Consumer attitudes about opioid addiction treatment: a focus group study in New York City

Barriers and facilitators for family physicians prescribing opioid agonist therapy in Saskatchewan

OBJECTIVE

To explore barriers and facilitators for family physicians in Saskatchewan prescribing opioid agonist therapy (OAT).

DESIGN

Self-administered postal survey.

SETTING

Family medicine practices in Saskatchewan.

PARTICIPANTS

A total of 218 Saskatchewan family physicians who were not authorized to prescribe OAT as of June 2022.

MAIN OUTCOME MEASURES

Descriptive and inferential statistics of physicians' self-reported barriers to and facilitators of prescribing OAT for opioid use disorder (OUD).

RESULTS

Most respondents (84.8%) had some comfort with diagnosing OUD. However, more than half (58.3%) did not feel confident or knowledgeable about prescribing OAT. Barriers to OAT prescribing included lack of time, incomplete training requirements, lack of interest, insufficient funding or support, feeling overwhelmed, and perceiving that OAT does not work and thus is not necessary. Physicians working in core neighbourhoods and those receiving fee-for-service compensation reported the least available time to prescribe OAT. Conversely, physicians working in interdisciplinary team settings had increased time for OAT prescribing compared with physicians in other settings. Having a close personal relationship with someone with OUD was correlated with increased comfort in diagnosing OUD as well as with knowledge about and confidence in prescribing OAT. Themes identified as facilitators to increasing OAT prescribing included the addition of resources and supports, increased training, more awareness about OUD and OAT, enhanced compensation, and altered prescribing regulations.

CONCLUSION

Despite the presence of several real and perceived barriers limiting OAT prescribing by Saskatchewan family physicians, there are family physicians interested in providing this therapy. Increased clinical resources and support, including increased interdisciplinary practice, are actionable steps that should be considered by policy decision makers to address this issue. Additionally, increased OUD and OAT education, which includes the perspectives of those with lived experience of OUD, would help address physician confidence, knowledge, and awareness in this area.

"I think we're getting better but we're still not there": Provider-based stigma and perceived barriers to care for people who use opioids (PWUO)

BACKGROUND

Despite significant efforts to improve access to medications for opioid use disorder (MOUD), uptake remains low relative to the scope of the problem in the United States. A growing body of quantitative and qualitative research has documented consistent barriers to MOUD treatment access and retention, at the level of individuals, institutions, and society at large. Stigma - surrounding both people who use opioids (PWUO) and treatment using MOUD - is among the most-cited barriers by patients and providers alike, yet few studies have examined provider-based stigma specifically, or considered its interaction with other impediments to OUD care.

METHODS

This paper employs a qualitative approach to the analysis of provider-based stigma among professionals involved in the treatment or supervision of individuals with OUD. We conducted and analyzed interviews with 19 professionals as part of a larger mixed methods study on stigma among substance use treatment providers and court personnel in Pennsylvania. Beyond capturing providers' perceptions of PWUO and MOUD, the authors asked participants to describe barriers to recovery, and the effective delivery of care within this population.

RESULTS

Interviewees enumerated multiple entrenched barriers that sometimes operated at different levels, such as criminal-legal involvement, which weakened PWUO's social networks and employment prospects, while undermining providers' attempts at continuity of care; moreover, participants cited the "War on Drugs" as an overarching impediment to effective substance use treatment, not least for its role in perpetuating stigma against PWUO.

CONCLUSIONS

Interestingly, while an overwhelming majority of participants named stigma as a barrier to treatment at every level, most also articulated stigmatizing beliefs around PWUO. Namely, providers evoked one element of stigma - blameworthiness - in their contention that many PWUO are inadequately motivated to recover. In addition to adding further complexity to MOUD barriers research, this study troubles the notion that professional training and education on the disease model of addiction serve to eradicate stigma.

Patient's and healthcare provider's experiences with Opioid Maintenance Treatment (OMT): a qualitative evidence synthesis

BACKGROUND

Opioid Maintenance Treatment (OMT) is the gold standard for people with opioid dependence. However, drop-out rates are high, and many patients do not reach desired outcomes. Understanding patients' and healthcare providers' experiences with the treatment can provide valuable information to improve the quality of OMT and to increase acceptability and accessibility of services. The aim of this systematic review is to explore and synthesise the experiences of OMT among persons with opioid dependence and health care providers, to inform policy makers and practitioners on how to improve OMT outcomes.

METHODS

We conducted a qualitative evidence synthesis. We systematically searched in electronic databases (CINAHL, Embase, MEDLINE, and nordic databases) and searched for grey literature. As we identified many studies that met our inclusion criteria, we purposively sampled a manageable number of studies to include in this review. Two researchers independently extracted and coded data from the included studies and used the Andersen's healthcare utilization model to organize and develop codes. We assessed the methodological limitations of the studies, and our confidence in the findings using GRADE CERQual.

