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Darke S, Duflou J, Peacock A, Farrell M, Lappin J. A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times. Addiction 2024; 119:559-569. [PMID: 37921084 DOI: 10.1111/add.16377] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND AND AIMS Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation. DESIGN Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System. SETTING This study was conducted Australia-wide. CASES There were 610 cases of fatal heroin-related drug toxicity. MEASUREMENTS Information was collected on characteristics, manner of death, toxicology and autopsy results. FINDINGS The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood. CONCLUSIONS The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.
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Affiliation(s)
- Shane Darke
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Johan Duflou
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- Sydney Medical School, University of Sydney, Sydney, Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Michael Farrell
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
| | - Julia Lappin
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, Australia
- School of Psychiatry, University of New South Wales, Sydney, Australia
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Amundsen EJ, Melsom AKM, Eriksen BO, Løchen ML. No decline in drug overdose deaths in Norway: An ecological approach to understanding at-risk groups and the impact of interventions. NORDIC STUDIES ON ALCOHOL AND DRUGS 2024; 41:111-130. [PMID: 38356787 PMCID: PMC10863554 DOI: 10.1177/14550725231195413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024] Open
Abstract
Aim: This Norwegian case study examines groups at risk of drug overdose deaths, evidence-based harm reduction interventions, low-threshold services and treatment implemented, as well as trends in drug overdose deaths between 2010 and 2021. We aimed to explore the relevance of interventions for at-risk groups and discuss their potential impact on drug overdose trends. Method/data: Using an ecological approach, we analysed the following: (1) groups identified through latent profile analysis (LPA) among a sample of 413 high-risk drug users collected in 2010-2012, supplemented with other relevant studies up to 2021; (2) published information on harm-reduction interventions, low-threshold services and treatment in Norway; and (3) nationwide drug overdose mortality figures supplemented with published articles on the topic. Results: High-risk drug users in 2010-2012 commonly engaged in frequent illegal drug use, injecting and poly-drug use (including pharmaceutical opioids), which continued into following decade. The interventions implemented between 2010 and 2021 were relevant for at-risk groups identified in the surveys. However, there was no decrease in the trend of drug overdose deaths up to 2021. While relevant interventions may have mitigated a theoretical increase in mortality, new at-risk groups may have contributed to fatal outcomes associated with pharmaceutical opioids. Conclusion: The interventions were relevant to the risk groups identified among high-risk drug users and potentially effective in preventing an increase in drug overdose trends. However, tailored interventions are needed for individuals at risk of death from prescribed opioids. Comprehensive studies encompassing all at-risk populations, including both legal and non-medical users of prescription opioids, are needed.
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Affiliation(s)
- Ellen J Amundsen
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
| | - Anne-Karine M Melsom
- Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø, Norway; Centre for Clinical Research and Education, University Hospital of North Norway, Tromsø, Norway
| | - Bjørn O Eriksen
- Section of Nephrology, University Hospital of North Norway, Tromsø, Norway; Metabolic and Renal Research Group, UiT The Arctic University of Norway, Tromsø, Norway
| | - Maja-Lisa Løchen
- Department of Cardiology, University Hospital of North Norway, Tromsø, Norway; Department of Clinical Medicine, UiT The Arctic University of Norway, Tromsø, Norway
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Hauck TS, Ladha KS, Le Foll B, Wijeysundera DN, Kurdyak P. Postoperative buprenorphine continuation in stabilized buprenorphine patients: A population cohort study. Addiction 2023; 118:1953-1964. [PMID: 37332171 DOI: 10.1111/add.16223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND AND AIMS Sudden discontinuation of buprenorphine in the treatment of opioid use disorder can increase the risk of subsequent relapse and overdose. Little is known about buprenorphine use in the perioperative period. The aim of this study was to determine the rate of buprenorphine continuation after hospital discharge following surgery and factors associated with continuation. DESIGN A population-based retrospective cohort study was conducted using administrative data from Ontario, Canada, between 2012 and 2018. The cohort included individuals on continuous buprenorphine prior to surgery. Logistic regression modeling was used to estimate the association of buprenorphine continuation with demographic, opioid agonist treatment, surgical and health service use factors. SETTING Administrative databases from Institute for Clinical Evaluative Sciences (ICES) were used, which capture the Ontario, Canada, population. The data sets describe physician billing, monitoring of controlled substances and hospital discharges. PARTICIPANTS Adults (≥ 18 years, n = 2176) had received a buprenorphine/naloxone product continuously for at least 60 days for the treatment of opioid use disorder and subsequently underwent a surgical procedure. MEASUREMENTS Continuation (versus discontinuation) of buprenorphine prescriptions in the 14 days after surgical discharge was recommended. Exposures included demographic, comorbidity, opioid agonist treatment, surgical and health service use characteristics. FINDINGS About 176 (8.1%) of the 2176 patients discontinued buprenorphine after surgery. Inpatient surgery (versus ambulatory) was associated with reduced odds of continuation, with an unadjusted odds ratio (OR) of 0.17 [95% confidence interval (CI) = 0.12-0.25] and an adjusted OR of 0.16 (95% CI = 0.11-0.23) after accounting for age, sex, rural residence, neighborhood income quintile, Charlson comorbidity index, psychiatric hospitalizations in the past 5 years and recent dispensed supply of buprenorphine (number needed to harm of 6.6). CONCLUSIONS In Ontario, Canada, from 2012 to 2018, most patients receiving continuous preoperative buprenorphine therapy continued buprenorphine use after surgery. Inpatient surgery was a strong predictor of discontinuation compared with ambulatory procedures.
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Affiliation(s)
- Tanya S Hauck
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
| | - Karim S Ladha
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Paul Kurdyak
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
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Havard A, Jones N, Bharat C, Gisev N, Pearson S, Shakeshaft A, Farrell M, Degenhardt L. Mortality during and after specialist alcohol and other drug treatment: Variation in rates according to principal drug of concern and treatment modality. Drug Alcohol Rev 2023; 42:1461-1471. [PMID: 37186492 PMCID: PMC10946946 DOI: 10.1111/dar.13669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/26/2023] [Accepted: 03/26/2023] [Indexed: 05/17/2023]
Abstract
INTRODUCTION For people accessing treatment for problems with drugs other than opioids, little is known about the relationship between treatment and mortality risk, nor how mortality risk varies across treatment modalities. We addressed these evidence gaps by determining mortality rates during and after treatment for people accessing a range of treatment modalities for several drugs of concern. METHODS We conducted a cohort study using linked data on publicly funded specialist alcohol or other drug treatment service use and mortality for people receiving treatment in New South Wales between January 2012 and December 2018. We calculated and compared during-treatment and post-treatment crude mortality rates and age- and sex-standardised mortality rates, separately for each principal drug of concern and modality. RESULTS Over the study period, 45,026 people accessed treatment for problems with alcohol, 26,407 for amphetamine-type stimulants, 23,047 for cannabinoids and 21,556 for opioids. People treated for alcohol or opioid problems had higher crude mortality rates (1.48, 1.91, 1.09 per 100 person years, respectively) than those with problems with amphetamine-type stimulants or cannabinoids (0.46, 0.30 per 100 person years, respectively). Mortality rates differed according to treatment status and modality only among people with alcohol or opioid problems. DISCUSSION AND CONCLUSIONS The observed variation in mortality rates indicates there is scope to reduce mortality among people accessing treatment with alcohol or opioid problems. Future research on mortality among people accessing drug and alcohol treatment should account for the variation in mortality by drug of concern and treatment modality.
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Affiliation(s)
- Alys Havard
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
- Centre for Big Data Research in Health, UNSW SydneySydneyAustralia
| | - Nicola Jones
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Natasa Gisev
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | | | | | - Michael Farrell
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre, UNSW SydneySydneyAustralia
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Ramey OL, Bonny AE, Silva Almodóvar A, Nahata MC. Urine Drug Test Results Among Adolescents and Young Adults in an Outpatient Office-Based Opioid Treatment Program. J Adolesc Health 2023; 73:141-147. [PMID: 37031090 DOI: 10.1016/j.jadohealth.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 04/10/2023]
Abstract
PURPOSE Urine drug testing (UDT) is an important feature of outpatient treatment for opioid use disorder, but associations with patient characteristics among adolescent and young adult patients are unknown. This study assessed UDT results in office-based opioid treatment and characteristics associated with treatment compliance. METHODS This was a retrospective study of adolescent and young adult patients enrolled in office-based opioid treatment between January 1, 2009, and December 31, 2020. UDT results were described as positive results or expected and unexpected results. Expected results were negative UDTs for opioids, marijuana (THC [tetrahydrocannabinol]), or cocaine/methamphetamine, or a positive UDT for buprenorphine. Unexpected results were positive UDTs for opioids, THC, or cocaine/methamphetamine, or a negative UDT for buprenorphine. Treatment compliance was defined as ≥75% of UDTs provided being expected results. Counts and percentages described UDT results. Regressions evaluated associations between patient characteristics (retention time, age, sex, race/ethnicity, insurance, and comorbid mental health diagnoses) with treatment compliance, and assessed change of positivity rates for UDTs over time. RESULTS A total of 407 patients were included. Overall, 305 patients (74.9%) demonstrated treatment compliance. Rates of expected UDT results increased with longer retention time (p <.001), except for methamphetamine. Buprenorphine expected results ranged from 77.0% to 96.5%. Diagnosis of stimulant use disorder was associated with decreased compliance (p = .04), while diagnoses of depression, anxiety, nicotine use disorder, and post-traumatic stress disorder were associated with increased compliance (p ≤.04). DISCUSSION Proportion of expected UDT results increased with retention time. Diagnosis of specific mental health conditions affected treatment compliance. Further research regarding long-term health outcomes is needed.
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Affiliation(s)
- Olivia L Ramey
- Department of Pharmacy Practice and Science, Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio
| | - Andrea E Bonny
- Division of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Department of Pediatrics, Columbus, Ohio
| | - Armando Silva Almodóvar
- Department of Pharmacy Practice and Science, Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio
| | - Milap C Nahata
- Department of Pharmacy Practice and Science, Institute of Therapeutic Innovations and Outcomes (ITIO), The Ohio State University College of Pharmacy, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio.
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Brandt L, Hu MC, Liu Y, Castillo F, Odom GJ, Balise RR, Feaster DJ, Nunes EV, Luo SX. Risk of Experiencing an Overdose Event for Patients Undergoing Treatment With Medication for Opioid Use Disorder. Am J Psychiatry 2023; 180:386-394. [PMID: 36891640 DOI: 10.1176/appi.ajp.20220312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
OBJECTIVE Overdose risk during a course of treatment with medication for opioid use disorder (MOUD) has not been clearly delineated. The authors sought to address this gap by leveraging a new data set from three large pragmatic clinical trials of MOUD. METHODS Adverse event logs, including overdose events, from the three trials (N=2,199) were harmonized, and the overall risk of having an overdose event in the 24 weeks after randomization was compared for each study arm (one methadone, one naltrexone, and three buprenorphine groups), using survival analysis with time-dependent Cox proportional hazard models. RESULTS By week 24, 39 participants had ≥1 overdose event. The observed frequency of having an overdose event was 15 (5.30%) among 283 patients assigned to naltrexone, eight (1.51%) among 529 patients assigned to methadone, and 16 (1.15%) among 1,387 patients assigned to buprenorphine. Notably, 27.9% of patients assigned to extended-release naltrexone never initiated the medication, and their overdose rate was 8.9% (7/79), compared with 3.9% (8/204) among those who initiated naltrexone. Controlling for sociodemographic and time-varying medication adherence variables and baseline substance use, a proportional hazard model did not show a significant effect of naltrexone assignment. Significantly higher probabilities of experiencing an overdose event were observed among patients with baseline benzodiazepine use (hazard ratio=3.36, 95% CI=1.76, 6.42) and those who either were never inducted on their assigned study medication (hazard ratio=6.64, 95% CI=2.12, 19.54) or stopped their medication after initial induction (hazard ratio=4.04, 95% CI=1.54, 10.65). CONCLUSIONS Among patients with opioid use disorder seeking medication treatment, the risk of overdose events over the next 24 weeks is elevated among those who fail to initiate or discontinue medication and those who report benzodiazepine use at baseline.
