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McAnulty C, Bastien G, Ledjiar O, Eugenia Socias M, Le Foll B, Lim R, Jutras-Aswad D. Mediating effect of craving on the impact of buprenorphine/naloxone and methadone treatment on opioid use: Results from a randomized controlled trial. Addict Behav 2024; 154:108023. [PMID: 38579594 DOI: 10.1016/j.addbeh.2024.108023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/07/2024]
Abstract
BACKGROUND The relationship between opioid craving and opioid use is unclear. We sought to determine to what extent craving mediated the relationship between opioid agonist therapy and changes in opioid use. METHODS Data came from a pragmatic, 24-week, pan-Canadian, multi-centric, open-label, randomized controlled trial comparing flexible buprenorphine/naloxone take-home doses to standard supervised methadone models of care for the treatment of prescription-type opioid use disorder. Participants were randomly allocated to buprenorphine/naloxone or methadone models of care. 270 people with prescription-type opioid use disorder were included in analyses. There were 93 women (34.4%) and 2 transgender (0.7%) participants. Most participants were white (67.4%), 45.9% reported unstable living conditions, and 44.8% had psychiatric comorbidities. Generalized linear mixed models followed by mediation analysis estimated the direct effect of treatment group on Timeline Followback-reported next-week opioid use and the indirect effect through past 24-hour opioid craving measured using the Brief Substance Craving Scale at week 2, 6, 10, 14, 18 and 22. RESULTS Upon mediation analysis, the average direct effect of treatment on opioid use was 0.465 (95 % CI = 0.183 to 0.751, p < 0.001). The average causal mediated effect was 0.144 (95 % CI = 0.021 to 0.110; p < 0.001). Craving accounted for 23.6 % of the effect of treatment on opioid use (p < 0.001). CONCLUSIONS Past 24-hour craving was associated with increased next-week opioid use; however, craving only partially mediated the effect of buprenorphine/naloxone and methadone on next-week opioid use. Research is needed to develop a comprehensive understanding of factors mediating opioid use during opioid agonist therapy.
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Affiliation(s)
- Christina McAnulty
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, 2900 boul. Edouard-Montpetit, Montréal, Québec H3T 1J4, Canada; Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montréal, Québec H2X 0A9, Canada
| | - Gabriel Bastien
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, 2900 boul. Edouard-Montpetit, Montréal, Québec H3T 1J4, Canada; Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montréal, Québec H2X 0A9, Canada
| | - Omar Ledjiar
- Unité de recherche Clinique appliquée (URCA), Research Centre, Centre Hospitalier Ste-Justine, 3175 chemin de la Côte Ste-Catherine, Montréal, Québec H3T 1C5, Canada
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, 400-1045 Howe Street, Vancouver, British Columbia V6Z 2A9, Canada; Department of Medicine, Faculty of Medicine, University of British Columbia, 1045 Howe Street, Vancouver, British Columbia V6Z 2A9, Canada
| | - Bernard Le Foll
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, 500 University Avenue, 5th Floor, Toronto, Ontario M5G 1V7, Canada; Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, Ontario M5T 1R8, Canada; Dalla Lana School of Public Health, University of Toronto, 155 College Street, Toronto, Ontario M5T 3M7, Canada; Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), 33 Ursula Franklin Street, Toronto, Ontario M5S 2S1, Canada; Department of Pharmacology and Toxicology, Faculty of Medicine, Medical Sciences Building, University of Toronto, 1 King's College Circle, Toronto, Ontario M5S 1A8, Canada; Waypoint Research Institute, Waypoint Centre for Mental Health Care, 500 Church Street, Penetanguishene, Ontario L9M 1G3, Canada
| | - Ron Lim
- Department of Psychiatry and Family Medicine, Cumming School of Medicine, University of Calgary, 2500 University Drive NW, Calgary, Alberta T2N 1N4, Canada
| | - Didier Jutras-Aswad
- Department of Psychiatry and Addictology, Faculty of Medicine, Université de Montréal, 2900 boul. Edouard-Montpetit, Montréal, Québec H3T 1J4, Canada; Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), 900 Saint-Denis Street, Montréal, Québec H2X 0A9, Canada.
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Walsh SL, Comer SD, Zdovc JA, Sarr C, Björnsson M, Strandgården K, Hjelmström P, Tiberg F. Pharmacokinetic-pharmacodynamic analysis of drug liking blockade by buprenorphine subcutaneous depot (CAM2038) in participants with opioid use disorder. Neuropsychopharmacology 2024; 49:1050-1057. [PMID: 38200140 DOI: 10.1038/s41386-023-01793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 12/14/2023] [Accepted: 12/19/2023] [Indexed: 01/12/2024]
Abstract
Buprenorphine is used to treat opioid use disorder (OUD). Weekly and monthly subcutaneous long-acting buprenorphine injections (CAM2038) provide more stable buprenorphine plasma levels and reduce the treatment burden, misuse, and diversion associated with sublingual transmucosal buprenorphine formulations. To characterize the pharmacokinetic/pharmacodynamic (PK/PD) relationship, a maximum inhibition (Imax) model was developed relating CAM2038 buprenorphine plasma concentration to drug liking maximum effect (Emax) visual analog scale (VAS; bipolar) score after intramuscular hydromorphone administration. Data included time-matched observations of buprenorphine plasma concentration and drug liking Emax VAS score after hydromorphone 18 mg administration in 47 non-treatment-seeking adults with moderate to severe OUD in a phase 2 study. Analysis used non-linear mixed-effects modeling (NONMEM®). The final Imax model adequately described the PK/PD relationship between buprenorphine plasma concentration and drug liking Emax VAS score. Simulations showed drug liking was effectively blocked at low buprenorphine plasma concentrations (0.4 ng/mL) where the upper 95% confidence interval of the drug liking Emax VAS score was below the pre-defined 11-point complete blockade threshold. The buprenorphine plasma concentration required to achieve 90% of the maximal effect (IC90) of drug liking was 0.675 ng/mL. Interindividual variability in responses to buprenorphine was observed; some participants experienced fluctuating responses, and a few did not achieve drug liking blockade even with higher buprenorphine plasma concentrations. This affirms the need to individualize treatment and titrate doses for optimal treatment outcomes. PK/PD models were also developed for desire to use VAS and Clinical Opiate Withdrawal Scale (COWS) scores, with results aligned to those for drug liking.
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Affiliation(s)
- Sharon L Walsh
- Behavioral Science, Pharmacology, Psychiatry and Pharmaceutical Sciences Departments, University of Kentucky College of Medicine and Pharmacy, Kentucky, KY, USA
| | - Sandra D Comer
- Department of Psychiatry, Columbia University, New York, NY, USA
| | | | | | | | | | - Peter Hjelmström
- Camurus AB, Lund, Sweden
- Uppsala Monitoring Centre, Uppsala, Sweden
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Talal AH, Markatou M, Liu A, Perumalswami PV, Dinani AM, Tobin JN, Brown LS. Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial. JAMA 2024; 331:1369-1378. [PMID: 38568601 PMCID: PMC10993166 DOI: 10.1001/jama.2024.2452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/13/2024] [Indexed: 04/06/2024]
Abstract
Importance Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration ClinicalTrials.gov Identifier: NCT02933970.
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Affiliation(s)
- Andrew H. Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York
| | | | - Anran Liu
- Department of Biostatistics, University at Buffalo, Buffalo, New York
| | - Ponni V. Perumalswami
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor
| | - Amreen M. Dinani
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Jonathan N. Tobin
- Clinical Directors Network, Inc (CDN), New York, New York
- The Rockefeller University Center for Clinical and Translational Science, New York, New York
| | - Lawrence S. Brown
- START Treatment & Recovery Centers, Brooklyn, New York
- Weill Cornell Medicine, New York, New York
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Pierlorenzi C, Nunzi M, Cirulli S, Direnzo GFM, Curatella L, Liberatori S, Pascucci A, Petrone E, Ventre G, Varango C, Pulito ML, Varango A, Dandolo C, Occupati B, Marenzi R, Leonardi C. Patients' perspectives on buprenorphine subcutaneous implant: a case series. J Med Case Rep 2024; 18:202. [PMID: 38581074 PMCID: PMC10998295 DOI: 10.1186/s13256-024-04483-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 03/01/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Considering the enormous burden represented by the opioid use disorder (OUD), it is important to always consider, when implementing opioid agonist therapy (OAT), the potential impact on patient's adherence, quality of life, and detoxification. Thus, the purpose of the study is to evaluate how the introduction of a novel OAT approach influences these key factors in the management of OUD. CASE PRESENTATION This article marks the pioneering use of OAT through buprenorphine implant in Europe and delves into the experience of six patients diagnosed with OUD at a relatively young age. The patients, comprising both males and a female, are of Caucasian Italian and African Italian ancestry (case 4) and exhibit an age range from 23 to 63, with an average drug abuse history of 19 ± 12 years. All patients were on stable traditional OAT before transitioning to buprenorphine implants. Despite the heterogeneity in social and educational backgrounds, health status, and drug abuse initiation histories, the case series reveals consistent positive treatment outcomes such as detoxification, absence of withdrawal symptoms and of side effects. Notably, all patients reported experiencing a newfound sense of freedom and improved quality of life. CONCLUSIONS These results emphasise the promising impact of OAT via buprenorphine implants in enhancing the well-being and quality of life in the context of OUD.
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Affiliation(s)
| | - Marco Nunzi
- UOS Patologie da Dipendenza D9 ASL Roma 2, Rome, Italy
| | | | | | | | | | | | - Edoardo Petrone
- UOS Terapia del Dolore ASL Roma 2 Ospedale S. Eugenio, Rome, Italy
| | | | | | | | | | - Cosimo Dandolo
- Servizio Dipendenze Casalpusterlengo, ASST Lodi, Lodi, Italy
| | - Brunella Occupati
- Tossicologia Medica, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Roberta Marenzi
- ASST Papa Giovanni XXII, Ospedale Di Bergamo, Bergamo, Italy
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Trammel CJ, Whitley J, Kelly JC. Pharmacotherapy for opioid use disorder in pregnancy. Curr Opin Obstet Gynecol 2024; 36:74-80. [PMID: 38193300 DOI: 10.1097/gco.0000000000000932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW Opioid use disorder (OUD) in pregnancy has significantly increased in the last decade, impacting 8.2 per 1000 deliveries. OUD carries significant risk of morbidity and mortality for both the birthing person and neonate, but outcomes for both are improved with opioid agonist treatment (OAT). Here, we describe the recommended forms of OAT in pregnancy, updates to the literature, and alternate OAT strategies, and share practical peripartum considerations for patients on OAT. RECENT FINDINGS Recent studies comparing buprenorphine and methadone have reaffirmed previous findings that buprenorphine is associated with superior outcomes for the neonate, without clear differences in morbidity or mortality for the birthing person. Optimal initiation and dosing of OAT remains unclear, with several recent studies evaluating methods of initiation, as well as a potential role for higher and more rapid dosing in the fentanyl era. Alternative products such as buprenorphine-naloxone and extended-release buprenorphine are of significant research interest, though randomized prospective data are not yet available. SUMMARY Buprenorphine and methadone are standard of care for treatment of OUD during pregnancy, and multiple patient factors impact the optimal choice. Insufficient data exist to recommend alternative agents as a primary strategy currently. All patients with OUD in pregnancy should be counseled regarding OAT. VIDEO http://links.lww.com/COOG/A94.
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Affiliation(s)
- Cassandra J Trammel
- Washington University in Saint Louis, Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, St. Louis, Missouri, USA
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McCann NC, LaRochelle MR, Morgan JR. Out-of-pocket spending and health care utilization associated with initiation of different medications for opioid use disorder: Findings from a national commercially insured cohort. J Subst Use Addict Treat 2024; 159:209281. [PMID: 38122988 PMCID: PMC10947919 DOI: 10.1016/j.josat.2023.209281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/05/2023] [Accepted: 12/15/2023] [Indexed: 12/23/2023]
Abstract
INTRODUCTION Buprenorphine and naltrexone are effective medications for opioid use disorder (MOUD). Naltrexone requires complete detoxification from opioids before initiation while buprenorphine does not, which leads to a differential clinical induction challenge. Few studies have evaluated economic costs associated with MOUD initiation. METHODS We conducted a retrospective cohort analysis using the 2014-2019 Merative MarketScan database. We included individuals diagnosed with opioid use, abuse, or dependence from 2014 to 2019 who initiated one of three MOUD types: 1) buprenorphine, 2) extended-release naltrexone, or 3) oral naltrexone. We calculated total and monthly out-of-pocket spending, for overall and MOUD-specific claims, for the three months prior through three months after MOUD initiation. We also calculated utilization of detoxification, inpatient, and outpatient services monthly over this period. RESULTS Our cohort included 27,133 individuals; 19,536, 1886, and 5711 initiated buprenorphine, extended-release naltrexone, and oral naltrexone, respectively. Individuals who initiated naltrexone had the highest out-of-pocket spending over the study period. MOUD-specific spending did not contribute substantially to total out-of-pocket spending. Difference in overall spending by MOUD type was driven by a subset of individuals who initiated naltrexone and had very high out-of-pocket spending in the month prior to MOUD initiation. In this month, mean monthly out-of-pocket spending for high-spenders (above 90th percentile within MOUD type category) was $5734 (95 % confidence interval [CI]: $5181-$6286) and $4622 (95 % CI: $4161-$5082) for those who initiated oral and extended-release naltrexone, respectively, compared with $1852 (95 % CI: $1754-$1950) for those who initiated buprenorphine. In the month prior to MOUD initiation, those who initiated naltrexone also had higher detoxification, inpatient, and outpatient episode/visit frequency. In the month prior to initiation, 28.8 % (95 % CI: 27.7 %-30.0 %) and 25.5 % (95 % CI: 23.6 %-27.5 %) of individuals who initiated oral and extended-release naltrexone had detoxification episodes, compared with 9.7 % (95 % CI: 9.3 %-10.1 %) of those who initiated buprenorphine. CONCLUSION Findings suggest that individuals who initiated naltrexone utilized more intensive health services, including detoxification, in the period prior to MOUD initiation, resulting in significantly higher out-of-pocket spending. Out-of-pocket spending is a patient-centered outcome reflecting potential patient burden. Our results should be considered as part of the shared decision-making process between patients and providers when choosing treatment for OUD.
