Hospital admissions among patients with Comorbid Substance Use disorders: a secondary analysis of predictors from the NavSTAR Trial

BACKGROUND

Individuals with substance use disorders (SUDs) frequently use acute hospital services. The Navigation Services to Avoid Rehospitalization (NavSTAR) trial found that a patient navigation intervention for hospitalized patients with comorbid SUDs reduced subsequent inpatient admissions compared to treatment-as-usual (TAU).

METHODS

This secondary analysis extends previous findings from the NavSTAR trial by examining whether selected patient characteristics independently predicted hospital service utilization and moderated the effect of the NavSTAR intervention. Participants were 400 medical/surgical hospital patients with comorbid SUDs. We analyzed 30- and 90-day inpatient readmissions (one or more readmissions) and cumulative incidence of inpatient admissions through 12 months using multivariable logistic and negative binomial regression, respectively.

RESULTS

Consistent with primary findings and controlling for patient factors, NavSTAR participants were less likely than TAU participants to be readmitted within 30 (P = 0.001) and 90 (P = 0.03) days and had fewer total readmissions over 12 months (P = 0.008). Hospitalization in the previous year (P < 0.001) was associated with cumulative readmissions over 12 months, whereas Medicaid insurance (P = 0.03) and index diagnoses of infection (P = 0.001) and injuries, poisonings, or procedural complications (P = 0.004) were associated with fewer readmissions. None of the selected covariates moderated the effect of the NavSTAR intervention.

CONCLUSIONS

Previous findings showed that patient navigation could reduce repeat hospital admissions among patients with comorbid SUDs. Several patient factors were independently associated with readmission. Future research should investigate risk factors for hospital readmission among patients with comorbid SUDs to optimize interventions.

TRIAL REGISTRATION

NIH ClinicalTrials.gov NCT02599818, Registered November 9, 2015 https://classic.

CLINICALTRIALS

gov/ct2/show/NCT02599818 .

A trial of implementation facilitation to increase timely admission to methadone treatment

BACKGROUND

During the ongoing opioid epidemic, some Opioid Treatment Programs (OTPs) are unable to admit program applicants in a timely fashion. Interim methadone (IM) treatment (without routine counseling) is an effective approach to overcome this challenge when counseling capacity is inadequate to permit admissions within 14 days of request. It requires both federal and state approval and has been rarely utilized since its incorporation into the federal OTP regulations in 1993.

METHODS

We evaluated the impact of Implementation Facilitation (IF) on OTPs providing timely admission to methadone treatment (i.e., within 14 days of request), adopting IM, and changing admissions procedures. IF included data collection on admission processes and an external facilitator who engaged OTP leadership, Local Champions through site visits, remote academic detailing, and feedback. Local Champions and State Opioid Treatment Authorities (SOTAs) participated in learning collaboratives. Using a modified stepped wedge design, six OTPs in four US states on the east and west coasts were randomly assigned to one of two clusters that staggered the timing of IF receipt. Study Phases included: Pre-Implementation, IF, and Sustainability. OTPs submitted data on treatment requests and admissions for 28 months (N = 3108 requests for treatment).

RESULTS

Although none of the OTPs adopted IM, all six developed policies and procedures to enable its use. Some OTPs streamlined admissions processes prior to study launch and during the IF intervention. OTPs reduced admission delays over time, although there was substantial site heterogeneity. The IF Phase for the early cluster coincided with the onset of COVID-19, complicating the study. Rates of timely admission within 14 days of request were 56.2 % (Pre-Implementation), 55.8 % (IF), and 78.8 % (Sustainability). Compared to the Pre-Implementation Phase, the odds of timely admission were not significantly different during the IF Phase but significantly higher during the Sustainability Phase (OR = 2.35 [95 % CI = 1.34, 4.12]; p = 0.003).

CONCLUSIONS

Committing to study participation and IF activities may have prompted some OTPs to change practices that improved timely admission. Attributing changes to IF should be done with caution considering study limitations. Data collection for the study spanned the COVID-19 pandemic, which complicates interpretation.

TRIAL REGISTRATION

Clinicaltrials.gov registration # NCT04188977.

Patient and provider medication preferences affect treatment outcomes among adolescents and young adults with opioid use disorder

BACKGROUND

The opioid epidemic in the United States has not spared youth or young adults, as evidenced by a six-fold increase in opioid use disorder (OUD) diagnoses in the last two decades. Given this dramatic rise, a call for greater uptake and accessibility of medications for opioid use disorder (MOUDs) among youth and young adults has ensued, resulting in an increasing number of MOUD treatment pathways for this vulnerable population.

METHODS

This secondary data analysis seeks to characterize patient and provider preferences for MOUD treatment pathways, and test for associations between baseline MOUD treatment preferences and opioid use and treatment adherence outcomes. Participants included 288 youth and young adults (age 15-21 years), recruited from a residential treatment program in Maryland. The study assessed patient preferences at baseline (n = 253) and provider preferences at patient treatment discharge (n = 224). Mixed-effects negative binomial regression models were conducted for opioid use outcomes, and logistic regressions were conducted for treatment adherence outcomes.

RESULTS

Results indicate that congruence of treatment with patients' (Incidence Rate Ratio [IRR] = 0.65) and providers' (IRR = 0.66) preferences was significantly associated with reduced self-reported days of opioid use in the past 90 days, but only for patients receiving extended-release naltrexone (XR-NTX). Results also indicated that patients were less likely to switch medication treatment pathways (e.g., from XR-NTX to buprenorphine, or vice versa) during follow-up if they received their preferred treatment at baseline, a finding which held true for both XR-NTX (Odds Ratio [OR] = 0.32) and buprenorphine (OR = 0.22).

CONCLUSIONS

Receipt of MOUD congruent with patient and provider preferences was associated with reduced opioid use and greater treatment adherence in this sample of youth and young adults with OUD.

State guidance and system changes related to COVID-19: Impact on opioid treatment programs

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.

Decreases in Employer Referrals to First-Time Substance Use Treatment for Adults From 2004 to 2020

OBJECTIVE

The aim of the study is to examine trends of employer/employee assistance program referred admissions to outpatient substance use disorder (SUD) treatment in the United States.

METHODS

The publicly available Treatment Episode Data Set was used. Full-time employed adults with no history of SUD treatment referred to outpatient treatment by an employer/employee assistance program from 2004 to 2020 were included ( N = 36,142). Joinpoint regression examined admission trends.

RESULTS

Employer/employee assistance program referred admissions to outpatient treatment decreased annually by 6.4% from 2004 to 2020 ( P < 0.001). Joinpoint analyses identified 2 linear segments from 2004 to 2008 (increased but not significant) and from 2008 to 2020. From 2008 to 2020, an average annual percent decrease of 8.7% ( P < 0.001) was identified.

CONCLUSIONS

Findings from this repeated cross-sectional study suggest a missed opportunity for workplaces to serve as a potential SUD treatment access point.

Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment

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.

The Relationship between Vaping Cannabis and Frequency of Cannabis Use and Cannabis-Related Problems among Urban High School Students

Background: Vaping, including vaping cannabis, is increasing among adolescents. In this longitudinal study, we examined the relationship between vaping cannabis and frequency of cannabis use and related problems over 6 months among adolescents. Material and Methods: Data were from 233 participants (46.8% male, 93.1% African American, mean age = 16.4 years) reporting cannabis use. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) assessed frequency of past 30-day cannabis use and cannabis-related problems at baseline, 3- and 6-months post-baseline. We used latent growth curve modeling to compare vaping to non-vaping adolescents on trends in cannabis use frequency and ASSIST cannabis scores. Results: Adolescents who vaped cannabis (11.7%) had higher past 30-day frequency (mean = 17.89 days, SD = 10.49) of cannabis use at baseline compared to adolescents who had not vaped (mean = 12.1 days, SD = 10.93), but reported a significantly sharper decline in frequency of cannabis use (b = -0.34, p = 0.017). A significantly steeper decrease existed in the mean cannabis ASSIST scores for the vaping group than for the non-vaping group (b = -0.34, p = 0.014). Mean ASSIST scores on the cannabis subscale between the two groups were significantly different at 6-month follow-up (Vape mean = 6.00, SD = 8.12 vs. Non-vape mean = 9.6, SD = 9.39; p < 0.021). Conclusions: In a sample of cannabis-using adolescents, adolescents with experience vaping cannabis, compared to adolescents without vaping experience, on average reported sharper decreases in frequency of cannabis use and cannabis-related problems such as health or social problems.

