Long-term retention in Office Based Opioid Treatment with buprenorphine

Acceptability and Feasibility of a Mobile Health Application for Video Directly Observed Therapy of Buprenorphine for Opioid Use Disorders in an Office-based Setting

INTRODUCTION/BACKGROUND

Video directly observed therapy (video-DOT) through a mobile health platform may improve buprenorphine adherence and decrease diversion. This pilot study tested the acceptability and feasibility of using this technology among patients receiving buprenorphine in an office-based setting.

METHODS

Participants were instructed to record videos of themselves taking buprenorphine. Data were collected from weekly in-person visits over a 4-week period; assessments included self-report of medication adherence, substance use, satisfaction with treatment and use of the application, and also urine drug testing. Open-ended questions at the final visit solicited feedback on patients' experiences using the mobile health application.

RESULTS

The sample consisted of 14 patients; a majority were male (86%) and White (79%). All participants except 1 (93%) were able to use the application successfully to upload videos. Among those who successfully used the application, the percentage of daily videos uploaded per participant ranged from 18% to 96%; on average, daily videos were submitted by participants 72% of the time. Most participants (10/14; 71%) reported being "very satisfied" with the application; of the remaining 4 participants, 2 were "satisfied" and 2 were "neutral." Participants reported liking the accountability and structure of the application provided and its ease of use. Negative feedback included minor discomfort at viewing one's self during recording and the time required.

CONCLUSIONS

Based on these results, use of a mobile health application for video-DOT of buprenorphine appears feasible and acceptable for patients who are treated in an office-based setting. Further research is needed to test whether use of such an application can improve treatment delivery and health outcomes.

Mental Health and Psychosocial Needs of Patients Being Treated for Opioid Use Disorder in a Primary Care Residency Clinic

Purpose: Primary care is an ideal setting to deliver efficacious treatments for opioid use disorder (OUD). Primary care providers need to be aware of other concerns patients with OUD might have in order to provide comprehensive care. This study describes the prevalence of mental health, comorbid substance use, and psychosocial concerns of patients seeking treatment for OUD in primary care and their relation to 6-month treatment retention. Methods: Patients (N = 100; M age = 34.9 years (SD = 10.8), 74% white, 46% female) with OUD who were starting treatment with buprenorphine at an academic family medicine residency clinic completed surveys of mental health concerns (depression, anxiety, trauma), psychosocial needs (food insecurity, income, transportation, employment), and demographic variables. Chart reviews were conducted to gather information on comorbid substance use, mental health diagnoses, and 6-month treatment retention. Results: Mental health symptoms were highly prevalent in this sample (44% screened positive for anxiety, 31% for depression, and 52% for posttraumatic stress disorder). Three-quarters reported use of illicit substances other than opioids. Many patients also had significant psychosocial concerns, including unemployment (54%), low income (75%), food insecurity (51%), and lacking reliable transportation (64%). Two-thirds (67%) of the sample were retained at 6 months; patients who previously used intravenous opioids were more likely to discontinue treatment (P = .003). Conclusions: Many patients receiving treatment for OUD have significant mental health problems, comorbid substance use, and psychosocial concerns; interestingly, none of these factors predicted treatment retention at 6 months. Primary care clinics would benefit from having appropriate resources, interventions, and referrals for these comorbid issues in order to enhance overall patient well-being and promote recovery.

Targeting the Barriers in the Substance Use Disorder Continuum of Care With Peer Recovery Support

Substance Use Disorder (SUD) has been recognized as a chronic, relapsing disorder. However, much of existing SUD care remains based in an acute care model that focuses on clinical stabilization and discharge, failing to address the longer-term needs of people in recovery from addiction. The high rates of client’s disengagement and attrition across the continuum of care highlight the need to identify and overcome the obstacles that people face at each stage of the treatment and recovery process. Peer recovery support services (PRSS) show promise in helping people initiate, pursue, and sustain long-term recovery from substance-related problems. Based on a comprehensive review of the literature, the goal of this article is to explore the possible roles of peers along the SUD care continuum and their potential to improve engagement in care by targeting specific barriers that prevent people from successfully transitioning from one stage to the next leading eventually to full recovery. A multidimensional framework of SUD care continuum was developed based on the adapted model of opioid use disorder cascade of care and recovery stages, within which the barriers known to be associated with each stage of the continuum were matched with the existing evidence of effectiveness of specific PRSSs. With this conceptual paper, we are hoping to show how PRSSs can become a complementary and integrated part of the system of care, which is an essential step toward improving the continuity of care and health outcomes.

An Exploratory Study of Sex and Gender Differences in Demographic, Psychosocial, Clinical, and Substance Use Treatment Characteristics of Patients in Outpatient Opioid Use Disorder Treatment with Buprenorphine

As treatment expansion in the opioid epidemic continues, it is important to examine how the makeup of individuals with opioid use disorder (OUD) is evolving. Treatment programs are increasingly utilizing buprenorphine, an effective OUD medication. This exploratory study examines sex and gender differences in psychosocial, clinical and substance use treatment characteristics of a clinical population in outpatient medication treatment for OUD with buprenorphine. This is a secondary data analysis from a cross-sectional survey study with retrospective medical record review conducted with patients recruited from an office-based opioid treatment clinic between July-September 2019. Participants on buprenorphine for at least 28 days at time of survey completion were included (n=133). Differences between men and women were explored with Pearson χ2 and Fisher's Exact Tests for categorical variables and T-Tests for continuous variables. The sample was 55.6% women and nearly three-fourths Black (70.7%). Mean days in current treatment episode was 431.6 (SD=244.82). Women were younger and more likely to be unemployed, identify as a sexual minority, and live alone with children than men. More women than men had a psychiatric comorbidity. Women reported more prescription opioid misuse while men had more heroin only opioid use. More men reported comorbid alcohol use and a history of drug overdose. One-third of participants reported recent discrimination in a healthcare setting due to substance use. As buprenorphine-based outpatient treatment programs continue to expand, present study findings support evaluation of the unique needs of men and women in order to better tailor OUD-related services and improve treatment outcomes.

Prospective Study on Factors Associated with Referral of Patients with Opioid Maintenance Therapy from Specialized Addictive Disorders Centers to Primary Care

Background: One of the most important issues for opiate maintenance therapy efficacy is the involvement of primary care physicians (PCPs) in opiate use disorder treatment, especially after referral from specialized units. This study aimed to analyze the progress of subjects in a specialized center and after referral to PCPs. Methods: This study was an observational prospective study. Recruitment took place in a specialized addictive disorder center in western France. All patients were evaluated (sociodemographical data, severity of substance use disorders through the TMSP scale, the quality of life through the TEAQV scale) by physicians during the 5-year-follow up of the study. Analysis focused on four main times during follow-up: entry/last visit into specialized care and into primary care. Results: 113 patients were included in this study; 93% were receiving methadone and 7% buprenorphine. Ninety (90) were referred to primary care. In primary care follow-up, the probability of the lowest severity score for substance use disorders remained stable over time. Conclusions: In daily practice, a center specialized in addictive disorders referred OMT management to PCPs for a majority of patients, and benefits regarding substance use disorders severity and quality of life remained stable after referral. Our results need to be confirmed.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Perspectives on electronic portal use among patients treated with medications for opioid use disorder in primary care

OBJECTIVES

Office-based opioid treatment (OBOT) with buprenorphine is increasingly integrated in primary care to treat opioid use disorder (OUD). Online portals seek to engage patients in care of their chronic medical conditions, yet we know little about how patients with OUD experience these portals. Our study explores how patients with OUD perceive the impact of portal use on addiction treatment and clinical care.

MATERIALS AND METHODS

We purposively sampled patients with an active portal account enrolled in an OBOT program embedded within primary care, stratifying by recent or distant portal use. The study conducted individual semistructured interviews to understand how patients perceived and interfaced with the portal until the study reached saturation of themes. The research team analyzed the data via thematic analysis and three investigators independently coded the data to identify themes, which all authors then refined.