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Affiliation(s)
- Nicole C McCann
- Department of Health Law, Policy, and Management, Boston University School of Public Health, United States of America.
| | - Marc R LaRochelle
- Grayken Center for Addiction, Boston Medical Center, United States of America; Department of Medicine, Boston University School of Medicine, United States of America
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, United States of America
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Liu C, Li Y. Psychosocial combined with methadone maintenance treatments versus methadone maintenance treatments alone for treatment of opioid use disorder: A meta-analysis. J Addict Dis 2024; 42:126-135. [PMID: 36607171 DOI: 10.1080/10550887.2022.2158664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Psychosocial combined with methadone maintenance treatment aimed at opioid use disorder is effective, but the efficacy of the psychosocial intervention in such treatment is questionable. OBJECTIVES This study aims to evaluate the effectiveness of psychosocial plus methadone maintenance treatment versus methadone maintenance treatment alone for opioid use disorder in improving treatment retention and reducing drug use. METHODS An exhaustive literature search was conducted in PubMed, EMBASE, Cochrane Library, Web of Science, PsycINFO, CINAHL, China National Knowledge Infrastructure database, "the Wan Fang database, the VIP database, and the Chinese Biomedical Literature Database", and randomized controlled trials were identified from their inception to February 2021. RESULTS Twenty-four studies were included. The results of this meta-analysis showed that adding any psychosocial treatment to standard methadone maintenance treatment significantly improved the illicit drug use during the treatment relative risk (RR) 0.62 (95% CI 0.48 to 0.79), and retention in treatment RR 1.18 (95% CI 1.11 to 1.25). No statistically significant additional benefit was detected in terms of retention at follow-up RR 1.08 (95% CI 0.95 to 1.22). CONCLUSIONS The present evidence suggests that adding psychosocial intervention to methadone maintenance treatment significantly improves the nonuse of opioids and retention in treatment. It should be noted that psychosocial treatment is only beneficial for methadone treatment when methadone is provided in subtherapeutic doses. Additionally, the finding about the improvement effect of retention at follow-up did not achieve statistical significance. Due to the diversity of outcome indicators in relevant original studies, the included studies are limited.
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Affiliation(s)
- Chengbin Liu
- School of Sociology, Huazhong University of Science and Technology, Wuhan, China
| | - Yangyang Li
- School of Sociology, Huazhong University of Science and Technology, Wuhan, China
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Johnson B, Monwell B, Capusan AJ. Long-acting injectable depot buprenorphine from a harm reduction perspective in patients with ongoing substance use and multiple psychiatric comorbidities: a qualitative interview study. Harm Reduct J 2024; 21:68. [PMID: 38528531 DOI: 10.1186/s12954-024-00984-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/07/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Long-acting injectable depot buprenorphine may increase access to opioid agonist treatment (OAT) for patients with opioid use disorder in different treatment phases. The aim of this study was to explore the experiences of depot buprenorphine among Swedish patients with ongoing substance use and multiple psychiatric comorbidities. METHOD Semi-structured qualitative interviews were conducted with OAT patients with experience of depot buprenorphine. Recruitment took place at two OAT clinics with a harm reduction focus, specializing in the treatment of patients with ongoing substance use and multiple comorbidities. Nineteen participants were included, 12 men and seven women, with a mean age of 41 years (range 24-56 years), and a mean of 21 years (5-35 years) of experience with illicit substance use. All participants had ongoing substance use and psychiatric comorbidities such as ADHD, anxiety, mood, psychotic and eating disorders. Interviews were transcribed verbatim. Thematic content analysis was conducted both manually and using qualitative data analysis software. RESULTS Participants reported social benefits and positive changes in self-perception and identity. In particular, depot buprenorphine contributed to a realization that it was possible to make life changes and engage in activities not related to substance use. Another positive aspect that emerged from the interviews was a noticeable relief from perceived pressure to divert OAT medication, while some expressed the lack of income from diverted oral/sublingual OAT medication as a negative, but still acceptable, consequence of the depot buprenorphine. Many participants considered that the information provided prior to starting depot buprenorphine was insufficient. Also, not all patients found depot buprenorphine suitable, and those who experienced coercion exhibited particularly negative attitudes towards the medication. CONCLUSIONS OAT patients with ongoing substance use and multiple psychiatric comorbidities reported clear benefits of depot buprenorphine, including changes in self-perception which has been theorized to play an important role in recovery. Clinicians should consider the specific information needs of this population and the extensive diversion of traditional OAT medications in this population to improve the treatment experience and outcomes. Overall, depot buprenorphine is a valuable treatment option for a population in need of harm reduction and may also contribute to psychological changes that may facilitate recovery in those with the greatest need.
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Affiliation(s)
- Björn Johnson
- School of Social Work, Lund University, Lund, Sweden.
| | - Bodil Monwell
- Department of Psychiatry, County Hospital Jönköping, Jönköping, Sweden
- Department of Social Work, Jönköping University, Jönköping, Sweden
| | - Andrea Johansson Capusan
- Department of Psychiatry in Linköping, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
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Abraham AJ, Harris SJ, Yarbrough CR. Introduction of Medicare coverage in opioid treatment programs: Findings from the first three years. J Subst Use Addict Treat 2024; 158:209247. [PMID: 38072386 PMCID: PMC10947910 DOI: 10.1016/j.josat.2023.209247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Prior to January of 2020, there was no Medicare reimbursement for services delivered in opioid treatment programs (OTPs). OTPs are the only authorized providers of opioid use disorder (OUD) treatment with methadone, a critical tool to address the opioid overdose crisis. While prior research has examined the availability of MOUD other than methadone for Medicare beneficiaries, research has not identified organizational and local Medicare beneficiary characteristics associated with Medicare insurance acceptance among OTPs. OBJECTIVES This study has two objectives: 1) to determine the extent to which OTPs began accepting Medicare insurance in the first three years following the new Medicare OTP benefit; and 2) to identify organizational characteristics and local Medicare beneficiary characteristics associated with OTP acceptance of Medicare. METHODS We used data from the 2021-2023 National Directory of Drug and Alcohol Abuse Treatment Facilities to examine OTP acceptance of Medicare. We used logistic regression to identify organizational characteristics and local Medicare beneficiary characteristics associated with OTP acceptance of Medicare (n = 4630 OTPs). RESULTS By 2022, about 78.7 % of OTPs accepted Medicare, compared to only 41.1 % of non-OTPs. The odds of Medicare acceptance were lower among for-profit OTPs, compared to non-profit OTPs, and higher among OTPs that accepted Medicaid and private insurance. Additionally, the odds of accepting Medicare were lower for OTPs located in the Northeast, Midwest, and South, compared to OTPs located in the West. Finally, the odds of accepting Medicare were higher for OTPs located in counties with higher percentages of Non-Hispanic White Medicare beneficiaries. CONCLUSIONS We found high rates of Medicare acceptance among OTPs in the first three years of the Medicare OTP benefit, suggesting increased access to OUD treatment via OTPs for Medicare beneficiaries. While promising, results indicate potential geographic and racial/ethnic disparities in access to OTPs.
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Affiliation(s)
- Amanda J Abraham
- University of Georgia, School of Public and International Affairs, Department of Public Administration and Policy, United States of America.
| | - Samantha J Harris
- Johns Hopkins University, Bloomberg School of Public Health, Department of Health Policy and Management, United States of America
| | - Courtney R Yarbrough
- Emory University, Rollins School of Public Health, Department of Health Policy and Management, United States of America
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Atluru S, Bruehlman AK, Vaughn P, Schauberger CW, Smid MC. Naltrexone Compared With Buprenorphine or Methadone in Pregnancy: A Systematic Review. Obstet Gynecol 2024; 143:403-410. [PMID: 38227945 DOI: 10.1097/aog.0000000000005510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/30/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Although naltrexone is an evidence-based medication for opioid use disorder (MOUD), few data are available with use in pregnancy. Our objective was to assess outcomes of pregnant individuals with opioid use disorder (OUD) taking naltrexone compared with those taking methadone or buprenorphine. DATA SOURCES We undertook a systematic review using electronic database search (PubMed, CINAHL, EMBASE, PsycInfo), conference proceedings, and trial registries including ClinicalTrials.gov . METHODS OF STUDY SELECTION We conducted an electronic search of research articles through May 2023 for randomized controlled trials, prospective cohort, and retrospective cohort studies of naltrexone (oral, implant, or extended release) compared with methadone or buprenorphine (sublingual or extended release) among pregnant individuals with OUD. After double review of all articles, we abstracted obstetric (primary outcome: gestational age at delivery), neonatal (primary outcome: neonatal abstinence syndrome [NAS]), and substance use outcomes. TABULATION, INTEGRATION, AND RESULTS Five studies met eligibility criteria; four were retrospective cohort studies, and one was a prospective cohort study. Four studies included data on gestational age at delivery (weeks) with no difference detected between the two groups in any study (mean difference ranging -0.20, 95% CI, -1.49-1.09 to 0.8, 95% CI, -0.15 to 1.75). Three studies included data on NAS with all studies detecting a lower risk in the naltrexone group compared with methadone or buprenorphine (relative risk ranging from 0.08, 95% CI, 0.01-1.16 to 0.15, 95% CI, 0.06-0.36). Most studies (four of five) had a moderate or high potential for selection bias primarily driven by small sample size and lack of controlling for confounders. CONCLUSION Although the evidence base is limited, available data suggest that naltrexone use in pregnancy is a reasonable MOUD option with reassuring perinatal outcomes. To enhance confidence in this conclusion and to assess substance use outcomes, further comparative studies of pregnant people with OUD taking naltrexone and other MOUD types are needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, 42017074249.
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Affiliation(s)
- Sreevalli Atluru
- Department of Family Medicine and Community Health, and the Division of Hospital Medicine, Department of Medicine, University of Wisconsin Madison School of Medicine and Public Health, Madison, and Addiction Medical Services, Onalaska, Wisconsin; the Department of Pediatrics, University of Utah School of Medicine, and the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah; and the Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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11
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Fuller DB, Gryczynski J, Schwartz RP, Halsted C, Mitchell SG, Whitter M. State guidance and system changes related to COVID-19: Impact on opioid treatment programs. J Subst Use Addict Treat 2024; 158:209214. [PMID: 38042301 PMCID: PMC10947927 DOI: 10.1016/j.josat.2023.209214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 10/20/2023] [Accepted: 11/13/2023] [Indexed: 12/04/2023]
Abstract
INTRODUCTION In the United States, methadone treatment may only be provided through opioid treatment programs (OTPs), which operate under a complex system of federal and state regulations. During the pandemic, federal regulators relaxed several longstanding restrictions for OTPs by permitting expanded eligibility for take-home medication and allowing counseling and medication management through telehealth. The purpose of this study was to assess the guidance provided by states regarding the revised guidelines and efforts to protect staff and patients in response to the pandemic. METHODS Between September and October of 2020, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Friends Research Institute, fielded a web-based qualitative survey of state opioid treatment authorities (SOTAs) across the United States, the District of Columbia, and Puerto Rico. The study conducted the survey prior to the availability of the COVID vaccines. It queried 42 SOTAs concerning state guidance provided to OTPs on treatment operations and practices for existing patients and new admissions; actions to protect staff and patients; changes in treatment need and operational capacity; and administrative practices regarding treatment. This study examines the responses of 42 SOTAs (65 %) who completed the survey. RESULTS Using content analysis, responses to the survey indicate that most states provided guidance to OTPs in response to the revised federal regulations and the need to protect staff and patients. All respondents reported that their states permitted increased number of take-homes doses for existing patients (100 %) and most reported doing so for new admissions (69 %; N=29). Ninety-eight percent (98 %; N=41) reported permitting remote counseling for existing patients and 90 % (N=38) permitting this for new admissions. SOTAs reported providing guidance on staff safety, operational procedures, oversight, and reforming billing practices to align with new models of service delivery. CONCLUSIONS SOTAs generally reported that federal guidance increased patient access, engagement, and retention. Increased take-home flexibilities were viewed as important for expanding access and continuity of treatment, with the majority of SOTAs stating that the revised treatment practices (e.g., expansion of telehealth, flexible medication dispensing practices) were beneficial. These regulatory flexibilities, many believe, promoted the continuation of treatment and successful patient outcomes during the pandemic.
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Affiliation(s)
- Douglas B Fuller
- National Association of State Alcohol & Drug Abuse Directors, Inc., 1919 Pennsylvania Avenue, NW, Suite M-250, Washington, DC 20006, United States of America.
| | - Jan Gryczynski
- Friends Research Institute, Inc., 1040 Park Avenue, #103, Baltimore, MD 21201, United States of America.
| | - Robert P Schwartz
- Friends Research Institute, Inc., 1040 Park Avenue, #103, Baltimore, MD 21201, United States of America.
| | - Caroline Halsted
- National Association of State Alcohol & Drug Abuse Directors, Inc., 1919 Pennsylvania Avenue, NW, Suite M-250, Washington, DC 20006, United States of America.
| | - Shannon Gwin Mitchell
- Friends Research Institute, Inc., 1040 Park Avenue, #103, Baltimore, MD 21201, United States of America.
| | - Melanie Whitter
- National Association of State Alcohol & Drug Abuse Directors, Inc., 1919 Pennsylvania Avenue, NW, Suite M-250, Washington, DC 20006, United States of America.
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Homayra F, Enns B, Min JE, Kurz M, Bach P, Bruneau J, Greenland S, Gustafson P, Karim ME, Korthuis PT, Loughin T, MacLure M, McCandless L, Platt RW, Schnepel K, Shigeoka H, Siebert U, Socias E, Wood E, Nosyk B. Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder. Epidemiology 2024; 35:218-231. [PMID: 38290142 PMCID: PMC10833049 DOI: 10.1097/ede.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). METHODS Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber's preference IV in analyzing the treatment assignment-treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. RESULTS The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in provider-level prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. CONCLUSIONS Our results suggest that prescriber's preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD.
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Affiliation(s)
- Fahmida Homayra
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Sander Greenland
- Department of Epidemiology, University of California, Los Angeles, California, USA
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammad Ehsanul Karim
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - P Todd Korthuis
- Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas Loughin
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm MacLure
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lawrence McCandless
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Robert William Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kevin Schnepel
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Hitoshi Shigeoka
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Uwe Siebert
- Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Rush AJ, Gore-Langton RE, Bart G, Bradley KA, Campbell CI, McKay J, Oslin DW, Saxon AJ, Winhusen TJ, Wu LT, Moran LM, Tai B. Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus. Addict Sci Clin Pract 2024; 19:14. [PMID: 38419116 PMCID: PMC10902994 DOI: 10.1186/s13722-024-00446-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/13/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The prevalence and associated overdose death rates from opioid use disorder (OUD) have dramatically increased in the last decade. Despite more available treatments than 20 years ago, treatment access and high discontinuation rates are challenges, as are personalized medication dosing and making timely treatment changes when treatments fail. In other fields such as depression, brief measures to address these tasks combined with an action plan-so-called measurement-based care (MBC)-have been associated with better outcomes. This workgroup aimed to determine whether brief measures can be identified for using MBC for optimizing dosing or informing treatment decisions in OUD. METHODS The National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN) in 2022 convened a small workgroup to develop consensus about clinically usable measures to improve the quality of treatment delivery with MBC methods for OUD. Two clinical tasks were addressed: (1) to identify the optimal dose of medications for OUD for each patient and (2) to estimate the effectiveness of a treatment for a particular patient once implemented, in a more granular fashion than the binary categories of early or sustained remission or no remission found in The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). DISCUSSION Five parameters were recommended to personalize medication dose adjustment: withdrawal symptoms, opioid use, magnitude (severity and duration) of the subjective effects when opioids are used, craving, and side effects. A brief rating of each OUD-specific parameter to adjust dosing and a global assessment or verbal question for side-effects was viewed as sufficient. Whether these ratings produce better outcomes (e.g., treatment engagement and retention) in practice deserves study. There was consensus that core signs and symptoms of OUD based on some of the 5 DSM-5 domains (e.g., craving, withdrawal) should be the basis for assessing treatment outcome. No existing brief measure was found to meet all the consensus recommendations. Next steps would be to select, adapt or develop de novo items/brief scales to inform clinical decision-making about dose and treatment effectiveness. Psychometric testing, assessment of acceptability and whether the use of such scales produces better symptom control, quality of life (QoL), daily function or better prognosis as compared to treatment as usual deserves investigation.
