Association of Opioid Agonist Treatment With All-Cause Mortality and Specific Causes of Death Among People With Opioid Dependence: A Systematic Review and Meta-analysis

Informing evidence-based medicine for opioid use disorder using pharmacoeconomic studies

INTRODUCTION

The health and economic consequences of inadequately treated opioid use disorder (OUD) are substantial. Healthcare systems in the United States (US) and other countries are facing a growing healthcare crisis due to opioids. Although effective medications for OUD exist, relying solely on clinical information is insufficient for addressing the opioid crisis.

AREAS COVERED

In this review, the role of pharmacoeconomic studies in informing evidence-based medication treatment for OUD is discussed, with a particular emphasis on the US healthcare system, where the economic burden is significantly higher than the global average. The scope/objective of pharmacoeconomics as a distinct scientific research program is briefly defined, followed by a discussion of existing evidence informed by data from systematic reviews, in addition to a convenience sample of recently published pharmacoeconomic studies and protocols. The review also explores the need for methodological advancements in the field.

EXPERT OPINION

Despite the potential of pharmacoeconomic research in shaping evidence-based medicine for OUD, significant challenges limiting its real-world application remain. How to address these challenges are explored, including how to combine cost-effectiveness and budget impact analyses to address the needs of the healthcare system as a whole and specific stakeholders interested in adopting new OUD treatment strategies.

Reducing overdose deaths among persons with opioid use disorder in connecticut

BACKGROUND

People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary.

METHODS

We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons.

RESULTS

Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime.

CONCLUSIONS

Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

Change in substance use among patients in opioid maintenance treatment: baseline to 1-year follow-up

BACKGROUND

Individuals with opioid use disorder (OUD) often have concurrent use of non-opioid substances. When patients enter opioid maintenance treatment (OMT), less is known about outcomes regarding the use of other types of drugs. Here we aimed to investigate changes in substance use among patients entering outpatient OMT, from treatment initiation to 1-year follow-up.

METHODS

We used data from the prospective Norwegian Cohort of Patient in OMT and Other Drug Treatment Study (NorComt). Among 283 patients who entered OMT at participating facilities across Norway, 179 were assessed at follow-up. Of these patients, 131 were in a non-controlled environment, and were included in the present analysis. The main outcome was change in substance use. Logistic regression analysis was applied to identify factors associated with abstinence from all substances (other than agonist medication) at follow-up.

RESULTS

Along with opioid use, most patients reported polysubstance use prior to entering treatment. No significant differences were found in baseline characteristics between the included and non-included groups when examining attrition. At the 1-year follow-up, reduced substance use was reported. While in treatment, around two-thirds of patients continued using other drugs to varying degrees. At follow-up, about one-third of patients reported abstinence from all drugs, apart from the agonist medication. Factors related to abstinence included a goal of abstinence at baseline (OR = 5.26; 95% CI 1.14-19.55; p = 0.013) and increasing age (OR = 1.05; 95% CI 1.00-1.09; p = 0.034).

CONCLUSIONS

The majority of patients entering OMT used other substances in addition to opioids. About one-third of patients reported abstinence at the 1-year follow up. Although the majority of patients continued co-use of other drugs while in treatment, for most substances, less than 10% reported daily use at follow-up, with the exception of cannabis which was used daily/almost daily by about 2 in 10. Higher age and treatment goal at the start of OMT were important factors related to reducing concomitant substance use during treatment. These findings suggest that many patients entering OMT are in need of treatment and support related to the use of other substances, to further improve prognosis.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov no. NCT05182918. Registered 10/01/2022 (the study was retrospectively registered).

Utilization of long-acting injectable monthly depot buprenorphine for opioid use disorder (OUD) in Kentucky, before and after COVID-19 related buprenorphine access policy changes

INTRODUCTION

Long-acting injectable buprenorphine (LAI-bup) formulations have advantages over transmucosal buprenorphine (TM-bup), but barriers may limit their utilization. Several policies shifted during the COVID-19 pandemic to promote buprenorphine access. The federal government expanded telemedicine treatment for opioid use disorder and Kentucky (KY) Medicaid lifted prior authorization requirements (PAs) for LAI-bup (i.e., Sublocade®). This retrospective cohort study evaluated changes in LAI-bup access, utilization, and retention before and after these policy changes in KY.

METHODS

Individual-level TM-bup and LAI-bup dispensing record data from KY's prescription drug monitoring program examined LAI-bup utilization and retention, without a >30-day gap in coverage, for patients starting a new episode of LAI-bup treatment. Two key time periods were examined: pre-policy changes (Apr 1, 2019 - Dec 31, 2019) and post-policy changes (Apr 1, 2020 - Dec 31, 2020). Data on PA requests among Medicaid managed care organizations and availability of LAI-bup Risk Evaluation and Mitigation Strategy (REMS)-certified pharmacies were also obtained. A multivariable Cox proportional hazard regression model analysis compared pre- versus post-policy period treatment discontinuation.

RESULTS

The number of patients initiating LAI-bup increased from 211 to 481 over the two periods. By the end of the post-policy period, 24.3 % of eligible patients were retained on LAI-bup, versus 12.5 % in the pre-policy change period. The adjusted hazard ratio, comparing discontinuation during the post- versus pre-policy change periods, was 0.70 (95 % confidence interval: 0.55-0.89). There were also more REMS-certified pharmacies and providers in the post-policy change period.

CONCLUSIONS

LAI-bup access, utilization, and retention increased after several policy changes.

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland

BACKGROUND

Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs.

METHODS

People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services.

RESULTS

The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors).

CONCLUSIONS

Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

A qualitative study of experiences with physical activity among people receiving opioid agonist therapy

BACKGROUND

Physical or mental health comorbidities are common among people with substance use disorders undergoing opioid agonist therapy. As both a preventive and treatment strategy, exercise offers various health benefits for several conditions. Exercise interventions to people with substance use disorders receiving opioid agonist therapy are limited. This study aims to explore experiences with physical activity, perceived barriers, and facilitators among people receiving opioid agonist therapy.

METHOD

Fourteen qualitative interviews were conducted with individuals receiving opioid agonist therapy in outpatient clinics in Western Norway.

RESULTS

Most were males in the age range 30 to 60 years. Participants had diverse and long-term substance use histories, and most received buprenorphine-based opioid agonist therapy. The identified themes were (1) Physical limitations: Participants experienced health-related problems like breathing difficulties, pain, and reduced physical function. (2) Social dynamics: Social support was essential for participating in physical activities and many argued for group exercises, but some were concerned about the possibility of meeting persons influenced by substances in a group setting, fearing temptations to use substances. (3) Shift in focus: As participants felt the weight of the health burden, their preference for activities shifted from sports aiming for "adrenaline" to a health promoting focus. (4) COVID-19's impact on exercise: because of the pandemic, group activities were suspended, and participants described it as challenging to resume. (5) Implementation preferences in clinics: Not interfering with opioid medication routines was reported to be essential.

CONCLUSION

This study offers valuable insights for the development of customized exercise interventions aimed at enhancing the health and well-being of patients undergoing opioid agonist therapy. These findings underscore the significance of addressing social dynamics, overcoming physical limitations, and implementing a practical and effective exercise regimen.

The Intersection of Substance Use Disorders and Infectious Diseases in the Emergency Department

Substance use disorders (SUDs) intersect clinically with many infectious diseases, leading to significant morbidity and mortality if either condition is inadequately treated. In this article, we will describe commonly seen SUDs in the emergency department (ED) as well as their associated infectious diseases, discuss social drivers of patient outcomes, and introduce novel ED-based interventions for co-occurring conditions. Clinicians should come away from this article with prescriptions for both antimicrobial medications and pharmacotherapy for SUDs, as well as an appreciation for social barriers, to care for these patients.

Time for Australia to increase take away doses in opioid agonist treatment

Opioid Agonist Treatment is the cornerstone of minimising harms related to opioid use, however its uptake is limited by a tightly regulated and stigmatising treatment environment. The COVID-19 pandemic necessitated relaxation of some treatment restrictions, with global evidence pointing to more patient-centred care in this time. In light of local evidence to support the safety of increased access to takeaway doses and a precedent set by the Substance Abuse and Mental Health Administration, we recommend adoption of the Australian Interim Medication Assisted Treatment of Opioid Dependence guidance in Australia.

Rethinking Substance Use as Social History: Charting a Way Forward

Physicians have traditionally asked about substance use within the Social History section of the consultation note. Drawing on social science theory and using the authors' own experiences as generalists and addiction scholars, we consider the possible unintended harms associated with this approach. The inclusion of the substance use history within the Social History reproduces the discourse of substance use disorders as "life-style choices" rather than medical conditions, and reinforces stigma among healthcare workers through the attribution of personal responsibility for complications associated with problematic substance use. The ongoing placement of the substance use history within the Social History may lead to a failure to diagnose and make appropriate management plans for clients with substance use disorders. These missed opportunities may include inadequate withdrawal management leading to discharge before medically advised, insufficient use of evidence-based pharmacotherapy and psychotherapy, polypharmacy, medical complications, and repeated admissions to hospital. We argue instead that the Substance Use History should be a stand-alone section within the consultation note. This new section would reduce the invisibility of substance use disorders within our medical systems and model that these chronic medical conditions are amenable to prevention, treatment and harm reduction through the application of evidence-based practices.

Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties

BACKGROUND

The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties.

METHODS

Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios.

RESULTS

Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county.

CONCLUSIONS

Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.

Analysis of rising cases of adolescent opioid use presentations to the emergency department and their management

OBJECTIVE

We sought to answer the question of how adolescents (ages 12-17 years old) with opioid-related presentations are currently managed in the ED. The two main outcomes were the proportion of visits where naloxone and buprenorphine were both used and prescribed, and the rate of revisits to the emergency department in the six months following ED presentation.

METHODS

This was a multi-center retrospective cross-sectional study. We studied patients presenting to the ED who were 12-17 years old with an opioid-related presentation.

RESULTS

Two-hundred and thirty-one patients were identified out of 571 encounters screened. Of these presentations, 77/231 (33%) were girls and 154/231 (67%) were boys. The majority of patients were Latino (64%; n=147); 26% were white (n=59), 6% were middle eastern or Arab (14), and 4% were black (10). Incidence of opioid use disorder per 100,000 presentations increased by 2800% from 2014 to 2022 (21/100,000 +/- 10 [2014] to 600/100,000 +/- 50 [2022]). A plurality of cases was related to opioid withdrawal (42%; 97). On discharge from the ED, 29% of patients received naloxone. For patients in withdrawal, 4% received a prescription for buprenorphine. Twenty-nine percent of patients had a return to the ED in the six months following initial visit.

CONCLUSIONS

Adolescent opioid-related presentations to the ED are rapidly increasing. Increasing ED presentations, compounded by a high 6-month revisit rate, pose a management challenge amid limited outpatient resources for this population. Opioid agonist therapy and naloxone are not routinely provided. Increasing the use of both are two ways to improve the quality of care for this population.

Buprenorphine prescribing and treatment accessibility in response to regulation changes due to the COVID-19 public health emergency

BACKGROUND

In 2021, over 80,000 fatal overdoses occurred in the United States. Since 2020, the federal government has enacted multiple regulatory changes around buprenorphine prescribing for opioid use disorder (OUD) to increase access to buprenorphine. This study aims to explore trends in buprenorphine treatment initiation pre- and post-public health emergency to evaluate changes in the context of X-waiver relaxations and telehealth allowances.

METHODS

In a cross-sectional study, all RI residents who filled a buprenorphine prescription at a pharmacy in Rhode Island (RI), Massachusetts, and Connecticut between January 2017 and December 2023 were obtained from the RI Prescription Drug Monitoring Program (PDMP). The study excluded buprenorphine products not approved for OUD treatment from the analysis. Identified individuals had initiated buprenorphine for OUD during the study period if they did not have a prior prescription or if they had >30 days without buprenorphine exposure between their prescriptions. Spearman's rank correlation tests were used to identify significant associations between outcomes and regulation changes.

RESULTS

The average number of patients dispensed buprenorphine did not significantly change over the study period, however the average number of initiates significantly decreased (ρ = -0.38255, p = .0003). The average number of providers prescribing CII-CV substances in RI has increased 3.4 % over the study period. The average percentage of prescribers in the PDMP prescribing buprenorphine for OUD doubled (ρ = 0.96075, p < .0001).

CONCLUSION

Though efforts have been made to increase buprenorphine initiation, buprenorphine initiates remain well below pre-PHE levels. Efforts must continue to eliminate existing barriers to treatment and improve access to individuals seeking treatment.

High COVID-19 vaccine uptake following initial hesitancy among people in Australia who inject drugs

BACKGROUND

Previous studies have reported high COVID-19 vaccine hesitancy among people who inject drugs. We aimed to examine COVID-19 vaccine coverage, motivations and barriers to vaccination, and factors associated with uptake among this population in Australia, 1.5 years after vaccine rollout commenced.

METHODS

In June-July 2022, 868 people (66.0 % male, mean age 45.6 years) who regularly inject drugs and reside in an Australian capital city reported the number of COVID-19 vaccine doses they had received and their primary motivation (if vaccinated) or barrier (if unvaccinated) to receive the vaccine. We compared vaccine uptake to Australian population estimates and used logistic regression to identify factors associated with ≥ 2 dose and ≥ 3 dose uptake.

RESULTS

Overall, 84.1 % (n = 730) had received at least one COVID-19 vaccine dose, 79.6 % (n = 691) had received ≥ 2 doses, and 46.1 % (n = 400) had received ≥ 3 doses. Participants were less likely to be vaccinated than the Australian general population (prevalence ratio: 0.82, 95 % confidence interval [CI]: 0.76-0.88). Key motivations to receive the vaccine were to protect oneself or others from COVID-19, while barriers pertained to vaccine or government distrust. Opioid agonist treatment (adjusted odds ratio [aOR]: 2.49, 95 % CI: 1.44-4.42), current seasonal influenza vaccine uptake (aOR: 6.76, 95 % CI: 3.18-16.75), and stable housing (aOR: 1.58, 95 % CI: 1.02-2.80) were associated with receipt of at least two vaccine doses. Participants aged ≥ 40 years (versus < 40 years; aOR: 1.66, 95 % CI: 1.10-2.53) or who reported a chronic health condition (aOR: 1.71, 95 % CI: 1.18-2.47) had higher odds of receiving at least three vaccine doses.

CONCLUSION

We observed higher COVID-19 vaccine uptake than expected given previous studies of vaccine acceptability among people who inject drugs. However, it was lower than the general population. People who inject drugs and reside in unstable housing are a subpopulation that require support to increase vaccine uptake.

Prevalence of opioid dependence in Scotland 2015-2020: A multi-parameter estimation of prevalence (MPEP) study

BACKGROUND AND AIMS

Drug-related deaths in Scotland more than doubled between 2011 and 2020. To inform policymakers and understand drivers of this increase, we estimated the number of people with opioid dependence aged 15-64 from 2014/15 to 2019/20.

DESIGN

We fitted a Bayesian multi-parameter estimation of prevalence (MPEP) model, using adverse event rates to estimate prevalence of opioid dependence jointly from Opioid Agonist Therapy (OAT), opioid-related mortality and hospital admissions data. Estimates are stratified by age group, sex and year.

SETTING

Scotland, 2014/15 to 2019/20.

PARTICIPANTS

People with opioid dependence and potential to benefit from OAT, whether ever treated or not. Using data from the Scottish Public Health Drug Linkage Programme, we identified a baseline cohort of individuals who had received OAT within the last 5 years, and all opioid-related deaths and hospital admissions (whether among or outside of this cohort).

MEASUREMENTS

Rates of each adverse event type and (unobserved) prevalence were jointly modelled.

FINDINGS

The estimated number and prevalence of people with opioid dependence in Scotland in 2019/20 was 47 100 (95% Credible Interval [CrI] 45 700 to 48 600) and 1.32% (95% CrI 1.28% to 1.37%). Of these, 61% received OAT during 2019/20. Prevalence in Greater Glasgow and Clyde was estimated as 1.77% (95% CrI 1.69% to 1.85%). There was weak evidence that overall prevalence fell slightly from 2014/15 (change -0.07%, 95% CrI -0.14% to 0.00%). The population of people with opioid dependence is ageing, with the estimated number of people aged 15-34 reducing by 5100 (95% CrI 3800 to 6400) and number aged 50-64 increasing by 2800 (95% CrI 2100 to 3500) between 2014/15 and 2019/20.

CONCLUSIONS

The prevalence of opioid dependence in Scotland remained high but was relatively stable, with only weak evidence of a small reduction, between 2014/15 and 2019/20. Increased numbers of opioid-related deaths can be attributed to increased risk among people with opioid dependence, rather than increasing prevalence.

Withdrawal during outpatient low dose buprenorphine initiation in people who use fentanyl: a retrospective cohort study

BACKGROUND

Buprenorphine is an effective treatment for opioid use disorder (OUD); however, buprenorphine initiation can be complicated by withdrawal symptoms including precipitated withdrawal. There has been increasing interest in using low dose initiation (LDI) strategies to reduce this withdrawal risk. As there are limited data on withdrawal symptoms during LDI, we characterize withdrawal symptoms in people with daily fentanyl use who underwent initiation using these strategies as outpatients.

METHODS

We conducted a retrospective chart review of patients with OUD using daily fentanyl who were prescribed 7-day or 4-day LDI at 2 substance use disorder treatment clinics in San Francisco. Two addiction medicine experts assessed extracted chart documentation for withdrawal severity and precipitated withdrawal, defined as acute worsening of withdrawal symptoms immediately after taking buprenorphine. A third expert adjudicated disagreements. Data were analyzed using descriptive statistics.

