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Fredericksen RJ, Mixson LS, Estadt AT, Leichtling G, Bresett J, Zule W, Walters SM, Friedmann PD, Romo E, Whitney BM, Delaney JAC, Crane HM, Tsui JI, Young A, Seal D, Stopka TJ. Barriers to retention in inpatient and residential drug treatment among persons who use opioids and/or injection drugs living in the rural U.S. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209453. [PMID: 39033853 PMCID: PMC11347080 DOI: 10.1016/j.josat.2024.209453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/30/2024] [Accepted: 07/02/2024] [Indexed: 07/23/2024]
Abstract
AIM Barriers to retention in inpatient and residential care for persons who use drugs are understudied in the rural context. We sought to better understand barriers to retention in inpatient and residential drug treatment in a large, multi-site, geographically diverse sample of persons who use opioids and/or injection drugs in the rural U.S. METHODS We conducted semi-structured individual interviews with persons currently using opioids and/or injection drugs in 9 U.S. states, including Illinois, Kentucky, Massachusetts, North Carolina, New Hampshire, Ohio, Oregon, Vermont, and Wisconsin. Content areas included substance use history and experiences with all modalities of drug treatment. We performed initial structural coding followed by an iterative "open-coding" process of itemizing and categorizing content within each code, and a multi-coder memoing process to summarize themes. We identified themes using three levels of the Social-Ecological Model (SEM): individual, interpersonal, and facility-level (organizational) barriers. RESULTS Among 304 interviewed, over half (n = 166, 54 %) reported having experienced inpatient and residential treatment. Lack of treatment retention was driven by interrelated factors at all levels of the SEM. Person-level factors inhibiting retention included lack of readiness to stop using, which was particularly true for court-ordered treatment, and dislike of "freedom limitations". The sole interpersonal-level factor was the influence of other patients on re-initiation of drug use. Facility-level barriers included unaddressed withdrawal symptoms and lack of access to MOUD, staff relatability, inadequate staff training, and, particularly in residential treatment, lack of structure and supervision. Lack of preparation for coping with real-world triggers was seen as a barrier to engagement in ongoing treatment. CONCLUSION Barriers to retention in inpatient and residential substance use treatment were present at three levels of the SEM. Interviews suggest much room for improvement in inpatient and residential drug treatment programs with respect to improving access to MOUD, tailoring content to better address social challenges in the rural context, and improving quality control measures with respect to staff and resident supervision.
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Affiliation(s)
- R J Fredericksen
- University of Washington, Department of Medicine, Seattle, WA, USA.
| | - L S Mixson
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - A T Estadt
- Ohio State University, College of Public Health, Columbus, OH, USA
| | | | - J Bresett
- Southern Illinois University, School of Human Sciences, Carbondale, IL, USA
| | - W Zule
- RTI International, Durham, NC, USA
| | - S M Walters
- New York University, School of Global Public Health, New York, NY, USA
| | - P D Friedmann
- University of Massachusetts, Department of Medicine, Springfield, MA, USA
| | - E Romo
- University of Massachusetts, Clinical and Population Health Research, Springfield, MA, USA
| | - B M Whitney
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J A C Delaney
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - H M Crane
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J I Tsui
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - A Young
- University of Kentucky, Department of Epidemiology, Lexington, KY, USA
| | - D Seal
- Tulane University, School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - T J Stopka
- Tufts University, Department of Public Health and Community Medicine, Boston, MA, USA
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Brummer J, Thylstrup B, Melis F, Hesse M. Predictors of retention in heroin-assisted treatment in Denmark 2010-2018 - A record-linkage study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 165:209449. [PMID: 38960145 DOI: 10.1016/j.josat.2024.209449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/25/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION While randomized-controlled trials have shown that heroin-assisted treatment (HAT) is superior to methadone maintenance alone in treatment of refractory clients, little is known about client factors associated with retention in HAT in routine care. METHODS This retrospective cohort study assessed predictors of retention in first treatment episode among a consecutive cohort of clients admitted to HAT in Denmark from 2010 to 2018, who could be matched to the Danish population register and for whom a Short Form Health Survey (SF-36) was available at admission (N = 432). The study derived predictors from client self-reports at intake and administrative data available in national registers. Cox proportional hazards regression modelled retention in treatment. RESULTS The one-year retention rate was 69.63 % (95 % CI 65.06 %-73.74 %), and the median time in treatment was 2.45 years (95 % CI, 1.83-3.12). Bivariate analyses showed that retention was lower for clients who had recent cocaine or benzodiazepine use and among those who had experienced an overdose in the year prior to enrollment in HAT. Age below 40, recent illegal activity, poorer emotional wellbeing, previous residential treatment experience, and previous intensive outpatient treatment were also predictors of dropout from HAT. CONCLUSIONS This observational study found that retention in HAT in routine care was similar to rates observed in randomized-controlled trials conducted in other countries. The results suggest that addressing polysubstance use as part of the HAT program may promote long-term retention, as may directing resources to certain subgroups identified at intake, including clients under 40 years and those who report recent criminal activity, emotional problems, or overdoses. The findings that previous residential treatment and intensive outpatient treatment were associated with dropout were unexpected.
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Affiliation(s)
- Julie Brummer
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
| | - Francesca Melis
- Norwegian Centre for Addiction Research (SERAF), Institute of Clinical Medicine, University of Oslo, Norway.
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Emdrup Campus, Aarhus BSS, Aarhus University, Tuborgvej 164, Building A, 2(nd) Floor, 2400 Copenhagen NV, Denmark.
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Killion JA, Jegede OS, Werb D, Davidson PJ, Smith LR, Gaines T, Graff Zivin J, Zúñiga ML, Pines HA, Garfein RS, Strathdee SA, Rivera Saldana C, Martin NK. Modeling the impact of a supervised consumption site on HIV and HCV transmission among people who inject drugs in three counties in California, USA. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 132:104557. [PMID: 39213827 DOI: 10.1016/j.drugpo.2024.104557] [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: 01/15/2024] [Revised: 08/01/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND Supervised consumption sites (SCS) have been shown to reduce receptive syringe sharing among people who inject drugs (PWID) in the United States and elsewhere, which can prevent HIV and hepatitis C virus (HCV) transmission. PWID are at risk of disease transmission and may benefit from SCS, however legislation has yet to support their implementation. This study aims to determine the potential impact of SCS implementation on HIV and HCV incidence among PWID in three California counties. METHODS A dynamic HIV and HCV joint transmission model among PWID (sexual and injecting transmission of HIV, injecting transmission of HCV) was calibrated to epidemiological data for three counties: San Francisco, Los Angeles, and San Diego. The model incorporated HIV and HCV disease stages and HIV and HCV treatment. Based on United States data, we assumed access to SCS reduced receptive syringe sharing by a relative risk of 0.17 (95 % CI: 0.04-1.03). This model examined scaling-up SCS coverage from 0 % to 20 % of the PWID population within the respective counties and assessed its impact on HIV and HCV incidence rates after 10 years. RESULTS By increasing SCS from 0 % to 20 % coverage among PWID, 21.8 % (95 % CI: -1.2-32.9 %) of new HIV infections and 28.3 % (95 % CI: -2.0-34.5 %) of new HCV infections among PWID in San Francisco County, 17.7 % (95 % CI: -1.0-30.8 %) of new HIV infections and 29.8 % (95 % CI: -2.1-36.1 %) of new HCV infections in Los Angeles County, and 32.1 % (95 % CI: -2.8-41.5 %) of new HIV infections and 24.3 % (95 % CI: -1.6-29.0 %) of new HCV infections in San Diego County could be prevented over ten years. CONCLUSION Our models suggest that SCS is an important intervention to enable HCV elimination and could help end the HIV epidemic among PWID in California. It could also have additional benefits such facilitating pathways into drug treatment programs and preventing fatal overdose.
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Affiliation(s)
- J A Killion
- University of California San Diego, CA, USA; San Diego State University, CA, USA.
| | - O S Jegede
- University of California San Diego, CA, USA; San Diego State University, CA, USA
| | - D Werb
- University of California San Diego, CA, USA; Centre on Drug Policy Evaluation, St. Michael's Hospital, Toronto, Canada
| | | | - L R Smith
- University of California San Diego, CA, USA
| | - T Gaines
- University of California San Diego, CA, USA
| | | | | | - H A Pines
- University of California San Diego, CA, USA; San Diego State University, CA, USA
| | | | | | | | - N K Martin
- University of California San Diego, CA, USA; University of Bristol, Bristol, UK
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Perdue M, Hosseini Ghomi R, Rees P, Arzubi E. 5-Day Injectable Extended-release Buprenorphine Initiation in Non-opioid-tolerant Individuals in a Carceral Setting: A Case Series. J Addict Med 2024:01271255-990000000-00382. [PMID: 39329393 DOI: 10.1097/adm.0000000000001387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2024]
Abstract
BACKGROUND Injectable extended-release buprenorphine (XR-Bup) addresses several barriers to the implementation of treatment with medications for opioid use disorder (MOUD) in carceral settings due to lower risk of diversion and reduced operational procedures. However, there is no standardized approach or guideline for initiating sublingual buprenorphine (SL-Bup) and transitioning to XR-Bup in persons with opioid use disorder (OUD) who are not actively using opioids, a clinical scenario commonly encountered in carceral settings. METHODS We conducted a retrospective case series of non-opioid-tolerant men with OUD at a Montana Department of Corrections facility who initiated XR-Bup using a 5-day induction protocol between May 1, 2023, and November 1, 2023. Primary outcome was receipt of the initial XR-Bup injection. Secondary outcomes were toleration of SL-Bup induction protocol and active continuation of XR-Bup at time of discharge. RESULTS Sixteen individuals initiated the SL-Bup induction protocol, and all were successfully transitioned to XR-Bup with no severe adverse effects. There were no required dose changes or severe adverse effects from SL-Bup induction. Two (12%) elected to discontinue XR-Bup due to commonly reported adverse effects. Fourteen (88%) remained on XR-Bup at discharge. CONCLUSIONS Five-day induction of SL-Bup and transition to XR-Bup may be considered for non-opioid-tolerant individuals with OUD in carceral settings.
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Affiliation(s)
- Matt Perdue
- From the Frontier Psychiatry, Department of Addiction Services, Billings, MT (MP, RHG, EA); Montana Department of Corrections, Helena, MT (PR); and Yale Child Study Center, New Haven, CT (EA)
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Friedman JR, Abramovitz D, Skaathun B, Rangel G, Harvey-Vera A, Vera CF, Artamonova I, Muñoz S, Martin NK, Eger WH, Bailey K, Go BS, Bourgois P, Strathdee SA. Illicit Fentanyl Use and Hepatitis C Virus Seroconversion Among People Who Inject Drugs in Tijuana and San Diego: Results From a Binational Cohort Study. Clin Infect Dis 2024:ciae372. [PMID: 39078273 DOI: 10.1093/cid/ciae372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Illicitly manufactured fentanyl (IMF) increases overdose mortality, but its role in infectious disease transmission is unknown. We examined whether IMF use predicts hepatitis C virus (HCV) and human immunodeficiency virus (HIV) incidence among a cohort of people who inject drugs (PWID) in San Diego, California and Tijuana, Mexico. METHODS PWID were recruited during 2020-2022, undergoing semi-annual interviewer-administered surveys and HIV and HCV serological rapid tests through 2024. Cox regression was conducted to examine predictors of seroconversion considering self-reported IMF use as a 6-month lagged, time-dependent covariate. RESULTS Of 398 PWID at baseline, 67% resided in San Diego, 70% were male, median age was 43 years, 42% reported receptive needle sharing, and 25% reported using IMF. HCV incidence was 14.26 per 100 person-years (95% confidence interval [CI]: 11.49-17.02), and HIV incidence was 1.29 (95% CI: .49-2.10). IMF was associated with HCV seroconversion, with a univariable hazard ratio (HR) of 1.64 (95% CI: 1.09-2.40), and multivariable HR of 1.57 (95% CI: 1.03-2.40). The direction of the relationship with HIV was similar, albeit not significant (HR 2.39; 95% CI: .66-8.64). CONCLUSIONS We document a novel association between IMF and HCV seroconversion among PWID in Tijuana-San Diego. Few HIV seroconversions (n = 10) precluded our ability to assess if a similar relationship held for HIV. IMF's short half-life may destabilize PWID-increasing the need for repeat dosing and sharing smoking materials and syringes. New preventive care approaches may reduce HCV transmission in the fentanyl era.
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Affiliation(s)
| | | | - Britt Skaathun
- Department of Medicine, University of California, San Diego
| | - Gudelia Rangel
- Department of Population Studies, Colegio de la Frontera Norte
- Sección mexicana, Comisión de Salud Fronteriza México-Estados Unidos
| | | | - Carlos F Vera
- Department of Medicine, University of California, San Diego
- Sección mexicana, Comisión de Salud Fronteriza México-Estados Unidos
| | | | - Sheryl Muñoz
- Sección mexicana, Comisión de Salud Fronteriza México-Estados Unidos
- Escuela de Medicina, Universidad Xochicalco, Campus Tijuana, Mexico
| | | | - William H Eger
- Department of Medicine, University of California, San Diego
- School of Social Work, San Diego State University, California
| | - Katie Bailey
- Department of Medicine, University of California, San Diego
| | - Bo-Shan Go
- School of Medicine, University of Amsterdam, The Netherlands
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Braun HM, Taylor JL, Axelrath S. Buprenorphine/naloxone - one formulation that doesn't fit all: a case report. Harm Reduct J 2024; 21:143. [PMID: 39080714 PMCID: PMC11287853 DOI: 10.1186/s12954-024-01054-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/03/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Sublingual buprenorphine, approved for treatment of opioid use disorder since 2002, is most commonly available in co-formulation with naloxone. Naloxone is an opioid antagonist minimally absorbed when sublingual (SL) buprenorphine/naloxone is taken as prescribed; it is thought to reduce potential for misuse via intravenous administration. However, growing data and clinical experience demonstrate that previously accepted assumptions about the pharmacokinetics of these medications may not apply to all patients. CASE PRESENTATION We present a patient whose adverse post-administration side effects on SL buprenorphine/naloxone resolved with transition to SL buprenorphine monoproduct. DISCUSSION Naloxone can be detected in nearly all patients taking SL buprenorphine/naloxone, though with apparent variability in clinical effect. In a minority of patients, naloxone can contribute to adverse and potentially treatment-limiting side effects. Furthermore, the naloxone component is commonly misunderstood by patients and providers and can foster mistrust in the therapeutic relationship if providers are perceived to be withholding a more tolerable formulation. Prescribers should have a low threshold to offer buprenorphine alone when clinically appropriate.
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Affiliation(s)
- Hannan M Braun
- Division of General Internal Medicine, Denver Health and Hospital Authority, 301 W 6th Ave, Denver, 80204, CO, USA.