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Affiliation(s)
- A John Rush
- Duke-NUS Medical School, The National University of Singapore, Duke University School of Medicine, Singapore, Singapore
| | | | - Gavin Bart
- School of Medicine & Division of Medicine at Hennepin Healthcare, University of Minnesota, Minneapolis, MN, USA
| | | | - Cynthia I Campbell
- Kaiser Permanente Northern California Division of Research, Oakland, CA, USA
| | - James McKay
- Penn Center on the Continuum of Care in the Addictions, Philadelphia VA Center of Excellence in Substance Addiction Treatment and Education, University of Pennsylvania, Philadelphia, PA, USA
| | - David W Oslin
- University of Psychiatry, VISN 4 Mental Illness, Research, Education and Clinical Center Crescenz VA Medical Center, Stephen A. Cohen Military Family Clinic at the Perelman School of Medicine, Philadelphia, PA, USA
| | - Andrew J Saxon
- University of Washington and Center of Excellence in Substance Addiction Treatment and Education at the VA Puget Sound Health Care System, Seattle, WA, USA
| | - T John Winhusen
- Addiction Sciences, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Li-Tzy Wu
- Duke University School of Medicine, Durham, NC, USA
| | - Landhing M Moran
- Center for Clinical Trials Network, National Institute on Drug Abuse, Bethesda, MD, USA
| | - Betty Tai
- Center for Clinical Trials Network, National Institute on Drug Abuse, National Institutes of Health, 11601 Landsdown Street (3WF), Bethesda, MD, 20892, USA.
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Morin KA, Tatangelo M, Marsh D. Canadian Addiction Treatment Centre (CATC) opioid agonist treatment cohort in Ontario, Canada. BMJ Open 2024; 14:e080790. [PMID: 38401902 PMCID: PMC10895228 DOI: 10.1136/bmjopen-2023-080790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/14/2024] [Indexed: 02/26/2024] Open
Abstract
PURPOSE The Canadian Addiction Treatment Centre (CATC) cohort was established during a period of increased provision of opioid agonist treatment (OAT), to study patient outcomes and trends related to the treatment of opioid use disorder (OUD) in Canada. The CATC cohort's strengths lie in its unique physician network, shared care model and event-level data, making it valuable for validation and integration studies. The CATC cohort is a valuable resource for examining OAT outcomes, providing insights into substance use trends and the impact of service-level factors. PARTICIPANTS The CATC cohort comprises 32 246 people who received OAT prescriptions between April 2014 and February 2021, with ongoing tri-annual updates planned until 2027. The cohort includes data from all CATC clinics' electronic medical records and includes demographic information and OAT clinical indicators. FINDINGS TO DATE This cohort profile describes the demographic and clinical characteristics of patients being treated in a large OAT physician network. As well, we report the longitudinal OAT retention by treatment type during a time of increasing exposure to a contaminated dangerous drug supply. Notable findings also include retention differences between methadone (32% of patients at 1 year) and buprenorphine (20% at 1 year). Previously published research from this cohort indicated that patient-level factors associated with retention include geographic location, concurrent substance use and prior treatment attempts. Service-level factors such as telemedicine delivery and frequency of urine drug screenings also influence retention. Additionally, the cohort identified rising OAT participation and a substantial increase in fentanyl use during the COVID-19 pandemic. FUTURE PLANS Future research objectives are the longitudinal evaluation of retention and flexible modelling techniques that account for the changes as patients are treated with OAT. Furthermore, future research aims are the use of conditional models, and linkage with provincial-level administrative datasets.
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Affiliation(s)
- Kristen A Morin
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
| | - Mark Tatangelo
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
| | - David Marsh
- Northern Ontario School of Medicine University, Sudbury, Ontario, Canada
- Health Sciences North, Sudbury, Ontario, Canada
- ICES North, Sudbury, Ontario, Canada
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Michener PS, Knee A, Wilson D, Boama-Nyarko E, Friedmann PD. Association of random and observed urine drug screening with long-term retention in opioid treatment programs. Drug Alcohol Depend 2024; 255:111067. [PMID: 38183832 PMCID: PMC10956422 DOI: 10.1016/j.drugalcdep.2023.111067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.
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Affiliation(s)
- Pryce S Michener
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA.
| | - Alexander Knee
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Donna Wilson
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA; Epidemiology/Biostatistics Research Core - Baystate Medical Center, Office of Research, 3601 Main Street, Third Floor, Springfield, MA 01199, USA
| | - Esther Boama-Nyarko
- Clinical and Population Health Research Program, Graduate School of Biomedical Sciences University of Massachusetts Chan Medical School, 55 N Lake Ave, Worcester, MA 01655, USA
| | - Peter D Friedmann
- Dept. of Medicine, UMass Chan Medical School - Baystate, 759 Chestnut St, Springfield, MA 01199, USA
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Panlilio LV, Burgess-Hull AJ, Feldman JD, Rogers JM, Tyburski M, Smith KE, Epstein DH. Activity space during treatment with medication for opioid use disorder: Relationships with personality, mood, and drug use. J Subst Use Addict Treat 2024; 157:209219. [PMID: 37981240 PMCID: PMC10922786 DOI: 10.1016/j.josat.2023.209219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 09/15/2023] [Accepted: 11/13/2023] [Indexed: 11/21/2023]
Abstract
INTRODUCTION Activity space in people with substance use disorders (SUDs) has been assessed for theoretical reasons and for detection/prevention of relapse. In this observational study, we relate passively obtained activity space measures to mental states and behaviors relevant to the success of treatment for opioid use disorder. Our long-term goal is to use such data to assess risk in real time and to recognize when SUD patients might benefit from a just-in-time intervention. METHODS We used GPS data from 238 urban residents in the first 16 weeks of stabilization on medication for opioid use disorder to test preregistered hypotheses about activity space (distance traveled, number of locations, time spent moving, and psychosocial-hazard levels of neighborhoods where participants spent time) in relation to certain static variables (personality, mood propensities) and time-varying treatment-relevant behaviors such as craving and use of opioids and cocaine. RESULTS The most consistent findings were that 1) mobility decreased over the course of the study; 2) neuroticism was associated with overall lower mobility; 3) trait-like positive mood (averaged from momentary ratings) was associated with higher mobility; 4) participants who used cocaine more frequently had lower mobility; 5) early in treatment, participants spent less time moving (i.e., were more sedentary) on days when they were craving. Some of these findings were in the expected direction (i.e., the ones involving neuroticism and positive mood), and some were opposite to the expected direction (i.e., we expected cocaine use to be associated with higher mobility); others (e.g., changes in mobility over time or in relation to craving) involved nondirectional hypotheses. CONCLUSIONS Real-time information that patients actively provide is valuable for assessing their current state, but providing this information can be burdensome. The current results indicate that certain static or passively obtained data (personality variables and GPS-derived mobility information) are relevant to time-varying, treatment-relevant mental states and drug-related behavior, and therefore might be useful when incorporated into algorithms for detecting need for intervention in real time. Further research should assess how population-specific these relationships are, and how these passive measures can best be combined with low temporal-density, actively-provided data to obtain valid, reliable assessments with minimal burden.
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Affiliation(s)
- Leigh V Panlilio
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA.
| | - Albert J Burgess-Hull
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA.
| | - Jeffrey D Feldman
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA.
| | - Jeffrey M Rogers
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA; SDSU/UCSD Joint Doctoral Program (in Clinical Psychology), 6363 Alvarado Ct, San Diego, CA 92120, USA.
| | - Matthew Tyburski
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA
| | - Kirsten E Smith
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA.
| | - David H Epstein
- Real-world Assessment, Prediction, and Treatment (RAPT) Unit, National Institute on Drug Abuse Intramural Research Program (NIDA IRP), 251 Bayview Blvd, Baltimore, MD 21224, USA.
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López-Castro T, Jakubowski A, Masyukova M, Peterson M, Pierz A, Kodali S, Arnsten JH, Starrels JL, Nahvi S. Loss, liberation, and agency: Patient experiences of methadone treatment at opioid treatment programs during the COVID-19 pandemic. J Subst Use Addict Treat 2024; 157:209235. [PMID: 38061636 PMCID: PMC10932891 DOI: 10.1016/j.josat.2023.209235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 08/14/2023] [Accepted: 11/20/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND Despite its safety and effectiveness, methadone treatment for opioid use disorder (OUD) remains highly stigmatized, and stringent opioid treatment program (OTP) attendance requirements create barriers to retention for many patients. The COVID-19 pandemic prompted a shift in federal regulations governing methadone, including a blanket exemption permitting increased take-home doses of methadone. We studied the impact of these changes upon established patients' experiences of OTP care. METHOD We conducted semi-structured qualitative interviews with 18 OTP patients who met our criteria of having established OTP care (i.e., enrolled at the OTP for at least 12 weeks) and were administered methadone three to six days weekly prior to the March 2020 blanket exemption. Interviews centered on how COVID-19 had affected their experiences of receiving treatment at an OTP. RESULTS We identified three interconnected themes relevant to transformation of OTP care by the COVID-19 pandemic. Participants described mourning therapeutic OTP relationships and structure (1. loss), yet feeling more satisfaction with fewer in-person OTP visits (2. liberation), and appreciating more opportunities to self-direct their OUD care (3. agency). DISCUSSION Structural changes made to OTP care early in the COVID-19 pandemic resulted in loss of community and structure. Increasing the availability of take-home methadone also improved patient experience and sense of agency. Our findings join a diverse body of converging evidence in support of policy changes allowing for more flexible dosing and individualized OTP care.
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Affiliation(s)
- Teresa López-Castro
- Department of Psychology, Colin Powell School of Civic and Global Leadership, The City College of New York, 160 Convent Avenue, New York, NY 10031, United States.
| | - Andrea Jakubowski
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Mariya Masyukova
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; Project Renwal, Inc. 200 Varick Street, 9th Floor New York, NY 10014
| | - Meghan Peterson
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; Department of Social Medicine, University of North Carolina - Chapel Hill School of Medicine, 321 S Columbia St, Chapel Hill, NC 27599, United States
| | - Amanda Pierz
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States; The City University of New York Graduate School of Public Health and Health Policy, 55 W. 125(th) Street, New York, NY 10027, United States
| | - Sruthi Kodali
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Julia H Arnsten
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Joanna L Starrels
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
| | - Shadi Nahvi
- Department of Medicine, Albert Einstein College of Medicine, Montefiore Health System, 111 East 210th Street, Bronx, NY 10467, United States
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Burruss-Cousins K, Mitchell SG, Gryczynski J, Whitter M, Fuller D, Ibrahim A, Schwartz RP. Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment. J Subst Use Addict Treat 2024; 157:209265. [PMID: 38103832 PMCID: PMC10922701 DOI: 10.1016/j.josat.2023.209265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 10/23/2023] [Accepted: 12/11/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION People seeking treatment at opioid treatment programs (OTPs) can face admission delays. Interim methadone (IM) treatment, an effective approach to expedite admissions when programs lack sufficient counseling staff, has been seldom implemented. A study of implementation facilitation to spur the use of IM was conducted among six OTPs and their state opioid treatment authorities (SOTAs) in four US states. Between study recruitment and launch, organizational changes at three OTPs eliminated their need for IM. Two OTPs' requests to their states to provide IM (one prior to study launch and one following launch) were deferred by the states due to internal issues that required resolution to comply with federal IM regulations. During the study, another OTP's delays resolved, and one OTP streamlined its admissions procedures. METHODS Virtual interviews were conducted with 16 OTP staff and SOTAs from six OTPs in four US states following their participation in the parent study. Interviews focused on the feasibility and acceptability of the implementation intervention for IM. We analyzed data using a constant comparative approach. RESULTS Two overarching themes emerged from the qualitative data with respect to the role that organizational culture plays in OTP staff views of efforts to implement interim methadone: (1) the contrasting views of interim methadone based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM. CONCLUSIONS Organizational treatment philosophy and program culture emerged as important factors determining the OTPs' staff's willingness to adopt new approaches to expedite admissions. Participants noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM, in part based on when they entered the drug treatment field. While understanding and addressing treatment philosophy and organizational culture and willingness to change is of importance when implementing new approaches in OTPs, leadership at the state and OTP level are powerful drivers of change.
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Affiliation(s)
| | | | - Jan Gryczynski
- Friends Research Institute, Inc., Baltimore, MD, United States of America
| | - Melanie Whitter
- National Association of State Alcohol and Drug Abuse Directors, Inc., Washington, DC, United States of America
| | - Douglas Fuller
- National Association of State Alcohol and Drug Abuse Directors, Inc., Washington, DC, United States of America
| | - Adila Ibrahim
- Friends Research Institute, Inc., Baltimore, MD, United States of America
| | - Robert P Schwartz
- Friends Research Institute, Inc., Baltimore, MD, United States of America
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Borelli CM, Gao HT. Implementation of an education session on buprenorphine induction in the emergency department, a resident-led initiative. Harm Reduct J 2024; 21:22. [PMID: 38282077 PMCID: PMC10822147 DOI: 10.1186/s12954-023-00917-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 12/11/2023] [Indexed: 01/30/2024] Open
Abstract
INTRODUCTION Many physicians including emergency medicine physicians report insufficient training and education on prescribing buprenorphine for opioid use disorder. As emergency departments implement buprenorphine induction protocols, educational sessions can provide physicians with further familiarity with the treatment of opioid use disorder. This quality improvement project aimed to address the barrier of physician education in the implementation of buprenorphine initiation in the emergency department and presents a model for resident-led education sessions of emergency medicine physicians. METHODS The project was a resident-led educational quality improvement project on educating members of the Department of Emergency Medicine on buprenorphine induction. The thirty-minute educational session included a pre-test survey, lecture, practice case workshop, questions, post-test survey, and a discussion. The survey questions were designed for physicians including residents and faculty, but medical students were invited to complete the session. RESULTS Physicians including faculty and resident physicians responded positively to the educational survey, with an increase from 42.5 to 100% responding that they understood the risks and benefits of prescribing buprenorphine in the emergency department pre and post-survey respectively. Based on post-survey results, 88.5% of physicians responded that they planned to prescribe buprenorphine in the emergency department for patients meeting clinical criteria after completing the educational session. CONCLUSION The results suggest that a resident-led training session can encourage peer involvement in buprenorphine induction to treat opioid use disorder in the emergency department.