RESULTS

There were 175 initiations in 126 patients. The mean age was 37 (SD 10 years). 71% were men, 26% women, and 2% non-binary. 21% identified as Black, 16% Latine, and 52% white. 60% were unstably housed and 75% had Medicaid insurance. Substance co-use included 74% who used amphetamines, 29% cocaine, 22% benzodiazepines, and 19% alcohol. Follow up was available for 118 (67%) initiations. There was deviation from protocol instructions in 22% of these initiations with follow up. 31% had any withdrawal, including 21% with mild symptoms, 8% moderate and 2% severe. Precipitated withdrawal occurred in 10 cases, or 8% of initiations with follow up. Of these, 7 had deviation from protocol instructions; thus, there were 3 cases with follow up (3%) in which precipitated withdrawal occurred without protocol deviation.

CONCLUSIONS

Withdrawal was relatively common in our cohort but was mostly mild, and precipitated withdrawal was rare. Deviation from instructions, structural barriers, and varying fentanyl use characteristics may contribute to withdrawal. Clinicians should counsel patients who use fentanyl that mild withdrawal symptoms are likely during LDI, and there is still a low risk for precipitated withdrawal. Future studies should compare withdrawal across initiation types, seek ways to support patients in initiating buprenorphine, and qualitatively elicit patients' withdrawal experiences.

Mortality among people who inject drugs - the interwoven roles of fentanyl and HIV: a community-based cohort study

BACKGROUND

Excess all-cause mortality is a key indicator for assessing direct and indirect consequences of injection drug use and data are warranted to delineate sub-populations within people who inject drugs at higher risk of death. Our aim was to examine mortality and factors associated with mortality among people who inject drugs in Estonia.

METHODS

Retrospective cohort study using data from people who inject drugs recruited in the community with linkage to death records. Standardized mortality ratios were used to compare the cohort mortality to the general population and potential predictors of death were examined through survival analysis (Cox regression). The cohort include a total of 1399 people who inject drugs recruited for cross-sectional surveys using respondent driven sampling between 2013 and 2018 in Estonia. A cohort with follow-up through 2019 was formed with linkage to national causes of death registry.

RESULTS

Among 1399 participants with 4684 person-years of follow-up, 10% were deceased by 2019. The all-cause mortality rate in the cohort was 28.9 per 1000 person-years (95% confidence interval 25.3-35.3). Being HIV positive, injecting mainly opioids (fentanyl), living in the capital region and the main source of income other than work were associated with greater mortality risk.

CONCLUSIONS

While low-threshold services have been available for a long time for people who inject drugs, there is still a need to widen the availability and integration of services, particularly the integration of HIV and opioid treatment.

"I want to stay here": Patient and staff perspectives on transitioning from a low-threshold buprenorphine program to clinic-based care

BACKGROUND

The Project Connections At Re-Entry (PCARE) Van is a low-threshold buprenorphine program operating outside the Baltimore City Detention Center. Like other low-threshold programs, PCARE seeks to engage a vulnerable population in care, stabilize patients, then transition patients to longer-term care; however, <10% of patients transition to clinic-based buprenorphine treatment. Our goal was to better understand these low transition rates and center patient perspectives in discussion of broader low-threshold program design.

METHODS

From December 2022 to June 2023, semi-structured interviews were conducted with 20 former and current PCARE patients and 6 staff members. We used deductive and inductive coding followed by thematic content analysis to identify themes around treatment experiences and care preferences.

RESULTS

There were strong preferences among current and former patients for continuing buprenorphine treatment at the PCARE Van. Several themes emerged from the data that explained patient preferences, including both advantages to continuing care at the van (preference for continuity, feeling respected by the program's structure and philosophy) and disadvantages to transitioning to a clinic (perceived harms associated with rigid or punitive care models). Staff noted limited program capacity, and patients expressed that if needed, they would transition to a clinic for altruistic reasons. Staff expressed varied perspectives on low-threshold care, emphasizing both larger systems factors, as well as beliefs about individual patient responsibility.

CONCLUSIONS

While many low-threshold care settings are designed as transitional bridge models, this research highlights patient preference for long-term care at low-threshold programs and supports efforts to adapt low-threshold models to be sustainable as longitudinal care.

Reasons for not entering opioid agonist treatment: A survey among high-risk opioid users in Finland

Aims: To characterise and understand the untreated high-risk opioid user population in Finland, and to determine the reasons why these people do not enter treatment. Methods: The study setting was a half-year cross-sectional survey in Finland during 2021-2022. An electronic questionnaire with 24 structured questions was concluded in 16 needle exchange units. Participants were opioid-dependent people without opioid agonist treatment (OAT), and they answered the survey voluntarily and anonymously. Results: Of the 167 respondents, 62% were men, 53% were aged ≤34 years, 66% had used opioids for >6 years, and 78% used drugs intravenously (IV) daily. The most used opioid (95%) was buprenorphine. Most respondents used opioids as self-medication for withdrawal symptoms (75%), or to treat psychological symptoms (59%) or pain (43%). Of them, 70% also used other substances for recreational purposes. The most common named reasons to stay outside OAT were as follows: seeking treatment is too difficult (37%); treatment is too binding (36%); and fear of actions from authorities (23%). Conclusions: For opioid-dependent respondents who would be eligible for OAT in Finland, treatment awareness is limited. These high-risk opioid users also think that the treatment would be too binding. In conclusion, there is a need for increase in general information about, accessibility to, acceptance for and individualisation of OAT.

A Systematic Review of State Office-Based Buprenorphine Treatment Laws Effective During 2022: Counseling, Dosage, and Visit Frequency Requirements

BACKGROUND

Buprenorphine is among the most effective treatments for opioid use disorder. Even though the federal government recently eliminated the waiver requirement and patient limits applicable to office-based buprenorphine treatment (OBBT), among other settings, some states may still have policies imposing requirements on OBBT providers not required by federal law.

METHODS

We collected statutes and regulations from 50 US states and the District of Columbia (ie, 51 jurisdictions) between August 11 and November 30, 2022 using the Nexis Uni legal database and search terms related to OBBT counseling, dosage, and/or frequency of visits. We then used template analysis, a mixed deductive-inductive qualitative method, to analyze legal content.

RESULTS

Ten jurisdictions (20%) in 2022 had an OBBT counseling, dosage, and/or visit frequency requirement. Four jurisdictions had at least one law in each OBBT policy category examined. One-fifth of jurisdictions have OBBT policies not required under federal law. Five of these jurisdictions are among those with the highest overdose death rates per capita, according to publicly available data from 2021. Some OBBT requirements could potentially limit clinician interest in offering buprenorphine treatment or result in inadequate care (eg, if dosage limitations are too low.).

CONCLUSIONS

Even though a federal waiver is no longer required for OBBT, our results suggests that at least some jurisdictions have other OBBT requirements, such as counseling, dosage, and/or frequency requirements. Given the severity of the ongoing opioid overdose crisis, policymakers should carefully consider the extent to which OBBT requirements are evidence based.

Nine-year substance use treatment outcomes with buprenorphine for opioid use disorder in a federally qualified health center

BACKGROUND

Prescribing medication for opioid use disorder (MOUD) in primary care helps meet treatment demand, but few studies examine long-term treatment retention among medically-underserved primary care patients.

METHODS

This 9-year retrospective study assessed overall retention at 6 months, and yearly up to 9 years, among 1451 patients with at least 6 months of buprenorphine prescription data from a federally-qualified health center (FQHC). We also examined whether patients who had gaps in treatment (>14 days without medication) later returned to care. Associations with treatment retention over total time in care were assessed.

RESULTS

On average, patients received buprenorphine treatment for 2.26 years. Among patients who experienced gaps in treatment but returned to care within 90 days, 64% were still receiving buprenorphine at six months (n=930 of 1451), and 70% (n =118 of 169) at 9 years, with an average yearly interval retention of 69% (range: 58-74%). Patients were on MOUD treatment and not in a gap about 81% of the time, and averaged 1.0 gap per patient per year (SD: 1.09; range 0-7.87). The mean gap length over the treatment period was 33.16 days. Older age, higher percentages of negative opioid tests, negative cocaine tests, and positive buprenorphine tests, and having diabetes were associated with longer treatment retention.

CONCLUSIONS

Opioid use disorder (OUD) can be treated successfully in primary care FQHCs. Treatment gaps are common and reflect the chronic relapsing nature of OUD.

Mobile treatment for opioid use disorder: Implementation of community-based, same-day medication access interventions

BACKGROUND

Medications for Opioid Use Disorder (MOUD) are lifesaving, but <20 % of individuals in the US who could benefit receive them. As part of the NIH-supported HEALing Communities Study (HCS), coalitions in several communities in Massachusetts and Ohio implemented mobile MOUD programs to overcome barriers to MOUD receipt. We defined mobile MOUD programs as units that provide same-day access to MOUD at remote sites. We aimed to (1) document the design and organizational structure of mobile programs providing same-day or next-day MOUD, and (2) explore the barriers and facilitators to implementation as well as the successes and challenges of ongoing operation.

