural controls decreased individual behavioural intention for this group of GPs. Diagnosing and managing pOUD in chronic pain patients prescribed opioids was perceived as difficult and unsupported. Interventions to change behaviour must address negative perceptions in order to lead to more positive intentions to engage in the management of pOUD.

Comorbidity Burden and Health Care Utilization by Substance use Disorder Patterns among People with HIV in Florida

Substance use disorder (SUD), a common comorbidity among people with HIV (PWH), adversely affects HIV clinical outcomes and HIV-related comorbidities. However, less is known about the incidence of different chronic conditions, changes in overall comorbidity burden, and health care utilization by SUD status and patterns among PWH in Florida, an area disproportionately affected by the HIV epidemic. We used electronic health records (EHR) from a large southeastern US consortium, the OneFlorida + clinical research data network. We identified a cohort of PWH with 3 + years of EHRs after the first visit with HIV diagnosis. International Classification of Diseases (ICD) codes were used to identify SUD and comorbidity conditions listed in the Charlson comorbidity index (CCI). A total of 42,271 PWH were included (mean age 44.5, 52% Black, 45% female). The prevalence SUD among PWH was 45.1%. Having a SUD diagnosis among PWH was associated with a higher incidence for most of the conditions listed on the CCI and faster increase in CCI score overtime (rate ratio = 1.45, 95%CI 1.42, 1.49). SUD in PWH was associated with a higher mean number of any care visits (21.7 vs. 14.8) and more frequent emergency department (ED, 3.5 vs. 2.0) and inpatient (8.5 vs. 24.5) visits compared to those without SUD. SUD among PWH was associated with a higher comorbidity burden and more frequent ED and inpatient visits than PWH without a diagnosis of SUD. The high SUD prevalence and comorbidity burden call for improved SUD screening, treatment, and integrated care among PWH.

Multimodal frontal neuroimaging markers predict longitudinal craving reduction in abstinent individuals with heroin use disorder

The variation in improvement among individuals with addiction after abstinence is a critical issue. Here, we aimed to identify robust multimodal markers associated with high response to 8-month abstinence in the individuals with heroin use disorder (HUD) and explore whether the identified markers could be generalized to the individuals with methamphetamine use disorder (MUD). According to the median of craving changes, 53 individuals with HUD with 8-month abstinence were divided into two groups: higher craving reduction and lower craving reduction. At baseline, clinical variables, cortical thickness and subcortical volume, fractional anisotropy (FA) of fibers and resting-state functional connectivity (RSFC) were extracted. Different strategies (single metric, multimodal neuroimaging fusion and multimodal neuroimaging-clinical data fusion) were used to identify reliable features for discriminating the individuals with HUD with higher craving reduction from those with lower reduction. The generalization ability of the identified features was validated in the 21 individuals with MUD. Multimodal neuroimaging-clinical fusion features with best performance was achieved an 87.1 ± 3.89% average accuracy in individuals with HUD, with a moderate accuracy of 66.7% when generalizing to individuals with MUD. The multimodal neuroimaging features, primarily converging in frontal regions (e.g., the left superior frontal (LSF) thickness, FA of the LSF-occipital tract, and RSFC of left middle frontal-right superior temporal lobe), collectively contributed to prediction alongside dosage and attention impulsiveness. In this study, we identified the validated multimodal frontal neuroimaging markers associated with higher response to long-term abstinence and revealed insights for the neural mechanisms of addiction abstinence, contributing to clinical strategies and treatment for addiction.

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.

Predictability of buprenorphine-naloxone treatment retention: A multi-site analysis combining electronic health records and machine learning

BACKGROUND AND AIMS

Opioid use disorder (OUD) and opioid dependence lead to significant morbidity and mortality, yet treatment retention, crucial for the effectiveness of medications like buprenorphine-naloxone, remains unpredictable. Our objective was to determine the predictability of 6-month retention in buprenorphine-naloxone treatment using electronic health record (EHR) data from diverse clinical settings and to identify key predictors.

DESIGN

This retrospective observational study developed and validated machine learning-based clinical risk prediction models using EHR data.

SETTING AND CASES

Data were sourced from Stanford University's healthcare system and Holmusk's NeuroBlu database, reflecting a wide range of healthcare settings. The study analyzed 1800 Stanford and 7957 NeuroBlu treatment encounters from 2008 to 2023 and from 2003 to 2023, respectively.

MEASUREMENTS

Predict continuous prescription of buprenorphine-naloxone for at least 6 months, without a gap of more than 30 days. The performance of machine learning prediction models was assessed by area under receiver operating characteristic (ROC-AUC) analysis as well as precision, recall and calibration. To further validate our approach's clinical applicability, we conducted two secondary analyses: a time-to-event analysis on a single site to estimate the duration of buprenorphine-naloxone treatment continuity evaluated by the C-index and a comparative evaluation against predictions made by three human clinical experts.

FINDINGS

Attrition rates at 6 months were 58% (NeuroBlu) and 61% (Stanford). Prediction models trained and internally validated on NeuroBlu data achieved ROC-AUCs up to 75.8 (95% confidence interval [CI] = 73.6-78.0). Addiction medicine specialists' predictions show a ROC-AUC of 67.8 (95% CI = 50.4-85.2). Time-to-event analysis on Stanford data indicated a median treatment retention time of 65 days, with random survival forest model achieving an average C-index of 65.9. The top predictor of treatment retention identified included the diagnosis of opioid dependence.

CONCLUSIONS

US patients with opioid use disorder or opioid dependence treated with buprenorphine-naloxone prescriptions appear to have a high (∼60%) treatment attrition by 6 months. Machine learning models trained on diverse electronic health record datasets appear to be able to predict treatment continuity with accuracy comparable to that of clinical experts.

The methods and baseline characteristics of a multi-site randomized controlled trial evaluating mindfulness-based relapse prevention in conjunction with peer support to improve adherence to medications for opioid use disorders

Introduction

Medications for opioid use disorders (MOUD) remain the gold standard for treating OUD, but treatment initiation and adherence remain challenging. Exclusive utilization of pharmacotherapy as a treatment modality for OUD is sub-optimal, and a combination of psychotherapies and pharmacotherapies is recommended. General trends indicate the benefits of peer mentoring and MBRP separately. Therefore, we hypothesize that the combined effect of MBRP and Peer mentoring will produce synergistic improvements in MOUD adherence compared to an enhanced twelve-step facilitation (TSF).

Methods

This paper describes the methods and baseline characteristics of a multi-site randomized controlled trial evaluating the effectiveness of a combination of MBRP and peer support (MiMP) compared to an enhanced TSF in improving adherence to MOUD. Both MiMP and TSF are 12-week manualized protocols that utilize licensed therapists. The interventions are delivered in weekly group sessions that last about 75-90 minutes per session. The primary outcome is MOUD adherence. Secondary and exploratory outcomes include relapse, cravings, depression, anxiety, stress, quality of life, and pain catastrophizing.

Results

The participants' ages ranged from 21 years to 77 years, with a mean age of 44.5 (SD ± 11.5 years). There was an almost equal distribution of gender and place of residence. Overall, 51.9% (n=54) of participants identified as female and 48.1% (n=50) were male. Similarly, 51.9% (n=54) of participants resided in urban areas, while 48.1% (n=50) resided in rural areas. Participants identified as either black or white, with over three-quarters identifying as white (77.9%, n= 81) and 22.1% (n= 23) as black. Most participants randomized to the 12-step facilitation group were white (93.1%). Relationships and employment status were well distributed between categories. Over half of the participants reported some college or higher education. Over 90% of the participants made less than $75,000 per year. Some participants indicated that they had both public and private health insurance.

Discussion and conclusion

This study is innovative in several ways including combining MBRP and peer support, addressing comorbid mental health issues among individuals with OUD, utilizing manualized protocols, and evaluating of both physiological and self-reported measures in assessing cortisol reactivity as a predictor of relapse and treatment outcomes.