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Costa GPA, Nunes JC, Heringer DL, Anand A, De Aquino JP. The impact of cannabis on non-medical opioid use among individuals receiving pharmacotherapies for opioid use disorder: a systematic review and meta-analysis of longitudinal studies. Am J Drug Alcohol Abuse 2024; 50:12-26. [PMID: 38225727 DOI: 10.1080/00952990.2023.2287406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/20/2023] [Indexed: 01/17/2024]
Abstract
Background: The relationship between cannabis use and the risk of returning to using opioids non-medically during treatment for opioid use disorder (OUD) remains unclear.Objective: We sought to quantify the impact of cannabis use on the risk of non-medical opioid use among people receiving pharmacotherapies for OUD.Methods: A comprehensive search was performed using multiple databases from March 1 to April 5 of 2023. Eligible studies longitudinally assessed the association between cannabis use and non-medical opioid use among people with OUD receiving treatment with buprenorphine, methadone, or naltrexone. We utilized a random-effects model employing the restricted maximum likelihood method. A sensitivity analysis was conducted to understand potential differences between each OUD treatment modality.Results: A total of 10 studies were included in the final meta-analysis. There were 8,367 participants (38% female). The average follow-up time across these studies was 9.7 months (SD = 3.77), ranging from 4 to 15 months. The pharmacotherapies involved were methadone (76.3%) buprenorphine (21.3%), and naltrexone (2.4%). The pooled odds ratio did not indicate that cannabis use significantly influenced non-medical opioid use (OR: 1.00, 95% CI: 0.97-1.04, p = .98). There is evidence of moderate heterogeneity and publication bias.Conclusion: There was no significant association between cannabis use and non-medical opioid use among patients receiving pharmacotherapies for OUD. These findings neither confirm concerns about cannabis increasing non-medical opioid use during MOUD, nor do they endorse its efficacy in decreasing non-medical opioid use with MOUD. This indicates a need for individualized approaches for cannabis use and challenges the requirement of cannabis abstinence to maintain OUD pharmacotherapies.
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Affiliation(s)
- Gabriel P A Costa
- Faculty of Medicine, University of Ribeirão Preto, Ribeirão Preto, SP, Brazil
| | - Julio C Nunes
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - Daniel L Heringer
- Faculty of Medicine, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Akhil Anand
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, OH, USA
- Department of Psychiatry, University Hospitals Medical Center, Cleveland, OH, USA
| | - Joao P De Aquino
- Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
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Arnouk S, Wunderlich JR, Sidelnik SA. Evaluation of Low-dose Buprenorphine Initiation With Buprenorphine Buccal Films in Hospitalized Patients: A Retrospective Cohort Study. J Addict Med 2024; 18:42-47. [PMID: 37847570 DOI: 10.1097/adm.0000000000001236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Low-dose buprenorphine initiation (LDBI) strategies to transition patients from full opioid agonists to buprenorphine have previously been described using sublingual films, intravenous solution, transdermal patches, and, more recently, buccal films. The objective of this study was to describe the effectiveness of LDBI using novel titration schedules with buccal films. METHODS This is a retrospective cohort study of hospitalized patients with opioid use disorder (OUD) or physiologic dependence to opioids who underwent LDBI with buprenorphine buccal films at NYU Langone Health. Two LDBI protocols were evaluated, including a short titration schedule over 4 days and a long schedule over 7 days. The primary outcomes of interest included LDBI completion rates and incidence of opioid withdrawal. RESULTS Forty-two patients underwent 46 LDBIs at NYU Langone Health between October 2020 and April 2022. The cohort comprised patients with OUD (57%), chronic pain with OUD (33%), and chronic pain without OUD (10%). Indications for LDBI most commonly included co-occurring pain precluding discontinuation of full opioid agonists (72%), prior history of precipitated withdrawal (30%), and methadone use (23%). The overall completion rate of LDBI was 78%. Withdrawal was encountered in 33% of patients; however, only 2 patients required LDBI discontinuation as a result. On multivariate analysis, a diagnosis of OUD was independently associated with withdrawal during LDBI. CONCLUSIONS Buprenorphine buccal films can successfully be used off-label to facilitate LDBI in the hospital setting. We present 4- and 7-day titration protocols, which were well-tolerated, and provide practical considerations for use.
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Affiliation(s)
- Serena Arnouk
- From the Department of Pharmacy, NYU Langone Health, New York, NY (SA); Department of Psychiatry, University of Iowa Hospitals & Clinics, Iowa City, IA (JRW); Department of Psychiatry, NYU Langone Health, New York, NY (SAS)
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Skogrand E, Sharpe J, Englander H. Dispensing Methadone at Hospital Discharge: One Hospital's Approach to Implementing the "72-hour Rule" Change. J Addict Med 2024; 18:71-74. [PMID: 37994453 PMCID: PMC10873107 DOI: 10.1097/adm.0000000000001246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
OBJECTIVES Methadone for opioid use disorder treatment in ambulatory settings is restricted to federally licensed opioid treatment programs (OTPs) in the United States. However, these restrictions do not apply during hospitalization. A recent change to the rule governing methadone in non-OTP settings created an opportunity to dispense methadone at hospital discharge for up to 72 hours. METHODS Here, we describe one hospital's approach to dispensing methadone at discharge in alignment with the "72-hour rule," including implementation challenges and considerations for other hospitals planning on adopting this practice. Implementation included creating a workflow and detailed documents outlining dispensing procedure, educating interprofessional staff, and coordinating with local OTPs. RESULTS Our experiences highlight the importance of pharmacy champions to support implementation and interdisciplinary staff education, the need to consider electronic health record capabilities, and the importance of having policies and practices that support appropriate interpretation of the "72-hour rule" renewal timeline. CONCLUSIONS Exceptions to federal regulations allow greater flexibility in discharge planning for patients with opioid use disorder; however, dispensation workflow falls outside standard hospital care and may be challenging to implement.
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Affiliation(s)
- Emily Skogrand
- Department of Pharmacy, Oregon Health & Science University, Portland Oregon
| | - Jackie Sharpe
- Department of Pharmacy, Oregon Health & Science University, Portland Oregon
| | - Honora Englander
- Section of Addiction Medicine, Department of Medicine, Oregon Health & Science University, Portland Oregon
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Schwarz T, Anzenberger J, Busch M, Gmel G, Kraus L, Krausz M, Labhart F, Meyer M, Schaub MP, Westenberg JN, Uhl A. Opioid agonist treatment in transition: A cross-country comparison between Austria, Germany and Switzerland. Drug Alcohol Depend 2024; 254:111036. [PMID: 38091902 DOI: 10.1016/j.drugalcdep.2023.111036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/14/2023] [Accepted: 11/16/2023] [Indexed: 01/08/2024]
Abstract
BACKGROUND AND AIMS OAT is a well developed and successful treatment strategy for opioid dependent patients in Europe. It has significantly contributed to the fight against the HIV and HCV pandemics, leading to an increased life expectancy in this population. Building on the OAT experiences in Austria, Germany, and Switzerland and their models of care, the objective of this study is to analyse experiences and changes in patient structures to identify necessary adaptations for the system of care. METHODS We analysed national register-based data from patients receiving OAT during the period spanning from 2010 to 2020 in Austria, Germany (cases), and Switzerland. We examined and compared OAT policies and practice at national levels through a review of literature and publicly available policy documents. RESULTS Across these three countries, the life expectancy of OAT patients increased substantially. The mean age increased from 33.0 in 2010 to 39.1 in 2020 in Austria, from 35.6 years to 41.5 years in Germany (cases), and from 39.6 to 47.1 in Switzerland, respectively. In all three countries, the percentage of patients/cases aged 60 years and older increased more than tenfold between 2010 and 2020. CONCLUSIONS Integrated support models, reliable care structures, internationally comparable high treatment coverage, flexible prescribing practices, and a wide range of available OAT medications are successful strategies. The experiences in these countries indicate that it is possible to address the complex and chronic nature of opioid dependence and its concurrent mental and physical health challenges, resulting in an increasing life expectancy of OAT patients.
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Affiliation(s)
- Tanja Schwarz
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Doctoral Programme Meduni Vienna, Medical University of Vienna, Spitalgasse 23, Vienna 1090, Austria.
| | - Judith Anzenberger
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Martin Busch
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria
| | - Gerhard Gmel
- Addiction Switzerland, Lausanne, Switzerland; Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ludwig Kraus
- IFT Institut für Therapieforschung, Mental Health and Addiction Research, Munich, Germany; Department of Public Health Sciences, Centre for Social Research on Alcohol and Drugs, Stockholm University, Stockholm, Sweden; Institute of Psychology, ELTE Eötvös Loránd University, Budapest, Hungary; Centre of Interdisciplinary Addiction Research (ZIS), Department of Psychiatry and Psychotherapy University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Krausz
- University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Florian Labhart
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Maximilian Meyer
- Psychiatric University Clinic Basel, University of Basel, Basel, Switzerland
| | - Michael P Schaub
- Swiss Research Institute for Public Health and Addiction, Zurich, Switzerland
| | - Jean N Westenberg
- Addiction Switzerland, Lausanne, Switzerland; University of British Columbia, Faculty of Medicine, Department of Psychiatry, Vancouver, BC, Canada
| | - Alfred Uhl
- Gesundheit Österreich GmbH, Austrian National Public Health Institute, Vienna, Austria; Sigmund Freud University Vienna, Vienna, Austria
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Junn S, Tugarinov N, Mark K. Low-dose Induction of Buprenorphine in Pregnancy: A Case Series. J Addict Med 2024; 18:62-64. [PMID: 37862120 DOI: 10.1097/adm.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
BACKGROUND Because of a risk of precipitated withdrawal occurring from buprenorphine induction in people who use fentanyl, low-dose inductions are becoming increasingly common. However, little evidence exists on the use of this method in pregnant people. METHODS We conducted a case series of all pregnant people treated for opioid use disorder with low-dose buprenorphine induction at the University of Maryland Medical Center between January 1, 2021, and August 22, 2022. Primary outcome was completion of induction regimen. Secondary outcomes were self-report of withdrawal, continuation of buprenorphine until delivery, and return to or continuation of illicit opioid use. RESULTS Six pregnant people were prescribed a total of 10 buprenorphine inductions. Five of the 6 pregnant people (83.3%) completed at least 1 induction, none of whom experienced precipitated withdrawal. Two of 6 (33.3%) continued buprenorphine until the time of delivery, and 1 of 6 (16.7%) abstained from illicit opioid use. CONCLUSIONS The low-dose buprenorphine induction regimen described was successful in 5 of 6 pregnant individuals. Further research, particularly regarding continuation rates, is needed.
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Affiliation(s)
- Sue Junn
- From the University of Maryland School of Medicine, College Park, MD
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Gonçalves SF, Izquierdo AM, Bates RA, Acharya A, Matto H, Sikdar S. Negative Urgency Linked to Craving and Substance Use Among Adults on Buprenorphine or Methadone. J Behav Health Serv Res 2024; 51:114-122. [PMID: 37414999 PMCID: PMC11002981 DOI: 10.1007/s11414-023-09845-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/08/2023]
Abstract
Despite the effectiveness of medication-assisted treatment (MAT), adults receiving MAT experience opioid cravings and engage in non-opioid illicit substance use that increases the risk of relapse and overdose. The current study examines whether negative urgency, defined as the tendency to act impulsively in response to intense negative emotion, is a risk factor for opioid cravings and non-opioid illicit substance use. Fifty-eight adults (predominately White cis-gender females) receiving MAT (with buprenorphine or methadone) were recruited from online substance use forums and asked to complete self-report questionnaires on negative urgency (UPPS-P Impulsive Behavior Scale), past 3-month opioid cravings (ASSIST-Alcohol, Smoking, and Substance Involvement Screening Test), and non-opioid illicit substance use (e.g., amphetamines, cocaine, benzodiazepines). Results revealed that negative urgency was associated with past 3-month opioid cravings, as well as past month illicit stimulant use (not benzodiazepine use). These results may indicate that individuals high in negative urgency would benefit from receiving extra intervention during MAT.
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Affiliation(s)
| | - Alyssa M Izquierdo
- Department of Psychology, George Mason University, Fairfax, VA, 22030, USA
| | - Rebecca A Bates
- Department of Psychology, George Mason University, Fairfax, VA, 22030, USA
| | - Angeela Acharya
- Department of Psychology, George Mason University, Fairfax, VA, 22030, USA
| | - Holly Matto
- Department of Psychology, George Mason University, Fairfax, VA, 22030, USA
| | - Siddhartha Sikdar
- Department of Psychology, George Mason University, Fairfax, VA, 22030, USA
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Green HD, Kaminski PC. Network Analysis of Medical Claims Data Suggests Network-Based, Regional Targeting and Intervention Delivery Strategies to Increase Access to Office Based Opioid Treatment (OBOT) for Opioid Use Disorder (OUD). Inquiry 2024; 61:469580241238422. [PMID: 38528788 DOI: 10.1177/00469580241238422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/27/2024]
Abstract
Opioid overdose and Opioid Use Disorder (OUD) statistics underscore an urgent need to significantly expand access to evidence-based OUD treatment. Office Based Opioid Treatment (OBOT) has proven effective for treating OUD. However, limited access to these treatments persists. Recognizing the need for significant investment in clinical, behavioral, and translational research, the Indiana State Department of Health and Indiana University embarked on a research initiative supported by the "Responding to the Addictions Crisis" Grand Challenge Program. This brief presents recommendations based on existing research and our own analyses of medical claims data in Indiana, where opioid misuse is high and treatment access is limited. The recommendations cover target providers, intervention focus, priority regions, and delivery methods.
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Friedmann Z, Binder A, Kinkel HT, Kühner C, Zsolnai A, Mick I. Exploring Patients' Perceptions on Injectable Opioid Agonist Treatment: Influences on Treatment Initiation and Implications for Practice. Eur Addict Res 2023; 30:32-42. [PMID: 38104539 PMCID: PMC10836922 DOI: 10.1159/000535416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/19/2023] [Indexed: 12/19/2023]
Abstract
INTRODUCTION Injectable opioid agonist treatment (iOAT) with diacetylmorphine is an effective option for individuals previously considered non-responsive to opioid substitution treatment. Despite implementation in Canada and several European countries, relatively few eligible people choose to initiate iOAT. To better understand what encourages or deters prospective patients from initiating iOAT, the current study explores patients' perceptions on iOAT and how these influence therapy initiation in practice. METHODS We conducted 34 semi-structured interviews with individuals currently in or eligible for iOAT in two German outpatient iOAT clinics. Transcripts were analysed following qualitative content analysis, with development of inductive categories and use of consensual coding. For member checking, we consulted individuals with lived experiences prior to data collection and publication. RESULTS Participants based their choice to initiate iOAT on the perceived implications of the treatment on one's daily life and individual recovery. Participants were encouraged to initiate iOAT due to the therapy's perceived potential in reducing cravings and substance use, its positive health consequences, and due to the image of iOAT as a path towards abstinence. Regarding deterring perceptions, participants feared a profound impairment of daily life due to factors such as the daily visits to the clinic, were concerned about whether iOAT would sufficiently promote or even impede one's recovery, and described negative health effects. CONCLUSION Perceptions found in this study profoundly influenced participants' decisions on iOAT enrolment and contextualize the previous literature. The study reveals the dynamic coexistence of different perceptions about iOAT and sheds light on the inner-group stigmatization of iOAT. Practitioners and future research should acknowledge the complexities found in the current study in order to exploit the full potential of effective treatment modalities such as iOAT.
