The impact of methamphetamine/amphetamine use on receipt and outcomes of medications for opioid use disorder: a systematic review

Trends in polysubstance use among patients in methadone maintenance treatment in Ireland: Evidence from urine drug testing 2010-2020

INTRODUCTION

The benefits of methadone maintenance treatment (MMT) may be compromised by the continued use of other substances during treatment. Polysubstance use has been identified as a major contributing factor to treatment discontinuation, a known risk factor for drug overdose. We examined trends in immunoassay drug positivity rates for amphetamines, benzodiazepines, cannabis, cocaine and opioids, and (2) trends in polysubstance positivity rates for drug combinations associated with increased risk of drug overdose among patients attending the national drug treatment centre in Ireland for MMT between 2010 and 2020.

METHODS

Repeated cross-sectional study of patients attending the national drug treatment centre (NDTC) for MMT (total N = 1942) between 2010 and 2020, focused on urine drug samples provided for testing to the NDTC clinical testing laboratory (n = 221,564). Samples were analysed using immunoassay during the study period. Mixed-effects logistic regression models evaluate time trends in drug positivity. A random intercept accounts for repeat testing of individual patients. The study reports Adjusted Odds Ratios (AOR) for time (per year) with 95 % Confidence Intervals (95 % CI).

RESULTS

Drug positivity rates increased over time for benzodiazepines (AOR 1.02, 95 % CI 1.01-1.03, p < .0001), cannabis (AOR 1.06, 95 % CI 1.05-1.08, p < .0001) and cocaine (AOR 1.28, 95 % CI 1.27-1.29, p < .0001), with decreasing trends for opioids (AOR 0.91, 95 % CI 0.91-0.92, p < .0001). Methadone and benzodiazepines were co-detected in over two-thirds of all samples during the study period. Co-detection of methadone and benzodiazepines with cocaine was also found to be increasing (AOR 1.24, 95 % CI 1.23-1.25, p < .0001), with weighted polysubstance positivity rates reaching 29.2 % in 2020. The co-detection of methadone and benzodiazepines with opioids decreased over the study period (AOR 0.92, 95 % CI 0.91-0.92, p < .0001), ranging from 36.7 % in 2010 to 26.9 % in 2020.

CONCLUSION

Interventions are needed to target the persistently high use of benzodiazepines among patients in receipt of methadone due to their synergistic effects with opioids on respiratory depression, enhancing the risk of overdose. The growing use of cocaine among people in MMT also needs to be addressed.

Levels of engagement among office-based opioid treatment (OBOT) patients with concurrent methamphetamine use

BACKGROUND AND OBJECTIVES

Recent increases in methamphetamine use among people seeking treatment for opioid use disorder (OUD) has created significant demand for effective approaches to support this clinical population. This study assessed the extent to which office-based opioid treatment (OBOT) patients, who were diagnosed with methamphetamine use disorder (MUD), engaged with providers.

METHODS

A retrospective analysis was conducted of adult patients (n = 470) seeking treatment for OUD who attended at least one visit between March 2020 and March 2023 at a rural regional OBOT provider. Approximately one quarter (28.7%) of patients were diagnosed with MUD in addition to receiving an OUD diagnosis. Bivariate methods and multivariate negative binomial regression models were estimated to examine the associations between clinical measures and the numbers of office visits, peer visits, and telehealth visits.

RESULTS

Regression results indicated patients who met criteria for MUD in addition to OUD attended a higher rate of peer visits (incidence rate ratio [IRR] = 2.63, p = .036) when compared to patients who did not meet criteria for MUD. In contrast, patients with MUD and OUD diagnoses displayed significantly lower (IRR = 0.68, p < .001) engagement rates through fewer office visits relative to those who did not meet MUD criteria.

DISCUSSION AND CONCLUSIONS

Patients seeking treatment for OUD who meet criteria for MUD are more likely to engage through peer support specialists rather than office visits.

SCIENTIFIC SIGNIFICANCE

This study demonstrates the ways patients who meet criteria for OUD and MUD engage with providers to receive treatment.

Induction to Methadone 80 mg in the First Week of Treatment of Patients Who Use Fentanyl: A Case Series From an Outpatient Opioid Treatment Program

OBJECTIVES

Current guidelines for methadone titration may unnecessarily delay reaching effective doses for patients using fentanyl, resulting in an increased risk of ongoing fentanyl use, dissatisfaction with treatment, and early dropout. Development and evaluation of rapid methadone induction protocols may improve treatment for patients using fentanyl.

METHODS

Retrospective chart review was conducted for patients admitted in 2022 to a single licensed opioid treatment program (OTP) where a rapid induction protocol provides methadone 40 mg on day 1, 60 mg on day 2, and 80 mg on day 3 to patients using fentanyl <65 years old without significant medical comorbidities. The primary feasibility outcome was completion of the protocol, defined by receipt of methadone dose 80 mg or more on treatment day 7. The primary safety outcomes were oversedation, nonfatal overdose, and death. A secondary outcome was retention in treatment at 30 days.

RESULTS

Rapid induction was ordered for 93 patients and completed by 65 (70%). Average dose on day 7 for patients who completed was 89 mg (SD 9.5 mg) versus 49 mg (SD 14.0 mg) for those who did not. No episodes of oversedation, nonfatal overdose, or death were observed. At 30 days, 85% of the patients who had the rapid protocol ordered (79/93) were retained, with 88% (57/65) who completed the protocol retained versus 79% (22/28) who did not complete (OR 1.9, 95% CI 0.6-6.2).

CONCLUSIONS

Rapid induction to methadone 80 mg by day 7 was feasible for outpatients using fentanyl in this study at a single OTP. No significant safety events were identified.

Comparison of Treatment Receipt and Hospitalization Among Patients With Stimulant Use Disorder and/or Opioid Use Disorder in the Veterans Health Administration

OBJECTIVES

Stimulant use is a growing problem, but little is known about service utilization among patients with stimulant use disorder (StUD). In the context of the overdose crisis, much research has focused on patients with opioid use disorder (OUD). It is unclear how the characteristics, treatment receipt, and hospitalization of patients with StUD differ from patients with OUD.

METHODS

Electronic health record data were extracted for national Veterans Health Administration patients with a visit from March 1, 2020, to February 28, 2021 with StUD and/or OUD (N = 132,273). We compared patients with StUD without OUD to those with (1) co-occurring StUD + OUD and (2) OUD without StUD. Patient characteristics, substance use disorder treatment, and hospitalizations in the year following patients' first study period visit were descriptively compared. Treatment and hospitalization were also compared in adjusted regression models.