Advancing opioid stewardship in low-middle-income countries: challenges and opportunities

The increased utilization of opioids in low- and middle-income countries (LMICs) presents a growing threat of opioid-related abuse, misuse and diversion. Pharmacists, as integral members of healthcare teams, are responsible for dispensing and monitoring opioid use and hold a pivotal role in opioid stewardship within LMICs. This commentary describes the potential and multifaceted roles of pharmacists in opioid stewardship in resource-constrained settings and highlights appropriate strategies for promoting responsible opioid utilization. Opioid stewardship involves prioritising evidence-based prescribing, management and practices for pain management. It includes measures such as incorporating prescription drug monitoring programmes for appropriate opioid prescription, implementing safe disposal through drug take-back programmes, promoting non-opioid pain management, addressing the opioid addiction stigma, tapering opioid dose, educating patients and caregivers, establishing drug information centers, providing rehabilitative services and integrating collaboration with communities and experts. The combined difficulties of restricted access to healthcare resources and services coupled with low levels of literacy worsen the susceptibility to opioid abuse, misuse, and diversion in LMICs. Early detection, assessment and implementation of interventions to optimise opioid use are imperative for ensuring safe and effective opioid utilization, thereby mitigating the risks of overdose and addiction. The involvement of pharmacists in promoting safe and effective opioid utilization through education, monitoring, collaboration, and policy advocacy serves as a critical component in bridging existing gaps in opioid stewardship within LMICs.

Extended-Release Injection vs Sublingual Buprenorphine for Opioid Use Disorder With Fentanyl Use: A Post Hoc Analysis of a Randomized Clinical Trial

Importance

Fentanyl has exacerbated the opioid use disorder (OUD) and opioid overdose epidemic. Data on the effectiveness of medications for OUD among patients using fentanyl are limited.

Objective

To assess the effectiveness of sublingual or extended-release injection formulations of buprenorphine for the treatment of OUD among patients with and without fentanyl use.

Design, Setting, and Participants

Post hoc analysis of a 24-week, randomized, double-blind clinical trial conducted at 35 outpatient sites in the US from December 2015 to November 2016 of sublingual buprenorphine-naloxone vs extended-release subcutaneous injection buprenorphine (CAM2038) for patients with OUD subgrouped by presence vs absence of fentanyl or norfentanyl in urine at baseline. Study visits with urine testing occurred weekly for 12 weeks, then 6 times between weeks 13 and 24. Data were analyzed on an intention-to-treat basis from March 2022 to August 2023.

Intervention

Weekly and monthly subcutaneous buprenorphine vs daily sublingual buprenorphine-naloxone.

Main Outcomes and Measures

Retention in treatment, percentage of urine samples negative for any opioids (missing values imputed as positive), percentage of urine samples negative for fentanyl or norfentanyl (missing values not imputed), and scores on opiate withdrawal scales and visual analog craving scales.

Results

Of 428 participants, 123 (subcutaneous buprenorphine, n = 64; sublingual buprenorphine-naloxone, n = 59; mean [SD] age, 39.1 [10.8] years; 75 men [61.0%]) had evidence of baseline fentanyl use and 305 (subcutaneous buprenorphine, n = 149; buprenorphine-naloxone, n = 156; mean [SD] age, 38.1 [11.1] years; 188 men [61.6%]) did not have evidence of baseline fentanyl use. Study completion was similar between the fentanyl-positive (60.2% [74 of 123]) and fentanyl-negative (56.7% [173 of 305]) subgroups. The mean percentage of urine samples negative for any opioid were 28.5% among those receiving subcutaneous buprenorphine and 18.8% among those receiving buprenorphine-naloxone in the fentanyl-positive subgroup (difference, 9.6%; 95% CI, -3.0% to 22.3%) and 36.7% among those receiving subcutaneous buprenorphine and 30.6% among those receiving buprenorphine-naloxone in the fentanyl-negative subgroup (difference, 6.1%; 95% CI, -1.9% to 14.1%), with significant main associations of baseline fentanyl status and treatment group. In the fentanyl-positive subgroup, the mean percentage of urine samples negative for fentanyl during the study was 74.6% among those receiving subcutaneous buprenorphine vs 61.9% among those receiving sublingual buprenorphine-naloxone (difference, 12.7%; 95% CI, 9.6%-15.9%). Opioid withdrawal and craving scores decreased rapidly after treatment initiation across all groups.

Conclusions and Relevance

In this post hoc analysis of a randomized clinical trial of sublingual vs extended-release injection buprenorphine for OUD, buprenorphine appeared to be effective among patients with baseline fentanyl use. Patients with fentanyl use had fewer opioid-negative urine samples during the trial compared with the fentanyl-negative subgroup. These findings suggest that the subcutaneous buprenorphine formulation may be more effective at reducing fentanyl use.

Trial Registration

ClinicalTrials.gov Identifier: NCT02651584.

Recent Opioid Use Impedes Range Adaptation in Reinforcement Learning in Human Addiction

BACKGROUND

Drugs like opioids are potent reinforcers thought to co-opt value-based decisions by overshadowing other rewarding outcomes, but how this happens at a neurocomputational level remains elusive. Range adaptation is a canonical process of fine-tuning representations of value based on reward context. Here, we tested whether recent opioid exposure impacts range adaptation in opioid use disorder, potentially explaining why shifting decision making away from drug taking during this vulnerable period is so difficult.

METHODS

Participants who had recently (<90 days) used opioids (n = 34) or who had abstained from opioid use for ≥ 90 days (n = 20) and comparison control participants (n = 44) completed a reinforcement learning task designed to induce robust contextual modulation of value. Two models were used to assess the latent process that participants engaged while making their decisions: 1) a Range model that dynamically tracks context and 2) a standard Absolute model that assumes stationary, objective encoding of value.

RESULTS

Control participants and ≥90-days-abstinent participants with opioid use disorder exhibited choice patterns consistent with range-adapted valuation. In contrast, participants with recent opioid use were more prone to learn and encode value on an absolute scale. Computational modeling confirmed the behavior of most control participants and ≥90-days-abstinent participants with opioid use disorder (75%), but a minority in the recent use group (38%), was better fit by the Range model than the Absolute model. Furthermore, the degree to which participants relied on range adaptation correlated with duration of continuous abstinence and subjective craving/withdrawal.

CONCLUSIONS

Reduced context adaptation to available rewards could explain difficulty deciding about smaller (typically nondrug) rewards in the aftermath of drug exposure.

Evolutionary perspectives on substance and behavioural addictions: Distinct and shared pathways to understanding, prediction and prevention

Addiction poses significant social, health, and criminal issues. Its moderate heritability and early-life impact, affecting reproductive success, poses an evolutionary paradox: why are humans predisposed to addictive behaviours? This paper reviews biological and psychological mechanisms of substance and behavioural addictions, exploring evolutionary explanations for the origin and function of relevant systems. Ancestrally, addiction-related systems promoted fitness through reward-seeking, and possibly self-medication. Today, psychoactive substances disrupt these systems, leading individuals to neglect essential life goals for immediate satisfaction. Behavioural addictions (e.g. video games, social media) often emulate ancestrally beneficial behaviours, making them appealing yet often irrelevant to contemporary success. Evolutionary insights have implications for how addiction is criminalised and stigmatised, propose novel avenues for interventions, anticipate new sources of addiction from emerging technologies such as AI. The emerging potential of glucagon-like peptide 1 (GLP-1) agonists targeting obesity suggest the satiation system may be a natural counter to overactivation of the reward system.