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Affiliation(s)
- Zoe Friedmann
- Department of Psychiatry and Psychotherapy, Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Binder
- Universitätsklinikum Tuebingen, Sektion Suchtmedizin und Suchtforschung (Addiction Medicine and Addiction Research Department, Medical University Hospital Tuebingen, University of Tuebingen), Tuebingen, Germany
| | - Hans-Tilmann Kinkel
- Praxiskombinat Neubau, Schwerpunktpraxis für Suchtmedizin (Outpatient Clinic for Addiction Medicine), Berlin, Germany
| | - Claudia Kühner
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Stuttgart, Germany
| | - Andreas Zsolnai
- Schwerpunktpraxis für Suchtmedizin Stuttgart (Outpatient Clinic for Addiction Medicine), Stuttgart, Germany
| | - Inge Mick
- Department of Psychiatry and Psychotherapy, Clinic for Psychiatry and Psychotherapy, Charité Universitätsmedizin Berlin, Berlin, Germany
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Work EC, Muftu S, MacMillan KDL, Gray JR, Bell N, Terplan M, Jones HE, Reddy J, Wilens TE, Greenfield SF, Bernstein J, Schiff DM. Prescribed and Penalized: The Detrimental Impact of Mandated Reporting for Prenatal Utilization of Medication for Opioid Use Disorder. Matern Child Health J 2023; 27:104-112. [PMID: 37253899 PMCID: PMC10229393 DOI: 10.1007/s10995-023-03672-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2023] [Indexed: 06/01/2023]
Abstract
OBJECTIVES Some states, including Massachusetts, require automatic filing of child abuse and neglect for substance-exposed newborns, including infants exposed in-utero to clinician-prescribed medications to treat opioid use disorder (MOUD). The aim of this article is to explore effects of these mandated reporting policies on pregnant and postpartum people receiving MOUD. METHODS We used modified grounded research theory, literature findings, and constant comparative methods to extract, analyze and contextualize perinatal experiences with child protection systems (CPS) and explore the impact of the Massachusetts mandated reporting policy on healthcare experiences and OUD treatment decisions. We drew from 26 semi-structured interviews originally conducted within a parent study of perinatal MOUD use in pregnancy and the postpartum period. RESULTS Three themes unique to CPS reporting policies and involvement emerged. First, mothers who received MOUD during pregnancy identified mandated reporting for prenatally prescribed medication utilization as unjust and stigmatizing. Second, the stress caused by an impending CPS filing at delivery and the realities of CPS surveillance and involvement after filing were both perceived as harmful to family health and wellbeing. Finally, pregnant and postpartum individuals with OUD felt pressure to make medical decisions in a complex environment in which medical recommendations and the requirements of CPS agencies often compete. CONCLUSIONS FOR PRACTICE Uncoupling of OUD treatment decisions in the perinatal period from mandated CPS reporting at time of delivery is essential. The primary focus for families affected by OUD must shift from surveillance and stigma to evidence-based treatment and access to supportive services and resources.
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Affiliation(s)
- Erin C Work
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St Suite 860, Boston, MA, 02114, USA.
- Department of Community Health Sciences, UCLA Fielding School of Public Health, 650 Charles E. Young Dr. S., Los Angeles, CA, 90095, USA.
- Department of Social Welfare, UCLA Luskin School of Public Affairs, 337 Charles E. Young Dr. E., Los Angeles, CA, 90095, USA.
| | - Serra Muftu
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St Suite 860, Boston, MA, 02114, USA
| | - Kathryn Dee L MacMillan
- Division of Newborn Medicine, Brigham and Women's Hospital, Boston, MA, 02114, USA
- Division of Pediatric Hospital Medicine, MassGeneral Hospital for Children, 55 Fruit St, Boston, MA, 02114, USA
| | - Jessica R Gray
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, 02114, USA
- Division of Pediatrics, MassGeneral for Children, Boston, USA
| | - Nicole Bell
- Living in Freedom Together-LIFT Inc, Worcester, MA, USA
| | - Mishka Terplan
- Friends Research Institute, 1040 Park Ave, Suite 103, Baltimore, MD, 21202, USA
| | - Hendree E Jones
- UNC Horizons and Department of Obstetrics and Gynecology, University of North Carolina Chapel Hill, 410 North Greensboro St., Carrboro, NC, USA
| | - Julia Reddy
- Gillings School of Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC, USA
| | - Timothy E Wilens
- Division of Child and Adolescent Psychiatry, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Shelly F Greenfield
- Division of Women's Mental Health and Division of Alcohol, Drugs, and Addiction, McLean Hospital, 115 Mill St, Belmont, MA, 02478, USA
- Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA
| | - Judith Bernstein
- Department of Community Health Sciences, Boston University School of Public Health, Boston, MA, USA
| | - Davida M Schiff
- Division of General Academic Pediatrics, MassGeneral for Children, 125 Nashua St Suite 860, Boston, MA, 02114, USA
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Hall NY, Le L, Abimanyi-Ochom J, Mihalopoulos C. Measuring the importance of different barriers to opioid agonist treatment using best-worst scaling in an Australian setting. Health Policy 2023; 138:104939. [PMID: 37949002 DOI: 10.1016/j.healthpol.2023.104939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023]
Abstract
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.
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Affiliation(s)
| | - Long Le
- Public Health and Preventative Medicine, Monash University, Australia
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Brown AR, Walters JE, Harmer B, Cates L, Jones AE. Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences. J Subst Use Addict Treat 2023; 155:209153. [PMID: 37673286 DOI: 10.1016/j.josat.2023.209153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/31/2023] [Accepted: 08/28/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION The United States has experienced substantial increases in opioid use for more than two decades. This growth has impacted rural areas where overdoses have risen drastically during this time period and more often involve prescription opioids than in urban areas. Medications for opioid use disorders (MOUDs) are highly underutilized in rural settings due to lack of access, inadequate prescribing, and stigma. METHODS The study collected data using a cross-sectional online survey of nonprescribing clinicians (NPCs) involved in the treatment of substance use disorders (SUDs) in the United States. The study used multiple recruitment methods to obtain a purposive sample of NPCs from a variety of geographical contexts across the nation. The survey assessed demographic and practice characteristics including rurality of practice location, exposure and training related to MOUDs, treatment orientation, treatment preferences for opioid use disorder (OUD), and attitudes toward MOUDs. The study compared treatment preferences for OUD and attitudes toward MOUDs based on rurality of practice location. We tested a mediation model to determine whether the relationship between rurality of practice setting and attitudes toward MOUDs is mediated by treatment orientation. RESULTS Most of the 636 NPCs surveyed favored a combination of MOUDs and psychosocial treatment. Compared to clinicians practicing in suburban or urban areas, self-identified rural clinicians were more likely to favor MOUDs alone as most effective and less likely to endorse a combination of MOUDs and psychosocial treatment. Although most NPCs were supportive of MOUDs overall, many endorsed misconceptions related to MOUDs. Rural clinicians were less likely to perceive MOUDs as effective or acceptable compared to those in urban settings. Results of a mediation analysis indicated that practicing in a rural location compared to in an urban location directly and indirectly influenced attitudes toward MOUDs through an effect on treatment orientation. CONCLUSIONS NPCs play important roles in the implementation of MOUDs, and while efforts to increase their knowledge of and exposure to MOUDs have contributed broadly to more favorable attitudes toward MOUDs among NPCs, this study's findings indicate that additional efforts are still needed, particularly among NPCs who work in rural settings. Findings also indicate that, among rural clinicians, increasing knowledge of and exposure to harm reduction principles may be a necessary prerequisite to engaging them in the implementation of specific harm reduction strategies such as MOUDs.
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Affiliation(s)
- Aaron R Brown
- University of Kentucky, College of Social Work, 619 Patterson Office Tower, Lexington, KY 40506-0027, USA.
| | - Jayme E Walters
- Utah State University, Department of Social Work, 0730 Old Main Hill, Logan, UT 84322-0730, USA
| | - Beth Harmer
- Western Carolina University, Department of Social Work, 3971 Little Savannah Rd, Cullowhee, NC 28723, USA
| | - Lara Cates
- Western Carolina University, Department of Social Work, 3971 Little Savannah Rd, Cullowhee, NC 28723, USA
| | - Aubrey E Jones
- University of Kentucky, College of Social Work, 619 Patterson Office Tower, Lexington, KY 40506-0027, USA
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Wartko PD, Bobb JF, Boudreau DM, Matthews AG, McCormack J, Lee AK, Qiu H, Yu O, Hyun N, Idu AE, Campbell CI, Saxon AJ, Liu DS, Altschuler A, Samet JH, Labelle CT, Zare-Mehrjerdi M, Stotts AL, Braciszewski JM, Murphy MT, Dryden D, Arnsten JH, Cunningham CO, Horigian VE, Szapocznik J, Glass JE, Caldeiro RM, Phillips RC, Shea M, Bart G, Schwartz RP, McNeely J, Liebschutz JM, Tsui JI, Merrill JO, Lapham GT, Addis M, Bradley KA, Ghiroli MM, Hamilton LK, Hu Y, LaHue JS, Loree AM, Murphy SM, Northrup TF, Shmueli-Blumberg D, Silva AJ, Weinstein ZM, Wong MT, Burganowski RP. Nurse Care Management for Opioid Use Disorder Treatment: The PROUD Cluster Randomized Clinical Trial. JAMA Intern Med 2023; 183:1343-1354. [PMID: 37902748 PMCID: PMC10616772 DOI: 10.1001/jamainternmed.2023.5701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023]
Abstract
Importance Few primary care (PC) practices treat patients with medications for opioid use disorder (OUD) despite availability of effective treatments. Objective To assess whether implementation of the Massachusetts model of nurse care management for OUD in PC increases OUD treatment with buprenorphine or extended-release injectable naltrexone and secondarily decreases acute care utilization. Design, Setting, and Participants The Primary Care Opioid Use Disorders Treatment (PROUD) trial was a mixed-methods, implementation-effectiveness cluster randomized clinical trial conducted in 6 diverse health systems across 5 US states (New York, Florida, Michigan, Texas, and Washington). Two PC clinics in each system were randomized to intervention or usual care (UC) stratified by system (5 systems were notified on February 28, 2018, and 1 system with delayed data use agreement on August 31, 2018). Data were obtained from electronic health records and insurance claims. An implementation monitoring team collected qualitative data. Primary care patients were included if they were 16 to 90 years old and visited a participating clinic from up to 3 years before a system's randomization date through 2 years after. Intervention The PROUD intervention included 3 components: (1) salary for a full-time OUD nurse care manager; (2) training and technical assistance for nurse care managers; and (3) 3 or more PC clinicians agreeing to prescribe buprenorphine. Main Outcomes and Measures The primary outcome was a clinic-level measure of patient-years of OUD treatment (buprenorphine or extended-release injectable naltrexone) per 10 000 PC patients during the 2 years postrandomization (follow-up). The secondary outcome, among patients with OUD prerandomization, was a patient-level measure of the number of days of acute care utilization during follow-up. Results During the baseline period, a total of 130 623 patients were seen in intervention clinics (mean [SD] age, 48.6 [17.7] years; 59.7% female), and 159 459 patients were seen in UC clinics (mean [SD] age, 47.2 [17.5] years; 63.0% female). Intervention clinics provided 8.2 (95% CI, 5.4-∞) more patient-years of OUD treatment per 10 000 PC patients compared with UC clinics (P = .002). Most of the benefit accrued in 2 health systems and in patients new to clinics (5.8 [95% CI, 1.3-∞] more patient-years) or newly treated for OUD postrandomization (8.3 [95% CI, 4.3-∞] more patient-years). Qualitative data indicated that keys to successful implementation included broad commitment to treat OUD in PC from system leaders and PC teams, full financial coverage for OUD treatment, and straightforward pathways for patients to access nurse care managers. Acute care utilization did not differ between intervention and UC clinics (relative rate, 1.16; 95% CI, 0.47-2.92; P = .70). Conclusions and Relevance The PROUD cluster randomized clinical trial intervention meaningfully increased PC OUD treatment, albeit unevenly across health systems; however, it did not decrease acute care utilization among patients with OUD. Trial Registration ClinicalTrials.gov Identifier: NCT03407638.
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Affiliation(s)
- Paige D Wartko
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Jennifer F Bobb
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Biostatistics, School of Public Health, University of Washington, Seattle
| | - Denise M Boudreau
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Genentech Inc, South San Francisco, California
| | | | | | - Amy K Lee
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Kaiser Permanente Washington, Renton
| | - Hongxiang Qiu
- Kaiser Permanente Washington Health Research Institute, Seattle
- Now with Department of Epidemiology and Biostatistics, Michigan State University, East Lansing
| | - Onchee Yu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Noorie Hyun
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Abisola E Idu
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Cynthia I Campbell
- Division of Research, Kaiser Permanente Northern California, Oakland
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco
| | - Andrew J Saxon
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound Health Care System, Seattle, Washington
| | - David S Liu
- National Institute on Drug Abuse Center for Clinical Trials Network, North Bethesda, Maryland
| | - Andrea Altschuler
- Division of Research, Kaiser Permanente Northern California, Oakland
| | - Jeffrey H Samet
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Colleen T Labelle
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
| | - Mohammad Zare-Mehrjerdi
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Angela L Stotts
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | - Jordan M Braciszewski
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Douglas Dryden
- MultiCare Health System, Tacoma, Washington
- Now with Mosaic Medical, Bend, Oregon
| | - Julia H Arnsten
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Chinazo O Cunningham
- Albert Einstein College of Medicine, Bronx, New York
- Now with New York State Office of Addiction Services and Supports, New York
| | - Viviana E Horigian
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - José Szapocznik
- Department of Public Health Sciences, Miller School of Medicine, University of Miami, Miami, Florida
| | - Joseph E Glass
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Ryan M Caldeiro
- Mental Health and Wellness Department, Kaiser Permanente Washington, Renton
| | | | - Mary Shea
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Gavin Bart
- Department of Medicine, Hennepin Healthcare, Minneapolis, Minnesota
- University of Minnesota Medical School, Minneapolis
| | | | - Jennifer McNeely
- Department of Population Health, Grossman School of Medicine, New York University, New York
| | - Jane M Liebschutz
- Center for Research on Health Care, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Judith I Tsui
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Joseph O Merrill
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
| | - Gwen T Lapham
- Kaiser Permanente Washington Health Research Institute, Seattle
- Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle
| | - Megan Addis
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Katharine A Bradley
- Kaiser Permanente Washington Health Research Institute, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle
- Kaiser Permanente Bernard J Tyson School of Medicine, Pasadena, California
| | - Megan M Ghiroli
- Montefiore Medical Center, Bronx, New York
- Albert Einstein College of Medicine, Bronx, New York
| | - Leah K Hamilton
- Kaiser Permanente Washington Health Research Institute, Seattle
| | - Yong Hu
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | | | - Amy M Loree
- Center for Health Policy and Health Services Research, Henry Ford Health, Detroit, Michigan
| | - Sean M Murphy
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Thomas F Northrup
- Department of Family and Community Medicine, UTHealth Houston McGovern Medical School, Houston, Texas
| | | | | | - Zoe M Weinstein
- Boston University Schools of Medicine and Public Health, Boston Medical Center, Boston, Massachusetts
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Moriates C, Boulton A, Walker B, Holliman R, Christian N, Weems J, Humphry E, Young S, Bottner R, Potter J. Hospital-based opioid treatment: Expanding and sustaining the model in Texas. J Hosp Med 2023; 18:1109-1112. [PMID: 37876117 DOI: 10.1002/jhm.13201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 08/18/2023] [Accepted: 08/22/2023] [Indexed: 10/26/2023]
Abstract
This Brief Report includes follow-up data about the sustainability and expansion of the Buprenorphine Team (B-Team), a hospital-based opioid treatment (HBOT) program. Between September 2018 and January 2023, the B-Team started 398 patients with opioid-use disorder (OUD) on buprenorphine therapy and coordinated outpatient care for 353 patients before discharge. Two-hundred and forty-nine of these patients were scheduled for follow-up at our partner addiction treatment clinic. Retention rates at our partner clinic remain relatively high: 73 patients (36% of eligible patients) continued to attend appointments between 6 and 12 months, and 40 of 180 patients (22%) who have been discharged from the hospital for at least 1 year continued to attend appointments. This model has been adopted at three additional Texas hospitals, resulting in rapid growth: 1037 patients were started on buprenorphine across these four sites during 2021-2022. Our longitudinal results support HBOT as an effective model for treating patients with OUD.
