Patient-centered methadone treatment: a randomized clinical trial

Extraction of Substance Use Information From Clinical Notes: Generative Pretrained Transformer-Based Investigation

BACKGROUND

Understanding the multifaceted nature of health outcomes requires a comprehensive examination of the social, economic, and environmental determinants that shape individual well-being. Among these determinants, behavioral factors play a crucial role, particularly the consumption patterns of psychoactive substances, which have important implications on public health. The Global Burden of Disease Study shows a growing impact in disability-adjusted life years due to substance use. The successful identification of patients' substance use information equips clinical care teams to address substance-related issues more effectively, enabling targeted support and ultimately improving patient outcomes.

OBJECTIVE

Traditional natural language processing methods face limitations in accurately parsing diverse clinical language associated with substance use. Large language models offer promise in overcoming these challenges by adapting to diverse language patterns. This study investigates the application of the generative pretrained transformer (GPT) model in specific GPT-3.5 for extracting tobacco, alcohol, and substance use information from patient discharge summaries in zero-shot and few-shot learning settings. This study contributes to the evolving landscape of health care informatics by showcasing the potential of advanced language models in extracting nuanced information critical for enhancing patient care.

METHODS

The main data source for analysis in this paper is Medical Information Mart for Intensive Care III data set. Among all notes in this data set, we focused on discharge summaries. Prompt engineering was undertaken, involving an iterative exploration of diverse prompts. Leveraging carefully curated examples and refined prompts, we investigate the model's proficiency through zero-shot as well as few-shot prompting strategies.

RESULTS

Results show GPT's varying effectiveness in identifying mentions of tobacco, alcohol, and substance use across learning scenarios. Zero-shot learning showed high accuracy in identifying substance use, whereas few-shot learning reduced accuracy but improved in identifying substance use status, enhancing recall and F1-score at the expense of lower precision.

CONCLUSIONS

Excellence of zero-shot learning in precisely extracting text span mentioning substance use demonstrates its effectiveness in situations in which comprehensive recall is important. Conversely, few-shot learning offers advantages when accurately determining the status of substance use is the primary focus, even if it involves a trade-off in precision. The results contribute to enhancement of early detection and intervention strategies, tailor treatment plans with greater precision, and ultimately, contribute to a holistic understanding of patient health profiles. By integrating these artificial intelligence-driven methods into electronic health record systems, clinicians can gain immediate, comprehensive insights into substance use that results in shaping interventions that are not only timely but also more personalized and effective.

Linkage to Care Outcomes Following Treatment in A Low-Threshold Substance Use Disorder Bridge Clinic

BACKGROUND

Treatment for substance use disorders (SUD) remains low in the United States. To better meet needs of people who use alcohol and other drugs, low threshold bridge clinics which offer treatment without barrier and harm reduction services have gained prevalence. Bridge clinics work to surmount barriers to care by providing same day medication and treatment for SUD and eventually transitioning patients to community-based treatment providers. In this study, we examine SUD treatment outcomes among patients who transitioned out of a bridge clinic.

METHODS

This is a retrospective cohort study of posttreatment outcomes of patients seen at an urban medical center's bridge clinic between 2017 and 2022. The primary outcome was being in care anywhere at time of follow-up. We also examined the proportion of patients who completed each step of the cascade of care following transfer: connection to transfer clinic, completion of a clinic visit, retention in care, and medication use among those remaining in care at the transfer clinic. We examined the association of different bridge clinic services with still being in care anywhere and the association between successful transfer with being in care and taking medication at follow-up.

RESULTS

Of 209 eligible participants, 63 were surveyed. Sixty-five percent of participants identified as male, 74% as white, 12% as Hispanic, 6% as Black, and 16% were unhoused. Most participants (78%) reported being connected to SUD treatment from the Bridge Clinic, and 37% remained in care at the same facility at the time of survey. Eighty-four percent reported being in treatment anywhere and 68% reported taking medication for SUD at follow-up, with most participants reporting taking buprenorphine (46%).

CONCLUSION

Of those participants who transitioned out of a bridge clinic into community-based SUD care, 78% were successfully connected to ongoing care and 84% were still in care at follow-up.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Shared decision making in patients with substance use disorders: A one-year follow-up study

Patient-centered care in therapeutic processes has been associated with better clinical outcomes, however, it remains a poorly studied aspect in Substance Use Disorder (SUD). The study aimed to evaluate patient's preferences, perceived participation in treatment decisions and activation level; and how they predict retention, pharmacological adherence and substance use during one-year follow-up. Logistic regression models were used to analyze the association between independent variables, along with a wide number of sociodemographic and clinical covariates, and outcomes. Most patients prefer a shared or passive role when making decisions about their treatment, and showed concordance between their preferred and perceived roles. In the univariate models, perceiving more involvement than desired showed a higher likelihood of treatment discontinuation at 12 months, and substance use at 6 and 12 months. No significant associations were found between the remaining decisional variables or the degree of activation with the assessed outcomes. A majority of SUD patients prefer and perceive to be involved in the decision-making process about their treatment. Patients perceiving more involvement than desired might experience an excess of responsibility that could negatively influence treatment continuation and substance use. Limitations of the study preclude any definitive conclusion, and more research is needed to confirm these results.