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Jessica L Taylor
- General Internal Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, USA
- Grayken Center for Addiction, Boston Medical Center, Boston, USA
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Tarfa A, Lier AJ, Shenoi SV, Springer SA. Considerations when prescribing opioid agonist therapies for people living with HIV. Expert Rev Clin Pharmacol 2024; 17:549-564. [PMID: 38946101 PMCID: PMC11299801 DOI: 10.1080/17512433.2024.2375448] [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: 01/30/2024] [Accepted: 06/28/2024] [Indexed: 07/02/2024]
Abstract
INTRODUCTION Medications for opioid use disorder (MOUD) include opioid agonist therapies (OAT) (buprenorphine and methadone), and opioid antagonists (extended-release naltrexone). All forms of MOUD improve opioid use disorder (OUD) and HIV outcomes. However, the integration of services for HIV and OUD remains inadequate. Persistent barriers to accessing MOUD underscore the immediate necessity of addressing pharmacoequity in the treatment of OUD in persons with HIV (PWH). AREAS COVERED In this review article, we specifically focus on OAT among PWH, as it is the most commonly utilized form of MOUD. Specifically, we delineate the intersection of HIV and OUD services, emphasizing their integration into the United States Ending the HIV Epidemic (EHE) plan by offering comprehensive screening, testing, and treatment for both HIV and OUD. We identify potential drug interactions of OAT with antiretroviral therapy (ART), address disparities in OAT access, and present the practical benefits of long-acting formulations of buprenorphine, ART, and pre-exposure prophylaxis for improving HIV prevention and treatment and OUD management. EXPERT OPINION Optimizing OUD outcomes in PWH necessitates careful attention to diagnosing OUD, initiating OUD treatment, and ensuring medication retention. Innovative approaches to healthcare delivery, such as mobile pharmacies, can integrate both OUD and HIV and reach underserved populations.
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Affiliation(s)
- Adati Tarfa
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
| | - Audun J. Lier
- Renaissance School of Medicine at Stony Brook University; Northport VA Medical Center, 79 Middleville Road, Northport, NY 11768
| | - Sheela V. Shenoi
- Yale School of Medicine, VA Connecticut Health System, 950 Campbell Avenue, West Haven, CT 06516
| | - Sandra A. Springer
- Yale University School of Medicine; 135 College Street, Suite 280, New Haven, New Haven, CT 06510
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Meadows L, Simonton A, Rolin D. Buprenorphine and Opioid Use Disorder Training: Graduate Nursing Curricula Recommendations. J Psychosoc Nurs Ment Health Serv 2024; 62:17-24. [PMID: 38095850 DOI: 10.3928/02793695-20231206-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Opioid use disorder (OUD) is a public health emergency, with a shortage of providers trained to prescribe buprenorphine for OUD treatment. We conducted a systematic review to examine advanced practice RN (APRN) and medical school programs that included OUD content or Drug Addiction Treatment Act waiver training and evaluate the outcomes of those curricular modifications. APRN and medical school programs that provided OUD content or waiver training saw improvements in students' knowledge and self-efficacy for managing buprenorphine treatment and reduced stigma toward individuals with OUD. Students' perceptions of training were largely positive, and the programs' results indicated improved practice outcomes related to the use of buprenorphine. Further inclusion of OUD content and training in APRN curricula will increase the number of capable buprenorphine prescribers, which will increase access to buprenorphine for individuals with OUD. [Journal of Psychosocial Nursing and Mental Health Services, 62(7), 17-24.].
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Patel EU, Grieb SM, Winiker AK, Ching J, Schluth CG, Mehta SH, Kirk GD, Genberg BL. Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland. Harm Reduct J 2024; 21:91. [PMID: 38720307 PMCID: PMC11077846 DOI: 10.1186/s12954-024-01008-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.
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Affiliation(s)
- Eshan U Patel
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA.
| | - Suzanne M Grieb
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abigail K Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jennifer Ching
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Catherine G Schluth
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Shruti H Mehta
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
| | - Gregory D Kirk
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Becky L Genberg
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD, 21205, USA
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Stopka TJ, Estadt AT, Leichtling G, Schleicher JC, Mixson LS, Bresett J, Romo E, Dowd P, Walters SM, Young AM, Zule W, Friedmann PD, Go VF, Baker R, Fredericksen RJ. Barriers to opioid use disorder treatment among people who use drugs in the rural United States: A qualitative, multi-site study. Soc Sci Med 2024; 346:116660. [PMID: 38484417 PMCID: PMC10997882 DOI: 10.1016/j.socscimed.2024.116660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 11/26/2023] [Accepted: 02/05/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND In 2020, 2.8 million people required substance use disorder (SUD) treatment in nonmetropolitan or 'rural' areas in the U.S. Among this population, only 10% received SUD treatment from a specialty facility, and 1 in 500 received medication for opioid use disorder (MOUD). We explored the context surrounding barriers to SUD treatment in the rural United States. METHODS We conducted semi-structured, in-depth interviews from 2018 to 2019 to assess barriers to SUD treatment among people who use drugs (PWUD) across seven rural U.S. study sites. Using the social-ecological model (SEM), we examined individual, interpersonal, organizational, community, and policy factors contributing to perceived barriers to SUD treatment. We employed deductive and inductive coding and analytical approaches to identify themes. We also calculated descriptive statistics for participant characteristics and salient themes. RESULTS Among 304 participants (55% male, mean age 36 years), we identified barriers to SUD treatment in rural areas across SEM levels. At the individual/interpersonal level, relevant themes included: fear of withdrawal, the need to "get things in order" before entering treatment, close-knit communities and limited confidentiality, networks and settings that perpetuated drug use, and stigma. Organizational-level barriers included: strict facility rules, treatment programs managed like corrections facilities, lack of gender-specific treatment programs, and concerns about jeopardizing employment. Community-level barriers included: limited availability of treatment in local rural communities, long distances and limited transportation, waitlists, and a lack of information about treatment options. Policy-level themes included insurance challenges and system-imposed barriers such as arrest and incarceration. CONCLUSION Our findings highlight multi-level barriers to SUD treatment in rural U.S. communities. Salient barriers included the need to travel long distances to treatment, challenges to confidentiality due to small, close-knit communities where people are highly familiar with one another, and high-threshold treatment program practices. Our findings point to the need to facilitate the elimination of treatment barriers at each level of the SEM in rural America.
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Affiliation(s)
- T J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - A T Estadt
- Division of Epidemiology, College of Public Health, The Ohio State University, Columbus, OH, USA
| | | | - J C Schleicher
- University of Wisconsin-Madison, School of Medicine and Public Health, Department of Medicine, Madison, WI, USA
| | - L S Mixson
- University of Washington, Department of Medicine, Seattle, WA, USA
| | - J Bresett
- Southern Illinois University at Carbondale, Dept of Public Health, Carbondale, IL, USA
| | - E Romo
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - P Dowd
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - S M Walters
- New York University's Grossman School of Medicine, New York, NY, USA
| | - A M Young
- College of Public Health, University of Kentucky, Lexington, KY, USA
| | - W Zule
- RTI International, Research Triangle, NC, USA
| | - P D Friedmann
- Chan Medical School-Baystate, University of Massachusetts, Springfield, MA, USA
| | - V F Go
- University, of North Carolina, Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - R Baker
- Oregon Health & Science University-Portland State University School of Public Health, Portland, OR, USA
| | - R J Fredericksen
- University of Washington, Department of Medicine, Seattle, WA, USA
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Tonin FS, Alves da Costa F, Fernandez-Llimos F. Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: an overview and evidence gap mapping. Addict Sci Clin Pract 2024; 19:9. [PMID: 38310293 PMCID: PMC10838443 DOI: 10.1186/s13722-024-00439-9] [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: 05/29/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND This study aimed to synthetize the evidence on the effectiveness of harm minimization interventions on reducing blood-borne infection transmission and injecting behaviors among people who inject drugs (PWID) through a comprehensive overview of systematic reviews and evidence gap mapping. METHODS A systematic review was conducted with searches in PubMed and Scopus to identify systematic reviews assessing the impact of interventions aimed at reducing the harms associated with injectable drug use. The overall characteristics of the studies were extracted and their methodological quality was assessed using AMSTAR-2. An evidence gap map was constructed, highlighting the most frequently reported outcomes by intervention (CRD42023387713). RESULTS Thirty-three systematic reviews were included. Of these, 14 (42.2%) assessed the impact of needle/syringe exchange programs (NSEP) and 11 (33.3%) examined opioid agonist therapy (OAT). These interventions are likely to be associated with reductions of HIV/HCV incidence (10-40% risk reduction for NSEP; 50-60% for OAT) and sharing injecting paraphernalia (50% for NSEP, 25-85% for OAT), particularly when combined (moderate evidence). Behavioral/educational interventions were assessed in 12 reviews (36.4%) with most authors in favor/partially in favor of the use of these approaches (moderate evidence). Take-home naloxone programs and supervised-injection facilities were each assessed in two studies (6.1%), which reported inconclusive results (limited/inconsistent evidence). Most authors reported high levels of heterogeneity and risk of bias. Other interventions and outcomes were inadequately reported. Most systematic reviews presented low or critically low quality. CONCLUSION The evidence is sufficient to support the effectiveness of OAT, NSEP and their combination in reducing blood-borne infection transmission and certain injecting behaviors among PWID. However, evidence of other harm minimizations interventions in different settings and for some outcomes remain insufficient.
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Affiliation(s)
- Fernanda S Tonin
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Filipa Alves da Costa
- Research Institute for Medicines (iMED.ULisboa), Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, Lisbon, Portugal.
| | - Fernando Fernandez-Llimos
- Applied Molecular Biosciences Unit, (UCIBIO-i4HB) Laboratory of Pharmacology, Faculty of Pharmacy, University of Porto, Porto, Portugal
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Cepeda JA, Beletsky L, Abramovitz D, Saldana CR, Kahn JG, Bañuelos A, Rangel G, Arredondo J, Vickerman P, Bórquez A, Strathdee SA, Martin NK. Cost-effectiveness of a police education program on HIV and overdose among people who inject drugs in Tijuana, Mexico. LANCET REGIONAL HEALTH. AMERICAS 2024; 30:100679. [PMID: 38327278 PMCID: PMC10847144 DOI: 10.1016/j.lana.2024.100679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 02/09/2024]
Abstract
Background Incarceration is associated with drug-related harms among people who inject drugs (PWID). We trained >1800 police officers in Tijuana, Mexico on occupational safety and HIV/HCV, harm reduction, and decriminalization reforms (Proyecto Escudo). We evaluated its effect on incarceration, population impact and cost-effectiveness on HIV and fatal overdose among PWID. Methods We assessed self-reported recent incarceration in a longitudinal cohort of PWID before and after Escudo. Segmented regression was used to compare linear trends in log risk of incarceration among PWID pre-Escudo (2012-2015) and post-Escudo (2016-2018). We estimated population impact using a dynamic model of HIV transmission and fatal overdose among PWID, with incarceration associated with syringe sharing and fatal overdose. The model was calibrated to HIV and incarceration patterns in Tijuana. We compared a scenario with Escudo (observed incarceration declines for 2 years post-Escudo among PWID from the segmented regression) compared to a counterfactual of no Escudo (continuation of stable pre-Escudo trends), assessing cost-effectiveness from a societal perspective. Using a 2-year intervention effect and 50-year time horizon, we determined the incremental cost-effectiveness ratio (ICER, in 2022 USD per disability-adjusted life years [DALYs] averted). Findings Compared to stable incarceration pre-Escudo, for every three-month interval in the post-Escudo period, recent incarceration among PWID declined by 21% (adjusted relative risk = 0.79, 95% CI: 0.68-0.91). Based on these declines, we estimated 1.7% [95% interval: 0.7%-3.5%] of new HIV cases and 12.2% [4.5%-26.6%] of fatal overdoses among PWID were averted in the 2 years post-Escudo, compared to a counterfactual without Escudo. Escudo was cost-effective (ICER USD 3746/DALY averted compared to a willingness-to-pay threshold of $4842-$13,557). Interpretation Escudo is a cost-effective structural intervention that aligned policing practices and human-rights-based public health practices, which could serve as a model for other settings where policing constitutes structural HIV and overdose risk among PWID. Funding National Institute on Drug Abuse, UC MEXUS CONACyT, and the San Diego Center for AIDS Research (SD CFAR).
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Affiliation(s)
- Javier A. Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Leo Beletsky
- School of Law, Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Daniela Abramovitz
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Carlos Rivera Saldana
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - James G. Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, CA, USA
| | | | - Gudelia Rangel
- Mexico Section, U.S.-Mexico Border Health Commission, Tijuana, Mexico
| | - Jaime Arredondo
- Canadian Institute for Substance Use Research, University of Victoria, BC, Canada
| | - Peter Vickerman
- Population Health Science Institute, University of Bristol, UK
| | - Annick Bórquez
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Steffanie A. Strathdee
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
| | - Natasha K. Martin
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, CA, USA
- Population Health Science Institute, University of Bristol, UK
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Simpson KA, Bolshakova M, Kirkpatrick MG, Davis JP, Cho J, Barrington-Trimis J, Kral AH, Bluthenthal RN. Characterizing Opioid Withdrawal Experiences and Consequences Among a Community Sample of People Who Use Opioids. Subst Use Misuse 2024; 59:886-894. [PMID: 38287506 PMCID: PMC11062512 DOI: 10.1080/10826084.2024.2306221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Opioid withdrawal symptoms are a highly salient and consequential health condition experienced by people who use opioids (PWUO). This study utilized qualitative interviews to explore opioid withdrawal experiences and consequences among PWUO in Los Angeles County, USA. METHODS Semi-structured qualitative interviews were conducted with 22 PWUO (aged 27-63 years) between May 2021 and May 2022. Participants self-reported opioid and injection drug use in the last 30 days. We employed an inductive thematic approach to systematically code and synthesize textual interview data. RESULTS Participants experienced withdrawal symptoms frequently, with many going to great lengths to avoid them. Withdrawal pain was described as incapacitating and interfered with PWUO's ability to sustain regular employment and ensure stable housing. Avoiding withdrawal was described as influential in driving decisions to continue using opioids. Mechanisms for managing withdrawal included using other substances to the point of sedation. PWUO who transitioned from heroin to fentanyl use revealed more frequent, painful, and faster onset of withdrawal symptoms. Adverse withdrawal experiences and fear of precipitated withdrawal from buprenorphine were barriers to treatment initiation and continuation. CONCLUSION Withdrawal symptoms among PWUO increase health risk. Improved strategies to treat opioid withdrawal are urgently needed. Solutions such as safe supply and intentional opioid withdrawal interventions (educational trainings, withdrawal comfort kits) are needed to improve withdrawal management and reduce opioid-related harm.
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Affiliation(s)
- Kelsey A. Simpson
- Division of Infectious Diseases and Global Public Health, Department of Medicine, University of California, San Diego, 9500, Gilman Drive, La Jolla, CA 92093
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Maria Bolshakova
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Matthew G. Kirkpatrick
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Jordan P. Davis
- University of Southern California Suzanne Dworak-Peck School of Social Work, 669 W 34th Street, Los Angeles, CA 90089
| | - Junhan Cho
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Jessica Barrington-Trimis
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
| | - Alex H. Kral
- Community Health Research Division, RTI International, 2150 Shattuck Avenue, Suite 800, Berkeley, CA 94704
| | - Ricky N. Bluthenthal
- Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, 1845 N. Soto St. Los Angeles, CA 90033
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Schwarz T, Anzenberger J, Busch M, Gmel G, Kraus L, Krausz M, Labhart F, Meyer M, Schaub MP, Westenberg JN, Uhl A. Opioid agonist treatment in transition: A cross-country comparison between Austria, Germany and Switzerland. Drug Alcohol Depend 2024; 254:111036. [PMID: 38091902 DOI: 10.1016/j.drugalcdep.2023.111036] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS OAT is a well developed and successful treatment strategy for opioid dependent patients in Europe. It has significantly contributed to the fight against the HIV and HCV pandemics, leading to an increased life expectancy in this population. Building on the OAT experiences in Austria, Germany, and Switzerland and their models of care, the objective of this study is to analyse experiences and changes in patient structures to identify necessary adaptations for the system of care. METHODS We analysed national register-based data from patients receiving OAT during the period spanning from 2010 to 2020 in Austria, Germany (cases), and Switzerland. We examined and compared OAT policies and practice at national levels through a review of literature and publicly available policy documents. RESULTS Across these three countries, the life expectancy of OAT patients increased substantially. The mean age increased from 33.0 in 2010 to 39.1 in 2020 in Austria, from 35.6 years to 41.5 years in Germany (cases), and from 39.6 to 47.1 in Switzerland, respectively. In all three countries, the percentage of patients/cases aged 60 years and older increased more than tenfold between 2010 and 2020. CONCLUSIONS Integrated support models, reliable care structures, internationally comparable high treatment coverage, flexible prescribing practices, and a wide range of available OAT medications are successful strategies. The experiences in these countries indicate that it is possible to address the complex and chronic nature of opioid dependence and its concurrent mental and physical health challenges, resulting in an increasing life expectancy of OAT patients.