Opioid Use Disorder Treatment Linkage at Strategic Touchpoints Using Buprenorphine (OUTLAST-B): Rationale, Design, and Evolution of a Randomized Controlled Trial

Background

Despite the effectiveness and growing availability of treatment for opioid use disorder (OUD) with buprenorphine, many people with OUD do not access treatment services. This article describes the rationale, methodological design, evolution, and progress of an ongoing clinical trial of treatment linkage strategies for people with untreated OUD.

Methods

The study, titled Opioid Use Disorder Treatment Linkage at Strategic Touchpoints using Buprenorphine (OUTLAST-B), uses "strategic touchpoints", initially sexual health clinics and subsequently broadened to other service venues and participant social networks, for recruitment and screening. Adults with untreated OUD (target N = 360) are randomized to one of the three arms: Usual Care (UC, enhanced with overdose education and naloxone distribution), Patient Navigation (PN), or Patient Navigation with an immediate short-term bridge prescription for buprenorphine (PN + BUP). In the PN and PN + BUP arms, the Patient Navigator works with participants for 2 months to facilitate treatment entry and early retention, resolve barriers (e.g., ID cards, transportation), and provide motivational support.

Results

The primary outcome is OUD treatment entry within 30 days of enrollment. Participants are assessed at baseline and followed at 3- and 6-months post-enrollment on measures of healthcare utilization, substance use, and general functioning. Challenges and recruitment adaptations pursuant to the COVID-19 pandemic are discussed.

Conclusions

This study could provide insights on how to reach people with untreated OUD and link them to care through non-traditional routes.

Trial Registration

The study is registered at ClinicalTrials.gov (NCT04991974).

Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder

Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.

The Spanish language version of the TAPS tool: protocol for a validation and implementation study in primary care

BACKGROUND

The TAPS Tool ("Tobacco, Alcohol, Prescription drug, and illicit Substance use") is a screening and brief assessment for detecting unhealthy substance use in healthcare settings that was developed by the National Institute on Drug Abuse Clinical Trials Network and validated in a multisite study. Our team developed a Spanish language version of the TAPS Tool that supports provider- and self-administration screening using a mobile/web-based platform, the TAPS Electronic Spanish Platform (TAPS-ESP).

METHODS

This article describes the protocol and rationale for a study to validate the TAPS-ESP in a sample of Spanish-speaking primary care patients recruited from a network of community-based clinics in Texas (target N = 1,000). The TAPS-ESP will be validated against established substance use disorder diagnostic measures, alternative screening tools, and substance use biomarkers. The study will subsequently examine barriers and facilitators to screening with the TAPS-ESP from a provider workflow perspective using qualitative interviews with providers.

DISCUSSION

Validating a Spanish language version of the TAPS Tool could expand access to evidence-based, linguistically accurate, and culturally relevant substance use screening and brief assessment for an underserved health disparity population.

TRIAL REGISTRATION

The study was registered with www.

CLINICALTRIALS

gov : NCT05476588, 07/22/2022.

Clinical Decision Support to Reduce Opioid Prescriptions for Dental Extractions using SMART on FHIR: Implementation Report

BACKGROUND

Clinical decision support (CDS) has the potential to improve clinical decision-making consistent with evidence-based care. CDS can be designed to save health care providers time and help them provide safe and personalized analgesic prescribing.

OBJECTIVE

The aim of this report is to describe the development of a CDS system designed to provide dentists with personalized pain management recommendations to reduce opioid prescribing following extractions. The use of CDS is also examined.

METHODS

This study was conducted in HealthPartners, which uses an electronic health record (EHR) system that integrates both medical and dental information upon which the CDS application was developed based on SMART (Substitutable Medical Applications and Reusable Technologies) on FHIR (Fast Healthcare Interoperability Resources). The various tools used to bring relevant medical conditions, medications, patient history, and other relevant data into the CDS interface are described. The CDS application runs a drug interaction algorithm developed by our organization and provides patient-specific recommendations. The CDS included access to the state Prescription Monitoring Program database.

IMPLEMENTATION (RESULTS)

The pain management CDS was implemented as part of a study examining opioid prescribing among patients undergoing dental extraction procedures from February 17, 2020, to May 14, 2021. Provider-level use of CDS at extraction encounters ranged from 0% to 87.4% with 12.1% of providers opening the CDS for no encounters, 39.4% opening the CDS for 1%-20% of encounters, 36.4% opening it for 21%-50% of encounters, and 12.1% opening it for 51%-87% of encounters.

CONCLUSIONS

The pain management CDS is an EHR-embedded, provider-facing tool to help dentists make personalized pain management recommendations following dental extractions. The SMART on FHIR-based pain management CDS adapted well to the point-of-care dental setting and led to the design of a scalable CDS tool that is EHR vendor agnostic.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03584789; https://clinicaltrials.gov/study/NCT03584789.

Health care use and cost of treatment for adolescents and young adults with opioid use disorder

BACKGROUND

Few studies have examined the cost of medication for opioid use disorder (MOUD) with counseling for the adolescent and young adult population. This study calculated the health care utilization and cost of MOUD treatment, other substance use disorder treatment, and general health care for adolescents and young adults receiving treatment for opioid use disorder.

METHODS

The study randomized youth ages 15 to 21 (N = 288) equally into the two study conditions: extended-release naltrexone (XR-NTX) or treatment as usual (TAU). While participants committed to treatment based on randomization the study observed considerable nonadherence to both randomized conditions. Instead of using the randomly assigned study conditions, we present descriptive costs by the type of MOUD treatment received: XR-NTX only, buprenorphine only, any other combination of MOUD treatments, and no MOUD. Health care use was aggregated over the 6-month period for each participant, and we calculated average/participant utilization for each treatment group. To determine participant costs, we multiplied the unit costs of health care services obtained from the literature by the reported amount of health care utilization for each participant. We then calculated the mean, standard error, median and IQR for MOUD costs, other substance use disorder treatment costs and general healthcare cost from the health care sector perspective.

RESULTS

On average, participants in the XR-NTX only group received 2.6 doses of XR-NTX (equivalent to approximately 78 days of treatment). The buprenorphine only group had an average of 97 days of buprenorphine treatment. The XR-NTX only group had higher/patient costs compared to participants in the buprenorphine only group ($10,491 vs. $8765) and higher XR-NTX utilization would further increase costs. Participants in the any other MOUD combination group had the highest total costs ($14,627) while participants in the no MOUD group at the lowest ($3453).

DISCUSSION

Our cost analysis calculates the real-world cost of MOUD treatment and, while not generalizable, provides policy makers an estimate of costs for adolescents and young adults. We found that participants in the XR-NTX only group received fewer days of medication compared to the buprenorphine only group, but their medication costs were higher due to the cost of XR-NTX injections. While the buprenorphine only group had the highest number of days of medication utilization of all the groups, the average number of days of medication utilization was considerably shorter than the six-month treatment period.

Impact of COVID-19-related methadone regulatory flexibilities: views of state opioid treatment authorities and program staff

BACKGROUND

During the COVID-19 pandemic, federal regulations in the USA for methadone treatment of opioid use disorder (OUD) were temporarily revised to reduce clinic crowding and promote access to treatment.

METHODS

As part of a study seeking to implement interim methadone without routine counseling to hasten treatment access in Opioid Treatment Programs with admission delays, semi-structured qualitative interviews were conducted via Zoom with participating staff (N = 11) in six OTPs and their State Opioid Treatment Authorities (SOTAs; N = 5) responsible for overseeing the OTPs' federal regulatory compliance. Participants discussed their views on the response of OTPs in their states to the pandemic and the impact of the COVID-related regulatory flexibilities on staff, established patients, and new program applicants. Interviews were audio recorded, transcribed, and a content analysis was conducted using ATLAS.ti.

RESULTS

All SOTAs requested the blanket take-home exemption and supported the use of telehealth for counseling. Participants noted that these changes were more beneficial for established patients than program applicants. Established patients were able to obtain a greater number of take-homes and attend individual counseling remotely. Patients with limited resources had greater difficulty or were unable to access remote counseling. The convenience of intake through telehealth did not extend to new program applicants because the admission physical exam requirement was not waived.