RESULTS

We retrieved 56 relevant studies and purposively sampled 24 qualitative studies of patients' and healthcare providers' experiences with OMT. Our analyses resulted in six main themes: (1) External stigma prevents engagement and retention in treatment, (2) Being identified as in OMT contributed to an increased experience of stigma (3) Inadequate knowledge and expertise among healthcare providers affected patients' treatment experiences, (4) Quality of communication between personnel and patients impacts patients' engagement with treatment and treatment outcomes, (5) Patients wanted help with many aspects of their lives not just medication, and (6) Balancing positive expectations of OMT with treatment stigma. We found that stigma was an overarching theme across these themes.

CONCLUSION

Our findings suggest that OMT could be more beneficial for patients if treatment programs prioritize efforts to diminish societal and OMT provider stigma and find strategies to better address patient needs. Initiatives should focus on improving treatment knowledge among providers, encouraging the use of client perspectives, considering the context of family members, and establishing a more holistic and flexible treatment environment.

Low-dose buprenorphine initiation and treatment continuation among hospitalized patients with opioid dependence: A retrospective cohort study

BACKGROUND

Buprenorphine is an effective treatment for both opioid use disorder (OUD) and chronic pain, but buprenorphine's pharmacology complicates treatment initiation for some patients. Low-dose buprenorphine initiation is a novel strategy that may reduce precipitated withdrawal. Few studies describe what patient populations benefit most from low-dose initiations and the clinical parameters that impact treatment continuation. This study aimed to 1) describe experiences with low-dose buprenorphine initiation, including both successes and failures among hospitalized patients in an urban underserved community; 2) identify patient- and treatment-related characteristics associated with unsuccessful initiation and treatment discontinuation; and 3) assess buprenorphine treatment continuation after discharge.

METHODS

This is a retrospective cohort study with opioid-dependent (meaning OUD or receiving long-term opioid therapy for chronic pain) patients who underwent low-dose buprenorphine initiation during hospital admission from October 2021 through April 2022. The primary outcome was successful completion of low-dose initiation. Bivariate analysis identified patient- and treatment-related factors associated with unsuccessful initiation. Secondary outcomes were buprenorphine treatment discontinuation at post-discharge follow-up, 30- and 90-days.

RESULTS

Of 28 patients who underwent low-dose buprenorphine initiation, 68 % successfully completed initiation. Unsuccessful initiation was associated with receipt of methadone during admission and higher morphine milligram equivalents (MME) of supplemental opioids. Of 22 patients with OUD, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 46 %, 36 %, and 36 %. Of 6 patients with chronic pain, the percent receiving a buprenorphine prescription at a follow-up visit, 30 days, and 90 days, respectively, was 100 %, 100 %, and 83 %.

CONCLUSION

Low-dose buprenorphine initiation can be successful in opioid-dependent hospitalized patients. Patients taking methadone or requiring higher MME of supplemental opioids may have more difficulty with the low-dose buprenorphine initiation approach, but these findings should be replicated in larger studies. This study suggests patient- and treatment-related factors that clinicians could consider when determining the optimal treatment strategy for patients wishing to transition to buprenorphine.

Measuring the importance of different barriers to opioid agonist treatment using best-worst scaling in an Australian setting

OBJECTIVE

Opioid agonist treatment (OAT) is an effective treatment for opioid use disorder (OUD), however several client barriers to OAT are reported. Client importance of these barriers using economic preference elicitation measures have not been identified. This paper determines the most important OAT barriers using best-worst scaling (BWS) and compares the results of BWS to Likert scale.

METHODS

Cross-sectional self-completed survey with 191 opioid dependent clients who attended Australian needle and syringe sites. Participants were presented 15 Likert scale barriers and 15 BWS barrier scenarios. The BWS data was presented using count analysis, multinomial logit and mixed logit models. The ranking of barrier items was completed using three BWS methods and one Likert scale method, with share preference results (BWS) or mean scores (Likert) used to rank the 15 barriers.

RESULTS

The most important client barriers were 'enjoy using opioids', 'lack of support services' and 'hard to access'. The four ranking methods produced different barrier rankings for the most important barriers, but similar results for the least important barriers.

CONCLUSION

Policies around OAT as a harm reduction approach, increased support services and increased availability of OAT services would be beneficial in improving OAT uptake. Comparing BWS and Likert methods produced different highest ranked barriers, indicating the method used to identify preferences has significant implications on the type of intervention prioritised.

Three decades of research in substance use disorder treatment for syringe services program participants: a scoping review of the literature

BACKGROUND

Syringe services programs (SSPs) provide a spectrum of health services to people who use drugs, with many providing referral and linkage to substance use disorder (SUD) treatment, and some offering co-located treatment with medications for opioid use disorder (MOUD). The objective of this study was to review the evidence for SSPs as an entry point for SUD treatment with particular attention to co-located (onsite) MOUD.

