Introduction to the special issue on innovative interventions and approaches to expand medication assisted treatment: Seizing research opportunities made available by the opioid STR program

Exploring the Determinants of Treatment Completion Among Youth Who Received Medication-Assisted Treatment in the United States

BACKGROUND

An effective treatment for Opioid Use Disorder is Medication-Assisted Treatment (MAT). However, in the United States (US), this is still being underutilized by youth. Research indicates the need to develop strategies to reduce treatment barriers among these youth. Thus, we explored the rates of treatment completion and dropout among youth receiving MAT in US substance use treatment facilities and examined factors associated with treatment completion and dropout.

METHODS

This study used the 2019 Treatment Episode Data Set-Discharges. Our analysis was restricted to youth (12-24 years) who primarily used heroin at admission. Log-binomial regression was used to examine various determinants of treatment completion and dropout, guided by Andersen's Behavioral Model.

RESULTS

The final sample size was 4917. Among youth reporting heroin use with receipt of MAT, those showing a higher likelihood of treatment completion than dropout were males [ARR: 1.23; 95% CI: 1.088-1.381; p = 0.0008], had 1-7 times [ARR: 1.33; 95% CI: 1.115-1.584; p = 0.0015] and 8-30 times self-help group participation [ARR: 1.50; 95% CI: 1.246-1.803; p < 0.0001], had co-occurring mental and substance use disorders [ARR: 1.28; 95% CI: 1.133-1.448, p < 0.0001], were admitted to detoxification [ARR: 2.80; 95% CI: 2.408-3.255; p < 0.0001] and residential/rehabilitation settings [ARR: 2.05; 95% CI: 1.749-2.400; p < 0.0001], and were located in the Midwest/West [ARR: 1.18; 95% CI: 1.030-1.358; p = 0.0173]. Conversely, other races (excluding Whites and Blacks/African Americans) [ARR: 0.75; 95% CI: 0.609-0.916; p = 0.0051], those who used MAT [ARR: 0.81; 95% CI: 0.694-0.946; p = 0.0077], and youth in the South [ARR: 0.45; 95% CI: 0.369-0.549; p < 0.0001] were less likely to report treatment completion than dropout.

CONCLUSIONS

The majority of youth receiving MAT dropped out of treatment. We identified various factors that should be prioritized to address youth underutilization of MAT in the US.

Introduction to the special issue on legislative-driven responses to the opioid crisis: Expanding research and implementation through federal and state funding

This special issue focuses on legislative-driven responses to the opioid crisis in the United States, emphasizing the expansion of research and implementation through federal and state funding. Since 2017, federal, state, and local initiatives have allocated billions of dollars to combat the opioid epidemic. This issue comprises 10 articles that collectively demonstrate the critical role of federal and state funding in enhancing opioid-related prevention, treatment, and recovery services. They also bring to light ongoing challenges such as funding sustainability and equitable service access that can guide future funding initiatives.

Results From the POINT Pragmatic Randomized Trial: An Emergency Department-Based Peer Support Specialist Intervention to Increase Opioid Use Disorder Treatment Linkage and Reduce Recurrent Overdose

BACKGROUND

People with opioid use disorder (OUD) frequently present at the emergency department (ED), a potentially critical point for intervention and treatment linkage. Peer recovery support specialist (PRSS) interventions have expanded in US-based EDs, although evidence supporting such interventions has not been firmly established.

METHODS

Researchers conducted a pragmatic trial of POINT (Project Planned Outreach, Intervention, Naloxone, and Treatment), an ED-initiated intervention for harm reduction and recovery coaching/treatment linkage in 2 Indiana EDs. Cluster randomization allocated patients to the POINT intervention (n = 157) versus a control condition (n = 86). Participants completed a structured interview, and all outcomes were assessed using administrative data from an extensive state health exchange and state systems. Target patients (n = 243) presented to the ED for a possible opioid-related reason. The primary outcome was overdose-related ED re-presentation. Key secondary outcomes included OUD medication treatment linkage, duration of medication in days, all-cause ED re-presentation, all-cause inpatient re-presentation, and Medicaid enrollment. All outcomes were assessed at 3-, 6-, and 12-months post-enrollment. Ad hoc analyses were performed to assess treatment motivation and readiness.

