Embarrassing, degrading, or beneficial: Patient and staff perspectives on urine drug testing in methadone maintenance treatment

Association between high-threshold practices and buprenorphine treatment termination

BACKGROUND

Regular counseling and frequent drug testing are common requirements for patients with opioid use disorder in buprenorphine treatment. State policies throughout the United States often reinforce these high-threshold practices, as was the case with Michigan, USA.

METHODS

We sought to explore the association between counseling requirements, drug testing practices, and buprenorphine treatment termination rates through administering a survey to buprenorphine prescribers in Michigan.

RESULTS

In our sample of 377 prescribers, we found associations between high-threshold practices like drug testing at every clinical visit and requiring counseling and buprenorphine treatment termination rates. Relative to prescribers who randomly drug tested, drug tested at fixed intervals, or did not require any drug testing, prescribers who drug-tested patients at every visit were 38% more likely to terminate treatment. Prescribers who required counseling were 33% more likely to terminate treatment than those who did not require counseling.

CONCLUSION

With the elimination of the USA Drug Enforcement Administration X-waiver in December 2022, state policies need to minimize high-threshold practices that reduce buprenorphine treatment continuity and undermine an effective response to the overdose crisis.

Typology of laws restricting access to methadone treatment in the United States: A latent class analysis

BACKGROUND

In the United States, methadone treatment for opioid use disorder is only available at opioid treatment programs (OTPs). In addition to federal regulations, states can enact laws which shape access to OTPs. We aimed to define classes of states according to restrictiveness of state OTP laws and examine population characteristics associated with class membership.

METHODS

A set of laws was extracted from a database of statutes and regulations governing OTPs in 49 states and the District of Columbia as of June 2021. Latent class analysis of laws was used to estimate the probability of class membership for each state. Class-weighted multinomial logistic regression analysis assessed state-level correlates of class membership and adjusted Relative Risk Ratio (aRRR) and 95% confidence intervals (95%CI) were generated.

RESULTS

States (n = 50) were assigned to three classes; Class 1) High restrictiveness on patient experience, low restrictiveness on access to service (n = 13); Class 2) Medium restrictiveness on patient experience, high restrictiveness on access to service (n = 14); Class 3) Low restrictiveness on patient experience, low restrictiveness on access to service (n = 23). States with a higher probability of membership in Classes with higher restrictiveness had higher rates of unemployment (Class 1 vs Class 3, aRRR:1.24; 95%CI:1.06-1.45), and Black residents (Class 2 vs Class 3, aRRR:1.10; 95%CI:1.04-1.15), and lower likelihood of Medicaid coverage of methadone (Class 1 vs Class 3, aRRR:0.25; 95%CI:0.07-0.88). States with a higher probability of membership in Classes with higher restrictiveness also had higher rates of potential indicators for opioid use disorder treatment need, including rates of opioid dispensing (Class 1 vs Class 3, aRRR:1.06; 95%CI:1.02-1.10, Class 2 vs Class 3, aRRR:1.07; 95%CI:1.03-1.11) and HIV diagnoses attributed to injection (Class 1 vs Class 3, aRRR:3.92; 95%CI:1.25-12.22).

CONCLUSIONS

States with indicators of greater potential need for opioid use disorder treatment have the most restrictions, raising concerns about unmet treatment need.

"I'm Going to Stop Myself Before Someone Stops Me": Complicating Narratives of Volitional Substance Use Treatment

