Self-Help Groups And Medication Use In Opioid Addiction Treatment: A National Analysis

Self-help groups and opioid use disorder treatment: An investigation using a machine learning-assisted robust causal inference framework

OBJECTIVES

This study investigates the impact of participation in self-help groups on treatment completion among individuals undergoing medication for opioid use disorder (MOUD) treatment. Given the suboptimal adherence and retention rates for MOUD, this research seeks to examine the association between treatment completion and patient-level factors. Specifically, we evaluated the causal relationship between self-help group participation and treatment completion for patients undergoing MOUD.

METHODS

We used the Substance Abuse and Mental Health Services Administration's (SAMHSA) Treatment Episode Data Set: Discharges (TEDS-D) from 2015 to 2019. The data are filtered by the patient's opioid use history, demographics, treatment modality, and other relevant information. In this observational study, machine learning models (Lasso Regression, Decision Trees, Random Forest, and XGBoost) were developed to predict treatment completion. Outcome Adaptive Elastic Net (OAENet) was used to select confounders and outcome predictors, and the robust McNemars test was used to evaluate the causal relationship between self-help group participation and MOUD treatment completion.

RESULTS

The machine-learning models showed a strong association between participation in self-help groups and treatment completion. Our causal analysis demonstrated an average treatment effect on treated (ATT) of 0.260 and a p-value < 0.0001 for the robust McNemars test.

CONCLUSIONS

Our study demonstrates the importance of participation in self-help groups for MOUD treatment recipients. We found that participation in MOUD along with self-help groups caused higher chances of treatment completion than MOUD alone. This suggests that policymakers should consider further integrating self-help groups into the treatment for OUD to improve the adherence and completion rate.

Disparities in Medication Use for Criminal Justice System-Referred Opioid Use Disorder Treatment

Importance

Individuals with opioid use disorder (OUD) and criminal justice system involvement experience high rates of overdose death. Historical data point to limited use of medications for opioid use disorder (MOUD) in criminal justice system-referred treatment for OUD as playing a role. However, how MOUD use among those referred to treatment by the criminal justice system has changed relative to other referral sources over time is still unclear, as well as how it varies across states.

Objective

To examine disparities in the use of MOUD between individuals referred to treatment by the criminal justice system compared to other referral sources over time.

Design, Setting, and Participants

This cross-sectional study included admissions to specialty substance use treatment facilities for OUD in the national Treatment Episodes Dataset-Admissions from 2014 to 2021. Logistic regression models were used to examine trends in the probability of MOUD use among individuals with and without criminal justice referrals for OUD treatment, as well as any differential trends by state. The data were analyzed from September 2023 to August 2024.

Main Outcome and Measure

The main outcome was the probability that treatment for individuals with OUD included MOUD.

Results

A total of 3 235 445 admissions were analyzed in the study data. Among individuals referred to OUD treatment by the criminal justice system, the probability that treatment included MOUD increased by 3.42 percentage points (pp) (95% CI, 3.37 pp to 3.47 pp) annually from 2014 to 2021. This was faster than the increase in the probability of MOUD use for noncriminal justice-referred admissions (2.49 pp [95% CI, 2.46 pp to 2.51 pp) and reduced, but did not eliminate, disparities in MOUD use between individuals with and without criminal justice system-referred treatment. In 2021, only 33.6% of individuals in criminal justice system-referred treatment received MOUD, 15.6 pp lower than for individuals referred to treatment by other sources. Trends in the probability of MOUD use varied substantially for individuals in criminal justice system-referred treatment across states, but very few experienced enough growth to eliminate this disparity.

Conclusions and Relevance

The results of this cross-sectional study suggest that targeted efforts to address persistent disparities in MOUD use among those with OUD and criminal justice system involvement are needed to address the poor health outcomes experienced by this population.

A Nationwide Survey Study of Recovery Community Centers Supporting People in Recovery From Substance Use Disorder

OBJECTIVE

The medical community has become aware of its role in contributing to the opioid epidemic and must be part of its resolution. Recovery community centers (RCCs) represent a new underused component of recovery support.

METHODS

This study performed an online national survey of all RCCs identified in the United States, and used US Census ZIP code tabulation area data to describe the communities they serve.

RESULTS

Residents of areas with RCCs were more likely to be Black (16.5% vs 12.6% nationally, P = 0.005) and less likely to be Asian (4.7% vs 5.7%, P = 0.005), American Indian, or Alaskan Native (0.6% vs 0.8%, P = 0.03), or live rurally (8.5% vs 14.0%, P < 0.0001). More than half of RCCs began operations within the past 5 years. Recovery community centers were operated, on average, by 8.8 paid and 10.2 volunteer staff; each RCC served a median of 125 individuals per month (4-1,500). Recovery community centers successfully engaged racial/ethnic minority groups (20.8% Hispanic, 22.5% Black) and young adults (23.5% younger than 25 years). Recovery community centers provide addiction-specific support (eg, mutual help, recovery coaching) and assistance with basic needs, social services, technology access, and health behaviors. Regarding medications for opioid use disorder (MOUDs), RCC staff engaged members in conversations about MOUDs (85.2%) and provided direct support for taking MOUD (77.0%). One third (36.1%) of RCCs reported seeking closer collaboration with prescribers.

