Opioid treatment program and community pharmacy collaboration for methadone maintenance treatment: results from a feasibility clinical trial

Effect of Acupuncture for Methadone Reduction : A Randomized Clinical Trial

BACKGROUND

Methadone maintenance treatment (MMT) is effective for managing opioid use disorder, but adverse effects mean that optimal therapy occurs with the lowest dose that controls opioid craving.

OBJECTIVE

To assess the efficacy of acupuncture versus sham acupuncture on methadone dose reduction.

DESIGN

Multicenter, 2-group, randomized, sham-controlled trial. (Chinese Clinical Trial Registry: ChiCTR2200058123).

SETTING

6 MMT clinics in China.

PARTICIPANTS

Adults aged 65 years or younger with opioid use disorder who attended clinic daily and had been using MMT for at least 6 weeks.

INTERVENTION

Acupuncture or sham acupuncture 3 times a week for 8 weeks.

MEASUREMENTS

The 2 primary outcomes were the proportion of participants who achieved a reduction in methadone dose of 20% or more compared with baseline and opioid craving, which was measured by the change from baseline on a 100-mm visual analogue scale (VAS).

RESULTS

Of 118 eligible participants, 60 were randomly assigned to acupuncture and 58 were randomly assigned to sham acupuncture (2 did not receive acupuncture). At week 8, more patients reduced their methadone dose 20% or more with acupuncture than with sham acupuncture (37 [62%] vs. 16 [29%]; risk difference, 32% [97.5% CI, 13% to 52%]; P < 0.001). In addition, acupuncture was more effective in decreasing opioid craving than sham acupuncture with a mean difference of -11.7 mm VAS (CI, -18.7 to -4.8 mm; P < 0.001). No serious adverse events occurred. There were no notable differences between study groups when participants were asked which type of acupuncture they received.

LIMITATION

Fixed acupuncture protocol limited personalization and only 12 weeks of follow-up after stopping acupuncture.

CONCLUSION

Eight weeks of acupuncture were superior to sham acupuncture in reducing methadone dose and decreasing opioid craving.

PRIMARY FUNDING SOURCE

National Natural Science Foundation of China.

Pharmacist-prescriber collaborative models of care for opioid use disorder: an overview of recent research

PURPOSE OF REVIEW

Collaborative models of care where pharmacists work alongside physicians have been developed for a range of physical health conditions, with benefits including improved patient outcomes and increased access to ongoing care. Opioid agonist treatment (methadone and buprenorphine) is a clinically effective and cost-effective treatment for opioid use disorder that is under-utilized in many countries due to a shortage of prescribers. In recent years, there has been increased interest in the development of collaborative models that utilize pharmacists to overcome barriers to treatment. In this article, we present a narrative review to synthesise recent work in this rapidly developing area.

RECENT FINDINGS

Two key aspects of opioid agonist treatment were identified: Collaborative models have utilized pharmacists to facilitate buprenorphine induction, and collaborative models provide increased capacity for delivering ongoing care in a variety of settings and patient groups where prescriber access is limited. Pharmacists have undertaken direct patient care responsibilities with varying degrees of autonomy, with benefits including a reduction in prescriber workload, and improvements in treatment retention and continuity of care.

SUMMARY

Collaborative models in which pharmacists are responsible for buprenorphine induction and ongoing management with methadone and buprenorphine have been shown to reduce demands on prescribers while improving or maintaining patient outcomes, and appear feasible and acceptable in a wide range of outpatient settings.

Persistence in the Methadone Maintenance Program and Its Relationship with the Medication Regimen Complexity Index in Opioid-Dependent Patients

It has been shown that the Medication Regimen Complexity Index (MRCI) is a useful and reliable tool for calculating the complexity of the pharmacotherapeutic regimen (CPR). Furthermore, a high MRCI is associated with lower adherence. However, the MRCI of opioid-dependent patients (ODP) has not been studied. The aim of this study is to calculate the Methadone Maintenance Program (MMP) persistence and the MRCI score in a ODP cohort. Second, to analyze its relationship and association with other variables. To accomplish this research, an observational study including adults with a confirmed diagnosis of opiate-dependency according to the DSM-5 in a MMP center was carried out. To define MMP-persistence, a group was created by the researchers who defined five weighted items according to their agreed importance. Our first contribution was to create a new definition of MMP-persistence. This study also identified age, comorbidities, and received methadone maintenance doses as successful predictors for MMP-persistence. We have also shown that the MRCI does not seem to be a useful tool to determine MMP-persistence, probably because there are multiple factors that influence it in addition to the CPR. It is necessary to continue searching for more precise selection and stratification tools for ODP to improve their persistence.