RESULTS

Among 17 participants, 9 were recent users and 8 were distant. Though we stratified analyses by level of portal use, the study observed no differences in resultant themes, thus the study combined themes, which we present here. Portal use was felt to (1) facilitate and reinforce OUD and other substance use treatment goals, (2) improve health care participation, (3) enable monitoring and addressing broader health concerns beyond SUD treatment, and (4) have mixed impacts on patient-provider trust.

DISCUSSION

Our findings suggest that patients with OUD identify aspects of the patient portal contributing to their engagement and retention in substance use treatment. Lingering concerns remain about the potential of portal use to negatively impact the patient-provider relationship.

Patterns of patient discontinuation from buprenorphine/naloxone treatment for opioid use disorder: A study of a commercially insured population in Massachusetts

BACKGROUND

Research has shown buprenorphine/naloxone to be an effective medication for treating individuals with opioid use disorder. At the same time, treatment discontinuation rates are reportedly high though much of the extant evidence comes from studies of the Medicaid population.

OBJECTIVES

To examine the pattern and determinants of buprenorphine/naloxone treatment discontinuation in a population of commercially insured individuals.

RESEARCH DESIGN

We performed a retrospective observational analysis of Massachusetts All Payer Claims Data (MA APCD) covering years 2013 through 2017. We defined treatment discontinuation as a gap of 60 consecutive days without a prescription for buprenorphine/naloxone within a time frame of 24 months from the initiation of treatment. A mixed-effect Cox proportional hazard model examined the associated risk of discontinuing treatment with baseline predictors.

SUBJECTS

A total of 5134 individuals who were commercially insured during the study period.

MEASURES

Buprenorphine/naloxone treatment discontinuation.

RESULTS

Overall 75% of individuals had discontinued treatment within two years of initiating treatment, and median time to discontinuation was 300 days. Patients aged between 18 and 24 years (HR = 1.436, 95%, CI = 1.240-1.663) and receiving treatment from prescribers with high panel-size (HR = 1.278, 95% CI = 1.112-1.468) had higher risk of discontinuing treatment. On the contrary, patients receiving treatment from multiple prescribers had lower associated risk of treatment discontinuation.

CONCLUSIONS

A substantial percentage of patients discontinue treatment well before they can typically meet criteria for sustained remission. Further investigations should assess the clinical outcomes following premature discontinuation and identify strategies for retaining patients in treatment.

A chance to do it better: Methadone maintenance treatment in the age of Covid-19

Methadone maintenance treatment (MMT) in the United States, and particularly the clinic system of distribution, is often criticized as punitive, over-regulated, and misaligned to the needs of many patients. However, changes to the regulations that COVID-19 caused may have provided an opportunity for improving service. This commentary uses literature and my own experience to provide a brief description of how MMT programs responded to the threat of Covid-19 and how such responses fit into the larger context of attempts to reform treatment. It discusses, in particular, opportunities for liberalizing "take-home" doses and implementing office-based MMT.

PRimary Care Opioid Use Disorders treatment (PROUD) trial protocol: a pragmatic, cluster-randomized implementation trial in primary care for opioid use disorder treatment

Background

Most people with opioid use disorder (OUD) never receive treatment. Medication treatment of OUD in primary care is recommended as an approach to increase access to care. The PRimary Care Opioid Use Disorders treatment (PROUD) trial tests whether implementation of a collaborative care model (Massachusetts Model) using a nurse care manager (NCM) to support medication treatment of OUD in primary care increases OUD treatment and improves outcomes. Specifically, it tests whether implementation of collaborative care, compared to usual primary care, increases the number of days of medication for OUD (implementation objective) and reduces acute health care utilization (effectiveness objective). The protocol for the PROUD trial is presented here.

Methods

PROUD is a hybrid type III cluster-randomized implementation trial in six health care systems. The intervention consists of three implementation strategies: salary for a full-time NCM, training and technical assistance for the NCM, and requiring that three primary care providers have DEA waivers to prescribe buprenorphine. Within each health system, two primary care clinics are randomized: one to the intervention and one to Usual Primary Care. The sample includes all patients age 16–90 who visited the randomized primary care clinics from 3 years before to 2 years after randomization (anticipated to be > 170,000). Quantitative data are derived from existing health system administrative data, electronic medical records, and/or health insurance claims (“electronic health records,” [EHRs]). Anonymous staff surveys, stakeholder debriefs, and observations from site visits, trainings and technical assistance provide qualitative data to assess barriers and facilitators to implementation. The outcome for the implementation objective (primary outcome) is a clinic-level measure of the number of patient days of medication treatment of OUD over the 2 years post-randomization. The patient-level outcome for the effectiveness objective (secondary outcome) is days of acute care utilization [e.g. urgent care, emergency department (ED) and/or hospitalizations] over 2 years post-randomization among patients with documented OUD prior to randomization.

Discussion

The PROUD trial provides information for clinical leaders and policy makers regarding potential benefits for patients and health systems of a collaborative care model for management of OUD in primary care, tested in real-world diverse primary care settings.

Trial registration # NCT03407638 (February 28, 2018); CTN-0074 https://clinicaltrials.gov/ct2/show/NCT03407638?term=CTN-0074&draw=2&rank=1

Systematic content analysis of patient evaluations of START NOW psychotherapy reveals practical strategies for improving the treatment of opioid use disorder

BACKGROUND

Clinical trials provide consistent evidence for buprenorphine's efficacy in treating opioid use disorder (OUD). While the Drug Addiction Treatment Act of 2000 requires physicians to combine medication-assisted treatment (MAT) with behavioral intervention, there is no clear evidence for what form or elements of psychotherapy are most effective when coupled with MAT to treat OUD. This investigation involves focus groups designed to collect patient opinions about a specific psychotherapy, called START NOW, as well as general beliefs about various elements of psychotherapy for treating OUD. Our analysis reveals trends about patient preferences and strategies for improving OUD treatment.

METHODS

Subjects included patients enrolled in buprenorphine/naloxone MAT at our institution's office-based opioid treatment program. All subjects participated in a single START NOW group session, which was led by a provider (physician or nurse practitioner trained and standardized in delivering START NOW). Consented subjects participated in satisfaction surveys and audio-recorded focus groups assessing individual beliefs about various elements of psychotherapy for treating OUD.

RESULTS

Overall, 38 different focus groups, 92 participation events, and 44 unique subjects participated in 1-to-6 different START NOW session/audio-recorded focus group sessions led by a certified moderator. Demographic data from 36/44 subjects was collected. Seventy-five percent (33/44) completed the START NOW Assessment Protocol, which revealed self-reported behavioral trends. Analysis of all 92 START NOW Satisfaction Questionnaire results suggests that subjects' opinions about START NOW improved with increased participation. Our analysis of audio-recorded focus groups is divided into three subsections: content strategies for new psychotherapies, implementation strategies, and other observations. For example, participants request psychotherapies to target impulsivity and to teach future planning and build positive relationships.

CONCLUSIONS

The results of this study may guide implementation of psychotherapy and improve the treatment of OUD, especially as it relates to improving the modified START NOW program for treating OUD. Our study also reveals a favorable outlook of START NOW with increased participation, suggesting that any initial reticence to this program can be overcome to allow for effective implementation.

Treatment Retention in Opioid Dependent Clients Receiving Medication-Assisted Treatment: Six-Month Rate and Baseline Correlates

In the current opioid overdose epidemic, treatment retention among clients receiving medication-assisted treatment (MAT) for opioid dependence is a significant and growing concern among treatment providers, policymakers, and researchers. Methods: We examined a sample of clients enrolled in a federally funded MAT expansion program implemented in four sites in Connecticut. Program participants received MAT for their opioid use disorders (OUDs). All program sites utilized a person in recovery from OUD (a recovery support coach, RSC) as part of the treatment team. By performing bivariate analyses and multivariate logistic regression models, we evaluated the association of 6-month retention and program site, gender, age, race/ethnicity, and past month substance use. Results: At 6-month follow-up, 58.9% of participants were classified as "retained." Multivariate logistic regression analysis revealed that participants who were older, reported no past month cocaine/crack use, or reported any illegal drug use other than cocaine/crack, were significantly more likely to be retained in treatment at follow-up. Conclusions: Retention rates were relatively high in these Connecticut sites compared to those examined in previous literature. Findings suggest that efforts for enhancing retention and successful treatment outcomes need to consider and potentially address the unique needs, problems, and risks of younger clients and clients with crack/cocaine involvement. The importance of drug use screening for those entering MAT is underscored. Future research needs to explore how levels of client involvement in adjunctive therapies may impact their retention.