METHODS

We performed a scoping review of the literature on SUD treatment for SSP participants. Our initial query in PubMed led to title and abstract screening of 3587 articles, followed by full text review of 173, leading to a final total of 51 relevant articles. Most articles fell into four categories: (1) description of SSP participants' SUD treatment utilization; (2) interventions to link SSP participants to SUD treatment; (3) post-linkage SUD treatment outcomes; (4) onsite MOUD at SSPs.

RESULTS

SSP participation is associated with entering SUD treatment. Barriers to treatment entry for SSP participants include: use of stimulants, lack of health insurance, residing far from treatment programs, lack of available appointments, and work or childcare responsibilities. A small number of clinical trials demonstrate that two interventions (motivational enhancement therapy with financial incentives and strength-based case management) are effective for linking SSP participants to MOUD or any SUD treatment. SSP participants who initiate MOUD reduce their substance use, risk behaviors, and have moderate retention in treatment. An increasing number of SSPs across the United States offer onsite buprenorphine treatment, and a number of single-site studies demonstrate that patients who initiate buprenorphine treatment at SSPs reduce opioid use, risk behaviors, and have similar retention in treatment to patients in office-based treatment programs.

CONCLUSIONS

SSPs can successfully refer participants to SUD treatment and deliver onsite buprenorphine treatment. Future studies should explore strategies to optimize the implementation of onsite buprenorphine. Because linkage rates were suboptimal for methadone, offering onsite methadone treatment at SSPs may be an appealing solution, but would require changes in federal regulations. In tandem with continuing to develop onsite treatment capacity, funding should support evidence-based linkage interventions and increasing accessibility, availability, affordability and acceptability of SUD treatment programs.

Perceptions and Experiences With Evidence-based Treatments Among People Who Use Opioids

OBJECTIVES

Even where treatment is available, people who use drugs (PWUD) may not seek help. Few published studies examine beliefs, experiences, and perceptions of evidence-based treatment among PWUD who are not actively engaged in care. This study aimed to explore the experiences of PWUD in considering or accessing treatment and gauge receptiveness to low-threshold treatment models.

METHODS

A purposeful sample of participants actively using opioids and with previous interest in or experience with treatment was recruited from a harm reduction program in Chicago. Semistructured interviews were conducted to explore key phenomena while allowing for unanticipated themes. The instrument included questions about historical drug use, treatment experience, and perceptions of how to improve treatment access and services. Private interviews were audio recorded, transcribed, and double coded by 2 analysts. Queries of coded data were analyzed using issue-focused analysis to identify themes.

RESULTS

The sample (N = 40) approximated groups at highest risk of fatal overdose in Chicago, with more than 80% between the ages of 45 to 64 years, 65% African American, and 62% male identified. The majority had prior treatment experience, although all resumed use after completing or leaving treatment. The most prevalent barriers to treatment included structural barriers related to social determinants, lack of readiness for abstinence, burdensome intake procedures, and regulatory/programmatic requirements. Most participants expressed interest in low-threshold treatment.

CONCLUSIONS

Existing treatment barriers may be addressed by shifting to lower-threshold intake processes and/or outreach-based delivery of opioid agonist treatment. Engaging PWUD in efforts to create lower-threshold treatment programs is necessary to ensure that needs are met.

Scope of, Motivations for, and Outcomes Associated with Buprenorphine Diversion in the United States: A Scoping Review

BACKGROUND

Expanding access to medications to treat opioid use disorder (OUD), such as buprenorphine, is an evidence-based response to the mounting drug overdose crisis. However, concerns about buprenorphine diversion persist and contribute to limited access.

METHODS

To inform decisions about expanding access, a scoping review was conducted on publications describing the scope of, motivations for, and outcomes associated with diverted buprenorphine in the U.S.

RESULTS

In the 57 included studies, definitions for diversion were inconsistent. Most studied use of illicitly-obtained buprenorphine. Across studies, the scope of buprenorphine diversion ranged from 0% to 100%, varying by sample type and recall period. Among samples of people receiving buprenorphine for OUD treatment, diversion peaked at 4.8%. Motivations for using diverted buprenorphine were self-treatment, management of drug use, to get high, and when drug of choice was unavailable. Associated outcomes examined trended toward positive or neutral, including improved attitudes toward and retention in MOUD.

CONCLUSIONS

Despite inconsistent definitions of diversion, studies reported a low scope of diversion among people receiving MOUD, with inability to access treatment as a motivating factor for using diverted buprenorphine, and increased retention in MOUD as an outcome associated with use of diverted buprenorphine. Future research should explore reasons for diverted buprenorphine use in the context of expanded treatment availability to address persistent barriers to evidence-based treatment for OUD.