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Affiliation(s)
- Laura Brandt
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Mei-Chen Hu
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Ying Liu
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Felipe Castillo
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Gabriel J Odom
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Raymond R Balise
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Daniel J Feaster
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Edward V Nunes
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
| | - Sean X Luo
- Department of Psychology, City College of New York, New York (Brandt); Division on Substance Use Disorders, New York State Psychiatric Institute, New York (Castillo, Nunes, Luo); Department of Psychiatry, Columbia University Irving Medical Center, New York (Hu, Liu, Nunes, Luo); Department of Biostatistics, Florida International University, Miami (Odom); Division of Biostatistics, Department of Public Health Sciences, University of Miami, Miami (Balise, Feaster)
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Marel C, Wilson J, Darke S, Ross J, Slade T, Haber PS, Haasnoot K, Visontay R, Keaveny M, Tremonti C, Mills KL, Teesson M. Patterns and Predictors of Heroin Use, Remission, and Psychiatric Health Among People with Heroin Dependence: Key Findings from the 18-20-Year Follow-Up of the Australian Treatment Outcome Study (ATOS). Int J Ment Health Addict 2023:1-18. [PMID: 36688114 PMCID: PMC9847452 DOI: 10.1007/s11469-022-01006-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/28/2022] [Indexed: 01/19/2023] Open
Abstract
This study aimed to investigate the long-term patterns and predictors of heroin use, dependence, and psychiatric health over 18-20 years among a cohort of Australians with heroin dependence, using a prospective longitudinal cohort study conducted in Sydney, Australia. The original cohort consisted of 615 participants, who were followed up at 3 months and 1, 2, 3, 11, and 18-20 years post-baseline; 401 (65.2%) were re-interviewed at 18-20 years. The Australian Treatment Outcome Study structured interview with established psychometric properties was administered to participants at each follow-up, addressing demographics, treatment and drug use history, overdose, crime, and physical and mental health. Overall, 96.7% completed at least one follow-up interview. At 18-20 years, 109 participants (17.7%) were deceased. Past-month heroin use decreased significantly over the study period (from 98.7 to 24.4%), with one in four using heroin at 18-20 years. Just under half were receiving treatment. Reductions in heroin use were accompanied by reductions in heroin dependence, other substance use, needle sharing, injection-related health, overdose, crime, and improvements in general physical and mental health. Major depression and borderline personality disorder (BPD) were consistently associated with poorer outcome. At 18-20 years, there is strong evidence that clinically significant levels of improvement can be maintained over the long term. The mortality rate over 18-20 years was devastating, with over one in six participants deceased. More sustained and targeted efforts are needed in relation to major depression and BPD to ensure evidence-based treatments are delivered to people with heroin dependence. Supplementary Information The online version contains supplementary material available at 10.1007/s11469-022-01006-6.
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Affiliation(s)
- Christina Marel
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Jack Wilson
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Shane Darke
- National Drug and Alcohol Research Centre, UNSW Australia, Kensington, NSW Australia
| | - Joanne Ross
- National Drug and Alcohol Research Centre, UNSW Australia, Kensington, NSW Australia
| | - Tim Slade
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Paul S. Haber
- University of Sydney Addiction Medicine, Royal Prince Alfred Hospital, Camperdown, NSW Australia
- Sydney Local Health District Drug Health Services, Camperdown, NSW Australia
| | - Katherine Haasnoot
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Rachel Visontay
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Madeleine Keaveny
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Chris Tremonti
- Sydney Local Health District Drug Health Services, Camperdown, NSW Australia
| | - Katherine L. Mills
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
| | - Maree Teesson
- University of Sydney Matilda Centre for Research in Mental Health and Substance Use, Sydney, NSW Australia
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Mitchell P, Samsel S, Curtin KM, Price A, Turner D, Tramp R, Hudnall M, Parton J, Lewis D. Geographic disparities in access to Medication for Opioid Use Disorder across US census tracts based on treatment utilization behavior. Soc Sci Med 2022; 302:114992. [PMID: 35512612 DOI: 10.1016/j.socscimed.2022.114992] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 03/07/2022] [Accepted: 04/22/2022] [Indexed: 10/18/2022]
Abstract
Drug overdose is the leading cause of accidental death in the U.S. with deaths from opioid overdose occurring at a higher rate in rural areas. The gaps in the provision of healthcare services have been exacerbated by the opioid crisis leaving vulnerable populations without access to preventative care and education, harm reduction, both chronic and acute treatment of the symptoms of opioid use disorder (OUD), and long-term psychological support for those with OUD and their families. There has been a call in the literature -and a federal mandate-for increased access to opioid treatment facilities, but to date this access has not been operationalized using best practices in geography. Medication for Opioid Use Disorder (MOUD) with FDA-approved methadone or buprenorphine has been shown to increase treatment retention, reduce opioid use and associated health and societal harms, and reduce opioid related overdose, and as such is considered the most effective treatment for OUD. The objective of this study is to examine U.S. adults' spatial access to MOUD - specifically locations of certified Opioid Treatment Programs (OTPs) and DATA-waived Buprenorphine providers. A gravity-based variant of the enhanced two-step floating catchment area model is employed, where friction of distance is based on previously published willingness to travel distances for patients visiting OTPs, to assess how opioid agonist treatment accessibility varies across the nation. Findings suggest that there are extensive 'treatment deserts' where there is little to no physical access to MOUD, especially in rural areas. The significance of this work lies in the incorporation of treatment utilization behavior in the access metric, and the continued confirmation of gaps in access to OUD services despite federal efforts to improve accessibility.
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Affiliation(s)
- Penelope Mitchell
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA.
| | - Steven Samsel
- Institute of Data & Analytics, University of Alabama, Tuscaloosa, AL, USA
| | - Kevin M Curtin
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Ashleigh Price
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Daniel Turner
- Department of Geography, Laboratory for Location Science, University of Alabama, Tuscaloosa, AL, USA
| | - Ryan Tramp
- Institute of Data & Analytics, University of Alabama, Tuscaloosa, AL, USA
| | - Matthew Hudnall
- Department of Information Systems, Operations Management, and Statistics, University of Alabama, Tuscaloosa, AL, USA
| | - Jason Parton
- Department of Information Systems, Operations Management, and Statistics, University of Alabama, Tuscaloosa, AL, USA
| | - Dwight Lewis
- Department of Management, University of Alabama, Tuscaloosa, AL, USA
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9
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Ghose R, Cowden F, Veluchamy A, Smith BH, Colvin LA. Characteristics of non-fatal overdoses and associated risk factors in patients attending a specialist community-based substance misuse service. Br J Pain 2022; 16:458-466. [PMID: 36032347 PMCID: PMC9411761 DOI: 10.1177/20494637221095447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction There are concerns about rising drug-related deaths and the potential contribution of prescription analgesics. There is limited understanding regarding the role of prescription analgesics in non-fatal overdoses (NFODs), nor is there a good understanding of what factors are associated with more severe overdose. Objectives To explore risk factors and characteristics of NFODs among people attending a specialist community-based substance misuse service. Methods After Caldicott approval, data on NFODs, in people attending the Tayside Substance Misuse Service (TSMS), were extracted from the Scottish Ambulance Service database, along with opioid replacement therapy (ORT) prescribing data. Statistical analysis was performed using R studio and Microsoft Excel. Results 557 people (78% [434/556] male, mean age ± standard deviation 38.4 ± 7.95) had an NFOD. Repeat NFODs were more likely in males compared to females ( p < .0065). Males were more likely to be administered naloxone (OR = 1.94, 95% CI = 1.10–3.40, p < .02). NFODs at home were more likely to be moderate to severe (categorized by Glasgow Comma Scale [ p < .02, OR = 4.95, 95% CI = 1.24–24.38]). Methadone (321/557, 57.63%), benzodiazepines (281/557, 50.45%) and heroin (244/557, 43.81%) were the commonest substances: prescribed methadone overdose was more likely than buprenorphine ( p < .00001). Opioids and benzodiazepines were often taken together (275/557, 49.40%), with almost all gabapentinoid NFODs also involving opioids (60/61, 98.40%). Conclusions Polysubstance use with opioids prescribed for ORT, such as methadone, is highly likely to be implicated in NFOD, with males being at the highest risk of severe and repeat NFOD. Future work should focus on strategies to further reduce NFODs.
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Affiliation(s)
- Riya Ghose
- Department of Medicine, School of Medicine, University of Dundee, Dundee, UK
| | | | - Abirami Veluchamy
- Department of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Blair H Smith
- Department of Population Health Sciences, Medical Research Institute, Dundee, UK
| | - Lesley A Colvin
- Department of Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
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Eisenberg MD, McCourt A, Stuart EA, Rutkow L, Tormohlen KN, Fingerhood MI, Quintero L, White SA, McGinty EE. Studying how state health services delivery policies can mitigate the effects of disasters on drug addiction treatment and overdose: Protocol for a mixed-methods study. PLoS One 2021; 16:e0261115. [PMID: 34914779 PMCID: PMC8675685 DOI: 10.1371/journal.pone.0261115] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 11/26/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The United States is experiencing a drug addiction and overdose crisis, made worse by the COVID-19 pandemic. Relative to other types of health services, addiction treatment and overdose prevention services are particularly vulnerable to disaster-related disruptions for multiple reasons including fragmentation from the general medical system and stigma, which may lead decisionmakers and providers to de-prioritize these services during disasters. In response to the COVID-19 pandemic, U.S. states implemented multiple policies designed to mitigate disruptions to addiction treatment and overdose prevention services, for example policies expanding access to addiction treatment delivered via telehealth and policies designed to support continuity of naloxone distribution programs. There is limited evidence on the effects of these policies on addiction treatment and overdose. This evidence is needed to inform state policy design in future disasters, as well as to inform decisions regarding whether to sustain these policies post-pandemic. METHODS The overall study uses a concurrent-embedded design. Aims 1-2 use difference-in-differences analyses of large-scale observational databases to examine how state policies designed to mitigate the effects of the COVID-19 pandemic on health services delivery influenced addiction treatment delivery and overdose during the pandemic. Aim 3 uses a qualitative embedded multiple case study approach, in which we characterize local implementation of the state policies of interest; most public health disaster policies are enacted at the state level but implemented at the local level by healthcare systems and local public health authorities. DISCUSSION Triangulation of results across methods will yield robust understanding of whether and how state disaster-response policies influenced drug addiction treatment and overdose during the COVID-19 pandemic. Results will inform policy enactment and implementation in future public health disasters. Results will also inform decisions about whether to sustain COVID-19 pandemic-related changes to policies governing delivery addiction and overdose prevention services long-term.
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Affiliation(s)
- Matthew D. Eisenberg
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Alexander McCourt
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth A. Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Lainie Rutkow
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Kayla N. Tormohlen
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Michael I. Fingerhood
- Division of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Luis Quintero
- Carey Business School, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Sarah A. White
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Emma Elizabeth McGinty
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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11
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Guille C, King C, Ramakrishnan V, Baker N, Cortese B, Nunn L, Rogers T, McRae-Clark A, Brady K. The impact of lofexidine on stress-related opioid craving and relapse: Design and methodology of a randomized clinical trial. Contemp Clin Trials 2021; 111:106616. [PMID: 34737091 PMCID: PMC8761253 DOI: 10.1016/j.cct.2021.106616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Revised: 09/27/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
Opioid Use Disorders (OUDs) and drug overdose deaths are increasing at alarmingly high rates in the United States. Stress and dysregulation in biologic stress response systems such as the hypothalamic-pituitary-adrenal axis and noradrenergic system appear to play an important role in the pathophysiology of substance use disorders and relapse to drug use, particularly for women. Alpha-2 adrenergic agonist medications effectively decrease noradrenergic activity and have demonstrated benefit in preventing relapse to substance use and decreasing stress-reactivity and craving in cocaine- and nicotine-dependent women, compared to men. Alpha-2 adrenergic agonists may help decrease stress reactivity in individuals with OUDs and prevent relapse to drug use, but gender differences have yet to be systematically explored. We describe the rationale, study design and methodology of a randomized, double-blind, placebo-controlled clinical trial examining gender differences in stress, craving and drug use among adult men and women with OUD taking methadone or buprenorphine and randomly assigned to an alpha-2 adrenergic agonist, lofexidine, compared to placebo. In addition, we describe methods for measuring daily stress, craving and drug use in participant's natural environment as well as participant's physiological (i.e., heart rate, cortisol) and psychological (i.e., stress, craving) response to laboratory social and drug cue stressors. Lastly, we detail methods adopted to sustain research activity while following guidelines for the COVID-19 pandemic. ClinicalTrials.gov Registration Number: NCT03718065.