Factors That Affect Patient Attrition in Buprenorphine Treatment for Opioid Use Disorder: A Retrospective Real-World Study Using Electronic Health Records

PURPOSE

To describe attrition patterns of opioid use disorder (OUD) patients treated with buprenorphine (BUP) and to assess how clinical, sociodemographic, or BUP medication dosing features are associated with attrition.

PATIENTS AND METHODS

Electronic health records of adults (16+ year-olds) with OUD treated with BUP from 23 different substance use or mental health care programs across 11 US states were examined for one year following BUP initiation in inpatient (IP), intensive outpatient (IOP), or outpatient (OP) settings. Treatment attrition was declared at >37 days following the last recorded visit. Survival analyses and predictive modelling were used.

RESULTS

Retention was consistently 2-3 times higher following BUP initiation in OP (n = 2409) than in IP/IOP (n = 2749) settings after 2 (50% vs 25%), 6 (27% vs 9%) and 12 months (14% vs 4%). Retention was higher for females, whites (vs blacks), and those with less severe OUD, better global function, or not using non-psychotropic medications. Comorbid substance use, other psychiatric disorders, and the number of psychotropic medications were variously related to retention depending on the setting in which BUP was initiated. Predictive modelling revealed that a higher global assessment of functioning and a smaller OUD severity based on the Clinical Global Impression - Severity led to longer retentions, a higher initial BUP dose led to higher retention in a few cases, an OP setting of BUP initiation led to longer retentions, and a lower total number of psychotropic and non-psychotropic medications led to longer retentions. These were the most important parameters in the model, which identified 75.2% of patients who left BUP treatment within three months post-initiation, with a precision of 90.5%.

CONCLUSION

Of all the OUD patients who began BUP, 50-75% left treatment within three months, and most could be accurately identified. This could facilitate patient-centered management to better retain OUD patients in BUP treatment.

Exploring the Interactions between Non-Medical Methamphetamine Use and Prescribed Buprenorphine or Naltrexone in Opioid Use Disorder Treatment Retention

OBJECTIVES

Our objectives were to examine the impact of methamphetamine use on opioid use disorder (OUD) treatment retention in patients prescribed either buprenorphine/buprenorphine-naloxone (BUP-NX) or naltrexone/extended-release naltrexone (XR-NTX), while also exploring the role of other risk factors that may modify the impact of methamphetamine use.

METHODS

We conducted an exploratory retrospective study examining OUD treatment retention in 127 patients in Ohio (USA). Patients were prescribed either BUP-NX or naltrexone/XR-NTX. Cox proportional hazard regression was used to compare time to dropout of treatment between patients positive and negative on screening for methamphetamines at intake, estimate the association between other risk factors and time to dropout, and test interactions between risk factors and methamphetamine status.

RESULTS

Among patients prescribed naltrexone/XR-NTX, those positive for methamphetamines had almost three times the risk of treatment dropout (AHR = 2.89, 95% CI =1.11, 7.07), significantly greater (interaction p = .039) than the methamphetamine effect among those prescribed BUP-NX (AHR = 0.94, 95% CI = 0.51, 1.65). Early in treatment, being prescribed BUP-NX was strongly associated with a greater risk of treatment dropout (at baseline: AHR = 2.90, 95% CI = 1.33, 7.15), regardless of baseline methamphetamine use status. However, this effect decreased with time and shifted to greater risk of dropout among those prescribed naltrexone/XR-NTX (non-proportional hazard; interaction with time AHR = 0.66, 95% CI = 0.49, 0.86), with the shift occurring sooner among those positive for methamphetamine at baseline.

CONCLUSIONS

Additional support should be provided to patients who use methamphetamines prior to starting OUD treatment.

Leveraging COVID-19 to sustain regulatory flexibility in the treatment of opioid use disorder

The U.S. government declared the opioid epidemic as a national public health emergency in 2017, but regulatory frameworks that govern the treatment of opioid use disorder (OUD) through pharmaceutical interventions have remained inflexible. The emergence of the COVID-19 pandemic has effectively removed regulatory restrictions that experts in the field of medications for opioid use disorder (MOUD) have been proposing for decades and has expanded access to care. The regulatory flexibilities implemented to avoid unnecessary COVID-related death must be made permanent to ensure that improved access to evidence-based treatment remains available to vulnerable individuals with OUD who otherwise face formidable barriers to MOUD. We must seize this moment of COVOD-19 regulatory flexibilities to demonstrate the feasibility, acceptability, and safety of delivering treatment for OUD through a low-threshold approach.

Prevalence of Mental Health Disorders among Individuals Enrolled in an Emergency Response Program for Treatment of Opioid Use Disorder

Background

Psychiatric co-occurring disorders among individuals with opioid use disorder has primarily focused on epidemiological surveys of patients in continuous or long-term treatment, yet little is known about the socio-economically vulnerable who are non-treatment seeking prior to an emergency response.

Methods

We retrospectively analyzed data from patients who had enrolled in a study involving home outreach to patients referred from police, emergency medical services (EMS), or hospital emergency departments following an emergency response. The sample is largely socio-economically vulnerable with high rates of unemployment and uninsured. Eligible consenting patients received an intervention consisting of medication (buprenorphine), behavioral counseling, and peer support. Participants completed semi-structured, psychological instruments to assess current and prior history for both substance use and mental health disorders. We used descriptive statistics to evaluate rates of co-occurring mental health comorbidity.

Results

Among 102 patients (average age = 36.5 years old), approximately 61 (59.8%) reported a prior mental health diagnosis, with 31 (30.3%) currently on medications for their diagnoses. Mood and anxiety disorders were most frequently recorded. Just over half (51%) had received any prior treatment for their substance use. Of those with dual disorders, 67.2% had experienced prior suicidal thoughts, and 63.7% reported polysubstance use of 5 or more substances.

Conclusion

Co-occurring psychiatric disorders, and specifically mood and anxiety disorders, appear to be prevalent in vulnerable populations at an increased rate. Mental health assessments should routinely be performed in the emergency setting and in early stages of treatment.

Same-day vs. delayed buprenorphine prescribing and patient retention in an office-based buprenorphine treatment program

BACKGROUND

Buprenorphine is a safe and effective treatment for opioid use disorder (OUD), yet a small fraction of people with OUD receive it, and rates of retention in treatment are suboptimal. Dropout most commonly occurs within 30 days of treatment initiation. Therefore, research needs to investigate modifiable factors contributing to early dropout. Requiring multiple visits for evaluation prior to providing an initial buprenorphine prescription (delayed prescription) may lead to more early dropout when compared with prescribing at the first medical visit (same-day prescription). Our objective was to determine whether same-day (vs. delayed) buprenorphine prescription was associated with 30-day retention in treatment.

METHODS

We conducted a retrospective cohort study of 237 patients who initiated buprenorphine treatment at an urban federally qualified community health center (FQHC) between June 1, 2015, and December 31, 2017. We measured prescription delays by determining the time between patients' first request for buprenorphine treatment (by calling, presenting to the FQHC in-person, or requesting treatment during a visit) and when providers wrote buprenorphine prescriptions. We included only patients with prescription delays less than or equal to 30 days in the analysis. We defined same-day prescription as the patient experiencing no delays in starting treatment and receiving a prescription during the first medical visit. We examined whether patients who received same-day prescriptions had different sociodemographic and clinical characteristics than patients who received delayed prescriptions. We also evaluated whether there was an association between the initial provider who made the decision about same-day vs. delayed buprenorphine prescribing and same-day prescription. We built a multivariable logistic regression model to evaluate the independent association between same-day vs. delayed prescription receipt and odds of 30-day retention in treatment.