Background: Often people assume that entry into drug treatment is a voluntary action for persons who use drugs (PWUD). This narrative informs the organizational and regulatory structure of most treatment programs and consequently affects patients' ability to exert agency over their own treatment. Yet, this view ignores the complex interplay between individual and structural factors in peoples' decision-making processes, particularly among people who use drugs who are stigmatized and criminalized. Treatment programs that assume voluntary entry may lack appropriate services for the populations of treatment seekers that they serve. Methods: This paper uses semi-structured interviews with 42 participants in Opioid Substitution Treatment (OST) (including patients, clinic doctors and staff, and advocates) informed by one of the author's own lived experience in OST, to examine patients' treatment decisions, and in particular, if and how, the structural context of drugs' illegality/criminalization affected their willingness to pursue treatment. A Critical Discourse Analysis was used to identify key themes. Results: Interview data demonstrates that most people who use drugs enter treatment under constrained conditions related to drugs' illegality. Themes that emerged included: 1. A feeling of limited choices due to drugs' illegality; 2. Peer and family pressure; 3. Fear of losing children; and 4. Internalized stigma (i.e. feeling they are dirty or bad for using). Conclusion: Narratives that frame PWUD's treatment decisions as volitional provide political cover to policies that criminalize PWUD by obscuring their effect on PWUD's treatment decisions. Treatment models, particularly those that serve highly criminalized populations, should be re-conceptualized outside of normative narratives of individual choice, and be broadened to understand how larger structures constrain choices. By looking at macro-level factors, including the interplay of criminalization and drug treatment, programs can begin to understand the complexity of PWUD motivations to enter drug treatment. Recognizing the role of the War on Drugs as a force of oppression for people who use drugs, and that their treatment decisions are made within that setting, may enable people in treatment, and providers, to develop more productive ways of interacting with one another. Additionally, this may lead to better retention in treatment programs.

Enacting Alcohol and Other Drug (Testing)-Related Harms in an Australian Drug Court

Alcohol and other drug testing is used in a range of environments including workplaces, schools, sporting tournaments, substance treatment and criminal justice system settings. It is also the cornerstone of the drug court model. Despite its centrality, it has received little scholarly attention. In this article, we address this gap through a study of how the drug-testing regime unfolds at one Australian drug court. Based on ethnographic observation, qualitative interviews with drug court participants, and analysis of drug court documents, this article examines how participants experience drug testing. Drawing on Carol Bacchi’s poststructuralist policy analysis framework, we examine how the “problem” of substance “dependence” is conceptualized in one drug court’s approach to drug testing, and we consider some of the effects of the policy. We argue that the everyday and seemingly mundane ritual of urination becomes a core technique for the governance of drug court subjects and note that the testing regime is onerous, regimented, and invasive. We also trace some of the effects of this policy and its implementation for participants. We suggest that the urine-testing regimen might operate counterproductively, intensifying participants’ involvement with the criminal justice system. Its reliance on an abstinence model may heighten exposure to substance-related harms and segregate drug court participants from the “rest of society,” inhibiting other aspects of their lives, including their relationships and employment prospects. Overall, we argue that these effects are at odds with the stated purposes of the drug court. We conclude with some reflections on claims about the therapeutic value and potential of drug courts and suggest opportunities for reform.

Patient-centred care for addiction treatment: a scoping review protocol

INTRODUCTION

Substance use disorders are chronic conditions that require a multidimensional treatment approach. Despite ongoing efforts to diversify such treatments, evidence continues to illuminate modest rates of treatment engagement and perceived barriers to treatment. Patient-centred care (PCC) is one approach that may strengthen the responsiveness of treatments for people with problematic substance use. The aim of this scoping review is to explore how the principles of PCC have been implemented and operationalised in healthcare settings for people with problematic substance use.

METHODS AND ANALYSIS

This scoping review follows the iterative stages of the Arksey and O'Malley framework. Both empirical (from Medline, Embase, PsycINFO, CINAHL and ISI Web of Science) and grey literature references will be considered if they focused on populations with problematic substance use and described or measured PCC or one of its principles in a health-oriented context. Two reviewers will independently screen references in two successive stages of title/abstract screening and then full-text screening for references meeting title/abstract criteria. A descriptive overview, tabular and/or graphical summaries, and a directed content analysis will be carried out on extracted data. This scoping review has been registered with Open Science Framework (https://osf.io/5swvd/).

ETHICS AND DISSEMINATION

This review will systematically examine the extent and nature of existing evidence of PCC in addiction research and clinical practice. Such evidence will contribute to the operationalisation of PCC for people with problematic substance use. A multidisciplinary team has been gathered to represent the needs of people with problematic substance use, healthcare providers and decision-makers. The team's knowledge users will be engaged throughout this review and will participate in dissemination activities (eg, workshops, presentations, publications, reports).