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Affiliation(s)
- Constance Guille
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Courtney King
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Viswanathan Ramakrishnan
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Nathaniel Baker
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Bernadette Cortese
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Lisa Nunn
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Taylor Rogers
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Aimee McRae-Clark
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Kathleen Brady
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston, SC, USA; Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA.
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12
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Kelsch JR, Bailey AM, Baum RA, Metts EL, Weant KA. Guidance for emergency medicine pharmacists to improve care for people with opioid use disorder. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jordan R. Kelsch
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Abby M. Bailey
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Regan A. Baum
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Elise L. Metts
- Department of Pharmacy University of Kentucky HealthCare Lexington Kentucky USA
| | - Kyle A. Weant
- Department of Clinical Pharmacy and Outcome Sciences University of South Carolina College of Pharmacy Columbia South Carolina USA
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13
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Amram O, Amiri S, Panwala V, Lutz R, Joudrey PJ, Socias E. The impact of relaxation of methadone take-home protocols on treatment outcomes in the COVID-19 era. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2021; 47:722-729. [PMID: 34670453 DOI: 10.1080/00952990.2021.1979991] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Background: In response to the COVID-19 pandemic, the US Substance Abuse and Mental Health Services Administration (SAMHSA) allowed for an increase in methadone take-home doses for the treatment of Opioid Use Disorder (OUD) in March 2020. OBJECTIVE To evaluate the effects of the SAMSHA exemption on methadone adherence and OUD-related outcomes. METHODS A convenience sample of 183 clients (58% female) were recruited from a methadone clinic in the fall of 2019 for a cross-sectional survey. Survey data was linked to clinical records, including urine drug testing (UDT) results for methadone and emergency department (ED) visits at the local hospital. Participants were on stable methadone dosing for 9 months prior to and following March 2020. Methadone adherence was assessed by UDTs; OUD-related outcomes were assessed by overdose events and ED visits. Logistic regression was used to assess the association between change in take-home methadone doses and outcomes. RESULTS Mean take-home doses increased nearly 200% (11.4 doses/30 days pre-COVID-19 vs. 22.3 post-SAMHSA exemption). ED visits dropped from 74 (40.4%) pre-COVID-19 to 56 (30.6%) post-SAMHSA exemption (p = <0.001). No significant changes were observed in either the number of clients experiencing overdose or those who experienced one or more methadone negative UDTs in the post-SAMHSA exemption period. Adjusted models did not show a significant association between changes in take-home doses and associated outcomes. CONCLUSIONS Despite a near-doubling of take-home methadone doses during the COVID-19 exemption period, the increase in take-home doses was not associated with negative treatment outcomes in methadone-adherent clients.
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Affiliation(s)
- Ofer Amram
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.,Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA, USA
| | - Solmaz Amiri
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Victoria Panwala
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Robert Lutz
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA.,Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Paul J Joudrey
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eugenia Socias
- Faculty of Medicine, British Columbia Centre on Substance Use, University of British Columbia, Vancouver, Canada.,Department of Medicine, University of British Columbia, Vancouver, Canada
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14
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King CA, Englander H, Korthuis PT, Barocas JA, McConnell KJ, Morris CD, Cook R. Designing and validating a Markov model for hospital-based addiction consult service impact on 12-month drug and non-drug related mortality. PLoS One 2021; 16:e0256793. [PMID: 34506517 PMCID: PMC8432751 DOI: 10.1371/journal.pone.0256793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 08/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD. METHODS We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards. RESULTS There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity. DISCUSSION Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.
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Affiliation(s)
- Caroline A. King
- Dept. of Biomedical Engineering, School of Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - P. Todd Korthuis
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
| | - Joshua A. Barocas
- Section of Infectious Diseases, Boston University School of Medicine and Boston Medical Center, Boston, MA, United States of America
| | - K. John McConnell
- Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR, United States of America
| | - Cynthia D. Morris
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, OR, United States of America
| | - Ryan Cook
- Department of Medicine, Section of Addiction Medicine, Oregon Health & Science University, Portland, OR, United States of America
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15
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Amram O, Amiri S, Thorn EL, Lutz R, Joudrey PJ. Changes in methadone take-home dosing before and after COVID-19. J Subst Abuse Treat 2021; 133:108552. [PMID: 34304950 PMCID: PMC8223136 DOI: 10.1016/j.jsat.2021.108552] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 05/12/2021] [Accepted: 06/14/2021] [Indexed: 01/31/2023]
Abstract
INTRODUCTION In response to the COVID-19 pandemic, a federal exemption allowed stable and less stable patients greater take-home doses of methadone. We assessed the adoption of increased take-home medication during COVID-19 and whether increased take-home doses is associated with clients' characteristics. METHODOLOGY We completed a pre-post study of adults receiving methadone for OUD from an OTP in Spokane, Washington. Our outcome was the change in the number of take-home methadone doses three months before and three months after the March 2020 take-home medication exemption. Clients' characteristics included age, gender, ethnicity, education level, homelessness, spatial access to the clinic, and methamphetamine use. RESULTS The study included 194 clients in treatment for a median of three years. All study participants experienced an average increase in take-home medication of 41.4 in the three-month period after the COVID-19 exemption. In the final adjusted models, clients who reported using methamphetamine in the last 30 days experienced a significantly larger increase in take-home dosage (55.6 days) compare to clients who did not use methamphetamine (p ≤0.001). Most of the clients who reported using methamphetamine were also likely to be homeless. All other variables were not associated with a change in take-home doses. CONCLUSION These results suggest that the Spokane OTP quickly expanded take-home medication dosing in response to the COVID-19 exemption and broadly expanded take-home dosing among established clients. Clients with concurrent methamphetamine use were allowed fewer take-home doses prior to COVID-19, but after the exemption the clinic provided them the same number of take-home doses as clients who had not used methamphetamine.
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Affiliation(s)
- Ofer Amram
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA; Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA 99164, USA.
| | - Solmaz Amiri
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Emily L Thorn
- Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Robert Lutz
- Department of Nutrition and Exercise Physiology, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA; Department of Medical Education and Clinical Sciences, Elson S. Floyd College of Medicine, Washington State University, Spokane, WA 99202, USA
| | - Paul J Joudrey
- Yale Program in Addiction Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT 06520, USA
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16
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Wood CA, Green L, La Manna A, Phillips S, Werner KB, Winograd RP, Stuckenschneider A. Balancing need and risk, supply and demand: Developing a tool to prioritize naloxone distribution. Subst Abus 2021; 42:974-982. [PMID: 33759727 DOI: 10.1080/08897077.2021.1901174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Background: Opioid overdose deaths continue to rise nationally. The demand for naloxone, the opioid overdose antidote, is outpacing the supply. With increasing naloxone requests, tools to prioritize distribution are critical to ensure available supplies will reach those at highest risk of overdose. Methods: We developed a standardized "Naloxone Request Form" (NRF) and corresponding weighted prioritization algorithm to serve as decisional aid to better enable grant staff to prioritize naloxone distribution in a data-driven manner. The algorithm computed raw priority scores for each agency, which were then separated into the predetermined quintiles. Historical naloxone distribution decisions were compared with agencies' prioritization quintile. Results: Results demonstrated that the NRF and corresponding algorithm was successful at prioritizing agencies based on potential impact. Although, overall, naloxone was distributed more heavily to the agencies deemed highest priority, our algorithm identified significant shortcomings of the "first come, first served" method of distribution we had initially deployed. Conclusions: This work has laid the foundation to use this tool prospectively to allow for data-driven decision-making for naloxone distribution. Our tool is flexible and can be customized to best fit the needs of a variety of programs and locations to ensure the distribution of limited supplies of naloxone have the greatest impact.
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Affiliation(s)
- Claire A Wood
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St Louis, MO, USA
| | - Lauren Green
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St Louis, MO, USA
| | - Anna La Manna
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St Louis, MO, USA
| | - Sarah Phillips
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St Louis, MO, USA
| | - Kimberly B Werner
- College of Nursing, University of Missouri-St. Louis, St Louis, MO, USA
| | - Rachel P Winograd
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St Louis, MO, USA
| | - Angie Stuckenschneider
- Division of Behavioral Health, Missouri Department of Mental Health, Jefferson City, MO, USA
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17
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Linas BP, Savinkina A, Madushani RWMA, Wang J, Eftekhari Yazdi G, Chatterjee A, Walley AY, Morgan JR, Epstein RL, Assoumou SA, Murphy SM, Schackman BR, Chrysanthopoulou SA, White LF, Barocas JA. Projected Estimates of Opioid Mortality After Community-Level Interventions. JAMA Netw Open 2021; 4:e2037259. [PMID: 33587136 PMCID: PMC7885041 DOI: 10.1001/jamanetworkopen.2020.37259] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/13/2020] [Indexed: 11/14/2022] Open
Abstract
Importance The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022. Objective To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations. Design, Setting, and Participants This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020. Main Outcomes and Measures Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs. Results No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD. Conclusions and Relevance In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.
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Affiliation(s)
- Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Alexandra Savinkina
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | | | - Jianing Wang
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
| | | | - Avik Chatterjee
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Grayken Center for Addiction at Boston Medical Center, Boston, Massachusetts
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Grayken Center for Addiction at Boston Medical Center, Boston, Massachusetts
| | - Jake R. Morgan
- Boston University School of Public Health, Boston, Massachusetts
| | - Rachel L. Epstein
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Sabrina A. Assoumou
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Sean M. Murphy
- Boston University School of Public Health, Boston, Massachusetts
- Department of Healthcare Quality and Research, Weill Cornell Medical College, New York, New York
| | - Bruce R. Schackman
- Boston University School of Public Health, Boston, Massachusetts
- Department of Healthcare Quality and Research, Weill Cornell Medical College, New York, New York
| | | | - Laura F. White
- Boston University School of Public Health, Boston, Massachusetts
| | - Joshua A. Barocas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
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Melby K, Nygård M, Brobakken MF, Gråwe RW, Güzey IC, Reitan SK, Vedul-Kjelsås E, Heggelund J, Tchounwou PB. Test-Retest Reliability of the Patient Activation Measure-13 in Adults with Substance Use Disorders and Schizophrenia Spectrum Disorders. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18031185. [PMID: 33572717 PMCID: PMC7908201 DOI: 10.3390/ijerph18031185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/22/2021] [Accepted: 01/25/2021] [Indexed: 11/16/2022]
Abstract
Patient Activation Measure-13 (PAM-13) is a valid and widely used questionnaire that assess an individual’s knowledge, confidence, and skills for self-management of their chronic illness. Although there is some evidence regarding its reliability, the test–retest reliability has not been investigated among patients with substance use disorders (SUDs) or schizophrenia spectrum disorders. We investigated the internal consistency and test–retest reliability of PAM-13 in these populations. Test–retest reliability was analysed using data from 29 patients with SUDs and 28 with schizophrenia spectrum disorders. Cronbach’s α and Intraclass Correlation Coefficient (ICC) scores were used to examine internal consistency and test–retest reliability, respectively. Of the 60 collected test–retest questionnaires, 57 were included in the analyses. No mean differences between time one (T1) and time two (T2) were observed in either patient group, except for item 12 in schizophrenia spectrum disorders patients (p < 0.05). Internal consistency for T1 and T2 was 0.75 and 0.84 in SUDs patients and 0.87 and 0.81 in schizophrenia spectrum disorders patients, respectively. The ICC was r = 0.86 in patients with SUDs and r = 0.93 in patients with schizophrenia spectrum disorders. To conclude, PAM-13 showed good internal consistency and test–retest reliability in SUDs and schizophrenia spectrum disorders patients.
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Affiliation(s)
- Katrine Melby
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway;
- Blue Cross Lade Addiction Treatment Centre, 7041 Trondheim, Norway
- Department of Clinical Pharmacology, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Mona Nygård
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Østmarka, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
- Correspondence: ; Tel.: +47-452-03-870
| | - Mathias Forsberg Brobakken
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Østmarka, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Rolf W. Gråwe
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Ismail Cüneyt Güzey
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Solveig Klæbo Reitan
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Einar Vedul-Kjelsås
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
| | - Jørn Heggelund
- Regional Center for Healthcare Improvement, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway;
| | - Paul B. Tchounwou
- Department of Mental Health, Norwegian University of Science and Technology (NTNU), 7491 Trondheim, Norway; (M.F.B.); (R.W.G.); (I.C.G.); (S.K.R.); (E.V.-K.); (M.L.L.-C.)