Retention of service users on opioid substitution therapy in the City of Tshwane, South Africa

BACKGROUND

Opioid substitution therapy (OST) is evidence-based treatment for opioid use disorders and, when taken as maintenance therapy, has proven health and social benefits. The benefits of OST are achieved through the retention of service users in the treatment programme.

AIM

To identify factors that affected retention of service users who had OST interrupted in less than 6 months of being in an OST programme.

SETTING

This qualitative study was conducted with 19 service users from eight Community-Oriented Substance Use Programme (COSUP) sites in the City of Tshwane, Gauteng, South Africa.

METHODS

Participants were COSUP service users who had interrupted OST in less than 6 months since initiation and were purposefully selected from all COSUP sites. Demographic information was obtained and four focus group discussions covered challenges of OST retention. Discussions were recorded, transcribed and qualitatively analysed using Attride-Stirling's thematic networks framework.

RESULTS

The 19 participants were all male, mostly black African, with a mean age of 26 years. Facilitators of retention in OST were individual readiness to change OST accessibility, positive family and peer support, treatment monitoring, understanding and managing expectations of service users, contribution in society and meaningful opportunities for engagement. Barriers were the cost of OST, bureaucracy within the programme, inability to communicate challenges timeously and effectively to treatment providers, boredom, cravings and poverty.

CONCLUSION

Opioid substitution therapy programmes can ensure a holistic approach to prevent and treat harms related to illicit opioid use if they remain person-centred and are well-funded.Contribution: Understanding the barriers to, and facilitators of retention on OST can contribute to improved community-based service delivery.

Low-threshold Buprenorphine Treatment in a Syringe Services Program: Program Description and Outcomes

OBJECTIVES

Low-threshold buprenorphine treatment aims to reduce barriers to evidence-based opioid use disorder treatment. We aimed to describe the treatment philosophy, practices, and outcomes of a low-threshold syringe services program (SSP)-based buprenorphine program developed through an SSP-academic medical center partnership.

METHODS

We included all SSP participants who received 1 or more buprenorphine prescription from Feb 5, 2019 to October 9, 2020. We collected data on patient characteristics, substance use, buprenorphine prescriptions, and urine drug tests (UDTs). We evaluated buprenorphine treatment retention using prescription data and buprenorphine adherence using UDTs. We used 2 retention definitions: (1) percentage of patients with buprenorphine prescriptions at 30, 90, and 180 days; and (2) total percentage of days "covered" with buprenorphine prescriptions through 180 days.

RESULTS

One-hundred and eighteen patients received 1 or more buprenorphine prescriptions. Patients were largely middle-aged (mean age 44, standard deviation 11), male (68%), Hispanic (31%) or Non-Hispanic Black (32%), with heroin (90%) and crack/cocaine (62%) use, and injection drug use (59%). Retention was 62%, 43%, and 31% at 30, 90, and 180 days, respectively. The median percentage of days covered with buprenorphine prescriptions through 180 days was 43% (interquartile range 8%-92%). Of the 82 patients who completed 2 or more UDTs, the median percentage of buprenorphine-positive UDTs was 71% (interquartile range 40%-100%).

CONCLUSIONS

In an SSP-based low-threshold buprenorphine treatment program, approximately one-third of patients continued buprenorphine treatment for 180 days or more, and buprenorphine adherence was high. SSPs can be a pathway to buprenorphine treatment for patients at high risk for opioid-related harms.

Beyond harm-producing versus harm-reducing: A qualitative meta-synthesis of people who use drugs' perspectives of and experiences with the extramedical use and diversion of buprenorphine

INTRODUCTION

This review synthesizes the literature on the perspectives and experiences of people who use drugs to better understand motivations and behaviors related to the extramedical use and diversion of buprenorphine. Given the particular social construction of buprenorphine against methadone, and the centrality of concerns around extramedical use in delivering opioid agonist therapies, a focus on extramedical buprenorphine use can provide an important lens through which to analyze treatment for opioid use disorder. This review is framed within persistent tensions between potential harm-producing versus harm-reducing effects of extramedical use that have long been described for opioid agonist therapies.

METHODS

The research team conducted a qualitative meta-synthesis based on a systematic search of eight databases as well as hand searching. The review includes all primary qualitative and mixed-methods studies related to the perspectives and experiences of people who use drugs on extramedical buprenorphine use. The study team carried out three rounds of qualitative coding using NVivo 12, and constructivist grounded theory and the constant comparative method informed the synthesis.

RESULTS

The review includes twenty-one studies. Findings are organized into the following three themes: 1) the experiences of people who use drugs (PWUD) with extramedical use of buprenorphine and their motivations to engage in it (including the desire to self-medicate and achieve "stability", to manage ongoing use of other opioids, and to "get high"); 2) the relationship between extramedical use and formal medical opioid agonist therapy programs; and 3) the established drug economy of extramedical buprenorphine.