METHODS

Program staff from five programs in two states (n = 11) participated in semi-structured interviews. Two authors conducted thematic analysis of the transcripts based on the domains of the social-ecological model and the semi-structured interview guide.

RESULTS

Mobile MOUD units sought to improve immediate access to MOUD ("Our answer is pretty much always, 'Yes, we'll get you started right here, right now,'"), advance equity ("making sure that we have staff who speak other languages, who are on the unit and have some resources that are in different languages,"), and decrease opioid overdose deaths. Salient program characteristics included diverse staff, including staff with lived experience of substance use ("She just had that personal knowledge of where we should be going"). Mobile units offered harm reduction services, broad medical services (in particular, wound care), and connection to transportation programs and incorporated consistency in service provision and telemedicine access. Implementation facilitators included trusting relationships with partner organizations (particularly pharmacies and correctional facilities), nuanced understanding of local politics, advertising, protocol flexibility, and on-unit prescriber hours. Barriers included unclear licensing requirements, staffing shortages and competing priorities for staff, funding challenges due to inconsistency in grant funding and low reimbursement ("It's not really possible that billing in and of itself is going to be able to sustain it"), and community stigma toward addiction services generally.

CONCLUSIONS

Despite organizational, community, and policy barriers, participants described mobile MOUD units as an innovative way to expand access to life-saving medications, promote equity in MOUD treatment, and overcome stigma.

Liver stiffness and associated risk factors among people with a history of injecting drugs: a prospective cohort study

BACKGROUND

Persons with opioid use disorders (OUD) and persons with substance use disorders (SUD) who inject substances have a reduced life expectancy of up to 25 years compared with the general population. Chronic liver diseases are a substantial cause of this. Screening strategies based on liver stiffness measurements (LSM) may facilitate early detection, timely intervention, and treatment of liver disease. This study aims to investigate the extent of chronic liver disease measured with transient elastography and the association between LSM and various risk factors, including substance use patterns, hepatitis C virus (HCV) infection, alcohol use, body mass index, age, type 2 diabetes mellitus, and high-density lipoprotein (HDL) cholesterol among people with OUD or with SUD who inject substances.

METHODS

Data was collected from May 2017 to March 2022 in a cohort of 676 persons from Western Norway. The cohort was recruited from two populations: Persons receiving opioid agonist therapy (OAT) (81% of the sample) or persons with SUD injecting substances but not receiving OAT. All participants were assessed at least once with transient elastography. A linear mixed model was performed to assess the impact of risk factors such as HCV infection, alcohol use, lifestyle-associated factors, and substance use on liver stiffness at baseline and over time. Baseline was defined as the time of the first liver stiffness measurement. The results are presented as coefficients (in kilopascal (kPa)) with 95% confidence intervals (CI).

RESULTS

At baseline, 12% (n = 83) of the study sample had LSM suggestive of advanced chronic liver disease (LSM ≥ 10 kPa). Advanced age (1.0 kPa per 10 years increments, 95% CI: 0.68;1.3), at least weekly alcohol use (1.3, 0.47;2.1), HCV infection (1.2, 0.55;1.9), low HDL cholesterol level (1.4, 0.64;2.2), and higher body mass index (0.25 per increasing unit, 0.17;0.32) were all significantly associated with higher LSM at baseline. Compared with persistent chronic HCV infection, a resolved HCV infection predicted a yearly reduction of LSM (-0.73, -1.3;-0.21) from baseline to the following liver stiffness measurement.

CONCLUSIONS

More than one-tenth of the participants in this study had LSM suggestive of advanced chronic liver disease. It underscores the need for addressing HCV infection and reducing lifestyle-related liver risk factors, such as metabolic health factors and alcohol consumption, to prevent the advancement of liver fibrosis or cirrhosis in this particular population.

Unintended consequences of methadone regulation for opioid use disorder treatment among hospitalized patients

BACKGROUND

In the United States, there are no federal restrictions on the use of methadone to manage opioid withdrawal symptoms when patients are hospitalized with a medical or surgical condition other than addiction. In contrast, in an outpatient setting, methadone for opioid use disorder (OUD) is highly regulated by federal and state governments and can only be dispensed from an opioid treatment program (OTP). Discrepancies in regulatory requirements across these settings may lead to barriers in care for patients with OUD.

OBJECTIVE

Identify how methadone regulation impacts the care of patients with OUD during hospitalization, care transitions, and in the OTP setting.

METHODS

We completed 26 interviews with clinicians and social workers working on hospital-based addiction consultation services across the United States. Study findings are the result of a secondary content analysis of interviews to identifying the word "methadone" and construct themes resulting from the data.

RESULTS

We identified three major themes related to "methadone" for OUD treatment, all of which impacted patient care: (1) limited OTP hours leads to tenuous or delayed hospital discharges; (2) inadequate information-sharing between hospitals and OTPs leads to delays in care; and (3) methadone regulations create treatment barriers for the most vulnerable patients.

CONCLUSION

Strict methadone regulations have resulted in unintended consequences for patients with OUD in the hospital setting, during care transitions, and in the OTP setting. Recent and ongoing federal efforts to reform methadone provision may improve some of the reported challenges, but significant hurdles remain in providing safe, equitable care to hospitalized patients with OUD.

Operationalizing the new DEA exception: A novel process for dispensing of methadone for opioid use disorder at discharge from acute care settings

PURPOSE

To describe one strategy for dispensing of methadone at emergency department (ED) and hospital discharge implemented within 2 urban academic medical centers.

SUMMARY

Expanding access to medications for opioid use disorder (OUD) is a national priority. ED visits and hospitalizations offer an opportunity to initiate or continue these lifesaving medications, including methadone and buprenorphine. However, federal regulations governing methadone treatment and significant gaps in treatment availability have made continuing methadone upon ED or hospital discharge challenging. To address this issue, the Drug Enforcement Administration (DEA) granted an exception allowing hospitals, clinics, and EDs to dispense a 72-hour supply of methadone while continued treatment is arranged. Though this exception addresses a critical unmet need, guidance for operationalizing this service is limited. To facilitate expanded patient access to methadone on ED or hospital discharge at 2 Baltimore hospitals, key stakeholders within the parent health system were identified, and a workgroup was formed. Processes were established for requesting, approving, preparing, and dispensing the methadone supply using an electronic health record order set. Multidisciplinary educational materials were created to support end users of the workflow. In the first 3 months of implementation, 42 requests were entered, of which 36 were approved, resulting in 79 dispensed methadone doses.

CONCLUSION

This project demonstrates feasibility of methadone dispensing at hospital and ED discharge. Further work is needed to evaluate impact on patient outcomes, such as hospital and ED utilization, length of stay, linkage to treatment, and retention in treatment.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose

Importance

Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.

Objective

To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.

Design, Setting, and Participants

This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.

Exposure

Hospital OORP implementation.

Main Outcomes and Measures

The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.

Results

A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.

Conclusions and Relevance

In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Application of an opioid use disorder cascade of care in a large public health system

Background: Over the past decade, hospitals and health systems have increasingly adopted interventions to address the needs of patients with substance use disorders. The Opioid Use Disorder (OUD) Cascade of Care provides a framework for organizing and tracking patient health milestones over time and can assist health systems in identifying areas of intervention to maximize the impact of evidence-based services. However, detailed protocols are needed to guide health systems in how to operationalize the OUD Cascade and track outcomes using electronic health records.Objective: In this paper, we describe the process of operationalizing and applying the OUD Cascade in a large, urban, public hospital system.Methods: Through this case example, we describe the technical processes around data mining, as well as the decision-making processes, challenges encountered, lessons learned from compiling preliminary patient data and defining stages and outcome measures for the OUD Cascade of Care, and preliminary dataResults: We identified 33,616 (26.17% female) individuals with an OUD diagnosis. Almost half (48%) engaged with addiction services, while only 10.7% initiated medication-based treatment in an outpatient setting, 6.7% had timely follow-up, and 3.5% were retained for a minimum of 6 months.Conclusion: The current paper serves as a primer for other health systems seeking to implement data-informed approaches to guide more efficient care and improved substance use-related outcomes. An OUD Cascade of Care must be tailored to local systems based on inherent data limitations and services design with an emphasis on early stages wherein drop-off is the greatest.