RESULTS

Compared with patients with OUD + StUD, those with StUD without OUD were less likely to receive outpatient (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.47-0.50) or any treatment (aOR 0.47, 95% CI 0.46-0.49). Compared with patients with OUD without StUD, those with StUD without OUD were less likely to receive outpatient (aOR 0.51, 95% CI 0.49-0.52) or any treatment (aOR 0.56, 95% CI 0.54-0.58) and more likely to receive residential treatment (aOR 2.18, 95% 2.05-2.30) and to be hospitalized (aOR 1.62, 95% 1.56-1.69).

CONCLUSIONS

Patients with StUD may be less likely to receive treatment and more likely to be hospitalized than patients with OUD. Efforts focused on mitigating hospitalization and increasing treatment receipt for patients with StUD are needed.

Evolution of the substance use landscape: Implications for contingency management

Contingency management (CM), which involves the delivery of incentives upon meeting behavioral goals, has the potential to improve substance use treatment outcomes. The intervention allows for flexibility through numerous modifiable components including changes to incentive magnitude and schedule, target behavior, and intervention structure. Unfortunately, numerous changes in the substance use landscape have occurred in the past 10 to 15 years: Substances are more potent, overdose risk has increased, new substances and methods of use have been introduced, and substance classes are increasingly being intentionally and unintentionally mixed. These developments potentially undermine CM outcomes. We explored recent substance use changes due to legislative, regulatory, social, and economic factors for four substance classes: stimulants, opioids, tobacco, and cannabis. We discuss potential adjustments to the modifiable components of CM for future research in response to these changes. By continually adapting to the shifting substance use landscape, CM can maintain optimal efficacy.

Opioid agonist treatment outcomes among individuals with a history of nonfatal overdose: Findings from a pragmatic, pan-Canadian, randomized control trial

BACKGROUND AND OBJECTIVES

History of nonfatal overdose (NFO) is common among people who use opioids, but little is known about opioid agonist treatment (OAT) outcomes for this high-risk subpopulation. The objective of this study was to investigate the relative effectiveness of buprenorphine/naloxone and methadone on retention and suppression of opioid use among individuals with opioid use disorder (OUD) and history of NFO.

METHODS

Secondary analysis of a pan-Canadian pragmatic trial comparing flexible take-home buprenorphine/naloxone and supervised methadone for people with OUD and history of NFO. Logistic regression was used to examine the impact of OAT on retention in the assigned or in any OAT at 24 weeks and analysis of covariance was used to examine the mean difference in opioid use between treatment arms.

RESULTS

Of the 272 randomized participants, 155 (57%) reported at least one NFO at baseline. Retention rates in the assigned treatment were 17.7% in the buprenorphine/naloxone group and 18.4% in the methadone group (adjusted odds ratio [AOR] = 0.54, 95% CI: 0.17-1.54). Rates of retention in any OAT were 28% and 20% in the buprenorphine/naloxone and methadone arms, respectively (AOR = 1.55, 95% CI: 0.65-3.78). There was an 11.9% adjusted mean difference in opioid-free urine drug tests, favoring the buprenorphine/naloxone arm (95% CI: 3.5-20.3; p = .0057).

CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE

Among adults with OUD and a history of overdose, overall retention rates were low but improved when retention in any treatment was considered. These findings highlight the importance of flexibility and patient-centered care to improve retention and other treatment outcomes in this population.

Incentivized collaborative care to disseminate and enhance contingency-management services

Contingency management is especially effective in supporting medication adherence and drug abstinence among people with opioid use disorder. However, the incorporation of contingency management into clinical practice has been slow. The present study was designed to evaluate the feasibility, acceptability, and usability of incentives for providers as a means of accelerating collaborative care with contingency management. Thirteen buprenorphine prescribers served as participants in a nonexperimental study. The prescribers who referred patients to a contingency-management service received monetary incentives for reviewing patient performance data and describing their use of these data in treatment decisions. The results show that this approach is feasible, acceptable, and easy to use for everyone involved. Self-reports indicate improved prescriber-patient relationships and more informed care. However, prescriber-focused incentives did not appear to greatly enhance access to contingency-management services for patients. Thus, provider incentives may be beneficial but further research is needed to advance adoption of contingency management.

Motivation and context of concurrent stimulant and opioid use among persons who use drugs in the rural United States: a multi-site qualitative inquiry

BACKGROUND

In recent years, stimulant use has increased among persons who use opioids in the rural U.S., leading to high rates of overdose and death. We sought to understand motivations and contexts for stimulant use among persons who use opioids in a large, geographically diverse sample of persons who use drugs (PWUD) in the rural settings.

METHODS

We conducted semi-structured individual interviews with PWUD at 8 U.S. sites spanning 10 states and 65 counties. Content areas included general substance use, injection drug use, changes in drug use, and harm reduction practices. We used an iterative open-coding process to comprehensively itemize and categorize content shared by participants related to concurrent use.

RESULTS

We interviewed 349 PWUD (64% male, mean age 36). Of those discussing current use of stimulants in the context of opioid use (n = 137, 39%), the stimulant most used was methamphetamine (78%) followed by cocaine/crack (26%). Motivations for co-use included: 1) change in drug markets and cost considerations; 2) recreational goals, e.g., seeking stronger effects after heightened opioid tolerance; 3) practical goals, such as a desire to balance or alleviate the effects of the other drug, including the use of stimulants to avoid/reverse opioid overdose, and/or control symptoms of opioid withdrawal; and 4) functional goals, such as being simultaneously energized and pain-free in order to remain productive for employment.

CONCLUSION

In a rural U.S. cohort of PWUD, use of both stimulants and opioids was highly prevalent. Reasons for dual use found in the rural context compared to urban studies included changes in drug availability, functional/productivity goals, and the use of methamphetamine to offset opioid overdose. Education efforts and harm reduction services and treatment, such as access to naloxone, fentanyl test strips, and accessible drug treatment for combined opioid and stimulant use, are urgently needed in the rural U.S. to reduce overdose and other adverse outcomes.

Providers' Experiences and Perspectives in Treating Patients With Co-Occurring Opioid and Stimulant Use Disorders in the Hospital

BACKGROUND

The overdose crisis is increasingly characterized by opioid and stimulant co-use. Despite effective pharmacologic treatment for both opioid use disorder (OUD) and contingency management for stimulant use disorders, most individuals with these co-occurring conditions are not engaged in treatment. Hospitalization is an important opportunity to engage patients and initiate treatment, however existing hospital addiction care is not tailored for patients with co-use and may not meet the needs of this population.

METHODS

Semi-structured interviews were conducted with hospital providers about their experiences and perspectives treating patients with opioid and stimulant co-use. We used directed content analysis to identify common experiences and opportunities to improve hospital-based treatment for patients with co-use.