Mobile treatment for opioid use disorder: Implementation of community-based, same-day medication access interventions

BACKGROUND

Medications for Opioid Use Disorder (MOUD) are lifesaving, but <20 % of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation.

METHODS

Program staff from five programs in two states (n = 11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide.

RESULTS

Mobile MOUD units sought to improve immediate access to MOUD ("Our answer is pretty much always, 'Yes, we'll get you started right here, right now,'"), advance equity ("making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,"), and decrease opioid overdose deaths. Salient program characteristics included diverse staff, including staff with lived experience of substance use ("She just had that personal knowledge of where we should be going"). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access. Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours. Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement ("It's not really possible that billing in and of itself is going to be able to sustain it"), and community stigma toward addiction services generally.

CONCLUSIONS

Despite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

Geographic variation in availability of opioid treatment programs across U.S. communities

Methadone for Opioid Use Disorder (OUD) treatment is only dispensed at Opioid Treatment Programs (OTPs). Little is known about the geographic variation in OTP availability and community characteristics associated with the availability across smaller geographic communities in the U.S. To (1) describe geographic distribution of OTPs and (2) examine OTP availability by community characteristics in the contiguous U.S. at Zip Code Area Tabulation (ZCTA) level. Logistic regression was used to examine community characteristics associated with OTP availability (N = 30,367). Chi-square and t-tests were conducted to examine statistically significant differences in OTP availability. Maps and descriptive statistics were used to examine geographic variation in OTP availability. Only 5% (1,417) of ZCTAs had at least one OTP for a total of 1,682 OTPs. Rural ZCTAs had 50% lower odds of having an OTP compared to urban ZCTAs [AOR 0.5; (95% CI: 0.41-0.60)]. ZCTAs in the lowest income quartile had higher odds of having an OTP compared to ZCTAs in the highest income quartile [AOR 3.4; (95% CI: 2.71-4.18)]. Further, ZCTAs with OTPs had a higher proportion of minority residents [Black: 17.5% vs. 7.2%; Hispanic: 19.2% vs. 9%] and a lower proportion of White residents [55.1% vs. 78.2%]. Nationally, OTPs are extremely scarce with notable regional and urban-rural disparities. Potential solutions to address these disparities are discussed.

Pilot study of a community pharmacist led program to treat hepatitis C virus among people who inject drugs

Background

People who inject drugs (PWID) are a key population for treatment with direct-acting antiviral medications (DAAs) to eliminate hepatitis C virus (HCV). We developed a Pharmacist, Physician, and Patient Navigator Collaborative Care Model (PPP-CCM) for delivery of HCV treatment; this study describes clinical outcomes related to HCV treatment (initial evaluation, treatment initiation, completion, and cure), as well as patient satisfaction.

Methods

We conducted a single-arm prospective pilot study of adult PWID living with HCV. Participants completed baseline and six-month follow-up surveys, and treatment and outcomes were abstracted from electronic health records. Primary outcome was linkage to pharmacist for HCV evaluation; secondary outcomes included DAA initiation, completion, and cure, as well as patient-reported satisfaction.

Results

Of the 40 PWID enrolled, mean age was 43.6 years, 12 (30 %) were female, 20 (50 %) were non-white, and 15 (38 %) were unhoused. Thirty-eight (95 %) were successfully linked to the pharmacist for initial evaluation. Of those, 21/38 (55 %) initiated DAAs, and 16/21 (76 %) completed treatment. Among those completing treatment who had viral load data to document whether they achieved "sustained virologic response", i.e. cure, 10/11 (91 %) were found to be cured. There was high satisfaction with 100 % responding "agree or strongly agree" that they had a positive experience with the pharmacist.

Conclusion

Nearly all participants in this pilot were successfully linked to the pharmacist for evaluation, and more than half were started on DAAs; results provide preliminary evidence of feasibility of pharmacist-led models of HCV treatment for PWID.

Clinicaltrialsgov registration number

NCT04698629.