Typology of laws restricting access to methadone treatment in the United States: A latent class analysis

BACKGROUND

In the United States, methadone treatment for opioid use disorder is only available at opioid treatment programs (OTPs). In addition to federal regulations, states can enact laws which shape access to OTPs. We aimed to define classes of states according to restrictiveness of state OTP laws and examine population characteristics associated with class membership.

METHODS

A set of laws was extracted from a database of statutes and regulations governing OTPs in 49 states and the District of Columbia as of June 2021. Latent class analysis of laws was used to estimate the probability of class membership for each state. Class-weighted multinomial logistic regression analysis assessed state-level correlates of class membership and adjusted Relative Risk Ratio (aRRR) and 95% confidence intervals (95%CI) were generated.

RESULTS

States (n = 50) were assigned to three classes; Class 1) High restrictiveness on patient experience, low restrictiveness on access to service (n = 13); Class 2) Medium restrictiveness on patient experience, high restrictiveness on access to service (n = 14); Class 3) Low restrictiveness on patient experience, low restrictiveness on access to service (n = 23). States with a higher probability of membership in Classes with higher restrictiveness had higher rates of unemployment (Class 1 vs Class 3, aRRR:1.24; 95%CI:1.06-1.45), and Black residents (Class 2 vs Class 3, aRRR:1.10; 95%CI:1.04-1.15), and lower likelihood of Medicaid coverage of methadone (Class 1 vs Class 3, aRRR:0.25; 95%CI:0.07-0.88). States with a higher probability of membership in Classes with higher restrictiveness also had higher rates of potential indicators for opioid use disorder treatment need, including rates of opioid dispensing (Class 1 vs Class 3, aRRR:1.06; 95%CI:1.02-1.10, Class 2 vs Class 3, aRRR:1.07; 95%CI:1.03-1.11) and HIV diagnoses attributed to injection (Class 1 vs Class 3, aRRR:3.92; 95%CI:1.25-12.22).

CONCLUSIONS

States with indicators of greater potential need for opioid use disorder treatment have the most restrictions, raising concerns about unmet treatment need.

Deimplementation in the provision of opioid agonist treatment to achieve equity of care for people engaged in treatment: a qualitative study

BACKGROUND

Deimplementation, the removal or reduction of potentially hazardous approaches to care, is key to progressing social equity in health. While the benefits of opioid agonist treatment (OAT) are well-evidenced, wide variability in the provision of treatment attenuates positive outcomes. During the COVID-19 pandemic, OAT services deimplemented aspects of provision which had long been central to treatment in Australia; supervised dosing, urine drug screening, and frequent in-person attendance for review. This analysis explored how providers considered social inequity in health of patients in the deimplementation of restrictive OAT provision during the COVID-19 pandemic.

METHODS

Between August and December 2020, semi-structured interviews were conducted with 29 OAT providers in Australia. Codes relating to the social determinants of client retention in OAT were clustered according to how providers considered deimplementation in relation to social inequities. Normalisation Process Theory was then used to analyse the clusters in relation to how providers understood their work during the COVID-19 pandemic as responding to systemic issues that condition OAT access.

RESULTS

We explored four overarching themes based on constructs from Normalisation Process Theory: adaptive execution, cognitive participation, normative restructuring, and sustainment. Accounts of adaptive execution demonstrated tensions between providers' conceptions of equity and patient autonomy. Cognitive participation and normative restructuring were integral to the workability of rapid and drastic changes within the OAT services. Key transformative actors included communities of practice and "thought leaders" who had long supported deimplementation for more humane care. At this early stage of the pandemic, providers had already begun to consider how this period could inform sustainment of deimplementation. When considering a future, post-pandemic period, several providers expressed discomfort at operating with "evidence-enough" and called for narrowly defined types of data on adverse events (e.g. overdose) and expert consensus on takeaway doses.

CONCLUSIONS

The possibilities for achieving social equity in health are limited by the divergent treatment goals of providers and people receiving OAT. Sustained and equitable deimplementation of obtrusive aspects of OAT provision require co-created treatment goals, patient-centred monitoring and evaluation, and access to a supportive community of practice for providers.

What's in a Name? Terminology Preferences Among Patients Receiving Methadone Treatment

BACKGROUND

Despite recognition of the importance of substance use disorder (SUD) terminology, few studies examine terminology preferences among patients with SUDs.

OBJECTIVE

To examine preferences of patients with opioid use disorder (OUD) concerning the terminology used by addiction counselors.

DESIGN

From January 1, 2019, to February 28, 2020, participants were recruited consecutively from 30-day treatment review sessions at outpatient methadone treatment programs in the Northeastern United States to complete a cross-sectional survey.

PARTICIPANTS

Participants were English-speaking adult patients with OUD enrolled in methadone treatment.

MAIN MEASURES

Participants completed 7-point Likert-type scales from 1 ("Strongly Disagree") to 7 ("Strongly Agree") to rate their preferences for (a) the presenting problem, (b) collective nouns referring to those with the presenting problem, and (c) personal descriptors. We used univariate analysis of covariance (ANCOVA) to examine the associations between demographics (i.e., age, sex, and race) and terminology preferences and ordinal logit regression to explore the association between 12-step program partiality and preference for the term "addict."