RESULTS

From qualitative interviews with 20 providers, we identified 4 themes describing how co-use complicated hospital-based substance use treatment: (1) patients' unstable circumstances impacting the treatment plan, (2) co-occurring withdrawals are difficult to identify and treat, (3) providers holding more stigmatizing views of patients with co-use, and (4) stimulant use is often "ignored" in the treatment plans. Participants also described a range of potential opportunities to improve hospital-based treatment of co-use that fall into 3 categories: (1) provider practice changes, (2) healthcare system changes, and (3) development and validation of clinical tools and treatment approaches.

CONCLUSIONS

We identified unique challenges providing hospital addiction medicine care to patients who use both opioids and stimulants. These findings inform the development, implementation, and testing of hospital-based interventions for patients with co-use.

The influence of transformations in supply on methamphetamine initiation among people injecting opioids in the United States

BACKGROUND

Co-use of methamphetamine (MA) and opioids (pharmaceutical pills, heroin and fentanyls) has increased in the United States and is represented in rising mortality. Although coinciding with the import of low cost, high potency and purity methamphetamine, the relationship between supply and demand in propelling this polydrug use is not well understood. We consider the influence of macro changes in supply on the uptake of opioid and methamphetamine co-use by injection at the level of individual drug and injection initiation in West Virginia, a state which leads the US in drug overdose mortality.

METHOD

We recruited n = 30 people for semi-structured interviews who self-reported injecting heroin/fentanyl and using methamphetamine by any route at a West Virginia syringe service program and through snowball sampling. Interviews were recorded and transcripts analyzed using a thematic approach. Ethnographic observation was also conducted and recorded in fieldnotes. Sequence of substance and mode of use initiation and use trajectories for opioids and stimulants were charted for each participant.

RESULTS

A clear pattern of individual drug initiation emerged that matched each successive supply wave of the US overdose epidemic: 25 participants had initiated opioid use with pills, followed by heroin, often mixed with/replaced by fentanyl, and subsequently added methamphetamine use. For participants, the supply and consumption of opioid analgesics had set in motion a series of steps leading to the addition of stimulant injection to existing opioid injecting repertoires. Unlike other studies that have found a birth cohort effect in patterns of initiation, participants showed the same sequence across age groups. Considerations of economy, availability, dependence, tolerance and the erosion of taboos that marked transitions from opioid pills to heroin injection influenced these subsequent trajectories in novel ways. The form, timing and extent of opioid and stimulant consumption was influenced by four stages of the changing drug supply, which in turn reflected back on demand.

CONCLUSION

Transformations in the social meaning and supply of methamphetamine enabled these transitions while other desired, non-injectable drugs were difficult to obtain. We discuss policy implications of injectable drugs' market dominance at this location and possible interventions.

Associations between stimulant use and return to illicit opioid use following initiation onto medication for opioid use disorder

AIM

The aim of this study was to estimate how ongoing stimulant use affects return to illicit opioid use after initiation onto medication for opioid use disorder (MOUD).

DESIGN

This was a secondary analysis of pooled data from two clinical trials comparing buprenorphine (BUP-NX) and extended-release naltrexone (XR-NTX).

SETTING

Thirteen opioid treatment programs and HIV clinics across 10 states in the United States from 2014 to 2019 took part in this study.

PARTICIPANTS

A total of 528 participants who initiated MOUD as part of trial participation were included. Nearly half (49%) were between 30 and 49 years of age, 69% were male and 66% were non-Hispanic White.

MEASUREMENTS

The primary outcome was first self-reported day of non-prescribed opioid use following MOUD initiation, and the exposure of interest was daily stimulant use (methamphetamine, amphetamines or cocaine). Both were defined using time-line follow-back. Among participants reporting at least 1 day of illicit opioid use, we also examined relapse to ongoing use, defined as (1) 7 days of continuous opioid use or (2) 4 consecutive weeks with self-reported opioid use, one or more positive urine drug screens (UDS) for opioids or one or more missing UDS.

FINDINGS

Forty-seven per cent of participants reported stimulant use following MOUD initiation, 58% returned to illicit opioid use and 66% of those relapsed to ongoing use. Stimulant use was strongly associated with increased risk of misusing opioids after MOUD initiation when measured daily [adjusted hazard ratio (aHR) = 9.23, 95% confidence interval (CI) = 6.80-12.50, P < 0.001] and over a 7-day period (aHR = 1.27 for each additional day, CI = 1.18-1.37, P < 0.001). Using stimulants weekly or more often was associated with increased likelihood of relapse to ongoing opioid use compared with less than weekly or no stimulant use (adjusted odds ratio = 2.30, CI = 1.05-5.39, P = 0.044).

CONCLUSIONS

People initiated on medication for opioid use disorder who subsequently use stimulants appear to be more likely to return to and continue using non-prescribed opioids compared with those without stimulant use. The association appears to be stronger among patients who initiate buprenorphine compared with those who initiate extended-release naltrexone.

The impact of polysubstance use patterns on engagement of substance use disorder treatment among emergency department patients at high risk of opioid overdose

Background

Substance use patterns are diverse, and multiple substances are often involved in fatal and nonfatal overdoses. Additionally, polysubstance use is associated with greater difficulty accessing and remaining in substance use disorder (SUD) treatment. The aim of this study was to identify substance use patterns and determine their association with SUD treatment engagement among emergency department (ED) patients at risk of opioid overdose.

Methods

This was a sub-analysis of a randomized controlled trial comparing two behavioral interventions for individuals at two EDs in Rhode Island from 2018 to 2021. Past six-month substance use frequency for eight substances plus injection drug use was self-reported at trial enrollment, and SUD treatment engagement within 90 days after enrollment was obtained using administrative data linkages. Latent class analysis identified substance use patterns and multivariable log-binomial models estimated the association with SUD treatment engagement.

Results

Among 607 participants, there were four substance use patterns: 1) low reported use (n = 295), 2) frequent injection and heroin use (n = 131), 3) high frequency broad polysubstance use (n = 62), and 4) low frequency broad polysubstance use (n = 119). Compared to participants with the low reported use pattern, those with the frequent injection and heroin pattern had a greater likelihood of SUD treatment engagement (adjusted risk ratio = 1.28; 95% confidence interval = 1.02-1.61).

Conclusions

Distinct and meaningful polysubstance use patterns showed differential SUD treatment engagement after ED discharge. Nuanced relationships between substance use patterns and treatment highlight the necessity for tailored harm reduction, treatment, and recovery services.

Using ADAPT-ITT framework to tailor evidence-based interventions for addressing methamphetamine use among methadone patients in Vietnam

INTRODUCTION

Methamphetamine use threatens positive treatment outcomes in substance use and HIV, for people with opioid use disorders (POUD) in many countries. This paper describes the adaptation of four evidence-based interventions (EBI) (motivational interviewing, contingency management, Matrix group model and SMS text messaging) for treating methamphetamine use among POUD receiving methadone maintenance therapy in Vietnam.

