Identifying patient-important outcomes in medication-assisted treatment for opioid use disorder patients: a systematic review protocol

Patient experiences with outpatient opioid use disorder treatment before and during COVID-19: results from a survey of Medicaid members

Background: Payers are increasingly interested in quality improvement for opioid use disorder (OUD) treatment, including incorporating patient experiences. Medicaid is the largest payer for OUD treatment, yet we know little about the treatment benefits Medicaid members report, how these vary across members, or changed with the COVID-19 pandemic.Objective: To examine Medicaid members' report of outpatient treatment benefits, employment, and housing outcomes before and during the pandemic.Methods: A representative sample of 1,032 Virginia Medicaid members (52% women) receiving OUD treatment completed a survey of treatment benefits, health status and social needs. A reported treatment benefit index was created based on seven self-reported items. Multivariable linear regression models, pooled and stratified by time (pre-COVID-19/COVID-19), assessed member characteristics associated with reported treatment benefit, employment and housing outcomes.Results: Members reported strong treatment benefit (mean: 21.8 [SD: 5.9] out of 28 points) and improvements in employment (2.4 [1.3] out of 5) and housing (2.8 [1.2] out of 5). After adjustment, mental distress (regression coefficient: -3.00 [95% CI:-3.97;-2.03]), polysubstance use (-1.25 [-1.99;-0.51]), and food insecurity (-1.00 [-1.71;-0.29]), were associated with decreased benefits from treatment. During COVID-19, justice-involved individuals reported decreased benefits (-2.17 [-3.54; -0.80]) compared to before the pandemic (-0.09 [-1.4-;1.24] p < .05).Conclusions: Medicaid members receiving outpatient OUD treatment reported positive treatment benefits, and housing and employment outcomes. However, those with comorbid health and social conditions often benefited the least. As payers move toward quality improvement and value-based purchasing initiatives, collecting and integrating patient reported outcomes into quality metrics is critical.

Patient reported goals for medications for opioid use disorder: A theory of proximal goal attainment

Background

There exist substantial patient barriers to accessing medications for opioid use disorder (MOUD), including travel distance, stigma, and availability of MOUD providers. Yet, despite these barriers, there exists a subset of patients who possess the requisite motivation to seek and remain adherent to treatment.

Objective

To explore patient-derived goals in MOUD treatment-adherent patients.

Methods

This study used in-depth interviews with patients receiving methadone who were enrolled in opioid treatment programs (OTPs) across Tennessee. Participants were recruited from 12 different OTPs to participate in telephonic semi-structured interviews to a point of saturation. Participants had to be adherent to treatment, in treatment for 6 months or greater, and English speaking. Analysis occurred inductively using a constructivist approach to Grounded Theory.

Results

In total, 17 patient interviews were conducted in the spring of 2021. Participants described goal setting across three general stages of treatment: (1) addressing acute physical and emotional needs upon treatment entry, (2) development of supportive structure and routine to develop healthy skills facilitated by treatment team, and (3) identifying and pursuing future-focused goals not directly linked to treatment. A Proximal Goals in MOUD Framework is introduced.

Conclusion

In this qualitative study on patient reported goals in MOUD it was found that goals are transitory and relative to the stage of treatment. Further research is needed to better understand goal evolution over the course of treatment and its impact on treatment retention.

The Inclusion of Patients' Reported Outcomes to Inform Treatment Effectiveness Measures in Opioid Use Disorder. A Systematic Review

Introduction

Patient centred care is needed now more than ever in the treatment of opioid use disorder. Trials, policy makers, and service providers have most often used treatment retention and opioid urine screens as measures of treatment effectiveness. However, patients receiving medication for opioid use disorder treatment (MOUD) may prioritise the use of different ways to assess treatment success.

Objective

The aim of this review is to synthesize literature examining the self-reported goals patients would like to achieve in MOUD for opioid use disorder.

Methods

We searched MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Web of Science, Cochrane Library, Cochrane Clinical Trials Registry, the National Institutes for Health Clinical Trials Registry, and the WHO International Clinical Trials Registry Platform from inception until April 30th, 2021. No restrictions were placed on language, age, or type of MOUD. A qualitative synthesis is presented given that a meta-analysis was not possible.

Results

The search yielded a total of 21,082 records from which 8 met criteria for inclusion in the qualitative synthesis. We identified a total of 43 patient-reported treatment goals from the 8 studies. Twelve domains were created from the 43 goals reported. These domains cover a range of important areas for patients' goals related to living a normal life, physical health, mental health, treatment, and substance use specific areas.

Conclusion

This review highlights several patient goals that they would like to achieve during treatment for opioid use disorder that are not commonly considered as markers of treatment effectiveness. Goals related to health, living a normal life, and overall substance use concerns by patients should be taken into consideration by clinical trialists, researchers, policy makers, service providers, patients, and communities engaged in developing and tailoring treatment plans for opioid use disorder.