Disparities in access to opioid treatment programs and buprenorphine providers by race and ethnicity in the contiguous U.S

BACKGROUND

The burden of drug overdose mortality varies by race and ethnicity, with American Indian/Alaska Native (AI/AN), Black, and White people experiencing the largest burden. We analyzed census block group data to evaluate differences in travel distance to opioid treatment programs (OTP) and buprenorphine providers by race and ethnicity.

METHODS

The Substance Abuse and Mental Health Services Administration provided the addresses of OTPs and buprenorphine providers. The study classified block groups as majority (≥50 %) AI/AN, Black, Asian, White, no single racial majority, or Hispanic. We classified deprivation and rurality using the Area Deprivation Index and Rural-Urban Commuting Area codes. The study applied generalized linear mixed models.

RESULTS

Among all block groups, the median road distance to the nearest OTPs and buprenorphine providers was 8 and 2 miles, respectively. AI/AN-majority block groups had the longest median distances to OTPs (88 miles versus 4-10 miles) and buprenorphine providers (17 miles versus 1-3 miles) compared to other racial or ethnic majority block groups. For OTPs and buprenorphine providers, travel distances were slightly greater in more deprived block groups compared to less deprived block groups. The median distance to the nearest OTPs and buprenorphine providers were larger in micropolitan and small town/rural block groups compared to metropolitan areas.

CONCLUSIONS

Disparities exist in travel distance to OTPs and buprenorphine providers. People in block groups with AI/AN-majority, nonmetropolitan, or more deprived designation experience travel disparities accessing treatment. Future research should develop targeted interventions to reduce access to care disparities for individuals with opioid use disorder.

Research Priorities for Expansion of Opioid Use Disorder Treatment in the Community Pharmacy

In the last decade, the U.S. opioid overdose crisis has magnified, particularly since the introduction of synthetic opioids, including fentanyl. Despite the benefits of medications for opioid use disorder (MOUD), only about a fifth of people with opioid use disorder (OUD) in the U.S. receive MOUD. The ubiquity of pharmacists, along with their extensive education and training, represents great potential for expansion of MOUD services, particularly in community pharmacies. The National Institute on Drug Abuse's National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) convened a working group to develop a research agenda to expand OUD treatment in the community pharmacy sector to support improved access to MOUD and patient outcomes. Identified settings for research include independent and chain pharmacies and co-located pharmacies within primary care settings. Specific topics for research included adaptation of pharmacy infrastructure for clinical service provision, strategies for interprofessional collaboration including health service models, drug policy and regulation, pharmacist education about OUD and OUD treatment, including didactic, experiential, and interprofessional curricula, and educational interventions to reduce stigma towards this patient population. Together, expanding these research areas can bring effective MOUD to where it is most needed.

Regional Disparities in Prescription Methamphetamine and Amphetamine Distribution Across the United States

OBJECTIVE

The objectives of this report were to characterize the regional and state differences in prescription methamphetamine and amphetamine distribution in the US.

METHODS

Prescription methamphetamine and amphetamine distribution was obtained from the Drug Enforcement Administration for 2019.

RESULTS

Total per capita drug weight distribution of amphetamine was 4,000 times higher than methamphetamine. Regionally, total per capita drug weight for methamphetamine was highest in the West (32.2% of total distribution) and lowest in the Northeast (17.4%). The total per capita drug weight for amphetamine was highest in the South (37.0% of total distribution) and lowest in the Northeast (19.4%). Distribution of methamphetamine was 16.1% while amphetamine was 54.0% of its production quota.

CONCLUSION

Overall, prescription amphetamine distribution was common while prescription methamphetamine distribution was rare. The patterns observed in distribution are likely the result of stigmatization, differences in accessibility, and the efforts of initiatives such as the Montana Meth Project.

Pharmacy-based methadone treatment in the US: views of pharmacists and opioid treatment program staff

BACKGROUND

The US federal regulations allow pharmacy administration and dispensing of methadone for opioid use disorder (PADMOUD) to increase the capability of opioid treatment programs (OTPs) in providing methadone maintenance treatment (MMT) for opioid use disorder (OUD) as part of a medication unit. However, there is a lack of research data from both pharmacy and OTP staff to inform the implementation of PADMOUD.

METHODS

Staff of a pharmacy (n = 8) and an OTP (n = 9) that participated in the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were recruited to participate in this qualitative interview study to explore implementation-related factors for PADMOUD. Each interview was recorded and transcribed verbatim. NVivo was used to help identify themes of qualitative interview data. The Promoting Action on Research Implementation in Health Services (PARIHS) framework was used to guide the coding and interpretation of data.