METHODS

Following the ADAPT-ITT (Assessment-Decision-Administration-Production-Topical experts-Training-Testing) framework, we conducted 16 focus group discussions with POUD (n = 25) and providers (n = 22) at four methadone clinics in two largest cities (Hanoi in the North, Ho Chi Minh City in the South) to assess patterns of methamphetamine use and to get feedback on proposed EBIs. The proposed EBIs were properly adapted and used to train providers in two of the four methadone clinics. The revised EBIs were tested over 12 weeks among 42 POUD on methadone who use methamphetamine. Post-intervention feedback served to fine-tune the revised EBIs.

RESULTS

Insights about patterns of methamphetamine use suggested that EBIs should focus on different triggers to methamphetamine use among POUD receiving methadone treatment in the two cities. All EBIs should emphasise family-related topics to build a strong motivation for treatment. Participants suggested when, where and how each EBI should be delivered. Most participants were satisfied with the adapted EBIs. Limited human resources at methadone clinics might hinder implementation of the adapted EBIs.

DISCUSSION AND CONCLUSIONS

We successfully completed the adaptation of EBIs for POUD who use methamphetamine on methadone in Vietnam. The pilot testing of the adapted EBIs demonstrated feasibility and acceptability.

TRIAL REGISTRATION

NCT04706624. Registered 13 January 2021. https://clinicaltrials.gov/ct2/show/NCT04706624.

Treatment Initiation, Substance Use Trajectories, and the Social Determinants of Health in Persons Living With HIV Seeking Medication for Opioid Use Disorder

BACKGROUND

People living with HIV and opioid use disorder (OUD) are disproportionally affected by adverse socio-structural exposures negatively affecting health, which have shown inconsistent associations with uptake of medications for OUD (MOUD). This study aimed to determine whether social determinants of health (SDOH) were associated with MOUD uptake and trajectories of substance use in a clinical trial of people seeking treatment.

METHODS

Data are from a 2018 to 2019 randomized trial comparing the effectiveness of different MOUD to achieve viral suppression among people living with HIV and OUD. SDOH were defined by variables mapping to Healthy People 2030 domains: education (Education Access and Quality), income (Economic Stability), homelessness (Neighborhood and Built Environment), criminal justice involvement (Social and Community Context), and recent SUD care (Health Care Access and Quality). Associations between SDOH and MOUD initiation were assessed with Cox proportional hazards models, and SDOH and substance use over time with generalized estimating equation models.

RESULTS

Participants (N = 114) averaged 47 years old, 63% were male, 56% were Black, and 12% Hispanic. Participants reported an average of 2.3 out of 5 positive SDOH indicators (SD = 1.2). Stable housing was the most commonly reported SDOH (61%), followed by no recent criminal justice involvement (59%), having a high-school level education or greater (56%), income stability (45%), and recent SUD care (13%). Each additional favorable SDOH was associated with a 25% increase in the likelihood of MOUD initiation during the study period [adjusted HR = 1.25, 95% CI = (1.01, 1.55), P = .044]. Positive SDOH were also associated with a decrease in the odds of baseline opioid use and a greater reduction in opioid use during subsequent weeks of the study (P < .001 for a joint test of baseline and slope differences).

CONCLUSIONS

Positive social determinants of health, in aggregate, may increase the likelihood of MOUD treatment initiation among people living with HIV and OUD.

Methamphetamine use and utilization of medications for opioid use disorder among rural people who use drugs

BACKGROUND

Methamphetamine use is common among persons with opioid use disorder. This study evaluated associations between methamphetamine use and treatment with agonist medications for opioid use disorder (MOUD, specifically buprenorphine, and/or methadone) in U.S. rural communities.

METHODS

The Rural Opioid Initiative (ROI) is a consortium spanning 10 states and 65 rural counties that included persons who reported past 30-day use of opioids and/or injection drug use between 1/2018 and 3/2020. Analyses were restricted to participants who had ever used opioids and had data on past 30-day methamphetamine use. Multivariable models examined the relationship between methamphetamine use and utilization of agonist MOUD.

RESULTS

Among 2899 participants, 2179 (75.2%) also reported recent methamphetamine use. Persons with methamphetamine use compared to those without were younger, more likely to have injected drugs, be unhoused, criminal justice involved, and less likely to have health insurance. Adjusted for age, sex, race, and study site, recent methamphetamine use was associated with lower relative odds of past 30-day methadone treatment (aOR=0.66; 95% CI: 0.45-0.99) and fewer methadone treatment days (aIRR=0.76; 0.57-0.99), but not past 30-day buprenorphine receipt (aOR=0.90; 0.67-1.20), buprenorphine treatment days in past 6 months: aIRR=0.88; 0.69-1.12) or perceived inability to access buprenorphine (aOR=1.12; 0.87-1.44) or methadone (aOR=1.06; 0.76-1.48).

CONCLUSION

Methamphetamine use is common among persons who use opioids in rural U.S. areas and negatively associated with current treatment and retention on methadone but not buprenorphine. Future studies should examine reasons for this disparity and reduce barriers to methadone for persons who use opioids and methamphetamine.

The impact of methamphetamine use on medications for opioid use disorder (MOUD) treatment retention: a scoping review

BACKGROUND

An emerging public health threat of methamphetamine/opioid co-use is occurring in North America, including increases in overdoses related to concomitant methamphetamine/opioid use. This presents a potential risk to established treatments for opioid use disorder (i.e., medications for opioid use disorder [MOUD]). To date, few studies have examined the impact of methamphetamine use on MOUD-related outcomes, and no studies have synthesized data on MOUD retention.

METHODS

A scoping review was undertaken to examine the impact of methamphetamine use on MOUD retention. All original published research articles were searched in Embase, MEDLINE, PsychINFO, CINAHL, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews and Cochrane Protocols, and Google scholar databases. Data were extracted into a standardized data extraction chart. Findings were presented narratively.

RESULTS

All eight included studies demonstrated an increased likelihood of treatment discontinuation or dropout among patients enrolled in MOUD who used methamphetamine. The frequency of methamphetamine use was also associated with MOUD dropout, in that those who used methamphetamine more often were more likely to discontinue MOUD. The definitions and measurements of MOUD retention varied considerably, as did the magnitude of effect size.

CONCLUSIONS

Results indicate that methamphetamine use has an undesirable impact on MOUD retention and results in an increased risk of treatment discontinuation or dropout. Strategies to identify concurrent methamphetamine use among individuals engaging in MOUD and educate them on the increased risk for dropout should be undertaken. Further research is needed to understand how MOUD retention among patients with concomitant opioid and methamphetamine use can be improved.