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Affiliation(s)
- Tanja Schwarz
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Doctoral Programme Meduni Vienna, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria.
| | - Judith Anzenberger
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Martin Busch
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Gerhard Gmel
- Addiction Switzerland, Lausanne, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ludwig Kraus
- IFT Institut für Therapieforschung, Mental Health and Addiction Research, Munich, Germany; Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden; Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary; Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Krausz
- University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Florian Labhart
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Maximilian Meyer
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction, Zurich, Switzerland
| | - Jean N Westenberg
- Addiction Switzerland, Lausanne, Switzerland; University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Alfred Uhl
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Sigmund Freud University Vienna, Vienna, Austria
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Lawson SG, Foudray CMA, Lowder EM, Ray B, Carey KL. The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 156:209192. [PMID: 37866440 DOI: 10.1016/j.josat.2023.209192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/25/2023] [Accepted: 10/10/2023] [Indexed: 10/24/2023]
Abstract
INTRODUCTION Individuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied. METHODS This retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes. RESULTS We found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization-specifically group therapy and substance use outpatient services-and psychiatric recovery (i.e., behavioral health needs at exit). CONCLUSIONS Co-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.
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Affiliation(s)
- Spencer G Lawson
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Chelsea M A Foudray
- Department of Criminology, Law and Society, George Mason University, Fairfax, VA, USA
| | - Evan M Lowder
- Department of Criminology, Law and Society, George Mason University, Fairfax, VA, USA
| | - Bradley Ray
- Division for Applied Justice Research, RTI International, Research Triangle Park, NC, USA
| | - Kory L Carey
- Indiana Family and Social Services Administration, Indianapolis, IN, USA
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16
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Pasman E, O'Shay S, Brown S, Madden EF, Agius E, Resko SM. Ambivalence and contingencies: A qualitative examination of peer recovery coaches' attitudes toward medications for opioid use disorder. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 155:209121. [PMID: 37474006 DOI: 10.1016/j.josat.2023.209121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/18/2023] [Accepted: 07/11/2023] [Indexed: 07/22/2023]
Abstract
INTRODUCTION Peer recovery coaches (PRCs) are an important provider group affecting medications for opioid use disorder (MOUD) uptake and retention. However, some PRCs may have experiences and beliefs that do not align with the use of MOUD. This study examines PRCs' perceptions of MOUD and how PRCs' attitudes affect their interactions with clients. The article also explores factors influencing PRCs' attitudes. METHODS The study team conducted semi-structured interviews by phone with PRCs in Michigan (N = 34, July through September 2021). The study asked participants about their opinion of MOUD, how they help clients to make decisions about MOUD, and whether they have encountered negative attitudes toward MOUD in their work. Data analysis was guided by Tracy's (2020) iterative phronetic approach. RESULTS Nearly all PRCs acknowledged the social stigma surrounding MOUD. PRCs described the stigma toward MOUD as affecting treatment access, utilization, and recovery support. While most PRCs expressed support for many recovery pathways, support for MOUD was contingent on the type of medication and the conditions under which it is used. PRCs often described MOUD as acceptable only in the short-term when paired with psychosocial interventions, after nonpharmacological treatment attempts had failed. PRCs with concerns about MOUD reported sometimes avoiding discussions about MOUD with clients, spreading misinformation about MOUD, and encouraging clients to discontinue treatment. However, many PRCs expressed a desire to support clients' self-determination despite their own biases. CONCLUSIONS Findings highlight a need for education and stigma reduction among PRCs and point to specific areas for intervention. PRCs described deeply engrained beliefs about MOUD rooted in their own treatment histories and recovery practices. Provision of high-quality training and supervision to shift attitudes among PRCs will be key to increasing the use of MOUD.
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Affiliation(s)
- Emily Pasman
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America.
| | - Sydney O'Shay
- Department of Communication Studies & Philosophy, Utah State University, 0720 Old Main Hill, Logan, UT 84322, United States of America
| | - Suzanne Brown
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America
| | - Erin Fanning Madden
- Department of Family Medicine and Public Health Sciences, Wayne State University School of Medicine, 3939 Woodward Ave, Detroit, MI 48201, United States of America
| | - Elizabeth Agius
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America
| | - Stella M Resko
- School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, United States of America; Merrill Palmer Skillman Institute, Wayne State University, 71 E Ferry St, Detroit, MI 48202, United States of America
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Hill K, Thakarar K, Eslinger H, Prosperino L, Sue KL. Improving the Health of People Who Inject Drugs Through COVID-19-Related Policies. Public Health Rep 2023; 138:862-864. [PMID: 37610106 PMCID: PMC10576482 DOI: 10.1177/00333549231192468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Affiliation(s)
- Katherine Hill
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Kinna Thakarar
- Center for Interdisciplinary Population & Health Research/Maine, Portland, ME, USA
- Department of Medicine, Maine Medical Center, Portland, ME, USA
- Tufts University School of Medicine, Boston, MA, USA
- Maine Medical Partners Adult Infectious Diseases, South Portland, ME, USA
| | | | | | - Kimberly L. Sue
- Department of General Internal Medicine, School of Medicine, Yale University, New Haven, CT, USA
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Corace K, Thavorn K, Suschinsky K, Willows M, Leece P, Kahan M, Nijmeh L, Aubin N, Roach M, Garner G, Saskin R, Kim E, Rice D, Taha S, Garber G, Hutton B. Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use. JAMA Netw Open 2023; 6:e2344528. [PMID: 37991762 PMCID: PMC10665968 DOI: 10.1001/jamanetworkopen.2023.44528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 10/12/2023] [Indexed: 11/23/2023] Open
Abstract
Importance New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. Objective To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. Design, Setting, and Participants A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Exposures Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. Main Outcomes and Measures The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. Results In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. Conclusions and Relevance In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.
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Affiliation(s)
- Kim Corace
- Substance Use and Concurrent Disorders Program, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- University of Ottawa Institute of Mental Health Research at The Royal, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Kednapa Thavorn
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Kelly Suschinsky
- Substance Use and Concurrent Disorders Program, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
| | - Melanie Willows
- Substance Use and Concurrent Disorders Program, Royal Ottawa Mental Health Centre, Ottawa, Ontario, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- University of Ottawa Institute of Mental Health Research at The Royal, Ottawa, Ontario, Canada
| | - Pamela Leece
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Substance Use Service, Women’s College Hospital, Toronto, Ontario, Canada
- Public Health Ontario, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Meldon Kahan
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Substance Use Service, Women’s College Hospital, Toronto, Ontario, Canada
| | - Larry Nijmeh
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Lakeridge Health, Oshawa, Ontario, Canada
- Department of Family Medicine, Queens University, Kingston, Ontario, Canada
| | - Natalie Aubin
- Health Sciences North, Sudbury, Ontario, Canada
- School of Northern and Rural Health, Laurentian University, Sudbury, Ontario, Canada
| | | | - Gord Garner
- Community Addictions Peer Support Association, Ottawa, Ontario, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eliane Kim
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Danielle Rice
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
- St Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Sheena Taha
- Canadian Centre on Substance Use and Addiction, Ottawa, Ontario, Canada
| | - Gary Garber
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Brian Hutton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Muthulingam D, Hassett TC, Madden LM, Bromberg DJ, Fraenkel L, Altice FL. Preferences in medications for patients seeking treatment for opioid use disorder: A conjoint analysis. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 154:209138. [PMID: 37544510 DOI: 10.1016/j.josat.2023.209138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 07/05/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION The opioid epidemic continues to be a public health crisis that has worsened during the COVID-19 pandemic. Medications for opioid use disorder (MOUD) are the most effective way to reduce complications from opioid use disorder (OUD), but uptake is limited by both structural and individual factors. To inform strategies addressing individual factors, we evaluated patients' preferences and trade-offs in treatment decisions using conjoint analysis. METHOD We developed a conjoint analysis survey evaluating patients' preferences for FDA-approved MOUDs. We recruited patients with OUD presenting to initiate treatment. This survey included five attributes: induction, location and route of administration, impact on mortality, side effects, and withdrawal symptoms with cessation. Participants performed 12 choice sets, each with two hypothetical profiles and a "none" option. We used Hierarchical Bayes to identify relative importance of each attribute and part-worth utility scores of levels, which we compared using chi-squared analysis. We used the STROBE checklist to guide our reporting of this cross-sectional observational study. RESULTS Five-hundred and thirty participants completed the study. Location with route of administration was the most important attribute. Symptom relief during induction and withdrawal was a second priority. Mortality followed by side effects had lowest relative importance. Attribute levels with highest part-worth utilities showed patients preferred monthly pick-up from a pharmacy rather than daily supervised dosing; and oral medications more than injection/implants, despite the latter's infrequency. CONCLUSION We measured treatment preferences among patients seeking to initiate OUD treatment to inform strategies to scale MOUD treatment uptake. Patients prioritize the route of administration in treatment preference-less frequent pick up, but also injections and implants were less preferred despite their convenience. Second, patients prioritize symptom relief during the induction and withdrawal procedures of medication. These transition periods influence the sustainability of treatment. Although health professionals prioritize mortality, it did not drive decision-making for patients. To our knowledge, this is the largest study on patients' preferences for MOUD among treatment-seeking people with OUD to date. Future analysis will evaluate patient preference heterogeneity to further target program planning, counseling, and decision aid development.
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Affiliation(s)
- Dharushana Muthulingam
- Washington University School of Medicine, Division of Infectious Disease, 4523 Clayton Ave., CB 8051, St. Louis, MO, 63110, United States of America.
| | - Thomas C Hassett
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America
| | - Lynn M Madden
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America; APT Foundation, New Haven, CT, United States of America
| | - Daniel J Bromberg
- Yale School of Public Health, New Haven, CT, United States of America
| | - Liana Fraenkel
- Yale School of Medicine, Section of Rheumatology, New Haven, CT, United States of America
| | - Frederick L Altice
- Yale School of Medicine, Section of Infectious Diseases, AIDS Program, New Haven, CT, United States of America; APT Foundation, New Haven, CT, United States of America; Yale School of Public Health, New Haven, CT, United States of America; University of Malaya, Kuala Lumpur, Malaysia
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20
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McCrary LM, Solomon DA. Source control: treating opioid use disorder among inpatients with related infections, an urgent call to action. AIDS 2023; 37:1901-1903. [PMID: 37646589 DOI: 10.1097/qad.0000000000003663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- L Madeline McCrary
- Division of Infectious Diseases, Department of Medicine
- Department of Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Daniel A Solomon
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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21
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Adams A, Blawatt S, Magel T, MacDonald S, Lajeunesse J, Harrison S, Byres D, Schechter MT, Oviedo-Joekes E. The impact of relaxing restrictions on take-home doses during the COVID-19 pandemic on program effectiveness and client experiences in opioid agonist treatment: a mixed methods systematic review. Subst Abuse Treat Prev Policy 2023; 18:56. [PMID: 37777766 PMCID: PMC10543348 DOI: 10.1186/s13011-023-00564-9] [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] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 09/13/2023] [Indexed: 10/02/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic led to an unprecedented relaxation of restrictions on take-home doses in opioid agonist treatment (OAT). We conducted a mixed methods systematic review to explore the impact of these changes on program effectiveness and client experiences in OAT. METHODS The protocol for this review was registered in PROSPERO (CRD42022352310). From Aug.-Nov. 2022, we searched Medline, Embase, CINAHL, PsycInfo, Web of Science, Cochrane Register of Controlled Trials, and the grey literature. We included studies reporting quantitative measures of retention in treatment, illicit substance use, overdose, client health, quality of life, or treatment satisfaction or using qualitative methods to examine client experiences with take-home doses during the pandemic. We critically appraised studies using the Mixed Methods Appraisal Tool. We synthesized quantitative data using vote-counting by direction of effect and presented the results in harvest plots. Qualitative data were analyzed using thematic synthesis. We used a convergent segregated approach to integrate quantitative and qualitative findings. RESULTS Forty studies were included. Most were from North America (23/40) or the United Kingdom (9/40). The quantitative synthesis was limited by potential for confounding, but suggested an association between take-home doses and increased retention in treatment. There was no evidence of an association between take-home doses and illicit substance use or overdose. Qualitative findings indicated that take-home doses reduced clients' exposure to unregulated substances and stigma and minimized work/treatment conflicts. Though some clients reported challenges with managing their medication, the dominant narrative was one of appreciation, reduced anxiety, and a renewed sense of agency and identity. The integrated analysis suggested reduced treatment burden as an explanation for improved retention and revealed variation in individual relationships between take-home doses and illicit substance use. We identified a critical gap in quantitative measures of patient-important outcomes. CONCLUSION The relaxation of restrictions on take-home doses was associated with improved client experience and retention in OAT. We found no evidence of an association with illicit substance use or overdose, despite the expansion of take-home doses to previously ineligible groups. Including patient-important outcome measures in policy, program development, and treatment planning is essential to ensuring that decisions around take-home doses accurately reflect their value to clients.
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Affiliation(s)
- Alison Adams
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
| | - Sarin Blawatt
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Tianna Magel
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Scott MacDonald
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Julie Lajeunesse
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - Scott Harrison
- Providence Health Care, Providence Crosstown Clinic, 84 West Hastings Street, Vancouver, BCV6B 1G6, Canada
| | - David Byres
- Provincial Health Services Authority, 200-1333 W Broadway, Vancouver, BC, V6H 4C1, Canada
| | - Martin T Schechter
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Eugenia Oviedo-Joekes
- Centre for Health Evaluation & Outcome Sciences, Providence Health Care, St. Paul's Hospital, 575-1081 Burrard St., Vancouver, BC, V6Z 1Y6, Canada.