CONCLUSIONS

The experienced reflections of SOTAs and OTP providers on methadone practice changes during the COVID-19 pandemic offer insights on SAMHSA's proposed revisions to its OTP regulations. Trial registration Clinicaltrials.gov # NCT04188977.

Comparing outcomes of extended-release naltrexone in adolescents and young adults with opioid use disorder

INTRODUCTION

Opioid use among youth is a public health concern in the United States, with >3300 overdose deaths occurring nationally each year. Unfortunately, youth in the United States are still prescribed medication for opioid use disorder (OUD) at a lower rate than their adult counterparts.

METHODS

From 10/2013 to 01/2018, adolescents (ages 15-17; n = 25) and young adults (ages 18-21; n = 263) with moderate to severe OUD enrolled in the parent trial of extended-release naltrexone (XR-NTX; n = 82) versus treatment-as-usual (TAU; either buprenorphine maintenance [n = 94] or counseling without buprenorphine maintenance [n = 112]). The study assessed opioid use outcomes for adolescents vs. young adults using timeline follow-back self-report procedures at baseline and 3-/6-month follow-up assessments. Mixed-effects longitudinal and clustered panel regression models compared treatment effects over time of XR-NTX and TAU on opioid use outcomes in this secondary analysis.

RESULTS

Though adolescent participants reported significantly less opioid use at baseline relative to their young adult counterparts (p < 0.05), the two age groups reported similar rates of opioid use throughout the intervention period. Additionally, both adolescents and young adults receiving XR-NTX evidenced lower rates of opioid use than those receiving TAU at all time points, and adolescents on XR-NTX were the only group who reduced their opioid use at all time points. Mixed-effects models indicated adolescents receiving XR-NTX demonstrated a 48 % lower rate of opioid use days [Incidence Rate Ratio (IRR) = 0.52; p = 0.020], while young adults receiving XR-NTX reported an estimated 26 % lower rate (IRR = 0.74; p = 0.009).

CONCLUSIONS

Results indicate that adolescents respond favorably to XR-NTX relative to TAU for treatment of OUD, demonstrating similar outcomes to young adults.

The effect of a non-congregate, integrated care shelter on health: A qualitative study

OBJECTIVE

To describe the experiences of unstably housed, medically vulnerable residents living at the Haven, a novel, non-congregate integrated care shelter operating in a historic hotel during the COVID-19 pandemic.

DESIGN

A qualitative descriptive design.

SAMPLE/MEASUREMENT

Semi-structured qualitative interviews were conducted in February and March 2022 with a purposive sample of 20 residents living in the integrated care shelter. Data were analyzed in May and June 2022 using the thematic analysis methods described by Braun and Clarke.

RESULTS

Six women and 14 men, ages 23-71 (M = 50, SD = 14), were interviewed. Lengths of stay at the time of the interview ranged from 74 to 536 days (M = 311 days). Medical co-morbidities and substance use details were collected at baseline. Three themes were identified: (1) Autonomy, (2) supportive environments, and (3) stability and the need for permanent housing. Participants characterized the integrated care, non-congregate model as having multiple advantages over traditional shelter systems. Participants emphasized the role of nurses and case managers in providing a respectful, caring environment in the integrated shelter model.

CONCLUSION

Participants described acute physical and mental health needs which were largely met by the innovative integrated shelter care model. The effect of homelessness and housing insecurity on health is well documented, but few solutions exist that promote autonomy. Participants in this qualitative study emphasized the benefits of living in a non-congregate integrated care shelter and the services which promoted their self-management of chronic diseases.

PATIENT OR PUBLIC CONTRIBUTION

Patients were the participants in the study, but were not involved in the design, analysis of interpretation of the data, or preparation of the manuscript. Due to this project's small scope, we could not involve patients or the public after the study concluded data collection.

De-Implementing Opioids for Dental Extractions (DIODE): a multi-clinic, cluster-randomized trial of clinical decision support strategies in dentistry

BACKGROUND

Opioid pain relievers are commonly prescribed following dental extractions, but evidence shows that non-opioid analgesics often provide adequate pain relief with fewer risks. The current study examined clinical decision support (CDS) as a tool for de-implementing opioid prescribing in dentistry.

METHODS

This prospective, cluster-randomized trial examined CDS for dental pain management at 22 HealthPartners Dental Group clinics in Minnesota. Dental providers (n = 49) were randomized to deliver care using CDS, CDS with patient education materials (CDS-E), or standard practice (SP). Randomization was stratified by provider type (dentist vs. oral surgeon) and baseline opioid prescribing volume. Patient records of dental extractions were examined for January 2019 through May 2021, representing a 12-month baseline and 15-month intervention period (N = 12,924). Opioid prescription at the visit (no vs. yes) was the primary outcome. Data were analyzed using generalized linear mixed models, adjusting for patient sex and age, extraction complexity, and baseline prescribing strata (volume and provider type).

RESULTS

Patients were 56.2% female, with a mean age of 46.7 (SD = 20.0) years. Providers were 8% oral surgeons, 57% female, and with a mean age of 43.7 (SD = 11.2) years. There were significant decreases in opioid prescribing during the study (P < 0.001), representing a continuation of pre-existing trends to reduce opioid prescribing in these dental practices. There were no significant differences in opioid prescribing between CDS and SP (OR = 1.29; 97.5% CI = 0.93, 1.79; P = 0.08), or CDS-E and SP arms (OR = 1.27; 97.5% CI = 0.86, 1.79; P = 0.18). The direction of the association favored greater reductions in opioid prescribing in the SP arm. Despite training and implementation support, utilization of the CDS was low, particularly among oral surgeons, who were significantly more likely than other dentists to prescribe opioids. Among non-oral surgeon providers with the opportunity to access it, CDS utilization was not significantly associated with opioid prescribing.

CONCLUSIONS

Equipping dentists with CDS resources, whether alone or accompanied by patient education materials, did not accelerate reductions in opioid prescribing beyond those observed in standard practice. Strategies are needed to enhance CDS utilization for patient care and safety surrounding analgesia following dental extractions.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03584789.

De-implementing opioid prescribing in a dental group practice: Lessons learned

BACKGROUND

Drug overdose has become a leading cause of accidental death in the United States. Between 2000 and 2015, the rate of deaths from drug overdoses increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (including opioid pain relievers and heroin). Unnecessary opioid prescribing is one of the factors driving this epidemic.

OBJECTIVES

The primary objective of this paper is to share lessons learned while conducting a randomized trial to de-implement opioids for post-extraction pain management utilizing clinical decision support (CDS) with and without patient education. The lessons learned from conducting this trial in a real-world setting can be applied to future dissemination and implementation oral health research.

METHODS

The sources informing lessons learned were generated from qualitative interviews conducted with 20 of the forty-nine dental providers involved in the study following the implementation phase of the trial. Ongoing policy, social and environmental factors were tracked throughout the study.

RESULTS

Dental providers in the trial identified the impact of training that involved health professionals sharing information about the personal impact of pain and opioid use. Additionally, they found utility in being presented with a dashboard detailing their prescribing patterns related to other dentists. For the 30 general dentists with access to the CDS, use of its portal varied widely, with most using it 10%-49% of the time related to extractions.

CONCLUSIONS

In the context of a downward trend in opioid prescribing and considering the influence of the COVID pandemic during the trial, dental providers indicated benefit in training about negative personal impacts of prescribing opioids, and personally relevant feedback about their prescribing patterns. Only modest use of the CDS was realized. Implementation of this trial was impacted by governmental and health system policies and the COVID pandemic, prompt the consideration of implications regarding continuing ways to limit opioid prescribing among dental providers.

Sustainability of Adolescent Screening and Brief Intervention Services in Primary Care After Removal of Implementation Supports

OBJECTIVE

Although many health care organizations have sought to increase the integration of substance use services into clinical practice, such practice changes can prove difficult to sustain.

METHOD

Seven primary care clinics participated in an implementation study of screening and brief intervention (BI) services for adolescent patients (ages 12-17). All sites delivered screening and brief advice (BA) for low-risk use using a uniform protocol. Clinics were randomized to deliver BI using generalist (provider-delivered) or specialist (behavioral health clinician-delivered) models. Implementation was facilitated by multiple supporting activities (e.g., trainings, local "champion," electronic health record [EHR] integration of screening and documentation, individualized feedback, project-specific materials, etc.). Data on the penetration of screening, BA, and BI delivery (N = 14,486 adolescent patient visits) were abstracted from the EHR for the 20-month implementation phase and a 12-month sustainability phase (during which implementation supports were removed).