Methamphetamine use and illicit opioid use during buprenorphine treatment

Introduction

Although methamphetamine use is rising in the United States, its impacts on patient outcomes among persons undergoing treatment for opioid use disorder (OUD) remain unclear. This study aims to assess the association between baseline methamphetamine/amphetamine (MA/A) use and subsequent illicit opioid use among patients with OUD initiating buprenorphine in an office-based setting.

Methods

We conducted a secondary analysis of a pilot randomized controlled trial of a behavioral mobile health intervention for buprenorphine adherence conducted over a 12-week study period at two clinic sites. The study defined baseline MA/A use by a positive urine drug test (UDT) and/or self-report of use within the past 30-days. Separate Poisson regression models with robust standard errors evaluated associations between MA/A and: i) illicit opioid use measured by weekly UDT (primary) and ii) self-reported past 30-day use at end of study (secondary). Other secondary outcomes included buprenorphine positive UDTs throughout the study and retention in OUD treatment at both weeks 12 and 24 post-randomization.

Results

At baseline, 28 (36%) of the 78 participants had MA/A use and use was associated with a statistically significant increase in risk of testing positive for illicit opioids on UDT during the study follow-up period (adjusted relative risk (aRR)=1.54; 95% CI=1.09-2.17; p=0.015), as well as an increased risk for reported past 30-day illicit opioid use at week 12 (aRR=3.86; 95% CI=1.47-10.18; P=0.006). The study found no significant associations between MA/A use and buprenorphine positive UDT or retention in OUD treatment.

Conclusions

In this sample of patients initiating buprenorphine, methamphetamine/amphetamine use at baseline was associated with illicit opioid use over a 12-week period. These findings demonstrate how co-use of methamphetamine can impede attainment of ideal OUD treatment outcomes.

Feasibility, Engagement, and Usability of a Remote, Smartphone-Based Contingency Management Program as a Treatment Add-On for Patients Who Use Methamphetamine: Single-Arm Pilot Study

BACKGROUND

In the United States, methamphetamine-related overdoses have tripled from 2015 to 2020 and continue to rise. However, efficacious treatments such as contingency management (CM) are often unavailable in health systems.

OBJECTIVE

We conducted a single-arm pilot study to evaluate the feasibility, engagement, and usability of a fully remotely delivered mobile health CM program offered to adult outpatients who used methamphetamine and were receiving health care within a large university health system.

METHODS

Participants were referred by primary care or behavioral health clinicians between September 2021 and July 2022. Eligibility criteria screening was conducted by telephone and included self-reported methamphetamine use on ≥5 out of the past 30 days and a goal of reducing or abstaining from methamphetamine use. Eligible participants who agreed to take part then completed an initial welcome phase that included 2 videoconference calls to register for and learn about the CM program and 2 "practice" saliva-based substance tests prompted by a smartphone app. Participants who completed these welcome phase activities could then receive the remotely delivered CM intervention for 12 consecutive weeks. The intervention included approximately 24 randomly scheduled smartphone alerts requesting a video recording of themselves taking a saliva-based substance test to verify recent methamphetamine abstinence, 12 weekly calls with a CM guide, 35 self-paced cognitive behavioral therapy modules, and multiple surveys. Financial incentives were disbursed via reloadable debit cards. An intervention usability questionnaire was completed at the midpoint.

RESULTS

Overall, 37 patients completed telephone screenings, with 28 (76%) meeting the eligibility criteria and consenting to participate. Most participants who completed a baseline questionnaire (21/24, 88%) self-reported symptoms consistent with severe methamphetamine use disorder, and most had other co-occurring non-methamphetamine substance use disorders (22/28, 79%) and co-occurring mental health disorders (25/28, 89%) according to existing electronic health records. Overall, 54% (15/28) of participants successfully completed the welcome phase and were able to receive the CM intervention. Among these participants, engagement with substance testing, calls with CM guides, and cognitive behavioral therapy modules varied. Rates of verified methamphetamine abstinence in substance testing were generally low but varied considerably across participants. Participants reported positive opinions about the intervention's ease of use and satisfaction with the intervention.

CONCLUSIONS

Fully remote CM can be feasibly delivered within health care settings lacking existing CM programs. Although remote delivery may help reduce barriers to treatment access, many patients who use methamphetamine may struggle to engage with initial onboarding. High rates of co-occurring psychiatric conditions in the patient population may also contribute to uptake and engagement challenges. Future efforts could leverage greater human-to-human connection, more streamlined onboarding procedures, larger incentives, longer durations, and the incentivization of non-abstinence-based recovery goals to increase uptake and engagement with fully remote mobile health-based CM.

The health needs of people leaving prison with a history of methamphetamine and/or opioid use

INTRODUCTION

Methamphetamine use is more common than opioid use among prison entrants in some countries, including Australia, yet most research and policy focuses on opioid use. This suggests that traditional opioid-focused interventions are no longer appropriate for the majority of this group in countries such as Australia. To inform policy and practice, we compared socio-demographic characteristics and health needs of people leaving prison with a history of methamphetamine use and/or opioid use.

METHODS

A cross-sectional survey of incarcerated adults administered the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test was used to identify moderate-/high-risk methamphetamine use (n = 909), opioid use (n = 115) or combined methamphetamine/opioid use (n = 356) before incarceration. We compared groups using modified log-linked Poisson regression with robust error variance.

RESULTS

Compared to the opioid-only group, the methamphetamine-only group were: significantly more often aged <25 years; significantly more likely to identify as Indigenous; significantly less likely to have a history of prior incarceration, drug injection or overdose. A significantly lower proportion of methamphetamine-only and methamphetamine-and-opioid participants self-reported current hepatitis C infection compared to opioid-only participants. A majority of participants in all groups screened positive for current psychological distress according to the K10.

DISCUSSION AND CONCLUSIONS

People leaving prison with a history of methamphetamine use differ from opioid users with respect to demographics, patterns of substance use and related health concerns. Treatment and harm reduction efforts for people who experience incarceration must respond to patterns of drug use in this population, and invest at scale in coordinated, continuous services for co-occurring substance use and mental health problems.

Predictors and motives of polydrug use in opioid users. A narrative review

PURPOSE OF REVIEW

To review the recent literature on predictors and personal motives of polydrug use in opioid users with a focus on combined use of opioids with stimulants, benzodiazepines and gabapentinoids.