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
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22
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Pytell JD, Fojo AT, Keruly JC, Snow LN, Falade-Nwulia O, Moore RD, Chander G, Lesko CR. Measuring time in buprenorphine treatment stages among people with HIV and opioid use disorder by retention definition and its association with cocaine and hazardous alcohol use. Addict Sci Clin Pract 2023; 18:51. [PMID: 37660116 PMCID: PMC10474763 DOI: 10.1186/s13722-023-00408-8] [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: 05/05/2023] [Accepted: 08/23/2023] [Indexed: 09/04/2023] Open
Abstract
BACKGROUND We use a novel, longitudinal approach to describe average time spent in opioid use disorder (OUD) cascade of care stages for people with HIV (PWH) and with OUD, incorporating four definitions of treatment retention. Using this approach, we describe the impact of cocaine or hazardous alcohol use on time spent retained on buprenorphine. METHODS We followed PWH with OUD enrolled in the Johns Hopkins HIV Clinical Cohort from their first buprenorphine treatment episode between 2013 and 2020. We estimated 4-year restricted mean time spent on buprenorphine below buprenorphine retention threshold, on buprenorphine above retention threshold, off buprenorphine and in HIV care, loss to follow-up, and death. Retention definitions were based on retention threshold (180 vs 90 days) and allowable treatment gap (7 vs 30 days). Differences in 2-year restricted mean time spent retained on buprenorphine were estimated for patients with and without cocaine or hazardous alcohol use. RESULTS The study sample (N = 179) was 63% male, 82% non-Hispanic Black, and mean age was 53 (SD 8) years. Patients spent on average 13.9 months (95% CI 11.4, 16.4) on buprenorphine over 4 years. There were differences in time spent retained on buprenorphine based on the retention definition, ranging from 6.5 months (95% CI 4.6, 8.5) to 9.6 months (95% CI 7.4, 11.8). Patients with cocaine use spent fewer months retained on buprenorphine. There were no differences for patients with hazardous alcohol use. CONCLUSIONS PWH with OUD spend relatively little time receiving buprenorphine in their HIV primary care clinic. Concurrent cocaine use at buprenorphine initiation negatively impact time on buprenorphine.
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Affiliation(s)
- Jarratt D Pytell
- Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Mail Stop B180, 12631 E. 17Th Ave, Aurora, CO, 80045, USA.
| | - Anthony T Fojo
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Jeanne C Keruly
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - LaQuita N Snow
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Oluwaseun Falade-Nwulia
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Moore
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Geetanjali Chander
- Division of General Internal Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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23
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Samet JH, Blokhina E, Cheng DM, Rosen S, Lioznov D, Lunze K, Truong V, Gnatienko N, Quinn E, Bushara N, Raj A, Krupitsky E. Rapid access to antiretroviral therapy, receipt of naltrexone, and strengths-based case management versus standard of care for HIV viral load suppression in people with HIV who inject drugs in Russia (LINC-II): an open-label, randomised controlled trial. Lancet HIV 2023; 10:e578-e587. [PMID: 37659841 PMCID: PMC10653654 DOI: 10.1016/s2352-3018(23)00143-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Antiretroviral therapy (ART) coverage in Russia is low for people with HIV who inject drugs. HIV and addiction treatment in Russia are not well integrated. We aimed to evaluate an intervention to link people with HIV in addiction treatment to HIV care to achieve HIV viral load suppression. METHODS LINC-II was a two-arm, open-label, randomised controlled trial at the City Addiction Hospital, Saint Petersburg, Russia. Eligible participants were aged 18 years or older, had a positive HIV status, were not currently on ART, were admitted to a narcology hospital, and had a current diagnosis of opioid use disorder. Participants were randomly assigned (1:1) to a multicomponent intervention (ie, rapid access to ART, naltrexone for opioid use disorder, and strengths-based case management) or standard of care. Blocked randomisation was stratified by history of ART use. The primary outcome was undetectable HIV viral load at 12 months, defined as less than 40 copies per mL. The trial was conducted and analysed according to the intention-to-treat principle. This trial is registered with ClinicalTrials.gov, NCT03290391. FINDINGS Between Sept 19, 2018, and Dec 25, 2020, 953 individuals were screened for eligibility, 225 of whom were randomly assigned to the intervention (n=111) or standard of care (n=114). 136 (60%) participants were male and 89 (40%) were female. Participants in the intervention group had higher odds of HIV viral load suppression at 12 months compared with participants in the standard-of-care group (52 [47%] vs 26 [23%]; adjusted odds ratio 3·0 [95% CI 1·4-6·4]; p=0·0039). 21 adverse events (18 in the intervention group and three in the standard-of-care group)and 14 deaths (four in the intervention group and ten in the standard-of-care group) were reported in the study. INTERPRETATION Given the effectiveness of the LINC-II intervention, scaling up this model could be one strategy to advance the UNAIDS goal of ending the HIV epidemic. FUNDING National Institute on Drug Abuse and Providence/Boston Center for AIDS Research.
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Affiliation(s)
- Jeffrey H Samet
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA.
| | - Elena Blokhina
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, Boston, MA, USA
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, MA, USA
| | - Dmitry Lioznov
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Karsten Lunze
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ve Truong
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Natalia Gnatienko
- Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Emily Quinn
- The Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, Boston, MA, USA
| | - Natalia Bushara
- First Pavlov State Medical University of St Petersburg, Saint Petersburg, Russia
| | - Anita Raj
- Center on Gender Equity and Health, University of California San Diego School of Medicine, San Diego, CA, USA
| | - Evgeny Krupitsky
- Bekhterev National Medical Research Center for Psychiatry and Neurology, Saint Petersburg, Russia
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Rudolph JE, Cepeda JA, Astemborski J, Kirk GD, Mehta SH, Genberg BL. Trajectories of drug treatment and illicit opioid use in the AIDS Linked to the IntraVenous Experience cohort, 2014-2019. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 118:104120. [PMID: 37429162 PMCID: PMC10528295 DOI: 10.1016/j.drugpo.2023.104120] [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] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/01/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Medication for opioid use disorder (MOUD) is an effective intervention to combat opioid use disorder and overdose, yet there is limited understanding of engagement in treatment over time in the community, contextualized by ongoing substance use. We aimed to identify concurrent trajectories of methadone prescriptions, buprenorphine prescriptions, and illicit opioid use among older adults with a history of injection drug use. METHODS We used data on 887 participants from the AIDS Linked to the IntraVenous Experience cohort, who were engaged in the study in 2013 and attended ≥1 visit during follow-up (2014-2019). Outcomes were self-reported MOUD prescription and illicit opioid use in the last 6 months. To identify concurrent trajectories in all 3 outcomes, we used group-based multi-trajectory modeling. We examined participant characteristics, including sociodemographics, HIV status, and other substance use, overall and by cluster. RESULTS We identified 4 trajectory clusters: (1) no MOUD and no illicit opioid use (43%); (2) buprenorphine and some illicit opioid use (11%); (3) methadone and no illicit opioid use (28%); and (4) some methadone and illicit opioid use (18%). While prevalence of each outcome was stable across time, transitions on/off treatment or on/off illicit opioid use occurred, with the rate of transition varying by cluster. The rate of transition was highest in Cluster 3 (0.74/person-year) and lowest in Cluster 1 (0.18/person-year). We saw differences in participant characteristics by cluster, including that the buprenorphine cluster had the highest proportion of people with HIV and participants who identified as non-Hispanic Black. CONCLUSIONS Most participants had discontinued illicit opioid use and were also not accessing MOUD. Trajectories defined by engagement with buprenorphine or methadone had distinct sociodemographic and behavioral characteristics, indicating that tailored interventions to expand access to both types of treatment are likely needed to reduce harms associated with untreated opioid use disorder.
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Affiliation(s)
- Jacqueline E Rudolph
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA.
| | - Javier A Cepeda
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Jacquie Astemborski
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory D Kirk
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA; Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Shruti H Mehta
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Becky L Genberg
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
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25
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Troberg K, Bråbäck M, Isendahl P, Nilsson S, Dahlman D, Håkansson A. Malmö Treatment Referral and Intervention Study (MATRIS)-36-month follow-up on retention and substance use among patients referred from needle exchange to opioid agonist treatment-The role of stimulant use at baseline. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023:209036. [PMID: 37054920 DOI: 10.1016/j.josat.2023.209036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 01/26/2023] [Accepted: 04/06/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Opioid use disorder (OUD) is the leading cause of overdose morbidity and mortality globally. Retention in opioid agonist treatment (OAT) is crucial as it effectively reduces overdose mortality among individuals suffering from OUD. Previous research on treatment retention among heroin-dependent individuals referred from needle exchange programs (NEP) to OAT is scarce, and with predictors for retention in OAT being somewhat inconclusive, further investigations into this subject is of great interest. The aim of our study was to assess 36-month treatment outcomes-defined as retention and illicit drug abstinence-and predictors of OAT discontinuation. METHODS This is a longitudinal cohort study of 71 study subjects successfully referred from a NEP to OAT. Participants were included between October 2011 and April 2013 and followed for 36 months. The study collected data from a structured baseline interview and from patient records, including laboratory data. RESULTS At the 36-month follow-up, retention was 51 % (n = 36), with mean days in treatment of 422 for those who discontinued treatment. Amphetamine use during the 30 days before inclusion was positively correlated with treatment discontinuation (AOR 1.22 [95 % CI 1.02-1.46]). No statistically significant association with retention was seen for gender, age, suicide attempt prior to treatment, or benzodiazepine use during 30 days prior to treatment. Opiate use and use of other substances were reduced over time, with major reductions occurring during the first 6 months. CONCLUSIONS Hitherto, baseline factors predicting retention in OAT have been insufficiently demonstrated. Active referral from NEP to OAT is effective when it comes to long-term retention and reduction of substance use while in treatment. Except from use of amphetamine, the use of other substances prior to OAT was not associated with treatment discontinuation. Further and in-depth analyses of baseline predictors are of importance for OAT retention.
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Affiliation(s)
- Katja Troberg
- Malmö Addiction Center, Region Skåne, Malmö, Sweden; Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden.
| | - Martin Bråbäck
- Malmö Addiction Center, Region Skåne, Malmö, Sweden; Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Pernilla Isendahl
- Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | | | - Disa Dahlman
- Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden; Center for Primary Health Care Research, Department of Clinical Sciences, Lund University, Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- Malmö Addiction Center, Region Skåne, Malmö, Sweden; Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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26
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Lanièce Delaunay C, Klein MB, Godin A, Cox J, Kronfli N, Lebouché B, Doyle C, Maheu-Giroux M. Public health interventions, priority populations, and the impact of COVID-19 disruptions on hepatitis C elimination among people who have injected drugs in Montreal (Canada): A modeling study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 116:104026. [PMID: 37075626 PMCID: PMC10080278 DOI: 10.1016/j.drugpo.2023.104026] [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: 10/26/2022] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/21/2023]
Abstract
BACKGROUND In Montreal (Canada), high hepatitis C virus (HCV) seroincidence (21 per 100 person-years in 2017) persists among people who have injected drugs (PWID) despite relatively high testing rates and coverage of needle and syringe programs (NSP) and opioid agonist therapy (OAT). We assessed the potential of interventions to achieve HCV elimination (80% incidence reduction and 65% reduction in HCV-related mortality between 2015 and 2030) in the context of COVID-19 disruptions among all PWID and PWID living with HIV. METHODS Using a dynamic model of HCV-HIV co-transmission, we simulated increases in NSP (from 82% to 95%) and OAT (from 33% to 40%) coverage, HCV testing (every 6 months), or treatment rate (100 per 100 person-years) starting in 2022 among all PWID and PWID living with HIV. We also modeled treatment scale-up among active PWID only (i.e., people who report injecting in the past six months). We reduced intervention levels in 2020-2021 due to COVID-19-related disruptions. Outcomes included HCV incidence, prevalence, and mortality, and proportions of averted chronic HCV infections and deaths. RESULTS COVID-19-related disruptions could have caused temporary rebounds in HCV transmission. Further increasing NSP/OAT or HCV testing had little impact on incidence. Scaling-up treatment among all PWID achieved incidence and mortality targets among all PWID and PWID living with HIV. Focusing treatment on active PWID could achieve elimination, yet fewer projected deaths were averted (36% versus 48%). CONCLUSIONS HCV treatment scale-up among all PWID will be required to eliminate HCV in high-incidence and prevalence settings. Achieving elimination by 2030 will entail concerted efforts to restore and enhance pre-pandemic levels of HCV prevention and care.
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Affiliation(s)
- Charlotte Lanièce Delaunay
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Marina B Klein
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; CIHR Canadian HIV Trials Network, Vancouver, British Columbia, Canada
| | - Arnaud Godin
- Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Joseph Cox
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Nadine Kronfli
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada
| | - Bertrand Lebouché
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada; Department of Medicine, McGill University Health Centre, Montreal, Quebec, Canada; Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Carla Doyle
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada
| | - Mathieu Maheu-Giroux
- Department of Epidemiology and Biostatistics, McGill University, Montreal, Quebec, Canada.
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27
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Cheema JS, Mathews WC, Wynn A, Bamford LB, Torriani FJ, Hill LA, Rajagopal AV, Yin J, Jain S, Garfein RS, Cachay ER, Martin NK. Hepatitis C Virus Micro-elimination Among People With HIV in San Diego: Are We on Track? Open Forum Infect Dis 2023; 10:ofad153. [PMID: 37065984 PMCID: PMC10099471 DOI: 10.1093/ofid/ofad153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 03/20/2023] [Indexed: 04/18/2023] Open
Abstract
Background Rising incidence of hepatitis C virus (HCV) among people with HIV (PWH) in San Diego County (SDC) was reported. In 2018, the University of California San Diego (UCSD) launched a micro-elimination initiative among PWH, and in 2020 SDC launched an initiative to reduce HCV incidence by 80% across 2015-2030. We model the impact of observed treatment scale-up on HCV micro-elimination among PWH in SDC. Methods A model of HCV transmission among people who inject drugs (PWID) and men who have sex with men (MSM) was calibrated to SDC. The model was additionally stratified by age, gender, and HIV status. The model was calibrated to HCV viremia prevalence among PWH in 2010, 2018, and 2021 (42.1%, 18.5%, and 8.5%, respectively), and HCV seroprevalence among PWID aged 18-39 years, MSM, and MSM with HIV in 2015. We simulate treatment among PWH, weighted by UCSD Owen Clinic (reaching 26% of HCV-infected PWH) and non-UCSD treatment, calibrated to achieve the observed HCV viremia prevalence. We simulated HCV incidence with observed and further treatment scale-up (+/- risk reductions) among PWH. Results Observed treatment scale-up from 2018 to 2021 will reduce HCV incidence among PWH in SDC from a mean of 429 infections/year in 2015 to 159 infections/year in 2030. County-wide scale-up to the maximum treatment rate achieved at UCSD Owen Clinic (in 2021) will reduce incidence by 69%, missing the 80% incidence reduction target by 2030 unless accompanied by behavioral risk reductions. Conclusions As SDC progresses toward HCV micro-elimination among PWH, a comprehensive treatment and risk reduction approach is necessary to reach 2030 targets.