"'You Just Want to Give me Some Medicine and be on my Way': Preferences, Beliefs, and Experiences Related to Western Medication among Members of a State-Recognized Tribe"

Background: Native American/American Indian (NA/AI) people have higher rates of chronic disease, including substance use and mental health disorders, compared to White Americans. Though pharmaceuticals can be helpful in addressing many chronic healthcare conditions, many people do not take medications as prescribed. NA/AI identity has been found to be associated with lower rates of medication adherence compared to White Americans. Purpose: The purpose of this study is to better understand NA/AI women's perceptions, beliefs, and experiences related to medication. Methods: Thirty-one semi-structured interviews were conducted with NA/AI women from a state-recognized tribe located in the Gulf South. Interviews were transcribed and analyzed using a qualitative description approach. Results: Eighteen women discussed their experiences using medications when asked about their healthcare experiences. Participants identified the following themes in their discussion of medication: (a) Cost of Medication as a Barrier; (b) Negative Side Effects of Western Medication; (c) Fear of Resistance and Dependence; (d) Preference for Traditional Medicine or None; and (e) Lack of Communication around Medications from Providers. Conclusion: Our findings support the growing call for cultural safety within medical settings and integrating NA/AI conceptualizations of health and well-being and traditional practices into western healthcare settings to better support NA/AI people.

Assessing the impact of public funding in alleviating participant reduction and improving the retention rate in methadone maintenance treatment clinics in Taiwan: an interrupted time series analysis

BACKGROUND

Given the steady decline in patient numbers at methadone maintenance treatment (MMT) clinics in Taiwan since 2013, the government initiated Patients' Medical Expenditure Supplements (PMES) in January 2019 and the MMT Clinics Accessibility Maintenance Program (MCAM) in September 2019. This study aims to evaluate the impact of the PMES and MCAM on the enrollment and retention of patients attending MMT clinics and whether there are differential impacts on MMT clinics with different capacities.

METHODS

The monthly average number of daily participants and 3-month retention rate from 2013 to 2019 were extracted from MMT databases and subjected to single interrupted time series analysis. Pre-PMES (from February 2013 to December 2018) was contrasted with post-PMES, either from January 2019 to December 2019 for clinics funded solely by the PMES or from January 2019 to August 2019 for clinics with additional MCAM. Pre-MCAM (from January 2019 to August 2019) was contrasted with post-MCAM (from September 2019 to December 2019). Based on the monthly average number of daily patients in 2018, each MMT clinic was categorized as tiny (1-50), small (51-100), medium (101-150), or large (151-700) for subsequent stratification analysis.

RESULTS

In terms of participant numbers after the PMES intervention, a level elevation and slope increase were detected in the clinics at every scale except medium in MMT clinics funded solely by PMES. In MMT clinics with subsequent MCAM, a level elevation was only detected in small-scale clinics, and a slope increase in the participant numbers was detected in tiny- and small-scale clinics. The slope decrease was also detected in medium-scale clinics. In terms of the 3-month retention rate, a post-PMES level elevation was detected at almost every scale of the clinics, and a slope decrease was detected in the overall and tiny-scale clinics for both types of clinics.

CONCLUSIONS

Supplementing the cost of a broad treatment repertoire enhances the enrollment of people with heroin use in MMTs. Further funding of human resources is vital for MMT clinics to keep up with the increasing numbers of participants and their retention.

Stakeholder perspectives on a telemedicine referral and coordination model to expand medication treatment for opioid use disorder in rural primary care clinics

INTRODUCTION

Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor.

METHODS

We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale.

RESULTS

Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff.

CONCLUSIONS

Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

Gender differences in receipt of telehealth versus in person behavioral therapy, medication for opioid use disorder (MOUD), and 90-day MOUD retention during the pandemic: A retrospective veteran cohort study

BACKGROUND

COVID-19 significantly negatively impacted access to care among patients with opioid use disorder (OUD). The Veterans Health Administration (VHA) enacted policies to expand telehealth and medication for OUD (MOUD) during the public health emergency, which offset risk of treatment disruption. In this study, we evaluated gender differences in utilization of behavioral therapy in person and via telehealth, MOUD utilization, and achieving 90-day MOUD retention pre-post pandemic onset, given known gender differences in treatment utilization between men and women. Secondarily, we examined MOUD receipt and retention as a function of in-person vs. telehealth behavioral therapy received over time.

METHODS

Using VHA's nationwide electronic health record data, we compared outcomes between men and women veterans, pre- to post-pandemic onset (January 2019-February 2020 vs. March 2020-April 2021). Primary outcomes included receipt of behavioral therapy (in person or telehealth), number of appointments attended, any MOUD, and whether patients achieved 90-day MOUD retention post-induction.

RESULTS

Veterans with OUD were less likely to receive behavioral therapy post-pandemic onset, which was driven by marked decreases in in-person care; these effects were strongest among women. The odds of receiving MOUD also decreased pre- to post-pandemic onset, particularly among men. Receipt of or achieving 90-day MOUD retention was differentially related to receipt of behavioral therapy via in person vs. telehealth; telehealth was more strongly associated with these utilization indicators post-pandemic onset-an effect that was more pronounced for men.

CONCLUSION

The likelihood of receiving behavioral therapy and MOUD were lower during COVID-19 and varied by gender, with men being less likely to receive MOUD over time and women being less likely to receive in-person behavioral therapy. Behavioral therapy received via telehealth was generally associated with improved MOUD utilization compared to in-person behavioral therapy, but this was less true for women than for men regarding utilization of or achieving 90-day MOUD retention. In addition to the need for further telehealth expansion for veterans with OUD, more research should explore how to better engage men in MOUD treatment and improve adherence to MOUD among women engaged in behavioral therapy.

The Psychiatrist's Role in Treating Perinatal Opioid Use Disorder and Reducing Maternal Mortality

Drug overdose is a leading cause of maternal mortality. Psychiatrists can play a critical role in reducing these deaths by delivering effective evidence-based treatments for perinatal opioid use disorder (POUD), including the use of buprenorphine. Medications for POUD (i.e., buprenorphine, methadone) are life-saving treatments, but only half of those who are diagnosed as having POUD will receive this treatment, which can result in an increased risk for return to opioid use, overdose, and death. Psychiatrists are well positioned to prescribe buprenorphine given the Drug Enforcement Administration's (DEA) removal of the requirement to submit a Notice of Intent to prescribe buprenorphine for the treatment of opioid use disorders. Psychiatrists who have a current DEA registration that includes Schedule III authority may now prescribe buprenorphine for opioid use disorders; the training requirements to do so are outlined herein. This article reviews the standard of care for screening, diagnosis, and treatment of POUD, and prescribing buprenorphine for POUD, as well as shared decision-making for medication selection, induction, and maintenance of buprenorphine during pregnancy, labor and delivery, and the postpartum year.

Implementation of medication for opioid use disorder treatment in Indian health clinics in California: A qualitative evaluation

INTRODUCTION

American Indians and Alaska Native (AIAN) populations are disproportionately affected by opioid misuse. Medication for opioid use disorder (MOUD) is essential to decrease overdose events and overdose deaths. AIAN communities can benefit from MOUD programs that are housed within primary care clinics to improve treatment accessibility. This study aimed to gather information on the needs, barriers, and successes related to implementing MOUD programs in Indian health clinics (IHCs) offering primary care.

METHODS

The study used the Reach, Effectiveness, Adoption, Implementation, and Maintenance Qualitative Evaluation for Systematic Translation (RE-AIM QuEST) evaluation framework to structure key informant interviews with clinic staff who received technical assistance for MOUD program implementation. The study incorporated RE-AIM dimensions into a semi-structured interview guide. We developed the coding approach for analyzing interview data using Braun and Clarke's (2006) reflexive thematic analysis in qualitative research.

RESULTS

Eleven clinics participated in the study. The research team conducted twenty-nine interviews with clinic staff. We found that inadequate education about MOUD, scant resources, and limited availability of AIAN providers adversely impacted reach. Challenges with integrating medical and behavioral care, patient-level barriers (e.g., rural conditions, geographical dispersion), and limited workforce capacity impacted MOUD effectiveness. Stigma at the clinic level was detrimental to MOUD adoption. Implementation was challenging due to a limited number of waivered providers, and the need for technical assistance and MOUD policies and procedures. Staff turnover and restricted physical infrastructure negatively influenced MOUD maintenance.