KEY RESULTS

We surveyed 450 patients with mean age of 38.5 (SD = 11.1) years; 59.6% self-identified as male, 77.6% as White, and 12.7% as Hispanic. The highest-rated preferences for presenting problem were "addiction," "substance use," and "substance abuse." The highest-rated collective noun terms were "client," "patient," and "guest." "Person with an addiction," "person with substance use disorder," and "substance-dependent person" were the highest-rated personal descriptors. There were significant differences in terminological preference based on race and age. Twelve-step program partiality was associated with greater preference for the term "addict" (F = 21.22, p < .001).

CONCLUSIONS

Terminology preferences among people receiving methadone treatment aligned with existing guidelines recommending that clinicians use medically accurate and destigmatizing terminology when referring to substance use disorders and the persons who have them. Demographic differences emerged in terminological preferences, warranting further examination.

Evaluation of real-world outcomes associated with use of a prescription digital therapeutic to treat substance use disorders

BACKGROUND AND OBJECTIVES

Digital therapeutics can expand the reach and fidelity of behavioral treatment for substance use disorders (SUDs). This analysis evaluated real-world engagement and clinical outcomes in patients diagnosed with SUD who were prescribed reSET®, an FDA-authorized prescription digital therapeutic (PDT).

METHODS

Patients were prescribed a 12-week PDT comprising 61 therapy lessons (31 "core" and 30 "keep learning" lessons) and contingency management rewards (positive reinforcement message or monetary gift cards) based on lesson completion and negative urine drug screens. Engagement (defined as any activity in the PDT), retention (any activity in Weeks 9-12), and substance use data were collected automatically by the PDT and analyzed descriptively. Associations between early lesson completion and end-of-treatment outcomes were assessed.

RESULTS

Six hundred and fifty-eight patients filled their prescription. Evaluated were 602 patients who were exposed to therapeutic content by completing at least one lesson (median age 37 years, 33% female, 41% male, 26% unreported sex). Median lessons completed was 33 (out of 61 possible), and 52% of patients completed all core modules. Retention in treatment during the last 4 weeks of treatment was 74%, and 62% were abstinent (missing data considered positive). [Correction added on 13 December 2022, after first online publication: In the preceding sentence, the treatment percentage values were revised from 74.6% to 74%.] DISCUSSION AND CONCLUSIONS: Patients with SUD exhibited robust engagement with a PDT, high rates of retention through 12 weeks, and substantial rates of abstinence at end of treatment when the therapeutic was used in a real-world setting. PDT's hold promise as a new way to access effective SUD treatment.

SCIENTIFIC SIGNIFICANCE

This study is the first to report real-world PDT engagement and clinical outcomes data from a large, geographically diverse population of patients with SUDs.

Treatment options and shared decision-making in the treatment of opioid use disorder: A scoping review

BACKGROUND

Shared decision-making (SDM) is an approach to clinical decision-making that includes patients' values and preferences during health-related decisions. Previous research suggests that SDM may be beneficial in the treatment of substance use disorders; however, the impact of SDM in the treatment of opioid use disorder (OUD) remains unclear.

OBJECTIVES

To identify relevant peer-reviewed literature related to SDM in the treatment of adults with OUD, and to summarize the main findings according to patient outcomes.

METHODS

The research team conducted a scoping review. The team searched five electronic health databases from database inception until September 2019 using MeSH and keywords related to SDM. The team included only peer-reviewed studies where adults (≥18 years) with OUD were provided a choice and/or allowed input into their treatment plan. Two independent reviewers screened, extracted, and assessed the quality of included studies.

RESULTS

Fourteen studies (n = 1748 participants) met inclusion criteria, including seven randomized controlled trials, three non-randomized controlled trials, two observational studies, and one qualitative study. Treatment options included: patient regulated methadone dosing vs. fixed dosing (n = 4 studies), optional vs. mandatory counseling (n = 4 studies), home vs. office buprenorphine inductions (n = 2 studies), and inpatient vs. outpatient treatment (n = 1 study). None of the studies measured SDM with a validated instrument. Seven of 14 studies reported at least one improved patient outcome.

CONCLUSIONS

The review found few studies that explored whether providing treatment options and/or encouraging participation in decision-making are beneficial for adults with OUD. Preliminary evidence suggests that SDM may be promising for this population. However, the field needs more research on person-centered care and SDM.

Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review

Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Readiness to Provide Medications for Addiction Treatment in HIV Clinics: A Multisite Mixed-Methods Formative Evaluation

BACKGROUND

We sought to characterize readiness, barriers to, and facilitators of providing medications for addiction treatment (MAT) in HIV clinics.

SETTING

Four HIV clinics in the northeastern United States.

METHODS

Mixed-methods formative evaluation conducted June 2017-February 2019. Surveys assessed readiness [visual analog scale, less ready (0-<7) vs. more ready (≥7-10)]; evidence and context ratings for MAT provision; and preferred addiction treatment model. A subset (n = 37) participated in focus groups.

