Characterization of diverted buprenorphine use among adults entering corrections-based drug treatment in Kentucky

Kratom (Mitragyna speciosa) Use and Mental Health: A Systematic Review and Multilevel Meta-Analysis

INTRODUCTION

Kratom (Mitragyna speciosa) is a medicinal tree native to Southeast Asia. The present multilevel meta-analysis describes the association between kratom use and the positive and negative indicators of mental health.

METHODS

A total of thirty-six articles were included in the meta-analysis to examine the associations, using a random-effects model.

RESULTS

The pooled effect size showed a very small positive association between kratom use and negative indicators of mental health {r = 0.092, 95% confidence interval (CI) = [0.020, 0.164], p < 0.05}, while no significant association was found with positive indicators of mental health (r = -0.031, 95% CI = [-0.149, 0.087], p > 0.05). Pooled effect sizes of specific mental health outcomes indicated that kratom use showed only a small positive correlation with externalizing disorders (r = 0.201, 95% CI = [0.107, 0.300], p < 0.001). No significant association was found between kratom use and quality of life (r = 0.069, 95% CI = [-0.104, 0.242], p > 0.05) and internalizing disorders (r = -0.001, 95% CI = [-0.115, 0.095], p > 0.05). Multilevel moderator analysis showed that the pooled effect size of the association between kratom use and substance use disorder was stronger in Malaysia (r = 0.347, 95% CI = [0.209, 0.516], p < 0.001), and with the mean age (β1 = -0.035, 95% CI = [-0.055, -0.014], p = 0.003), and the drug profile of those who were not co-using other drugs (r = 0.347, 95% CI = [0.209, 0.516], p < 0.001).

CONCLUSION

The meta-analysis supports the kratom instrumentalization concept, in that a positive gain from kratom consumption can be achieved without any significant adverse associations with mental health.

Sources of nonmedically used prescription psychotherapeutic drugs using real-world data from adolescents and adults assessed for substance use treatment--2014-2022

BACKGROUND

Nonmedical use (NMU) of prescription psychotherapeutic drugs (PPD) may increase risk for significant morbidity and mortality in the overdose crisis.

OBJECTIVE

This study examines sources of PPD using real-world data from adolescents and adults reporting past 30-day NMU of PPDs.

METHODS

A convenience sample of individuals aged ≥10 years assessed for substance use disorders (SUD) treatment was analyzed using the 2014-2022 National Addictions Vigilance Intervention and Prevention Program datasets. PPD include prescription opioids, prescription tranquilizers/sedatives, and prescription stimulants.

RESULTS

Overall, among assessments of adolescents aged 10-18 years (N = 1991) and young adults aged 19-24 years (N = 15,166), "family/friend" (46.08-47.41 %) and "dealer" (33.82-42.71 %) were the most common sources. Among assessments of adults aged ≥25 years (N = 89,225), "own prescription" was the most common source and increased in frequency as age increased. Across all age groups, "family/friend" was the most frequent source for all drug classes (41.96-48.76 %) except for nonmedically used buprenorphine/methadone, for which "own prescription" was the most common source (51.85 %) among adults.

CONCLUSIONS

Our study demonstrates heterogeneity in sources of nonmedically used PPD across age groups. Tailored prevention strategies for different age groups and improving timely access to medical care to ensure proper treatment of chronic medical conditions including SUD are needed.

Buprenorphine use and setting type among reproductive-aged women self-reporting nonmedical prescription opioid use

INTRODUCTION

Screening for opioid misuse and treatment for opioid use disorder are critical for reducing morbidity and mortality. We sought to understand the extent of self-reported past 30-day buprenorphine use in various settings among women of reproductive age with self-reported nonmedical prescription opioid use being assessed for substance use problems.

METHODS

The study collected data from individuals being assessed for substance use problems using the Addiction Severity Index-Multimedia Version in 2018-2020. We stratified the sample of 10,196 women ages 12-55 self-reporting past 30-day nonmedical prescription opioid use by buprenorphine use and setting type. We categorized setting types as: buprenorphine in specialty addiction treatment, buprenorphine in office-based opioid treatment, and diverted buprenorphine. We included each woman's first intake assessment during the study period. The study assessed number of buprenorphine products, reasons for using buprenorphine, and sources of buprenorphine procurement. The study calculated frequency of reasons for using buprenorphine to treat opioid use disorder outside of a doctor-managed treatment, overall and by race/ethnicity.

RESULTS

Overall, 25.5 % of the sample used buprenorphine in specialty addiction treatment, 6.1 % used buprenorphine prescribed in office-based treatment, 21.7 % used diverted buprenorphine, and 46.7 % reported no buprenorphine use during the past 30 days. Among women who reported using buprenorphine to treat opioid use disorder, but not as part of a doctor-managed treatment, 72.3 % could not find a provider or get into a treatment program, 21.8 % did not want to be part of a program or see a provider, and 6.0 % reported both; a higher proportion of American Indian/Alaska Native women (92.1 %) reported that they could not find a provider or get into a treatment program versus non-Hispanic White (78.0 %), non-Hispanic Black (76.0 %), and Hispanic (75.0 %) women.