RESULTS

POINT and standard care participants did not differ significantly on any outcomes measured. Participants who presented to the ED for overdose had significantly lower scores (3.5 vs 4.2, P < .01) regarding readiness to begin treatment compared to those presenting for other opioid-related issues.

CONCLUSIONS

This is the first randomized trial investigating overdose outcomes for an ED peer recovery support specialist intervention. Though underpowered, results suggest no benefit of PRSS services over standard care. Given the scope of PRSS, future work in this area should assess more recovery- and harm reduction-oriented outcomes, as well as the potential benefits of integrating PRSS within multimodal ED-based interventions for OUD.

Patterns of opioid use behaviors among patients seen in the emergency department: Latent class analysis of baseline data from the POINT pragmatic trial

INTRODUCTION

The nation's overdose epidemic has been characterized by increasingly potent opioids resulting in more emergency department (ED) encounters over time. ED-based opioid use interventions are growing in popularity; however, they tend to treat people who use opioids as a homogenous population. The current study sought to understand heterogeneity among people who use opioids who encounter the ED by identifying qualitatively different subgroups among participants in an opioid use intervention clinical trial at baseline and examining associations between subgroup membership and multiple correlates.

METHODS

Participants were from a larger pragmatic clinical trial of the Planned Outreach, Intervention, Naloxone, and Treatment (POINT) intervention (n = 212; 59.2 % male, 85.3 % Non-Hispanic White, mean age = 36.6 years). The study employed latent class analysis (LCA) using five indicators of opioid use behavior: preference for opioids, preference for stimulants, usually use drugs alone, injection drug use, and opioid-related problem at ED encounter. Correlates of interest included participants' demographics, prescription histories, health care contact histories, and recovery capital (e.g., social support, naloxone knowledge).

RESULTS

The study identified three classes: (1) noninjecting opioid preferers, (2) injecting opioid and stimulant preferers, and (3) social nonopioid preferers. We identified limited significant differences in correlates across the classes: differences existed for select demographics, prescription histories, and recovery capital but not for health care contact histories. For example, members of Class 1 were the most likely to be a race/ethnicity other than non-Hispanic White, oldest on average, and most likely to have received a benzodiazepine prescription, whereas members of Class 2 had the highest average barriers to treatment and members of Class 3 were the least likely to have been diagnosed with a major mental health illness and had the lowest average barriers to treatment.

CONCLUSIONS

LCA identified distinct subgroups among POINT trial participants. Knowledge of such subgroups assists with the development of better-targeted interventions and can help staff to identify the most appropriate treatment and recovery pathways for patients.

Evaluation of post-discharge engagement for emergency department patients with opioid use history who received telehealth recovery coaching services

BACKGROUND

In recent years, emergency departments (EDs) across the nation have implemented peer recovery coach (PRC) services to support patients who use opioids. The majority of such interventions discussed in the literature follow an in-person modality where PRCs engage patients directly at the ED bedside. However, the use of telehealth services in EDs is becoming more popular. These services connect PRCs with ED patients in real-time via secure communications technology, and very little is known about the service- and clinical-based outcomes with which they are associated. The current study sought to assess factors associated with successful post-discharge follow-up of patients with a history of opioid use who received PRC telehealth services while in the ED.

METHOD

Data come from records for 917 patients who engaged with a telehealth PRC one or more times (1208 total engagements) at 1 of 13 EDs within the same health system. A multilevel Poisson regression model was used to assess the degree to which variables predicted successful post-discharge follow-up, defined as the number of times a PRC successfully spoke with the patient each month after ED discharge.

RESULTS

At least one follow-up was successfully completed by a PRC for 23% of enrolled patients. Significant predictors of successful follow-up included patient employment at baseline (Incidence Rate Ratio [IRR]: 2.8, CI: 2.05-3.9), living in a rural area (IRR: 1.8, CI: 1.04-3.2), PRC provision of referrals (IRR: 1.7, CI: 1.2-2.2), number of ED encounters in the previous 365 days (IRR: 0.99, CI: 0.98-0.99), and duration of the initial PRC telehealth interaction (IRR: 0.87, CI: 0.85-0.88).