RESULTS

Among 71 survey respondents (48% prescribers), the proportion more ready to provide addiction treatment medications varied across substances [tobacco (76%), opioid (61%), and alcohol (49%) treatment medications (P values < 0.05)]. Evidence subscale scores were higher for those more ready to provide tobacco [median (interquartile range) = 4.0 (4.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.008] treatment medications, but not significantly different for opioid [5.0 (4.0, 5.0) vs. 4.0 (4.0, 5.0), P = 0.11] and alcohol [4.0 (3.0, 5.0) vs. 4.0 (3.0, 4.0), P = 0.42] treatment medications. Median context subscale scores ranged from 3.3 to 4.0 and generally did not vary by readiness status (P values > 0.05). Most favored integrating MAT into HIV care but preferred models differed across substances. Barriers to MAT included identification of treatment-eligible patients, variable experiences with MAT and perceived medication complexity, perceived need for robust behavioral services, and inconsistent availability of on-site specialists. Facilitators included knowledge of adverse health consequences of opioid and tobacco use, local champions, focus on quality improvement, and multidisciplinary teamwork.

CONCLUSIONS

Efforts to implement MAT in HIV clinics should address both gaps in perspectives regarding the evidence for MAT and contextual factors and may require substance-specific models.

Randomized trial of methadone treatment of arrestees: 24-month post-release outcomes

BACKGROUND

We report on the 24-month post-release outcomes of arrestees with opioid use disorder (OUD) enrolled in a randomized trial comparing three treatment approaches initiated in jail.

METHODS

Adults (N = 225) receiving medically supervised withdrawal from opioids in the Baltimore Detention Center within a few days of arrest were randomly assigned to: (1) interim methadone treatment plus patient navigation (IM + PN) started in the Detention Center; (2) IM; or (3) Enhanced Treatment-as-Usual (ETAU) consisting of detoxification with methadone and referral to treatment in the community. Participants in both methadone conditions could transfer to standard methadone treatment following release. Participants were interviewed at baseline, and 1, 3, 6, 12, and 24 months post-release. Urine was drug tested at follow-up and official arrest records were obtained.

RESULTS

On an intention-to-treat basis, there were no significant differences among the three conditions over the 24-month post-release period in terms of opioid- or cocaine-positive urine test results or self-reported opioid or cocaine use, meeting opioid or cocaine use disorder criteria, self-reported criminal behavior, or the number of official arrests. There were 9 fatal overdoses, none occurring during methadone treatment, and 109 hospitalizations unrelated to the study.

CONCLUSIONS

Given the high morbidity and mortality found in this population of arrestees and costs to society associated with their health care utilization and continued crime and arrests, research aimed at finding more effective interventions should be continued.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02334215.

Retention Strategies for Medications for Opioid Use Disorder in Adults: A Rapid Evidence Review

OBJECTIVES

Although medications for opioid use disorder (MOUD) save lives, treatment retention remains challenging. Identification of interventions to improve MOUD retention is of interest to policymakers and researchers. On behalf of the Agency for Healthcare Research and Quality, we conducted a rapid evidence review on interventions to improve MOUD retention.

METHODS

We searched MEDLINE and the Cochrane Library from February 2009 through August 2019 for systematic reviews and randomized trials of care settings, services, logistical support, contingency management, health information technology (IT), extended-release (XR) formulations, and psychosocial interventions that assessed retention at least 3 months.

RESULTS

Two systematic reviews and 39 primary studies were included; most did not focus on retention as the primary outcome. Initiating MOUD in soon-to-be-released incarcerated people improved retention following release. Contingency management may improve retention using antagonist but not agonist MOUD. Retention with interventions integrating medical, psychiatric, social services, or IT did not differ from in-person treatment-as-usual approaches. Retention was comparable with XR- compared to daily buprenorphine formulations and conflicting with XR-naltrexone monthly injection compared to daily buprenorphine. Most psychosocial interventions did not improve retention.

DISCUSSION

Consistent but sparse evidence supports criminal justice prerelease MOUD initiation, and contingency management interventions for antagonist MOUD. Integrating MOUD with medical, psychiatric, social services, delivering through IT, or administering via XR-MOUD formulations did not worsen retention. Fewer than half of the studies we identified focused on retention as a primary outcome. Studies used different measures of retention, making it difficult to compare effectiveness. Additional inquiry into the causes of low retention would inform future interventions.Registration: PROSPERO: CRD42019134739.

A qualitative investigation of addiction counselors' perceptions and experiences implementing an open-access model for treating opioid use disorder

OBJECTIVE

To examine addiction counselors' perceptions and experiences of implementing an open-access model for methadone maintenance treatment (MMT), in which the program rapidly enrolled prospective patients, irrespective of ability to pay, and provided real-time access to multiple voluntary treatment options. Between 2006, when the treatment program initially implemented this model, and 2020, the census of clients receiving methadone maintenance at the study site grew from 1431 to 4500.

METHODS

Participants were 31 addiction counselors employed at a treatment organization that implemented an open-access model to scale up MMT. We examined counselors' perceptions and experiences of working in programs that employed this model, using individual semi-structured interviews, which an interdisciplinary team audiotaped, transcribed, and systematically coded using grounded theory. The team reviewed themes and reconciled disagreements (rater agreement was 98%). We describe themes that more than 10% of participants reported.

RESULTS

Counselors described perceived advantages of the open-access model for clients (e.g., "individualized to client needs"), clinicians (e.g., "fewer demands"), and the community (e.g., "crime reduced"). Counselors also described perceived disadvantages of the open-access model for clinicians (e.g., "uneven workload") and clients (e.g., "need for more intensive services for some clients"), as well as program-level concerns (e.g., "perceived lack of structure").