RESULTS

Penetration of screening continued to slowly increase across the implementation-to-sustainability phases (62% vs. 70%; p = .04). Although uptake during implementation was low for BA (29%) and BI (22%), there was no significant decrease in service provision during the sustainability phase. Although overall delivery of BI was significantly higher in generalist compared with specialist sites (p < .001), sustainability did not differ by generalist versus specialist conditions. There were considerable differences in penetration across clinic sites.

CONCLUSIONS

Clinics sustained a high level of substance use screening. Uptake of intervention services was low but did not decrease further following the cessation of implementation supports. This study illustrates the challenges of successfully implementing and sustaining substance use services in adolescent primary care.

The impact of COVID-19 on the treatment of opioid use disorder in carceral facilities: a cross-sectional study

While the COVID-19 pandemic disrupted healthcare delivery everywhere, persons with carceral system involvement and opioid use disorder (OUD) were disproportionately impacted and vulnerable to severe COVID-associated illness. Carceral settings and community treatment programs (CTPs) rapidly developed protocols to sustain healthcare delivery while reducing risk of COVID-19 transmission. This survey study assessed changes to OUD treatment, telemedicine use, and re-entry support services among carceral and CTPs participating in the National Institute on Drug Abuse (NIDA)-funded study, Long-Acting Buprenorphine vs. Naltrexone Opioid Treatments in Criminal Justice System-Involved Adults (EXIT-CJS) study. In December 2020, carceral sites (n = 6; median pre-COVID 2020 monthly census = 3468 people) and CTPs (n = 7; median pre-COVID 2020 monthly census = 550 patients) participating in EXIT-CJS completed a cross-sectional web-based survey. The survey assessed changes pre- (January-March 2020) and post- (April-September 2020) COVID-19 in OUD treatment, telemedicine use, re-entry supports and referral practices. Compared to January-March 2020, half of carceral sites (n = 3) increased the total number of persons initiating medication for opioid use disorder (MOUD) from April-September 2020, while a third (n = 2) decreased the number of persons initiated. Most CTPs (n = 4) reported a decrease in the number of new admissions from April-September 2020, with two programs stopping or pausing MOUD programs due to COVID-19. All carceral sites with pre-COVID telemedicine use (n = 5) increased or maintained telemedicine use, and all CTPs providing MOUD (n = 6) increased telemedicine use. While expansion of telemedicine services supported MOUD service delivery, the majority of sites experienced challenges providing community support post-release, including referrals to housing, employment, and transportation services. During the COVID-19 pandemic, this small sample of carceral and CTP sites innovated to continue delivery of treatment for OUD. Expansion of telemedicine services was critical to support MOUD service delivery. Despite these innovations, sites experienced challenges providing reintegration supports for persons in the community. Pre-COVID strategies for identifying and engaging individuals while incarcerated may be less effective since the pandemic. In addition to expanding research on the most effective telemedicine practices for carceral settings, research exploring strategies to expand housing and employment support during reintegration are critical.

Characteristics and correlates of fentanyl preferences among people with opioid use disorder

OBJECTIVES

Fentanyl has come to dominate the U.S. illicit opioid supply. We aimed to characterize and examine correlates of preferences for fentanyl vs. other opioids among individuals starting OUD treatment.

METHODS

We interviewed 250 adults initiating buprenorphine treatment with positive fentanyl toxicology at intake. We characterized opioid preferences and examined bivariate associations between opioid preference (preference for heroin, fentanyl, heroin-fentanyl mix, or other opioid) and sociodemographic characteristics, psychosocial factors, and substance use behaviors. We then used multinomial logistic regression to examine factors independently associated with fentanyl preferences.

RESULTS

Over half (52.0 %) of participants preferred fentanyl (21.2 % fentanyl alone, 30.8 % heroin-fentanyl mix). In bivariate comparisons, participants who preferred fentanyl were a higher acuity group with respect to risks and problems in general. In the multinomial logistic regression, people who preferred fentanyl, either alone or mixed with heroin, used non-prescribed buprenorphine less in the 30 days preceding treatment entry compared to people who preferred heroin or other opioids (RRRalone= 0.88 [0.78, 0.99]; P = 0.037 and RRRmixed= 0.91 [0.84, 0.99]; P = 0.046). People who preferred fentanyl alone were also younger (RRR= 0.93 [0.90, 0.97]; P < 0.001) and more likely to have severe mental illness (RRR= 2.5 [1.1, 5.6]; P = 0.027) than people who prefer heroin or other opioids.

CONCLUSIONS

Many people with OUD report preferring fentanyl. People who express preference for fentanyl differ substantively from those with other opioid preferences, and may be at elevated risk for poor health outcomes. Understanding preferences surrounding fentanyl could inform treatment and harm reduction interventions.

Cost and Cost Savings of Navigation Services to Avoid Rehospitalization for a Comorbid Substance Use Disorder Population

BACKGROUND

A randomized clinical trial found that patient navigation for hospital patients with comorbid substance use disorders (SUDs) reduced emergency department (ED) and inpatient hospital utilization compared with treatment-as-usual.

OBJECTIVE

To compare the cost and calculate any cost savings from the Navigation Services to Avoid Rehospitalization (NavSTAR) intervention over treatment-as-usual.

RESEARCH DESIGN

This study calculates activity-based costs from the health care providers and uses a net benefits approach to calculate the cost savings generated from NavSTAR. NavSTAR provided patient navigation focused on engagement in SUD treatment, starting before hospital discharge and continuing for up to 3 months postdischarge.

SUBJECTS

Adult hospitalized medical/surgical patients with comorbid SUD for opioids, cocaine, and/or alcohol.

COST MEASURES

Cost of the 3-month NavSTAR patient navigation intervention and the cost of all inpatient days and ED visits over a 12-month period.

RESULTS OF BASE CASE ANALYSIS

NavSTAR generated $17,780 per participant in cost savings. Ninety-seven percent of bootstrapped samples generated positive cost savings, and our sensitivity analyses did not change our results.

LIMITATIONS

Participants were recruited at one hospital in Baltimore, MD through the hospital's addiction consultation service. Findings may not generalize to the broader population. Outpatient health care cost data was not available through administrative records.

CONCLUSION

Our findings show that patient navigation interventions should be considered by payors and policy makers to reduce the high hospital costs associated with comorbid SUD patients.

Sexually Transmitted Infection Testing After Brief Intervention for Risk Behaviors in School-Based Health Centers

PURPOSE

The initiation and escalation of substance use and sex behaviors is prevalent during adolescence. School-based health centers (SBHCs) are well-equipped to provide interventions for risky behaviors and offer sexually transmitted infection (STI) testing services. This study examined receipt of STI testing following brief intervention (BI) among sexually active adolescents.

METHODS

This is a secondary analysis of data from a randomized trial comparing computer versus nurse practitioner-delivered BI approaches among adolescents (ages 14-18) with risky alcohol and/or cannabis use at two SBHCs within two urban high schools. Associations were examined among receipt of STI testing and participant characteristics, BI format, site, and frequency of substance use/sexual behaviors.

RESULTS

Among sexually active participants (N = 254), 64.2% received STI testing at their SBHC within 6 months of receiving a BI. Participants receiving nurse practitioner-delivered BI had higher odds of getting STI testing than participants receiving computer-delivered BI (adjusted odds ratio 2.51, 95% confidence interval 1.41-4.47, p = .002). Other variables associated with STI testing in multivariable logistic regression included female sex (p = .001), being in a serious relationship (p = .018), and SBHC site (p < .001). Frequency of substance use and sexual risk behaviors were not independently associated with receipt of STI testing services.

CONCLUSION

Sexually active adolescents who received in-person BI from a nurse practitioner were more likely to get STI testing than adolescents who received BI via computer. Nurse practitioners working in SBHCs can successfully engage adolescents in additional sexual health services subsequent to BI for risky behaviors.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care

OBJECTIVE

This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT).

METHOD

SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars.

RESULTS

The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist.