Systematic Review Registration

PROSPERO CRD42018095553.

Core outcomes set for research on the treatment of opioid use disorder (COS-OUD): the National Institute on Drug Abuse Clinical Trials Network protocol for an e-Delphi consensus study

BACKGROUND

A lack of consensus on the optimal outcome measures to assess the efficacy and effectiveness of interventions for the treatment of opioid use disorder (OUD) has hampered the pooling of research data for evidence synthesis and clinical guidelines. A core outcome set (COS) is a minimum set of outcome measures that are recommended for all studies of a particular condition. The National Drug Abuse Treatment Clinical Trials Network (CTN) Core Outcome Set for OUD (COS-OUD) is a development study to identify core constructs, meaningful outcomes, and their optimal measurement for all efficacy and effectiveness studies of OUD treatment and service delivery.

METHODS/DESIGN

Overseen by an expert workgroup, a modified, stepwise, e-Delphi methodology will be used to gain consensus among a panel of clinical practitioners and researchers involved in the treatment of OUD, who are members of the CTN. Sequential rounds of anonymous, online questionnaires will be used to identify, rate the importance of, and refine a core outcome set. A consensus threshold will be achieved if at least 70% of the panel rate the measure as critical for inclusion in the COS-OUD. Where consensus is not reached or there are suggestions for new measures, these will be brought forward to a further round of review prior to a consensus meeting. Products from this study will be communicated via peer-reviewed scientific journals and conferences.

DISCUSSION

This initiative will develop a COS for OUD intervention trials, treatment studies, and service delivery and will support the pooling of research and clinical practice data and efforts to develop measurement-based care within the OUD treatment cascade.

TRIAL REGISTRATION

http://www.comet-initiative.org/Studies/Details/1579.

Design and Implementation of a Curriculum for Emergency Medicine Residents to Address Medications and Treatment Referral for Opioid Use Disorder

Background: Medications for Opioid Use Disorder (MOUD) are recognized as successful treatments for Opioid Use Disorder (OUD). The Emergency Department is well situated to initiate MOUD and begin the referral process. Unfortunately, uptake of this practice among Emergency Medicine (EM) physicians has been slow. EM physicians may feel inadequately prepared to provide MOUD and addiction referral services due to lack of previous training and experience. The goal of this pilot study was to create, implement, and evaluate an OUD management curriculum for EM residents and measure impact on knowledge, practice, and empathy. Methods: A 4.5-hour curriculum was developed, incorporating the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment mission statement as well as the Accreditation Council for Graduate Medical Education and the American Board of Emergency Medicine resident physician milestones. The curriculum was inserted into an existing EM residency didactic block at an urban, tertiary care, residency program. Surveys were obtained pre- and post-intervention. Results: Post curriculum surveys demonstrated improved knowledge of buprenorphine/naloxone including indications, clinical effects and side-effects (p < 0.05). Surveys also noted increased comfort prescribing buprenorphine/naloxone for opioid withdrawal and misuse and instructing patients on home induction (p < 0.05). Additionally, residents responded positively regarding the impact of the curriculum on their understanding of the topic and their subsequent confidence in managing patients with OUD in the ED setting. Conclusion: A dedicated brief MOUD and referral curriculum can be effectively integrated into EM resident education to provide valuable clinical knowledge that may affect clinical practice.

Ranking evidence in substance use and addiction

Evidence-based medicine has consistently prized the epistemological value of randomized-controlled trials (RCTs) owing to their methodological advantages over alternative designs such as observational studies. However, there are limitations to RCTs that hinder their ability to study chronic and dynamic conditions such as substance use and addiction. For these conditions, observational studies may provide superior evidence based on methodological and practical strengths. Assuming epistemic superiority of RCTs has led to an inappropriate devaluation of other study designs and the findings they support, including support for harm reduction services, especially needle exchange programs and supervised injection facilities. The value offered by observational studies should be reflected in evidence-based medicine by allowing more flexibility in evidence hierarchies that presume methodological superiority of RCTs. Despite the popularity of evidence ranking systems and hierarchies, nothing should replace critical appraisal of study methodology and examining the suitability of applying a given study design to a specific research question.