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Affiliation(s)
- Jaskaran S Cheema
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - William C Mathews
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Adriane Wynn
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Laura B Bamford
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Francesca J Torriani
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Lucas A Hill
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Amutha V Rajagopal
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Jeffrey Yin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Sonia Jain
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, California, USA
| | - Richard S Garfein
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Edward R Cachay
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California, USA
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
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Stone J, Trickey A, Walker JG, Bivegete S, Semchuk N, Sazonova Y, Varetska O, Altice FL, Saliuk T, Vickerman P. Modelling the impact and cost-effectiveness of non-governmental organizations on HIV and HCV transmission among people who inject drugs in Ukraine. J Int AIDS Soc 2023; 26:e26073. [PMID: 37012669 PMCID: PMC10070931 DOI: 10.1002/jia2.26073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 02/23/2023] [Indexed: 04/05/2023] Open
Abstract
INTRODUCTION People who inject drugs (PWID) in Ukraine have high prevalences of HIV and hepatitis C virus (HCV). Non-governmental organizations (NGOs) provide PWID with needles/syringes, condoms, HIV/HCV testing and linkage to opioid agonist treatment (OAT) and antiretroviral therapy (ART). We estimated their impact and cost-effectiveness among PWID. METHODS A dynamic HIV and HCV transmission model among PWID was calibrated using data from four national PWID surveys (2011-2017). The model assumed 37-49% coverage of NGOs among community PWID, with NGO contact reducing injecting risk and increasing condom use and recruitment onto OAT and ART. We estimated the historic (1997-2021) and future (2022-2030, compared to no NGO activities from 2022) impact of NGOs in terms of the proportion of HIV/HCV infections averted and changes in HIV/HCV incidence. We estimated the future impact of scaling-up NGOs to 80% coverage with/without scale-up in OAT (5-20%) and ART (64-81%). We estimated the cost per disability-adjusted life-year (DALY) averted of current NGO provision over 2022-2041 compared to NGO activities stopping over 2022-2026, but restarting after that till 2041. We assumed average unit costs of US$80-90 per person-year of NGO contact for PWID. RESULTS With existing coverage levels of NGOs, the model projects that NGOs have averted 20.0% (95% credibility interval: 13.3-26.1) and 9.6% (5.1-14.1) of new HIV and HCV infections among PWID over 1997-2021, respectively, and will avert 31.8% (19.6-39.9) and 13.7% (7.5-18.1) of HIV and HCV infections over 2022-2030. With NGO scale-up, HIV and HCV incidence will decrease by 54.2% (43.3-63.8) and 30.2% (20.5-36.2) over 2022-2030, or 86.7% (82.9-89.3) and 39.8% (31.4-44.8) if OAT and ART are also scaled-up. Without NGOs, HIV and HCV incidence will increase by 51.6% (23.6-76.3) and 13.4% (4.8-21.9) over 2022-2030. Current NGO provision over 2022-2026 will avert 102,736 (77,611-137,512) DALYs when tracked until 2041 (discounted 3% annually), and cost US$912 (702-1222) per DALY averted; cost-effective at a willingness-to-pay threshold of US$1548/DALY averted (0.5xGDP). CONCLUSIONS NGO activities have a crucial preventative impact among PWID in Ukraine which should be scaled-up to help achieve HIV and HCV elimination. Disruptions could have a substantial detrimental impact.
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Affiliation(s)
- Jack Stone
- Population Health SciencesUniversity of BristolBristolUK
| | - Adam Trickey
- Population Health SciencesUniversity of BristolBristolUK
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Breland H, Larkins S, Antonini V, Freese T, McGovern M, Dunn J, Rawson R. Stimulant use among patients in opioid treatment settings: Provider perspectives. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023:209012. [PMID: 36931604 DOI: 10.1016/j.josat.2023.209012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 01/20/2023] [Accepted: 03/05/2023] [Indexed: 03/17/2023]
Abstract
INTRODUCTION Methadone maintenance therapy (MMT) has been a pillar of opioid addiction treatment. Opioid treatment programs (OTPs) have been faced with an escalating threat of stimulant use and related overdose deaths among patients. We know little about how providers currently address stimulant use while maintaining treatment for opioid use disorder. METHODS We conducted 5 focus groups with 36 providers (n = 11 prescribers; 25 behavioral health staff), and collected an additional 46 surveys (n = 7 prescribers; 12 administrators; 27 behavioral health staff). Questions focused on perceptions of patient stimulant use and interventions. We applied inductive analysis to identify themes relevant to identification of stimulant use, use trends, intervention approaches, and perceived needs to improve care. RESULTS Providers indicated a trend of rising stimulant use among patients, especially those experiencing homelessness or comorbid health conditions. They reported a range of approaches to patient screening and intervention, including medication and harm reduction, improving treatment engagement, increasing level of care, and providing incentives. Providers expressed less agreement as to which of these interventions were effective, and though providers saw stimulant use as a common and severe problem, they reported little problem recognition and interest in treatment from their patients. A particular concern of providers was the prevalence and danger of synthetic opioids, such as fentanyl. They sought more research and resources to identify effective interventions and medications to address these issues. Also notable was an interest in contingency management (CM) and use of reinforcements/rewards to encourage stimulant use reduction. CONCLUSION Providers face challenges in treating patients who use both opioids and stimulants. Although methadone is available to treat opioid use, no such "silver bullet" exists for stimulant use disorder. The rise in stimulant and synthetic opioid (e.g., fentanyl) combination products is presenting an extraordinary challenge for providers whose patients are at unprecedented risk for overdose. Providing OTPs with more resources to address polysubstance use is critical. Existing research indicates strong support for CM in OTPs, but providers reported regulatory and financial barriers to implementation. Further research should develop effective interventions that are accessible to providers in OTPs.
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Affiliation(s)
- Haley Breland
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Sherry Larkins
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
| | - Valerie Antonini
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Thomas Freese
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Mark McGovern
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Julia Dunn
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Richard Rawson
- Integrated Substance Abuse Programs, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
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Mark TL, Parish WJ, Weber EM, Steinberg DG, Henretty K. The cost of opioid use disorder-related conditions in Medicare. Drug Alcohol Depend 2023; 244:109778. [PMID: 36701935 DOI: 10.1016/j.drugalcdep.2023.109778] [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: 11/17/2022] [Revised: 01/06/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
BACKGROUND Medicare coverage excludes some levels of substance use disorder (SUD) care, such as intensive outpatient and residential treatment. Expanding access to SUD treatment could increase Medicare spending. However, these costs could be offset if SUD treatment resulted in cost savings from reducing SUD-related medical events and SUD-related medical comorbidities. METHODS This study estimated cost savings from expanding access to SUD treatment for persons with opioid use disorders (OUD) using three methods. First, we compared total Medicare fee-for-service spending on individuals with OUD and no treatment with OUD medications (MOUD) to Medicare spending on individuals without OUD after matching on age/sex/Medicare-Medicaid eligibility status. Second, we compared Medicare spending on individuals with OUD who received MOUD to spending individuals with OUD who did not receive MOUD. Third, we determined OUD-attributable Medicare spending for comorbid physical and mental conditions with a strong association with OUD. RESULTS Beneficiaries with OUD but no MOUD totaled $15.8 billion more than beneficiaries without OUD. Beneficiaries with OUD but no MOUD totaled $12.1 billion more than individuals with OUD and MOUD. Lastly, Medicare spending on OUD-attributable comorbidities was $4.7 billion if all medical and mental health comorbidities were included and $3.0 billion with only medical comorbidities. The totals could be 1.7 times higher if Medicare Advantage enrollees were included. CONCLUSION Expanding Medicare coverage of appropriate levels of care could improve access to effective treatment and reduce the costs associated with untreated OUD. This will likely result in substantial Medicare cost savings.
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Affiliation(s)
- Tami L Mark
- RTI International, 701 13th Street NW, Suite 750, Washington, DC 20005, USA.
| | - William J Parish
- RTI International, 3040 East Cornwallis Rd, P.O. Box 12194, Research Triangle Park, NC 27709, USA.
| | - Ellen M Weber
- Legal Action Center, 810 1st Street, NE, Suite 200, Washington DC 20002, USA.
| | - Deborah G Steinberg
- Legal Action Center, 810 1st Street, NE, Suite 200, Washington DC 20002, USA.
| | - Kristen Henretty
- RTI International, 3040 East Cornwallis Rd, P.O. Box 12194, Research Triangle Park, NC 27709, USA.
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Rich KM, Solomon DA. Medical Complications of Injection Drug Use - Part II. NEJM EVIDENCE 2023; 2:EVIDra2300019. [PMID: 38320028 DOI: 10.1056/evidra2300019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Medical Complications of Injection Drug Use - Part IIDuring the past 2 decades, the risk of death, as well as the prevalence of hospitalizations in the United States, has increased substantially among people who inject drugs, mainly because of the opioid epidemic. In Part Two of this two-part review, the authors review complications observed in people who inject drugs and strategies to reduce harm.
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Affiliation(s)
| | - Daniel A Solomon
- Harvard Medical School, Boston
- Division of Infectious Diseases, Brigham and Women's Hospital, Boston
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Ryan DA, Montoya ID, Koutoujian PJ, Siddiqi K, Hayes E, Jeng PJ, Cadet T, McCollister KE, Murphy SM. Budget impact tool for the incorporation of medications for opioid use disorder into jail/prison facilities. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 146:208943. [PMID: 36880906 PMCID: PMC10084043 DOI: 10.1016/j.josat.2022.208943] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/02/2022] [Accepted: 12/30/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Given the personal and public consequences of untreated/undertreated OUD among persons involved in the justice system, an increasing number of jails and prisons are incorporating medication for opioid use disorder (MOUD) into their system. Estimating the costs of implementing and sustaining a particular MOUD program is vital to detention facilities, which typically face modest, fixed health care budgets. We developed a customizable budget impact tool to estimate the implementation and sustainment costs of numerous MOUD delivery models for detention facilities. METHODS The aim is to describe the tool and present an application of a hypothetical MOUD model. The tool is populated with resources required to implement and sustain various MOUD models in detention facilities. We identified resources via micro-costing techniques alongside randomized clinical trials. The resource-costing method is used to assign values to resources. Resources/costs are categorized as (a) fixed, (b) time-dependent, and (c) variable. Implementation costs include (a), (b), and (c) over a specified timeframe. Sustainment costs include (b) and (c). The MOUD model example entails offering all three FDA-approved medications, with methadone and buprenorphine provided by vendors, and naltrexone by the jail/prison facility. RESULTS Fixed resources/costs are incurred only once, including accreditation fees and trainings. Time-dependent resources/costs are recurring, but fixed over a given time-period; e.g., medication delivery and staff meetings. Variable resources/costs are those that are a direct function of the number of persons treated, such as the medication provided to each patient. Using nationally representative prices, we estimated fixed/sustainment costs to be $2919/patient, over 1 year. This article estimates annual sustainment costs to be $2885/patient. CONCLUSION The tool will serve as a valuable asset to jail/prison leadership, policymakers, and other stakeholders interested in identifying/estimating the resources and costs associated with alternative MOUD delivery models, from the planning stages through sustainment.
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Affiliation(s)
- Danielle A Ryan
- Weill Cornell Medical College, Department of Population Health Sciences, 425 East 61(st) Street, Suite 301, New York, NY 10065, United States of America.
| | - Iván D Montoya
- University of Miami Miller School of Medicine, Department of Public Health Sciences, 1120 N.W. 14(th) Street, Suite 1024, Miami, FL 33136, United States of America
| | - Peter J Koutoujian
- Middlesex House of Corrections and Jail, 269 Treble Cove Rd., North Billerica, MA 01862, United States of America
| | - Kashif Siddiqi
- Middlesex House of Corrections and Jail, 269 Treble Cove Rd., North Billerica, MA 01862, United States of America
| | - Edmond Hayes
- Franklin County Jail, 160 Elm St., Greenfield, MA 01301, United States of America
| | - Philip J Jeng
- Weill Cornell Medical College, Department of Population Health Sciences, 425 East 61(st) Street, Suite 301, New York, NY 10065, United States of America
| | - Techna Cadet
- Weill Cornell Medical College, Department of Population Health Sciences, 425 East 61(st) Street, Suite 301, New York, NY 10065, United States of America
| | - Kathryn E McCollister
- University of Miami Miller School of Medicine, Department of Public Health Sciences, 1120 N.W. 14(th) Street, Suite 1024, Miami, FL 33136, United States of America
| | - Sean M Murphy
- Weill Cornell Medical College, Department of Population Health Sciences, 425 East 61(st) Street, Suite 301, New York, NY 10065, United States of America
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Applying Game Theory Models to Inpatient Medicine: Opportunities to Improve Care. J Community Hosp Intern Med Perspect 2023; 13:20-24. [PMID: 36817294 PMCID: PMC9924631 DOI: 10.55729/2000-9666.1135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/01/2022] [Accepted: 10/11/2022] [Indexed: 01/11/2023] Open
Abstract
Inpatient hospital costs have been increasing exponentially in the United States. Part of this increase is attributed to over and undertreatment, leading to higher costs and potential patient harm. Research improving clinician-patient interactions can help minimize and optimize the costs. Game theory has the ability improve clinician-patient interaction by modeling outcomes. Using variations of game theory, the bad doctor bad patient stigma can reframed to incentives. We believe the use of different models (prisoner dilemma, centipede game, assurance game, and chicken game) can outline the challenges faced during common inpatient scenarios, including end of life conversations and aggressive procedures. Applying game theory to multiple inpatient scenarios may also assist with analysis during morbidity and mortality conferences and quality improvement projects.
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Carlisle VR, Maynard OM, Bagnall D, Hickman M, Shorrock J, Thomas K, Kesten J. Should I Stay or Should I Go? A Qualitative Exploration of Stigma and Other Factors Influencing Opioid Agonist Treatment Journeys. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1526. [PMID: 36674280 PMCID: PMC9865602 DOI: 10.3390/ijerph20021526] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 06/15/2023]
Abstract
(1) The harm-reduction benefits of opioid agonist treatment (OAT) are well-established; however, the UK government's emphasis on "recovery" may be contributing to a high proportion of people leaving treatment and low retention rates. We wanted to develop a rich and nuanced understanding of the factors that might influence the treatment journeys of people who use OAT. (2) We explored factors at each level of the socioecological system and considered the ways these interact to influence treatment journeys in OAT. We carried out semi-structured interviews with people who use OAT (n = 12) and service providers (n = 13) and analysed data using reflexive thematic analysis. (3) We developed three themes representing participant perceptions of treatment journeys in OAT. These were: (1) The System is Broken; (2) Power Struggles; and (3) Filling the Void. (4) Conclusions: The data suggest that prioritisation of treatment retention is important to preserve the harm-reduction benefits of OAT. Stigma is a systemic issue which presents multiple barriers to people who use OAT living fulfilling lives. There is an urgent need to develop targeted interventions to address stigma towards people who use OAT.
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Affiliation(s)
- Victoria Rice Carlisle
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
- School of Psychological Sciences, University of Bristol, Bristol BS8 1TU, UK
| | - Olivia M. Maynard
- School of Psychological Sciences, University of Bristol, Bristol BS8 1TU, UK
| | - Darren Bagnall
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
| | - Jon Shorrock
- Avon & Wiltshire NHS Mental Health Trust, Specialist Drug and Alcohol Services, Colston Fort, Montague Place, Bristol BS6 5UB, UK
| | - Kyla Thomas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
| | - Joanna Kesten
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
- The National Institute for Health and Care Applied Research Collaboration West (NIHR ARC West) at University Hospitals Bristol and Weston NHS Foundation Trust, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol BS8 1TL, UK
- The National Institute for Health and Care Health Protection Research Unit (HPRU) in Behavioural Science and Evaluation, University of Bristol, Bristol BS8 1TL, UK
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Rhodes T, Kyaw KWY, Harris M. Precarious Lives, Precarious Treatments: Making Drug Treatment Work in Northern Myanmar. Med Anthropol 2023; 42:4-20. [PMID: 36306464 DOI: 10.1080/01459740.2022.2133706] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
We explore how precarious livelihoods intersect with precarious treatments for heroin dependency in a setting affected by longstanding conflicts and an illicit drug economy as well as by recent events of pandemic and political change. Working with 33 qualitative interviews with people who inject drugs in Kachin State, northern Myanmar, we explore how drug dependency treatment, especially methadone substitution, is made to work in efforts to sustain everyday livelihoods. Our analysis attends to the work that is done to enable therapeutic trajectories to emerge as "generous constraints" in precarity. We trace methadone substitution as an emergent intervention of livelihood survival.