CONCLUSIONS

Clinical infrastructure should be strengthened. The integration of culture into clinic services must be embraced by staff to support MOUD adoption. Increased representation from AIAN clinical staff is needed to appropriately represent the population being served. Stigma at various levels must be addressed, and the multiple barriers that AIAN communities face must be considered in understanding MOUD program implementation and outcomes.

Emergency-department initiated buprenorphine: Impact on quality of life

Introduction

Emergency department (ED)-initiated medications for opioid use disorder (MOUD) have emerged as an acute care strategy against the opioid epidemic. When initiated in the outpatient setting, MOUD has been demonstrated to have a positive impact on patients' quality of life (QoL). It is unclear how engagement in ED-initiated MOUD, a novel initiation setting and unique patient cohort, might impact QoL. We sought to describe QoL variables reported by patients engaged in ED-initiated MOUD.

Methods

A retrospective observational study of an ED-initiated MOUD program was performed, inclusive of enrollments from July 2019 through February 2022. Participants were interviewed at intake, 3-months, and 6-months, during which QoL indices were measured via Government Performance and Results Act (GPRA) variables. Descriptive statistics and Pearson's Chi-Square analyses were utilized to assess the data.

Results

Of 315 participants, majority were white (78.4 %), male (64.4 %), between the ages of 25-44 (74.6 %), and heavily burdened by lack of insurance, homelessness, and unemployment. One hundred forty participants (44.4 % eligible) completed 3-month follow-up and 90 (28.5 %) completed 6-month follow-up. There were no significant demographic differences amongst respondents at 3- and 6-months as compared to intake. Objective QoL variables significantly improved at 3- and 6-months as compared to intake (p < 0.01). Subjective QoL variables also demonstrated significant improvement at follow-up (p < 0.05).

Conclusion

ED patients with OUD, eligible for MOUD, may face a number of social and interpersonal variables which heavily impact QoL. ED-initiated MOUD may positively impact subsequent QoL when measured over time.

Promoting HIV care continuum outcomes among people who use drugs and alcohol: a systematic review of randomized trials evaluating behavioral HIV care interventions published from 2011 to 2023

BACKGROUND

Substance use remains a robust predictor of HIV infection and a serious impediment to HIV care continuum progression for people living with HIV. The primary research question of this systematic review is focused on understanding the extent to which behavioral HIV care interventions have been efficacious in helping people who live with HIV and who use substances along the HIV care continuum.

METHODS

Using PubMed and ProQuest databases, we performed a systematic review of randomized trials of behavioral HIV care continuum interventions among people who use substances published from 2011 to August 2023, since the beginning of the treatment-as-prevention era.

RESULTS

We identified 11 studies (total participants: N = 5635), ten intentionally targeting substance-using populations. Four studies involved samples using ≥ 1 substance (e.g., alcohol, opioids, stimulants, marijuana); four involved injection drug use; one involved methamphetamine use; and one involved alcohol use. One study targeted a population with incidental substance use (i.e., alcohol, injection drug use, non-injection drug use reported in most participants). Each study defined one or more HIV care outcomes of interest. Viral suppression was an outcome targeted in 9/11 studies, followed by uptake of antiretroviral therapy (ART; 7/11), ART adherence (6/11), retention in care (5/11), and linkage to care (3/11). While most (nine) of the studies found significant effects on at least one HIV care outcome, findings were mostly mixed. Mediated (2/11) and moderated (2/11) effects were minimally examined.

CONCLUSIONS

The results from this systematic review demonstrate mixed findings concerning the efficacy of previous HIV care interventions to improve HIV care continuum outcomes among people who use substances. However, heterogeneity of study components (e.g., diversity of substances used/assessed, self-report vs. objective measures, attrition) prevent broad deductions or conclusions about the amenability of specific substance-using populations to HIV care intervention. More coordinated, comprehensive, and targeted efforts are needed to promote and disentangle intervention effects on HIV care continuum outcomes among substance-using populations.

A Comparison of Medication-Assisted Treatment Options for Opioid Addiction: A Review of the Literature

ABSTRACT

In individuals in the United States with opioid addiction, what is the effect of a medication-assisted treatment (MAT) in reducing the relapse and harm reduction when comparing the use of buprenorphine, methadone, and naltrexone? In 2017, it was estimated that 1.7 million individuals suffer from overuse of prescription opiates, 652,000 individuals suffer from heroin use disorder, and greater than 130 individuals die from opiate overdose daily (National Institutes of Health, 2019). Using a systematic literature review, the following results were found. Buprenorphine is currently the second most effective MAT in harm reduction and relapse prevention, can be initiated and maintained through primary care, has a low risk for overdose, but needs to be started only when moderate withdrawals have begun. Methadone is currently the gold standard in MAT and can be started in any stage of withdrawal; however, titrating to effective dose is a lengthy process, and it must be administered at a specialty clinic. Naltrexone in oral form has not been shown to be effective because of lack of adherence; however, the extended-release intramuscular injection form has been shown to reduce relapse and increase the quality of life before initiation individuals must be opioid free for 7-14 days. Choosing the proper MAT is highly individualized. It is recommended that more research be conducted in comparing all MAT options, looking at the quality of life on each MAT, researching motivations to stay on MAT and remain opioid free, and looking at the impact of external reward on adherence to the MAT program.

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.

Comparing professional communities: Opioid prescriber networks and Public Health Preparedness Districts

Problem opioid use and opioid-related drug overdoses remain a major public health concern despite attempts to reduce and monitor opioid prescriptions and increase access to office-based opioid treatment. Current provider-focused interventions are implemented at the federal, state, regional, and local levels but have not slowed the epidemic. Certain targeted interventions aimed at opioid prescribers rely on populations defined along geographic, political, or administrative boundaries; however, those boundaries may not align well with actual provider-patient communities or with the geographic distribution of high-risk opioid use. Instead of relying exclusively on commonly used geographic and administrative boundaries, we suggest augmenting existing strategies with a social network-based approach to identify communities (or clusters) of providers that prescribe to the same set of patients as another mechanism for targeting certain interventions. To test this approach, we analyze 1 year of prescription data from a commercially insured population in the state of Indiana. The composition of inferred clusters is compared to Indiana's Public Health Preparedness Districts (PHPDs). We find that in some cases the correspondence between provider networks and PHPDs is very high, while in other cases the overlap is low. This has implications for whether an intervention is reaching its intended provider targets efficiently and effectively. Assessing the best intervention targeting strategy for a particular outcome could facilitate more effective interventions to tackle the ongoing opioid use epidemic.

Caring for Our Patients With Opioid Use Disorder in the Perioperative Period: A Guide for the Anesthesiologist

Opioid use disorder (OUD) is a rising public health crisis, impacting millions of individuals and families worldwide. Anesthesiologists can play a key role in improving morbidity and mortality around the time of surgery by informing perioperative teams and guiding evidence-based care and access to life-saving treatment for patients with active OUD or in recovery. This article serves as an educational resource for the anesthesiologist caring for patients with OUD and is the second in a series of articles published in Anesthesia & Analgesia on the anesthetic and analgesic management of patients with substance use disorders. The article is divided into 4 sections: (1) background to OUD, treatment principles, and the anesthesiologist; (2) perioperative considerations for patients prescribed medications for OUD (MOUD); (3) perioperative considerations for patients with active, untreated OUD; and (4) nonopioid and nonpharmacologic principles of multimodal perioperative pain management for patients with untreated, active OUD, or in recovery. The article concludes with a stepwise approach for the anesthesiologist to support OUD treatment and recovery. The anesthesiologist is an important leader of the perioperative team to promote these suggested best practices and help save lives.