CONCLUSIONS

Recovery community centers are welcoming environments for people who take MOUDs. Closer collaboration between the medical community and community-based peer-led RCCs may lead to significantly improved reach of efforts to end the opioid epidemic.

Prevalence and correlates of 12-step and second-wave mutual-help attendance in a nationally representative US sample

BACKGROUND

Mutual-help organizations (MHOs) are effective community-based, recovery support options for individuals with alcohol and other drug use disorders (i.e., substance use disorder; SUD). Greater understanding of second-wave MHOs, such as SMART Recovery, can help build on existing research that has focused primarily on 12-step MHOs, such as Alcoholics Anonymous, to inform scientific, practice, and policy recommendations.

METHODS

We conducted a secondary analysis of the National Recovery Study, a representative sample of US adults who resolved a substance use problem (N = 1984). Using survey-weighted estimates, we examined descriptive statistics for any lifetime, weekly lifetime, and past 90-day MHO attendance; we compared rates of 12-step and second-wave MHO attendance over time by descriptively examining distributions for calendar year of the first meeting attended. We also used two logistic regression models to examine demographic, substance use, clinical, and recovery-related correlates of weekly lifetime attendance separately for 12-step (n = 692) and second-wave MHOs (n = 32).

RESULTS

For any attendance, 41.4% attended a 12-step MHO and 2.9% a second-wave MHO; for weekly attendance, 31.9% attended a 12-step MHO, and 1.7% a second-wave MHO. Two-thirds (64%) of initial second-wave attendance occurred between 2006 and 2017 compared to 22% of initial 12-step attendance during this time frame. Significant correlates of weekly 12-step MHO attendance included histories of SUD treatment and arrest. Significant correlates of weekly second-wave MHO attendance included Black identity (vs. White) and history of SUD medication.

CONCLUSIONS

Attendance at second-wave MHOs is far less common than 12-step MHOs, but appears to be on the rise. Observed correlates of second-wave MHO attendance should be replicated in larger second-wave MHO samples before integrating these findings into best practices. Enhanced linkages from clinical and criminal justice settings to both second-wave and 12-step groups may help to "broaden the base" of MHOs.

Medications For Opioid Use Disorder Increased Among Louisiana Medicaid Enrollees During Policy Reforms, 2018-21

Increasing access to medications for opioid use disorder (MOUD) is a key strategy in addressing the opioid crisis. To increase MOUD access, state governments have pursued a combination of increased funding for MOUD and requirements that providers offer treatment. Louisiana has pursued multiple strategies, including a requirement that residential treatment programs offer MOUD as part of their licensure. Using Louisiana Medicaid claims data for enrollees with diagnosed OUD from the period 2018-21, we analyzed trends in MOUD between enrollees treated in residential and nonresidential settings and across demographic subgroups, and we compared trends by MOUD type. MOUD use more than tripled from 2018 to 2021 among Louisiana Medicaid enrollees diagnosed with OUD. Most of the increase in MOUD was attributable to buprenorphine use. Methadone uptake also contributed to greater MOUD use but was almost exclusively used by enrollees treated in nonresidential settings, whereas naltrexone was consistently more common in residential treatment. By 2021, differences persisted across demographic groups: MOUD use was highest among enrollees who were White, were older, had comorbidities, and lived in a metropolitan area. Policies that promote MOUD in substance use treatment programs, particularly residential programs, are critical tools for policy makers confronting a complex and unprecedented national overdose crisis.

Alcohol or Drug Self-Help Use Among Adults in the United States: Age, Period, and Cohort Effects Between 2002 and 2018

In the context of an ongoing and worsening drug overdose epidemic in the USA, increases in free support services like self-help groups may be expected. We estimated differences in self-help use by age, period, or cohort among people who may have needed treatment. We included N = 92,002 adults from the 2002-2018 National Surveys on Drug Use and Health who met past-year DSM-IV substance use disorder criteria or received alcohol/drug treatment in any location. We used hierarchical age-period-cohort (HAPC) modeling to estimate average age-period-cohort associations with self-help. Level-1 covariates included age, race and ethnicity, household income, and sex. We quantified level-2 variance components using the median odds ratio (MOR). We found small positive HAPC period effects for alcohol/drug self-help that were driven by alcohol-specific effects. Birth cohort differences were observed starting at age 48. Younger birth cohorts, especially among Black adults, were less likely to report self-help use than older birth cohorts. MOR was consistently elevated for cohort effects (MOR = 1.17; covariance parameter: 0.15; 95% CI [0.11, 0.23]) but not for period effects. Overall, self-help use did not increase in the context of substantial treatment needs and worsening overdose racialized disparities. Instead, cohort effects explained trends in alcohol/drug self-help. Findings could indicate that younger birth cohorts may need additional supports, especially services tailored for Black and Hispanic people.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11469-023-01012-2.