RESULTS

Of the 237 patients who initiated buprenorphine treatment from June 1, 2015, to December 31, 2017, 222 had delays less than or equal to 30 days and we included them in the analysis. Of the 222 patients, the mean age was 46 (SD 10.4), the majority were Hispanic (n = 160, 72%), male (n = 175, 79%), and publicly insured (n = 165, 74%). The majority of patients experienced delayed buprenorphine prescription receipt (n = 133, 60%). The median time to buprenorphine prescription was 5 days (IQR 0-11). Of those who experienced a delay (n = 133), the median delay time was 8 days (IQR 5-20). Compared to those with same-day prescription receipt, more patients with delayed prescription receipt were non-Hispanic white (11% vs. 2%, p = 0.01), had a history of alcohol use (43% vs. 21%, p < 0.01) or benzodiazepine use (22% vs. 9%, p = 0.01), and had the buprenorphine coordinator as their initial provider (57 vs. 13%, p < 0.01). Same-day prescription receipt was not significantly associated with 30-day treatment retention in the adjusted analysis (AOR 1.92, 95% CI 0.81-4.56).

CONCLUSION

Patients who received buprenorphine prescriptions on the same day as their initial evaluation differed from those who received delayed prescriptions. After adjustment for these differences, same-day prescription was not significantly associated with higher 30-day treatment retention. Providers may be delaying treatment when there is concern about alcohol and/or benzodiazepine use; however, providers could institute enhanced monitoring based on clinical concern for sedation or overdose risk without delaying buprenorphine prescription. Prospective studies of same-day vs. delayed buprenorphine receipt would elucidate the association between delays and retention more definitively.

A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference

US military Veterans have been disproportionately impacted by the US opioid overdose crisis. In the fall of 2019, the Veterans Health Administration (VHA) convened a state-of-the-art (SOTA) conference to develop research priorities for advancing the science and clinical practice of opioid safety, including both use of opioid analgesics and managing opioid use disorder. We present the methods and consensus recommendations from the SOTA. A core group of researchers and VA clinical stakeholders defined three areas of focus for the SOTA: managing opioid use disorder, long-term opioid therapy for pain including consideration for opioid tapering, and treatment of co-occurring pain and substance use disorders. The SOTA participants divided into three workgroups and identified key questions and seminal studies related to those three areas of focus. The strongest recommendations included testing implementation strategies in the VHA for expanding access to medication treatment for opioid use disorder, testing collaborative tapering programs for patients prescribed long-term opioids, and larger trials of behavioral and exercise/movement interventions for pain among patients with substance use disorders.

Prison sentencing increases the risk of unemployment among illegal heroin users in Taiwan

BACKGROUND

Previous studies have rarely explored the effect of type of sentencing on employment status among illegal heroin users, therefore, we aims to examine the association of the sentencing types and employment outcomes among illegal heroin users in Taiwan.

METHODS

Participants with illegal heroin use were identified through the national prison register system and deferred prosecution system: 2406 with deferred prosecutions, 4741 with observation and rehabilitation, 15 compulsory rehabilitation and 1958 sentenced to prison in calendar 2011. Logistic regression models were built to estimate the effect of sentencing type on unemployment status at 2 years after release. Stratification analysis was conducted to determine the effect of sentencing type based on the offender's employment status before sentencing.

RESULTS

Illegal heroin users receiving a prison sentence were more than twice as likely to be unemployed 2 years later than those receiving deferred prosecution. The unemployment rate was also higher for those with observation and rehabilitation and compulsory rehabilitation than deferred prosecution in the 2 years following sentencing. Males, older users, without a job before sentencing, divorced or widowed and higher prior drug use criminal records were also higher risk of unemployment. Subgroup analysis by prior employment status revealed that being sentenced to prison, observation and rehabilitation and compulsory rehabilitation affected the subsequent employment status only for those heroin users with a job before sentencing. The strength of associations showed dose-dependent relationship between different sentencing types (sentenced to prison> compulsory rehabilitation> observation and rehabilitation) and employment outcomes.

CONCLUSIONS

Illegal heroin users who receive a prison sentence have a much higher risk of unemployment than those who receive deferred prosecution after controlling potential confounders, especially those who had a job before sentencing. The implication is the stronger freedom of punishment, the higher risk of unemployment outcomes. Our study support that illegal heroin user is legally regarded as a patient before being regarded as a criminal, so giving priority to quit addition rather than imprisonment.

The Influence of Co-Occurring Substance Use on the Effectiveness of Opiate Treatment Programs According to Intervention Type

This systematic review describes the influence of co-occurring substance use on the effectiveness of opiate treatment programs. MEDLINE/PubMed, Embase, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature were searched from database inception to November 28, 2018, to identify eligible opioid treatment studies in the United States that assessed the relationship between co-occurring substance use and treatment outcome (i.e., opioid abstinence and treatment retention). A total of 34 eligible studies were included. Overall, co-occurring substance use was associated with negative treatment outcomes regardless of intervention type. However, patterns varied by substance and intervention type. In particular, co-occurring use of cocaine or marijuana with opioids was associated with reduced treatment retention and opioid abstinence regardless of intervention type. Co-occurring use of amphetamines, compared with no use or reduced use of amphetamines, decreased treatment retention. Co-occurring use of alcohol was both positively and negatively associated with treatment outcomes. One study reported a significant positive association between sedative use and opioid abstinence. Generally, findings suggest that combined interventions reported better health outcomes compared with pharmacological or behavioral intervention studies alone. The findings of this review emphasize the need to comprehensively study and address co-occurring substance use to improve opiate treatment programs.

Comparative effectiveness of buprenorphine-naloxone versus methadone for treatment of opioid use disorder: a population-based observational study protocol in British Columbia, Canada

INTRODUCTION

Despite a recent meta-analysis including 31 randomised controlled trials comparing methadone and buprenorphine for the treatment of opioid use disorder, important knowledge gaps remain regarding the long-term effectiveness of different treatment modalities across individuals, including rigorously collected data on retention rates and other treatment outcomes. Evidence from real-world data represents a valuable opportunity to improve personalised treatment and patient-centred guidelines for vulnerable populations and inform strategies to reduce opioid-related mortality. Our objective is to determine the comparative effectiveness of methadone versus buprenorphine/naloxone, both overall and within key populations, in a setting where both medications are simultaneously available in office-based practices and specialised clinics.

METHODS AND ANALYSIS

We propose a retrospective cohort study of all adults living in British Columbia receiving opioid agonist treatment (OAT) with methadone or buprenorphine/naloxone between 1 January 2008 and 30 September 2018. The study will draw on seven linked population-level administrative databases. The primary outcomes include retention in OAT and all-cause mortality. We will determine the effectiveness of buprenorphine/naloxone vs methadone using intention-to-treat and per-protocol analyses-the former emulating flexible-dose trials and the latter focusing on the comparison of the two medication regimens offered at the optimal dose. Sensitivity analyses will be used to assess the robustness of results to heterogeneity in the patient population and threats to internal validity.

ETHICS AND DISSEMINATION

The protocol, cohort creation and analysis plan have been approved and classified as a quality improvement initiative exempt from ethical review (Providence Health Care Research Institute and the Simon Fraser University Office of Research Ethics). Dissemination is planned via conferences and publications, and through direct engagement and collaboration with entities that issue clinical guidelines, such as professional medical societies and public health organisations.

Study design to evaluate a group-based therapy for support persons of adults on buprenorphine/naloxone

Background

Opioid use disorders (OUDs) have devastating effects on individuals, families, and communities. While medication treatments for OUD save lives and are increasingly utilized, rates of treatment dropout are very high. In addition, most existing medication treatments for OUD may often neglect the impact of untreated OUD on relationships and ignore the potential role support persons (SPs) could have on encouraging long-term recovery, which can also impact patient treatment retention.