CONCLUSIONS

The review identified varied and often divergent perspectives and experiences with extramedical buprenorphine use. An examination of the reported "normalizing" effects of extramedical buprenorphine suggests this practice as extending medicalized discipline beyond the clinical environment. Taken together, these findings identify a need to move beyond the tension of harm-reducing versus harm-producing effects toward forms of health care and promotion that focus on the needs, perspectives, and priorities of people who use drugs.

Treatment-seeking behaviour among people with opioid use disorder in the high-income countries: A systematic review and meta-analysis

OBJECTIVES

To determine treatment seeking behaviour in those with opioid use disorder (OUD) in the high-income countries.

METHODS

Five databases were searched in November 2019 for quantitative studies that reported OUD treatment seeking behaviour. Data analysis involved determining an overall pooled proportion estimate of treatment seeking behaviour for the two base groups, lifetime treatment and past 12-month or less treatment using the IVhet effect model. Subgroup analysis included heroin OUD, prescription OUD and general OUD. The sensitivity analysis included removal of outliers, separating adults and adolescents and the metaXL sensitivity analysis (studies are excluded if outside the pooled proportion confidence interval of the base case). Systematic review Prospero database registration number [CRD42020159531].

RESULTS

There were 13 quantitative studies included in the systematic review, with all studies being from the United States of America (USA). IVhet models showed that 40% (95% CI: 23%, 58%) and 21% (95% CI: 16%, 26%) sought treatment in their lifetime and past 12 months respectively. Sub-group analysis found that lifetime treatment seeking for prescription OUD, 29% (95% CI: 27%, 31%), was less than for heroin plus combined OUD, 54% (95% CI: 26%, 82%). Most of the pooled results had high heterogeneity statistics except for results of lifetime treatment seeking for prescription OUD and past 12-month treatment seeking for prescription OUD.

CONCLUSION

All included studies in this meta-analysis were from the USA and indicate modest levels of treatment seeking for those with OUD. In particular, this review found that in the USA one in five people with OUD sought OUD treatment in the previous 12 months and two in five people with OUD sought OUD treatment in their lifetime. Further research is urgently required to explore the barriers and facilitators that can improve this low treatment seeking in those with OUD.

Ingenuity and resiliency of syringe service programs on the front lines of the opioid overdose and COVID-19 crises

As COVID-19 accelerated throughout 2020, syringe service programs (SSPs) faced challenges necessitating programmatic adaptations to prevent overdose deaths while simultaneously keeping workers and participants safe from COVID-19. We used qualitative methods to gain an understanding of the social context within which SSPs are operating during the COVID-19 pandemic. We conducted 36 in-depth interviews with program representatives from 18 programs and used the Exploration, Preparation, Implementation, Sustainment (EPIS) implementation framework to guide data analysis. We focused on 3 of the 4 EPIS constructs: Outer context, inner context, and innovation factors. Our data indicate that responding to the pandemic led to innovations in service delivery such as secondary and mail-based distribution, adoption of telemedicine for enrolling participants in medications for opioid use disorder (MOUD) and use of virtual training platforms for overdose prevention. We found high levels of staff and volunteer commitment, which was a cornerstone to the success of these innovations. We observed that many SSPs were short-staffed because of their commitment to safety, and some lost current funding as well as opportunities for future funding. Despite minimal staffing and diminished funding, SSPs innovated at an accelerated pace. To ensure the sustainability of these new approaches, a supportive external context (federal, state, and local policies and funding) is needed to support the development of SSPs' inner contexts (organizational characteristics, characteristics of individuals) and sustainment of the innovations achieved regarding delivery of naloxone and MOUD.

Barriers to accessing opioid substitution treatment for opioid use disorder: A systematic review from the client perspective

OBJECTIVES

To update the existing evidence to identify specific barriers to initiation of opioid substitution therapy (OST) for those with opioid use disorder (OUD).

METHODS

The review follows Preferred Reporting Items for Systematic Reviews andMeta-Analyses (PRISMA) guidelines. Six databases were initially searched in November 2019, with the search updated on 11 November 2020, for qualitative or quantitative studies reporting the barriers to initiating OST from the client with OUD perspective. Thematic analysis of the barriers to OST was undertaken to determine barrier themes and subthemes.

RESULTS

There were 37 studies included in the review; 18 were qualitative, 15 were quantitative and four were mixed methods. The barrier themes identified were stigma and fear, regulatory, logistical, attitudinal and social factors. Within these barrier themes 19 barrier subthemes were identified. The most reported OST barrier subthemes were negative treatment perceptions, cost, stigma and lack of flexibility.