CONCLUSION

Given that relationship development is a key tool in the PRC profession, understanding successful follow-up associated with telehealth engagement has unique importance. The results have potential utility for planning and implementing peer telehealth services in EDs and other locations, which is needed for the development of the PRC profession and the likely expansion of peer telehealth services.

Promoting sustainable responses to the US opioid epidemic with community-academic partnerships: qualitative outcomes from a statewide program

Background

Drug overdose deaths in the United States have continued to increase at an alarming rate. The Substance Abuse and Mental Health Services Administration (SAMHSA) distributed more than $7 billion between January 2016 and June 2020 to address the drug overdose crisis. The funds support evidence-based responses, including medications for opioid use disorder, and other prevention, treatment and recovery activities. Although the State Opioid Response (SOR) grants finance much-needed community level interventions, many of the services they support may not be sustainable, without ongoing assessment, evaluation and planning for continuation.

Methods

This paper describes a statewide effort to support local entities through SAMHSA’s SOR grants in Virginia. Community agencies across the state participated in detailed needs assessment exercises with VHEOC investigators, and developed requests for proposals (RFPs) to sustain their SOR programs. The RFPs were then distributed to prospective academic partners at the five VHEOC universities, based on the required subject matter expertise identified in the RFP. All responsive proposals were then provided to the local agencies who selected the proposal most likely to meet their needs. VHEOC investigators also conducted an inductive, three-phase content analysis approach to examine the RFPs submitted to the VHEOC to identify nominal categories of support requested of the VHEOC investigators.

Results

VHEOC Investigators received and coded 27 RFPs from ten community agencies representing four of five regions of the state. We identified six nominal categories of academic assistance with high inter-coder agreement. The six categories of support requested of the academic partners were program development and support, literature review and best practices, outreach and education, data analysis and interpretation, program evaluation, and grant writing assistance. Several RFPs requested up to three categories of support in a single project.

Conclusions

Our analysis of the requests received by the consortium identified several categories of academic support for SOR-grantees addressing the drug overdose crisis. The most common requests related to development and maintenance of supportive collaborations, which existing research has demonstrated is necessary for the long-term sustainability of SOR-funded services. In this way, the academic partners reinforced sustainable SOR-funded programs. As the state opioid response program is implemented nationally, we hope that other states will consider similar models in response to the opioid crisis.

Stepped implementation-to-target: a study protocol of an adaptive trial to expand access to addiction medications

BACKGROUND

In response to the US opioid epidemic, significant national campaigns have been launched to expand access to `opioid use disorder (MOUD). While adoption has increased in general medical care settings, specialty addiction programs have lagged in both reach and adoption. Elevating the quality of implementation strategy, research requires more precise methods in tailoring strategies rather than a one-size-fits-all-approach, documenting participant engagement and fidelity to the delivery of the strategy, and conducting an economic analysis to inform decision making and policy. Research has yet to incorporate all three of these recommendations to address the challenges of implementing and sustaining MOUD in specialty addiction programs.

METHODS

This project seeks to recruit 72 specialty addiction programs in partnership with the Washington State Health Care Authority and employs a measurement-based stepped implementation-to-target approach within an adaptive trial design. Programs will be exposed to a sequence of implementation strategies of increasing intensity and cost: (1) enhanced monitoring and feedback (EMF), (2) 2-day workshop, and then, if outcome targets are not achieved, randomization to either internal facilitation or external facilitation. The study has three aims: (1) evaluate the sequential impact of implementation strategies on target outcomes, (2) examine contextual moderators and mediators of outcomes in response to the strategies, and (3) document and model costs per implementation strategy. Target outcomes are organized by the RE-AIM framework and the Addiction Care Cascade.

DISCUSSION

This implementation project includes elements of a sequential multiple assignment randomized trial (SMART) design and a criterion-based design. An innovative and efficient approach, participating programs only receive the implementation strategies they need to achieve target outcomes. Findings have the potential to inform implementation research and provide key decision-makers with evidence on how to address the opioid epidemic at a systems level.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov (NCT05343793) on April 25, 2022.