CONCLUSIONS

The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Continuing Care App for Probationers and Parolees with Substance use Disorders

This pilot proof-of-concept study examined the feasibility and acceptability of a Continuing Care mobile application (app) designed to meet the recovery and personal support needs of individuals under justice supervision who were receiving outpatient substance use disorder (SUD) treatment. The study included adults on probation or parole who were enrolled in an outpatient SUD treatment program (N = 15; 86.7% males). Participants were instructed to utilize the Continuing Care app daily for 4 weeks. At the end of the study, they completed a satisfaction questionnaire. Of the 15 participants enrolled in the study, 12 (80%) completed the Continuing Care app modules and the satisfaction questionnaire, and all of these participants indicated high levels of satisfaction with the app (on a scale of 1-10, Mean = 1.8, SD = 1.2). The Continuing Care app was well-utilized and perceived as valuable by this group of low-income, underserved, and hard-to-reach individuals. Further research is needed to refine app content and evaluate its ability to meaningfully enhance and extend the benefits of SUD treatment.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Patient, Provider Type, and Procedure Type Factors Associated with Opioid Prescribing by Dentists in a Health Care System

Introduction

Reports examining opioid prescribing for dental conditions are limited and do not examine patient-level factors. This study examines the association of patient age, sex, race, ethnicity, Medicaid coverage, and the need for an interpreter in addition to procedure type and dental provider type with receipt of an opioid prescription in dental care settings within a large health system.

Materials and Methods

This study was conducted utilizing data from the electronic health record of HealthPartners, a large dental practice embedded within a health care system. The analytic sample consisted of all 169,173 encounters from 90,487 patients undergoing a dental procedure in the baseline period (9/1/2018 to 8/30/2019), prior to implementing a clinical trial to de-implement opioids in dentistry.

Results

Opioids were prescribed at 1.9% of all 169,173 encounters and rates varied by patient factors, procedure category, and provider type. Opioid prescriptions were most likely for extraction encounters (25.9%). In a multivariable analysis of 8760 extraction encounters, all patient age groups were more likely than those age 66+ to receive an opioid prescription, particularly those age 18–25 (OR=6.94). Patients having a complex rather than simple extraction were more likely to receive an opioid prescription (OR=6.31) and those seen by an oral surgeon rather than a general dentist (OR=9.11) were more likely to receive an opioid prescription. Among 108,748 encounters with a diagnostic procedure, opioid prescribing was more likely among male than female patients (OR=1.20), Black patients relative to White (OR=1.69), patients with Medicaid coverage (OR=1.86), and patients seeing an oral surgeon rather than a general dentist (OR=27.81).

Conclusion

Opioid prescribing rates vary considerably depending on procedure type. Patterns of associations between patient factors and opioid prescribing also vary considerably across procedure type. To understand which patient groups are more at risk of being prescribed opioids, it is essential to consider the procedures they are receiving.

Long-acting buprenorphine vs. naltrexone opioid treatments in CJS-involved adults (EXIT-CJS)

The EXIT-CJS (N = 1005) multisite open-label randomized controlled trial will compare retention and effectiveness of extended-release buprenorphine (XR-B) vs. extended-release naltrexone (XR-NTX) to treat opioid use disorder (OUD) among criminal justice system (CJS)-involved adults in six U.S. locales (New Jersey, New York City, Delaware, Oregon, Connecticut, and New Hampshire). With a pragmatic, noninferiority design, this study hypothesizes that XR-B (n = 335) will be noninferior to XR-NTX (n = 335) in retention-in-study-medication treatment (the primary outcome), self-reported opioid use, opioid-positive urine samples, opioid overdose events, and CJS recidivism. In addition, persons with OUD not eligible or interested in the RCT will be recruited into an enhanced treatment as usual arm (n = 335) to examine usual care outcomes in a quasi-experimental observational cohort.

Preventing Hospital Readmission for Patients With Comorbid Substance Use Disorder : A Randomized Trial

BACKGROUND

Hospitalized patients with comorbid substance use disorders (SUDs) are at high risk for poor outcomes, including readmission and emergency department (ED) use.

OBJECTIVE

To determine whether patient navigation services reduce hospital readmissions.

DESIGN

Randomized controlled trial comparing Navigation Services to Avoid Rehospitalization (NavSTAR) versus treatment as usual (TAU). (ClinicalTrials.gov: NCT02599818).

SETTING

Urban academic hospital in Baltimore, Maryland, with an SUD consultation service.

PARTICIPANTS

400 hospitalized adults with comorbid SUD (opioid, cocaine, or alcohol).

INTERVENTION

NavSTAR used proactive case management, advocacy, service linkage, and motivational support to resolve internal and external barriers to care and address SUD, medical, and basic needs for 3 months after discharge.

MEASUREMENTS

Data on inpatient readmissions (primary outcome) and ED visits for 12 months were obtained for all participants via the regional health information exchange. Entry into SUD treatment, substance use, and related outcomes were assessed at 3-, 6-, and 12-month follow-up.

RESULTS

Participants had high levels of acute care use: 69% had an inpatient readmission and 79% visited the ED over the 12-month observation period. Event rates per 1000 person-days were 6.05 (NavSTAR) versus 8.13 (TAU) for inpatient admissions (hazard ratio, 0.74 [95% CI, 0.58 to 0.96]; P = 0.020) and 17.66 (NavSTAR) versus 27.85 (TAU) for ED visits (hazard ratio, 0.66 [CI, 0.49 to 0.89]; P = 0.006). Participants in the NavSTAR group were less likely to have an inpatient readmission within 30 days than those receiving TAU (15.5% vs. 30.0%; P < 0.001) and were more likely to enter community SUD treatment after discharge (P = 0.014; treatment entry within 3 months, 50.3% NavSTAR vs. 35.3% TAU).

LIMITATION

Single-site trial, which limits generalizability.

CONCLUSION

Patient navigation reduced inpatient readmissions and ED visits in this clinically challenging sample of hospitalized patients with comorbid SUDs.

PRIMARY FUNDING SOURCE

National Institute on Drug Abuse.

Drug and sexual HIV-risk behaviors among adolescents and young adults with opioid use disorder

Opioid use disorder (OUD) among adolescents and young adults (youth) is associated with drug use and sexual HIV-related risk behaviors and opioid overdose. This mixed methods analysis assesses risk behaviors among a sample of 15-21-year-olds (N = 288) who were being treated for OUD in a residential drug treatment program in Baltimore, Maryland. Participants were enrolled in a parent study in which they received either extended-release naltrexone (XR-NTX) or Treatment as Usual (TAU), consisting of outpatient counseling with or without buprenorphine, prior to discharge. At baseline, participants were administered the HIV-Risk Assessment Battery (RAB), and clinical intake records were reviewed to determine participants' history of sexual, physical, or other abuse, as well as parental and partner substance use. A sub-sample of study participants completed semi-structured qualitative interviews (N = 35) at baseline, three-, and six-month follow-up periods. This analysis identified gender (e.g., female IRR = 1.63, CI 1.10-2.42, p = .014), the experience of dependence (e.g., previous detoxification IRR = 1.08, CI 1.01-1.15, p = .033) and withdrawal (e.g., severe withdrawal symptoms IRR = 1.41, CI 1.08-1.84, p = .012), and the role of relationships (e.g., using with partner IRR = 2.45, CI 1.15-5.22, p = .021) as influencing high-risk substance use behaviors. Similarly, high-risk sex was influenced by gender (e.g., female IRR = 1.43, CI 1.28-1.59, p < .001), and the role of relationships (e.g., using with partner IRR = 0.78, CI 0.62-0.98, p = .036). These are key targets for future prevention, treatment, and intervention.

Extended-release naltrexone for youth with opioid use disorder

BACKGROUND

Few published research studies have examined the effectiveness of extended-release naltrexone (XR-NTX) for the treatment of opioid use disorder (OUD) among adolescents and young adults.

METHODS

This two-group randomized controlled trial recruited 288 youth, ages 15-21, with moderate/severe OUD from a residential addiction treatment program in Baltimore, Maryland. The study randomized the youth within the first week of treatment entry to receive either XR-NTX or treatment-as-usual (TAU; either buprenorphine maintenance treatment or treatment without OUD medication following medically managed withdrawal) prior to discharge, with continued treatment in the community for 6 months. However, due to various reasons spanning patients' and caregivers' preferences and constraints, considerable participant nonadherence to randomized condition occurred (i.e., only 30% of the participants randomized to XR-NTX received an initial injection, while 27% of participants randomized to TAU received an XR-NTX injection at treatment discharge, instead of their assigned treatment). The study used generalized linear mixed modeling (GLiMM) to examine self-reported 90-day opioid, cocaine, marijuana, and alcohol use as well as DSM-5 OUD criteria on "intention-to-treat" (as randomized), "as-received" (XR-NTX vs. not XR-NTX), and "as-medicated" (XR-NTX vs. buprenorphine vs. no medication) bases.