CONCLUSIONS

Counselors who work in opioid treatment programs that use an open-access framework described multiple benefits to themselves, their clients, and the public; they also outlined disadvantages for themselves and clients, which research should further explore and address to facilitate MMT scale up.

Re-thinking patient stability for methadone in opioid treatment programs during a global pandemic: Provider perspectives

COVID-19 necessitated rapid changes in methadone take-home policies in opioid treatment programs (OTPs); these changes markedly contrast with existing, long-standing federal mandates on OTP rules about take-home methadone. OTP providers describe how these changes have affected clinical decision-making, equity in patient care, and workflow. We also discuss implications for medical ethics and patient autonomy. We provide suggestions for future research that will examine the impact of COVID-19 on OTP treatment and its patients, as well as the effect of making methadone take-home polices patient centered, all of which may foreshadow larger changes in the ways OTPs deliver their services.

Creating an ethical culture to support recovery from substance use disorders

There is a long-standing failure to create an ethical culture around substance use disorders (SUDs) or dependence that actively supports people's recovery efforts. Issues which impede the development of prorecovery environments are complex, but include the far-reaching effects of the social stigma that surrounds SUDs; and the failure to harness relational and social support that allows debates to transcend blaming individual substance users. As part of efforts to create prorecovery environments, it is important to acknowledge that bioethics debate on SUDs is narrow in scope, prioritising topics related to its traditional interests in individual autonomy and novel technologies. As a result, it has not played a significant role in helping to transform the ethical cultures in which substance use recovery takes place. For example, it largely neglects the ethical challenges of developing an empathic, person-centred approach to substance use problems that listens and responds to the voices of clients. It has also participated little in efforts to develop a positive response to reducing the toxic effects of stigma. Indeed, some contributions from the field fan stigma, rather than alleviate it. The aim of this paper is to seed broader ethical debate, in academic literature and lay/professional communities, on how societies should respond to SUDs: steering a course between the critical, but narrow approach of bioethics and the empowerment discourse of evidence-based treatments.

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

Importance

Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking.

Objective

To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence.

Design, Setting, and Participants

This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019.

Exposures

One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health.

Main Outcomes and Measures

Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment.

Results

A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up.

Conclusions and Relevance

Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

Building healthcare provider relationships for patient-centered care: A qualitative study of the experiences of people receiving injectable opioid agonist treatment

BACKGROUND

Injectable opioid agonist treatment (iOAT) was designed as a pragmatic and compassionate approach for people who have not benefitted from medication assisted treatment with oral opioids (e.g., methadone). While, a substantial body of clinical trial evidence has demonstrated the safety and effectiveness of iOAT, considerably less is known about the patient-centered aspects of this treatment and their role in self-reported treatment goals and outcomes. The aim of this study was to explore participants' experiences in iOAT as they broadly relate to the domains of patient-centered care. A secondary goal was to explore how these experiences affected participants' self-reported treatment outcomes.

METHODS

A qualitative methodology, and constructivist grounded theory approach, was used to guide sampling, data collection and analysis. A total of 30 in-depth interviews were conducted with people receiving iOAT in North America's first clinic. Audio-recordings for each semi-structured interview were transcribed and read repeatedly. The strategy of constant comparison was used through iterative stages of line-by-line, focused and theoretical coding until theoretical saturation was achieved.

RESULTS

"Building healthcare provider relationships for patient-centered care in iOAT" was the emergent core concept. Healthcare provider relationships were established through two interrelated processes: 'Opening up' was attributed to the positive environment, and to feeling understood and supported by healthcare providers. 'Being a part of care' emerged as participants felt safe to ask for what was needed and had opportunities to collaborate in treatment decisions. These processes established a foundation in which participants experienced care that was responsive to their individual dose, health and psychosocial needs.

CONCLUSIONS

The core concept suggested that therapeutic relationships were fundamental to experiences of patient-centered care in iOAT. When relationships were respectful and understanding, participants received individualized and holistic care in iOAT. These findings offer a valuable example of how therapeutic relationships can be strengthened in other substance use treatment settings, particularly when responding to the diverse treatment needs of clients.

Latent Profiles of Health and Reproductive Risk and Protective Factors among Women in Appalachia

Women who use opiates and are involved in the criminal justice system in Appalachia may be prone to adverse health outcomes. In this study, we performed a latent class analysis of risk and protective factors on 400 drug-using women recruited from rural, Appalachian jails. A two-profile solution best fit the data. Both profiles evinced low levels of condom use, reproductive and physical health screens, and STD history. However, the primary substantive difference between the profiles was partner risk behavior: the higher risk class had main male partners with histories of injection drug use and incarceration. Results suggest that interventions need to be tailored to unique profiles of risk and protective factors, which should include taking partner risk into consideration.

Conceptualizing patient-centered care for substance use disorder treatment: findings from a systematic scoping review

BACKGROUND

Despite ongoing efforts aimed to improve treatment engagement for people with substance-related disorders, evidence shows modest rates of utilization as well as client-perceived barriers to care. Patient-centered care (PCC) is one widely recognized approach that has been recommended as an evidence-based practice to improve the quality of substance use disorder treatment. PCC includes four core principles: a holistic and individualized focus to care, shared decision-making and enhanced therapeutic alliance.