CONCLUSION

This review discusses important barriers to OST and examines reported barriers from the client perspective. OST guidelines and programs would benefit by introducing programs that reduce stigma, increase treatment knowledge and health literacy, reduce treatment costs, increase treatment flexibility and allow for easier treatment access.

A systematic review of patients' and providers' perspectives of medications for treatment of opioid use disorder

BACKGROUND

The opioid epidemic is a public health crisis. Medications for opioid use disorder (MOUD) include: 1) buprenorphine, 2) methadone, and 3) extended-release naltrexone (XR-NTX). Research should investigate patients' and providers' perspectives of MOUD since they can influence prescription, retention, and recovery.

METHODS

This systematic review focused on patients' and providers' perceptions of MOUD. The review eligibility criteria included inclusion of the outcome of interest, in English, and involving persons ≥18 years. A PubMed database search yielded 1692 results; we included 152 articles in the final review.

RESULTS

There were 63 articles about buprenorphine, 115 articles about methadone, and 16 about naltrexone. Misinformation and stigma associated with MOUD were common patient themes. Providers reported lack of training and resources as barriers to MOUD.

CONCLUSION

This review suggests that patients have significant misinformation regarding MOUD. Due to the severity of the opioid epidemic, research must consider the effects of patients' and providers' perspectives on treatment for OUD, including the effects on the type of MOUD prescribed, patient retention and adherence, and ultimately the number of patients treated for OUD, which will aid in curbing the opioid epidemic.

Buprenorphine in the United States: Motives for abuse, misuse, and diversion

Opioid use disorder (OUD) and its consequences are a major public health concern. The partial agonist buprenorphine is a safe and effective treatment for OUD, but concerns about abuse, misuse, and diversion of buprenorphine have been raised. This narrative review examined the rates and motives for use of illicit buprenorphine in the United States. Findings from the 17 included studies suggest the majority of study participants using illicit buprenorphine do so for reasons related to misuse (to manage opioid withdrawal symptoms or achieve or maintain abstinence from other opioids). A smaller percentage of study respondents reported using buprenorphine for reasons related to abuse (to get high). There appears to be a gap between need for buprenorphine and access to adequate treatment. Attenuation of policy-related barriers and adoption of appropriate buprenorphine use by the treatment community are critical tools in the continued effort to reduce the burdens associated with OUD.

Using nominal group technique to identify barriers, facilitators, and preferences among patients seeking treatment for opioid use disorder: A needs assessment for decision making support

BACKGROUND

The opioid crisis requires rapid scale-up of evidence-based interventions to treat opioid use disorder (OUD), of which pharmacologic therapies with methadone, buprenorphine or long-acting naltrexone are most effective. With recently-developed formulations, there are unprecedented treatment options. Even when pharmacologic treatment is accessible, however, uptake remains low, suggesting individual-level barriers. Decision aids are an evidence-based strategy that may overcome these barriers. This study aims to inform such a tool by describing and rank-ordering patients' considerations when deciding whether to start medication and, if starting, choosing a medication.

METHODS

Adults with OUD (N = 81) attending an addiction treatment center or syringe exchange program completed focus groups using nominal group technique, a consensus method that generates and ranks response. The qualitative component generates a broad array of responses, followed by rank-ordering to prioritize responses. Responses to questions about starting any medications and the pros and cons of five specific medications were ranked and coded.

RESULTS

The decision to initiate pharmacologic therapy and choose among medications was influenced by six key attributes in decreasing priority: (1) benefits, (2) side effects of treatment, (3) medication delivery strategies, (4) convenience, (5) how expectations for treatment are met, and (6) how medication (especially methadone) can represents trading one addiction for another.

CONCLUSIONS

Pharmacologic properties, logistical factors, and managing expectations were important themes in decision-making for starting, choosing, and staying on medications, and to a lesser degree, negative views about medications, specifically OAT, as an addiction itself. Desire for more control over treatment persisted in all themes. This study identified specific knowledge gaps, expectations, and priorities which are important for developing a decision aid for OUD treatment relevant to the target group. Nominal group technique is an established mixed-methodology that we have applied to a new population and purpose, that of conducting needs assessment for decision aid development.

Quality of primary care among individuals receiving treatment for opioid use disorder

OBJECTIVE

To determine if people receiving opioid agonist treatment (OAT), a long-term treatment approach, are also receiving high-quality primary care.

DESIGN

Retrospective cohort study.

SETTING

Ontario.

PARTICIPANTS

Recipients of public drug benefits who had at least 6 months of continuous use of methadone or buprenorphine between October 1, 2012, and September 30, 2013.

MAIN OUTCOME MEASURES

Rates of cancer screening and diabetes monitoring among those who had at least 6 months of continuous OAT were compared with matched controls. Conditional logistic regression models were used to assess differences after adjusting for confounders. In secondary analyses, outcomes by type of OAT and factors related to health care delivery were compared.