RESULTS

Six pharmacy staff and eight OTP staff (n = 14) completed the interview. Results based on PARIHS domains were summarized, including evidence, context, and facilitation domains. Participants perceived benefits of PADMOUD for patients, pharmacies, OTPs, and payers. PADMOUD was considered to increase access for stable patients, provide additional patient service opportunities and revenues for pharmacies/pharmacists, enhance the capability of OTPs to treat more new patients, and reduce patients' cost when receiving medication at a pharmacy relative to an OTP. Both pharmacy and OTP staff were perceived to be supportive of the implementation of PADMOUD. Pharmacy staff/pharmacists were perceived to need proper training on addiction and methadone as well as a protocol of PADMOUD to conduct PADMOUD. Facilitators include having thought leaders to guide the operation, a certification program to ensure proper training of pharmacy staff/pharmacist, having updated pharmacy service software or technology to streamline the workflow of delivering PADMOUD and inventory management, and reimbursement for pharmacists.

CONCLUSION

This study presents the first findings on perspectives of PADMOUD from both staff of a community pharmacy and an OTP in the US. Finding on barriers and facilitators are useful data to guide the development of strategies to implement PADMOUD to help address the US opioid crisis.

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.

Methadone Treatment Gap in Tennessee and How Medication Units Could Bridge the Gap: A Review

The opioid epidemic has been an ongoing public health concern in the United States (US) for the last few decades. The number of overdose deaths involving opioids, hereafter referred to as overdose deaths, has increased yearly since the mid-1990s. One treatment modality for opioid use disorder (OUD) is medication-assisted treatment (MAT). As of 2022, only three pharmacotherapy options have been approved by the Food and Drug Administration (FDA) for treating OUD: buprenorphine, methadone, and naltrexone. Unlike buprenorphine and naltrexone, methadone dispensing and administrating are restricted to opioid treatment programs (OTPs). To date, Tennessee has no medication units, and administration and dispensing of methadone is limited to licensed OTPs. This review details the research process used to develop a policy draft for medication units in Tennessee. This review is comprised of three parts: (1) a rapid review aimed at identifying obstacles and facilitators to OTP access in the US, (2) a descriptive analysis of Tennessee's geographic availability of OTPs, pharmacies, and federally qualified health centers (FQHCs), and (3) policy mapping of 21 US states' OTP regulations. In the rapid review, a total of 486 articles were imported into EndNote from PubMed and Embase. After removing 152 duplicates, 357 articles were screened based on their title and abstract. Thus, 34 articles underwent a full-text review to identify articles that addressed the accessibility of methadone treatment for OUD. A total of 18 articles were identified and analyzed. A descriptive analysis of Tennessee's availability of OTP showed that the state has 22 OTPs. All 22 OTPs were matched to a county and a region based on their address resulting in 15 counties (16%) and all three regions having at least one OTP. A total of 260 FQHCs and 2294 pharmacies are in Tennessee. Each facility was matched to a county based on its address resulting in 70 counties (74%) having at least one FQHC and 94 counties (99%) having at least one pharmacy. As of 31 December 2022, 17 states mentioned medication units in their state-level OTP regulations. Utilizing the regulations for the eleven states with medication units and federal guidelines, a policy draft was created for Tennessee's medication units.

Patient perspectives on community pharmacy administered and dispensing of methadone treatment for opioid use disorder: a qualitative study in the U.S

BACKGROUND

Pharmacy administration and dispensing of methadone treatment for opioid use disorder (PADMOUD) may address inadequate capability of opioid treatment programs (OTPs) in the US by expanding access to methadone at community pharmacies nationally. PADMOUD is vastly underutilized in the US. There is no published US study on OUD patients' perspectives on PADMOUD. Data are timely and needed to inform the implementation of PADMOUD in the US to address its serious opioid overdose crisis.

METHODS

Patient participants of the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were interviewed to explore implementation-related factors for PADMOUD. All 20 participants of the parent study were invited to participate in this interview study. Each interview was recorded and transcribed verbatim. Thematic analysis was conducted to identify emergent themes.