CONCLUSIONS

Appropriate screening for nonmedical prescription opioid use to assess need for treatment with medication for opioid use disorder is important for all women of reproductive age. Our data highlight opportunities to improve treatment program accessibility and availability and support the need to increase equitable access for all women.

Diversion of medications to treat opioid use disorder: Qualitative findings from formerly incarcerated adults in Massachusetts

BACKGROUND

Carceral officials often cite diversion of medication for opioid use disorder (MOUD) (e.g., buprenorphine) as a reason for not offering MOUD treatment in jails and prisons with little understanding of patient perspectives. We aimed to understand patient perceptions of medication diversion from jail-based MOUD programs and the factors that contribute to and reduce diversion.

METHODS

We conducted thematic analyses of semi-structured interviews held in 2021-22 with 38 adults who received MOUD treatment and were released from eight Massachusetts jails that had implemented a MOUD program on or after September 2019.

RESULTS

Consistent with prior reports from carceral staff, patients perceived MOUD diversion to happen less frequently than expected, which they attributed to dosing protocols that have effectively reduced it. Patients reported that MOUD availability reduced the contraband buprenorphine market, although other contraband substances have entered jails (fentanyl, oxycodone, K2). Patients perceived Subutex to have greater misuse potential and added diversion risks. Patients valued graduated consequences and other efforts to reduce MOUD diversion and contraband for making jails safer and for enabling patients to receive treatment. Nearly all participants reported having heard about, witnessed, or been involved in actual or attempted diversion, with variation in reports by jail. Patients suggested that dispensing MOUD to all who need it immediately upon intake would be the most effective way to reduce MOUD diversion and contraband.

CONCLUSION

Formerly incarcerated patients perceived MOUD diversion within jail medication programs as occurring less often than expected and that it can be reduced with appropriate protocols. To help limit medication diversion, patients recommended provision of MOUD upon intake to all individuals with opioid use disorder who need it. Findings have implications for MOUD program adaptation, successful routinization, and diffusion in carceral settings.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Investigation of buprenorphine-related deaths using urinary metabolite concentrations

Quantitative analysis of postmortem urine, instead of blood, for buprenorphine and metabolites may provide additional evidence for the diagnosis of fatal buprenorphine poisoning. In this study, 247 autopsy urine samples, previously testing positive for buprenorphine or norbuprenorphine, were quantitatively reanalysed with a recently developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) method for unconjugated buprenorphine (BUP), norbuprenorphine (NBUP), naloxone (NAL), and their respective conjugated metabolites, buprenorphine glucuronide (BUPG), norbuprenorphine glucuronide (NBUPG), and naloxone glucuronide (NALG). The cases were divided, according to medical examiners' decision, to buprenorphine poisonings and other causes of death. The groups were compared for urinary concentrations and metabolite concentration ratios of the six analytes. All median concentrations were higher in the buprenorphine poisoning group. The median concentration of BUPG was significantly higher and the median metabolite ratios NBUP/BUP, NBUPG/BUPG, and NBUPtotal/BUPtotal were significantly lower in poisonings than in other causes of death. Naloxone-related concentrations and ratios were not significantly different between the groups.

Negative attitudes about medications for opioid use disorder among criminal legal staff

Background

Stigma is a barrier to the treatment of opioid use disorder (OUD) in the criminal legal system. Staff sometimes have negative attitudes about medications for OUD (i.e., MOUD), but there is little research on what drives these attitudes. How staff think about criminal involvement and addiction may explain their attitudes toward MOUD.

Methods

A convenience sample of U.S. criminal legal staff (e.g., correctional/probation officers, nurses, psychologists, court personnel) were recruited via online methods (N = 152). Participants completed an online survey of their attitudes about justice-involved people and addiction, and these were entered as predictors of an adapted version of the Opinions about Medication Assisted Treatment survey (OAMAT) in a linear regression, controlling for sociodemographics (cross-sectional design).

Results

At the bivariate level, measures capturing more stigmatizing attitudes toward justice-involved people, believing addiction represents a moral weakness, and believing people with addiction are responsible for their actions and their recovery were related to more negative attitudes about MOUD, whereas higher educational attainment and believing addiction has a genetic basis were related to more positive attitudes about MOUD. In a linear regression, only stigma toward justice-involved people significantly predicted negative attitudes about MOUD (B = -.27, p = .010).

Conclusion

Criminal legal staff's stigmatizing attitudes about justice-involved people, such as believing they are untrustworthy and cannot be rehabilitated, contributed significantly to negative attitudes about MOUD, above their beliefs about addiction. The stigma tied to criminal involvement needs to be addressed in attempts to increase MOUD adoption in the criminal legal system.