Methods/design

The current study adapts Community Reinforcement and Family Training (CRAFT) for use with SPs (family member, spouse or friend) of patients using buprenorphine/naloxone (buprenorphine) in an outpatient community clinic setting. The study will evaluate whether the adapted intervention, also known as integrating support persons into recovery (INSPIRE), is effective in increasing patient retention on buprenorphine when compared to usual care. We will utilize a two-group randomized design where patients starting or restarting buprenorphine will be screened for support person status and recruited with their support person if eligible. Support persons will be randomly assigned to the INSPIRE intervention, which will consist of 10 rolling group sessions led by two facilitators. Patients and SPs will each be assessed at baseline, 3 months post-baseline, and 12 months post-baseline. Patient electronic medical record data will be collected at six and 12 months post-baseline. We will examine mechanisms of intervention effectiveness and also conduct pre/post-implementation surveys with clinic staff to assess issues that would affect sustainability.

Discussion

Incorporating the patient’s support system may be an important way to improve treatment retention in medication treatments for OUD. If SPs can serve to support patient retention, this study would significantly advance work to help support the delivery of effective treatments that prevent the devastating consequences associated with OUD.

Trial registration This study was registered with ClinicalTrials.gov, NCT04239235. Registered 27 January 2020, https://clinicaltrials.gov/ct2/show/NCT04239235.

Retention of patients in opioid substitution treatment: A systematic review

Background

Retention in opioid substitution (OST) treatment is associated with substantial reductions in all cause and overdose mortality. This systematic review aims to identify both protective factors supporting retention in OST, and risk factors for treatment dropout.

Methods

A systematic search was performed using MEDLINE, Embase, PsycInfo, CINAHL and Web of Science (January 2001 to October 2019). Randomised controlled trials (RCTs) and observational cohort studies reporting on retention rates and factors associated with retention in OST were included. Factors associated with treatment retention and dropout were explored according to the Maudsley Addiction Profile. A narrative synthesis is provided.

Results

67 studies were included in this review (4 RCTs and 63 observational cohort studies; N = 294,592), all assessing factors associated with retention in OST or treatment dropout. The median retention rate across observational studies was approximately 57% at 12 months, which fell to 38.4% at three years. Studies included were heterogeneous in nature with respect to treatment setting, type of OST, risk factor assessment, ascertainment of outcome and duration of follow-up. While the presence of such methodological heterogeneity makes it difficult to synthesise results, there is limited evidence to support the influence of a number of factors on retention, including age, substance use, OST drug dose, legal issues, and attitudes to OST.

Conclusions

Younger age, substance use particularly cocaine and heroin use, lower doses of methadone, criminal activity/incarceration, and negative attitudes to MMT appear to be associated with reduced retention in OST. A consensus definition of retention is required to allow for comparability across future studies.

Identification and Management of Opioid Use Disorder in Primary Care: an Update

PURPOSE OF REVIEW

The rising prevalence of opioid use disorder (OUD) and related complications in North America coupled with limited numbers of specialists in addiction medicine has led to large gaps in treatment. Primary care providers (PCPs) are ideally suited to diagnose and care for people with OUD and are increasingly being called upon to improve access to care. This review will highlight the recent literature pertaining to the care of patients with OUD by PCPs.

RECENT FINDINGS

The prevalence of patients with OUD in primary care practice is increasing, and models of office-based opioid treatment (OBOT) are evolving to meet local needs of both ambulatory practices and patients. OBOT has been shown to increase access to care and demonstrates comparable outcomes when compared to more specialty-driven care. OBOT is an effective means of increasing access to care for patients with OUD. The ideal structure of OBOT depends on local factors. Future research must explore ways to increase the identification and diagnosis of patients with OUD, improve treatment retention rates, reduce stigma, and promote interdisciplinary approaches to care.

Retention of Patients With Multiple Vulnerabilities in a Federally Qualified Health Center Buprenorphine Program: Pennsylvania, 2017-2018

Objectives. To describe and report initial outcomes of a low-threshold, group-based primary care medication for opioid use disorder (OUD) program in a federally qualified health center.Methods. We performed a retrospective chart review of patients enrolled in the program from October 4, 2017, to October 3, 2018, in Philadelphia, Pennsylvania. The main outcome measure was time retained in treatment, defined as time from treatment initiation to unplanned treatment termination. Secondary outcomes were the relationships between treatment retention and cocaine use or housing status. We analyzed retention in treatment using Kaplan-Meier survival estimates.Results. The 3- and 6-month retention rates were 82% and 63%, respectively. The log-rank test showed no significant differences for comparisons between homeless versus not homeless (P = .25) and cocaine use versus no cocaine use (P = .12).Conclusions. The medication for OUD program engaged a large number of patients from marginalized groups. Three- and 6-month retention rates were comparable with those reported of other federally qualified health center populations.Public Health Implications. Integrating treatment of OUD into primary care shows promise for increasing access to and retention in medication for OUD services. The federally qualified health center payment structure supports the sustainability of the group visit model.

Long-term treatment retention in West Virginia's comprehensive opioid addiction treatment (COAT) program

BACKGROUND

The United States continues to experience an opioid epidemic of unprecedented proportions despite FDA approval of life saving medications, such as buprenorphine. This paper describes a novel group-based buprenorphine treatment model and summarizes patient characteristics and treatment retention. This model, known as the Comprehensive Opioid Addiction Treatment (COAT) program, was developed in West Virginia, the epicenter of the opioid epidemic.

METHODS

Data on 454 patients actively enrolled in the COAT program were extracted from an administrative clinical data set and electronic medical records and analyzed using descriptive and quantitative analysis to determine long-term retention in treatment using frequencies and means.

RESULTS

The characteristics of the 454 patients are as follows: average age of 39, 53% female, predominantly white (94%) and Medicaid was the primary insurance provider (68%). Analysis of retention showed 37.8% of patents were retained less than one year and 14.7% were retained 10 or more years. Initiating treatment at a younger age was associated with long-term retention.

CONCLUSION

Opioid use disorder is a chronic relapsing disease and treatment models that retain patients long-term have the greatest benefit. The COAT model has been successful in retaining patients long-term in a rural setting where barriers to treatment are many.

Prevalence and treatment of opioid use disorders among primary care patients in six health systems

BACKGROUND

The U.S. experienced nearly 48,000 opioid overdose deaths in 2017. Treatment of opioid use disorder (OUD) with buprenorphine is a recommended part of primary care, yet little is known about current U.S. practices in this setting. This observational study reports the prevalence of documented OUD and OUD treatment with buprenorphine among primary care patients in six large health systems.

METHODS

Adults with ≥2 primary care visits during a three-year period (10/1/2013-9/30/2016) in six health systems were included. Data were obtained from electronic health record and claims data, with measures, assessed over the three-year period, including indicators for documented OUD from ICD 9 and 10 codes and OUD treatment with buprenorphine. The prevalence of OUD treatment was adjusted for age, gender, race/ethnicity, and health system.

RESULTS

Among 1,368,604 primary care patients, 13,942 (1.0 %) had documented OUD, and among these, 21.0 % had OUD treatment with buprenorphine. For those with documented OUD, the adjusted prevalence of OUD treatment with buprenorphine varied across demographic and clinical subgroups. OUD treatment was lower among patients who were older, women, Black/African American and Hispanic (compared to white), non-commercially insured, and those with non-cancer pain, mental health disorders, greater comorbidity, and more opioid prescriptions, emergency department visits or hospitalizations.

CONCLUSIONS

Among primary care patients in six health systems, one in five with an OUD were treated with buprenorphine, with disparities across demographic and clinical characteristics. Less buprenorphine treatment among those with greater acute care utilization highlights an opportunity for systems-level changes to increase OUD treatment.