RESULTS

A cohort of 20 406 OAT patients was identified; they had a mean (SD) of 31 (15) physician clinic visits during the 6-month study period. Compared with the control group, OAT patients were less likely to receive screening for cervical cancer (48.7% vs 62.6%; adjusted odds ratio [AOR] of 0.34, 95% CI 0.31 to 0.36), breast cancer (23.3% vs 49.1%; AOR = 0.19, 95% CI 0.16 to 0.24), and colorectal cancer (32.5% vs 49.0%; AOR = 0.34, 95% CI 0.30 to 0.38), and less likely to have monitoring for diabetes (11.7% vs 28.5%; AOR = 0.16, 95% CI 0.13 to 0.21). Patients receiving OAT who were taking buprenorphine, enrolled in a medical home, or seeing a low-volume prescriber were generally more likely to receive cancer screening and diabetes monitoring.

CONCLUSION

Patients receiving OAT were less likely to receive chronic disease prevention and management than matched controls were despite frequent health care visits, indicating a gap in equitable access to primary care.

Helpful Ingredients in the Treatment of Long-Term Substance Use Disorders: A Collaborative Narrative Study

Relatively few individuals with a substance use disorder (SUD) seek or receive treatment, and knowledge about the effective ingredients in SUD treatment, from the perspective of those who receive it, is scarce. Our study purpose was to explore the experiences of those with long-term SUDs and the aspects they found helpful during treatment and long-term recovery. Semi-structured interviews were conducted with 18 participants, each of whom had been diagnosed with a long-term SUD, and who had been abstinent for at least 5 years. A resource group of peer consultants in long-term recovery from SUDs contributed to study planning, preparation, and initial analyses. Participants preferred individualized, long-term treatment, and support from both therapists and other clients. They further acknowledged the importance of their own sense of responsibility for their treatment and recovery success. Greater focus should be placed on viewing long-term SUD as a long-term condition, similar to somatic diseases, and SUD treatment services should place greater emphasis on developing partnership care models, long-term monitoring and support, and actively engaging recovered clients in the care of others in SUD treatment.

Dissatisfaction with opioid maintenance treatment partly explains reported side effects of medications

BACKGROUND

Drop-out is a core problem in opioid maintenance treatment (OMT), but patients' reactions to and acceptance of the various OMT medications are insufficiently investigated. In Norway, there has been vocal patient resistance to the newest medication, buprenorphine-naloxone (BNX), and complaints have focused on the side effect profile. There has been no comparison of patient satisfaction and side effects of the three most common OMT medications.

AIM

To compare patient satisfaction with OMT and side effects of BNX, buprenorphine monopreparate (BUP), and methadone (MET) as reported by patients.

METHODS

Data were drawn from a national peer-to-peer survey developed by a patient advocacy group. The survey engaged more than 1000 OMT patients, corresponding to one seventh of OMT patients in Norway. The associations between side effects, treatment satisfaction, and patient characteristics were tested in multinomial logistic regressions.

RESULTS

High patient satisfaction with OMT overall was reported despite lower satisfaction with medication itself and widely prevalent side effects. Among each medication group, dissatisfaction with medications or OMT in general along with poor health status increased the relative risk ratio of reporting the heaviest side effect burden. MET users reported the highest side effect burden and BNX users the lightest, but BNX users were more dissatisfied with their medication.

CONCLUSIONS

Side effects are a concern for nearly all OMT patients, and they do not appear to accumulate with age or length of treatment. BNX users' dissatisfaction with their medication is of particular concern, and expectations and preferences of medication may be influencing their dissatisfaction.

Perspectives on the Pharmacological Treatment of Heroin Addiction

Opioids are very addictive drugs because of their powerful effects on reward and pain pathways in the brain. Opioid addiction is currently a worldwide problem and injecting heroin presents serious health risks including death from overdose. The increase in the nonmedical use of prescription opioids and the increase in overdose deaths are worrying trends in North America. There is therefore an increasing need for access to effective treatments. The 2 major drug treatments, methadone and buprenorphine, have proven efficacy but are not necessarily administered in the most effective doses or under optimum conditions. Alternative approaches such as slow-release oral morphine, tincture of opium, and the use of the opioid antagonist naltrexone to maintain abstinence are used seemingly effectively in some countries but have yet to be fully evaluated in randomized controlled trials. Heroin-assisted treatment has proven to be a valuable and effective treatment when administered in specialized clinics but is only appropriate for those who have failed to improve on optimal methadone or buprenorphine maintenance. Recent innovations and substitution treatment as an alternative to incarceration are described. Drug treatment of opioid addiction is most effective when administered as part of a therapeutic program as demonstrated in the initial methadone evaluations and the more recent trials with heroin-assisted treatment.