Use of in-network insurance benefits is critical for improving retention in telehealth-based buprenorphine treatment

An empiric evidence base is lacking regarding the relationship between insurance status, payment source, and outcomes among patients with opioid use disorder (OUD) on telehealth platforms. Such information gaps may lead to unintended impacts of policy changes. Following the phase-out of the COVID-19 Public Health Emergency, states were allowed to redetermine Medicaid eligibility and disenroll individuals. Yet, financial barriers remain a common and significant hurdle for patients with OUD and are associated with worse outcomes. We studied 3842 patients entering care in 2022 at Ophelia Health, one of the nation's largest OUD telehealth companies, to assess associations between insurance status and 6-month retention. In multivariable analyses, in-network patients who could use insurance benefits were more likely to be retained compared with cash-pay patients (adjusted risk ratio [aRR]: 1.50; 95% CI: 1.40-1.62; P < .001). Among a subsample of 882 patients for whom more detailed insurance data were available (due to phased-in electronic health record updates), in-network patients were also more likely to be retained at 6 months compared with insured, yet out-of-network patients (aRR: 1.86; 95% CI: 1.54-2.23; P < .001). Findings show that insurance status, and specifically the use of in-network benefits, is associated with superior retention and suggest that Medicaid disenrollment and insurance plan hesitation to engage with telehealth providers may undermine the nation's response to the opioid crisis.

Differences in heroin overdose deaths in Australia by age, 2020-2022: Disease and estimated survival times

Background

The age of people who use illicit opioids has increased, with a clinical picture of accelerated ageing. The study aimed to determine, stratified by age: 1. The circumstances and characteristics of heroin-related toxicity deaths in Australia, 2020-2022; 2. The toxicological profile and autopsy findings; 3. The proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a measure of survival time.

Methods

Retrospective study of 610 cases of fatal heroin-related drug toxicity in Australia, 2020-2022. Cases were stratified as: <30 years, 30-39 years, 40-49 years, ≥50 years.

Results

Compared to the youngest group, those aged ≥50 years were more likely to have a history of chronic pain (12.4 v 3.3 %), to have their death attributed to combined drug toxicity/disease (20.1 v 3.3 %), and to have evidence of a sudden collapse (21.3 v 11.1 %). There were no differences in free morphine concentrations or glucuronide concentrations. Compared to the youngest group, however, the two older groups were significantly more likely to have 6AM present in blood, a proxy measure of a shorter survival time (52.0, 55.2 v 34.5 %). Compared to the youngest group, cases aged ≥50 years were more likely to be diagnosed with cardiomegaly (44.0 v 16.7 %), coronary artery disease (46.0 v 15.0 %), emphysema (35.0 v 5.1 %), hepatic steatosis (15.4 v 3.4 %), hepatic fibrosis (17.6 v 3.4 %), and cirrhosis (19.8 v 0.0 %).

Conclusions

Older cases of heroin overdose had more extensive heart, lung, and liver disease, and appeared more likely to have shorter survival times.

A descriptive coronial study of heroin toxicity deaths in Australia, 2020-2022: Characteristics, toxicology and survival times

BACKGROUND AND AIMS

Mortality rates among people who use heroin are estimated to be 15 times that of the general population. The study aimed to determine (1) the case characteristics and circumstances of death of heroin-related toxicity deaths in Australia, 2020-2022; (2) their toxicological profile and major autopsy findings; (3) the proportion of cases in which blood 6-acetyl morphine (6AM) was detected, as a proxy measure of survival times; and (4) compare 6AM positive and negative cases on toxicology, circumstances of death and acute clinical presentation.

DESIGN

Retrospective study of heroin toxicity deaths in Australia, 2020-2022, retrieved from the National Coronial Information System.

SETTING

This study was conducted Australia-wide.

CASES

There were 610 cases of fatal heroin-related drug toxicity.

MEASUREMENTS

Information was collected on characteristics, manner of death, toxicology and autopsy results.

FINDINGS

The mean age was 42.6 years (range 18-73 years), 80.5% were male and 7.5% were enrolled in a drug treatment programme. The circumstances of death were as follows: unintentional drug toxicity (86.2%), combined unintentional drug toxicity/disease (11.3%) and intentional drug toxicity (2.5%). The median free morphine concentration was 0.17 mg/L (range 0.00-4.20 mg/L). Psychoactive drugs other than heroin were present in 95.2% (Confidence Interval 93.1%-96.8%), most commonly hypnosedatives (62.3%, 58.2%-66.4%) and psychostimulants (44.8%, 40.7%-49.1%). Major autopsy findings of clinical significance included acute bronchopneumonia (14.8%, 11.3%-18.8%), emphysema (16.9%, 13.2%-21.1%), cardiomegaly (30.1%, 12.7%-28.2%), coronary artery disease (27.4%, 23.0%-32.3%), coronary replacement fibrosis (13.4%, 10.1%-17.3%), hepatic cirrhosis (8.8%, 6.6%-12.2%) and renal fibrosis (10.3%, 7.3%-14.0%). In 47.0% (42.3%-51.2%), 6AM was present in blood.

CONCLUSIONS

The 'typical' heroin overdose case in Australia from 2020 to 2022 was a male who injected heroin, aged in the 40s, not enrolled in a treatment programme and had used multiple drugs. In over half of cases, there had been a sufficient survival time for 6-acetyl morphine to have been metabolised, which may indicate times in excess of 20-30 min.

Neurocognitive Functions After 6-Month Buprenorphine (Naloxone)-Based Opioid Agonist Maintenance Treatment: A Controlled Prospective Study

BACKGROUND

Medications for opioid use disorder (OUD) may influence neurocognitive functions. Inadequate power, confounders, and practice effects limit the validity of the existing research. We examined the change in cognitive functions in patients with OUD at 6-month buprenorphine (naloxone) posttreatment and compared the cognitive performance of the buprenorphine-treated group with control subjects.

METHODS

We recruited 498 patients with OUD within a week of initiating buprenorphine. Assessments were done twice-at baseline and 6 months. Those abstinent from illicit opioids and adherent to treatment (n = 199) underwent follow-up assessments. Ninety-eight non-substance-using control subjects were recruited from the community. The neurocognitive assessments comprised the Wisconsin Card Sorting Test, Iowa Gambling Task, Trail-Making Tests A and B (TMT-A and TMT-B), and verbal and visual N-Back Test. We controlled for potential effect modifiers.

RESULTS

Twenty-five of the 32 test parameters significantly improved with 6 months of buprenorphine treatment; 20 parameters withstood corrections for multiple comparisons (P < 0.001). The improved test domains spread across cognitive tests: Wisconsin Card Sorting Test (perseverative errors and response, categories completed, conceptual responses), TMTs (time to complete), verbal and visual N-Back Tests (hits, omission, and total errors). After treatment, OUD (vs control subjects) had less perseverative response and error (P < 0.001) and higher conceptual response (P = 0.004) and took lesser time to complete TMT-A (P < 0.001) and TMT-B (P = 0.005). The baseline neurocognitive functions did not differ between those who retained and those who discontinued the treatment.

CONCLUSION

Cognitive functions improve in patients with OUD on buprenorphine. This improvement is unlikely to be accounted for by the practice effect, selective attrition, and potential confounders.

Clinical stakeholders' perceptions of patient engagement in outpatient medication treatment for opioid use disorder: A qualitative study

INTRODUCTION

Medications for opioid use disorder (MOUD) reduce risk of opioid overdose and promote recovery from opioid use disorder, but poor retention in MOUD limits these positive effects. This study explored patient engagement in MOUD from the perspective of clinical stakeholders within an outpatient addiction medicine program to identify program factors influencing patient engagement with treatment.

METHODS

We conducted a qualitative case study of a multi-clinic outpatient addiction medicine program embedded within an integrated health system that serves a geographically diverse area of Pennsylvania. Collectively, the program's clinics provide MOUD (primarily buprenorphine) to ~2000 patients annually. From January to March 2021, we conducted semi-structured telephone/video interviews with three stakeholder groups involved in delivering MOUD: administrators (n = 4), providers (n = 7), and addiction care coordinators (n = 5). Data analysis utilized the framework method.

RESULTS

We identified five themes related to patient engagement. First, participants described health system integration as enhancing quality and offering opportunities for addressing patients' comprehensive health care needs. However, lack of knowledge about addiction and stigma among health system providers was felt to limit patient benefits from this integration, including access to MOUD. Second, participants viewed patient engagement as central to the program's policies, practices, and clinical environment. Adoption of a harm reduction approach and maintenance of a non-stigmatizing clinic environment were described as essential facilitators of engagement. Third, while clinics followed uniform operations, physician leads expressed differing philosophical approaches to treatment, which participants associated with variations in clinical practice and patient engagement. Fourth, participants identified key services that bolstered engagement in MOUD, including psychosocial services, psychiatric care, and telemedicine. Finally, staff well-being emerged as a key consideration for patient engagement.

CONCLUSIONS

Understanding perceptions of those who administer and deliver care is critical for identifying barriers and facilitators to patient engagement in MOUD. Findings suggest potential opportunities for addiction treatment programs to improve patient engagement and ultimately MOUD retention, including integration with other healthcare services to meet comprehensive healthcare needs; adoption of a harm reduction approach; creation of non-stigmatizing clinical environments; investment in psychosocial services, psychiatric care, and telemedicine; and prioritization of staff wellness.