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Affiliation(s)
- Tim Rhodes
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Khine Wut Yee Kyaw
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | - Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
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Corneli A, Perry B, Des Marais A, Choi Y, Chen H, Lilly R, Ayers D, Bennett J, Kestner L, Meade CS, Sachdeva N, McKellar MS. Participant perceptions on the acceptability and feasibility of a telemedicine-based HIV PrEP and buprenorphine/naloxone program embedded within syringe services programs: a qualitative descriptive evaluation. Harm Reduct J 2022; 19:132. [PMID: 36463214 PMCID: PMC9719634 DOI: 10.1186/s12954-022-00718-1] [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: 09/08/2022] [Accepted: 11/19/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND People who inject drugs (PWID) are at risk for HIV and opioid overdose. We piloted PARTNER UP, a telemedicine-based program to provide PWID with access to both oral pre-exposure prophylaxis (PrEP) for HIV prevention and medication for opioid use disorder (MOUD) through two syringe services programs (SSPs) in North Carolina. We conducted a qualitative evaluation to assess the acceptability and feasibility of PARTNER UP from the participant perspective. METHODS PARTNER UP participants met with a provider for an initial in-person visit at the SSP, followed by weekly telemedicine visits in month 1 and then monthly telemedicine visits until program end at month 6. Using a qualitative descriptive study design, we conducted in-depth interviews with a subsample of PARTNER UP participants at 1 month and 4 months. Informed by the technology acceptance model, we assessed participant perceptions of the usefulness and ease of use of PARTNER UP, as well as their intent to continue to use the program's components. We audio-recorded all interviews with participants' permission and used applied thematic analysis to analyze the verbatim transcripts. RESULTS We interviewed 11 of 17 people who participated in PARTNER UP-10 in the month 1 interview and 8 in the month 4 interview. Nearly all participants were motivated to join for consistent and easy access to buprenorphine/naloxone (i.e., MOUD); only a few joined to access PrEP. Most were comfortable accessing healthcare at the SSP because of their relationship with and trust toward SSP staff, and accessing services at the SSP was preferred compared with other healthcare centers. Some participants described that telemedicine allowed them to be honest and share more information because the visits were not in-person and they chose the location, although the initial in-person meeting was helpful to build provider trust and rapport. Most participants found the visit schedule to be feasible, although half described needing to reschedule at least once. Nearly all participants who were interviewed intended to continue with MOUD after the program ended, whereas none were interested in continuing with PrEP. CONCLUSIONS Participant narratives suggest that the PARTNER UP telemedicine program was acceptable and feasible. Future studies should continue to explore the benefits of embedding both PrEP and MOUD into SSPs with larger numbers of participants. Trial registration Clinicaltrials.gov Identifier: NCT04521920.
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Affiliation(s)
- Amy Corneli
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.26009.3d0000 0004 1936 7961Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC USA ,grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
| | - Brian Perry
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Andrea Des Marais
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Yujung Choi
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Hillary Chen
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA
| | - Rebecca Lilly
- North Carolina Harm Reduction Coalition, Wilmington, NC USA ,Present Address: Port City Harm Reduction, Wilmington, NC USA
| | - Denae Ayers
- Queen City Harm Reduction, Charlotte, NC USA
| | - Jesse Bennett
- North Carolina Harm Reduction Coalition, Wilmington, NC USA
| | | | - Christina S. Meade
- grid.26009.3d0000 0004 1936 7961Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, NC USA
| | - Nidhi Sachdeva
- grid.26009.3d0000 0004 1936 7961Department of Population Health Sciences, Duke University School of Medicine, 215 Morris St, Durham, NC 27701 USA ,grid.10698.360000000122483208Present Address: North Carolina Association of County Commissioners, Raleigh, NC USA
| | - Mehri S. McKellar
- grid.26009.3d0000 0004 1936 7961Department of Medicine, Duke University School of Medicine, Durham, NC USA
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Stone J, Fraser H, Walker JG, Mafirakureva N, Mundia B, Cleland C, Bartilol K, Musyoki H, Waruiru W, Ragi A, Bhattacharjee P, Chhun N, Lizcano J, Akiyama MJ, Cherutich P, Wisse E, Kurth A, Luhmann N, Vickerman P. Modelling the impact of HIV and hepatitis C virus prevention and treatment interventions among people who inject drugs in Kenya. AIDS 2022; 36:2191-2201. [PMID: 36111533 PMCID: PMC9671825 DOI: 10.1097/qad.0000000000003382] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 04/11/2022] [Accepted: 04/19/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES People who inject drugs (PWID) in Kenya have high HIV (range across settings: 14-26%) and hepatitis C virus (HCV; 11-36%) prevalence. We evaluated the impact of existing and scaled-up interventions on HIV and HCV incidence among PWID in Kenya. DESIGN HIV and HCV transmission model among PWID, calibrated to Nairobi and Kenya's Coastal region. METHODS For each setting, we projected the impact (percent of HIV/HCV infections averted in 2020) of existing coverages of antiretroviral therapy (ART; 63-79%), opioid agonist therapy (OAT; 8-13%) and needle and syringe programmes (NSP; 45-61%). We then projected the impact (reduction in HIV/HCV incidence over 2021-2030), of scaling-up harm reduction [Full harm reduction ('Full HR'): 50% OAT, 75% NSP] and/or HIV (UNAIDS 90-90-90) and HCV treatment (1000 PWID over 2021-2025) and reducing sexual risk (by 25/50/75%). We estimated HCV treatment levels needed to reduce HCV incidence by 90% by 2030. RESULTS In 2020, OAT and NSP averted 46.0-50.8% (range of medians) of HIV infections and 50.0-66.1% of HCV infections, mostly because of NSP. ART only averted 12.9-39.8% of HIV infections because of suboptimal viral suppression (28-48%). Full HR and ART could reduce HIV incidence by 51.5-64% and HCV incidence by 84.6-86.6% by 2030. Also halving sexual risk could reduce HIV incidence by 68.0-74.1%. Alongside full HR, treating 2244 PWID over 2021-2025 could reduce HCV incidence by 90% by 2030. CONCLUSION Existing interventions are having substantial impact on HIV and HCV transmission in Kenya. However, to eliminate HIV and HCV, further scale-up is needed with reductions in sexual risk and HCV treatment.
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Affiliation(s)
- Jack Stone
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Hannah Fraser
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | - Josephine G. Walker
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
| | | | | | | | | | | | - Wanjiru Waruiru
- Global Programs for Research and Training, Surveillance Department, University of California San Francisco, San Francisco, California, USA
| | | | | | - Nok Chhun
- Yale University School of Nursing, New Haven, Connecticut
| | - John Lizcano
- Yale University School of Nursing, New Haven, Connecticut
| | - Matthew J. Akiyama
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | | | - Ann Kurth
- Yale University School of Nursing, New Haven, Connecticut
| | - Niklas Luhmann
- Global HIV, Hepatitis and Sexually Transmitted Infections Programmes, World Health Organization, Geneva, Switzerland
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation at University of Bristol, Bristol, UK
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Madden LM, Farnum SO, Bromberg DJ, Barry DT, Mazhnaya A, Fomenko T, Meteliuk A, Marcus R, Rozanova J, Poklad I, Dvoriak S, Altice FL. The development and initial validation of the Russian version of the BASIS-24. Addict Sci Clin Pract 2022; 17:65. [PMID: 36435811 PMCID: PMC9701377 DOI: 10.1186/s13722-022-00343-0] [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: 03/30/2022] [Accepted: 10/19/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Efficient and linguistically appropriate instruments are needed to assess response to addiction treatment, including severity of addiction/mental health status. This is critical for Russian-speaking persons in Eastern Europe and Central Asia (EECA) where Medications for Opioid Use Disorder (MOUD) remain underscaled to address expanding and intertwined opioid, HIV, HCV and tuberculosis epidemics. We developed and conducted a pilot validation of a Russian version of the 24-item Behavior and Symptom Identification Scale (BASIS-24), an addiction/mental health severity instrument with six subscales, previously validated in English. METHODS Using the Mapi approach, we reviewed, translated, and back-translated the content to Russian, pilot-tested the Russian-version (BASIS-24-R) among new MOUD patients in Ukraine (N = 283). For a subset of patients (n = 44), test-rest was performed 48 h after admission to reassess reliability of BASIS-24-R. Exploratory principal component analysis (PCA) assessed underlying structure of BASIS-24-R. RESULTS Cronbach alpha coefficients for overall BASIS-24-R and 5 subscales exceeded 0.65; coefficient for Relationship subscale was 0.42. The Pearson correlation coefficients for overall score and all subscales on the BASIS-24-R exceeded 0.8. Each item loaded onto factors that corresponded with English BASIS-24 subscales ≥ 0.4 in PCA. CONCLUSION Initial version of BASIS-24-R appears statistically valid in Russian. Use of the BASIS-24-R has potential to guide MOUD treatment delivery in the EECA region and help to align addiction treatment with HIV prevention goals in a region where HIV is concentrated in people who inject opioids and where healthcare professionals have not traditionally perceived MOUD as effective treatment, particularly for those with mental health co-morbidities.
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Affiliation(s)
- Lynn M. Madden
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Scott O. Farnum
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
| | - Declan T. Barry
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Department of Psychiatry, Yale University School of Medicine, 300 George Street, Suite 901, New Haven, CT 06510 USA
- grid.47100.320000000419368710Child Study Center, Yale University School of Medicine, 230 S Frontage Road, New Haven, CT 06519 USA
| | - Alyona Mazhnaya
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.77971.3f0000 0001 1012 5630School of Public Health, National University of Kyiv-Mohyla Academy, Hryhoriya Skovorody Street, Kiev, 2 04655 Ukraine
| | - Tetiana Fomenko
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Anna Meteliuk
- grid.511905.9ICF Alliance for Public Health, 24 Bulvarno-Kudriavska Street, Kyiv, 01601 Ukraine
| | - Ruthanne Marcus
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Julia Rozanova
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
| | - Iurii Poklad
- Chernihiv Regional Narcological Dispensary, 3 Shchorsa Street, Chernihiv, 14005 Ukraine
| | - Sergii Dvoriak
- European Institute of Public Health Policy, 1 Malopidvalna Street, Office 10, Kiev, 01054 Ukraine
| | - Frederick L. Altice
- grid.422797.d0000 0004 0558 5300APT Foundation, Inc, 1 Long Wharf Drive, Suite 321, New Haven, CT 06511 USA
- grid.47100.320000000419368710Yale School of Public Health, Laboratory of Epidemiology and Public Health, 60 College St, New Haven, CT 06510 USA
- grid.47100.320000000419368710Section of Infectious Diseases, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06510 USA
- grid.10347.310000 0001 2308 5949Centre of Excellence On Research in AIDS (CERiA), University of Malaya, Malaysia Level 17, Wisma R&DJalan Pantai Baharu, 59990 Kuala Lumpur, Malaysia
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Martin RA, Berk J, Rich JD, Kang A, Fritsche J, Clarke JG. Use of long-acting injectable buprenorphine in the correctional setting. J Subst Abuse Treat 2022; 142:108851. [PMID: 35939914 PMCID: PMC9743485 DOI: 10.1016/j.jsat.2022.108851] [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: 04/22/2022] [Revised: 06/29/2022] [Accepted: 07/22/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND As overdoses due to opioids rise, medications for opioid use disorder (MOUD) continue to be underemployed, resulting in limited access to potentially life-saving treatment. Substance use disorders are prevalent in individuals who are incarcerated, and these individuals are at increased risk for death postrelease due to overdose. Few jails and prisons offer MOUD and most limit access. Extended-release buprenorphine (XR-BUP), a novel monthly injectable MOUD formulation, could be uniquely poised to address treatment access in correctional settings. METHODS This study linked a retrospective cohort design of statewide datasets to evaluate the real-world use of XR-BUP. The study included individuals (N = 54) who received XR-BUP while incarcerated from January 2019 through February 2022. The study was conducted at the Rhode Island Department of Corrections, with the nation's first comprehensive statewide correctional MOUD program. RESULTS Fifty-four individuals received a combined total of 162 injections during the study period. The study found no evidence of tampering with the injection site, indicating no attempts by participants to remove, hoard, or divert the medication. Sixty-one percent reported at least one adverse effect after injections were received, with an average of 2.8 side effects. Sixty-one percent of those released on XR-BUP engaged in MOUD after release, 30 % continued with XR-BUP. CONCLUSIONS XR-BUP is feasible and acceptable in correctional settings. XR-BUP addresses administrative concerns of diversion that obstruct lifesaving MOUD and offers another safe and effective treatment option. Further studies and trials should continue to assess this novel medication's ability to treat opioid addiction in the correctional setting and upon release to the community.
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Affiliation(s)
- Rosemarie A Martin
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA.
| | - Justin Berk
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Rhode Island Department of Corrections, 40 Howard Avenue, Cranston, RI 02920, USA
| | - Josiah D Rich
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA; Department of Epidemiology, Brown University School of Public Health, 121 South Main Street, Providence, RI 02903, USA; The Center for Health and Justice Transformation, The Miriam Hospital, 1125 N. Main Street Providence, RI 02904, USA; Center of Biomedical Research Excellence on Opioids and Overdose, The Rhode Island Hospital, Providence, RI, USA
| | - Augustine Kang
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA; Stanford University School of Medicine, 291 Campus Drive, Stanford, CA 94305, USA
| | - John Fritsche
- Center for Alcohol and Addiction Studies, Brown University School of Public Health, 121 S Main St, Providence, RI 02903, USA
| | - Jennifer G Clarke
- Warren Alpert Medical School of Brown University, 222 Richmond St, Providence, RI 02903, USA
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Chen J, Wang S, Li Z, Li Y, Huang P, Zhu J, Wang F, Li Y, Liu W, Xue J, Shi H, Li W, Liang Z, Wang W, Li Q. The effect of long-term methadone maintenance treatment on coupling among three large-scale brain networks in male heroin-dependent individuals: A resting-state fMRI study. Drug Alcohol Depend 2022; 238:109549. [PMID: 35810622 DOI: 10.1016/j.drugalcdep.2022.109549] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Methadone maintenance treatment (MMT) is considered as an effective and mainstream therapy for heroin dependence. However, whether long-term MMT would improve the coupling among the three core large-scale brain networks (salience, default mode, and executive control) and its relationship with the craving for heroin is unknown. METHODS Forty-four male heroin-dependent individuals during long-term MMT, 27 male heroin-dependent individuals after short-term detoxification/abstinence (SA), and 26 demographically matched healthy controls (HC) underwent resting-state functional magnetic resonance imaging. We analyzed the difference in coupling among the salience, default mode, and executive control networks among the three groups and examined how the coupling among these large-scale networks was associated with craving before and after drug-cue exposure. RESULTS Compared with the SA group, the MMT group showed lower craving before and after cue exposure and stronger connectivity between the dorsal anterior cingulate cortex (a key node of the salience network) and key regions of the bilateral executive control network, including the bilateral dorsolateral prefrontal cortex, posterior parietal cortex, and dorsomedial prefrontal cortex. Among the heroin-dependent individuals, the functional connectivity was negatively correlated with the craving before and after heroin-cue exposure. CONCLUSION Our findings suggest that long-term MMT could increase the coupling between the salience and bilateral executive control networks and decrease craving for heroin. These findings contribute to the understanding of the neural mechanism of MMT, from the perspective of large-scale brain networks.