RECENT FINDINGS

In North America, methamphetamine is now the most prevalent co-drug in opioid users and is responsible for high mortality rates. In Europe, opioids are rather combined with either cocaine, benzodiazepines or gabapentionoids, but recent data are lacking.Main personal motives of opioid users to combine opioids with methamphetamine or cocaine is to boost the opioid high, inhibit the withdrawal effects of heroin and have a cheaper alternative to maintain the opioid high. Risk factors of polydrug use by opioid users included being male, younger age, homelessness, high-risk sexual behavior, needle sharing, incarceration, poor mental health and recent use of cocaine or prescription opioids. The motives for co-use of opioids and gabapentinoids also include seeking a better high, lower price and to self-medicate pain/physical symptoms, including those resulting from withdrawal.

SUMMARY

When treating opioid users with polydrug drug use, special attention should be paid to dosing when in opioid agonist methadone/buprenorphine treatment and to the presence of physical pain. The validity of part of the personal motives seems questionable which deserves attention when counselling opioid users with polydrug use.

Extended-Release Naltrexone and Case Management for Treatment of Alcohol Use Disorder in the Emergency Department

STUDY OBJECTIVE

To assess the feasibility of initiating treatment for alcohol use disorder with extended-release naltrexone and case management services in the emergency department (ED) and measure the intervention's impact on daily alcohol consumption and quality of life.

METHODS

This is a 12-week prospective open-label single-arm study of a multimodal treatment for alcohol use disorder consisting of monthly extended-release naltrexone injections and case management services initiated at an urban academic ED. Participants were actively drinking adult patients in ED with known or suspected alcohol use disorder and an AUDIT-C score more than 4. The main feasibility outcomes included the rates of participant enrollment, retention in the study, and continuing treatment after study completion. Efficacy outcomes were the change in daily alcohol consumption (drinks per day; 14 g ethanol per drink), measured by a 14-day timeline followback, and the change in quality of life measured with a single-item Kemp quality of life scale.

RESULTS

One hundred seventy-nine patients were approached, and 32 were enrolled (18%). Of the 32 enrolled patients, 25 (78%) completed all visits, and 22 (69%) continued naltrexone after the trial. The mean baseline daily alcohol consumption was 7.6 drinks per day (interquartile range, 4.5, 13.4), and the mean quality of life was 3.6 (SD 1.7) on a 7-point scale. The median daily alcohol consumption change was -7.5 drinks per day (Hodges-Lehmann 95% confidence interval -8.6, -5.9). The mean quality of life change was 1.2 points (95% confidence interval 0.5, 1.9; P<.01).

CONCLUSION

We found that initiation of treatment of alcohol use disorder with extended-release naltrexone and case management is feasible in an ED setting and observed significant reductions in drinking with improved quality of life in the short term. Multicenter randomized controlled trials are needed to further validate these findings.

Trends in amphetamine prescriptions given at discharge in emergency departments: A national analysis (2012-2019)

OBJECTIVES

In parallel with the opioid epidemic, there has been a resurgence in abuse, medical complications, and deaths related to amphetamines. The opioid epidemic began with increasing rates of prescription products that evolved overtime to include heroin and more recently, fentanyl analogues. Current trends in amphetamine prescriptions are less well described. We sought to determine if there has been a change in amphetamine prescriptions given at discharge in U.S. emergency departments (EDs) in recent years.

METHODS

We conducted a retrospective review of data provided by the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2012 to 2019. We computed total number of visits that were given amphetamine prescriptions (amphetamine salts, methylphenidate derivatives, and dexmethylphenidate) at discharge for each year. We computed the total number and rate of visits (of all ED visits) that had both amphetamines and opioids prescribed at discharge over the years. We computed data normality using Shapiro Wilke's test and used descriptive statistics such as mean to describe the data distribution as applicable. We used spearman's rho (SR) or pearson's correlation (PC) as applicable to describe trends in data. All p-values were one-tailed and were reported at a 0.05 significance level. All analyses were conducted in IBM SPSS version 28.

RESULTS/FINDINGS

From 2012 to 2019, there were an estimated 817,895 ED visits where an amphetamine prescription was given at discharge, with an overall strong increase in rate over time (SR = 0.71, p = 0.02). At the beginning of the study period (2012) there were 83,503 (0.06%) visits and in 2019 there were 186,539 (0.12%) visits (123% absolute increase). On average, there were 102,237 (SD: 52,725) visits with discharge amphetamine prescriptions per year. There was a strong, linear increase in number of visits that involved a discharge amphetamine salt prescription (PC = 0.92, p = 0.001). In 2012, there were a total of 23,676 visits and in 2019, a total of 124,773 visits (427% increase). There was no trend in visits where both an amphetamine and opioid were prescribed (PC: 0.61, p = 0.06).

CONCLUSION

There have been increases in discharge prescriptions for amphetamines in the ED over time. This was largely driven by prescriptions for amphetamine salts. Future research initiatives should continue to monitor this trend and in prescriptions and associated abuse in the setting of rising amphetamine abuse.

Stimulant use among patients in opioid treatment settings: Provider perspectives

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.

Estimating the impact of stimulant use on initiation of buprenorphine and extended-release naltrexone in two clinical trials and real-world populations

BACKGROUND

Co-use of stimulants and opioids is rapidly increasing. Randomized clinical trials (RCTs) have established the efficacy of medications for opioid use disorder (MOUD), but stimulant use may decrease the likelihood of initiating MOUD treatment. Furthermore, trial participants may not represent "real-world" populations who would benefit from treatment.

METHODS

We conducted a two-stage analysis. First, associations between stimulant use (time-varying urine drug screens for cocaine, methamphetamine, or amphetamines) and initiation of buprenorphine or extended-release naltrexone (XR-NTX) were estimated across two RCTs (CTN-0051 X:BOT and CTN-0067 CHOICES) using adjusted Cox regression models. Second, results were generalized to three target populations who would benefit from MOUD: Housed adults identifying the need for OUD treatment, as characterized by the National Survey on Drug Use and Health (NSDUH); adults entering OUD treatment, as characterized by Treatment Episodes Dataset (TEDS); and adults living in rural regions of the U.S. with high rates of injection drug use, as characterized by the Rural Opioids Initiative (ROI). Generalizability analyses adjusted for differences in demographic characteristics, substance use, housing status, and depression between RCT and target populations using inverse probability of selection weighting.

RESULTS

Analyses included 673 clinical trial participants, 139 NSDUH respondents (weighted to represent 661,650 people), 71,751 TEDS treatment episodes, and 1,933 ROI participants. The majority were aged 30-49 years, male, and non-Hispanic White. In RCTs, stimulant use reduced the likelihood of MOUD initiation by 32% (adjusted HR [aHR] = 0.68, 95% CI 0.49-0.94, p = 0.019). Stimulant use associations were slightly attenuated and non-significant among housed adults needing treatment (25% reduction, aHR = 0.75, 0.48-1.18, p = 0.215) and adults entering OUD treatment (28% reduction, aHR = 0.72, 0.51-1.01, p = 0.061). The association was more pronounced, but still non-significant among rural people injecting drugs (39% reduction, aHR = 0.61, 0.35-1.06, p = 0.081). Stimulant use had a larger negative impact on XR-NTX initiation compared to buprenorphine, especially in the rural population (76% reduction, aHR = 0.24, 0.08-0.69, p = 0.008).