- Department of Research and Development, Division of Mental Health Care, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
- Tiller Community Mental Health Centre, Division of Psychiatry, St. Olavs Hospital, Trondheim University Hospital, 7006 Trondheim, Norway
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19
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Becker WC, Heimer R, Dormitzer CM, Doernberg M, D'Onofrio G, Grau LE, Hawk K, Lin HJ, Secora AM, Fiellin DA. Merging statewide data in a public/university collaboration to address opioid use disorder and overdose. Addict Sci Clin Pract 2021; 16:1. [PMID: 33397480 PMCID: PMC7780404 DOI: 10.1186/s13722-020-00211-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/16/2020] [Indexed: 11/21/2022] Open
Abstract
Objective Describe methods to compile a unified database from disparate state agency datasets linking person-level data on controlled substance prescribing, overdose, and treatment for opioid use disorder in Connecticut. Methods A multidisciplinary team of university, state and federal agency experts planned steps to build the data analytic system: stakeholder engagement, articulation of metrics, funding to establish the system, determination of needed data, accessing data and merging, and matching patient-level data. Results Stakeholder meetings occurred over a 6-month period driving selection of metrics and funding was obtained through a grant from the Food and Drug Administration. Through multi-stakeholder collaborations and memoranda of understanding, we identified relevant data sources, merged them and matched individuals across the merged dataset. The dataset contains information on sociodemographics, treatments and outcomes. Step-by-step processes are presented for dissemination. Conclusions Creation of a unified database linking multiple sources in a timely and ongoing fashion may assist other states to monitor the public health impact of controlled substances, identify and implement interventions, and assess their effectiveness.
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Affiliation(s)
- William C Becker
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA. .,VA Connecticut Healthcare System, 950 Campbell Avenue, Mail Stop 151B, West Haven, CT, 06516, USA.
| | - Robert Heimer
- Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
| | - Catherine M Dormitzer
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - Molly Doernberg
- Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
| | - Gail D'Onofrio
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Lauretta E Grau
- Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
| | - Kathryn Hawk
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA
| | - Hsiu-Ju Lin
- University of Connecticut School of Social Work, 38 Prospect Street, Hartford, CT, 06103, USA
| | - Alex M Secora
- U.S. Food and Drug Administration, 10903 New Hampshire Avenue, Silver Spring, MD, 20993, USA
| | - David A Fiellin
- Yale School of Medicine, 333 Cedar Street, New Haven, CT, 06510, USA.,Yale School of Public Health, 60 College Street, New Haven, CT, 06510, USA
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20
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Gjersing L, Helle MK. Injecting Alone is More Common among Men, Frequent Injectors and Polysubstance Users in a Sample of People Who Inject Drugs. Subst Use Misuse 2021; 56:2214-2220. [PMID: 34565289 DOI: 10.1080/10826084.2021.1981388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Injecting alone increases the risk of a fatal overdose. We examined the extent of such behavior in a sample of people who inject drugs (PWID) and the typical characteristics of those injecting alone at least once during the past four weeks. A cross-sectional study. PWID recruited from the street and from low-threshold services in seven Norwegian cities in September 2017 (n = 359). Associations between characteristics and injecting alone were examined using logistic regression analysis. The independent variables were gender (female/male), age, having received overdose-prevention education (no/yes), and, in the past four weeks; homelessness/shelter use (no/yes), in opioid substitution treatment (no/yes), injecting ≥ four days a week (no/yes), and substances injected (opioids only/opioids and other/other only/central stimulants (CS) only/CS and other/CS and opioids/CS, opioids and other). The adjusted odds ratios (aOR) and 95% Confidence Intervals (CI) were reported. Of the 359 PWID, 84.4% reported having injected alone. Males were more likely than females to inject alone (aOR = 1.88 95% CI 1.00-3.54). Furthermore, those injecting frequently (aOR = 1.99 95% CI 1.02-3.86) and those injecting multiple substances (CS, opioids and other) (aOR = 2.94 95% CI 1.01-8.58) were more likely to inject alone compared to those injecting less frequently and opioids only. Although not statistically significant, the effect sizes in the logistic regression models suggest that polysubstance use may be driven by CS use. Injecting alone was common in our sample of PWID, and male gender, frequent injecting and polysubstance injecting were associated with this behavior.
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Affiliation(s)
- Linn Gjersing
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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21
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Sharp A, Armstrong A, Moore K, Carlson M, Braughton D. Patient Perspectives on Detox: Practical and Personal Considerations through a Lens of Patient-Centered Care. Subst Use Misuse 2021; 56:1593-1606. [PMID: 34228598 DOI: 10.1080/10826084.2021.1936050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Inpatient detoxification is often required before a client can move on to additional substance abuse treatment services. Although often short-term, time spent in inpatient detoxification tends to have long-lasting effects on the recovery process. This qualitative study focuses on one treatment facility in Tampa, Florida that offers a range of recovery services, including inpatient detox and outpatient treatment. Focus groups (N = 70 participants) captured client perceptions of direct clinical care operations, access to resources, and relationships with direct care staff within the inpatient detox program. Perceptions were then assessed using a thematic analysis approach with attention to the literature on person-centered care best practices, behavior change, and patient engagement theories to better understand how facility practices affect treatment engagement and retention. Findings elucidated several practical facilitators and barriers to recovery such as facility resources, services offered, transition to aftercare, and sustainability of treatment. Findings also illuminated several personal facilitators and barriers including patient-staff interactions, personal motivation, and family and community support. The resulting recommendations for practice and research are discussed.
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Affiliation(s)
- Amanda Sharp
- University of South Florida, Tampa, Florida, USA
| | | | | | | | - David Braughton
- Agency for Community Treatment Services, Tampa, Florida, USA
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22
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Ameral V, Palm Reed KM. Envisioning a future: Values clarification in early recovery from opioid use disorder. J Subst Abuse Treat 2020; 121:108207. [PMID: 33357601 DOI: 10.1016/j.jsat.2020.108207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 09/04/2020] [Accepted: 11/11/2020] [Indexed: 10/23/2022]
Abstract
High rates of relapse and overdose during early recovery from opioid use disorder (OUD) highlight the importance of providing effective treatment during this crucial phase. While early treatment often focuses on managing urges and withdrawal symptoms, eliciting personally salient motivators may help to target predictors of treatment outcomes such as motivation and self-efficacy. This experimental study examined the effect of a brief values clarification exercise on motivation and self-efficacy for abstinence in a sample of n = 93 individuals in brief residential treatment for OUD. Participants were randomly assigned to values clarification or a time management control condition exercise. Self-efficacy for abstinence as measured by a validated single-item measure was higher for participants in the values condition (M = 8.7) compared to control (M = 7.8, p = .013), while motivation for abstinence as measured by the commitment to sobriety scale was similarly high for both the values clarification (M = 28.0) and control (M = 27.8, p = .642) groups. There were no group differences in delay discounting, the theorized mediator of these relationships. Taken together, these results suggest that even a brief values clarification exercise may increase self-efficacy for abstinence when added to early residential treatment for OUD.
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Affiliation(s)
- Victoria Ameral
- Clark University, 950 Main Street, Worcester, MA 01610, USA; VA Bedford Healthcare System, 200 Springs Road, Bedford, MA 01730, USA.
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23
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Warfield SC, Pack RP, Degenhardt L, Larney S, Bharat C, Ashrafioun L, Marshall BDL, Bossarte RM. The next wave? Mental health comorbidities and patients with substance use disorders in under-resourced and rural areas. J Subst Abuse Treat 2020; 121:108189. [PMID: 33162261 DOI: 10.1016/j.jsat.2020.108189] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 09/10/2020] [Accepted: 10/22/2020] [Indexed: 01/30/2023]
Abstract
The rapid spread of the coronavirus disease (COVID-19) has impacted the lives of millions around the globe. The COVID-19 pandemic has caused increasing concern among treatment professionals about mental health and risky substance use, especially among those who are struggling with a substance use disorder (SUD). The pandemic's impact on those with an SUD may be heightened in vulnerable communities, such as those living in under-resourced and rural areas. Despite policies loosening restrictions on treatment requirements, unintended mental health consequences may arise among this population. We discuss challenges that under-resourced areas face and propose strategies that may improve outcomes for those seeking treatment for SUDs in these areas.
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Affiliation(s)
- Sara C Warfield
- Injury Control Research Center, West Virginia University, United States of America; Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Behavioral Medicine and Psychiatry, West Virginia University, United States of America.
| | - Robert P Pack
- Department of Community & Behavioral Health, College of Public Health, East Tennessee State University, United States of America; Addiction Science Center, East Tennessee State University, United States of America
| | | | - Sarah Larney
- National Drug and Alcohol Research Centre, UNSW Sydney, Australia; Department of Family Medicine and Emergency Medicine, Université de Montréal, Canada; Université de Montréal Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Canada
| | - Chrianna Bharat
- National Drug and Alcohol Research Centre, UNSW Sydney, Australia
| | - Lisham Ashrafioun
- Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Psychiatry, University of Rochester, United States of America
| | - Brandon D L Marshall
- Department of Epidemiology, School of Public Health, Brown University, United States of America
| | - Robert M Bossarte
- Injury Control Research Center, West Virginia University, United States of America; Center of Excellence for Suicide Prevention, Department of Veterans Affairs, United States of America; Department of Behavioral Medicine and Psychiatry, West Virginia University, United States of America
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24
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Durand L, O'Driscoll D, Boland F, Keenan E, Ryan BK, Barry J, Bennett K, Fahey T, Cousins G. Do interruptions to the continuity of methadone maintenance treatment in specialist addiction settings increase the risk of drug-related poisoning deaths? A retrospective cohort study. Addiction 2020; 115:1867-1877. [PMID: 32034837 PMCID: PMC7540578 DOI: 10.1111/add.15004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/02/2019] [Accepted: 02/05/2020] [Indexed: 12/01/2022]
Abstract
AIMS To examine the risk of mortality associated with interruptions to the continuity of methadone maintenance treatment (MMT), including transfers between services, in opioid-dependent individuals attending specialist addiction services. DESIGN Retrospective cohort study using addiction services and primary care dispensing records, the National Methadone Register and National Drug-Related Death Index (NDRDI). SETTING Geographically defined population in Dublin, Ireland. PARTICIPANTS A total of 2899 people prescribed and dispensed methadone in specialist addiction services between January 2010 and December 2015. There were five exposure groups: weeks 1-4 following transfer between treatment providers; weeks 1-4 out of treatment; weeks 5-52 out of treatment; weeks 1-4 of treatment initiation; and weeks 5+ of continuous treatment (reference category). MEASUREMENTS Primary outcome: drug-related poisoning (DRP) deaths. Secondary outcome: all-cause mortality (ACM). Mortality rates calculated by dividing number of deaths (DRP; ACM) in exposure groups by person-years exposure. Unadjusted and adjusted Poisson regression (covariates age, sex, incarceration, methadone dose and comorbidities) estimated differences in mortality rates. FINDINGS There were 154 ACM deaths, 55 (35.7%) identified as DRP deaths. No deaths were observed in the first month following transfer between treatment providers. The risk of DRP mortality was highest in weeks 1-4 out of treatment [adjusted relative risk (aRR = 4.04, 95% confidence interval (CI) = 1.43-11.43, P = 0.009] and weeks 1-4 of treatment initiation (ARR = 3.4, 95% CI = 1.2-9.64, P = 0.02). Similarly, risk of ACM was highest in weeks 1-4 out of treatment (ARR = 11.78, 95% CI = 7.73-17.94, P < 0.001), weeks 1-4 of treatment initiation (aRR = 5.11, 95% CI = 2.95-8.83, P < 0.001) and weeks 5-52 off treatment (aRR = 2.04, 95% CI = 1.2-3.47, P = 0.009). CONCLUSIONS Interruptions to the continuity of methadone maintenance treatment by treatment provider do not appear to be periods of risk for drug-related poisoning or all-cause mortality deaths. Risk of drug related poisoning and all-cause mortality deaths appears to be greatest during the first 4 weeks of treatment initiation/re-initiation and after treatment cessation.