Assessment of Co-Occurring Substance Use During Opiate Treatment Programs in the United States

The effectiveness of opiate treatment programs (OTPs) can be significantly influenced by co-occurring substance use, yet there are no standardized guidelines for assessing the influence of co-occurring substance use on treatment outcomes. In this review, we aim to provide an overview on the status of the assessment of co-occurring substance use during participation in OTPs in the United States. We searched 4 databases-MEDLINE/PubMed, EMBASE, PsychINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL)-from database inception to November 2018 to select relevant publications on OTPs that assessed participants' co-occurring substance use. We used a standardized protocol to extract study, intervention, and co-occurring substance use characteristics. Methodological quality was assessed using the Quality in Prognosis Studies tool. Of the 3,219 titles screened, 614 abstracts and 191 full-text original publications were assessed, leaving 85 eligible articles. Co-occurring substance use was most often assessed during opioid treatments using combined (pharmacological and behavioral) (n = 57 studies) and pharmacological (n = 25 studies) interventions. Cocaine, alcohol, marijuana, and benzodiazepines were frequently measured, while amphetamines and tobacco were rarely assessed. Great variation existed between studies in the timing and measurement of co-occurring substance use, as well as definitions for substances and polysubstance/polydrug use. Inconsistencies in the investigation of co-occurring substance use make comparison of results across studies challenging. Standardized measures and consensus on research on co-occurring substance use is needed to produce the evidence required to develop personalized treatment programs for persons using multiple substances and to inform best-practice guidelines for addressing polydrug use during participation in OTPs.

Racial/Ethnic and Gender Differences in Associations of Medication-Assisted Therapy and Reduced Opioid Use between Outpatient Treatment Admission and Discharge

Medication-assisted therapy (MAT) for opioid use disorders is an effective treatment strategy. Racial/ethnic and gender disparities in MAT utilization have been documented, but less is known about disparities in MAT outcomes. We used the Treatment Episodes Dataset-Discharges (TEDS-D; 2015- 2017) to identify outpatient treatment episodes with heroin or illicit opioids indicated at admission (n = 232,547). We used multivariate logistic regression to model the association between MAT and a reduction in opioid use between treatment admission and discharge. We explored moderation by race/ethnicity and gender by including an interaction term. We identified a strong moderating effect of race/ethnicity and gender. American Indian/Alaska Native (AI/AN) women demonstrated the strongest association between MAT (versus no MAT) and a reduction in opioid use (aOR = 6.05, 95% CI = 4.81- 7.61), while White men demonstrated the weakest association (aOR = 2.78, CI = 2.70- 2.87). Our findings could inform changes in clinical MAT settings that are based on harm reduction and the incremental transition from illicit opioids to medication-assistance among a diverse opioid use disorder population.

Adherence to and Retention in Medications for Opioid Use Disorder Among Adolescents and Young Adults

The volatile opioid epidemic is associated with higher levels of opioid use disorder (OUD) and negative health outcomes in adolescents and young adults. Medications for opioid use disorder (MOUD) demonstrate the best evidence for treating OUD. Adherence to and retention in MOUD, defined as continuous engagement in treatment, among adolescents and young adults, however, is incompletely understood. We examined the state of the literature regarding the association of age with adherence to and retention in MOUD using methadone, buprenorphine, or naltrexone among persons aged 10-24 years, along with related facilitators and barriers. All studies of MOUD were searched for that examined adherence, retention, or related concepts as an outcome variable and included adolescents or young adults. Search criteria generated 10,229 records; after removing duplicates and screening titles and abstracts, 587 studies were identified for full-text review. Ultimately, 52 articles met inclusion criteria for abstraction and 17 were selected for qualitative coding and analysis. Younger age was consistently associated with shorter retention, although the overall quality of included studies was low. Several factors at the individual, interpersonal, and institutional levels, such as concurrent substance use, MOUD adherence, family conflict, and MOUD dosage and flexibility, appeared to have roles in MOUD retention among adolescents and young adults. Ways MOUD providers can tailor treatment to increase retention of adolescents and young adults are highlighted, as is the need for more research explaining MOUD adherence and retention disparities in this age group.

Hospitalization outcomes of people who use drugs: One size does not fit all

People with opioid use disorder (OUD) have worse hospital outcomes and higher healthcare costs. There are rising reports of people with OUD also using other classes of drugs, however patterns of substance use have not been evaluated for differential effects on hospital outcomes. We performed a data-analysis of the Healthcare Utilization Project's National Readmissions Database, examining the effects of patterns of substance use, age, gender, and diagnosis on the outcomes of Against Medical Advice (AMA) discharges and 30-day readmissions. About one-third of the patients with OUD who were admitted to the hospital had at least one additional substance use disorder (SUD). Thirteen percent of persons with OUD were discharged AMA, and 12% were readmitted to the hospital within 30 days of discharge. Compared to people with OUD alone, people who used stimulants had increased odds of AMA discharge (aOR 1.83 (CI 1.73, 1.96)) and 30-day readmission (aOR 1.30 (95% CI 1.23, 1.37)). Multiple concomitant substance use disorders were associated with increased odds of AMA discharge and 30-day readmission. Conclusions: People with OUD have high rates of both AMA discharges and 30 day-readmissions, and there is a layered effect of increasing co-occurring SUDs leading to worse hospitalization outcomes. The heterogeneity of drug use patterns needs to be considered when developing strategies to improve health care outcomes for people with substance use disorder.

A pilot study of mindful body awareness training as an adjunct to office-based medication treatment of opioid use disorder

The purpose of this study was to pilot-test a mind-body intervention called Mindful Awareness in Body-oriented Therapy (MABT) as an adjunct to buprenorphine for individuals with opioid use disorder (OUD). MABT, a manualized 8 week protocol, teaches interoceptive awareness skills to promote self-care and emotion regulation. A small study was designed to assess MABT recruitment and retention feasibility, and intervention acceptability, among this population. Individuals were recruited from two office-based programs providing buprenorphine treatment within a large urban community medical center. Participants were randomized to receive either treatment as usual (TAU), or TAU plus MABT. Assessments administered at baseline and 10-week follow-up included validated self-report health questionnaires and a process measure, the Multidimensional Assessment of Interoceptive Awareness, to examine interoceptive awareness skills. An additional survey and exit interview for those in the MABT study arm were administered to assess intervention satisfaction. Results showed the ability to recruit and enroll 10 participants within two-weeks, and no loss to follow-up. The MABT study group showed an increase in interoceptive awareness skills from baseline to follow-up, whereas the control group did not. Responses to the satisfaction questionnaire and exit interview were positive, indicating skills learned, satisfaction with the interventionists, and overall perceived benefit of the intervention. In summary, study results demonstrated recruitment and retention feasibility, and high intervention acceptability. This pilot study suggests preliminary feasibility of successfully implementing a larger study of MABT as an adjunct to office-based medication treatment for opioid use disorder.

The Washington State Hub and Spoke Model to increase access to medication treatment for opioid use disorders

INTRODUCTION

The federal Opioid State Targeted Response (Opioid STR) grants provided funding to each state to ramp up the range of responses to reverse the ongoing opioid crisis in the U.S. Washington State used these funds to develop and implement an integrated care model to expand access to medication treatment and reduce unmet need for people with opioid use disorders (OUD), regardless of how they enter the treatment system. This paper examines the design, early implementation and results of the Washington State Hub and Spoke Model.

METHODS

Descriptive data were gathered from key informants, document review, and aggregate data reported by hubs and spokes to Washington State's Opioid STR team.

RESULTS

The Washington State Hub and Spoke Model reflects a flexible approach that incorporates primary care and substance use treatment programs, as well as outreach, referral and social service organizations, and a nurse care manager. Hubs could be any type of program that had the required expertise and capacity to lead their network in medication treatment for OUD, including all three FDA-approved medications. Six hub-spoke networks were funded, with 8 unique agencies on average, and multiple sites. About 150 prescribers are in these networks (25 on average). In the first 18 months, nearly 5000 people were inducted onto OUD medication treatment: 73% on buprenorphine, 19% on methadone, and 9% on naltrexone.