CONCLUSIONS

Stimulant use is a barrier to buprenorphine or XR-NTX initiation in clinical trials and real-world populations that would benefit from OUD treatment. Interventions to address stimulant use among patients with OUD are urgently needed, especially among rural people injecting drugs, who already suffer from limited access to MOUD.

Does sexuality matter? A cross-sectional study of drug use, social injecting, and access to injection-specific care among men who inject drugs in Melbourne, Australia

BACKGROUND

Gay, bisexual and other men who have sex with men (GBMSM) are overrepresented in cohorts of people who inject drugs. GBMSM's substance use is usually explored in the context of its contribution to sexual risk. We examined drug use practices, connectedness to other people who inject drugs, peer-to-peer injecting, and access to care among men who inject drugs in Melbourne, Australia. We aim to describe similarities and differences in these parameters for GBMSM and other men.

METHODS

Data were drawn from a prospective cohort study of people who inject drugs conducted in Melbourne, Australia, since 2009. This cross-sectional study used data collected between 2016 and 2021. Descriptive statistics were used to assess differences between GBMSM and other men.

RESULTS

Of 525 men who injected drugs over the study period, 48 (9%) identified as gay or bisexual, or reported sex with other men in the past 12 months. GBMSM and other men reported similar socio-demographics, drug practices (age of injecting initiation, most injected drug, peer-to-peer injecting, receptive syringe sharing) and access to injecting-specific care (drug treatment, source of needle-syringes). A significantly greater percentage of GBMSM reported past 12-month hepatitis C testing (69% vs. 52%, p = 0.028) and preferring methamphetamine (31% vs. 16%, p = 0.022). A higher percentage of GBMSM reported knowing > 50 other people who inject drugs (46% vs. 37%), but this difference was not statistically significant. Both groups primarily obtained injecting equipment from needle-syringe programs; a minority had accessed injecting-specific primary care.

CONCLUSION

Men who injected drugs in this cohort and those who identified as GBMSM reported similar drug and health-seeking practices. The higher prevalence of methamphetamine injecting among GBMSM may warrant different harm reduction support for this group. Health promotion should utilise opportunities to connect men who inject drugs in Melbourne to injecting-specific primary health care.

Methamphetamines and Serious Injection-Related Infections: Opioid Use Care Continuum and Opportunities to End Alabama's Drug Crisis

Background

Increasingly, injection opioid use and opioid use disorder (OUD) are complicated by methamphetamine use, but the impact of stimulant use on the care of people who inject drugs (PWID) with serious injection-related infections (SIRIs) is unknown. The objective of this study was to explore hospital outcomes and postdischarge trends for a cohort of hospitalized PWID to identify opportunities for intervention.

Methods

We queried the electronic medical record for patients hospitalized at the University of Alabama at Birmingham with injection drug use-related infections between 1/11/2016 and 4/24/2021. Patients were categorized as having OUD only (OUD), OUD plus methamphetamine use (OUD/meth), or injection of other substance(s) (other). We utilized statistical analyses to assess group differences across hospital outcomes and postdischarge trends. We determined the OUD continuum of care for those with OUD, with and without methamphetamine use.

Results

A total of 370 patients met inclusion criteria-many with readmissions (98%) and high mortality (8%). The majority were White, male, and uninsured, with a median age of 38. One in 4 resided outside of a metropolitan area. There were significant differences according to substance use in terms of sociodemographics and hospital outcomes: patients with OUD/meth were more likely to leave via patient-directed discharge, but those with OUD only had the greatest mortality. Comorbid methamphetamine use did not significantly impact the OUD care continuum.

Conclusions

The current drug crisis in AL will require targeted interventions to engage a young, uninsured population with SIRI in evidence-based addiction and infection services.

Evaluation of the Impact of HIV Serostatus on the Hepatitis C Virus Care Cascade and Injection Drug Use Among Persons Initiating Medication Treatment for Opioid Use Disorder

Background

Persons who inject drugs are at increased risk for acquiring hepatitis C virus (HCV). Medications for opioid use disorder (MOUD) are associated with reduced injection drug use (IDU) frequency among persons with opioid use disorder (OUD). However, whether HCV treatment uptake or changes in IDU frequency differ by HIV serostatus among persons receiving MOUD is incompletely understood.

Methods

A secondary analysis was performed of data collected from 2 prospective cohort studies of participants with (PWH) or without HIV with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-diagnosed OUD who were initiated on methadone, buprenorphine, or naltrexone.

Results

Of 129 participants, 78 (60.5%) were HCV antibody positive. PWH underwent increased HCV viral load testing (76.7% vs 43.3%; P = .028), but HCV treatment rates did not differ (17.6% vs 10.0%; P = .45) by HIV status. Participants without HIV reported a greater reduction in mean opioid IDU at 90 days (10.7 vs 2.0 fewer days out of 30; P < .001), but there were no group differences at 90 days. Stimulant use did not differ between groups. Urine opioid positivity declined from baseline to 90 days among the entire cohort (61.4% to 38.0%; P < .001) but did not differ by HIV serostatus.

Conclusions

PWH who received MOUD underwent higher rates of follow-up HCV testing, but HCV treatment rates did not significantly differ by HIV serostatus. Participants without HIV on MOUD reported a greater reduction in opioid IDU. Improved integration of concomitant OUD with HCV and HIV screening, linkage to care, and treatment are needed for persons without HIV.

A randomized, sham-controlled, quintuple-blinded trial to evaluate the NET device as an alternative to medication for promoting opioid abstinence

Background

There is an unmet need for non-medication approaches to illicit opioid discontinuation and relapse prevention. The NET (NeuroElectric Therapy) Device is a non-invasive, battery-operated, portable, re-useable device designed to deliver bilateral transcranial transcutaneous alternating current electrical stimulation, and is intended to treat opioid use disorder (OUD) without medication. The device is a CE-marked Class IIa, non-significant risk, investigational medical device.

Objective

This prospective trial (NRC021) tests the hypothesis that the NET Device provides safe and effective neurostimulation treatment for persons with OUD who express a desire to be opioid abstinent without medications for opioid use disorder (MOUD).