Opioid Use Disorder Stigma and Support for Harm Reduction in Rural Counties

Background: The opioid crisis is a public health emergency in the United States, particularly in rural Pennsylvania. Stigma in rural communities is a treatment barrier and impacts harm reduction programming availability.Objectives: The current study utilized an observational, cross-sectional design to examine latent subgroups of stigma and differences in support for harm reduction strategies (i.e., safe injection facilities, syringe services programs, fentanyl test strips, Naloxone distribution). Participants included rural Pennsylvanians (n = 252), taken from a statewide survey of opioid use disorder (OUD) stigma. Participants reported OUD public stigma (i.e., attitudes/perceptions about OUD, willingness to engage with individuals with OUD) and support for harm reduction strategies.Results: Latent class analysis identified 4 stigma classes: 1) high stigma (HS), 2) high judgment/low stigmatizing behavior (HJ/LB), 3) high stigmatizing behavior/low stigmatizing attitude (HB/LA), and 4) low stigma (LS). ANCOVAs identified subgroup differences in harm reduction support. The HS group indicated less support for safe injection sites, syringe services programs, and fentanyl test strips, compared to the HB/LA and LS groups. The HS group indicated less support for Naloxone distribution compared to the HJ/LB, HB/LA, and LS groups. Lastly, the HJ/LB group indicated less support for each program compared to the LS group.Conclusions/Importance: Findings highlight that OUD stigma profiles differ across rural Pennsylvania and are associated with varying support for harm reduction strategies. Individuals with less stigma report more support for harm reduction strategies. Interventions to implement harm reduction strategies should consider varying levels of stigma and use a targeted approach to inform implementation and messaging strategies.

Association of Medication-Assisted Therapy and Risk of Drug Overdose-Related Hospitalization or Emergency Room Visits in Patients With Opioid Use Disorder

Objective To examine the differential impacts of medication-assisted therapy (MAT) medications (naltrexone, methadone, and buprenorphine) on drug overdose-related hospitalizations or emergency room (ER) visits in patients with opioid use disorder (OUD). Patients and methods A retrospective cohort study was performed on patients 18 years or older diagnosed with OUD, using Optum's de-identified Clinformatics® Data Mart database. To ensure a new diagnosis of OUD from 2018 to 2019, each patient required one year of continuous enrollment before OUD diagnosis. The primary outcome was the incidence of drug overdose-related hospitalization or ER visits in the follow-up period. Patients were censored at loss of coverage or end of the study (9/30/2020). A multivariable Cox proportional hazard model was built to compare the outcomes across three MAT medications (buprenorphine, methadone, and naltrexone). Results Only 10.38% of the 145,317 OUD patients received MAT prescriptions in the 12 months after diagnosis. The majority of MAT users (77.8%) received buprenorphine. At one year of follow-up, the incidence of drug overdose-related hospitalization or ER visits varied by MAT drug type: naltrexone (14.26%), methadone (12.26%), and buprenorphine (10.23%). Compared to methadone drug users, buprenorphine users had a lower risk of negative outcomes (adjusted hazard ratio: 0.84; 95% confidence interval: 0.73-0.97). Conclusion Buprenorphine was associated with the lowest risk of drug overdose-related hospitalization or ER visits among the MAT drugs. However, only 10.38% of OUD patients received MAT. Increasing MAT availability to patients with OUD is a key step toward preventing relapse and reducing adverse health outcomes.

Associations Between Patient-Reported Experiences with Opioid Use Disorder Treatment and Unmet Treatment Needs and Discontinuation Among Virginia Medicaid Members

BACKGROUND

Many payers, including Medicaid, the largest payer of opioid use disorder (OUD) treatment, are pursuing treatment-related quality improvement initiatives. Yet, how patient-reported experiences with OUD treatment relate to patient-centered outcomes remains poorly understood.

AIM

To examine associations between Medicaid members' OUD treatment experiences, outpatient treatment settings, demographic and social factors, and members' self-report of unmet needs during treatment and treatment discontinuation.

METHODS

A sample of Virginia Medicaid members aged 21 years or older with OUD diagnoses who received outpatient OUD treatment completed a mail survey between January 2020 and August 2021 (n = 1042, weighted n = 9244). A treatment experience index was constructed from responses to four items from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) relating to feelings of involvement, safety, and respect and having treatment explained in an understandable way; two additional CAHPS items: "given options for treatment" and "able to refuse treatment" were also assessed. Weighted imputed logistic regressions tested adjusted associations between members' treatment experiences, demographic and social factors, and two outcomes capturing unmet needs during treatment and treatment discontinuation.

RESULTS

More positive scores on the treatment experiences index were associated with lower adjusted odds of reporting unmet needs during treatment (aOR: 0.52, 95% CI: 0.41-0.66) and discontinuation (aOR: 0.63, 95% CI: 0.47-0.79). Respondents with serious psychological distress had higher odds of reporting unmet needs during treatment (aOR: 1.69 95% CI: 1.14-2.51) and discontinuation (aOR: 1.84, 95% CI: 1.21-2.82), as did individuals with housing insecurity (unmet needs: (aOR: 1.65, 95% CI: 1.11-2.44); treatment discontinuation: (aOR: 1.56, 95% CI: 1.04-2.36)).

CONCLUSION

Using a first-of-its-kind survey of Medicaid members with OUD, we found that members who had more positive treatment experiences were less likely to report unmet treatment needs and discontinue treatment. Care approaches focused on improving patient experience are critical to delivering effective, high-quality OUD treatment.

The Lived Experience of Medication for Opioid Use Disorder: Qualitative Metasynthesis

PURPOSE OF THE STUDY

Buprenorphine and methadone, when used as maintenance therapy in opioid use disorder (OUD), can significantly reduce the risk of death after an opioid overdose. Despite the many benefits, medication for OUD (MOUD) remains controversial and underutilized. The aim of this study was to (a) identify studies that explicate the lived experience of MOUD, (b) conduct a methodologically sound critical quality assessment, (c) conduct a metasynthesis of identified qualitative studies, and (d) analyze the results through the lenses of critical social justice, feminist standpoint, and social theories to inform a more culturally responsive, effective, and holistic approach to treatment to increase the utilization of and receptivity to MOUD in the treatment of OUDs.

DESIGN AND METHODS

Metasynthesis is the deliberate process of synthesizing data from multiple qualitative studies to create a new interpretation of previously published research. Our metasynthesis focused on forming a new interpretation of the lived experience of MOUD. Of the 292 studies identified, eight met inclusion criteria. The overall quality of the studies was variable. The study population included adults aged ≥ 18 years with OUD or dependency.

RESULTS

Metasynthesis produced three overarching themes: (a) The duplexity of MOUD creates ambivalence in how a person experiences MOUD; (b) the structure of treatment and systemic influences matter, and (c) MOUD as a stepping-stone with multiple meanings in recovery.

IMPLICATIONS

Understanding experiential dualities allows professionals to see from other perspectives and can inform interventions and treatment structures as well as serve as a backdrop for social change. The synthesized new meaning of MOUD was an ambivalent experience influenced by intersectionality.

Targeting Opioid Receptors in Addiction and Drug Withdrawal: Where Are We Going?

This review article offers an outlook on the use of opioids as therapeutics for treating several diseases, including cancer and non-cancer pain, and focuses the analysis on the opportunity to target opioid receptors for treating opioid use disorder (OUD), drug withdrawal, and addiction. Unfortunately, as has been well established, the use of opioids presents a plethora of side effects, such as tolerance and physical and physiological dependence. Accordingly, considering the great pharmacological potential in targeting opioid receptors, the identification of opioid receptor ligands devoid of most of the adverse effects exhibited by current therapeutic agents is highly necessary. To this end, herein, we analyze some interesting molecules that could potentially be useful for treating OUD, with an in-depth analysis regarding in vivo studies and clinical trials.

A qualitative exploration of barriers and facilitators to drug treatment services among people who inject drugs in west Virginia

BACKGROUND

The opioid overdose crisis in the USA has called for expanding access to evidence-based substance use treatment programs, yet many barriers limit the ability of people who inject drugs (PWID) to engage in these programs. Predominantly rural states have been disproportionately affected by the opioid overdose crisis while simultaneously facing diminished access to drug treatment services. The purpose of this study is to explore barriers and facilitators to engagement in drug treatment among PWID residing in a rural county in West Virginia.