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Affiliation(s)
- Christopher Moriates
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Alanna Boulton
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Blair Walker
- Department of Psychiatry, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Rachel Holliman
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
| | - Nicholaus Christian
- VA Connecticut Healthcare System, West Haven, Connecticut, USA
- Program in Addiction Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - John Weems
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
- CommUnityCare, Austin, Texas, USA
| | | | | | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, Texas, USA
- Colorado Hospital Association, Denver, Colorado, USA
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Miller JC, Brooks MA, Wurzel KE, Cox EJ, Wurzel JF. A Guide to Expanding the Use of Buprenorphine Beyond Standard Initiations for Opioid Use Disorder. Drugs R D 2023; 23:339-362. [PMID: 37938531 PMCID: PMC10676346 DOI: 10.1007/s40268-023-00443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/18/2023] [Indexed: 11/09/2023] Open
Abstract
Buprenorphine has become an important medication in the context of the ongoing opioid epidemic. However, complex pharmacologic properties and varying government regulations create barriers to its use. This narrative review is intended to facilitate buprenorphine use-including non-traditional initiation methods-by providers ranging from primary care providers to addiction specialists. This article briefly discusses the opioid epidemic and the diagnosis and treatment of opioid use disorder (OUD). We then describe the basic and complex pharmacologic properties of buprenorphine, linking these properties to their clinical implications. We guide readers through the process of initiating buprenorphine in patients using full agonist opioids. As there is no single recommended approach for buprenorphine initiation, we discuss the details, advantages, and disadvantages of the standard, low-dose, bridging-strategy, and naloxone-facilitated initiation techniques. We consider the pharmacology of, and evidence base for, buprenorphine in the treatment of pain, in both OUD and non-OUD patients. Throughout, we address the use of buprenorphine in children and adolescent patients, and we finish with considerations related to the settings of pregnancy and breastfeeding.
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Affiliation(s)
- James C Miller
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Michael A Brooks
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Kelly E Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA
| | - Emily J Cox
- Providence Research Network, Renton, WA, USA
| | - John F Wurzel
- Psychiatry Residency Spokane, Providence Sacred Heart Medical Center and Children's Hospital, 101 W Eighth Ave, Spokane, WA, 99204, USA.
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Wang L, Volkow ND, Berger NA, Davis PB, Kaelber DC, Xu R. Cardiac and mortality outcome differences between methadone, buprenorphine and naltrexone prescriptions in patients with an opioid use disorder. J Clin Psychol 2023; 79:2869-2883. [PMID: 37584532 DOI: 10.1002/jclp.23582] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 07/01/2023] [Accepted: 08/08/2023] [Indexed: 08/17/2023]
Abstract
IMPORTANCE More than 109,000 Americans died of drug overdose in 2022, with 81,231 overdose deaths involving opioids. Methadone, buprenorphine and naltrexone are the most widely used medications for opioid use disorders (MOUD) and the most effective intervention for preventing overdose deaths. However, there is a concern that methadone results in long QT syndrome, which increases the risk for fatal cardiac arrythmias. Currently few studies have systematically evaluated both the short-term and long-term differences in cardiac and mortality outcomes between MOUD. OBJECTIVES To compare the risks of cardiac arrythmias, long QT syndrome and overall mortality between patients with opioid use disorders (OUD) who were prescribed methadone, buprenorphine or naltrexone. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study based on a multicenter and nationwide database of electronic health records (EHRs) in the United States. The study population was comprised of 144,141 patients who had medical encounters for OUD in 2016-2022, were prescribed MOUD within 1 month following a medical encounter for OUD diagnosis and had no diagnosis of cardiac arrythmias or long QT syndrome before any MOUD prescription. The study population was divided into three cohorts: (1) Methadone cohort (n = 40,938)-who were only prescribed methadone. (2) Buprenorphine cohort (n = 80,055)-who were only prescribed buprenorphine. (3) Naltrexone cohort (n = 5,738)-who were only prescribed naltrexone. EXPOSURES methadone, buprenorphine, or naltrexone. MAIN OUTCOMES AND MEASURES Cardiac arrythmias, long QT syndrome, and death. Hazard ratio (HR) and 95% confidence interval (CI) of outcomes at six different follow-up time frames (1-month, 3-month, 6-month, 1-year, 3-year, and 5-year) by comparing propensity-score matched cohorts using Kaplan-Meier survival analysis. RESULTS Patients with OUD who were prescribed methadone had significantly higher risks of cardiac arrhythmias, long QT syndrome and death compared with propensity-score matched patients with OUD who were prescribed buprenorphine or naltrexone. For the 1-month follow-up, the overall risk for cardiac arrythmias was 1.03% in the Methadone cohort, higher than the 0.87% in the matched Buprenorphine cohort (HR: 1.20, 95% CI: 1.04-1.39); The overall risk for long QT syndrome was 0.35% in the Methadone cohort, higher than the 0.15% in the matched Buprenorphine cohort (HR: 2.40, 95% CI: 1.75-3.28); The overall mortality was 0.59% in the Methadone cohort, higher than the 0.41% in the matched Buprenorphine cohort (HR: 1.48, 95% CI: 1.21-1.81). The increased risk persisted for 5 years: cardiac arrhythmias (HR: 1.31, 95% CI: 1.23-1.38), long QT syndrome (HR: 3.14, 95% CI: 2.76-3.58), death (HR: 1.50, 95% CI: 1.41-1.59). CONCLUSIONS AND RELEVANCE Methadone was associated with a significantly higher risk for cardiac and mortality outcomes than buprenorphine and naltrexone. These findings are relevant to the development of guidelines for medication selection when initiating MOUD treatment and inform future medication development for OUD that minimizes risks while maximizing benefits.
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Affiliation(s)
- Lindsey Wang
- Center for Science, Health, and Society, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Nora D Volkow
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland, USA
| | - Nathan A Berger
- Center for Science, Health, and Society, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Pamela B Davis
- Center for Community Health Integration, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - David C Kaelber
- The Center for Clinical Informatics Research and Education, The MetroHealth System, Cleveland, Ohio, USA
| | - Rong Xu
- Center for Artificial Intelligence in Drug Discovery, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
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French R, Lyons E, Schachter A, Treston JA, Marshall A, Lattimer J, Bisaga A, Behar E, Aronowitz SV. "Because of this rotation, this is what I want to do": Implementation and evaluation of a telehealth opioid use disorder clinical placement for nurse practitioner students. J Am Assoc Nurse Pract 2023; 35:826-834. [PMID: 37756445 PMCID: PMC10840880 DOI: 10.1097/jxx.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/25/2023] [Indexed: 09/29/2023]
Abstract
ABSTRACT The lack of clinicians comfortable prescribing buprenorphine is a barrier to access for people with opioid use disorder (OUD). Accordingly, a telehealth OUD treatment clinic, Ophelia, launched a clinical training program for nurse practitioner (NP) students. The goal of this study was to assess a telehealth-based model of OUD clinical training. To evaluate the program, we (1) identified students' knowledge related to providing OUD care to patients before and after their clinical rotation with Ophelia and (2) characterized students' attitudes about providing OUD care following their clinical rotation with Ophelia. Online pre- and postsurveys were conducted with 57 and 29 students, respectively, and semistructured interviews were conducted with 19 students who completed clinical rotations with Ophelia. We used quantitative descriptive analysis to compare presurvey and postsurvey results and conducted thematic analysis to analyze qualitative interview data. We identified three themes from the interviews: the continuum of learning opportunities, the comfort providing OUD treatment following participants' clinical rotation, and the relevance of a substance use disorder clinical rotation for all NP students. The survey also supported these findings. Of note, there were descriptive differences between presurvey and postsurvey responses related to an increase in knowledge, preparedness, and acquisition of skills to treat OUD. Using a telehealth clinical rotation for NP students to learn about OUD treatment may represent an important step in increasing the number of clinicians who can prescribe buprenorphine. These findings can inform interventions and policies that target clinician training barriers.
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Affiliation(s)
- Rachel French
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia, Pennsylvania
- Department of Psychiatry, Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Ophelia Health Inc., New York, New York
| | | | - Allison Schachter
- Department of Psychiatry, Center for Mental Health, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - June A Treston
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | | | - Jennie Lattimer
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
| | - Adam Bisaga
- Ophelia Health Inc., New York, New York
- Department of Psychiatry, Columbia University Medical Center, New York, New York
| | | | - Shoshana V Aronowitz
- University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Ophelia Health Inc., New York, New York
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Ventuneac A, Dickerson SS, Dharia A, George SJ, Talal AH. Scaling and Sustaining Facilitated Telemedicine to Expand Treatment Access Among Underserved Populations: A Qualitative Study. Telemed J E Health 2023; 29:1862-1869. [PMID: 37252770 DOI: 10.1089/tmj.2022.0534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023] Open
Abstract
Background: Opioid treatment programs are an essential component of the management of opioid use disorder (OUD). They have also been proposed as "medical homes" to expand health care access for underserved populations. We utilized telemedicine as a method to increase access for hepatitis C virus (HCV) care among people with OUD. Methods: We interviewed 30 staff and 15 administrators regarding the integration of facilitated telemedicine for HCV into opioid treatment programs. Participants provided feedback and insight for sustaining and scaling facilitated telemedicine for people with OUD. We utilized hermeneutic phenomenology to develop themes related to telemedicine sustainability in opioid treatment programs. Results: Three themes emerged on sustaining the facilitated telemedicine model: (1) Telemedicine as a Technical Innovation in Opioid Treatment Programs, (2) Technology Transcending Space and Time, and (3) COVID-19 Disrupting the Status Quo. Participants identified skilled staff, ongoing training, technology infrastructure and support, and an effective marketing campaign as key to maintaining the facilitated telemedicine model. Participants highlighted the study-supported case manager's role in managing the technology to transcend temporal and geographical challenges for HCV treatment access for people with OUD. COVID-19 fueled changes in health care delivery, including facilitated telemedicine, to expand the opioid treatment program's mission as a medical home for people with OUD. Conclusions: Opioid treatment programs can sustain facilitated telemedicine to increase health care access for underserved populations. COVID-19-induced disruptions promoted innovation and policy changes recognizing telemedicine's role in expanding health care access to underserved populations. ClinicalTrials.gov Identifier: NCT02933970.
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Affiliation(s)
- Ana Ventuneac
- START Treatment & Recovery Centers, Brooklyn, New York, USA
| | - Suzanne S Dickerson
- Division of Biobehavioral Health & Clinical Sciences, School of Nursing, University at Buffalo, Buffalo, New York, USA
| | - Arpan Dharia
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Saliyah J George
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Andrew H Talal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
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Pascual Pastor F, Muñoz Á, Oraa R, Flórez G, Notario P, Seijo P, Gonzalvo B, Assaf C, Gómez M, Casado MÁ. Patients'satisfaction and experience in treatment with opioid substitution therapy in Spain. The PREDEPO study. Adicciones 2023; 35:433-444. [PMID: 34882243 DOI: 10.20882/adicciones.1684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to compare patients' satisfaction, experience, objectives, and opinion based on their current opioid substitution therapy (OST) (buprenorphine/naloxone (B/N) or methadone). The PREDEPO study is an observational, cross-sectional, multicentric study performed in Spain. Adult patients diagnosed with opioid use disorder (OUD) receiving OST were included. They were asked to fill in a questionnaire regarding their current OST. A total of 98 patients were enrolled (B/N: 50%, methadone: 50%). Mean age was 47 ± 8 years old and 80% were male. Treatment satisfaction was similar between groups. The most frequently reported factor for being "very/quite satisfied" was "being able to distribute the dose at different times throughout the day" (44% B/N vs. 63% methadone; p = .122). A significantly lower proportion of patients in the B/N group versus the methadone group reported that having to collect the medication daily was "very/quite annoying" (19% vs. 52%, p = .032). Treatment objectives reported by the majority of patients were similar between groups ("not feeling in withdrawal anymore", "reduce/definitely stop drug use", "improve my health", and "stop thinking about using daily") except for "not having money problems anymore" (73% B/N vs. 92% methadone; p = .012). These results suggest there are several unmet expectations regarding current OST. There is a need for new treatments that reduce the burden of OUD, avoid the need for daily dosing, and are less stigmatizing which in turn could improve patient management, adherence and, quality of life.
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Kennalley AL, Fanelli JL, Furst JA, Mynarski NJ, Jarvis MA, Nichols SD, McCall KL, Piper BJ. Dynamic changes in methadone utilisation for opioid use disorder treatment: a retrospective observational study during the COVID-19 pandemic. BMJ Open 2023; 13:e074845. [PMID: 37973543 PMCID: PMC10661065 DOI: 10.1136/bmjopen-2023-074845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 10/18/2023] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVES Opioid use disorder (OUD) is a major public health concern in the USA, resulting in high rates of overdose and other negative outcomes. Methadone, an OUD treatment, has been shown to be effective in reducing the risk of overdose and improving overall health and quality of life. This study analysed the distribution of methadone for the treatment of OUD across the USA over the past decade and through the COVID-19 pandemic. DESIGN Retrospective observational study using secondary data analysis of the Drug Enforcement Administration and Medicaid Databases. SETTING USA. PARTICIPANTS Patients who were dispensed methadone at US opioid treatment programmes (OTPs). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcomes were the overall pattern in methadone distribution and the number of OTPs in the USA per year. The secondary outcome was Medicaid prescriptions for methadone. RESULTS Methadone distribution for OUD has expanded significantly over the past decade, with an average state increase of +96.96% from 2010 to 2020. There was a significant increase in overall distribution of methadone to OTP from 2010 to 2020 (+61.00%, p<0.001) and from 2015 to 2020 (+26.22%, p<0.001). However, the distribution to OTPs did not significantly change from 2019 to 2021 (-5.15%, p=0.491). There was considerable state-level variation in methadone prescribing to Medicaid patients with four states having no prescriptions. CONCLUSIONS There have been dynamic changes in methadone distribution for OUD. Furthermore, pronounced variation in methadone distribution among states was observed, with some states having no OTPs or Medicaid coverage. New policies are urgently needed to increase access to methadone treatment, address the opioid epidemic in the USA and reduce overdose deaths.