Methods

NRC021 is a randomized, parallel-group, sham-controlled, quintuple-blinded, single-site study. Persons with OUD entering a residential treatment facility for opioid detoxification are assigned to active or sham treatment (n = 50/group). Group assignment is stratified on presence of any current non-opioid substance use disorder and by sex. The biostatistician maintains the blinding so that the study sponsor, principal investigator, research assistants, treatment staff, and participants remain blinded. Following discharge from the inpatient facility, participants are assessed once weekly over 12 weeks for substance use (using timeline followback interview and video assessment of observed oral fluid sample provision and testing). The primary efficacy endpoint is each participant's overall percentage of weekly abstinence from illicit opioid use without use of MOUD. The secondary efficacy endpoint is each participant's percentage of non-opioid drug-free weeks. Safety outcomes are also measured.

Conclusion

NRC021 is designed to assess the efficacy of a novel non-medication treatment for OUD.

Clinical trial registration

ClinicalTrials.gov with the identifier NCT04916600.

Association of Methamphetamine and Opioid Use With Nonfatal Overdose in Rural Communities

Importance

Overdoses continue to increase in the US, but the contribution of methamphetamine use is understudied in rural communities.

Objective

To estimate the prevalence of methamphetamine use and its correlates among people who use drugs (PWUD) in rural US communities and to determine whether methamphetamine use is associated with increased nonfatal overdoses.

Design, Setting, and Participants

From January 2018 through March 2020, the National Rural Opioid Initiative conducted cross-sectional surveys of PWUD in rural communities in 10 states (Illinois, Kentucky, New Hampshire, Massachusetts, North Carolina, Ohio, Oregon, Vermont, West Virginia, and Wisconsin). Participants included rural PWUD who reported any past-30-day injection drug use or noninjection opioid use to get high. A modified chain-referral sampling strategy identified seeds who referred others using drugs. Data analysis was performed from May 2021 to January 2022.

Exposures

Use of methamphetamine alone, opioids alone, or both.

Main Outcomes and Measures

Unweighted and weighted prevalence of methamphetamine use, any past-180-day nonfatal overdose, and number of lifetime nonfatal overdoses.

Results

Among the 3048 participants, 1737 (57%) were male, 2576 (85%) were White, and 225 (7.4%) were American Indian; the mean (SD) age was 36 (10) years. Most participants (1878 of 2970 participants with any opioid or methamphetamine use [63%]) reported co-use of methamphetamine and opioids, followed by opioids alone (702 participants [24%]), and methamphetamine alone (390 participants [13%]). The estimated unweighted prevalence of methamphetamine use was 80% (95% CI, 64%-90%), and the estimated weighted prevalence was 79% (95% CI, 57%-91%). Nonfatal overdose was greatest in people using both methamphetamine and opioids (395 of 2854 participants with nonmissing overdose data [22%]) vs opioids alone (99 participants [14%]) or methamphetamine alone (23 participants [6%]). Co-use of methamphetamine and opioids was associated with greater nonfatal overdose compared with opioid use alone (adjusted odds ratio, 1.45; 95% CI, 1.08-1.94; P = .01) and methamphetamine use alone (adjusted odds ratio, 3.26; 95% CI, 2.06-5.14; P < .001). Those with co-use had a mean (SD) of 2.4 (4.2) (median [IQR], 1 [0-3]) lifetime overdoses compared with 1.7 (3.5) (median [IQR], 0 [0-2]) among those using opioids alone (adjusted rate ratio, 1.20; 95% CI, 1.01-1.43; P = .04), and 1.1 (2.9) (median [IQR], 0 [0-1]) among those using methamphetamine alone (adjusted rate ratio, 1.81; 95% CI, 1.45-2.27; P < .001). Participants with co-use most often reported having tried and failed to access substance use treatment: 827 participants (44%) for both, 117 participants (30%) for methamphetamine alone, and 252 participants (36%) for opioids alone (χ22 = 33.8; P < .001). Only 66 participants (17%) using methamphetamine alone had naloxone.

Conclusions and Relevance

These findings suggest that harm reduction and substance use disorder treatment interventions must address both methamphetamine and opioids to decrease overdose in rural communities.

Diagnosis and Management of Infective Endocarditis in People Who Inject Drugs: JACC State-of-the-Art Review

The incidence of injection drug use-associated infective endocarditis has been increasing rapidly over the last decade. Patients with drug use-associated infective endocarditis present an increasingly common clinical challenge with poor long-term outcomes and high reinfection and readmission rates. Their care raises issues unique to this population, including antibiotic selection and administration, indications for and ethical issues surrounding surgical intervention, and importantly management of the underlying substance use disorder to minimize the risk of reinfection. Successful treatment of these patients requires a broad understanding of these concerns. A multidisciplinary, collaborative approach providing a holistic approach to treating both the acute infection along with effectively addressing substance use disorder is needed to improve short-term and longer-term outcomes.

A Novel Program to Provide Drug Recovery Assistance and Outpatient Parenteral Antibiotic Therapy in People Who Inject Drugs

Background

Safe hospital discharge on parenteral antibiotic therapy is challenging for people who inject drugs (PWID) admitted with serious bacterial infections (SBI). We describe a Comprehensive Care of Drug Addiction and Infection (CCDAI) program involving a partnership between Intermountain Healthcare hospitals and a detoxification facility (DF) to provide simultaneous drug recovery assistance and parenteral antibiotic therapy (DRA-OPAT).

Methods

The CCDAI program was evaluated using a pre-/poststudy design. We compared outcomes in PWID hospitalized with SBI during a 1-year postimplementation period (2018) with similar patients from a historical control period (2017), identified by propensity modeling and manual review.

Results

Eighty-seven patients were candidates for the CCDAI program in the implementation period. Thirty-five participants (40.2%) enrolled in DRA-OPAT and discharged to the DF; 16 (45.7%) completed the full outpatient parenteral antibiotic therapy (OPAT) duration. Fifty-one patients with similar characteristics were identified as a preimplementation control group. Median length of stay (LOS) was reduced from 22.9 days (interquartile interval [IQI], 9.8–42.7) to 10.6 days (IQI, 6–17.4) after program implementation (P &lt; .0001). Total median cost decreased from $39 220.90 (IQI, $23 300.71–$82 506.66) preimplementation to $27 592.39 (IQI, $18 509.45–$48 369.11) postimplementation (P &lt; .0001). Ninety-day readmission rates were similar (23.5% vs 24.1%; P = .8). At 1-year follow-up, all-cause mortality was 7.1% in the preimplementation group versus 1.2% postimplementation (P = .06).

Conclusions

Partnerships between hospitals and community resources hold promise for providing resource-efficient OPAT and drug recovery assistance. We observed significant reductions in LOS and cost without increases in readmission rates; 1-year mortality may have been improved. Further study is needed to optimize benefits of the program.