RESULTS

The condition x time interactions in the intention-to-treat analyses failed to reach significance for past-90-day self-reported use of illicit opioids, cocaine, marijuana, or alcohol, or in meeting DSM-5 OUD criteria at 3 or 6 months [all ps > 0.05]. However, these findings are of limited interpretive value due to participant nonadherence to their randomized condition. When the study analyzed results by the treatment received at discharge, the "as-received" group x time interaction for illicit opioid use was significant [p = .003], with the XR-NTX group reporting less opioid use in the past 90 days at 3 and 6 months. Participants who received their first XR-NTX dose at inpatient discharge (n = 82) received, on average, 1.3 subsequent injections in the community over the 6-month study follow-up period. Only 2 of the 82 study participants received XR-NTX continuously through the 6-month postdischarge follow-up period. Twelve serious adverse events (SAEs) occurred during the study, but the study determined that only 1 was possibly study related (hepatitis C/elevated liver function test results).

CONCLUSION

None of the condition x time interactions in the intention-to-treat analyses reached significance. Participants' nonadherence may have contributed to the failure to reject the null hypothesis. Irrespective of randomized condition, participants who received XR-NTX for OUD demonstrated low retention in treatment, receiving an average of only 1.3 subsequent injections, yet reported less opioid use at follow-up than participants who did not received XR-NTX. Treatment programs should consider XR-NTX as a treatment option for youth motivated to receive it. Future research should focus on building developmentally informed strategies to improve uptake of and adherence to relapse prevention medication in this population.

De-Implementing Opioid Use and Implementing Optimal Pain Management Following Dental Extractions (DIODE): Protocol for a Cluster Randomized Trial

Background

Overdose deaths from prescription opioid analgesics are a continuing crisis in the United States. Opioid analgesics are among the most frequently prescribed drugs by dentists. An estimated 5 million people undergo third-molar extractions in the United States each year, resulting in postoperative pain. Studies show that, in most cases, the combination of ibuprofen and acetaminophen is an effective alternative to commonly prescribed opioid analgesics for the management of postextraction pain. Nevertheless, many dentists routinely prescribe opioids after dental extractions.

Objective

We describe the rationale, design, and methods for a randomized trial of interventions designed to de-implement opioid prescribing by dentists while implementing effective nonopioid analgesics following dental extractions.

Methods

Using a prospective, 3-arm, cluster randomized trial design with dentists as the unit randomized and patient-level prescribing data as the primary outcome, we will compare different strategies to reduce the reliance on opioids and increase the use of alternative pain management approaches utilizing information support tools aimed at both providers and their patients. The study will test the efficacy of 2 interventions to decrease opioid prescribing following dental extractions: clinical decision support with (CDS-E) and without patient education (CDS). Providers will be randomized to CDS, CDS-E, or standard practice. Patient-level outcomes will be determined via review of comprehensive electronic health records. We will compare study arms on differential change in prescribing patterns from pre- to postimplementation of the intervention. The primary outcome of interest is a binary indicator of whether or not the patient received an opioid prescription on the day of the extraction encounter. We will also examine recommendations or prescriptions for nonopioid analgesics, patients’ perceptions of shared decision making, and patients’ pain experiences following the extraction.

Results

The HealthPartners Institutional Review Board approved the study. All study materials including the CDS and patient education materials have been developed and pilot tested, and the protocol has been approved by the National Institute of Dental and Craniofacial Research. The intervention was implemented in February 2020, with 51 dentists who were randomized to 1 of the 3 arms.

Conclusions

If the intervention strategies are shown to be effective, they could be implemented more broadly in dental settings with high levels of opioid prescribing.

Trial Registration

ClinicalTrials.gov NCT03584789, https://clinicaltrials.gov/ct2/show/NCT03584789

International Registered Report Identifier (IRRID)

DERR1-10.2196/24342

Use of non-prescribed buprenorphine in the criminal justice system: Perspectives of individuals recently released from incarceration

Buprenorphine, an effective treatment for opioid use disorder (OUD), remains underutilized in many U.S. jails and prisons. However, use of non-prescribed (i.e., diverted) buprenorphine has been reported in these settings. The current study examined non-prescribed buprenorphine use experiences in correctional and community contexts. The study conducted face-to-face interviews with 300 adults with OUD/opioid misuse and recent incarceration, recruited in Baltimore, MD, and New York, NY (n = 150 each). Illicit/non-prescribed opioid use during incarceration was reported by 63% of participants; 39% reported non-prescribed buprenorphine. Non-prescribed buprenorphine was considered the most widely available opioid in jails/prisons in both states (81% reported "very" or "somewhat" easy to get). The average price of non-prescribed buprenorphine in jail/prison was ~10× higher than in the community (p < 0.001). Participants were more likely to endorse getting high/mood alteration as reasons for using non-prescribed buprenorphine during incarceration, but tended to ascribe therapeutic motives to use in the community (e.g., self-treatment; p < 0.001). Multivariable logistic regression analyses showed that different individual-level characteristics were associated with history of non-prescribed buprenorphine use during incarceration and in the community. Use of non-prescribed buprenorphine during incarceration was associated with younger age (p = 0.006) and longer incarceration history (p < 0.001), while use of non-prescribed buprenorphine in the community was associated with MD recruitment site (p = 0.001), not being married (p < 0.001), prior buprenorphine treatment experience (p < 0.001), and housing situation (p = 0.01). These findings suggest that different dynamics and demand characteristics underlie the use of non-prescribed buprenorphine in community and incarceration contexts, with implications for efforts to expand OUD treatment in correctional settings.

An alternative analysis of illicit opioid use during treatment in a randomized trial of extended-release naltrexone versus buprenorphine-naloxone: A per-protocol and completers analysis

BACKGROUND

The distinct pharmacological properties and clinical uses of extended-release naltrexone (XR-NTX) and sublingual buprenorphine-naloxone (BUP-NX) present challenges in analyzing patient outcomes.

METHODS

We conducted a secondary analysis of a multi-site randomized trial comparing XR-NTX with sublingual BUP-NX treatment for opioid use disorder initiated during inpatient detoxification and continued in outpatient treatment. Urine testing data for non-study opioids from the last 22 weeks of the 24-week trial were analyzed in both a per-protocol sample (n = 474 participants who received at least one dose of medication) and a completers sample (n = 211 participants who received all XR-NTX doses or all BUP-NX prescriptions). The present analyses sought to identify differences in the weekly percentages of opioid-positive urine tests between participants treated with the two medications.

RESULTS

The proportion of opioid-positive tests in both conditions was less than 20 % for 21 of the 22 weeks in the per-protocol sample and all 22 weeks in the completers sample. Generalized linear mixed model analyses revealed a significant treatment (XR-NTX vs. BUP-NX) X week (weeks 3-24) interaction in the per-protocol sample but not the completers sample. In the per-protocol analysis, the BUP-NX, compared to XR-NTX, had significantly greater proportions of opioid-positive tests in 14 out of the 22 weeks.

CONCLUSIONS

Longitudinal modeling approaches that utilize flexible procedures for handling missing data can offer a different perspective on study findings. Results from the present analyses suggest that XR-NTX appeared to be somewhat more effective than BUP-NX in reducing illicit opioid use in the per-protocol sample.

Development and Feasibility of a Spanish Language Version of the Tobacco, Alcohol, Prescription Drug, and Illicit Substance Use (TAPS) Tool

OBJECTIVES

The Tobacco, Alcohol, Prescription drug, and illicit Substance use (TAPS) Tool is a validated two-stage screening and brief assessment in primary care for unhealthy substance use. We developed a Spanish language version of the TAPS Tool and conducted a small study of its feasibility, acceptability, and preliminary validity.