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Affiliation(s)
- Amy L Kennalley
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Jessica L Fanelli
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - John A Furst
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Nicholas J Mynarski
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Margaret A Jarvis
- Division of Addiction Medicine, Department of Psychiatry, Geisinger Clinic, Danville, Pennsylvania, USA
| | - Stephanie D Nichols
- Department of Pharmacy Practice, University of New England, Portland, Maine, USA
| | - Kenneth L McCall
- Department of Pharmacy Practice, Binghamton University, Binghamton, New York, USA
| | - Brian J Piper
- Department of Medical Education, Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- Center for Pharmacy Innovation and Outcomes, Danville, Pennsylvania, USA
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Suen LW, Steiger S, Shapiro B, Castellanos S, Joshi N, Lambdin BH, Knight KR. "Get in and get out, get on with life": Patient and provider perspectives on methadone van implementation for opioid use disorder treatment. Int J Drug Policy 2023; 121:104214. [PMID: 37778132 DOI: 10.1016/j.drugpo.2023.104214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Expanding access to opioid use disorder (OUD) treatment, including methadone, is imperative to address the US overdose crisis. In June 2021, the Drug Enforcement Administration announced new regulations allowing all opioid treatment programs (OTPs) to deploy mobile medication units, or methadone vans, to dispense OUD medication treatment outside of clinic walls, ending a 13-year moratorium. We conducted a qualitative study evaluating one opioid treatment program's experience, including benefits and challenges with implementing a methadone van, to inform future policy and clinical practice. METHODS We recruited staff and patients receiving OUD medication treatment from an OTP in San Francisco, CA. The OTP had one operating van before March 2020 and began operating an additional van in response to COVID-19-related efforts to de-populate clinic settings. We interviewed 10 providers and 20 patients from August to November 2020. We transcribed, coded, and analyzed all interviews using modified grounded theory methodologies. RESULTS Both patients and providers perceived significant benefits with receiving OUD medications using methadone vans. Patients preferred dosing at the van over the clinic because they were able to "get in and out" faster. Both staff and patients appreciated being able to use phone counseling to connect with counselors which helped reduce in-person visits and streamline workflows. Providers also noted van implementation challenges, including daily van set up, urine drug testing, and delivering counseling to patients who lacked phones. CONCLUSIONS Eased restrictions on methadone van implementation represent a new strategy for expanding OUD treatment access. In our qualitative study, patients and staff were satisfied with methadone van implementation, though the OTP still faced implementation challenges. Audio-only counseling and other workflow solutions helped facilitate implementation, and several policy considerations like maintaining audio-only counseling flexibilities are key to ensuring future van success. Methadone vans offer the potential to expand treatment uptake, while prioritizing patient-centered care.
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Affiliation(s)
- Leslie W Suen
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, United States.
| | - Scott Steiger
- Division of General Internal Medicine at San Francisco General Hospital, Department of Medicine, University of California San Francisco, San Francisco, CA, United States
| | - Brad Shapiro
- Division of Substance Abuse and Addiction Medicine, Department of Psychiatry, University of California San Francisco, San Francisco, CA, United States
| | - Stacy Castellanos
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States; Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Neena Joshi
- Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
| | - Barrot H Lambdin
- Research Triangle Institute International, Berkeley, CA, United States
| | - Kelly R Knight
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, United States; Department of Humanities and Social Sciences, University of California San Francisco, San Francisco, CA, United States
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Gao E, Melnick ER, Paek H, Nath B, Taylor RA, Loza AJ. Adoption of Emergency Department-Initiated Buprenorphine for Patients With Opioid Use Disorder: Secondary Analysis of a Cluster Randomized Trial. JAMA Netw Open 2023; 6:e2342786. [PMID: 37948075 PMCID: PMC10638655 DOI: 10.1001/jamanetworkopen.2023.42786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
Importance Emergency department (ED) initiation of buprenorphine is safe and effective but underutilized in practice. Understanding the factors affecting adoption of this practice could inform more effective interventions. Objective To quantify the factors, including social contagion, associated with the adoption of the practice of ED initiation of buprenorphine for patients with opioid use disorder. Design, Setting, and Participants This is a secondary analysis of the EMBED (Emergency Department-Initiated Buprenorphine For Opioid Use Disorder) trial, a multicentered, cluster randomized trial of a clinical decision support intervention targeting ED initiation of buprenorphine. The trial occurred from November 2019 to May 2021. The study was conducted at ED clusters across health care systems from the northeast, southeast, and western regions of the US and included attending physicians, resident physicians, and advanced practice practitioners. Data analysis was performed from August 2022 to June 2023. Exposures This analysis included both the intervention and nonintervention groups of the EMBED trial. Graph methods were used to construct the network of clinicians who shared in the care of patients for whom buprenorphine was initiated during the trial before initiating the practice themselves, termed exposure. Main Outcomes and Measures Cox proportional hazard modeling with time-dependent covariates was performed to assess the association of the number of these exposures with self-adoption of the practice of ED initiation of buprenorphine while adjusting for clinician role, health care system, and intervention site status. Results A total of 1026 unique clinicians in 18 ED clusters across 5 health care systems were included. Analysis showed associations of the cumulative number of exposures to others initiating buprenorphine with the self-practice of buprenorphine initiation. This increased in a dose-dependent manner (1 exposure: hazard ratio [HR], 1.31; 95% CI, 1.16-1.48; 5 exposures: HR, 2.85; 95% CI, 1.66-4.89; 10 exposures: HR, 3.55; 95% CI, 1.47-8.58). Intervention site status was associated with practice adoption (HR, 1.50; 95% CI, 1.04-2.18). Health care system and clinician role were also associated with practice adoption. Conclusions and Relevance In this secondary analysis of a multicenter, cluster randomized trial of a clinical decision support tool for buprenorphine initiation, the number of exposures to ED initiation of buprenorphine and the trial intervention were associated with uptake of ED initiation of buprenorphine. Although systems-level approaches are necessary to increase the rate of buprenorphine initiation, individual clinicians may change practice of those around them. Trial Registration ClinicalTrials.gov Identifier: NCT03658642.
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Affiliation(s)
- Evangeline Gao
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Edward R. Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
- Yale School of Public Health, New Haven, Connecticut
| | - Hyung Paek
- Information Technology Services, Yale New Haven Health, Stratford, Connecticut
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - R. Andrew Taylor
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Andrew J. Loza
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
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Adams JW, Duprey M, Khan S, Cance J, Rice DP, Bobashev G. Examining buprenorphine diversion through a harm reduction lens: an agent-based modeling study. Harm Reduct J 2023; 20:150. [PMID: 37848945 PMCID: PMC10580611 DOI: 10.1186/s12954-023-00888-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 10/09/2023] [Indexed: 10/19/2023] Open
Abstract
BACKGROUND Recent policies have lessened restrictions around prescribing buprenorphine-naloxone (buprenorphine) for the treatment of opioid use disorder (OUD). The primary concern expressed by critics of these policies is the potential for buprenorphine diversion. However, the population-level effects of increased buprenorphine diversion are unclear. If replacing the use of heroin or fentanyl, use of diverted buprenorphine could be protective. METHODS Our study aim was to estimate the impact of buprenorphine diversion on opioid overdose using an agent-based model calibrated to North Carolina. We simulated the progression of opioid misuse and opioid-related outcomes over a 5-year period. Our status quo scenario assumed that 50% of those prescribed buprenorphine diverted at least one dose per week to other individuals with OUD and 10% of individuals with OUD used diverted buprenorphine at least once per week. A controlled prescription only scenario assumed that no buprenorphine would be diverted, while an increased diversion scenario assumed that 95% of those prescribed buprenorphine diverted and 50% of individuals with OUD used diverted buprenorphine. We assumed that use of diverted buprenorphine replaced the use of other opioids for that day. Sensitivity analyses increased the risk of overdose when using diverted buprenorphine, increased the frequency of diverted buprenorphine use, and simulated use of diverted buprenorphine by opioid-naïve individuals. Scenarios were compared on opioid overdose-related outcomes over the 5-year period. RESULTS Our status quo scenario predicted 10,658 (credible interval [CI]: 9699-11,679) fatal opioid overdoses. A scenario simulating controlled prescription only of buprenorphine (i.e., no diversion) resulted in 10,741 (9895-11,650) fatal opioid overdoses versus 10,301 (9439-11,244) within a scenario simulating increased diversion. Compared to the status quo, the controlled prescription only scenario resulted in a similar number of fatal overdoses, while the scenario with increased diversion of buprenorphine resulted in 357 (3.35%) fewer fatal overdoses. Even when increasing overdose risk while using diverted buprenorphine and incorporating use by opioid naïve individuals, increased diversion did not increase overdoses compared to a scenario with no buprenorphine diversion. CONCLUSIONS A similar number of opioid overdoses occurred under modeling conditions with increased rates of buprenorphine diversion among persons with OUD, with non-statistical trends toward lower opioid overdoses. These results support existing calls for low- to no-barrier access to buprenorphine for persons with OUD.
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Affiliation(s)
| | | | - Sazid Khan
- RTI International, Research Triangle, NC, USA
| | | | - Donald P Rice
- Division of Infectious Disease, Department of Medicine, Alpert Medical School of Brown University, Providence, RI, USA
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Hauck TS, Ladha KS, Le Foll B, Wijeysundera DN, Kurdyak P. Postoperative buprenorphine continuation in stabilized buprenorphine patients: A population cohort study. Addiction 2023; 118:1953-1964. [PMID: 37332171 DOI: 10.1111/add.16223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 04/05/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND AND AIMS Sudden discontinuation of buprenorphine in the treatment of opioid use disorder can increase the risk of subsequent relapse and overdose. Little is known about buprenorphine use in the perioperative period. The aim of this study was to determine the rate of buprenorphine continuation after hospital discharge following surgery and factors associated with continuation. DESIGN A population-based retrospective cohort study was conducted using administrative data from Ontario, Canada, between 2012 and 2018. The cohort included individuals on continuous buprenorphine prior to surgery. Logistic regression modeling was used to estimate the association of buprenorphine continuation with demographic, opioid agonist treatment, surgical and health service use factors. SETTING Administrative databases from Institute for Clinical Evaluative Sciences (ICES) were used, which capture the Ontario, Canada, population. The data sets describe physician billing, monitoring of controlled substances and hospital discharges. PARTICIPANTS Adults (≥ 18 years, n = 2176) had received a buprenorphine/naloxone product continuously for at least 60 days for the treatment of opioid use disorder and subsequently underwent a surgical procedure. MEASUREMENTS Continuation (versus discontinuation) of buprenorphine prescriptions in the 14 days after surgical discharge was recommended. Exposures included demographic, comorbidity, opioid agonist treatment, surgical and health service use characteristics. FINDINGS About 176 (8.1%) of the 2176 patients discontinued buprenorphine after surgery. Inpatient surgery (versus ambulatory) was associated with reduced odds of continuation, with an unadjusted odds ratio (OR) of 0.17 [95% confidence interval (CI) = 0.12-0.25] and an adjusted OR of 0.16 (95% CI = 0.11-0.23) after accounting for age, sex, rural residence, neighborhood income quintile, Charlson comorbidity index, psychiatric hospitalizations in the past 5 years and recent dispensed supply of buprenorphine (number needed to harm of 6.6). CONCLUSIONS In Ontario, Canada, from 2012 to 2018, most patients receiving continuous preoperative buprenorphine therapy continued buprenorphine use after surgery. Inpatient surgery was a strong predictor of discontinuation compared with ambulatory procedures.
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Affiliation(s)
- Tanya S Hauck
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
| | - Karim S Ladha
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Bernard Le Foll
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Paul Kurdyak
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
- ICES Central, Toronto, ON, Canada
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Calcaterra SL, Lockhart S, Natvig C, Mikulich S. Barriers to initiate buprenorphine and methadone for opioid use disorder treatment with postdischarge treatment linkage. J Hosp Med 2023; 18:896-907. [PMID: 37608527 PMCID: PMC10592161 DOI: 10.1002/jhm.13193] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/27/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Hospitals are an essential site of care for people with opioid use disorder (OUD). Buprenorphine and methadone are underutilized in the hospital. OBJECTIVES Characterize barriers to in-hospital buprenorphine or methadone initiation to inform implementation strategies to increase OUD treatment provision. DESIGN, SETTINGS, AND PARTICIPANTS Survey of hospital-based clinicians' perceptions of OUD treatment from 12 hospitals conducted between June 2022 and August 2022. MEASURES Survey questions were grouped into six domains: (1) evidence to treat OUD, (2) hospital processes to treat OUD, (3) buprenorphine or methadone initiation, (4) clinical practices to treat OUD, (5) leadership prioritization of OUD treatment, and (6) job satisfaction. Likert responses were dichotomized and associations between "readiness" to initiate buprenorphine or methadone and each domain were assessed. RESULTS Of 160 respondents (60% response rate), 72 (45%) reported higher readiness to initiate buprenorphine compared to methadone, 55 (34%). Respondents with higher readiness to initiate medications for OUD were more likely to perceive that evidence supports the use of buprenorphine and methadone to treat OUD (p < .001), to perceive fewer barriers to treat OUD (p < .001), to incorporate OUD treatment into their clinical practice (p < .001), to perceive leadership support for OUD treatment (p < .007), and to have great job satisfaction (p < .04). Clinicians reported that OUD treatment protocols with treatment linkage, increased education, and addiction specialist support would facilitate OUD treatment provision. CONCLUSION Interventions that incorporate protocols to initiate medications for OUD, include addiction specialist support and education, and ensure postdischarge OUD treatment linkage could facilitate hospital-based OUD treatment provision.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Divisions of General Internal Medicine and Hospital Medicine, Univeristy of Colorado, Aurora, CO, USA
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Steven Lockhart
- Adult and Child Center for Health Outcomes Research and Delivery Service, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Crystal Natvig
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
| | - Susan Mikulich
- Department of Psychiatry, Univeristy of Colorado, Aurora, CO, USA
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Abstract
ABSTRACT In individuals in the United States with opioid addiction, what is the effect of a medication-assisted treatment (MAT) in reducing the relapse and harm reduction when comparing the use of buprenorphine, methadone, and naltrexone? In 2017, it was estimated that 1.7 million individuals suffer from overuse of prescription opiates, 652,000 individuals suffer from heroin use disorder, and greater than 130 individuals die from opiate overdose daily (National Institutes of Health, 2019). Using a systematic literature review, the following results were found. Buprenorphine is currently the second most effective MAT in harm reduction and relapse prevention, can be initiated and maintained through primary care, has a low risk for overdose, but needs to be started only when moderate withdrawals have begun. Methadone is currently the gold standard in MAT and can be started in any stage of withdrawal; however, titrating to effective dose is a lengthy process, and it must be administered at a specialty clinic. Naltrexone in oral form has not been shown to be effective because of lack of adherence; however, the extended-release intramuscular injection form has been shown to reduce relapse and increase the quality of life before initiation individuals must be opioid free for 7-14 days. Choosing the proper MAT is highly individualized. It is recommended that more research be conducted in comparing all MAT options, looking at the quality of life on each MAT, researching motivations to stay on MAT and remain opioid free, and looking at the impact of external reward on adherence to the MAT program.