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Affiliation(s)
- Jiajie Chen
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Shu Wang
- Biomedical Engineering, School of Life Science and Technology, Xi'an Jiao Tong University, Xi'an 710038, Shaanxi, China
| | - Zhe Li
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Yiyao Li
- School of basic medicine, Air Force Military Medical University, Xi 'an 710038, Shaanxi, China
| | - Peng Huang
- School of basic medicine, Air Force Military Medical University, Xi 'an 710038, Shaanxi, China
| | - Jia Zhu
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Fan Wang
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Yongbin Li
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Wei Liu
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Jiuhua Xue
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Hong Shi
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Wei Li
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China
| | - Zifei Liang
- Center for Biomedical Imaging, Radiology, New York University School of Medicine, New York 10012, USA
| | - Wei Wang
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China.
| | - Qiang Li
- Department of Radiology, Tangdu Hospital, Fourth Military Medical University, Xi'an 710038, Shaanxi, China.
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Ivasiy R, Madden LM, Farnum SO, Shumskaya N, de Leon SJG, Bromberg DJ, Kurmanalieva A, Duishenaliev A, Tokubaev R, Altice FL. Implementation opportunities for scaling up methadone maintenance treatment in Kyrgyzstan: Methadone dosage and retention on treatment over two years. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100075. [PMID: 36267100 PMCID: PMC9581459 DOI: 10.1016/j.dadr.2022.100075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/14/2022] [Accepted: 06/15/2022] [Indexed: 12/01/2022]
Abstract
Background Methadone maintenance treatment (MMT) is the most effective and cost-effective strategy to control HIV in Central Asian countries, where the epidemic is concentrated among people who inject drugs (PWID) who use opioids. Methods Using data from a prospective observational database of all people initiated on MMT in Kyrgyzstan since 2008, we analyzed a more contemporary subset of data for all persons receiving MMT from January 2017 through June 2021 after the national treatment guidelines were changed. Retention on MMT was assessed at 1, 6, 12, and 24 months and predictive variables included were dosage levels, HIV status, and type of clinical setting using survival analysis. Predictors of treatment dropout were estimated using Cox multivariate regression models. Results Among the 940 MMT patients, the proportion receiving low (<40mg), medium (40-85mg), and high (>85mg) dosage levels was 37.9%, 42.2%, and 19.9%, respectively. Increasing MMT dosage level was significantly (p<0.0001) correlated with retention at 1 (90%, 98%, 100%), 6 (42%, 63%, 95%), 12 (33%, 55%, 89%), and 24 (16%, 45%, 80%) months, respectively, with no differences between community and correctional settings. Significant predictors of dropout at 12 months included low (aHR=8.0; 95%CL=5.8-11.0) and medium (aHR=3.5; 95%CL=2.5-4.9) methadone dosage level relative to high dose, receiving MMT in three administrative regions relative to the capital Bishkek, and lower in the tuberculosis-specialized clinic in Bishkek. Clients with HIV receive higher average MMT doses (79.5mg vs 63.1mg; p<0.0001), but MMT retention did not differ after controlling for dosage in this group. Conclusions The proportion of patients receiving optimal dosage was low (19.9%). An implementation strategy that focused on getting a larger proportion of MMT on the optimal dosage to promote retention could potentially improve the quality of existing treatment and promote further scale-up of MMT in Kyrgyzstan.
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Affiliation(s)
- Roman Ivasiy
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Lynn M. Madden
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Scott O. Farnum
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- APT Foundation, New Haven, USA
| | - Natalia Shumskaya
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | - Samy J. Galvez de Leon
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
| | - Daniel J. Bromberg
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
- Center for Interdisciplinary Research on AIDS at Yale University, New Haven, USA
| | - Ainura Kurmanalieva
- Public Foundation “AIDS Foundation East-West in the Kyrgyz Republic”, Bishkek, Kyrgyzstan
| | | | | | - Frederick L. Altice
- Yale School of Medicine, Department of Medicine, Section of Infectious Diseases, 135 College Street, Suite 355, New Haven, CT 06511 USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, USA
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Marsden J, Kelleher M, Hoare Z, Hughes D, Bisla J, Cape A, Cowden F, Day E, Dewhurst J, Evans R, Hearn A, Kelly J, Lowry N, McCusker M, Murphy C, Murray R, Myton T, Quarshie S, Scott G, Turner S, Vanderwaal R, Wareham A, Gilvarry E, Mitcheson L. Extended-release pharmacotherapy for opioid use disorder (EXPO): protocol for an open-label randomised controlled trial of the effectiveness and cost-effectiveness of injectable buprenorphine versus sublingual tablet buprenorphine and oral liquid methadone. Trials 2022; 23:697. [PMID: 35986418 PMCID: PMC9389497 DOI: 10.1186/s13063-022-06595-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 07/25/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sublingual tablet buprenorphine (BUP-SL) and oral liquid methadone (MET) are the daily, standard-of-care (SOC) opioid agonist treatment medications for opioid use disorder (OUD). A sizable proportion of the OUD treatment population is not exposed to sufficient treatment to attain the desired clinical benefit. Two promising therapeutic technologies address this deficit: long-acting injectable buprenorphine and personalised psychosocial interventions (PSI). This study will determine (A) the effectiveness and cost-effectiveness - monthly injectable, extended-release (BUP-XR) in a head-to-head comparison with BUP-SL and MET, and (B) the effectiveness of BUP-XR with adjunctive PSI versus BUP-SL and MET with PSI. Safety, retention, craving, substance use, quality-adjusted life years, social functioning, and subjective recovery from OUD will be also evaluated. METHODS This is a pragmatic, multi-centre, open-label, parallel-group, superiority RCT, with a qualitative (mixed-methods) evaluation. The study population is adults. The setting is five National Health Service community treatment centres in England and Scotland. At each centre, participants will be randomly allocated (1:1) to BUP-XR or SOC. At the London study co-ordinating centre, there will also be allocation of participants to BUP-XR with PSI or SOC with PSI. With 24 weeks of study treatment, the primary outcome is days of abstinence from non-medical opioids during study weeks 2-24 combined with up to 12 urine drug screen tests for opioids. For 90% power (alpha, 5%; 15% inflation for attrition), 304 participants are needed for the BUP-XR versus SOC comparison. With the same planning parameters, 300 participants are needed for the BUP-XR and PSI versus SOC and PSI comparison. Statistical and health economic analysis plans will be published before data-lock on the Open Science Framework. Findings will be reported in accordance with the Consolidated Standards of Reporting Trials and Consolidated Health Economic Evaluation Reporting Standards. DISCUSSION This pragmatic randomised controlled trial is the first evaluation of injectable BUP-XR versus the SOC medications BUP-SL and MET, with personalised PSI. If there is evidence for the superiority of BUP-XR over SOC medication, study findings will have substantial implications for OUD clinical practice and treatment policy in the UK and elsewhere. TRIAL REGISTRATION EU Clinical Trials register 2018-004460-63.
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Affiliation(s)
- John Marsden
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, Division of Academic Psychiatry, King's College London, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, UK.
- South London & Maudsley NHS Foundation Trust, London, UK.
| | - Mike Kelleher
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Zoë Hoare
- School of Health Sciences, Bangor University, Bangor, Wales, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, Wales, UK
| | - Jatinder Bisla
- King's Clinical Trials Unit, Research Management and Innovation Directorate, King's College London, London, UK
| | - Angela Cape
- King's Clinical Trials Unit, Research Management and Innovation Directorate, King's College London, London, UK
| | | | - Edward Day
- Birmingham & Solihull Mental Health, NHS Foundation Trust, Birmingham, UK
| | - Jonathan Dewhurst
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Rachel Evans
- School of Health Sciences, Bangor University, Bangor, Wales, UK
| | - Andrea Hearn
- Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, UK
| | - Joanna Kelly
- King's Clinical Trials Unit, Research Management and Innovation Directorate, King's College London, London, UK
| | - Natalie Lowry
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, Division of Academic Psychiatry, King's College London, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, UK
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Martin McCusker
- Patient and Public Involvement Representative, Lambeth Service User Council, South London & Maudsley NHS Foundation Trust, London, UK
| | - Caroline Murphy
- King's Clinical Trials Unit, Research Management and Innovation Directorate, King's College London, London, UK
| | - Robert Murray
- Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, UK
| | - Tracey Myton
- Addictions Division, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Sophie Quarshie
- Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, UK
| | - Gemma Scott
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Sophie Turner
- South London & Maudsley NHS Foundation Trust, London, UK
| | - Rob Vanderwaal
- South London & Maudsley NHS Foundation Trust, London, UK
| | - April Wareham
- Patient and Public Involvement Representative, London, UK
| | - Eilish Gilvarry
- Northumberland, Tyne & Wear NHS Foundation Trust, Newcastle Addictions Service, Newcastle Upon Tyne, UK
| | - Luke Mitcheson
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, Division of Academic Psychiatry, King's College London, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, UK
- South London & Maudsley NHS Foundation Trust, London, UK
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Liu S, Ma ZQ, Songer TJ, Mair C, Wahed AS, Krans E, Talbott E. Effect of HCV or HIV infection on mortality among hospitalized persons who used opioids, 2000-2010. Prev Med 2022; 161:107155. [PMID: 35817162 DOI: 10.1016/j.ypmed.2022.107155] [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] [Received: 11/11/2021] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 11/28/2022]
Abstract
Mortality due to opioid misuse and overdose has increased substantially in the United States over the past two decades. The study objective was to describe the causes of death among persons with opioid-related hospitalizations and examine survival by Hepatitis C virus (HCV) or HIV. Opioid-related hospitalization records in Pennsylvania from 2000 to 2010 were linked to death registry files to assess cause of death, and survival from first hospital discharge date to death date, or December 31, 2010. Accelerated failure time models were used to compare survival between persons with and without HCV or HIV diagnoses. Among the 136,416 individuals with an opioid-related hospitalization, 13.0% died over a median of 56 months of follow-up; the most common causes of death were circulatory diseases (26.4%) and drug overdose (23.5%). There were 27,122 (19.9%) and 3662 (2.7%) persons who had an HCV and HIV diagnosis, respectively. Among patients aged ≥20 years, those with HCV had shorter survival time compared to those without HCV, with discrepancies more pronounced at older ages. Patients with HIV also had shorter survival time (time ratio: 0.29 [95% CI: 0.26, 0.34]) compared to without HIV. These findings show that in a cohort of patients with opioid-related hospitalizations, those with HCV or HIV diagnoses have shorter survival. This has public health implications, providing further evidence that medical providers should educate patients who use opioids about the risks of HCV and HIV infection and focus prevention and treatment to decrease mortality among patients hospitalized for opioid use.
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Affiliation(s)
- Stephen Liu
- University of Pittsburgh, Department of Epidemiology, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, PA.15261, USA.
| | - Zhen-Qiang Ma
- Pennsylvania Department of Health, 625 Forster Street, Harrisburg, PA 17120, USA
| | - Thomas J Songer
- University of Pittsburgh, Department of Epidemiology, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, PA.15261, USA
| | - Christina Mair
- University of Pittsburgh, Department of Behavioral and Community Health Sciences, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, PA 15261, USA
| | - Abdus S Wahed
- University of Pittsburgh, Department of Biostatistics, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, PA 15261, USA
| | - Elizabeth Krans
- University of Pittsburgh, Department of Obstetrics, Gynecology and Reproductive Sciences, 300 Halket Street, Pittsburgh, PA 15213, USA; Magee-Womens Research Institute, 204 Craft Ave, Pittsburgh, PA 15213, USA
| | - Evelyn Talbott
- University of Pittsburgh, Department of Epidemiology, Graduate School of Public Health, 130 DeSoto St, Pittsburgh, PA.15261, USA
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O'Brien S, Kyaw KWY, Jaramillo MM, Roberts B, Bijl M, Platt L. Determinants of health among people who use illicit drugs in the conflict-affected countries of Afghanistan, Colombia and Myanmar: a systematic review of epidemiological evidence. Confl Health 2022; 16:39. [PMID: 35799203 PMCID: PMC9264525 DOI: 10.1186/s13031-022-00467-9] [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] [Received: 11/10/2021] [Accepted: 06/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Afghanistan, Colombia and Myanmar are the world's leading heroin and cocaine producers and have also experienced prolonged periods of armed conflict. The link between armed conflict and drug markets is well established but how conflict impacts on the health and social determinants of people who use drugs is less clear. The aim was to investigate health outcomes and associated factors among people who use illicit drugs in Afghanistan, Colombia and Myanmar. METHODS We conducted a systematic review searching Medline, EMBASE, PsychINFO and Global Health databases using terms relating to Afghanistan, Colombia and Myanmar; illicit drug use (all modes of drug administration); health and influencing factors. Quality assessment was assessed with the Newcastle-Ottawa-Scale and papers were analysed narratively. RESULTS 35 studies were included in Afghanistan (n = 15), Colombia (n = 9) and Myanmar (n = 11). Health outcomes focused predominantly on HIV, Hepatitis C (HCV), Hepatitis B and sexually transmitted infections (STIs), with one study looking at human rights violations (defined as maltreatment, abuse and gender inequality). Drug use was predominantly injection of heroin, often alongside use of amphetamines (Myanmar), cocaine and cocaine-based derivatives (Colombia). Only one study measured the effect of a period of conflict suggesting this was linked to increased reporting of symptoms of STIs and sharing of needles/syringes among people who inject drugs. Findings show high levels of external and internal migration, alongside low-income and unemployment across the samples. External displacement was linked to injecting drugs and reduced access to needle/syringe programmes in Afghanistan, while initiation into injecting abroad was associated with increased risk of HCV infection. Few studies focused on gender-based differences or recruited women. Living in more impoverished rural areas was associated with increased risk of HIV infection. CONCLUSIONS More research is needed to understand the impact of armed-conflict and drug production on the health of people who use drugs. The immediate scale-up of harm reduction services in these countries is imperative to minimize transmission of HIV/HCV and address harms associated with amphetamine use and other linked health and social care needs that people who use drugs may face.
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Affiliation(s)
- Sally O'Brien
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Khine Wut Yee Kyaw
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Margarita Marin Jaramillo
- Observatorio de Restitución Y Regulación de los Derechos de Propiedad Agraria, Universidad Nacional de Colombia, Bogotá, Colombia
| | - Bayard Roberts
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Murdo Bijl
- Asian Harm Reduction Network (AHRN), Yangon, Myanmar
| | - Lucy Platt
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
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Banta-Green CJ, Owens MD, Williams JR, Sears JM, Floyd AS, Williams-Gilbert W, Kingston S. The Community-Based Medication-First program for opioid use disorder: a hybrid implementation study protocol of a rapid access to buprenorphine program in Washington State. Addict Sci Clin Pract 2022; 17:34. [PMID: 35799210 PMCID: PMC9261214 DOI: 10.1186/s13722-022-00315-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 06/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid use disorder (OUD) is a serious health condition that is effectively treated with buprenorphine. However, only a minority of people with OUD are able to access buprenorphine. Many access points for buprenorphine have high barriers for initiation and retention. Health care and drug treatment systems have not been able to provide services to all-let alone the majority-who need it, and many with OUD report extreme challenges starting and staying on buprenorphine in those care settings. We describe the design and protocol for a study of a rapid access buprenorphine program model in six Washington State communities at existing sites serving people who are unhoused and/or using syringe services programs. This study aimed to test the effectiveness of a Community-Based Medication-First Program model. METHODS We are conducting a hybrid effectiveness-implementation study of a rapid access buprenorphine model of care staffed by prescribers, nurse care managers, and care navigators. The Community-Based Medication-First model of care was designed as a 6-month, induction-stabilization-transition model to be delivered between 2019 and 2022. Effectiveness outcomes will be tested by comparing the intervention group with a comparison group derived from state records of people who had OUD. Construction of the comparison group will align characteristics such as geography, demographics, historical rates of arrests, OUD medication, and health care utilization, using restriction and propensity score techniques. Outcomes will include arrests, emergency and inpatient health care utilization, and mortality rates. Descriptive statistics for buprenorphine utilization patterns during the intervention period will be documented with the prescription drug monitoring program. DISCUSSION Results of this study will help determine the effectiveness of the intervention. Given the serious population-level and individual-level impacts of OUD, it is essential that services be readily available to all people with OUD, including those who cannot readily access care due to their circumstances, capacity, preferences, and related systems barriers.