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Affiliation(s)
- Louise Durand
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | | | - Fiona Boland
- HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Eamon Keenan
- HSE National Social Inclusion Office, Stewarts HospitalDublinIreland
| | - Benedict K. Ryan
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Joseph Barry
- Department of Public Health and Primary CareTrinity College DublinIreland
| | - Kathleen Bennett
- Division of Population Health SciencesRoyal College of Surgeons in IrelandDublinIreland
| | - Tom Fahey
- Department of General Practice and HRB Centre for Primary Care ResearchRoyal College of Surgeons in IrelandDublinIreland
| | - Gráinne Cousins
- School of Pharmacy and Biomolecular SciencesRoyal College of Surgeons in IrelandDublinIreland
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25
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Faggiano F, Mathis F, Diecidue R, Vigna-Taglianti F, Paola Caria M, Colledge S, Hickman M, Bargagli A, Davoli M. Opioid overdose risk during and after drug treatment for heroin dependence: An incidence density case-control study nested in the VEdeTTE cohort. Drug Alcohol Rev 2020; 40:281-286. [PMID: 32969097 DOI: 10.1111/dar.13173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 08/10/2020] [Accepted: 08/12/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS To corroborate protective effects of a range of drug treatment modalities against overdose mortality risk. DESIGN AND METHODS Nested case-control study, with incidence density sampling, selecting controls retrospectively at each case event. Cases and controls came from a sub-cohort of opioid-dependent patients (n = 4444) from two Italian regions (Lazio and Piedmont). From 1998 to 2005, there were 91 overdose deaths (cases) matched to 352 controls. The primary outcome was overdose mortality and the primary exposure was drug treatment: opioid agonist treatment (OAT), opioid detoxification, residential community, psychosocial and other pharmacological treatment. Conditional logistic regression models generated intervention effects comparing mortality risk in and out of treatment, adjusting for confounding variables. RESULTS Overall, drug treatment reduced overdose mortality risk by 80% [adjusted odds ratio (AOR) 0.18, 95% confidence interval (CI) 0.10-0.33, P < 0.001] compared to being out of treatment. There was a particularly strong protective effect of OAT on overdose mortality (AOR 0.08, 95% CI 0.03-0.23, P < 0.001) compared to being out of treatment. There was evidence of a substantially elevated risk of overdose in the first month of leaving treatment (AOR 23.50, 95% CI 7.84-70.19, P < 0.001) compared to being in treatment. DISCUSSION AND CONCLUSIONS The nested case-control design strengthened earlier findings that OAT in Italy has strong protective effects on overdose mortality risk, much stronger than has been previously seen in other Western European settings.
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Affiliation(s)
- Fabrizio Faggiano
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Federica Mathis
- Piedmont Centre for Drug Addiction Epidemiology, A.S.L. TO3, Torino, Italy
| | - Roberto Diecidue
- Piedmont Centre for Drug Addiction Epidemiology, A.S.L. TO3, Torino, Italy
| | - Federica Vigna-Taglianti
- Piedmont Centre for Drug Addiction Epidemiology, A.S.L. TO3, Torino, Italy.,Department of Clinical and Biological Sciences, University of Torino, Torino, Italy
| | - Maria Paola Caria
- Department of Translational Medicine, Avogadro University, Novara, Italy
| | - Samantha Colledge
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Science, Bristol Medical School, University of Bristol, Bristol, UK
| | - Annamaria Bargagli
- Department of Biomedical Sciences, University of Cagliari, Cagliari, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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26
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Krawczyk N, Mojtabai R, Stuart E, Fingerhood M, Agus D, Lyons BC, Weiner JP, Saloner B. Opioid agonist treatment and fatal overdose risk in a state-wide US population receiving opioid use disorder services. Addiction 2020; 115:1683-1694. [PMID: 32096302 PMCID: PMC7426244 DOI: 10.1111/add.14991] [Citation(s) in RCA: 96] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 12/17/2019] [Accepted: 01/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND AIMS Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non-medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non-medication treatments in specialty care settings. DESIGN Retrospective cohort study using state-wide treatment data linked to death records. Survival analysis was used to analyze data in a time-to-event framework. SETTING Services delivered by 757 providers in publicly funded out-patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. PARTICIPANTS A total of 48 274 adults admitted to out-patient specialty treatment programs in 2015-16 for primary diagnosis of opioid use disorder. MEASUREMENTS Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non-medication treatments and time following non-medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. FINDINGS The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non-medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08-0.40]. Periods after discharge from non-medication treatment (aHR = 5.45, 95% CI = 2.80-9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10-11.02) had similar and substantially elevated risks compared with periods in non-medication treatments. CONCLUSIONS Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non-medication treatments during care but not after treatment is discontinued.
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Affiliation(s)
- Noa Krawczyk
- Department of Population Health, NYU School of Medicine, New York, NY,Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Elizabeth Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Michael Fingerhood
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,Johns Hopkins School of Medicine, Baltimore, MD
| | - Deborah Agus
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - B. Casey Lyons
- Office of Provider Engagement and Regulation, Maryland Department of Health, Catonsville, MD,Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Jonathan P. Weiner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Brendan Saloner
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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27
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Walley AY, Lodi S, Li Y, Bernson D, Babakhanlou-Chase H, Land T, Larochelle MR. Association between mortality rates and medication and residential treatment after in-patient medically managed opioid withdrawal: a cohort analysis. Addiction 2020; 115:1496-1508. [PMID: 32096908 PMCID: PMC7854020 DOI: 10.1111/add.14964] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/16/2019] [Accepted: 01/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Medically managed opioid withdrawal (detox) can increase the risk of subsequent opioid overdose. We assessed the association between mortality following detox and receipt of medications for opioid use disorder (MOUD) and residential treatment after detox. DESIGN Cohort study generated from individually linked public health data sets. SETTING Massachusetts, USA. PARTICIPANTS A total of 30 681 opioid detox patients with 61 819 detox episodes between 2012 and 2014. MEASUREMENTS Treatment categories included no post-detox treatment, MOUD, residential treatment or both MOUD and residential treatment identified at monthly intervals. We classified treatment exposures in two ways: (a) 'on-treatment' included any month where a treatment was received and (b) 'with-discontinuation' individuals were considered exposed through the month following treatment discontinuation. We conducted multivariable Cox proportional hazards analyses and extended Kaplan-Meier estimator cumulative incidence for all-cause and opioid-related mortality for the treatment categories as monthly time-varying exposure variables. FINDINGS Twelve months after detox, 41% received MOUD for a median of 3 months, 35% received residential treatment for a median of 2 months and 13% received both for a median of 5 months. In on-treatment analyses for all-cause mortality compared with no treatment, adjusted hazard ratios (AHR) were 0.34 [95% confidence interval (CI) = 0.27-0.43] for MOUD, 0.63 (95% CI = 0.47-0.84) for residential treatment and 0.11 (95% CI = 0.03-0.43) for both. In with-discontinuation analyses for all-cause mortality, compared with no treatment, AHRs were 0.52 (95% CI = 0.42-0.63) for MOUD, 0.76 (95% CI = 0.59-0.96) for residential treatment and 0.21 (95% CI = 0.08-0.55) for both. Results were similar for opioid-related overdose mortality. CONCLUSIONS Among people who have undergone medically managed opioid withdrawal, receipt of medications for opioid use disorder, residential treatment or the combination of medications for opioid use disorder and residential treatment were associated with substantially reduced mortality compared with no treatment.
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Affiliation(s)
- Alexander Y. Walley
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118,Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | - Sara Lodi
- Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA 02118
| | - Yijing Li
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108
| | | | - Thomas Land
- University of Massachusetts Medical School, 55 N Lake Avenue, Worcester, MA 01655
| | - Marc R. Larochelle
- Boston University School of Medicine-Boston Medical Center, 801 Massachusetts Avenue, Boston, MA 02118
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28
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Gicquelais RE, Jannausch M, Bohnert AS, Thomas L, Sen S, Fernandez AC. Links between suicidal intent, polysubstance use, and medical treatment after non-fatal opioid overdose. Drug Alcohol Depend 2020; 212:108041. [PMID: 32470753 PMCID: PMC7336718 DOI: 10.1016/j.drugalcdep.2020.108041] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 04/14/2020] [Accepted: 04/15/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses. METHODS Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (wanted to die), or passively suicidal (didn't care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment. RESULTS Of opioid overdoses, 51 % involved suicidal intent (44 % passive and 7 % active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95 % CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95 % CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the 2 weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27 %) with opioids during their last overdose relative to unintentional overdoses (16 %). CONCLUSIONS Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.
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Affiliation(s)
- Rachel E. Gicquelais
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA,Corresponding author at: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E7133A, Baltimore, MD, 21205, USA.
| | - Mary Jannausch
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI 48105, USA
| | - Amy S.B. Bohnert
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI 48105, USA,Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA,Department of Anesthesiology, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Laura Thomas
- Veterans Affairs Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI 48105, USA,Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
| | - Srijan Sen
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA,Molecular and Behavioral Neuroscience Institute, University of Michigan, 205 Zina Pitcher Place, Ann Arbor, MI 48109, USA
| | - Anne C. Fernandez
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA
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The relationship between incarceration history and overdose in North America: A scoping review of the evidence. Drug Alcohol Depend 2020; 213:108088. [PMID: 32498032 PMCID: PMC7683355 DOI: 10.1016/j.drugalcdep.2020.108088] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/07/2020] [Accepted: 05/09/2020] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Rates of opioid overdose (OD) have risen to unprecedented numbers and more than half of incarcerated individuals meet the criteria for substance use disorder, placing them at high risk. This review describes the relationship between incarceration history and OD. METHODS A scoping review was conducted and criteria for inclusion were: set in North America, published in English, and non-experimental study of formerly incarcerated individuals. Due to inconsistent definitions of opioid OD, we included all studies examining OD where opioids were mentioned. RESULTS The 18 included studies were all published in 2001 or later. Four associations between incarceration history and OD were identified: (1) six studies assessed incarceration history as a risk factor for OD and four found a significantly higher risk of OD among individuals with a history of incarceration compared to those without; (2) nine studies examined the rate of OD compared to the general population: eight found a significantly higher risk of fatal OD among those with a history of incarceration and three documented the highest risk of death immediately following release; (3) six studies found demographic, substance use and mental health, and incarceration-related risk factors for OD among formerly incarcerated individuals; and (4) four studies assessed the proportion of deaths due to OD and found a range from 5 % to 57 % among formerly incarcerated individuals. DISCUSSION Findings support the growing call for large-scale implementation of evidence-based OD prevention interventions in correctional settings and among justice-involved populations to reduce OD burden in this high-risk population.
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Pearce LA, Min JE, Piske M, Zhou H, Homayra F, Slaunwhite A, Irvine M, McGowan G, Nosyk B. Opioid agonist treatment and risk of mortality during opioid overdose public health emergency: population based retrospective cohort study. BMJ 2020; 368:m772. [PMID: 32234712 PMCID: PMC7190018 DOI: 10.1136/bmj.m772] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To compare the risk of mortality among people with opioid use disorder on and off opioid agonist treatment (OAT) in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. DESIGN Population based retrospective cohort study. SETTING Individual level linkage of five health administrative datasets capturing drug dispensations, hospital admissions, physician billing records, ambulatory care reports, and deaths in British Columbia, Canada. PARTICIPANTS 55 347 people with opioid use disorder who received OAT between 1 January 1996 and 30 September 2018. MAIN OUTCOME MEASURES All cause and cause specific crude mortality rates (per 1000 person years) to determine absolute risk of mortality and all cause age and sex standardised mortality ratios to determine relative risk of mortality compared with the general population. Mortality risk was calculated according to treatment status (on OAT, off OAT), time since starting and stopping treatment (1, 2, 3-4, 5-12, >12 weeks), and medication type (methadone, buprenorphine/naloxone). Adjusted risk ratios compared the relative risk of mortality on and off OAT over time as fentanyl became more prevalent in the illicit drug supply. RESULTS 7030 (12.7%) of 55 347 OAT recipients died during follow-up. The all cause standardised mortality ratio was substantially lower on OAT (4.6, 95% confidence interval 4.4 to 4.8) than off OAT (9.7, 9.5 to 10.0). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 (95% confidence interval 1.8 to 2.4) times higher than on OAT before the introduction of fentanyl, increasing to 3.4 (2.8 to 4.3) at the end of the study period (65% increase in relative risk). CONCLUSIONS Retention on OAT is associated with substantial reductions in the risk of mortality for people with opioid use disorder. The protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, whereas the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.