Change in self-reported somatic symptoms among patients in opioid maintenance treatment from baseline to 1-year follow-up

BACKGROUND

High somatic comorbidity is common among patients in treatment for opioid use disorder (OUD). The present study aims to investigate changes in self-reported somatic health conditions and somatic symptoms among patients entering opioid maintenance treatment (OMT) programs.

METHODS

We used data from the Norwegian Cohort of Patients in OMT and Other Drug Treatment (NorComt) study. Of 283 patients who entered OMT, 176 were included for analysis at a 1-year follow-up. Participants provided self-reported data during structured interviews on somatic conditions, somatic symptoms, substance use severity measures, and mental distress. A multivariable linear regression analysis identified factors associated with changes in the burden of somatic symptoms.

RESULTS

Patients entering OMT reported a high prevalence of somatic conditions at the beginning of treatment, with 3 of 5 patients reporting at least one. The most prevalent condition was hepatitis C, followed by asthma and high blood pressure. Patients reported experiencing a high number of somatic symptoms. The intensity of these symptoms varied across a wide spectrum, with oral health complaints and reduced memory perceived as the most problematic. Overall, for the entire sample, there was no significant change in somatic symptoms from baseline to 1 year. Further analysis indicated that those who reported a higher burden of somatic symptoms at baseline had the greatest improvement at the 1-year follow-up. A higher number of somatic conditions and higher mental distress at baseline was associated with improvements in somatic symptoms burden at follow-up.

CONCLUSIONS

Patients in OMT report a range of somatic conditions and somatic symptoms. Given the wide range of symptoms reported by patients in OMT, including some at high intensity levels, healthcare providers should take into consideration the somatic healthcare needs of individuals in OMT populations.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov no. NCT05182918. Registered 10/01/2022 (the study was retrospectively registered).

An emergency-department-initiated outreach program for patients with opioid use disorder is associated with an increase in agonist therapy and engagement in addictions care: a one-year cohort study

BACKGROUND

People with opioid use disorder (OUD) are high-risk for short-term mortality and morbidity. Emergency department (ED) interventions can reduce those risks, but benefits wane without ongoing community follow-up.

OBJECTIVE

To evaluate an ED-based intensive community outreach program.

METHODS

At two urban EDs between October 2019 and March 2020, we enrolled patients with OUD not currently on opioid agonist therapy (OAT) in a prospective cohort study evaluating a one-year intensive community outreach program, which provided ongoing addictions care, housing resources, and community support. We surveyed patients at intake and at scheduled outreach encounters at one, two, six, and twelve months. Follow-up surveys assessed OAT uptake, addictions care engagement, housing status, quality of life scores, illicit opioid use, and outreach helpfulness. We used descriptive statistics for each period and conducted sensitivity and subgroup analyses to account for missing data.

RESULTS

Of 84 baseline participants, 29% were female and 32% were housed, with a median age of 33. Sixty participants (71%) completed at least one follow-up survey. Survey completion rates were 37%, 38%, 39%, and 40% respectively at one, two, six, and twelve months. Participants had a median of three outreach encounters. Among respondents, OAT was 0% at enrolment and ranged from 38% to 56% at follow-up; addictions care engagement was 22% at enrolment and ranged from 65% to 81% during follow-up; and housing was 40% at enrolment and ranged from 48% to 59% during follow-up. Improvements from baseline to follow-up occurred for all time periods. OAT and engagement in care benefits were maintained in sensitivity and subgroup analyses. Respondents rated the outreach program as helpful at all time periods, CONCLUSION: An ED-initiated intensive outreach program for patients with OUD not yet on OAT was associated with a persistent increase in OAT use and engagement in care, as well as housing.

Novel Uses of Methadone Under the "72-Hour Rule" to Facilitate Transitions of Care and Low-Dose Buprenorphine Induction in an Outpatient Bridge Clinic

BACKGROUND

Federal regulations restrict methadone for opioid use disorder (OUD) treatment to licensed opioid treatment programs (OTPs). However, providers in other settings can administer methadone for opioid withdrawal under the "72-hour rule" while linking to further care. Prior work has demonstrated that methadone initiation in a low-barrier bridge clinic is associated with high OTP linkage and 1-month retention rates. We describe 2 other novel applications of the 72-hour rule in which methadone withdrawal management facilitated linkage to inpatient hospitalization and outpatient buprenorphine induction.

CASE PRESENTATIONS

Patient 1 was a 46-year-old woman with OUD complicated by serious injection-related infections. Severe opioid withdrawal limited her ability to tolerate emergency department wait times and receive inpatient care. We administered methadone for opioid withdrawal in an outpatient bridge clinic immediately before emergency department referral; this enabled hospital admission for intravenous antibiotics and anticoagulation. Patient 2 was a 36-year-old man with OUD desiring buprenorphine treatment. He had been unable to complete traditional buprenorphine induction without experiencing precipitated withdrawal. Thus, we recommended a low-dose buprenorphine induction overlapping with a full opioid agonist. Given the patient's preference to stop using fentanyl immediately, he received 72 hours of methadone for withdrawal treatment during the induction phase and successfully transitioned to buprenorphine without significant concomitant fentanyl use.

CONCLUSION

In addition to facilitating OTP linkage, on-demand 72-hour methadone administration for opioid withdrawal can reduce barriers to acute medical care and buprenorphine treatment.

Factors associated with frequent buprenorphine / naloxone initiation in a national survey of Canadian emergency physicians

OBJECTIVE

To identify individual and site-related factors associated with frequent emergency department (ED) buprenorphine/naloxone (BUP) initiation. BUP initiation, an effective opioid use disorder (OUD) intervention, varies widely across Canadian EDs.

METHODS

We surveyed emergency physicians in 6 Canadian provinces from 2018 to 2019 using bilingual paper and web-based questionnaires. Survey domains included BUP-related practice, demographics, attitudes toward BUP, and site characteristics. We defined frequent BUP initiation (the primary outcome) as at least once per month, high OUD prevalence as at least one OUD patient per shift, and high OUD resources as at least 3 out of the following 5 resources: BUP initiation pathways, BUP in ED, peer navigators, accessible addiction specialists, and accessible follow-up clinics. We excluded responses from sites with <50% participation (to minimize non-responder bias) and those missing the primary outcome. We used univariate analysis to identify associations between frequent BUP initiation and factors of interest, stratifying by OUD prevalence.

RESULTS

We excluded 3 responses for missing BUP initiation frequency and 9 for low response rate at one ED. Of the remaining 649 respondents from 34 EDs, 374 (58%) practiced in metropolitan areas, 384 (59%) reported high OUD prevalence, 312 (48%) had high OUD resources, and 161 (25%) initiated BUP frequently. Age, gender, board certification and years in practice were not associated with frequent BUP initiation. Site-specific factors were associated with frequent BUP initiation (high OUD resources [OR 6.91], high OUD prevalence [OR 4.45], and metropolitan location [OR 2.39],) as were individual attitudinal factors (willingness, confidence, and responsibility to initiate BUP.) Similar associations persisted in the high OUD prevalence subgroup.

CONCLUSIONS

Individual attitudinal and site-specific factors were associated with frequent BUP initiation. Training to increase physician confidence and increasing OUD resources could increase BUP initiation and benefit ED patients with OUD.

There goes the neighborhood? The public safety enhancing effects of a mobile harm reduction intervention

BACKGROUND

Buprenorphine is a gold-standard treatment for opioid use disorders, but most people with these disorders do not access it. Barriers to treatment access may be diminished by low-threshold mobile treatment programs but concern regarding their impact on local public safety challenges their adoption.

METHODS

This quasi-experimental study uses difference-in-differences analyses to measure the impact of four mobile buprenorphine clinics in Pittsburgh on neighborhood arrest rates. The study period spans 2018 to 2022, with a pre-intervention period of 11 to 12 quarters and a post-intervention period of 7 to 8 quarters (dependent on neighborhood). A treatment group of 84 census block groups in the areas surrounding clinics during the time period after their establishment were compared to a control group of city census blocks not within one mile of a clinic plus treated block groups in the two years prior to clinic establishment. Outcome variables include drug, non-drug, and total arrests, measured quarterly per 100 in population.

RESULTS

Compared to block groups further than 1 mile from a clinic, arrests fell by 34.13 % (b = -0.358, 95 % CI = -0.557, -0.158), drug arrests by 33.85 % (b = -0.087, 95 % CI = -0.151, -0.023), and non-drug related arrests by 22.29 % (b = -0.179, 95 % CI = -0.302, -0.057). Drug arrests declined significantly on days when the clinics were not present (b = -0.015, 95 % CI = -0.025, -0.006), with no significant change on clinic operational days (b = -0.002, 95 % CI = -0.016, -0.013). Total arrests declined significantly on days when clinics were and were not present (b = -0.045, 95 % CI = -0.078, -0.012; and b = -0.052, CI = -0.082, -0.023, respectively).