METHODS

From June to July 2018, in-depth interviews (n = 21) that explored drug treatment experiences among PWID were conducted in Cabell County, West Virginia. Participants were recruited from locations frequented by PWID such as local service providers and public parks. An iterative, modified constant comparison approach was used to code and synthesize interview data.

RESULTS

Participants reported experiencing a variety of barriers to engaging in drug treatment, including low thresholds for dismissal, a lack of comprehensive support services, financial barriers, and inadequate management of withdrawal symptoms. However, participants also described several facilitators of treatment engagement and sustained recovery. These included the use of medications for opioid use disorder and supportive health care workers/program staff.

CONCLUSIONS

Our findings suggest that a range of barriers exist that may limit the abilities of rural PWID to successfully access and remain engaged in drug treatment in West Virginia. Improving the public health of rural PWID populations will require expanding access to evidence-based drug treatment programs that are tailored to participants' individual needs.

Transcriptional and epigenetic regulation of microglia in substance use disorders

Microglia are widely known for their role in immune surveillance and for their ability to refine neurocircuitry during development, but a growing body of evidence suggests that microglia may also play a complementary role to neurons in regulating the behavioral aspects of substance use disorders. While many of these efforts have focused on changes in microglial gene expression associated with drug-taking, epigenetic regulation of these changes has yet to be fully understood. This review provides recent evidence supporting the role of microglia in various aspects of substance use disorder, with particular focus on changes to the microglial transcriptome and the potential epigenetic mechanisms driving these changes. Further, this review discusses the latest technical advances in low-input chromatin profiling and highlights the current challenges for studying these novel molecular mechanisms in microglia.

Patient-Centered Outcomes Associated With a Novel Office-Based Opioid Treatment Program in a District Health Department: Mixed Methods Pilot Study

BACKGROUND

Granville and Vance counties have some of the highest opioid-related death rates in North Carolina, and have significant unmet needs with regard to opioid treatment. Medication for opioid use disorder (MOUD) is the most effective evidence-based approach to address opioid use disorder. Despite demonstrated efficacy and substantial need, access to MOUD is still insufficient in many parts of the United States. In order to connect patients with needed MOUD services, the district health department, Granville Vance Public Health (GVPH), established an office-based opioid treatment (OBOT) program.

OBJECTIVE

In this formative pilot study, we sought to describe patients' goals and outcomes in a program delivered at a rural local health department using an integrated care approach.

METHODS

We used a mixed methods concurrent nested research design. The primary method of investigation was one-on-one qualitative interviews with active OBOT patients (n=7) focused on patients' goals and perceived impacts of the program. Trained interviewers followed a semistructured interview guide developed iteratively by the study team. The secondary method was a descriptive quantitative analysis (79 patients; 1478 visits over 2.5 years) of treatment retention and patient-reported outcomes (anxiety and depression).

RESULTS

Participants in the OBOT program were 39.6 years of age on average, and 25.3% (20/79) were uninsured. The average retention in the program was 18.4 months. The proportion of individuals in the program with moderate to severe depression (Patient Health Questionnaire-9 scores ≥10) decreased between program initiation (66%, 23/35) and at the most recent assessment (34%, 11/32). In qualitative interviews, participants credited the OBOT program for reducing or stopping the use of opioids and other substances (eg, marijuana, cocaine, and benzodiazepines). Many participants noted how the program helped them manage withdrawal symptoms and cravings, which helped them feel more in control of their use. Participants also attributed improvements in quality of life to the OBOT program, such as improved relationships with loved ones, improved mental and physical health, and improved financial stability.

CONCLUSIONS

Initial data show promising patient outcomes for active GVPH OBOT participants, including reduction in opioid use and improvements in quality of life. As a pilot study, a limitation of this study is a lack of a comparison group. However, this formative project demonstrates promising patient-centered outcome improvements for GVPH OBOT participants.

Drug use patterns and factors related to the use and discontinuation of medications for opioid use disorder in the age of fentanyl: findings from a mixed-methods study of people who use drugs

BACKGROUND

Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation.

METHODS

From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use.

RESULTS

Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose.

CONCLUSIONS

Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity.

Measurement Approaches to Estimating Methadone Continuity in Opioid Use Disorder Care

BACKGROUND

Long-term treatment with medications for opioid use disorder (OUD), including methadone, is lifesaving. There has been little examination of how to measure methadone continuity in claims data.

OBJECTIVES

To develop an approach for measuring methadone continuity in claims data, and compare estimates of methadone versus buprenorphine continuity.

RESEARCH DESIGN

Observational cohort study using de-identified commercial claims from OptumLabs Data Warehouse (January 1, 2017-June 30, 2021).

SUBJECTS

Individuals diagnosed with OUD, ≥1 methadone or buprenorphine claim and ≥180 days continuous enrollment (N=29,633).

MEASURES

OUD medication continuity: months with any use, days of continuous use, and proportion of days covered.

RESULTS

5.4% (N=1607) of the study cohort had any methadone use. Ninety-seven percent of methadone claims (N=160,537) were from procedure codes specifically used in opioid treatment programs. Place of service and primary diagnosis codes indicated that several methadone procedure codes were not used in outpatient OUD care. Methadone billing patterns indicated that estimating days-supply based solely on dates of service and/or procedure codes would yield inaccurate continuity results and that an approach incorporating the time between service dates was more appropriate. Among those using methadone, mean [s.d.] months with any use, days of continuous use, and proportion of days covered were 4.8 [1.8] months, 79.7 [73.4] days, and 0.64 [0.36]. For buprenorphine, the corresponding continuity estimates were 4.6 [1.9], 80.7 [70.0], and 0.73 [0.35].

CONCLUSIONS

Estimating methadone continuity in claims data requires a different approach than that for medications largely delivered by prescription fills, highlighting the importance of consistency and transparency in measuring methadone continuity across studies.

HIV, opioid use, and alterations to the gut microbiome: elucidating independent and synergistic effects

Background

The microbiome is essential to immune development, defense against pathogens, and modulation of inflammation. Microbial dysbiosis has been reported in various diseases including human immunodeficiency virus (HIV) and opioid use disorder (OUD). Notably, people living with HIV (PLWH) have been reported to both have higher rates of OUD and use opioids at higher rates than the general public. Thus, studying gut microbial alterations in people living with HIV and with OUD could elucidate mechanisms pertaining to how these conditions both shape and are shaped by the microbiome. However, to date few studies have investigated how HIV and OUD in combination impact the microbiome.

Aim of review

Here, we review previous studies outlining interactions between HIV, opioid use, and microbial dysbiosis and describe attempts to treat this dysbiosis with fecal microbial transplantation, probiotics, and dietary changes.

Key scientific concepts of review

While the limited number of studies prevent overgeneralizations; accumulating data suggest that HIV and opioid use together induce distinct alterations in the gut microbiome. Among the three existing preclinical studies of HIV and opioid use, two studies reported a decrease in Lachnospiraceae and Ruminococcaceae, and one study reported a decrease in Muribaculaceae in the combined HIV and opioid group relative to HIV-alone, opioid-alone, or control groups. These bacteria are known to modulate immune function, decrease colonic inflammation, and maintain gut epithelial barrier integrity in healthy individuals. Accordingly, modulation of the gut microbiome to restore gut homeostasis may be attempted to improve both conditions. While mixed results exist regarding treating dysbiosis with microbial restoration in PLWH or in those with opioid dependency, larger well-defined studies that can improve microbial engraftment in hosts hold much promise and should still be explored.

Association of receiving opioid medication-assisted treatment with sexual identity and mental health/substance use disorder symptoms in a nationally representative sample of adults

Background

Although the literature suggests that medication-assisted treatment (MAT) is an effective treatment for opioid use disorder, limited studies have assessed the prevalence or the association between MAT use and sexual identity, mental health, or substance use disorder among a nationally representative sample. We assessed the prevalence and association of opioid MAT use between sexual identity, depressive disorder symptoms, alcohol use dependence, and marijuana use dependence in the United States.