Medication for opioid use disorder treatment continuity post-release from jail: A qualitative study with community-based treatment providers

BACKGROUND

People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail.

METHODS

We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes.

RESULTS

Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation.

CONCLUSION

Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition.

Association between Prescribers’ Perceptions of the Utilization of Medication for Opioid Use Disorder and Opioid Dependence Treatability

Background: Medication for opioid use disorder (MOUD) has been proven to be effective, yet the perceptions or beliefs of prescribers of MOUD may have a substantial impact on their prescribing and dispensing of MOUD and their patients’ accessibility and utilization of MOUD services. We examined the associations of the perceptions of medical and pharmacy professionals regarding MOUD with sociodemographic characteristics, personal experiences with substance use disorders, and perceptions of opioid treatment. Method: Data were collected via telephone or online survey from March to August 2021, in Texas, to assess medical and pharmacy professionals’ perceptions of MOUD. Our sample included 542 participants who completed the survey. A multinomial logistic regression analysis was conducted to assess perceptions of MOUD, its use, and their correlates. Results: The participants had a mean age of 35 years (SD = 7.13) and had worked, on average, 6.90 years (SD = 5.37) in their current positions. The majority of the participants were males (50.93%) and medical professionals (82.01%). More than one third of the participants believed MOUD did not lead to abstinence or recovery (36.16%). Those who had personal experiences with a substance use disorder were more likely to believe that MOUD could be a replacement drug for previously misused substance(s) (RRR = 2.06, 95% CI = 1.19, 3.59) and that MOUD did not lead to abstinence or recovery (RRR = 2.34, 95% CI = 1.40, 3.91). However, the risk ratio values were lower for those who believed that a stigma against MOUD was a barrier for patients initiating and adhering to MOUD (MOUD is a replacement drug for previously misused substances (initiation RRR = 0.43, 95% CI = 0.19, 0.93 and adhering RRR = 0.30, 95% CI = 0.13, 0.71) or MOUD does not lead to abstinence or recovery (initiation RRR = 0.26, 95% CI = 0.13, 0.54 and adhering RRR = 0.36, 95% CI = 0.17, 0.78)). The various perceptions of the utilization of MOUD were not statistically different between medical and pharmacy professionals. Conclusion: Perceptions, experience with substance use disorder, and stigma against the utilization of MOUD influenced negative perceptions about MOUD. An innovative strategy is needed to improve medical and pharmacy professionals’ perceptions of MOUD, while efforts are being made to promote the use of MOUD for patients with opioid use disorders.

Stigmatization of medications for opioid use disorder in 12-step support groups and participant responses

Background: 12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. Objectives: We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. Methods: We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. Results: We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. Conclusion: Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.

The effect of medications for opioid use disorder (MOUD) on residential treatment completion and retention in the US

BACKGROUND

This study examines whether MOUD increases treatment completion and retention in both short-term (ST) and long-term (LT) residential programs using a national dataset.

METHODS

Data were extracted from the 2015-2017 TEDS-D (Treatment Episode Dataset-Discharge) datasets for opioid using adults in ST (n = 87,296) and LT (n = 66,623) residential treatment. Primary outcome variables were treatment completion and retention (ST: length of stay >10 days; LT: >90 days). Logistic regression estimated the effects of MOUD on the probability of treatment completion and retention separately for ST and LT residential treatment, controlling for individual background characteristics.

RESULTS

Only 18% of clients in residential treatment programs had MOUD in their treatment plans. For ST residential treatment, MOUD was associated with a 40% increased likelihood of treatment completion (OR = 1.404) and 34% increased retention (OR = 1.337). For LT residential treatment, MOUD was associated with a 26% reduced likelihood of treatment completion (OR = 0.743) and no significant increase in retention. Post hoc analysis suggests insurance coverage may be influencing outcomes.

CONCLUSIONS

Despite MOUD being a standard of care for OUD, MOUD is particularly under-utilized in residential treatment. Further research should focus on how best to integrate MOUD within short-term residential treatment and to explore the potential viability of MOUD in long-term residential programs. Given the risk of overdose following residential treatment, for at least short-term residential programs, this setting may be advantageous for integrating psychosocial treatments with early MOUD engagement in a structured therapeutic environment as part of a long-term continuum of care recovery program.