AIMS

This scoping review aimed to explore which PCC principles have been described and how they have defined and measured among people with substance-related disorders.

METHODS

Following the iterative stages of the Arksey and O'Malley scoping review methodology, empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references were eligible if they focused on people accessing treatment for substance-related disorders and described PCC. Two reviewers independently screened the title/abstract and full-texts of references. Descriptive analyses and a directed content analysis were performed on extracted data.

FINDINGS

One-hundred and forty-nine references met inclusion from the 2951 de-duplicated references screened. Therapeutic alliance was the most frequent principle of PCC described by references (72%); this was consistently defined by characteristics of empathy and non-judgment. Shared decision-making was identified in 36% of references and was primarily defined by client and provider strategies of negotiation in the treatment planning process. Individualized care was described by 30% of references and included individualized assessment and treatment delivery efforts. Holistic care was identified in 23% of references; it included an integrated delivery of substance use, health and psychosocial services via comprehensive care settings or coordination. Substance use and treatment engagement outcomes were most frequently described, regardless of PCC principle.

CONCLUSIONS

This review represents a necessary first step to explore how PCC has been defined and measured for people accessing substance use disorder treatment. The directed content analysis revealed population and context-specific evidence regarding the defining characteristics of PCC-principles that can be used to further support the implementation of PCC.

Using nominal group technique to identify barriers, facilitators, and preferences among patients seeking treatment for opioid use disorder: A needs assessment for decision making support

BACKGROUND

The opioid crisis requires rapid scale-up of evidence-based interventions to treat opioid use disorder (OUD), of which pharmacologic therapies with methadone, buprenorphine or long-acting naltrexone are most effective. With recently-developed formulations, there are unprecedented treatment options. Even when pharmacologic treatment is accessible, however, uptake remains low, suggesting individual-level barriers. Decision aids are an evidence-based strategy that may overcome these barriers. This study aims to inform such a tool by describing and rank-ordering patients' considerations when deciding whether to start medication and, if starting, choosing a medication.

METHODS

Adults with OUD (N = 81) attending an addiction treatment center or syringe exchange program completed focus groups using nominal group technique, a consensus method that generates and ranks response. The qualitative component generates a broad array of responses, followed by rank-ordering to prioritize responses. Responses to questions about starting any medications and the pros and cons of five specific medications were ranked and coded.

RESULTS

The decision to initiate pharmacologic therapy and choose among medications was influenced by six key attributes in decreasing priority: (1) benefits, (2) side effects of treatment, (3) medication delivery strategies, (4) convenience, (5) how expectations for treatment are met, and (6) how medication (especially methadone) can represents trading one addiction for another.

CONCLUSIONS

Pharmacologic properties, logistical factors, and managing expectations were important themes in decision-making for starting, choosing, and staying on medications, and to a lesser degree, negative views about medications, specifically OAT, as an addiction itself. Desire for more control over treatment persisted in all themes. This study identified specific knowledge gaps, expectations, and priorities which are important for developing a decision aid for OUD treatment relevant to the target group. Nominal group technique is an established mixed-methodology that we have applied to a new population and purpose, that of conducting needs assessment for decision aid development.

Inadequate prenatal care utilization among women with and without methadone-treated opioid use disorders in Taiwan

AIMS

The present study aims to investigate the utilization pattern of prenatal care and correlates for women with opioid use disorders (OUD) in Taiwan.

METHOD

Using the data linkage between the Methadone Maintenance Treatment (MMT) register with national health insurance, national birth notification system, and birth registration system, we identified 1712 pregnancies with 20 or more gestational weeks from women enrolled in the MMT (heroin-exposed: receiving no methadone treatment during pregnancy, n = 1053 by 882 women; methadone-treated: receiving methadone for at least one day during pregnancy, n = 659 by 574 women) and their 1:10 matched pregnancies from 17,060 women without substance use disorder in the period of 2004-2013. The generalized linear mixed models with negative binomial and logit distributions were performed to evaluate the relationship between individual sociodemographic, health, and addiction treatment characteristics with the number of prenatal visits and receiving prenatal care in the first trimester (i.e., early entry).

FINDINGS

Eighteen percent of pregnancies by women with OUD received no prenatal services and 21% had started prenatal care in the first trimester as compared with 1% and 46% in pregnancies by women without substance use disorders. For pregnancies by women with OUD, methadone treatment was not linked associated with prenatal care visits (adjusted relative risk [aRR] = 1.02; 95% = 0.92, 1.12). For methadone-treated pregnancies, treatment enrollment before pregnancy and spousal methadone treatment elevated prenatal visits by 8% and 18% (0.48 and 1.08 visits, respectively). Additionally, HIV infection (adjusted odds ratio [aOR] = 0.30, 95% CI = 0.10, 0.83) and prior delivery (aOR = 0.05, 95% CI = 0.01, 0.19) significantly reduced the odds of early entry into prenatal care.

CONCLUSION

Integrating addiction treatment programs with prenatal care is urgently needed to increase adequate prenatal care for pregnant women with OUD, especially the multiparous ones.

An intervention trial targeting methadone maintenance treatment providers to improve clients' treatment retention in China

BACKGROUND

Service providers including doctors, nurses, and other healthcare professionals play an essential role in methadone maintenance treatment (MMT). This study evaluated the impact of an intervention targeting MMT providers on their clients' treatment retention.