CONCLUSIONS

The Washington State Hub and Spoke Model built on prior approaches to improve the delivery system for OUD medication treatment and support services, by increasing integration of care, ensuring "no wrong door," engaging with community agencies, and supporting providers who are offering medication treatment. It used essential elements from existing integrated care OUD treatment models, but allowed for organic restructuring to meet the population needs within a community. To date, there have been challenges and successes, but with this approach, Washington State has provided medication treatment for OUD to nearly 5000 people. Sustainability efforts are underway. In the face of the ongoing opioid crisis, it remains essential to develop, implement and evaluate novel models, such as Washington's Hub and Spoke approach, to improve treatment access and increase capacity.

Association between methamphetamine use and retention among patients with opioid use disorders treated with buprenorphine

BACKGROUND

Methamphetamine use is increasing in parts of the U.S., yet its impact on treatment for opioid use disorder is relatively unknown.

METHODS

The study utilized data on adult patients receiving buprenorphine from Washington State Medication Assisted Treatment-Prescription Drug and Opioid Addiction program clinics between November 1, 2015 and April 31, 2018. Past 30-day substance use data were collected at baseline and 6-months, as well as date of program discharge. Cox proportional hazards regression was used to estimate the relative hazards for treatment discharge comparing methamphetamine users at baseline with non-users, adjusting for site, time period, age, gender, race, ethnicity, and education. For a subset of patients with data, we describe the proportion of individuals reporting methamphetamine use at baseline versus 6-months.

RESULTS

The sample included 799 patients, of which 237 (30%) reported using methamphetamine in the past 30 days; of those, 156 (66%) reported 1-10 days of use, 46 (19%) reported 11-20 days of use, and 35 (15%) reported 21-30 days of use. Baseline methamphetamine use was associated with more than twice the relative hazards for discharge in adjusted models (aHR = 2.39; 95% CI: 1.94-2.93). In the sub-sample with data (n = 516), there was an absolute reduction of 15% in methamphetamine use: 135 (26%) reported use at baseline versus 57 (11%) at follow-up.

CONCLUSIONS

In summary, this study found that patients who concurrently used methamphetamine were less likely to be retained in buprenorphine treatment compared to non-users. For persons who were retained, however, methamphetamine use decreased over time.

Effects of access barriers and medication acceptability on buprenorphine-naloxone treatment utilization over 2 years: Results from a multisite randomized trial of adults with opioid use disorder

BACKGROUND

Nationwide efforts seek to address the opioid epidemic by increasing access to medications for opioid use disorder (OUD), particularly with buprenorphine. A poorly understood challenge is that among individuals with OUD who do receive buprenorphine, many do not adhere to the pharmacotherapy long enough to achieve sustained benefits. We aimed to identify factors associated with buprenorphine treatment utilization over time.

METHODS

We used random-intercept modeling to identify factors associated with buprenorphine treatment utilization over 2 years after first follow-up by 789 individuals with OUD who had participated in a multi-site randomized clinical trial of buprenorphine compared to methadone. Key predictors were participants' reports of buprenorphine treatment accessibility and acceptability (assessed at first follow-up) and their interaction effects, controlling for baseline randomization status, sociodemographics, and other covariates.

RESULTS

Approximately 9.3-11.2% of participants utilized buprenorphine treatment over the 2 years of follow-up. Interaction effects indicated that individuals who perceived buprenorphine to be both accessible and acceptable were most likely to use buprenorphine during follow-up, controlling for other factors. In contrast, individuals who perceived buprenorphine to be unacceptable were least likely to use buprenorphine, regardless the level of perceived access to the medication. Buprenorphine treatment utilization was also negatively associated with Hispanic ethnicity, West coast context, and cumulative months receiving methadone treatment and incarceration during follow-up.

CONCLUSIONS

To engage more individuals with OUD in long-term treatment with buprenorphine, interventions should target buprenorphine treatment acceptability, in addition to increasing buprenorphine access, and tailor efforts to meet the needs of vulnerable populations.

TRIAL REGISTRATION

The START Follow-up Study on ClinicalTrials.gov (NCT01592461).

Prescription opioid misuse among U.S. Hispanics

BACKGROUND

As a risk factor for addiction, heroin use, and overdose, the misuse of prescription opioids represents a critical public health challenge. While public attention has primarily centered on opioid misuse among White individuals, less attention has been devoted to opioid misuse among one of the United States' fastest-growing demographic groups: Hispanic immigrants and their descendants. This study therefore examined prescription opioid misuse among U.S. Hispanic adults, with attention to within-group differences and the role of acculturation-related characteristics.

METHODS

Data were derived from the 7037 U.S. Hispanic adults in the National Epidemiologic Survey on Alcohol and Related Conditions-III (2012-2013). Weighted proportions, adjusted odds ratios, and 95% confidence intervals were computed for past-year and lifetime prescription opioid misuse. Binomial logistic regression models examined the association between acculturation-related characteristics and prescription opioid misuse.

RESULTS

Past-year prevalence of prescription opioid misuse among U.S. Hispanic adults was lower in the first generation (1.6%), compared with the second (4.1%), third (6.8%), and higher-than-third (6.2%) generations, and a similar pattern was observed for lifetime prevalence. Higher generation, greater English language orientation, and length of time living in the United States were significantly associated with higher odds of past-year and lifetime prescription opioid misuse.

CONCLUSIONS

Relying solely on comparisons of prevalence between ethnic groups may obscure significant variations within ethnic groups. Second, third, and higher generation Hispanics are higher-risk subgroups, with rates of prescription opioid misuse approaching or surpassing the rates reported among non-Hispanic Whites.

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

Alexander Tsai and co-authors discuss the role of stigma in responses to the US opioid crisis.

Understanding site variability in a multisite clinical trial of a technology-delivered psychosocial intervention for substance use disorders

BACKGROUND

Significant fixed effects of site (main effects of site and/or site by treatment interactions) on primary outcome have been identified in the majority of studies performed by NIDA's National Drug Abuse Treatment Clinical Trials Network. While rarely explored, identifying patient- and site-level variables that are associated with site effects can provide information about the context in which outcome is optimized.

METHODS

In a 10-site clinical trial that evaluated the effectiveness of a web-based psychosocial intervention compared to usual treatment of patients (N = 507) with substance use disorders, the primary outcome analysis revealed significant main effect of site, modeled as a fixed effect, on the outcome of abstinence (Campbell et al., 2014). In the current analysis, we use a two-level, hierarchical generalized linear model (HGLM) to identify patient- and site-level variables associated with abstinence outcome, while modeling site as a random factor.

RESULTS

The site-specific percentage of patients abstinent in the last 4 weeks of the study varied from 6.1% to 40%. However, only 6.7% (p = 0.08) of variability in end-of-study abstinence was accounted for by site, indicating a small-moderate effect. Among patient-level predictors, older age (OR = 1.40; 95% CI = 1.15, 1.71; p = 0.0009), abstinence at baseline (OR = 2.77; 95% CI = 1.73, 4.45; p < 0.0001), and among site-level predictors, higher annual clinic admissions (OR = 1.28; 95% CI = 1.03, 1.59; p = 0.0251) were significantly associated with increased likelihood of abstinence. When controlling for these three variables in a HGLM, only patient age and abstinence at baseline remained significant, and random factor site explained only 1.4% of variability in end-of-study abstinence, a 79% reduction in magnitude.

CONCLUSIONS

The findings suggest that only some amount of variability in abstinence outcomes among sites can be explained by a combination of patient- and site-level variables. Our findings support the case that variability between sites is a natural phenomenon, and our methodological recommendation is that site be modeled as a random factor when analyzing multi-site clinical trials.