Development and evaluation of a community-based buprenorphine treatment intervention

Background

The majority of Americans with opioid use disorder remain out of treatment. Operating in 33 states, Washington DC, and Puerto Rico, harm reduction agencies, which provide sterile syringes and other health services to people who inject drugs, are a key venue to reach out-of-treatment opioid users. Aiming to link out-of-treatment individuals with opioid use disorder to buprenorphine treatment, we developed a community-based buprenorphine treatment (CBBT) intervention in collaboration with New York City harm reduction agencies.

Methods

Intervention development included formative data collection, feasibility testing at one harm reduction agency, and pilot testing for preliminary effectiveness at a second harm reduction agency. We used a pre-post design for both feasibility and pilot testing. In the CBBT intervention, we trained harm reduction agency staff to provide (1) buprenorphine education, (2) motivational interviewing, (3) referrals to buprenorphine-prescribing doctors, and (4) treatment retention support. We assessed feasibility by measuring staff satisfaction with the intervention and changes in knowledge about buprenorphine. We assessed preliminary effectiveness by comparing rates of buprenorphine initiation among groups of harm reduction agency clients before and after intervention implementation.

Results

Among staff members at the first harm reduction agency, knowledge increased from 52% correct answers pre-intervention to 79% correct post-intervention. Among clients at the second harm reduction agency, initiation of buprenorphine treatment was low and did not differ between pre- and post-intervention groups.

Conclusions

The CBBT intervention was feasible and well-received, but initiation of buprenorphine treatment among harm reduction agency clients was low. More robust interventions may be necessary to increase initiation of buprenorphine treatment.

National and State Treatment Need and Capacity for Opioid Agonist Medication-Assisted Treatment

OBJECTIVES

We estimated national and state trends in opioid agonist medication-assisted treatment (OA-MAT) need and capacity to identify gaps and inform policy decisions.

METHODS

We generated national and state rates of past-year opioid abuse or dependence, maximum potential buprenorphine treatment capacity, number of patients receiving methadone from opioid treatment programs (OTPs), and the percentage of OTPs operating at 80% capacity or more using Substance Abuse and Mental Health Services Administration data.

RESULTS

Nationally, in 2012, the rate of opioid abuse or dependence was 891.8 per 100 000 people aged 12 years or older compared with national rates of maximum potential buprenorphine treatment capacity and patients receiving methadone in OTPs of, respectively, 420.3 and 119.9. Among states and the District of Columbia, 96% had opioid abuse or dependence rates higher than their buprenorphine treatment capacity rates; 37% had a gap of at least 5 per 1000 people. Thirty-eight states (77.6%) reported at least 75% of their OTPs were operating at 80% capacity or more.

CONCLUSIONS

Significant gaps between treatment need and capacity exist at the state and national levels. Strategies to increase the number of OA-MAT providers are needed.

Buprenorphine in the treatment of opioid addiction: opportunities, challenges and strategies

INTRODUCTION

Buprenorphine follows the success of methadone as another milestone in the history of treatment for opioid addiction. Buprenorphine can be used in an office-based setting where it is clearly effective, highly accepted by patients and has a favorable safety profile and less abuse potential. However, the adoption of buprenorphine treatment has been slow in the USA.

AREAS COVERED

This article first reviews the history of medication-assisted opioid addiction treatment and the current epidemic opioid addiction, followed by a review of the efficacy, pharmacology and clinical prescription of buprenorphine in office-based care. We then explore the possible barriers in using buprenorphine and the ways to overcome these barriers, including new formulations, educational programs and policy regulations that strike a balance between accessibility and reducing diversion.

EXPERT OPINION

Buprenorphine can align addiction treatment with treatments for other chronic medical illnesses. However, preventing diversion will require graduate and continuing medical education and integrated care models for delivery of buprenorphine to those in need.

Illicit buprenorphine use, interest in and access to buprenorphine treatment among syringe exchange participants

Poor access to buprenorphine maintenance treatment (BMT) may contribute to illicit buprenorphine use. This study investigated illicit buprenorphine use and barriers to BMT among syringe exchange participants. Computer-based interviews conducted at a New York City harm reduction agency determined: prior buprenorphine use; barriers to BMT; and interest in BMT. Of 102 opioid users, 57 had used illicit buprenorphine and 32 had used prescribed buprenorphine. When illicit buprenorphine users were compared to non-users: barriers to BMT ("did not know where to get treatment") were more common (64 vs. 36%, p<0.01); mean levels of interest in BMT were greater (3.37 ± 1.29 vs. 2.80 ± 1.34, p=0.03); and more participants reported themselves likely to initiate treatment (82 vs. 50%, p<0.01). Illicit buprenorphine users were interested in BMT but did not know where to go for treatment. Addressing barriers to BMT could reduce illicit buprenorphine use.