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Affiliation(s)
- Caleb J Banta-Green
- Addictions, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA. .,Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA. .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA.
| | - Mandy D Owens
- Addictions, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA
| | - Jason R Williams
- Addictions, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA
| | - Jeanne M Sears
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, USA.,Institute for Work and Health, Toronto, ON, Canada
| | - Anthony S Floyd
- Addictions, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA
| | | | - Susan Kingston
- Addictions, Drug & Alcohol Institute, University of Washington, Seattle, WA, USA
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Brothers TD, Lewer D, Jones N, Colledge-Frisby S, Farrell M, Hickman M, Webster D, Hayward A, Degenhardt L. Opioid agonist treatment and risk of death or rehospitalization following injection drug use-associated bacterial and fungal infections: A cohort study in New South Wales, Australia. PLoS Med 2022; 19:e1004049. [PMID: 35853024 PMCID: PMC9295981 DOI: 10.1371/journal.pmed.1004049] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 06/12/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Injecting-related bacterial and fungal infections are associated with significant morbidity and mortality among people who inject drugs (PWID), and they are increasing in incidence. Following hospitalization with an injecting-related infection, use of opioid agonist treatment (OAT; methadone or buprenorphine) may be associated with reduced risk of death or rehospitalization with an injecting-related infection. METHODS AND FINDINGS Data came from the Opioid Agonist Treatment Safety (OATS) study, an administrative linkage cohort including all people in New South Wales, Australia, who accessed OAT between July 1, 2001 and June 28, 2018. Included participants survived a hospitalization with injecting-related infections (i.e., skin and soft-tissue infection, sepsis/bacteremia, endocarditis, osteomyelitis, septic arthritis, or epidural/brain abscess). Outcomes were all-cause death and rehospitalization for injecting-related infections. OAT exposure was classified as time varying by days on or off treatment, following hospital discharge. We used separate Cox proportional hazards models to assess associations between each outcome and OAT exposure. The study included 8,943 participants (mean age 39 years, standard deviation [SD] 11 years; 34% women). The most common infections during participants' index hospitalizations were skin and soft tissue (7,021; 79%), sepsis/bacteremia (1,207; 14%), and endocarditis (431; 5%). During median 6.56 years follow-up, 1,481 (17%) participants died; use of OAT was associated with lower hazard of death (adjusted hazard ratio [aHR] 0.63, 95% confidence interval [CI] 0.57 to 0.70). During median 3.41 years follow-up, 3,653 (41%) were rehospitalized for injecting-related infections; use of OAT was associated with lower hazard of these rehospitalizations (aHR 0.89, 95% CI 0.84 to 0.96). Study limitations include the use of routinely collected administrative data, which lacks information on other risk factors for injecting-related infections including injecting practices, injection stimulant use, housing status, and access to harm reduction services (e.g., needle exchange and supervised injecting sites); we also lacked information on OAT medication dosages. CONCLUSIONS Following hospitalizations with injection drug use-associated bacterial and fungal infections, use of OAT is associated with lower risks of death and recurrent injecting-related infections among people with opioid use disorder.
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Affiliation(s)
- Thomas D. Brothers
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
- Department of Medicine, Dalhousie University, Halifax, Canada
| | - Dan Lewer
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Nicola Jones
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | | | - Michael Farrell
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
| | - Matthew Hickman
- Population Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Duncan Webster
- Department of Medicine, Dalhousie University, Halifax, Canada
- Division of Infectious Diseases, Saint John Regional Hospital, Saint John, Canada
| | - Andrew Hayward
- UCL Collaborative Centre for Inclusion Health, Institute of Epidemiology and Health Care, University College London, London, United Kingdom
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre (NDARC), UNSW Sydney, Sydney, Australia
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47
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Puzhko S, Eisenberg MJ, Filion KB, Windle SB, Hébert-Losier A, Gore G, Paraskevopoulos E, Martel MO, Kudrina I. Effectiveness of Interventions for Prevention of Common Infections Among Opioid Users: A Systematic Review of Systematic Reviews. Front Public Health 2022; 10:749033. [PMID: 35273933 PMCID: PMC8901608 DOI: 10.3389/fpubh.2022.749033] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 01/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The North American opioid crisis is marked by high opioid-related mortality and morbidity, including opioid use-associated infections (OUAIs). Users of pharmaceutical and non-pharmaceutical opioids are at an increased risk of acquiring hepatitis C (HCV), human immunodeficiency virus (HIV), and other infections. No high-level evidence, however, has been synthesized regarding effectiveness of interventions to prevent OUAIs in legal, and illegal/mixed opioid users. The aim of the study is to synthesize available systematic review (SR)-level evidence on the scope and effectiveness of interventions to prevent OUAIs among opioid users. Methods A SR of SRs approach was applied. We searched PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar from inception to September 2020. Data selection and extraction were performed independently by three researchers. Risk of bias and quality of evidence were assessed using the AMSTAR2 tool. Results were narratively synthesized. Strength of evidence for each category was reported. Results Eleven of twelve identified SRs included interventions to prevent HCV/HIV transmission in persons who inject drugs (PWID), including opioids. One SR evaluated interventions to prevent recurrent infectious endocarditis. There was sufficient and tentative SR of SRs-level evidence for the effectiveness of opioid substitution therapy (OST) in preventing HIV and HCV, respectively. We found tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV prevention, and sufficient evidence to support effectiveness of the combined OST and NSP in HCV prevention. There was insufficient SR-level evidence to support or discount effectiveness of other interventions to prevent OUAIs. No SR focused on non-PWID populations. Conclusion SR-level evidence supports the use of OST, NSP, and combined interventions for the reduction of HCV and HIV transmission in PWID. More research on prevention of other OUAIs and on prevention of OUAIs in non-PWID populations is urgently needed. Systematic Review Registration Registered in PROSPERO on July 30, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=195929, identifier: #195929.
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Affiliation(s)
- Svetlana Puzhko
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Mark J Eisenberg
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Division of Cardiology, Department of Medicine, Faculty of Medicine and Health Sciences, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Kristian B Filion
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada.,Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Department of Medicine, Faculty of Medicine and Health Sciences, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Sarah B Windle
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
| | - Andréa Hébert-Losier
- Jewish General Hospital, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Genevieve Gore
- Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal, QC, Canada
| | | | - Marc O Martel
- Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Faculty of Dentistry, McGill University, Montréal, QC, Canada
| | - Irina Kudrina
- Department of Family Medicine, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada.,Department of Anesthesia, Faculty of Medicine and Health Sciences, McGill University, Montreal, QC, Canada
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Harris M, Holland A, Lewer D, Brown M, Eastwood N, Sutton G, Sansom B, Cruickshank G, Bradbury M, Guest I, Scott J. Barriers to management of opioid withdrawal in hospitals in England: a document analysis of hospital policies on the management of substance dependence. BMC Med 2022; 20:151. [PMID: 35418095 PMCID: PMC9007696 DOI: 10.1186/s12916-022-02351-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 03/24/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND People who use illicit opioids are more likely to be admitted to hospital than people of the same age in the general population. Many admissions end in discharge against medical advice, which is associated with readmission and all-cause mortality. Opioid withdrawal contributes to premature discharge. We sought to understand the barriers to timely provision of opioid substitution therapy (OST), which helps to prevent opioid withdrawal, in acute hospitals in England. METHODS We requested policies on substance dependence management from 135 National Health Service trusts, which manage acute hospitals in England, and conducted a document content analysis. Additionally, we reviewed an Omitted and Delayed Medicines Tool (ODMT), one resource used to inform critical medicine categorisation in England. We worked closely with people with lived experience of OST and/or illicit opioid use, informed by principles of community-based participatory research. RESULTS Eighty-six (64%) trusts provided 101 relevant policies. An additional 44 (33%) responded but could not provide relevant policies, and five (4%) did not send a definitive response. Policies illustrate procedural barriers to OST provision, including inconsistent application of national guidelines across trusts. Continuing community OST prescriptions for people admitted in the evening, night-time, or weekend was often precluded by requirements to confirm doses with organisations that were closed during these hours. 42/101 trusts (42%) required or recommended a urine drug test positive for OST medications or opioids prior to OST prescription. The language used in many policies was stigmatising and characterised people who use drugs as untrustworthy. OST was not specifically mentioned in the reviewed ODMT, with 'drugs used in substance dependence' collectively categorised as posing low risk if delayed and moderate risk if omitted. CONCLUSIONS Many hospitals in England have policies that likely prevent timely and effective OST. This was underpinned by the 'low-risk' categorisation of OST delay in the ODMT. Delays to continuity of OST between community and hospital settings may contribute to inpatient opioid withdrawal and increase the risk of discharge against medical advice. Acute hospitals in England require standardised best practice policies that account for the needs of this patient group.
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Affiliation(s)
- Magdalena Harris
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
| | - Adam Holland
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.,Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Dan Lewer
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Michael Brown
- Division of Infection, University College London Hospital, London, UK.,Department of Clinical Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | | | - Gary Sutton
- Release, 61 Mansell Street, London, E1 8AN, UK
| | - Ben Sansom
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Gabby Cruickshank
- Bristol Medical School, University of Bristol, Oakfield Grove, Clifton, Bristol, BS8 2BN, UK
| | - Molly Bradbury
- Severn Foundation School, Park House, 1200 Parkway, Bristol, BS34 8YU, UK
| | - Isabelle Guest
- Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS10 5NB, UK
| | - Jenny Scott
- Department of Pharmacy & Pharmacology, University of Bath, Claverton Down, Bath, BA2 7AY, UK
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49
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Nordeck CD, Welsh C, Schwartz RP, Mitchell SG, O'Grady KE, Gryczynski J. Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 2:100031. [PMID: 36845893 PMCID: PMC9948812 DOI: 10.1016/j.dadr.2022.100031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 02/02/2022] [Accepted: 02/02/2022] [Indexed: 11/20/2022]
Abstract
Background Facilitating opioid agonist treatment (OAT) for opioid use disorder (OUD) is an important role of hospital substance use disorder (SUD) consultation services. In the NavSTAR trial, hospital patients receiving SUD consultation who were randomly assigned to patient navigation services for 3 months post-discharge had fewer readmissions compared to usual care. Methods This secondary analysis examined hospital-based OAT initiation (pre-randomization) and community-based OAT linkage (post-discharge) among NavSTAR trial participants with OUD (N=314). Associations between OAT initiation and linkage, and patient demographics, housing status, comorbid SUD diagnoses, recent substance use, and study condition were examined using multinomial and dichotomous logistic regression. Results Overall, 57.6% initiated OAT during hospitalization (36.3% methadone, 21.3% buprenorphine). Compared to participants not initiating OAT, participants who received methadone were more likely to be female (Relative Risk Ratio [RRR]=2.05, 95% CI=1.11, 3.82, p=0.02), while participants who received buprenorphine were more likely to report homelessness (RRR=2.57, 95% CI=1.24, 5.32, p=0.01). Compared to participants initiating methadone, participants initiating buprenorphine were more likely to be non-White (RRR=3.89; 95% CI=1.55, 9.70; p=0.004) and to report prior buprenorphine treatment (RRR=2.57; 95% CI=1.27, 5.20; p=0.009). OAT linkage within 30-days post-discharge was associated with hospital-based buprenorphine initiation (Adjusted Odds Ratio [AOR]=3.86, 95% CI=1.73, 8.61, p=0.001) and patient navigation intervention (AOR=2.97, 95% CI=1.60, 5.52, p=0.001). Conclusions OAT initiation differed by sex, race, and housing status. Hospital-based OAT initiation and patient navigation were independently associated with linkage to community-based OAT. Hospitalization is a reachable moment to begin OAT to alleviate withdrawal and facilitate treatment continuity post-discharge.
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Affiliation(s)
- Courtney D. Nordeck
- Friends Research Institute, Inc., Baltimore, MD, United States
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Christopher Welsh
- Department of Psychiatry, University of Maryland School of Medicine, Baltimore, MD, United States
| | | | | | - Kevin E. O'Grady
- Department of Psychology, University of Maryland, College Park, MD, United States
| | - Jan Gryczynski
- Friends Research Institute, Inc., Baltimore, MD, United States
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50
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Bartlett SR, Wong S, Yu A, Pearce M, MacIsaac J, Nouch S, Adu P, Wilton J, Samji H, Clementi E, Velasquez H, Jeong D, Binka M, Alvarez M, Wong J, Buxton J, Krajden M, Janjua NZ. The Impact of Current Opioid Agonist Therapy on Hepatitis C Virus Treatment Initiation Among People Who Use Drugs From the Direct-acting Antiviral (DAA) Era: A Population-Based Study. Clin Infect Dis 2022; 74:575-583. [PMID: 34125883 PMCID: PMC8886915 DOI: 10.1093/cid/ciab546] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Evidence that opioid agonist therapy (OAT) is associated with increased odds of hepatitis C virus (HCV) treatment initiation among people who use drugs (PWUD) is emerging. The objective of this study was to determine the association between current OAT and HCV treatment initiation among PWUD in a population-level linked administrative dataset. METHODS The British Columbia Hepatitis Testers Cohort was used for this study, which includes all people tested for or diagnosed with HCV in British Columbia, linked to medical visits, hospitalizations, laboratory, prescription drug, and mortality data from 1992 until 2019. PWUD with injecting drug use or opioid use disorder and chronic HCV infection were identified for inclusion in this study. HCV treatment initiation was the main outcome, and subdistribution proportional hazards modeling was used to assess the relationship with current OAT. RESULTS In total, 13 803 PWUD with chronic HCV were included in this study. Among those currently on OAT at the end of the study period, 47% (2704/5770) had started HCV treatment, whereas 22% (1778/8033) of those not currently on OAT had started HCV treatment. Among PWUD with chronic HCV infection, current OAT was associated with higher likelihood of HCV treatment initiation in time to event analysis (adjusted hazard ratio 1.84 [95% confidence interval {CI}, 1.50, 2.26]). CONCLUSIONS Current OAT was associated with a higher likelihood of HCV treatment initiation. However, many PWUD with HCV currently receiving OAT have yet to receive HCV treatment. Enhanced integration between substance use care and HCV treatment is needed to improve the overall health of PWUD.
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Affiliation(s)
- Sofia R Bartlett
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stanley Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Amanda Yu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Margo Pearce
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Julia MacIsaac
- Division of Addiction Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Susan Nouch
- Department of Family and Community Practice, Vancouver Coastal Health, Vancouver, BC, Canada
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Prince Adu
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - James Wilton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Hasina Samji
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Vancouver, BC, Canada
| | - Emilia Clementi
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Hector Velasquez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Dahn Jeong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mawuena Binka
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Maria Alvarez
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
| | - Jason Wong
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jane Buxton
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Mel Krajden
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Naveed Z Janjua
- British Columbia Centre for Disease Control, Vancouver, BC, Canada
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
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