Price elasticity of demand for buprenorphine/naloxone prescriptions

Although there have been supply-side efforts in response to the opioid crisis (e.g., prescription drug monitoring programs), little information exists on demand-side approaches related to patient cost sharing that may affect utilization of and adherence to pharmacotherapy by individuals with opioid use disorder. Among individuals who had initiated pharmacotherapy, we estimated the price elasticity of demand of prescription fills of buprenorphine/naloxone, a common pharmacotherapy drug, overall and by patient characteristics. Using the IBM MarketScan® Commercial Claims and Encounters Database for individuals with employer-sponsored private health insurance coverage, we examined the relationship between cost sharing and the number of buprenorphine/naloxone prescription fills using enrollee-level longitudinal fixed effects models. Cost sharing was expressed as a price index for each employer-plan. By including enrollee-level fixed effects, the identification of the effect of interest comes from longitudinal variation in prices across multiple time points for each enrollee. Overall, the demand for buprenorphine/naloxone was price inelastic (p = 0.191). However, some subgroups were responsive to price. A doubling of price was associated with a decrease in fills by 3.0% for enrollees aged 45-64 years (p = 0.029); 5.7% for those in rural areas (p = 0.033); 5.8% for residents of the South (p ≤0.001); and 3.0% for those enrolled in an HMO (p = 0.004). Insurers should consider the effects on these groups before increasing beneficiary out-of-pocket costs for pharmacotherapy and efforts to increase adherence should consider that price may be a barrier for some subgroups with OUD.

Innovative Solutions for State Medicaid Programs to Leverage Their Data, Build Their Analytic Capacity, and Create Evidence-Based Policy

As states have embraced additional flexibility to change coverage of and payment for Medicaid services, they have also faced heightened expectations for delivering high-value care. Efforts to meet these new expectations have increased the need for rigorous, evidence-based policy, but states may face challenges finding the resources, capacity, and expertise to meet this need. By describing state-university partnerships in more than 20 states, this commentary describes innovative solutions for states that want to leverage their own data, build their analytic capacity, and create evidence-based policy. From an integrated web-based system to improve long-term care to evaluating the impact of permanent supportive housing placements on Medicaid utilization and spending, these state partnerships provide significant support to their state Medicaid programs. In 2017, these partnerships came together to create a distributed research network that supports multi-state analyses. The Medicaid Outcomes Distributed Research Network (MODRN) uses a common data model to examine Medicaid data across states, thereby increasing the analytic rigor of policy evaluations in Medicaid, and contributing to the development of a fully functioning Medicaid innovation laboratory.

Review: Sex-Based Differences in Treatment Outcomes for Persons With Opioid Use Disorder

BACKGROUND AND OBJECTIVES

In order to address the current opioid crisis, research on treatment outcomes for persons with opioid use disorder (OUD) should account for biological factors that could influence individual treatment response. Women and men might have clinically meaningful differences in their experience in OUD treatment and might also have unique challenges in achieving successful, long-term recovery. This review summarizes and synthesizes the current literature on sex-based differences in OUD treatment outcomes.

METHODS

Relevant literature was identified via automated and manual searches using the terms "opioid treatment outcome sex [or gender] differences" and "opiate treatment outcome sex [or gender] differences." Search methodology was consistent with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), and were conducted within the PubMed electronic database during March and April of 2018.

RESULTS

The initial PubMed search yielded 241 manuscripts and 31 original research articles that met inclusion/exclusion criteria were synthesized in this review. Several important trends emerged, including findings that women are more likely than men to present to treatment with co-occurring mental health conditions such as depression, and that women might respond particularly well to buprenorphine maintenance.

DISCUSSION AND CONCLUSIONS

While much of the literature on this topic is subject to potential cohort effects, interventions that address co-occurring mental health conditions and psychosocial stress might improve treatment outcomes for women with OUD.

SCIENTIFIC SIGNIFICANCE

Funding agencies and researchers should focus attention toward human laboratory studies and clinical trials that are prospectively designed to assess sex-based differences in OUD recovery. (Am J Addict 2019;28:246-261).

A comparison of adherence, outcomes, and costs among opioid use disorder Medicaid patients treated with buprenorphine and methadone: A view from the payer perspective

Medication-assisted treatment (MAT) with methadone or buprenorphine has been shown to be more effective at reducing the use of illicit opioids, the risk of drug-related overdose, and overall healthcare costs, on average, compared to abstinence-based addiction treatments for individuals with an opioid use disorder (OUD). Individuals who are adherent to MAT are more likely to experience positive outcomes. We used physical and behavioral Medicaid claims data of individuals newly treated with methadone (n = 212) and buprenorphine (n = 972) to examine the overall predictors of adherence, differences in adherence to each medication, the relationship between adherence and ED nonfatal drug-related overdose, and differences in total cost of care between the two medications. We found that older individuals and women had significantly lower risk of non-adherence. At six months, only 3.6% of individuals who were adherent to either treatment experienced a nonfatal drug-related overdose in the ED, compared to 13.2% of individuals who were non-adherent. We found no significant difference between methadone and buprenorphine on nonfatal drug-related overdose. Non-adherence to methadone was associated with a significant increase in total cost of care. Implications for how these results could be used to improve the overall impact of MAT are discussed.

Long-Term Retention in an Outpatient Behavioral Health Clinic With Buprenorphine

BACKGROUND AND OBJECTIVES

Despite high comorbidity between substance use disorders and other mental health diagnoses, there is a paucity of literature on buprenorphine treatment outcomes in outpatient mental health settings. This study aimed to identify rates and predictors of outpatient buprenorphine treatment retention in a Behavioral Health Clinic (BHC).

METHODS

This retrospective cohort study of adults on buprenorphine used multiple logistic regression to identify clinical and demographic factors associated with 1- and 2-year treatment retention and buprenorphine adherence.

RESULTS

Of 321 subjects, 169 (52.6%) were retained in treatment for at least 1 year; 114 (35.5%) were retained for 2 years or more. Buprenorphine adherence was 95.8% and 97.3% for 1- and 2-year retention groups, respectively. Predictors of 1-year retention included benzodiazepine co-prescription (adjusted odds ratio [AOR] = 2.4; 95% CI [1.30, 4.55]), having a diagnosis of other mood disorder (AOR = 3.4; [1.95, 5.98]), or nicotine use disorder (AOR = 2.4; [1.35, 4.27]). Predictors of 2-year retention included female gender (AOR = 2.1; [1.16, 3.73]), having a diagnosis of depressive disorder (AOR = 4.6; [1.49, 14.29]), other mood disorder (AOR = 3.6; [1.88, 6.88]), or nicotine use disorder (AOR = 2.0; [1.13, 3.52]).

DISCUSSION AND CONCLUSION

During the study period, 52.7% and 35.5% of BHC patients treated with buprenorphine were retained for 1 and 2 years, respectively, comparable to the studies performed within primary care. Providing buprenorphine treatment within mental health clinics may serve patients who are already engaged with mental health providers but are reluctant to start new treatment within another treatment setting.

SCIENTIFIC SIGNIFICANCE

Identifying common predictors of retention can help determine which patients require additional substance use treatment support. (Am J Addict 2019;28:339-346).

The importance of buprenorphine research in the opioid crisis

With the urgency to treat patients more effectively for opioid use disorder in the midst of the opioid epidemic, a key area for precision medicine is to improve individualized medication-assisted treatment for opioid use disorder. The expansion of medication-assisted treatment is a key to reducing illicit opioid use, preventing opioid overdose deaths, and reducing the comorbidities and societal impacts of opioid use disorder. The most common medication for opioid use disorder will soon be buprenorphine. Research to date shows the successful impact of buprenorphine treatment, including the pharmacogenomics of buprenorphine response and treatment efficacy. Buprenorphine is also a promising treatment for depression and anxiety, and neonatal opioid withdrawal syndrome (NOWS). However, the rates of success with medication-assisted treatment for opioid use disorder, particularly at the beginning of treatment, still show many individuals relapsing to illicit opioid use. With the scope of the opioid crisis, there is an urgent need for expansion of buprenorphine treatment research to provide critical information for improving outcomes of opioid use disorder. Implementing the best strategies for opioid use disorder treatment is of dire urgency and will save lives.