Methods

We used the 2019 National Survey on Drug Use and Health public-use data on adults aged 18-64 years (N = 38,841) to conduct a weighted multivariable logistic regression analysis.

Results

A total of 4.80% and 2.32% of the population identified as bisexual and lesbian/gay, respectively. About 0.31% (612,750 people) of the population reported receiving opioid MAT, 3.73% had alcohol use dependence, 1.42% had marijuana use dependence, and 9.13% had major depressive episode (MDE) symptoms. Of those who had received opioid MAT, 0.57% were bisexuals and 1.07% were lesbians/gays, 0.65% were people with alcohol use dependence, 2.32% with marijuana use dependence, and 1.59% with MDE symptoms. Lesbian/gay individuals were more likely to receive opioid MAT (AOR = 3.43, 95% CI = 1.42, 8.25) compared to heterosexual individuals. The odds were higher for people with marijuana use dependence (AOR = 3.44, 95% CI = 1.47, 8.06) and MDE symptoms (AOR = 5.22, 95% CI = 3.46, 7.89) than their counterparts.

Conclusions

In this study, sexual minorities, people with MDE symptoms, and those dependent on marijuana use were more likely to receive opioid MAT, suggesting the need to investigate further opioid use disorder symptoms and their risk factors among these populations.

Barriers to opioid use disorder treatment: A comparison of self-reported information from social media with barriers found in literature

Introduction

Medications such as buprenorphine and methadone are effective for treating opioid use disorder (OUD), but many patients face barriers related to treatment and access. We analyzed two sources of data-social media and published literature-to categorize and quantify such barriers.

Methods

In this mixed methods study, we analyzed social media (Reddit) posts from three OUD-related forums (subreddits): r/suboxone, r/Methadone, and r/naltrexone. We applied natural language processing to identify posts relevant to treatment barriers, categorized them into insurance- and non-insurance-related, and manually subcategorized them into fine-grained topics. For comparison, we used substance use-, OUD- and barrier-related keywords to identify relevant articles from PubMed published between 2006 and 2022. We searched publications for language expressing fear of barriers, and hesitation or disinterest in medication treatment because of barriers, paying particular attention to the affected population groups described.

Results

On social media, the top three insurance-related barriers included having no insurance (22.5%), insurance not covering OUD treatment (24.7%), and general difficulties of using insurance for OUD treatment (38.2%); while the top two non-insurance-related barriers included stigma (47.6%), and financial difficulties (26.2%). For published literature, stigma was the most prominently reported barrier, occurring in 78.9% of the publications reviewed, followed by financial and/or logistical issues to receiving medication treatment (73.7%), gender-specific barriers (36.8%), and fear (31.5%).

Conclusion

The stigma associated with OUD and/or seeking treatment and insurance/cost are the two most common types of barriers reported in the two sources combined. Harm reduction efforts addressing barriers to recovery may benefit from leveraging multiple data sources.

Natural Polyphenols-Resveratrol, Quercetin, Magnolol, and β-Catechin-Block Certain Aspects of Heroin Addiction and Modulate Striatal IL-6 and TNF-α

We have examined the effects of four different polyphenols in attenuating heroin addiction using a conditioned place preference (CPP) paradigm. Adult male Sprague Dawley rats received heroin (alternating with saline) in escalating doses starting from 10 mg/kg, i.p. up to 80 mg/kg/d for 14 consecutive days. The rats were treated with distilled water (1 mL), quercetin (50 mg/kg/d), β-catechin (100 mg/kg/d), resveratrol (30 mg/kg/d), or magnolol (50 mg/kg/d) through oral gavage for 7 consecutive days, 30 min before heroin administration, starting on day 8. Heroin withdrawal manifestations were assessed 24 h post last heroin administration following the administration of naloxone (1 mg/kg i.p). Heroin CPP reinstatement was tested following a single dose of heroin (10 mg/kg i.p.) administration. Striatal interleukin 6 (IL-6) and tumor necrosis factor alpha (TNF-α) were quantified (ELISA) after naloxone-precipitated heroin withdrawal. Compared to the vehicle, the heroin-administered rats spent significantly more time in the heroin-paired chamber (p < 0.0001). Concomitant administration of resveratrol and quercetin prevented the acquisition of heroin CPP, while resveratrol, quercetin, and magnolol blocked heroin-triggered reinstatement. Magnolol, quercetin, and β-catechin blocked naloxone-precipitated heroin withdrawal and increased striatal IL-6 concentration (p < 0.01). Resveratrol administration was associated with significantly higher withdrawal scores compared to those of the control animals (p < 0.0001). The results of this study show that different polyphenols target specific behavioral domains of heroin addiction in a CPP model and modulate the increase in striatal inflammatory cytokines TNF-α and IL-6 observed during naloxone-precipitated heroin withdrawal. Further research is needed to study the clinical utility of polyphenols and to investigate the intriguing finding that resveratrol enhances, rather than attenuates naloxone-precipitated heroin withdrawal.

Oral buprenorphine utilization, concomitant benzodiazepines and opioid analgesics, and payment source: Trends from 2015 to 2019

INTRODUCTION

This study describes utilization patterns of oral buprenorphine products indicated for the treatment of opioid use disorder with a focus on patterns consistent with prescribing guidelines and the safe use conditions during induction and maintenance treatment outlined by the Risk Evaluation and Mitigation Strategy (REMS) Program, including trends over time.

METHODS

Using an anonymized longitudinal patient-level dataset that captures information on medical and pharmacy claims in the United States (October 1, 2014 through March 31, 2020), buprenorphine prescriptions, days' supply, and daily dose were described overall and stratified by induction (month 1) vs. maintenance (month 2-6) treatment, along with duration of concomitant benzodiazepines or opioid analgesics.

RESULTS

Overall, there were 1.5 million buprenorphine treatment episodes initiated between January 1, 2015 to September 30, 2019 (2015: 258,899; 2019: 351,378). Treatment episodes included an average of 6.8 buprenorphine prescriptions (standard deviation [SD] = 6.7), 16.8 days' supply per prescription (SD = 10.5), 94.2 total days' supply per treatment episode (SD = 71.4), and a mean daily dose of 13.6 mg (SD = 6.3), with the number of prescriptions and total days' supply per treatment episode declining over the study period. There was a lower mean number of days' supply per prescription in the first month of treatment compared to months 2-6 (month 1: 15.8 [SD = 11.0]; month 2-6: 19.0 [SD = 10.1]) and daily dose per prescription (month 1: 13.3 mg [SD = 6.4]; months 2-6: 14.3 mg [SD = 6.2]), and a higher mean number of prescriptions per month (month 1: 2.5 per month [SD = 1.7]; months 2-6: 1.8 per month [SD = 1.2]). From 2015 to 2019, there appeared to be a shift in payer mix, with increases in Medicaid/Medicare and declines in cash and commercial insurance. Concomitant benzodiazepine and opioid analgesic use declined over time; in 2019, 16.6 % and 14.3 % of treatment episodes had any concomitant benzodiazepine or opioid analgesic, respectively, and <5 % had chronic (>90 overlapping days) concomitant use (3.0 % and 0.4 %, respectively).

CONCLUSIONS

The number of oral buprenorphine treatment episodes increased over the study period, and prescribing was generally consistent with the REMS and other treatment guidelines. There was a decline in concomitant buprenorphine and benzodiazepine or opioid analgesics, and chronic concomitant use was rare.

“A Profound, Abiding Hatred”: An Analysis of Hermann Goering’s Alleged Morphine Addiction

Hermann Goering, one of the most prominent members of the Nazi Party and for many years the presumed heir to Adolf Hitler, had a well-known history of morphine addiction. By the last days of the Second World War, he was widely considered by his contemporaries to have been completely incapacitated by his addiction. In this article, we argue that Goering's addiction, while possibly present, was purposefully exaggerated by his rivals for political purposes. His habit of ingesting paracodeine pills may have been a crude form of opioid maintenance therapy, similar to that of methadone today. Ultimately, his history of substance abuse had no significant impact on his capacity, ruthlessness, and leading role in Nazi crimes.