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Affiliation(s)
- Lindsay A Pearce
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Jeong Eun Min
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Micah Piske
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Haoxuan Zhou
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Fahmida Homayra
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
| | - Amanda Slaunwhite
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Mike Irvine
- British Columbia Centre for Disease Control and Prevention, Vancouver, BC, V5Z 4R4, Canada
| | - Gina McGowan
- British Columbia Ministry of Mental Health and Addictions, Victoria, BC, V8W 9P1, Canada
| | - Bohdan Nosyk
- Health Economic Research Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, BC, V6Z 1Y6, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, V5A 1S6, Canada
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Mortality Among People With Opioid Use Disorder: A Systematic Review and Meta-analysis. J Addict Med 2020; 14:e118-e132. [DOI: 10.1097/adm.0000000000000606] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Morgan JR, Wang J, Barocas JA, Jaeger JL, Durham NN, Babakhanlou-Chase H, Bharel M, Walley AY, Linas BP. Opioid overdose and inpatient care for substance use disorder care in Massachusetts. J Subst Abuse Treat 2020; 112:42-48. [PMID: 32199545 DOI: 10.1016/j.jsat.2020.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/27/2020] [Accepted: 01/28/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Inpatient treatment for substance use disorders is a collection of strategies ranging from short term detoxification to longer term residential treatment. How those with opioid use disorder (OUD) navigate this inpatient treatment system after an encounter for detoxification and subsequent risk of opioid-related overdose is not well understood. METHODS We used a comprehensive Massachusetts database to characterize the movement of people with OUD through inpatient care from 2013 to 2015, identifying admissions to inpatient detoxification, subsequent inpatient care, and opioid overdose while navigating treatment. We measured the person-years accumulated during each transition period to calculate rates of opioid-related overdose, and investigated how overdose differed in select populations. RESULTS Sixty-one percent of inpatient detoxification admissions resulted in a subsequent inpatient detoxification admission without progressing to further inpatient care. Overall, there were 287 fatal and 7337 non-fatal overdoses. Persons exiting treatment after detoxification had the greatest risk of overdose (17.3 per 100 person-years) compared to those who exited after subsequent inpatient care (ranging from 5.9 to 6.6 overdoses per 100 person-years). Non-Hispanic whites were most at risk for opioid related overdose with 16 overdoses per 100 person-years and non-Hispanic blacks had the lowest risk with 5 overdoses per 100 person-years. CONCLUSIONS The majority of inpatient detoxification admissions do not progress to further inpatient care. Recurrent inpatient detoxification admission is common, likely signifying relapse. Rather than functioning as the first step to inpatient care, inpatient detoxification might be more effective as a venue for implementing strategies to expand addiction services or treatment such as medications for opioid use disorder.
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Affiliation(s)
- Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, MA, USA.
| | - Jianing Wang
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA
| | - Joshua A Barocas
- Massachusetts General Hospital, Division of Infectious Diseases, Boston, MA, USA; Brigham and Women's Hospital, Division of Infectious Diseases, Boston, MA, USA
| | | | | | | | - Monica Bharel
- Massachusettes Department of Public Health, Boston, MA, USA
| | - Alexander Y Walley
- Massachusettes Department of Public Health, Boston, MA, USA; Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, MA, USA
| | - Benjamin P Linas
- Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA, USA; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
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Effects of medication-assisted treatment on mortality among opioids users: a systematic review and meta-analysis. Mol Psychiatry 2019; 24:1868-1883. [PMID: 29934549 DOI: 10.1038/s41380-018-0094-5] [Citation(s) in RCA: 190] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 03/27/2018] [Accepted: 04/18/2018] [Indexed: 11/08/2022]
Abstract
Opioid use disorder (OUD) is associated with a high risk of premature death. Medication-assisted treatment (MAT) is the primary treatment for opioid dependence. We comprehensively assessed the effects of different MAT-related characteristics on mortality among those with OUD by a systematic review and meta-analysis. The all-cause and overdose crude mortality rates (CMRs) and relative risks (RRs) by treatment status, different type, period, and dose of medication, and retention time were pooled using random effects, subgroup analysis, and meta-regression. Thirty cohort studies involving 370,611 participants (1,378,815 person-years) were eligible in the meta-analysis. From 21 studies, the pooled all-cause CMRs were 0.92 per 100 person-years (95% CI: 0.79-1.04) while receiving MAT, 1.69 (1.47-1.91) after cessation, and 4.89 (3.54-6.23) for untreated period. Based on 16 studies, the pooled overdose CMRs were 0.24 (0.20-0.28) while receiving MAT, 0.68 (0.55-0.80) after cessation of MAT, and 2.43 (1.72-3.15) for untreated period. Compared with patients receiving MAT, untreated participants had higher risk of all-cause mortality (RR 2.56 [95% CI: 1.72-3.80]) and overdose mortality (8.10 [4.48-14.66]), and discharged participants had higher risk of all-cause death (2.33 [2.02-2.67]) and overdose death (3.09 [2.37-4.01]). The all-cause CMRs during and after opioid substitution treatment with methadone or buprenorphine were 0.93 (0.76-1.10) and 1.79 (1.47-2.10), and corresponding estimate for antagonist naltrexone treatment were 0.26 (0-0.59) and 1.97 (0-5.18), respectively. Retention in MAT of over 1-year was associated with a lower mortality rate than that with retention ≤1 year (1.62, 1.31-1.93 vs. 5.31, -0.09-10.71). Improved coverage and adherence to MAT and post-treatment follow-up are crucial to reduce the mortality. Long-acting naltrexone showed positive advantage on prevention of premature death among persons with OUD.
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Predictors of Leaving an Inpatient Medical Withdrawal Service Against Medical Advice: A Retrospective Analysis. J Addict Med 2019; 12:453-458. [PMID: 29939875 DOI: 10.1097/adm.0000000000000431] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to determine the frequency and predictors of patients leaving an inpatient medical withdrawal unit against medical advice (AMA). METHODS This study used a case-control design to compare patients who were discharged AMA (n = 164) with those who completed treatment (n = 678). Logistic regression analysis was used to determine which variables were independent predictors of patients leaving AMA. RESULTS We found that being admitted through the emergency department (odds ratio [OR] 3.17, confidence interval [CI] 1.66-6.08), having gamma-hydroxybutyrate (OR 7.61, CI 1.81-32.09) as a primary substance of concern compared to alcohol, and having multiple axis I psychiatric diagnoses (OR 2.20, CI 1.16-4.18) or depression (OR 2.86, CI 1.32-6.17) compared with no psychiatric diagnosis increased the odds of leaving inpatient medical withdrawal AMA. By contrast, not being dependent on nicotine (OR 0.45, CI 0.23-0.88) and increasing time since admission (OR 0.42, CI 0.36-0.48) reduced the odds of leaving AMA. CONCLUSIONS The findings of this study reveal novel information about patients who leave inpatient medical withdrawal AMA and can inform targeted interventions to prevent vulnerable patients from terminating treatment early and improve healthcare service utilization.
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The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:172-184. [DOI: 10.1016/j.drugpo.2019.07.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022]
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Larochelle MR, Bernstein R, Bernson D, Land T, Stopka TJ, Rose AJ, Bharel M, Liebschutz JM, Walley AY. Touchpoints - Opportunities to predict and prevent opioid overdose: A cohort study. Drug Alcohol Depend 2019; 204:107537. [PMID: 31521956 PMCID: PMC7020606 DOI: 10.1016/j.drugalcdep.2019.06.039] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 06/21/2019] [Accepted: 06/27/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Medical care, public health, and criminal justice systems encounters could serve as touchpoints to identify and intervene with individuals at high-risk of opioid overdose death. The relative risk of opioid overdose death and proportion of deaths that could be averted at such touchpoints are unknown. METHODS We used 8 individually linked data sets from Massachusetts government agencies to perform a retrospective cohort study of Massachusetts residents ages 11 and older. For each month in 2014, we identified past 12-month exposure to 4 opioid prescription touchpoints (high dosage, benzodiazepine co-prescribing, multiple prescribers, or multiple pharmacies) and 4 critical encounter touchpoints (opioid detoxification, nonfatal opioid overdose, injection-related infection, and release from incarceration). The outcome was opioid overdose death. We calculated Standardized Mortality Ratios (SMRs) and Population Attributable Fractions (PAFs) associated with touchpoint exposure. RESULTS The cohort consisted of 6,717,390 person-years of follow-up with 1315 opioid overdose deaths. We identified past 12-month exposure to any touchpoint in 2.7% of person-months and for 51.8% of opioid overdose deaths. Opioid overdose SMRs were 12.6 (95% CI: 11.1, 14.1) for opioid prescription and 68.4 (95% CI: 62.4, 74.5) for critical encounter touchpoints. Fatal opioid overdose PAFs were 0.19 (95% CI: 0.17, 0.21) for opioid prescription and 0.37 (95% CI: 0.34, 0.39) for critical encounter touchpoints. CONCLUSIONS Using public health data, we found eight candidate touchpoints were associated with increased risk of fatal opioid overdose, and collectively identified more than half of opioid overdose decedents. These touchpoints are potential targets for development of overdose prevention interventions.
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Affiliation(s)
- Marc R. Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA,Corresponding author at: Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA. (M.R. Larochelle)
| | - Ryan Bernstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA
| | - Dana Bernson
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
| | - Thomas Land
- Department of Medicine, University of Massachusetts Medical School, 55 North Lake Avenue, Worcester, MA 01655, USA
| | - Thomas J. Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA 02111, USA
| | - Adam J. Rose
- RAND Corporation, 20 Park Plaza #920, Boston, MA 02116, USA
| | - Monica Bharel
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
| | - Jane M. Liebschutz
- Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh School of Medicine, 200 Lothrop Street, Suite 933 West MUH, Pittsburgh, PA 15213, USA
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02218, USA,Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
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Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012. Drug Alcohol Depend 2019; 204:107473. [PMID: 31520924 DOI: 10.1016/j.drugalcdep.2019.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 02/23/2019] [Accepted: 05/06/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Patients have higher mortality immediately after substance abuse treatment discharge, but there are few data on post-discharge mortality differences across treatment modalities. METHODS A retrospective cohort study examined individuals discharged from substance abuse treatment during 2006-2012 and probabilistically matched treatment records to death records. Logistic regression examined associations between drug-related death (DRD) and demographics; route, frequency, and classes of drugs abused; and treatment. Primary outcome was DRD during post-discharge days 0-28; secondary outcomes examined DRD during days 29-90 and 91-365. RESULTS We examined 178,749 patients discharged from 254,814 treatment episodes. There were 97 DRD during days 0-28 (4.1/1000 person-years), 115 DRD during days 29-90 (2.6/1000 person-years; IRR 0.6 [95% CI 0.5-0.8]), and 293 DRD during days 91-365 (1.9/1000 person-years; IRR 0.5 [0.4-0.6]). Higher 28-day DRD was associated with abuse of opioids (aOR 2.5 [1.4-4.4]), depressants (aOR 2.0 [1.2-3.4]), or alcohol (aOR 1.7 [1.1-2.6]); and opioid injection (aOR 2.2 [1.3-3.7]). Lower DRD was associated with treatment completion (aOR 0.6 [0.4-0.9]), female sex (aOR 0.6 [0.4-0.8]), and employment (aOR 0.5 [0.3-0.9]). Among all patients, DRD rates were higher following residential (IRR 2.6, [1.6-4.2]) and detoxification (IRR 2.9, [1.7-4.9]) treatment compared to outpatient. Patients with prior opioid abuse had higher 28-day DRD after outpatient (6.7/1000 person-years; IRR 4.1 [1.8-9.1]), residential (13.6/1000 person-years; IRR 4.2 [2.2-8.2]), and detoxification (8.8/1000 person-years; IRR 3.2 [1.2, 8.5]) compared to those without. CONCLUSIONS Drug-related mortality is highest during days 0-28 after discharge, especially following residential and detoxification treatment. Opioid abuse is strongly associated with early post-discharge mortality.