METHODS

Participants were adult primary care patients ages 18 or older with Spanish as their primary language (N = 10 for development/refinement using qualitative congnitive interviewing; N = 100 for the preliminary validation study). The Spanish language TAPS Tool was administered in both interviewer- and selfadministered tablet format (in random order). We examined disclosure of substance use on the TAPS by administration format, and compared it with established measures for identifying substance use and substance use disorders.

RESULTS

The Spanish language TAPS was feasible to use and participants reported high levels of acceptability. The rates of past 12-month substance use were 11% for tobacco, 28% for risky alcohol, 4% for illicit drugs, 1% for nonmedical prescription drugs and substance use disorders rates were 7% for tobacco, 2% for alcohol, and 1% for other substances. The selfadministered TAPS elicited 1, 3, and 1 additional disclosures of tobacco, risky, alcohol, and marijuana use than the interviewer-administered TAPS, respectively. Rates of disclosure on the TAPS were similar to those on established measures for past 12-month and 3-month time frames.

CONCLUSIONS

The current study represents a starting point for expanding the availability of the TAPS Tool beyond its original English language version into Spanish. The Spanish language TAPS Tool could expand options for substance use screening in primary care settings with Spanish-dominant/preferred populations.

TRIAL REGISTRATION

The studies were registered with www.clinicaltrials.gov: NCT03879785, March 19, 2019.

Randomized trial of methadone treatment of arrestees: 24-month post-release outcomes

BACKGROUND

We report on the 24-month post-release outcomes of arrestees with opioid use disorder (OUD) enrolled in a randomized trial comparing three treatment approaches initiated in jail.

METHODS

Adults (N = 225) receiving medically supervised withdrawal from opioids in the Baltimore Detention Center within a few days of arrest were randomly assigned to: (1) interim methadone treatment plus patient navigation (IM + PN) started in the Detention Center; (2) IM; or (3) Enhanced Treatment-as-Usual (ETAU) consisting of detoxification with methadone and referral to treatment in the community. Participants in both methadone conditions could transfer to standard methadone treatment following release. Participants were interviewed at baseline, and 1, 3, 6, 12, and 24 months post-release. Urine was drug tested at follow-up and official arrest records were obtained.

RESULTS

On an intention-to-treat basis, there were no significant differences among the three conditions over the 24-month post-release period in terms of opioid- or cocaine-positive urine test results or self-reported opioid or cocaine use, meeting opioid or cocaine use disorder criteria, self-reported criminal behavior, or the number of official arrests. There were 9 fatal overdoses, none occurring during methadone treatment, and 109 hospitalizations unrelated to the study.

CONCLUSIONS

Given the high morbidity and mortality found in this population of arrestees and costs to society associated with their health care utilization and continued crime and arrests, research aimed at finding more effective interventions should be continued.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov: NCT02334215.

Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care

Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Leveraging health information exchange for clinical research: Extreme underreporting of hospital service utilization among patients with substance use disorders

BACKGROUND

Substance use disorders are associated with inefficient and fragmented use of healthcare services. The Chesapeake Regional Information System for Our Patients, Inc. (CRISP) is a Health Information Exchange (HIE) linking disparate systems of care in the mid-Atlantic region.

METHODS

This article describes applications of HIE for tracking hospital service utilization in substance use disorder clinical and services research, drawing upon data from one of the first studies approved to access the CRISP HIE. Participants were 200 medical/surgical inpatients with comorbid opioid, cocaine, and/or alcohol use disorder (45.5 % female; 56.5 % black; 77.5 % opioid use disorder; 42.0 % homeless). This study compared HIE-identified hospital service utilization with conventional methods of participant self-report during in-person research follow-ups (3-, 6-, and 12-months post-discharge) and electronic health record (EHR) review from the hospital system of the index admission.

RESULTS

This sample exhibited high levels of hospital utilization, which would have been underestimated using conventional methods. Relying exclusively on self-report in the 12-month observation period would have identified only 33.8 % of 429 inpatient hospitalizations and 9.0 % of 1,287 ED visits, due to both loss-to-follow-up and failure to report events. Even combining self-report with single-system EHR review identified only 66.2 % of inpatient hospitalizations and 59.8 % of ED visits.

CONCLUSIONS

CRISP HIE data were superior to conventional methods for ascertaining hospital service utilization in this sample of patients exhibiting high-volume and fragmented care. The use of HIE holds implications for improving rigor, safety, and efficiency in research studies.

A Latent Class Analysis of HIV Risk Factors Among Men and Women with Opioid Use Disorder in Pre-trial Detention

Adults entering pre-trial detention who inject drugs are at high risk for acquiring HIV/AIDS. In the current study, we examined pre-incarceration HIV risk behaviors among 114 people with opioid use disorder who inject drugs. Participants were recruited from the Baltimore City Detention Center as part of a randomized controlled trial of pre-release methadone treatment. Using latent class analysis, we found three separate latent classes, which we identified as the sex exchange class (14.2%), drug equipment sharing class (36.8%) and lower risk class (49.0%). Women in the sex exchange class (n = 16) reported having multiple male partners and selling sex for money or drugs; however, this group also reported more consistent condom use and less frequent injection drug and equipment sharing than participants in the drug equipment sharing class. Our findings highlight distinct profiles of jail detainees with OUD based on their risks for HIV, and could inform more targeted interventions for each group.Clinical Trials Registration: Clinicaltrials.gov NCT02334215.

A novel telehealth platform for alcohol use disorder treatment: preliminary evidence of reductions in drinking

BACKGROUND

Alcohol use disorder (AUD) treatment remains greatly underutilized. Innovative strategies are needed to improve AUD treatment access and patient engagement. The Ria Treatment Platform (RTP) is a patient-centered telemedicine AUD treatment program accessed through a smartphone application (app) that includes a package of physician visits (with AUD prescriptions as appropriate), text- and phone-based support from a recovery coach, video monitoring of medication adherence, and Bluetooth-linked breathalyzer tracking of alcohol intake.

OBJECTIVES

The purpose of the current study is to examine changes in alcohol use among patients utilizing the RTP.

METHODS

This study examines daily breathalyzer blood alcohol content (BAC) readings collected from 77 adult patients (50.7% male) over the first 90 days in treatment with the RTP. Data were analyzed using dynamic structural equation modeling.

RESULTS

The treatment retention rate at 90 days was 55%. The best fit for the BAC data was given by a cubic curve, which showed that among patients who remained engaged for 90 days average BAC levels declined approximately 50% (from .091 to .045) from baseline to day 90.

CONCLUSION

This study provides preliminary evidence of substantial alcohol use reductions among patients utilizing the RTP, an innovative telemedicine program accessed via smartphone. Although other alcohol-reduction apps have shown promise from scientific evaluations, the RTP appears to be the only app that incorporates physician-prescribed medication and a recovery coach. Research incorporating random assignment and meaningful comparison groups is needed to further evaluate this promising strategy.

Comparison of timeline follow-back self-report and oral fluid testing to detect substance use in adult primary care patients

BACKGROUND

Timeline Follow-back (TLFB) interviews using self-report are often used to assess substance use. Oral fluid testing (OFT) offers an objective measure of substance use. There are limited data on the agreement between TLFB and OFT.

METHODS

In this secondary analysis from a multisite study in five primary care sites, self-reported TLFB and OFT data collected under confidential conditions were compared to assess concordance (N=1799). OFT samples were analyzed for marijuana, heroin, cocaine, and non-medical use of prescription opioids. Demographic differences in discordance relative to TLFB and OFT concordant results for marijuana, the only substance with an adequate sample size in this analysis, were examined using multinomial logistic regression.

RESULTS

Overall concordance rates between TLFB and OFT were 94.9 % or higher for each substance, driven by large subgroups with no use. Among participants with discordant use, marijuana was the only substance with lower detection on OFT than self-report (27.6 % OFT-positive only vs 32.2 % TLFB-positive only), whereas cocaine (65.6 % vs 8.6 %), prescription opioids (90.4 % vs 6.0 %), and heroin (40.7 % vs 26.0 %) all had higher detection via OFT than TLFB. Participants who reported marijuana use but had a negative OFT were more likely to be younger, Hispanic, and White compared to those with TLFB and OFT concordant positive results.

CONCLUSIONS

TLFB and OFT show disparate detection of different substances. Researchers should consider the implications of using either self-report or oral fluid testing in isolation, depending on the substance and collection setting. Triangulating multiple sources of information may improve detection of drug use.