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Perceptions and experiences toward extended-release buprenorphine among persons leaving jail with opioid use disorders before and during COVID-19: an in-depth qualitative study

BACKGROUND

Extended-release buprenorphine (XRB) offers a novel approach to sustained monthly treatment for people who use opioids in criminal justice settings (CJS). This study explores the experiences of adults receiving XRB as a jail-to-community treatment.

METHODS AND FINDINGS

In-depth qualitative interviews were conducted among adult participants with opioid use disorder (OUD; n  = 16) who were recently released from NYC jails and maintained on XRB after switching from daily sublingual buprenorphine (SLB). Interviews elaborated on the acceptability and barriers and facilitators of XRB treatment pre- and post-release. Interviews were audio recorded, transcribed, and analyzed for content related to factors influencing XRB treatment uptake and community reentry. Important themes were grouped into systems, medication, and patient-level factors. Key systems-level factors influencing initiation of XRB in jail included an alternative to perceived stigmatization and privacy concerns associated with daily in-jail SLB administration and less concerns with buprenorphine diversion. In-jail peer networks positively influenced participant adoption of XRB. XRB satisfaction was attributed to reduced in-jail clinic and medication administration visits, perceived efficacy and blockade effects upon the use of heroin/fentanyl following release, and averting the risk of criminal activities to fund opioid use. Barriers to retention included post-injection withdrawal symptoms and cravings attributed to perceived suboptimal medication dosing, injection site pain, and lack of in-jail provider information about the medication.

CONCLUSION

Participants were generally favorable to XRB initiation in jail and retention post-release. Further studies are needed to address factors influencing access to XRB in criminal justice settings, including stigma, ensuring patient privacy following initiation on XRB, and patient-, provider-, and correctional staff education pertaining to XRB. Trial Registration ClinicalTrials.gov Identified: NCT03604159.

Buprenorphine Treatment Intake and Critical Encounters following a Nonfatal Opioid Overdose

BACKGROUND

Individuals with prior opioid-related overdose events have an increased risk for opioid-related mortality. Buprenorphine is a partial agonist that has shown to be an effective medication for opioid use disorder (MOUD). Yet, few studies have investigated whether buprenorphine reduces the risk of opioid-related mortality following a nonfatal opioid-related overdose.

METHODS

A retrospective study was conducted on all overdose cases in Indiana between January 1, 2017 and December 31, 2017. Data were linked from multiple administrative sources. Cases were linked to vital records to assess mortality. Bivariate analyses were conducted to assess group differences between survivors and decedents. A series of multiple logistic regression models were used to determine main and interaction effects of opioid-related mortality.

RESULTS

Among the 10,195 nonfatal overdoses, 2.4% (247) resulted in a subsequent fatal overdose. Overdose decedents were on average 36.4 years-old, 66.8% male, 91.1% White, and 83.8% did not receive a buprenorphine dispensation. Incremental increases in the number of buprenorphine dispensations decreased the likelihood of fatal overdose by 94% (95% CI = 0.88-0.98, p = .001). Incremental increases in arrest encounters were found to significantly increase the likelihood of a fatal overdose (AOR = 2.16; 95% CI = 1.13-3.55). Arrest encounters were a significant moderator of the relationship between buprenorphine uptake effectiveness and drug-related mortality.

CONCLUSIONS

Analysis of linked data provided details of risk and protective factors of fatal overdose. Buprenorphine reduced the risk of death; however, criminal justice involvement remains an area of attention for diversion and overdose death prevention interventions.

Technology-Based Educational Approaches to Address Opioid Use Management by Advanced Practice Registered Nurses

Opioid overdose remains the leading cause of accidental death, with 64,000 deaths attributable to opioid-related overdoses in 2016 and a 20% increase in mortality since 2015. Advanced practice registered nurses (APRNs) are now eligible to prescribe buprenorphine. The purpose of this project was to develop educational training materials regarding opioid use management; widely disseminate these materials; monitor reach and intervention efficacy in precipitating practice change; and to evaluate barriers and facilitators of buprenorphine prescribing. The authors developed a three-webinar series pertaining to opioid use management. A broad marketing and dissemination approach was utilized. Demographic data was collected when individuals registered to participate in the webinar series. Follow-up data was collected post-webinar and sought to assess practice change, and barriers to and facilitators of buprenorphine prescribing. Of the 670 individuals that viewed one or more of the live webinars, 218 (32.5%) completed a portion of one or both of the follow-up surveys (at 3- and 6-months post-webinar). Of the respondents, 39 (18%) had obtained the DATA 2000 (buprenorphine) waiver since viewing the webinar series, and 11 (5.1%) were in the process of obtaining the DATA 2000 waiver. Barriers to buprenorphine prescribing included regulatory factors, patient-specific factors, and provider-specific factors. Facilitators to buprenorphine prescribing included institutional support and mentorship, collaboration with professional organizations, increased community awareness, and patient outcomes. APRNs should be abreast of best practices in the management of opioid use disorders. Barriers to and facilitators of buprenorphine prescribing must be understood and addressed.