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Namiranian K, Siglin J, Sorkin JD, Norris EJ, Aghevli M, Covington EC. Postoperative opioid misuse in patients with opioid use disorders maintained on opioid agonist treatment. J Subst Abuse Treat 2019; 109:8-13. [PMID: 31856954 DOI: 10.1016/j.jsat.2019.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Patients recovering from opioid use disorders (OUD) may be prone to relapse and opioid misuse in the postoperative period due to re-exposure to prescription opioids for pain control. This retrospective study analyzed the incidence of confirmed opioid misuse in the postoperative period in patients with OUDs enrolled in an opioid agonist treatment (OAT) program. METHODS The study population was US veterans with a diagnosis of OUD who enrolled in the OAT program at VA Maryland Health Care System (Baltimore, Maryland, USA) between 1/1/2000 and 12/31/2016. The patients were excluded if they were enrolled in OAT for less than a year, or if they had surgery within the first 180 days after OAT admission. The surgical group consisted of veterans who had surgery or an invasive procedure during their enrollment in the OAT program. The control (reference) group consisted of enrolled veterans who did not have any invasive procedure. The primary outcome was the first opioid misuse within 365 days after surgery date in the surgical group or a randomly assigned sham surgery date in controls. Opioid misuse was defined as either inappropriate use of opioids detected via urinalysis or admission with a diagnosis of an opioid overdose. RESULTS From a total of 1352 patients enrolled in the OAT program, 413 were excluded because they were enrolled for less than a year, and 26 were excluded because they had surgery within the first 180 days after admission to the OAT program. Of the 923 eligible patients, 87 had surgery while enrolled and 836 did not. Using propensity scores, all 87 of the surgical cases were matched to 249 of the control cases. In the matched groups, surgery was positively associated with postoperative opioid misuse (odds ratio (OR) of 1.91, 95% CI 1.05-3.48, p = 0.034) in logistic regression. CONCLUSION Among patients with a history of opioid use disorders, the postoperative period was associated with an increased risk of opioid misuse. Moreover, opioid misuse among patients in an opioid agonist treatment program may well be considered a surgical hazard.
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Affiliation(s)
- Khodadad Namiranian
- VA Maryland Health Care System, Baltimore, MD, United States of America; Department of Anesthesiology, University of Maryland, Baltimore, MD, United States of America.
| | - Jonathan Siglin
- School of Medicine, University of Maryland, Baltimore, MD, United States of America
| | - John David Sorkin
- Baltimore VA Medical Center Geriatric Research, Education and Clinical Center, VA Maryland Health Care System, Baltimore, MD, United States of America; Division of Gerontology and Geriatric Medicine, University of Maryland, Baltimore, MD, United States of America
| | - Edward J Norris
- VA Maryland Health Care System, Baltimore, MD, United States of America; Department of Anesthesiology, University of Maryland, Baltimore, MD, United States of America
| | - Minu Aghevli
- VA Maryland Health Care System, Baltimore, MD, United States of America
| | - Edward C Covington
- Neurological Institute (Emeritus), Cleveland Clinic, Cleveland, OH, United States of America
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Bahji A, Cheng B, Gray S, Stuart H. Reduction in mortality risk with opioid agonist therapy: a systematic review and meta-analysis. Acta Psychiatr Scand 2019; 140:313-339. [PMID: 31419306 DOI: 10.1111/acps.13088] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Opioid agonist therapies are effective medications that can greatly improve the quality of life of individuals with opioid use disorder. However, there is significant uncertainty about the risks of cause-specific mortality in and out of treatment. OBJECTIVE This systematic review and meta-analysis explored the association between methadone and buprenorphine with cause-specific mortality among opioid-dependent persons. METHODS We searched six online databases to identify relevant cohort studies, calculating all-cause and overdose-specific mortality rates during periods in and out of treatment. We pooled mortality estimates using multivariate random effects meta-analysis of the crude mortality rate per 1000 person-years of follow-up as well as relative risks comparing mortality in vs. out of treatment. RESULTS A total of 32 cohort studies (representing 150 235 participants, 805 423.6 person-years, and 9112 deaths) met eligibility criteria. Crude mortality rates were substantially higher among methadone cohorts than buprenorphine cohorts. Relative risk reduction was substantially higher with methadone relative to buprenorphine when time in-treatment was compared to time out-of-treatment. Furthermore, the greatest mortality reduction was conferred during the first 4 weeks of treatment. Mortality estimates were substantially heterogeneous and varied significantly by country, region, and by the nature of the treatment provider. CONCLUSION Precautions are necessary for the safer implementation of opioid agonist therapy, including baseline assessments of opioid tolerance, ongoing monitoring during the induction period, education of patients about the risk of overdose, and coordination within healthcare services.
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Affiliation(s)
- A Bahji
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada.,Department of Psychiatry, Queen's University, Kingston, ON, Canada.,Substance Treatment and Recovery Team, Kingston Health Sciences Centre, Kingston, ON, Canada
| | - B Cheng
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - S Gray
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
| | - H Stuart
- Department of Public Health Sciences, Queen's University, Kingston, ON, Canada
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Stuart Bradley E, Liss D, Pepper Carreiro S, Brush DE, Babu K. Potential uses of naltrexone in emergency department patients with opioid use disorder. Clin Toxicol (Phila) 2019; 57:753-759. [PMID: 30831039 PMCID: PMC6908461 DOI: 10.1080/15563650.2019.1583342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 01/21/2019] [Accepted: 01/25/2019] [Indexed: 10/27/2022]
Abstract
Introduction: Despite widespread recognition of the opioid crisis, opioid overdose remains a common reason for Emergency Department (ED) utilization. Treatment for these patients after stabilization often involves the provision of information for outpatient treatment options. Ideally, an ED visit for overdose would present an opportunity to start treatment for opioid use disorder (OUD) immediately. Although widely recognized as effective, opioid agonist therapy with methadone and buprenorphine commonly referred to as "medication-assisted therapy" but more correctly as "medication for addiction treatment" (MAT), can be difficult to access even for motivated individuals due to shortages of prescribers and treatment programs. Moreover, opioid agonist therapy may not be appropriate for all patients, as many patients who present after overdose are not opioid dependent. More treatment options are required to successfully match patients with diverse needs to an optimal treatment plan in order to avoid relapse. Naltrexone, a long-acting opioid antagonist, available orally and as a monthly extended-release intramuscular injection, may represent another treatment option. Methods: We conducted a literature search of MEDLINE and PubMed. We aimed to capture references related to naltrexone and is use as MAT for OUD, as well as manuscripts that discussed naltrexone in comparison toother agents used for MAT, opioid detoxification, and naltrexone metabolism. Our initial search logic returned a total of 618 articles. Following individual evaluation for relevance, we selected 65 for in-depthreview. Manuscripts meeting criteria were examined for citations meriting further review, leading to the addition of 30 manuscripts Conclusions: Here, we review the pharmacology of naltrexone as it relates to OUD, its history of use, and highlight recent studies and new approaches for use of the drug as MAT including its potential initiation after ED visit for opioid overdose.
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Affiliation(s)
- Evan Stuart Bradley
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Liss
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie Pepper Carreiro
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - David Eric Brush
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
| | - Kavita Babu
- Department of Emergency Medicine, Division of Medical Toxicology, University of Massachusetts Medical School and Umass Memorial Medical Center, Worcester, MA, USA
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Abstract
In 2014, Russian authorities in occupied Crimea shut down all medication-assisted treatment (MAT) programs for patients with opioid use disorder. These closures dramatically enacted a new political order. As the sovereign occupiers in Crimea advanced new constellations of citizenship and statehood, so the very concept of "right to health" was re-tooled. Social imaginations of drug use helped single out MAT patients as a population whose "right to health," protected by the state, would be artificially restricted. Here, I argue that such acts of medical disenfranchisement should be understood as contemporary acts of statecraft.
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Affiliation(s)
- Jennifer J Carroll
- Department of Sociology and Anthropology, Elon University , Elon , North Carolina , USA
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42
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Fortier E, Artenie AA, Zang G, Jutras-Aswad D, Roy É, Grebely J, Bruneau J. Short and sporadic injecting cessation episodes as predictors of incident hepatitis C virus infection: findings from a cohort study of people who inject drugs in Montréal, Canada. Addiction 2019; 114:1495-1503. [PMID: 30957310 DOI: 10.1111/add.14632] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 01/18/2019] [Accepted: 03/18/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND AND AIMS For most people who inject drugs (PWID), drug injecting follows a dynamic process characterized by transitions in and out of injecting. The objective of this investigation was to examine injecting cessation episodes of 1-3-month duration as predictors of hepatitis C virus (HCV) acquisition. DESIGN Cohort study. SETTING Montréal, Canada. PARTICIPANTS A total of 372 HCV-uninfected (HCV RNA-negative, HCV antibody-positive or -negative) PWID (mean age = 39.3 years, 82% male, 45% HCV antibody-positive) enrolled between March 2011 and June 2016. MEASUREMENTS At 3-month intervals, participants completed an interviewer-administered questionnaire and were tested for HCV particles (HCV RNA). At each visit, participants indicated whether they injected in each of the past 3 months (defined as three consecutive 30-day periods). Injecting cessation patterns were evaluated on a categorical scale: persistent injecting (no injecting cessation in the past 3 months), sporadic injecting cessation (injecting cessation in 1 of 3 or 2 of 3 months) and short injecting cessation (injecting cessation in 3 of 3 months). Their association with HCV infection risk was examined using Cox regression analyses with time-dependent covariates, including age, gender, incarceration, opioid agonist treatment and other addiction treatments. FINDINGS At baseline, 61, 26 and 13% of participants reported persistent injecting, sporadic injecting cessation and short injecting cessation, respectively. HCV incidence was 7.5 per 100 person-years [95% confidence interval (CI) = 5.9-9.5; 916 person-years of follow-up]. In adjusted Cox models, sporadic injecting cessation and short injecting cessation were associated with lower risks of incident HCV infection compared to persistent injecting (adjusted hazard ratios = 0.56, 95% CI = 0.30-1.04 and 0.24, 95% CI = 0.09-0.61), respectively. CONCLUSION Short and sporadic injecting cessation episodes were common among a cohort of people who inject drugs in Montréal, Canada. Injecting cessation episodes appear to be protective against hepatitis C virus acquisition, particularly when maintained for at least 3 months.
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Affiliation(s)
- Emmanuel Fortier
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.,Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Andreea Adelina Artenie
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.,Department of Social and Preventive Medicine, School of Public Health, Université de Montréal, Montréal, QC, Canada
| | - Geng Zang
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada
| | - Didier Jutras-Aswad
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.,Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Élise Roy
- Addiction Research and Study Program, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Longueuil, QC, Canada.,Institut national de santé publique du Québec, Montréal, QC, Canada
| | - Jason Grebely
- The Kirby Institute, UNSW Sydney, Sydney, NSW, Australia
| | - Julie Bruneau
- CHUM Research Centre, Centre hospitalier de l'Université de Montréal, Montréal, QC, Canada.,Department of Family and Emergency Medicine, Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
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43
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Kearley BW, Cosgrove JA, Wimberly AS, Gottfredson DC. The impact of drug court participation on mortality: 15-year outcomes from a randomized controlled trial. J Subst Abuse Treat 2019; 105:12-18. [PMID: 31443886 DOI: 10.1016/j.jsat.2019.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 06/14/2019] [Accepted: 07/10/2019] [Indexed: 11/26/2022]
Abstract
AIM To test the effects of drug court participation on long-term mortality risk. METHODS During 1997-98, 235 individuals charged with a non-violent offense were randomly assigned to Baltimore City Drug Treatment Court (BCDTC) or traditional adjudication. Heroin was the predominant substance of choice among the sample. Participant mortality was observed for 15 years following randomization. RESULTS Over 20% of participants died during the study, at an average age of 46.6 years, and 64.4% of deaths were substance-use related. Survival analyses estimated that neither mortality from any cause nor from substance use-related causes significantly differed between BCDTC and traditional adjudication. CONCLUSIONS Frequent and premature death among the sample indicates that this is a high-risk population in need of effective substance use treatment. Roughly half of drug treatment courts are now estimated to offer medication assisted treatment (MAT), which is currently the most effective treatment for opioid use disorders. In this study of BCDTC implemented over 15 years ago, only 7% of participants received MAT, which may explain the lack of program impact on mortality. Historical barriers to providing MAT in drug court settings include access, concerns about diversion, negative attitudes, blanket prohibitions, and stigma. Drug treatment courts should implement best practice standards for substance use treatment and overdose prevention, including increased access to MAT and naloxone, and training to reduce stigmatizing language and practice.