RESULTS

Seventeen participants completed the interview. Patients' perspectives on PADMOUD were grouped into five areas. Participants reported feasibility of taking the tablet formulation of methadone at the pharmacy and identified benefits from PADMOUD (e.g., better access, efficiency, convenience) compared with usual care at the OTP. Participants perceived support for PADMOUD from their family/friends, OTP staff, and pharmacy staff. PADMOUD was perceived to be a great option for stable patients with take-home doses and those with transportation barriers. The distance (convenience), office hours, and the cost were considered factors most influencing their decision to receive methadone from a pharmacy. Nonjudgmental communication, pharmacists' training on methadone treatment, selection of patients (stable status), workflow of PADMOUD, and protection of privacy were considered key factors for improving operations of PADMOUD.

CONCLUSION

This study presents the first findings on patient perspectives on PADMOUD. Participants considered pharmacies more accessible than OTPs, which could encourage more people to receive methadone treatment earlier and help transition stable patients from an OTP into a local pharmacy. The findings have timely implications for informing implementation strategies of PADMOUD that consider patients' views and needs.

Barriers and facilitators to implementing a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) to treat hepatitis C among people who inject drugs

BACKGROUND

Direct-acting antivirals (DAAs) offer an unprecedented opportunity to eliminate hepatitis C virus (HCV) infection, yet barriers among people who inject drugs (PWID) remain. Having pharmacists provide care through collaborative drug therapy agreements (CDTAs) offers a promising solution. We developed and piloted a Pharmacist, Physician, and Patient Navigator-Collaborative Care Model (PPP-CCM) which utilized pharmacists to directly deliver HCV care at community organizations serving PWID. We conducted formative evaluation of the PPP-CCM pilot to characterize implementation experiences.

METHODS

The PPP-CCM was implemented from November of 2020 through July of 2022. Formative evaluation team members observed implementation-related meetings and conducted multiple site visits, taking detailed fieldnotes. Fieldnotes were iteratively reviewed to identify barriers and facilitators to implementation and used to inform 7 key informant interviews conducted with programmatic staff at the end of the pilot. All data were analyzed using a Rapid Assessment Process (RAP) guided by the Consolidated Framework for Implementation Research (CFIR). The formative evaluation team shared results with program stakeholders (pharmacists, physicians, and other site staff) to verify and expand on learnings.

RESULTS

Evaluation of PPP-CCM revealed 5 themes, encompassing all CFIR domains: 1) PPP-CCM was feasible but challenging to deliver efficiently; 2) the pharmacist role and characteristics (e.g., being flexible, available, and patient-centered) were key to PPP-CCM successes; 3) the PPP-CCM team met challenges engaging patients over time, but some team-based strategies helped; 4) community site characteristics (e.g., existing trusting relationships with PWID and physical space that enabled program visibility) were important contributors; and 5) financial barriers may limit PPP-CCM scale-up and sustainability.

CONCLUSION

PPP-CCM is a novel and promising approach to HCV care delivery for PWID who may previously lack engagement in traditional care models, but careful attention needs to be paid to financial barriers to ensure scalability and sustainability.

Research priorities for expanding access to methadone treatment for opioid use disorder in the United States: A National Institute on Drug Abuse Center for Clinical Trials Network Task Force report

In the US, methadone treatment can only be provided to patients with opioid use disorder (OUD) through federal and state-regulated opioid treatment programs (OTPs). There is a shortage of OTPs, and racial and geographic inequities exist in access to methadone treatment. The National Institute on Drug Abuse Center for Clinical Trials Network convened the Methadone Access Research Task Force to develop a research agenda to expand and create more equitable access to methadone treatment for OUD. This research agenda included mechanisms that are available within and outside the current regulations. The task force identified 6 areas where research is needed: (1) access to methadone in general medical and other outpatient settings; (2) the impact of methadone treatment setting on patient outcomes; (3) impact of treatment structure on outcomes in patients receiving methadone; (4) comparative effectiveness of different medications to treat OUD; (5) optimal educational and support structure for provision of methadone by medical providers; and (6) benefits and harms of expanded methadone access. In addition to outlining these research priorities, the task force identified important cross-cutting issues, including the impact of patient characteristics, treatment, and treatment system characteristics such as methadone formulation and dose, concurrent behavioral treatment, frequency of dispensing, urine or oral fluid testing, and methods of measuring clinical outcomes. Together, the research priorities and cross-cutting issues represent a compelling research agenda to expand access to methadone in the US.