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Affiliation(s)
- Amanda Spayde-Baker
- Amanda Spayde-Baker, RN, and Jennifer Patek, RN, Simmons University, Boston, Massachusetts
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Gabrhelík R, Hesse M, Nechanská B, Handal M, Mravčík V, Tjagvad C, Thylstrup B, Seid AK, Bukten A, Clausen T, Skurtveit S. Large variations in all-cause and overdose mortality among >13,000 patients in and out of opioid maintenance treatment in different settings: a comparative registry linkage study. Front Public Health 2023; 11:1179763. [PMID: 37809010 PMCID: PMC10558053 DOI: 10.3389/fpubh.2023.1179763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Opioid maintenance treatment (OMT) has the potential to reduce mortality rates substantially. We aimed to compare all-cause and overdose mortality among OMT patients while in or out of OMT in two different countries with different approaches to OMT. Methods Two nation-wide, registry-based cohorts were linked by using similar analytical strategies. These included 3,637 male and 1,580 female patients enrolled in OMT in Czechia (years 2000-2019), and 6,387 male and 2,078 female patients enrolled in OMT in Denmark (years 2007-2018). The direct standardization method using the European (EU-27 plus EFTA 2011-2030) Standard was employed to calculate age-standardized rate to weight for age. All-cause and overdose crude mortality rates (CMR) as number of deaths per 1,000 person years (PY) in and out of OMT were calculated for all patients. CMRs were stratified by sex and OMT medication modality (methadone, buprenorphine, and buprenorphine with naloxone). Results Age-standardized rate for OMT patients in Czechia and Denmark was 9.7/1,000 PY and 29.8/1,000 PY, respectively. In Czechia, the all-cause CMR was 4.3/1,000 PY in treatment and 10.8/1,000 PY out of treatment. The overdose CMR was 0.5/1,000 PY in treatment and 1.2/1,000 PY out of treatment. In Denmark, the all-cause CMR was 26.6/1,000 PY in treatment and 28.2/1,000 PY out of treatment and the overdose CMR was 7.3/1,000 PY in treatment and 7.0/1,000 PY out of treatment. Conclusion Country-specific differences in mortality while in and out of OMT in Czechia and Denmark may be partly explained by different patient characteristics and treatment systems in the two countries. The findings contribute to the public health debate about OMT management and may be of interest to practitioners, policy and decision makers when balancing the safety and accessibility of OMT.
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Affiliation(s)
- Roman Gabrhelík
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czechia
- Department of Addictology, General University Hospital in Prague, Prague, Czechia
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Aarhus University, Aarhus, Denmark
| | - Blanka Nechanská
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czechia
- Department of Addictology, General University Hospital in Prague, Prague, Czechia
| | - Marte Handal
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Viktor Mravčík
- First Faculty of Medicine, Department of Addictology, Charles University, Prague, Czechia
- Department of Addictology, General University Hospital in Prague, Prague, Czechia
| | - Christian Tjagvad
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Aarhus University, Aarhus, Denmark
| | - Abdu Kedir Seid
- Centre for Alcohol and Drug Research, Aarhus University, Aarhus, Denmark
| | - Anne Bukten
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Thomas Clausen
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Svetlana Skurtveit
- Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
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Magee T, Peters C, Jacobsen SM, Nees D, Dunford B, Ford AI, Vassar M. Inequities in the treatment of opioid use disorder: A scoping review. J Subst Use Addict Treat 2023; 152:209082. [PMID: 37271346 DOI: 10.1016/j.josat.2023.209082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 05/05/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023]
Abstract
BACKGROUND Given the lack of access to evidenced-based OUD treatment and the corresponding overdose crisis, researchers must evaluate and report health care inequities involving the treatment of OUD. Additionally, clinicians should be aware of these inequities in the treatment of patients. METHODS We carried out a scoping review of the literature regarding health inequities in treatment for OUD in July 2022. The study team retrieved articles published between 2016 and 2021 from MEDLINE and Ovid Embase. After authors received training, screening and data extraction were performed in masked, duplicate fashion. The team screened a total of 3673 titles and abstracts, followed by 172 articles for full-text review. The inequities that we examined were race/ethnicity, sex or gender, income, under-resourced/rural, occupational status, education level, and LGBTQ+. We used Stata 17.0 (StataCorp, LLC, College Station, TX) to summarize data and statistics of the studies within our sample. RESULTS A total of 44 studies evaluating inequities in OUD treatment met inclusion criteria. The most common inequity that studies examined was race/ethnicity (34/44 [77.27 %] studies), followed by under-resourced/rural (19/44 [43.18 %] studies), and sex or gender (18/44 [40.91 %] studies). LGBTQ+ (0/44 [0.0 %] studies) was not reported in the included studies. Our results indicate that many historically marginalized populations experience inequities related to access and outcomes in OUD treatment. The included studies in our scoping review occasionally demonstrated inconsistent findings. CONCLUSIONS Gaps exist within the literature on health inequities in treatment for OUD. The most examined inequities were race/ethnicity, under-resourced/rural and sex or gender, while studies did not examine LGBTQ+ status. Future research should aim to advance and supplement literature investigating health inequities in OUD treatment to ensure inclusive, patient-centered care.
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Affiliation(s)
- Trevor Magee
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States.
| | - Caleb Peters
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Samuel M Jacobsen
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Danya Nees
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Bryan Dunford
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Alicia Ito Ford
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
| | - Matt Vassar
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States; Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK, United States
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Dugosh KL, Lent MR, Burkley SB, Millard CM, McKay JR, Kampman KM. Nonopioid Substance Use among Patients Who Recently Initiated Office-based Buprenorphine Treatment. J Addict Med 2023; 17:612-614. [PMID: 37788620 PMCID: PMC10583252 DOI: 10.1097/adm.0000000000001168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023]
Abstract
OBJECTIVES Medications for opioid use disorder (MOUDs) like buprenorphine are a first-line treatment for individuals who have opioid use disorder (OUD); however, these medications are not designed to impact the use of other classes of drugs. This descriptive study provides up-to-date information about nonopioid substance use among patients who recently initiated office-based buprenorphine treatment for OUD using data from 2 ongoing clinical trials. METHODS The study sample was composed of 257 patients from 6 federally qualified health centers in the mid-Atlantic region who recently (i.e., within the past 28 days) initiated office-based buprenorphine treatment between July 2020 and May 2022. After the screening and informed consent processes, participants completed a urine drug screen and psychosocial interview as a part of the study baseline assessment. Descriptive analyses were performed on urine drug screen results to identify the prevalence and types of substances detected. RESULTS More than half of participants provided urine specimens that were positive for nonopioid substances, with marijuana (37%, n = 95), cocaine (22%, n = 56), and benzodiazepines (11%, n = 28) detected with the highest frequencies. CONCLUSIONS A significant number of participants used nonopioid substances after initiating buprenorphine treatment, suggesting that some patients receiving MOUDs could potentially benefit from adjunctive psychosocial treatment and supports to address their nonopioid substance use.
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Affiliation(s)
- Karen L. Dugosh
- Research & Evaluation Group, Public Health Management Corporation, Philadelphia PA
| | - Michelle R. Lent
- School of Professional and Applied Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia PA
| | - S. Brook Burkley
- Research & Evaluation Group, Public Health Management Corporation, Philadelphia PA
| | - Conor M.K. Millard
- Research & Evaluation Group, Public Health Management Corporation, Philadelphia PA
| | - James R. McKay
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Kyle M. Kampman
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
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Soto-Nevarez A, Abo M, Hudson M, Bobak T, Jason LA. Lived experiences of Oxford House residents prescribed medication-assisted treatment. J Community Psychol 2023; 51:2828-2844. [PMID: 36994805 DOI: 10.1002/jcop.23038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 03/17/2023] [Accepted: 03/20/2023] [Indexed: 06/19/2023]
Abstract
Qualitative studies have examined the recovery experiences of individuals prescribed medication-assisted treatment (MAT), including their experiences within treatment facilities. However, the literature lacks qualitative studies exploring the recovery process of individuals prescribed MAT while living in recovery housing, such as Oxford House (OH). The purpose of this study was to explore how OH residents, who are prescribed MAT, make sense of recovery. The fact that OHs are drug-free recovery housing is what makes the issue of using MATs potentially contentious in these settings. Interpretative phenomenological analysis (IPA) was used to document the lived experiences of individuals prescribed MAT in OH. The sample included: five women and three men, prescribed either methadone or Suboxone, that were living in an OH in the United States. Participants were interviewed on four topics: their recovery process, their transition to OH, and their experience living in and outside of an OH. Analysis of results followed the recommendations for IPA from Smith, Flowers, and Larkin. Four general themes emerged from the data: Recovery Process, Managing Logistics of MAT Utilization, Personal Development, and Familial Values. In conclusion, individuals prescribed MAT did benefit from living in an OH to manage their recovery as well as stay compliant with their medication.
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Affiliation(s)
| | - Mary Abo
- Center for Community Research, DePaul University, Chicago, Illinois, USA
| | - Mackenzie Hudson
- Center for Community Research, DePaul University, Chicago, Illinois, USA
| | - Ted Bobak
- Center for Community Research, DePaul University, Chicago, Illinois, USA
| | - Leonard A Jason
- Center for Community Research, DePaul University, Chicago, Illinois, USA
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Bakouni H, McAnulty C, Tatar O, Socias ME, Foll BL, Lim R, Ahamad K, Jutras-Aswad D. Associations of methadone and buprenorphine-naloxone doses with unregulated opioid use, treatment retention, and adverse events in prescription-type opioid use disorders: Exploratory analyses of the OPTIMA study. Am J Addict 2023; 32:469-478. [PMID: 37308805 DOI: 10.1111/ajad.13439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 03/13/2023] [Accepted: 05/23/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Buprenorphine/naloxone (BUP-NX) and methadone are used to treat opioid use disorder (OUD), yet there is insufficient evidence on the impact of doses on interventions' effectiveness and safety when treating OUD attributable to other opioids than heroin. METHODS We explored associations between methadone and BUP-NX doses and treatment outcomes using data from OPTIMA, a 24-week, pragmatic, open-label, multicenter, pan-Canadian, randomized controlled, two-arm parallel trial with participants (N = 272) with OUD who primarily use opioids other than heroin. Participants were randomized to receive flexible take-home BUP-NX (n = 138) or standard supervised methadone treatment (n = 134). We examined associations between highest BUP-NX and methadone doses, and (1) percentage of opioid-positive urine drug screens (UDS); (2) retention in the assigned treatment; and (3) adverse events (AEs). RESULTS The mean (SD) highest BUP-NX and methadone dose were 17.31 mg/day (8.59) and 67.70 mg/day (34.70). BUP-NX and methadone doses were not associated with opioid-positive UDS percentages or AEs. Methadone dose was associated with higher retention in treatment (odds ratio [OR]: 1.025; 95% confidence interval [CI]: 1.010; 1.041), while BUP-NX dose was not (OR: 1.055; 95% CI: 0.990; 1.124). Higher methadone doses (70-110 mg/day) offered higher odds of treatment retention. DISCUSSION AND CONCLUSION Methadone dose was associated with higher retention, which may be related to its full µ-opioid receptor agonism. Future research should notably ascertain the effect of pace of titration on a wide range of outcomes. SCIENTIFIC SIGNIFICANCE Our results extend previous findings of high doses of methadone increasing retention to be applied in our population using opioids other than heroin, including highly potent opioids.
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Affiliation(s)
- Hamzah Bakouni
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Quebec, Montréal, Canada
| | - Christina McAnulty
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Quebec, Montréal, Canada
- Department of Psychiatry and Addictology, Université de Montréal, Québec, Montréal, Canada
| | - Ovidiu Tatar
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Quebec, Montréal, Canada
- Department of Psychiatry and Addictology, Université de Montréal, Québec, Montréal, Canada
| | - M Eugenia Socias
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Bernard Le Foll
- Department of Pharmacology and Toxicology, Faculty of Medicine, Medical Sciences Building, University of Toronto, Ontario, Toronto, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Ontario, Toronto, Canada
- Department of Psychiatry, University of Toronto, Ontario, Toronto, Canada
- Dalla Lana School of Public Health, University of Toronto, Ontario, Toronto, Canada
- Translational Addiction Research Laboratory, Campbell Family Mental Health Research Institute, Center for Addiction and Mental Health (CAMH), Ontario, Toronto, Canada
- Waypoint Research Institute, Waypoint Centre for Mental Health Care, Ontario, Penetanguishene, Canada
| | - Ron Lim
- Department of Family Medicine and Psychiatry, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Keith Ahamad
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Family Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Didier Jutras-Aswad
- Research Centre, Centre Hospitalier de l'Université de Montréal (CRCHUM), Quebec, Montréal, Canada
- Department of Psychiatry and Addictology, Université de Montréal, Québec, Montréal, Canada
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Tofighi B, Marini C, Lee JD, Garland EL. Patient Perceptions of Integrating Meditation-based Interventions in Office-based Opioid Treatment with Buprenorphine: A Mixed-methods Survey. J Addict Med 2023; 17:517-520. [PMID: 37788602 PMCID: PMC10533745 DOI: 10.1097/adm.0000000000001160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
INTRODUCTION Recent findings support the provision of meditation-based interventions (MBIs) in primary care. However, the acceptability of MBI among patients prescribed medications for opioid use disorder (eg, buprenorphine) in primary care remains unclear. This study assessed experiences and preferences for adopting MBI among patients prescribed buprenorphine in office-based opioid treatment (OBOT). METHODS This 23-item, semistructured cross-sectional survey was administered by study staff to patients enrolled in OBOT (N = 72) and consisted of demographic and clinical characteristics, perceptions, experiences with MBI, and preferred strategies to access MBI to support their treatment on buprenorphine. RESULTS Most participants reported practicing at least 1 category of MBI (90.3%) on at least a daily (39.6%) or weekly (41.7%) basis including (1) spiritual meditation (eg, centering prayer; 67.7%); (2) nonmantra meditation (eg, comfortable posture; 61.3%); (3) mindfulness meditation (eg, mindfulness-based stress reduction; 54.8%); and (4) mantra meditation (eg, transcendental meditation; 29.0%). Interest in MBI was motivated by improving one's general health and well-being (73.4%), treatment outcomes with medications for OUD (eg, buprenorphine; 60.9%), and relationships with others (60.9%). Perceived clinical benefits of MBI included reduced anxiety or depression symptoms (70.3%), pain (62.5%), illicit substance or alcohol use (60.9%), cravings for illicit substances (57.8%), and opioid-related withdrawal symptoms (51.6%). CONCLUSIONS Findings from this study indicate high acceptability for adopting MBI among patients prescribed buprenorphine in OBOT. Further research is needed to assess the efficacy of MBI to improve clinical outcomes among patients initiating buprenorphine in OBOT.
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Affiliation(s)
- Babak Tofighi
- New York University School of Medicine, Department of Population Health
- Bellevue Hospital Center Division of General Internal Medicine
- Center for Drug Use and HIV Research
- Nathan Kline Institute for Psychiatric Research
| | - Christina Marini
- New York University School of Medicine, Department of Population Health
| | - Joshua D. Lee
- New York University School of Medicine, Department of Population Health
- Bellevue Hospital Center Division of General Internal Medicine
- Center for Drug Use and HIV Research
| | - Eric L. Garland
- University of Utah, Center on Mindfulness and Integrative Health Intervention Development, College of Social Work
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