CONCLUSIONS

Mobile clinics providing medication for opioid use disorders were associated with reduced neighborhood arrest rates. Expansion of mobile services could promote health equity and public safety.

Association of medications for opioid use disorder with reduced risk of repeat opioid overdose in Medicaid: A cohort study

INTRODUCTION

Following a nonfatal opioid overdose, patients are at high risk for repeat overdose. The objective of this study was to examine the association of MOUD after nonfatal opioid overdose with risk of repeat overdose in the following year.

METHODS

This retrospective cohort study analyzed Missouri Medicaid claims from July 2012 to December 2021. The study identified opioid overdoses occurring between 2013 and 2020 using diagnosis codes for opioid poisoning in an inpatient or emergency department setting. The study implemented Cox models with a time-varying covariate for post-overdose receipt of MOUD.

RESULTS

During the study period, MOUD receipt after overdose more than tripled, from 4.8 % to 18.9 %. Overall, only 12.1 % of patients received MOUD in the year after index. MOUD during follow-up was associated with significantly lower risk of repeat overdose (HR = 0.34, 95 % CI = 0.14-0.82). Out of 3017 individuals meeting inclusion criteria, 13.6 % had a repeat opioid overdose within 1 year. Repeat overdose risk was higher for those whose index overdose involved heroin or synthetic opioids (HR = 1.71, 95 % CI = 1.35-2.15), but MOUD was associated with significantly reduced risk in this group (HR = 0.34, 95 % CI = 0.13-0.92).

CONCLUSIONS

MOUD receipt was associated with reduced risk of repeat overdose. Those whose index overdoses involved heroin or synthetic opioids were at greater risk of repeat overdose, but MOUD was associated with reduced risk in this group.

Impact of the Russian invasion on opioid agonist therapy programs in Ukraine: A qualitative study

BACKGROUND

Opioid Agonist Treatment (OAT) combines opioid agonist medications with counseling and therapy for a whole-patient approach to treating opioid use disorder. The war in Ukraine threatened the continuity of care and well-being of individuals receiving OAT. This study aimed to capture patients' experiences accessing OAT during the war in Ukraine to provide insights that can inform and improve the programs that serve them.

METHODS

In October - November 2022, we conducted semi-structured interviews with 17 OAT patients who are peer advocates in the Ukrainian Patient Network VOLNA. All interviews were conducted virtually via Zoom, recorded, and transcribed. Through thematic analysis, we generated codes from the transcripts, iteratively using both inductive and deductive approaches.

RESULTS

The qualitative interviews revealed four themes: 1) 'medication,' focusing on concerns about availability, dosage, and quality of OAT; 2) 'patient barriers,' discussing access challenges for specific patient groups, such as refugees or patients living under the occupation; 3) 'clinic-level challenges,' involving dosing adequacy, treatment continuity, patient volume, and clinician stigma, and 4) 'regulatory inflexibility,' describing uneven implementation of regulations and increased policing to receive OAT during the war.

CONCLUSION

Our study emphasizes the importance of adapting OAT programs in Ukraine to better serve vulnerable patients affected by the war. The Russian invasion has severely disrupted OAT provision, increasing the risks of opioid withdrawal, overdose, and diversion. By understanding patients' experiences, treatment preferences, and barriers to care, OAT programs can provide continuity of care to those in need.

Perspectives on APRN prescribing of medications for opioid use disorder: Key barriers remain

INTRODUCTION

Deaths from drug overdoses are rising dramatically in the United States. Treatment for opioid use disorders may include behavioral treatments as well as medications for opioid use disorders (MOUD). Buprenorphine can be prescribed by physicians, nurse practitioners (NPs), other advanced practice registered nurses (APRNs), and physician assistants (PAs) and required a training and a federal waiver until recently. The number of NP MOUD prescribers grew steadily over the past decade, but research has identified state-level scope of practice regulations as a barrier to NP MOUD prescribing. This article explores the contributions of, and remaining barriers faced by NP and other APRN MOUD prescribers. We describe qualitative findings from a study of NPs and other key stakeholders involved in MOUD treatment in four states with two differing levels of regulatory structure.

METHODS

In this qualitative study, we conducted site visits and semi-structured interviews with NPs and other APRNs, physicians, clinic managers, and regulators in four states including New Mexico and West Virginia (full practice authority for NPs), and Ohio and Michigan (which require physician supervision). Interview notes were entered into a qualitative software package and coded and reviewed by two members of the research team. Data were grouped into key themes.

RESULTS

A total of 76 participants participated in individual or small group interviews in the four states. We found key themes and several subthemes that describe NP practice in MOUD. Participants described key contributions of NP engagement in MOUD, including increasing access, serving rural areas, the unique role of psychiatric NPs, and the value of the nursing model of care in working with people with substance use disorders (SUD). Participants also identified barriers including scope of practice regulations, other regulatory barriers, stigma, and lack of supportive services to address psychosocial needs.

CONCLUSIONS

The waiver requirements were eliminated at the end of 2022 in federal budget legislation. Other barriers for NP and other APRN prescribers remain and should be addressed in practice, and in state and federal regulations. Research needs to explore the impact of the waiver elimination on MOUD prescribing and access to services.

Social networks, secondary syringe exchange, and opioid agonist therapy retention among people who inject drugs in Hartford, CT

BACKGROUND

Opioid agonist therapies (OAT) and  harm reduction such as syringe service programs (SSP) have been shown to be effective in preventing adverse outcomes such as overdose deaths, HIV and Hepatitis C infections among people who inject drugs (PWID). The importance of social network influence on disease transmission is well established, yet the interplay between harm reduction and network structures is, generally, not well understood. This study aims to analyze how social networks can mediate the harm reduction effects associated with secondary exchange through syringe service programs (SSP) and opioid agonist therapies (OAT) among injection network members.

METHODS

Sociometric data on networks on people who inject drugs from Hartford, CT, which were collected in 2012-2013, provided assessment of risk behaviors among 1574 injection network members, including participation in OAT and SSP. Subject's network characteristics were examined in relation to retention in OAT, as well as secondary syringe exchange using exponential random graph model (ERGM) and regression.

RESULTS

Based on the analysis, we found that probability of individuals being retained in OAT was positively associated with the OAT retention status of their peers within the network. Using simulations, we found that higher levels of positive correlation of OAT retention among network members can result in reduced risk of transmission of HIV to network partners on OAT. In addition, we found that secondary syringe exchange engagement was associated with higher probability of sharing of paraphernalia and unsterile needles at the network level.

CONCLUSIONS

Understanding how networks mediate risk behaviors is crucial for making progress toward ending the HIV epidemic.

Women and Treatment for Opioid Use Disorder: Contributors to Treatment Success From the Perspectives of Women in Recovery, Women With Past Attempts in Drug Treatment, and Health and Criminal Justice Professionals

Introduction

The disproportionate incidence of opioid use disorder (OUD) and the alarming increases in opioid-related overdose deaths among women highlight a clear need for the expansion of effective harm reduction and treatment practices. Research supports medications for opioid use disorders (MOUD) as an effective intervention; however, with low rates of utilization of such, there is a need to identify factors that facilitate MOUD treatment uptake and retention for women. Thus, the current study examines contributors to treatment success through the triangulation of perspectives from affected women as well as health and criminal justice professionals.

Methods

Interviews (N = 42) were conducted from May to July 2022 with women in recovery who previously used or currently use MOUD (N = 10), women who currently use opioids who terminated a MOUD program previously (N = 10), SUD treatment professionals (N = 12), and criminal justice professionals who work with women who use opioids (N = 10). Interviews for all participants centered around their backgrounds, perceived barriers and facilitators to MOUD treatment, and issues specific to women in treatment for substance use disorder. We used a thematic qualitative data analysis process to analyze transcripts.

Results

Participants highlighted contributors to treatment success from 3 domains: (1) internal processes (including promoting self-efficacy and setting realistic goals), (2) access to resources (including material resources, such as food and shelter, educational resources and social support), and (3) treatment structure (such as treatment type and protocol).

Conclusion

Internal processes, access to resources, and treatment structure contribute to MOUD treatment success for women with OUD. Structured support where experiences are shared, and realistic goals are set, may promote feelings of acceptance and empowerment, thereby bolstering chances of treatment success. Additionally, the court system can promote evidence-based and trauma-informed substance use treatment and provide accessible educational resources related to substance use to extend these benefits to more women.

Barriers and facilitators to the involvement of general practitioners in the prescription of buprenorphine

INTRODUCTION

France has one of the highest opioid agonist treatment (OAT) coverage rates in the world. French general practitioners (GPs) are providing the majority of prescriptions. However, a fall in the number of GPs initiating buprenorphine has been observed over the last decade.

METHODS

The objective of this study was to explore the obstacles and facilitators to the involvement of GPs in the prescription of buprenorphine. A qualitative study comprising 14 individual interviews and a focus group bringing together 5 GPs was conducted among GPs based in France between June 2021 and March 2022. We performed data analysis using a grounded theory methodology.