METHODS

This study was conducted in 68 MMT clinics in five provinces of China with 36 clients randomly selected from each clinic. The clinics were randomized to intervention or control condition. The MMT CARE intervention started with group sessions to enhance providers' communication skills. The trained providers were encouraged to conduct individual sessions with clients to promote treatment engagement. The outcomes, which include client retention (main outcome) and their reception of provider-delivered individual sessions (process outcome), were measured over a 24-month period.

RESULTS

Significantly fewer intervention clients dropped out from MMT than control clients during the study period (31% vs. 41%; p < 0.0001). Dropout hazard was significantly lower in the intervention condition compared to the control condition (HR = 0.71, 95% CI: 0.57, 0.89). More intervention clients had individual sessions than control clients (93% vs. 70%; p < 0.0001). Having individual sessions was associated with a significantly lower dropout hazard (HR = 0.30, 95% CI: 0.23, 0.40). The intervention clients had a significantly lower dropout hazard than the control clients if they started the individual sessions during the first six months (HR = 0.68, 95% CI: 0.51, 0.90).

CONCLUSIONS

The MMT CARE intervention focusing on provider capacity building has demonstrated efficacy in reducing clients' treatment dropout. This study sheds light on MMT service improvement in China and other global community-based harm reduction programs.

Patient-centred care for addiction treatment: a scoping review protocol

INTRODUCTION

Substance use disorders are chronic conditions that require a multidimensional treatment approach. Despite ongoing efforts to diversify such treatments, evidence continues to illuminate modest rates of treatment engagement and perceived barriers to treatment. Patient-centred care (PCC) is one approach that may strengthen the responsiveness of treatments for people with problematic substance use. The aim of this scoping review is to explore how the principles of PCC have been implemented and operationalised in healthcare settings for people with problematic substance use.

METHODS AND ANALYSIS

This scoping review follows the iterative stages of the Arksey and O'Malley framework. Both empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references will be considered if they focused on populations with problematic substance use and described or measured PCC or one of its principles in a health-oriented context. Two reviewers will independently screen references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria. A descriptive overview, tabular and/or graphical summaries, and a directed content analysis will be carried out on extracted data. This scoping review has been registered with Open Science Framework (https://osf.io/5swvd/).

ETHICS AND DISSEMINATION

This review will systematically examine the extent and nature of existing evidence of PCC in addiction research and clinical practice. Such evidence will contribute to the operationalisation of PCC for people with problematic substance use. A multidisciplinary team has been gathered to represent the needs of people with problematic substance use, healthcare providers and decision-makers. The team's knowledge users will be engaged throughout this review and will participate in dissemination activities (eg, workshops, presentations, publications, reports).

Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users

BACKGROUND

Problem alcohol use is common among people who use illicit drugs (PWID) and is associated with adverse health outcomes. It is also an important factor contributing to a poor prognosis among drug users with hepatitis C virus (HCV) as it impacts on progression to hepatic cirrhosis or opioid overdose in PWID.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to reduce alcohol consumption in PWID (users of opioids and stimulants).

SEARCH METHODS

We searched the Cochrane Drugs and Alcohol Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, and PsycINFO, from inception up to August 2017, and the reference lists of eligible articles. We also searched: 1) conference proceedings (online archives only) of the Society for the Study of Addiction, International Harm Reduction Association, International Conference on Alcohol Harm Reduction and American Association for the Treatment of Opioid Dependence; and 2) online registers of clinical trials: Current Controlled Trials, ClinicalTrials.gov, Center Watch and the World Health Organization International Clinical Trials Registry Platform.

SELECTION CRITERIA

We included randomised controlled trials comparing psychosocial interventions with other psychosocial treatment, or treatment as usual, in adult PWIDs (aged at least 18 years) with concurrent problem alcohol use.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included seven trials (825 participants). We judged the majority of the trials to have a high or unclear risk of bias.The psychosocial interventions considered in the studies were: cognitive-behavioural coping skills training (one study), twelve-step programme (one study), brief intervention (three studies), motivational interviewing (two studies), and brief motivational interviewing (one study). Two studies were considered in two comparisons. There were no data for the secondary outcome, alcohol-related harm. The results were as follows.Comparison 1: cognitive-behavioural coping skills training versus twelve-step programme (one study, 41 participants)There was no significant difference between groups for either of the primary outcomes (alcohol abstinence assessed with Substance Abuse Calendar and breathalyser at one year: risk ratio (RR) 2.38 (95% confidence interval [CI] 0.10 to 55.06); and retention in treatment, measured at end of treatment: RR 0.89 (95% CI 0.62 to 1.29), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was very low.Comparison 2: brief intervention versus treatment as usual (three studies, 197 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the Alcohol Use Disorders Identification Test (AUDIT) or Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) at three months: standardised mean difference (SMD) 0.07 (95% CI -0.24 to 0.37); and retention in treatment, measured at three months: RR 0.94 (95% CI 0.78 to 1.13), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 3: motivational interviewing versus treatment as usual or educational intervention only (three studies, 462 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured as scores on the AUDIT or ASSIST at three months: SMD 0.04 (95% CI -0.29 to 0.37); and retention in treatment, measured at three months: RR 0.93 (95% CI 0.60 to 1.43), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.Comparison 4: brief motivational intervention (BMI) versus assessment only (one study, 187 participants)More people reduced alcohol use (by seven or more days in the past month, measured at six months) in the BMI group than in the control group (RR 1.67; 95% CI 1.08 to 2.60). There was no difference between groups for the other primary outcome, retention in treatment, measured at end of treatment: RR 0.98 (95% CI 0.94 to 1.02), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was moderate.Comparison 5: motivational interviewing (intensive) versus motivational interviewing (one study, 163 participants)There was no significant difference between groups for either of the primary outcomes (alcohol use, measured using the Addiction Severity Index-alcohol score (ASI) at two months: MD 0.03 (95% CI 0.02 to 0.08); and retention in treatment, measured at end of treatment: RR 17.63 (95% CI 1.03 to 300.48), or for any of the secondary outcomes reported. The quality of evidence for the primary outcomes was low.