Medication for opioid use disorder treatment and specialty outpatient substance use treatment outcomes: Differences in retention and completion among opioid-related discharges in 2016

Opioid medication treatment access is a public health priority aimed to improve opioid use treatment outcomes. However, Medicaid does not cover all forms of MOUD, particularly methadone, in many states. We examined associations between medication for opioid use disorder (MOUD) plans and substance use treatment discharge reason (e.g., completed treatment, dropped out of treatment) as well as treatment retention (i.e., length of stay), and estimated whether these relationships were modified by state Medicaid methadone coverage. Data from the 2016 Treatment Episode Data Set for Discharges (TEDS-D) included 152,196 opioid-related treatment episodes from 47 states using relative risk regression with state clustering. Discharges involving MOUD had higher treatment retention for >180 days (aRR: 1.60, 95% CI: 1.29, 1.99) and >365 days (aRR: 2.64, 95% CI: 2.00, 3.49) but lower treatment completion (aRR: 0.46, 95% CI: 0.38, 0.57). There was no evidence that state Medicaid methadone coverage modified any of these relationships. Focusing on treatment completion alone may obscure health benefits associated with longer MOUD treatment retention.

Social functioning outcomes in men and women receiving medication-assisted treatment for opioid use disorder

Background

Social functioning (SF), the ability to engage with life and fulfill roles may be a salient “patient important outcome” in addiction treatment. It is not known if medication-assisted treatment (MAT) impacts SF in opioid use disorder (OUD). There is a growing evidence to suggest that men and women are impacted differently by OUD. This study is the largest to date to study sex differences in OUD and explore associations between MAT and SF.

Methods

Data were collected from 2736 participants with OUD, enrolled in MAT for varying lengths of time, in outpatient clinics across Ontario. SF was defined according to the Maudsley Addiction Profile’s domains of (1) employment, (2) criminal activity, and (3) interpersonal conflict. Using logistic regression analysis, we examined sociodemographic and clinical factors associated with domains of SF.

Results

There were 1544 men (56%) and 1192 women (44%) in this study, and ages varied from 17 to 76 years for men and 18 to 69 years for women. At study entry, participants had been on MAT for a median of 2 years. Compared to men, women reported more psychological (mean MAP score 14/40, SD = 9.55, versus 11/40, SD = 8.64; p < 0.001) and physical symptoms (mean MAP score 17/40, SD = 7.70 versus 14/40, SD = 7.74; p < 0.001). More women reported unemployment(74% versus 58%; p < 0.0001) and interpersonal conflict (46% versus 35%; p < 0.0001). Men were more likely than women to report criminal activity (11%, versus 8%; p = 0.001). Psychological symptoms increased the risk of worse SF, across domains, for men and for women. Every year on MAT was associated with a 7% increase in the odds of women engaging with criminal activity (OR = 1.07, 95% CI 1.02, 1.12, p = 0.006).

Conclusions

Men and women had different SF profiles and psychological symptoms scores while on MAT. The length of time on MAT increased the risk of criminal activity in women, and overall, duration of MAT was not associated with improvement in SF. This may suggest that MAT alone may not support continual improvements in SF in OUD.

Tramadol-associated hallucinations: a systematic review and narrative synthesis of their pathophysiology, diagnosis, and treatment

BACKGROUND

Recent prescribing trends reflect government-led efforts undertaken in both the U.S. and Canada to decrease opioid use. These provisions reflect a reduction in the use of many potent opioids in favour of tramadol. Despite the purported benefits of tramadol over other opioids, little remains known about tramadol-associated hallucinations (TAH).

METHODS

We conducted a systematic literature search in Embase, Medline, Cochrane CENTRAL, CINAHL, PubMed, Scopus, PAHO Virtual Health Library, MedNar, and ClinicalTrials.gov to find reported cases of hallucinations associated with the use of tramadol. For all corresponding cases reporting hallucinations secondary to tramadol use, we extracted data on patient demographics, medical management, and the details on hallucinations. Cases were categorized as "probable TAH" if the evidence supported an association between hallucinations and tramadol use, or "possible TAH" if hallucinations were attributed to tramadol use but the supporting evidence was weak. The "probable TAH" cases were further classified as "isolated TAH" if hallucinations were the primary complaint, or "other existing medical condition" if concurrent signs and symptoms alluded to a diagnosis of an existing medical condition. We then conducted a narrative synthesis of the available literature to contextualize these results.

RESULTS

A total of 941 articles were identified in the initial search. No observational studies or randomized clinical trials were identified with our systematic review; only case reports were found. After a thorough screening, 34 articles comprising 101 patients reported an association between tramadol use and hallucinations. Among these 101 cases, 31 were "probable TAH" and 70 were "possible TAH". Of the 31 cases of "probable TAH", 16 cases were "isolated TAH" while the remaining 15 cases belonged to "other existing medical condition".

CONCLUSIONS

Tramadol-associated hallucinations can result in auditory or visual disturbances, although multisensory symptoms have also been reported. The mechanism underlying TAH remains poorly understood and likely involves numerous receptor types. The relative risk of hallucinations from tramadol compared with other opioids remains unclear.