Identifying unique barriers to implementing rural emergency department-based peer services for opioid use disorder through qualitative comparison with urban sites

BACKGROUND

In an effort to address the current opioid epidemic, a number of hospitals across the United States have implemented emergency department-based interventions for engaging patients presenting with opioid use disorder. The current study seeks to address gaps in knowledge regarding implementation of a sub-type of such interventions, emergency department-based peer support services, in rural areas by comparing implementation of rural and urban programs that participated in Indiana's Recovery Coach and Peer Support Initiative (RCPSI).

METHODS

We conducted a secondary analysis of qualitative semi-structured implementation interviews collected as part of an evaluation of 10 programs (4 rural and 6 urban) participating in the RCPSI. We conducted interviews with representatives from each program at 3 time points over the course of the first year of implementation. Our deductive coding process was guided by the Consolidated Framework for Implementation Research (CFIR) and an external context taxonomy.

RESULTS

We identified key differences for rural programs corresponding to each of the 5 primary constructs in the coding scheme. (1) Intervention characteristics: rural sites questioned intervention fit with their context, required more adaptations, and encountered unexpected costs. (2) External context: rural sites were not appropriately staffed to meet patient needs, encountered logistical and legal barriers regarding patient privacy, and had limited patient transportation options. (3) Inner setting: rural sites lacked strong mechanisms for internal communication and difficulties integrating with pre-existing culture and climate. (4) Characteristics of individuals: some rural providers resisted working with peers due to pre-existing attitudes and beliefs. (5) Implementation process: rural sites spent more time identifying external partners and abandoned more components of their initial implementation plans.

CONCLUSIONS

Findings demonstrate how rural programs faced greater challenges implementing emergency department-based peer services over time. These challenges required flexible adaptations to originally intended plans. Rural programs likely require flexibility to adapt interventions that were developed in urban settings to ensure success considering local contextual constraints that were identified by our analysis.

Adaptations to Indiana's 21st Century Cures-funded recovery coaching initiative in the wake of COVID-19

This brief commentary discusses how provider organizations from Indiana's Recovery Coach and Peer Support Initiative (RCPSI) adapted their practices in response to the COVID-19 pandemic and associated restrictions. The RCPSI, which is funded through the 21st Century Cures Act, placed peer recovery coaches (PRCs) in emergency departments (EDs) to link opioid overdose patients to medication for opioid use disorder. This commentary discusses how COVID-19 restrictions increased use of telehealth to replace in-person PRC contacts with patients, affected the timing of initial PRC contacts with patients, and led to allowances for Medicaid billing of recovery coach support sessions conducted via telehealth. Future research should further determine the effects of these changes on PRC services in the ED.

Evaluation of an emergency department-based opioid overdose survivor intervention: Difference-in-difference analysis of electronic health record data to assess key outcomes

BACKGROUND

In recent years, a number of emergency department (ED)-based interventions have been developed to provide supports and/or treatment linkage for people who use opioids. However, there is limited research supporting the effectiveness of the majority of these interventions. Project POINT is an ED-based intervention aimed at providing opioid overdose survivors with naloxone and recovery supports and connecting them to evidence-based medications for opioid use disorder (MOUD). An evaluation of POINT was conducted.

METHODS

A difference-in-difference analysis of electronic health record data was completed to understand the difference in outcomes for patients admitted to the ED when a POINT staff member was working versus times when they were not. The observation window was January 1, 2012 to July 6, 2019, which included N = 1462 unique individuals, of which 802 were in the POINT arm. Outcomes of focus include MOUD opioid prescriptions dispensed, active non-MOUD opioid prescriptions dispensed, naloxone access, and drug poisonings.

RESULTS

The POINT arm had a significant increase in MOUD prescriptions dispensed, non-MOUD prescriptions dispensed, and naloxone access (all p-values < 0.001). There was no significant effect related to subsequent drug poisoning-related hospital admissions.

CONCLUSIONS

The results support the assertion that POINT is meeting its two primary goals related to increasing naloxone access and connecting patients to MOUD. Generalization of these results is limited; however, the evaluation contributes to a nascent area of research and can serve a foundation for future work.