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.

A legal dispute resolution intervention for patients with substance use disorders: a study protocol for a randomized controlled trial

BACKGROUND

Substance use disorders (SUDs) represent major public health concerns and are linked to enhanced risk of legal consequences. Unresolved legal issues may prevent individuals with SUD from completing treatment. Interventions aimed at improving SUD treatment outcomes are limited. Filling that gap, this randomized controlled trial (RCT) tests the ability of a technology-assisted intervention to increase SUD treatment completion rates and improve post-treatment health, economic, justice-system, and housing outcomes.

METHODS

A randomized controlled trial with a two-year administrative follow-up period will be conducted. Eight hundred Medicaid eligible and uninsured adults receiving SUD treatment will be recruited at community-based non-profit health care clinics in Southeast, Michigan, USA. Using an algorithm embedded in a community-based case management system, we randomly assign all eligible adults to one of two groups. The treatment/intervention group will receive hands-on assistance with a technology aimed at resolving unaddressed legal issues and the control group receives no treatment. Upon enrollment into the intervention, both treatment (n = 400) and control groups (n = 400) retain traditional options to resolve unaddressed legal issues, such as hiring an attorney, but only the treatment group is targeted the technology and offered personalized assistance in navigating the online legal platform. To develop baseline and historical contexts for participants, we collect life course history reports from all participants and intend to link those in each group to administrative data sources. In addition to the randomized controlled trial (RCT), we used an exploratory sequential mixed methods and participatory-based design to develop, test, and administer our life course history instruments to all participants. The primary objective is to test whether targeting no-cost online legal resources to those experiencing SUD improves their long-term recovery and decreases negative health, economic, justice-system, and housing outcomes.

DISCUSSION

Findings from this RCT will improve our understanding of the acute socio-legal needs faced by those experiencing SUD and provide recommendations to help target resources toward the areas that best support long-term recovery. The public health impact includes making publicly available a deidentified, longitudinal dataset of uninsured and Medicaid eligible clients in treatment for SUD. Data include an overrepresentation of understudied groups including African American and American Indian Alaska Native persons documented to experience heightened risk for SUD-related premature mortality and justice-system involvement. Within these data, several intended outcome measures can inform the health policy landscape: (1) health, including substance use, disability, mental health diagnosis, and mortality; (2) financial health, including employment, earnings, public assistance receipt, and financial obligations to the state; (3) justice-system involvement, including civil and criminal legal system encounters; (4) housing, including homelessness, household composition, and homeownership.

TRIAL REGISTRATION

Retrospectively registered # NCT05665179 on December 27, 2022.

The Role of Physical Exercise in Opioid Substitution Therapy: Mechanisms of Sequential Effects

It is generally accepted that chronic opioid use is associated with structural and functional changes in the human brain that lead to an enhancement of impulsive behavior for immediate satisfaction. Interestingly, in recent years, physical exercise interventions have been used as an adjunctive treatment for patients with opioid use disorders (OUDs). Indeed, exercise has positive effects on both the biological and psychosocial basis of addiction, modifying neural circuits such as the reward, inhibition, and stress systems, and thus causing behavioral changes. This review focuses on the possible mechanisms that contribute to the beneficial effects of exercise on the treatment of OUDs, with emphasis placed on the description of a sequential consolidation of these mechanisms. Exercise is thought to act initially as a factor of internal activation and self-regulation and eventually as a factor of commitment. This approach suggests a sequential (temporal) consolidation of the functions of exercise in favor of gradual disengagement from addiction. Particularly, the sequence in which the exercise-induced mechanisms are consolidated follows the pattern of internal activation-self-regulation-commitment, eventually resulting in stimulation of the endocannabinoid and endogenous opioid systems. Additionally, this is accompanied by modification of molecular and behavioral aspects of opioid addiction. Overall, the neurobiological actions of exercise in combination with certain psychological mechanisms appear to promote its beneficial effects. Given the positive effects of exercise on both physical and mental health, exercise prescription is recommended as a complement to conventional therapy for patients on opioid maintenance treatment.

A scoping review of the opioid epidemic among U.S. Immigrants: Implications for treatment practices

The purpose of this review was to identify knowledge gaps within the literature regarding the impact of opioid use disorder, specific to immigrants in the United States, by addressing the following questions: 1) What is presented in the literature about the impact of opioid use disorder (OUD) and the opioid epidemic on immigrants in the United States?; and 2) What role does culture play in the opioid use disorder experiences of immigrants in the United States? Nineteen research articles were uncovered that addressed immigrants in the U.S. and opioid use disorder. The following themes prevailed: 1) OUD comparisons, 2) OUD comorbidities, 3) disparate OUD treatment engagement, and 4) the role of country of origin. Limited review findings support the need for future research on the topic of opioid misuse among immigrants in the United States. The authors elaborated on additional issues that influence OUD rates and warrant further exploration. Matters related to the potential positive roles of religion and faith leaders, cultural perceptions and expectations about gender roles, immigration status, ethnically diverse needs among sub-groups of immigrants, the role of geographic location within the U.S., and the implications of COVID-19 on OUD among immigrants need to be addressed to alleviate the deleterious impact of opioid misuse among immigrants.

Telemedicine Use and Quality of Opioid Use Disorder Treatment in the US During the COVID-19 Pandemic

IMPORTANCE

Little is known about the potential implications of the rapid transition to telehealth during the COVID-19 pandemic for treatment of opioid use disorder (OUD).

OBJECTIVE

To examine the association between telemedicine adoption during the COVID-19 pandemic and indicators of OUD treatment quality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study analyzed deidentified administrative claims data from OptumLabs Data Warehouse. Claims for telemedicine visits were included for both the prepandemic period (March 14, 2019, to March 13, 2020) and pandemic period (March 14, 2020, to March 13, 2021). Patients with OUD and continuous enrollment in either commercial insurance or Medicare Advantage plans were included. Clinicians who provided office-based OUD care were included and categorized into low, medium, or high telemedicine use groups. Patients were attributed to the clinician (and corresponding telemedicine use group) from whom they received a plurality of OUD visits.

MAIN OUTCOMES AND MEASURES

The 4 outcomes were all outpatient visits, OUD visits (in person vs telemedicine) within 90 days of an index visit, medications for OUD (MOUD) prescribing, and OUD-related clinical events (including drug overdose, inpatient detoxification and rehabilitation center stay, or injection drug use-related infections).

RESULTS

The analysis included 11 801 patients (mean [SD] age, 53.9 [15.7] years; 5902 males [50.0%]) who were treated by 1768 clinicians. Clinicians with low vs high telemedicine use conducted a mean (SD) of 2.1% (2.5%) vs 69.5% (18.6%) of their office visits virtually in the pandemic period. While telemedicine use for OUD increased significantly from the prepandemic to pandemic periods, total OUD visit volume (in person plus telemedicine) per patient episode remained stable among both high (2.6 to 2.7 visits per patient episode) and low (3.1 to 3.3 visits per patient episode) telemedicine use groups. In adjusted analyses comparing the prepandemic with pandemic periods, there was no differential change in MOUD initiation (adjusted odds ratio [OR], 1.00; 95% CI, 0.84-1.19), MOUD days' supply (differential change in days' supply, -0.27; 95% CI, -1.84 to 1.30), or OUD-related clinical events (adjusted OR, 1.01; 95% CI, 0.73-1.24) among patients who were treated by clinicians in low vs high telemedicine use groups.

CONCLUSIONS AND RELEVANCE

Results of this study revealed that clinical outcomes were similar among patients who were treated by clinicians with high and low telemedicine use during the COVID-19 pandemic, suggesting that telemedicine is a comparable alternative to in-person OUD care. There was no evidence that telemedicine was associated with increased access to or improved quality of OUD treatment.