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Affiliation(s)
- Brook W Kearley
- University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA.
| | - John A Cosgrove
- University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA.
| | - Alexandra S Wimberly
- University of Maryland School of Social Work, 525 West Redwood Street, Baltimore, MD 21201, USA.
| | - Denise C Gottfredson
- University of Maryland, Department of Criminology and Criminal Justice, 2220 Samuel J. LeFrak Hall, 7251 Preinkert Drive, College Park, MD 20742, USA.
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44
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Heimer R, Hawk K, Vermund SH. Prevalent Misconceptions About Opioid Use Disorders in the United States Produce Failed Policy and Public Health Responses. Clin Infect Dis 2019; 69:546-551. [PMID: 30452633 PMCID: PMC6637277 DOI: 10.1093/cid/ciy977] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/13/2018] [Indexed: 12/20/2022] Open
Abstract
The current opioid crisis in the United States has emerged from higher demand for and prescribing of opioids as chronic pain medication, leading to massive diversion into illicit markets. A peculiar tragedy is that many health professionals prescribed opioids in a misguided response to legitimate concerns that pain was undertreated. The crisis grew not only from overprescribing, but also from other sources, including insufficient research into nonopioid pain management, ethical lapses in corporate marketing, historical stigmas directed against people who use drugs, and failures to deploy evidence-based therapies for opioid addiction and to comprehend the limitations of supply-side regulatory approaches. Restricting opioid prescribing perversely accelerated narco-trafficking of heroin and fentanyl with consequent increases in opioid overdose mortality As injection replaced oral consumption, outbreaks of hepatitis B and C virus and human immunodeficiency virus infections have resulted. This viewpoint explores the origins of the crisis and directions needed for effective mitigation.
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Affiliation(s)
- Robert Heimer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and Departments of
- Pharmacology, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn Hawk
- Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Sten H Vermund
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, and Departments of
- Pediatrics, Yale School of Medicine, New Haven, Connecticut
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45
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Gicquelais RE, Mezuk B, Foxman B, Thomas L, Bohnert ASB. Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment. Harm Reduct J 2019; 16:46. [PMID: 31311572 PMCID: PMC6636104 DOI: 10.1186/s12954-019-0317-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/05/2019] [Indexed: 12/17/2022] Open
Abstract
Background Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described. Methods We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014–2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors. Results Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1–2.0]). Conclusions All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders. Electronic supplementary material The online version of this article (10.1186/s12954-019-0317-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rachel E Gicquelais
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA. .,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA. .,Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA. .,Current Address: Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, E7133A, Baltimore, MD, 21205, USA.
| | - Briana Mezuk
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Betsy Foxman
- Department of Epidemiology, University of Michigan School of Public Health, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Laura Thomas
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Veterans Affairs Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
| | - Amy S B Bohnert
- Department of Psychiatry, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI, 48109, USA.,Veterans Affairs Center for Clinical Management Research, 2215 Fuller Road, Ann Arbor, MI, 48105, USA
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46
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U.S. prescribing trends of fentanyl, opioids, and other pain medications in outpatient and emergency department visits from 2006 to 2015. Prev Med 2019; 123:123-129. [PMID: 30894321 PMCID: PMC6534435 DOI: 10.1016/j.ypmed.2019.03.022] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 03/08/2019] [Accepted: 03/15/2019] [Indexed: 11/20/2022]
Abstract
The United States is currently facing an epidemic of opioid-related deaths, increasingly associated with fentanyl use. Our objective was to characterize rates of fentanyl, general opioid and non-opioid pain medication prescription at a national level in both outpatient and emergency department settings. We used a retrospective cross-sectional research design using data from the 2006-2015 National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Surveys. Between 2006-2015, 66,987 (17.4%) of 390,538 office-based outpatient visits (nationally-representative of 961 million visits) and 134,953 (45.0%) of 305,570 ED visits (nationally-representative of 130 million visits) listed a pain medication prescription. The proportion of all outpatient visits in which any pain medication was prescribed increased from 15.0% in 2006-2007 to 20.5% in 2014-2015 (p < 0.001). The proportion of all outpatient visits in which any fentanyl product was prescribed remained stable at 0.3% and 0.4% (p = 0.32), but increased among ED visits from 0.5% to 1.1% (p = 0.006). In contrast, the proportion of all outpatient visits in which any opioid product was prescribed increased from 6.6% to 9.7% (p < 0.001), but remained relatively stable among ED visits from 26.2% to 24.4% (p = 0.07). Non-opioid pain medication prescription increased in both settings, from 9.7% to 13.7% (p < 0.001) in the outpatient setting and from 25.6% to 27.6% (p = 0.02) in the ED setting between 2006-2007 and 2014-2015, respectively. To address current opioid crisis, both clinical and public health interventions are needed, such as targeted education outreach on evidence-based opioid prescribing and non-opioid alternatives.
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47
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Davidson PJ, Wagner KD, Tokar PL, Scholar S. Documenting need for naloxone distribution in the Los Angeles County jail system. Addict Behav 2019; 92:20-23. [PMID: 30576883 DOI: 10.1016/j.addbeh.2018.12.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 11/14/2018] [Accepted: 12/11/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Los Angeles County Jail system is the largest jail system in the United States, with an average daily inmate population of 17,024 in 2017. Existing literature shows the weeks following release from incarceration are associated with increased risk of overdose death among individuals who previously used opioids. One response is to train inmates in overdose prevention and response (OPR) and to provide the opioid antagonist naloxone on release. However, in large jail systems training all inmates can be logistically and financially difficult, leading to interest identifying individuals most likely to benefit from such programs. METHOD In 2017, the Los Angeles County Office of Diversion and Reentry collaborated with the Los Angeles County Sheriff Department to conduct an OPR needs assessment evaluation with all inmates entering the jail over a two week period. RESULTS 3781 inmates provided complete data for this analysis (3315 men, 466 women). 17% reported using opioids within the last 12 months, 7% reported witnessing an overdose within the last 12 months, and 5% report ever having received medication assisted treatment (MAT). 39% reported interest in being trained in overdose prevention and response. The single largest predictor of interest in OPR was being present at an overdose in the past year. CONCLUSION Our results suggest OPR should be provided to all inmates who opt-in to receiving training regardless of other risk factors. Our results also suggest this population has had little prior exposure to MAT and incarceration could represent a significant opportunity to provide such evidence-based treatments.
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Affiliation(s)
- Peter J Davidson
- University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA.
| | - Karla D Wagner
- University of Nevada, Reno, 1664 N Virginia Street, Reno, NV 89557, USA.
| | - Paula L Tokar
- Los Angeles County Sheriff's Department, Hall of Justice, 211 W Temple Street, Los Angeles, CA 90012, USA..
| | - Shoshanna Scholar
- Los Angeles County Department of Health Services, 313 N Figueroa Street, Los Angeles, CA 90012, USA..
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48
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Carroll JJ, Rich JD, Green TC. Reducing Collateral Damage in Responses to the Opioid Crisis. Am J Public Health 2019; 108:349-350. [PMID: 29412724 DOI: 10.2105/ajph.2017.304270] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jennifer J Carroll
- Jennifer J. Carroll is with the Department of Medicine at Brown University, Providence, RI. Traci C. Green is with the Department of Emergency Medicine at Boston University School of Medicine, Boston, MA, and the Departments of Medicine and Epidemiology at Brown Medical School. Josiah D. Rich is with the Departments of Medicine and Epidemiology at Brown University, and is the Director of the Center for Prisoner Health and Human Rights at the Miriam Hospital, Providence
| | - Josiah D Rich
- Jennifer J. Carroll is with the Department of Medicine at Brown University, Providence, RI. Traci C. Green is with the Department of Emergency Medicine at Boston University School of Medicine, Boston, MA, and the Departments of Medicine and Epidemiology at Brown Medical School. Josiah D. Rich is with the Departments of Medicine and Epidemiology at Brown University, and is the Director of the Center for Prisoner Health and Human Rights at the Miriam Hospital, Providence
| | - Traci C Green
- Jennifer J. Carroll is with the Department of Medicine at Brown University, Providence, RI. Traci C. Green is with the Department of Emergency Medicine at Boston University School of Medicine, Boston, MA, and the Departments of Medicine and Epidemiology at Brown Medical School. Josiah D. Rich is with the Departments of Medicine and Epidemiology at Brown University, and is the Director of the Center for Prisoner Health and Human Rights at the Miriam Hospital, Providence
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49
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Kelty E, Joyce D, Hulse G. A retrospective cohort study of mortality rates in patients with an opioid use disorder treated with implant naltrexone, oral methadone or sublingual buprenorphine. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2019; 45:285-291. [DOI: 10.1080/00952990.2018.1545131] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Erin Kelty
- Discipline of Psychiatry, University of Western Australia, Nedlands, Western Australian, Australia
- School of Population and Global Health, University of Western Australia, Crawley, Western Australian, Australia
| | - David Joyce
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - Gary Hulse
- Discipline of Psychiatry, University of Western Australia, Nedlands, Western Australian, Australia
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50
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Abbasi AB, Salisbury-Afshar E, Jovanov D, Berberet C, Arunkumar P, Aks SE, Layden JE, Pho MT. Health Care Utilization of Opioid Overdose Decedents with No Opioid Analgesic Prescription History. J Urban Health 2019; 96:38-48. [PMID: 30607879 PMCID: PMC6391294 DOI: 10.1007/s11524-018-00329-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Opioid overprescribing is a major driver of the current opioid overdose epidemic. However, annual opioid prescribing in the USA dropped from 782 to 640 morphine milligram equivalents per capita between 2010 and 2015, while opioid overdose deaths increased by 63%. To better understand the role of prescription opioids and health care utilization prior to opioid-related overdose, we analyzed the death records of decedents who died of an opioid overdose in Illinois in 2016 and linked to any existing controlled substance monitoring program (CSMP) and emergency department (ED) or hospital discharge records. We found that of the 1893 opioid-related overdoses, 573 (30.2%) decedents had not filled an opioid analgesic prescription within the 6 years prior to death. Decedents without an opioid prescription were more likely to be black (33.3% vs 20.2%, p < .001), Hispanic (16.3% vs 8.8%, p < .001), and Chicago residents (46.8% vs 25.6%, p < .001) than decedents with at least one filled opioid prescription. Decedents who did not fill an opioid prescription were less likely to die of an overdose involving prescribed opioids (7.3% vs 19.5%, p < .001) and more likely to fatally overdose on heroin (63% vs 50.4%, p < .001) or fentanyl/fentanyl analogues (50.3% vs 41.8%, p = .001). Between 2012 and the time of death, decedents without an opioid prescription had fewer emergency department admissions (2.5 ± 4.2 vs 10.6 ± 15.8, p < .001), were less likely to receive an opioid use disorder diagnosis (41.3% vs 47.5%, p = .052), and were less likely to be prescribed buprenorphine for opioid use disorder treatment (3.3% vs 8.6%, p < .001). Public health interventions have often focused on opioid prescribing and the use of CSMPs as the core preventive measures to address the opioid crisis. We identified a subset of individuals in Illinois who may not be impacted by such interventions. Additional research is needed to understand what strategies may be successful among high-risk populations that have limited opioid analgesic prescription history and low health care utilization.
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Affiliation(s)
- Ali B Abbasi
- University of Chicago Pritzker School of Medicine, Chicago, IL, USA. .,Illinois Department of Public Health, Chicago, IL, USA.
| | - Elizabeth Salisbury-Afshar
- Center for Multi-System Solutions to the Opioid Epidemic, American Institutes for Research, Chicago, IL, USA
| | - Dejan Jovanov
- Division of Patient Safety and Quality, Illinois Department of Public Health, Chicago, IL, USA
| | - Craig Berberet
- Prescription Monitoring Program, Illinois Department of Human Services, Chicago, IL, USA
| | | | - Steven E Aks
- Department of Emergency Medicine, Cook County Health and Hospitals System, Chicago, IL, USA
| | | | - Mai T Pho
- Illinois Department of Public Health, Chicago, IL, USA.,Section of Infectious Diseases and Global Health, University of Chicago Medicine, Chicago, IL, USA
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