RESULTS

The interviews showed a great diversity in the level of involvement of GPs, depending on their experience, their representations of patients with OUD, their mode of exercise, and their personal preferences. The negative representations of the patients associated with the feeling of physical and ethical endangerment, the feeling of powerlessness, the fear of a disruption of the practice and the feeling of incompetence appeared at the forefront of the difficulties stated. Conversely, the strengthening of initial training and the facilitation of access to self-training tools and multidisciplinarity, the consideration of opioid use disorder (OUD) as a chronic illness with the application of a patient-centered motivational approach, as well as the defining and respecting one's own limits when prescribing buprenorphine seem to be the keys to a balanced and fulfilling practice.

CONCLUSION

Raising awareness of the frequency of OUD appeared to be an additional lever to enhance the interest of the GPs concerned. Additional studies focusing on the evolution of professional practices would be necessary to extend these findings.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder

OBJECTIVE

Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death.

METHODS

National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death.

RESULTS

The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]).

CONCLUSIONS

The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.

Medications for Opioid Use Disorder and Mortality and Hospitalization Among People With Opioid Use-related Infections

BACKGROUND

Severe skin and soft tissue infections related to injection drug use have increased in concordance with a shift to heroin and illicitly manufactured fentanyl. Opioid agonist therapy medications (methadone and buprenorphine) may improve long-term outcomes by reducing injection drug use. We aimed to examine the association of medication use with mortality among people with opioid use-related skin or soft tissue infections.

METHODS

An observational cohort study of Medicaid enrollees aged 18 years or older following their first documented medical encounters for opioid use-related skin or soft tissue infections during 2007-2018 in North Carolina. The exposure was documented medication use (methadone or buprenorphine claim) in the first 30 days following initial infection compared with no medication claim. Using Kaplan-Meier estimators, we examined the difference in 3-year incidence of mortality by medication use, weighted for year, age, comorbidities, and length of hospital stay.

RESULTS

In this sample, there were 13,286 people with opioid use-related skin or soft tissue infections. The median age was 37 years, 68% were women, and 78% were white. In Kaplan-Meier curves for the total study population, 12 of every 100 patients died during the first 3 years. In weighted models, for every 100 people who used medications, there were four fewer deaths over 3 years (95% confidence interval = 2, 6).

CONCLUSION

In this study, people with opioid use-related skin and soft tissue infections had a high risk of mortality following their initial healthcare visit for infections. Methadone or buprenorphine use was associated with reductions in mortality.

Trends in use of medicines for opioid agonist treatment in Australia, 2013-2022

BACKGROUND

There are limited longitudinal data on national patterns of opioid agonist treatment (OAT). This study describes 10-year trends in the sales of OAT medicines in Australia.

METHODS

A descriptive and time-series analysis of methadone, sublingual (SL) buprenorphine (+/-naloxone), and long-acting injectable (LAI) buprenorphine sold in Australia between 2013 and 2022 was performed. Total units sold were converted into an estimate of the number of clients that could be treated over a 28-day period with that amount of medicine ('client-months').

RESULTS

Between January 2013 and December 2022, the estimated number of client-months on: any OAT increased by 50 % to 53,501, methadone decreased (-8.5%), SL buprenorphine increased (+78%), and LAI buprenorphine increased substantially after September 2019. In January 2013, 78 % of OAT client-months received methadone. By December 2022, 48 % received methadone, 26 % SL buprenorphine, and 26 % LAI buprenorphine. Between 2013 to 2022, OAT client-months per capita were highest in the state of New South Wales. Over the study period, greater increases in OAT were observed in very remote areas (88%) compared to major cities (53%). The number of client-months in non-community pharmacy settings remained stable from 2013 to 2019/20, before increasing markedly. The introduction of LAI buprenorphine was associated with an immediate, sustained increase of 1,636 OAT client-months, and further increases of 190 OAT client-months each month.

CONCLUSION

Patterns of OAT have shifted over the last 10-years with buprenorphine (SL/LAI) now the most common OAT used in Australia. The introduction of LAI buprenorphine has expanded OAT access, particularly in non-community pharmacy settings, and in remote areas.

Receipt of opioid use disorder treatments prior to fatal overdoses and comparison to no treatment in Connecticut, 2016-17

OBJECTIVE

To determine the relative risk of death following exposure to treatments for OUD compared to no treatment.

METHODS

In this retrospective cohort study we compiled and merged state agency data on accidental and undetermined opioid overdose deaths in 2017 and exposures to OUD treatment in the prior six months to determine incidence rates following exposure to different treatment modalities. These rates were compared to the estimated incidence among those exposed to no treatment to determine relative risk of death for each treatment exposure.

RESULTS

Incidence rates for opioid poisoning deaths for those exposed to treatment ranged from 6.06±1.40 per 1000 persons exposed to methadone to 17.36±3.22 per 1000 persons exposed to any non-medication treatment. The estimated incidence rate for those not exposed to treatment was 9.80±0.72 per 1000 persons. With no exposure to treatment as referent, exposure to methadone or buprenorphine reduced the relative risk by 38% or 34%, respectively; the relative risk of non-medication treatments was equal to or worse than no exposure to treatment (RR = 1.27-1.77).

PRINCIPAL CONCLUSIONS

Exposure to non-MOUD treatments provided no protection against fatal opioid poisoning whereas the relative risk was reduced following exposures to MOUD treatment, even if treatment was not continued. Population level efforts to reduce opioid overdose deaths need to focus on expanding access to agonist-based MOUD treatments and are unlikely to succeed if access to non-MOUD treatments is made more available.

Missed Opportunities: Substance Use Hotline Operator Uncertainty of State Buprenorphine Prescribing via Telemedicine

OBJECTIVES

We examined substance use hotline operator certainty of each US state and Washington, DC's endorsement of buprenorphine (initiation and continuation) prescribing via telemedicine.

METHODS

Between March and May 2021, we called hotlines in 50 US states and Washington, DC, requesting information on whether practitioners in that state could initiate or continue buprenorphine treatment for opioid use disorder (OUD) via telephone or video conference. We compared operator responses to state implementation of buprenorphine telemedicine initiation. This study was designated as not human subjects research by the Boston University Institutional Review Board.

RESULTS

We spoke with operators in 47 states and Washington, DC. Operators could not be reached in Alaska, California, and Montana. Most operators were uncertain (don't know, probably yes, probably no) whether the state permitted buprenorphine initiation (81%, n = 39) or continuation (83%, n = 40) via telemedicine. Practitioners could initiate buprenorphine prescribing via telemedicine in 7 states (100%) where operators were certain practitioners could initiate buprenorphine, 1 state (100%) where the operator was certain practitioners could not, and 6 states (86%) where operators indicated practitioners probably could not.

CONCLUSIONS

Most US states and Washington, DC, expanded the role of telemedicine in OUD treatment. However, most operators expressed uncertainty and sometimes communicated inaccurate information regarding whether practitioners could initiate buprenorphine treatment via telemedicine. There is an urgent need for policy mandates institutionalizing the role of telemedicine, and of buprenorphine specifically, in OUD treatment and for resources to train and support substance use hotline operators in this evolving policy environment.

Effects of the Connections program on return-to-custody, mortality and treatment uptake among people with a history of opioid use: Retrospective cohort study in an Australian prison system

BACKGROUND AND AIMS

Connections is a voluntary health program that facilitates access to opioid agonist treatment (OAT) and social services for people with opioid use exiting prison. This study aimed to measure the effectiveness of Connections in reducing recidivism and improving health outcomes for people with a history of opioid use on leaving prison.

DESIGN

Retrospective cohort study with quasi-random allocation to the program.

SETTING

Public adult prisons in New South Wales, Australia, 2008-2015.

PARTICIPANTS

Adults released from custody with a history of opioid use. Of 5549 eligible releasees, 3973 were allocated to Connections and 1576 to treatment-as-usual.

MEASUREMENTS

Outcomes were return-to-custody, all-cause mortality, and OAT participation.

FINDINGS

Regression analyses on an intention-to-treat basis, and adjusting for baseline propensity scores, comparing patients allocated to Connections versus treatment-as-usual showed no difference in rates of return-to-custody within 2 years (hazard ratio [HR]: 1.01; 95% confidence interval [CI]: 0.92 -1.12). Patients allocated to the Connections program were more likely to access OAT (odds ratio [OR]: 1.21; 95% CI: 1.06-1.39) and had lower mortality within 28 days of release (0.25% vs. 0.66%; HR: 0.38; 95% CI: 0.14-1.03). Differences in mortality did not persist beyond 28 days. Subgroup analyses showed that allocation to Connections was associated with higher risk of return-to-custody within 28 days for Aboriginal and/or Torres Strait Islander (Indigenous) and female releasees.

CONCLUSIONS

The Connections program for people with opioid use exiting prison did not reduce the likelihood of return-to-custody but did facilitate opioid agonist treatment participation on release from prison.