Commentary on "The More Things Change: Buprenorphine/Naloxone Diversion Continues While Treatment is Inaccessible"

: This commentary puts the recent findings by Carroll et al into historical perspective, noting both the long-held problem of medication diversion when pharmacotherapy access is limited, and the ways in which medication diversion concerns and regulations help create those treatment access barriers. Recent efforts to bridge the treatment gap, including increases in Federal funding through the 21st Century Cures Act and expanding the buprenorphine patient cap and scope of eligible providers under the Comprehensive Addiction Recovery Act (CARA) will likely help; however, important structural barriers remain. Health insurance barriers, including limited Medicaid coverage, combined with stigma against pharmacotherapy persist, which likely means that people in need of treatment will continue to self-treat their symptoms with diverted medications, such as the buprenorphine/naloxone use noted by Carroll and colleagues.

Computerizing NIAAA's Best Practices for Youth Screening and Brief Intervention: A Proof-of-Concept Pilot Study of an Automated Alcohol Screening and Intervention Resource Tool

This article reports findings from formative research on translating key elements of the National Institute on Alcohol Abuse and Alcoholism (NIAAA) and American Academy of Pediatrics Practitioner's Guide for pediatric alcohol misuse to a computerized web- and mobile-compatible format with patient risk screening and tailored decision support content. Five practitioners at an urban primary care center used a prototype computerized version of the NIAAA/American Academy of Pediatrics Practitioner's Guide with 80 adolescent patients during routine health-care visits. Practitioners reported a high level of practitioner and adolescent patient engagement and satisfaction with the prototype. Study findings indicate that computerization of the NIAAA Practitioner's Guide is feasible and well accepted by providers and adolescent patients and could be useful for addressing alcohol misuse in primary care settings.

Adolescent SBIRT implementation: Generalist vs. Specialist models of service delivery in primary care

BACKGROUND

Drug, alcohol, and tobacco use among adolescents pose significant short- and long-term health consequences and are associated with more severe use as adults. Screening, brief intervention, and referral to treatment in primary care settings has the potential to deliver preventive interventions to a diverse range of adolescents, but optimal implementation of these services needs to be determined. The purpose of this study was to compare implementation of two different SBIRT service delivery models in primary care settings.

METHODS

This cluster-randomized trial assigned 7 primary care clinics of a federally qualified health center to implement brief interventions (BI) using a Generalist model (4 sites), in which BIs were delivered by the primary care provider (PCP), or a Specialist model (3 sites), in which BIs were delivered by a behavioral health counselor (BHC) for adolescent patients ages 12-17 years. Implementation was tracked through the clinic's electronic health record, spanning 9639 clinic visits over 20 months. Multilevel logistic regression modeling was used to compare Generalist and Specialist strategies on penetration of BI for patients scoring ≥2 on the CRAFFT substance use screen, delivered by the PCP in the Generalist sites, and via warm hand-off to a BHC in the Specialist sites.

RESULTS

Approximately 62% of adolescent patient visits were screened with the CRAFFT (with <4% screening positive with a CRAFFT score ≥ 2). The Generalist Condition had significantly higher self-reported penetration of BI delivery than the Specialist Condition (38% vs. 8%; Adjusted Odds Ratio = 6.53; p = .005).

DISCUSSION

Despite having co-located behavioral health services at all sites, a Specialist approach to providing BI was less effectively implemented than a Generalist approach in this FQHC. BI delivered by PCPs rather than by hand-off to a BHC may ensure greater penetration of these services in primary care settings. Both implementation models provided a framework for identifying and intervening with adolescent primary care patients whose substance use might have otherwise gone undetected.

Fentanyl exposure and preferences among individuals starting treatment for opioid use disorder

BACKGROUND

Fentanyl has become widespread in the illicit opioid supply, and is a major driver of overdose mortality.

METHODS

This study used a medical records review at a community opioid use disorder treatment program to examine patient-level correlates of fentanyl exposure as measured by urine testing at admission (N= 1,174). Additionally, an anonymous survey was conducted with 114 patients about their experiences and preferences regarding fentanyl.

RESULTS

Overall, 39% of patients entering treatment tested positive for fentanyl. Prevalence of fentanyl exposure differed based on other drug test results (fentanyl-positive = 81.1% vs. 15.4% among participants positive vs. negative for heroin/opioids, p < .001; 59.0% vs. 38.3% among participants positive vs. negative for methadone, p = .001; 53.8% vs. 24.9% among participants positive vs. negative for cocaine, p < .001), prior addiction treatment (40.6% vs. 32.0% among participants with vs. without prior treatment, p < .05), and mental health (36.7% vs. 43.1% among participants with vs. without co-occurring psychiatric diagnosis, p < .05). Most participants reported knowingly using fentanyl (56.1%) and knowing people who prefer fentanyl as a drug of choice (65.8%). Preference for fentanyl (alone or mixed with heroin) was expressed by 44.7% of participants. Participants thought fentanyl withdrawal had faster onset (53.5%), greater severity (74.8%), and longer duration (62.0%) than heroin withdrawal.

CONCLUSIONS

Recent opioid and cocaine use were strongly associated with fentanyl exposure in this sample. Although fentanyl exposure is often unintentional, there may be a subgroup of individuals who come to prefer fentanyl. Future research should examine the relationship between fentanyl use, patient preferences for fentanyl, and treatment outcomes.

Disclosure of Adolescent Substance Use in Primary Care: Comparison of Routine Clinical Screening and Anonymous Research Interviews

PURPOSE

The American Academy of Pediatrics recommends substance use screening in adolescent primary care. Many studies of substance use prevalence and screening tool validation are conducted under research protocols that differ from routine clinical screening in context, consequences, and privacy implications.

METHODS

This study is a secondary analysis drawing from two projects focused on adolescent primary care patients, aged 12-17, conducted nearly contemporaneously in a Federally Qualified Health Center system. The first project conducted anonymous research interviews with patients (N = 525), while the other tracked routine clinical screening as part of a larger service implementation project (N = 5,971). Both projects assessed substance use with the CRAFFT screening tool.

RESULTS

Rates of substance use disclosure and substance use problems were over three and four times higher, respectively, in the anonymous research interview sample compared to rates found in routine clinical screening (p values < .001).

CONCLUSIONS

Routine clinical screening may underestimate substance use among adolescents.

Initiating methadone in jail and in the community: Patient differences and implications of methadone treatment for reducing arrests

The extent to which patient characteristics differ between individuals entering methadone treatment through community programs and jail-based programs is not known. Such differences could impact the likelihood of relapse and recidivism in these two populations and inform efforts at targeting interventions. We compared treatment-entry characteristics of participants enrolling in methadone treatment in two studies conducted in Baltimore, one conducted in community programs (N = 295) and the other in a jail-based program (N = 225). Controlling for age, race, and gender, individuals starting methadone treatment in jail compared to the community, had more severe drug use and criminal justice profiles. These different characteristics suggest that patients initiating methadone in a jail-based program could have greater likelihood of future arrest compared to patients entering community-based treatment. CLINICAL TRIALS REGISTRATION: Clinicaltrials.gov NCT 02334215 and NCT 01442493.

Pharmacotherapy for opioid addiction in community corrections

Pharmacotherapy for opioid addiction with methadone, buprenorphine, and naltrexone has proven efficacy in reducing illicit opioid use. These treatments are under-utilized among opioid-addicted individuals on parole, probation, or in drug courts. This paper examines the peer-reviewed literature on the effectiveness of pharmacotherapy for opioid addiction of adults under community-based criminal justice supervision in the US. Compared to general populations, there are relatively few papers addressing the separate impact of pharmacotherapy on individuals under community supervision. Tentative conclusions can be drawn from the extant literature. Reasonable evidence exists that illicit opioid use and self-reported criminal behaviour decline after treatment entry, and that these outcomes are as favourable among individuals under criminal justice supervision as the general treatment population. Surprisingly, there is no conclusive evidence regarding the extent to which pharmacotherapy impacts the likelihood of arrest and incarceration among individuals under supervision. However, given the proven efficacy of these three medications in reducing illicit opioid use and the evidence that, in the general population, methadone and buprenorphine treatment are associated with reduction in overdose mortality, the use of all three pharmacotherapies among patients under criminal justice supervision should be expanded while more data are collected on their impact on arrest and incarceration.