Barriers impacting the POINT pragmatic trial: the unavoidable overlap between research and intervention procedures in "real-world" research

BACKGROUND

This manuscript provides a research update to the ongoing pragmatic trial of Project POINT (Planned Outreach, Intervention, Naloxone, and Treatment), an emergency department-based peer recovery coaching intervention for linking patients with opioid use disorder to evidence-based treatment. The research team has encountered a number of challenges related to the "real-world" study setting since the trial began. Using an implementation science lens, we sought to identify and describe barriers impacting both the intervention and research protocols of the POINT study, which are often intertwined in pragmatic trials due to the focus on external validity.

METHOD

Qualitative data were collected from 3 peer recovery coaches, 2 peer recovery coach supervisors, and 3 members of the research team. Questions and deductive qualitative analysis were guided by the Consolidated Framework for Implementation Research (CFIR).

RESULTS

Nine unique barriers were noted, with 5 of these barriers impacting intervention and research protocol implementation simultaneously. These simultaneous barriers were timing of intervention delivery, ineffective communication with emergency department staff, lack of privacy in the emergency department, the fast-paced emergency department setting, and patient's limited resources. Together, these barriers represent the intervention characteristics, inner setting, and outer setting domains of the CFIR.

CONCLUSION

Results highlight the utility of employing an implementation science framework to assess implementation issues in pragmatic trials and how this approach might be used as a quality assurance mechanism given the considerable overlap that exists between research and intervention protocols in real-world trial settings. Previously undocumented changes to the trial design that have been made as a result of the identified barriers are discussed.

Online Medication Assisted Treatment Education for Court Professionals: Need, Opportunities and Challenges

Although medication-assisted treatment (MAT) effectively treats opioid use disorders (OUD), MAT access is restricted in criminal justice (CJ) settings. Previous studies have documented that stigma and limited knowledge about MAT are prevalent among CJ court personnel. We describe development and pilot testing of an eLearning intervention to improve MAT knowledge and increase MAT referrals in Ohio courts. Methods: Building upon a nationwide survey conducted in 2011 of drug courts and informed by MAT opinions from judges who supervised OUD clients, we developed two eLearning MAT modules. Judges completed a brief online MAT knowledge-attitude scale (K-A) before, after, and at 3 months. Judges were asked about MAT referrals pretest and 3 months later. Results: Sixty-three judges expressed interest in the study, 25 completed the pretest and viewed the modules, 11 completed a 3 month posttest. At pretest, K-A scores were significantly (p<.05) lower for agonist medications than for extended-release naltrexone (XR-NTX; Vivitrol). K-A scores improved at posttest for agonist medications (p<.05) but declined to pretest levels three months later. Three months after the pretest, buprenorphine referrals increased from 2.6% to 9.7% (p<.05). There was no significant difference on K-A scores for agonist medication between the Ohio sample (at pretest) and the 2011 sample. Conclusion: Although there is some indication that eLearning may have strengthened knowledge gains and increased buprenorphine referrals, a more robust eLearning intervention will likely be required to increase court personnel participation and sustain eLearning knowledge gains. Recruiting and sustaining judges' participation in the study represented a significant study limitation.

The prospects for sustaining evidence-based responses to the US opioid epidemic: state leadership perspectives

BACKGROUND

The US 21st Century Cures Act provided $7.5 billion in grant funding to states and territories for evidence-based responses to the opioid epidemic. Currently, little is known about optimal strategies for sustaining these programs beyond this start-up funding.

METHODS

Using an inductive, conventional content analysis, we conducted key informant interviews with former and current state leaders (n = 16) about barriers/facilitators to sustainment and strategies for sustaining time-limited grants.

RESULTS

Financing and reimbursement, service integration, and workforce capacity were the most cited barriers to sustainment. Status in state government structure, public support, and spending flexibility were noted as key facilitators. Effective levers to increase chances for sustainment included strong partnerships with other state agencies, workforce and credentialing changes, and marshalling advocacy through public awareness campaigns.

CONCLUSIONS

Understanding the strategies that leaders have successfully used to sustain programs in the past can inform how to continue future time-limited, grant-funded initiatives.