AUTHORS' CONCLUSIONS

We found low to very low-quality evidence to suggest that there is no difference in effectiveness between different types of psychosocial interventions to reduce alcohol consumption among people who use illicit drugs, and that brief interventions are not superior to assessment-only or to treatment as usual. No firm conclusions can be made because of the paucity of the data and the low quality of the retrieved studies.

Re-engineering methadone-Cost-effectiveness analysis of a patient-centered approach to methadone treatment

Methadone maintenance treatment has proven effectiveness in the treatment of opioid use disorder, but significant barriers remain to treatment retention. In a randomized clinical trial, 300 newly-admitted methadone patients were randomly assigned to patient-centered methadone (PCM) v. treatment-as-usual (TAU). In PCM, participants were treated under revised program rules which permitted voluntary attendance at counseling and other changes focused on reducing involuntary discharge, and different staff roles which shifted disciplinary responsibility from the participant's counselor to the supervisor. The study found no significant differences in treatment retention, measures of opioid use, or other patient outcomes. This paper employs an activity-based costing approach to estimate the cost and cost-effectiveness of the two study conditions. We found that service use and costs were similar between PCM and TAU. Specifically, the average cost for PCM patients was $2396 compared to $2292 for standard methadone, while the average length of stay was 2 weeks longer for PCM patients. Incremental cost-effectiveness ratios (ICER) for self-reported heroin use, opioid positive urine screens, and meeting DSM-IV criteria for opioid dependence were mixed, with TAU achieving non-significantly better outcomes at lower treatment episode costs (i.e., economically dominating) for opioid positive urine screens. PCM patients reported slightly more days abstinent from heroin and fewer meet the opioid dependence criteria. While these differences are small and not statistically significant, we can still examine the cost-effectiveness implications. For days, abstinent from heroin, the ICER was $242 for one additional day of abstinence, however, there was notable uncertainty around this estimate. For opioid dependence criteria, the ICER was $1160 for a one-percentage point increase in the probability that a participant no longer met criteria for opioid dependence at follow-up. This economic study finds that patient choice concepts can be introduced into methadone treatment without significant impacts on costs or patient outcomes.

Counseling Staff's Views of Patient-Centered Methadone Treatment: Changing Program Rules and Staff Roles

Conflicts with methadone program counseling staff and violations of program rules can contribute to patients leaving treatment prematurely. This qualitative study was conducted as part of a larger trial of patient-centered methadone treatment (PCM). In-depth, semi-structured interviews at baseline and 12-month follow-up were conducted with five counselors and three clinical supervisors from the programs participating in the PCM parent study. Data were analyzed using Atlas.ti. Counselors reported that, in some cases, PCM allowed them to focus on building a therapeutic alliance with patients because they were not addressing program rule issues. Some reported using more pro-active, innovative strategies for engaging PCM patients and that counseling sessions tended to include a broader range of individually tailored topics, compared to topics normally addressed in typical treatment sessions. Adjusting to the new counselor role was challenging for some counselors and required a shift in tactics to encourage patients' participation in counseling services.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov NCT 01442493.

When does methadone treatment reduce arrest and severity of arrest charges? An analysis of arrest records

This is an analysis of the odds of arrest, severity of charges, and factors predicting these outcomes in the year after methadone treatment entry using arrest records of patients (N=289) participating in two opioid treatment programs (OTPs) in Baltimore, MD as part of a previously-reported study. Baseline Addiction Severity Index data were examined along with publicly-available dates of arrest and arrest charges from the year before and after OTP entry. Severity of charges was rated independently by three researchers using a 1-7 point scale. Data were analyzed using Generalized Estimating Equations and Multiple Regression. The majority of the patients had no arrests over both time periods (61.6% and 65.7%, respectively). Of those arrested, the majority of the sample were charged with non-severe crimes in the year before and after OTP entry (82.9% and 73.7%, respectively). There were no significant differences in the odds of arrest or severity of charges in the year before versus the year after OTP admission (both ps>0.05). Predictors of arrest following admission included an arrest in the year prior to admission (p<0.001), younger age (p<0.001), and more lifetime months of incarceration (p=0.045). Predictors of the higher severity of charges included younger age (p<0.001), African-American race (p=0.032), and more lifetime months of incarceration (p=0.018). While in this population, the odds of arrest and severity of charges did not decrease significantly in the year following OTP entry, we discuss the need to avoid generalizing findings without considering those factors that may influence the likelihood of post-OTP entry arrest.