Naturalistic follow-up after a trial of medications for opioid use disorder: Medication status, opioid use, and relapse

Risk of Relapse Following Discharge from Non-Hospital Residential Opioid Use Disorder Treatment: A Systematic Review of Studies Published from 2018 to 2022

Relapsing on opioids after residential treatment may involve fatal outcomes, considering the potential for reduced tolerance and the potency of fentanyl in the illicit opioid market. The present paper examines recent literature on the risk of relapse among adults with opioid use disorder after discharge from residential treatment. We searched for published studies from 2018 to 2022 through database searches, including CINAHL, PsychINFO, PubMed, and Scopus. Across the N=10 studies included in this review, returning to substance use after residential treatment was captured differently, including self-report, hair samples, and urine samples. Follow-up relapse data after discharging from treatment was also captured across different time periods of included studies ranging from one month to six months. Variability was also identified in the percentage of individuals who relapsed after treatment, ranging from 0% to 95%. Considering the potential for a fatal overdose in the current fentanyl era, it is imperative to provide resources during residential treatment that can reduce the risk of relapse after discharge.

Optimizing retention strategies for opioid use disorder pharmacotherapy: The retention phase of the CTN-0100 trial (RDD)

INTRODUCTION AND BACKGROUND

The three medications approved to address OUD are effective in decreasing opioid use and morbidity and mortality; however, their utility is limited by high rates of dropout from treatment. The CTN-0100 trial will develop an evidence base for strategies to improve retention on buprenorphine and extended-release naltrexone.

RESEARCH DESIGN AND METHODS

The National Drug Abuse Treatment Clinical Trials Network (CTN) study CTN-0100, "Optimizing Retention, Duration and Discontinuation Strategies for Opioid Use Disorder Pharmacotherapy" (RDD), is a multicenter, randomized, non-blinded trial enrolling more than a thousand patients from 18 community-based substance use disorder treatment programs. Participants are adult volunteers seeking to initiate medication treatment for OUD (MOUD). Individuals choose between buprenorphine or extended-release injectable naltrexone. The trial randomizes participants choosing buprenorphine, in a 3 × 2 factorial design, to a medication condition (standard-dose sublingual buprenorphine, high-dose sublingual buprenorphine, or extended-release injectable buprenorphine) and to a behavioral condition (Medical Management or Medical Management plus a digital therapeutic (smartphone) app). Individuals choosing extended-release naltrexone are randomized only to a behavioral condition. Participants receive study medication for 74 weeks and are then followed for a further 24 weeks. The primary outcome is successful retention on MOUD at 26 weeks (six months), with 50- and 74-week retention among the secondary outcomes.

DISCUSSION/CONCLUSION

Dropout from treatment is a major barrier to the effectiveness of MOUD. The CTN-0100 study will determine whether strategies such as high dose sublingual or extended-release buprenorphine, or an app-based behavioral intervention improve retention on MOUD.

CLINICALTRIALS

gov Identifier: NCT04464980.

Effects of randomization to buprenorphine or naltrexone for OUD on cannabis use outcomes: A secondary analysis of the X:BOT trial

AIMS

Cannabis use is highly prevalent in patients seeking treatment for opioid use disorder. Studies have shown mixed results on the association between cannabis use and opioid use as well as the impact of MOUD on cannabis use. The current study aims to investigate the effects of buprenorphine versus naltrexone on cannabis use outcomes in treatment seeking individuals with Opioid Use Disorder (OUD).

METHODS

The current study was based on data from the CTN-0051 X:BOT trial, which compared the time to return to significant opioid use survival outcomes of two treatment seeking groups, one receiving Extended-Release Naltrexone (XR-naltrexone) (N = 283) versus another receiving Buprenorphine-Naloxone (N = 287) for OUD. A mixed-effects logistic regression model including treatment assignment (buprenorphine-naloxone vs XR-naltrexone), time, and a time by treatment interaction was run on the sample with the odds of cannabis use as the outcome, as well as two cross-lagged mediation models to explore the prospective mediation of cannabis use on opioid use outcomes (and opioid use on cannabis use outcomes) by treatment assignment during the trial.

RESULTS

There was a significant effect of buprenorphine treatment on reduced cannabis use. Participants receiving buprenorphine treatment were 39 % less likely to use cannabis than those receiving naltrexone over all the timepoints (p = .0499). No significant mediation was found between treatment assignment and opioid use on cannabis use outcomes or between treatment assignment and cannabis use on opioid use outcomes in this trial.

CONCLUSION

Participants in this trial receiving buprenorphine treatment for OUD used less cannabis than those receiving naltrexone treatment.

Noninvasive Brain Stimulation for Opioid Use Disorder: An Update of the Literature

Purpose of review

Although medications for opioid use disorder (OUD) are effective, relapse remains common. Noninvasive brain stimulation (NIBS) has emerged as a potential adjunctive treatment. We review publications since 2020 that tested NIBS interventions in humans and assessed clinically relevant outcomes.

Recent findings

We identified a total of 19 studies of NIBS for treatment of craving; acute detoxification, withdrawal, and early abstinence; relapse prevention; cognitive dysfunction associated with OUD; mood and anxiety symptoms in OUD; co-occurring SUDs with OUD; and post-operative pain management and prevention of OUD.

Summary

NIBS interventions, particularly repetitive transcranial magnetic stimulation and transcranial direct current stimulation have demonstrated preliminary evidence of effectiveness to treat OUD and its associated symptoms.

Organization of primary care and early MOUD discontinuation

Primary care clinic structures and operations may influence early MOUD discontinuation. Flexible scheduling can improve early MOUD retention but must be balanced with clinic efficiency. Multidisciplinary teams can improve retention but require additional resources. Addressing comorbid pain and polydrug use early in the treatment process can help prevent MOUD discontinuation.

Buprenorphine/Naloxone vs Methadone for the Treatment of Opioid Use Disorder

Importance

Previous studies on the comparative effectiveness between buprenorphine and methadone provided limited evidence on differences in treatment effects across key subgroups and were drawn from populations who use primarily heroin or prescription opioids, although fentanyl use is increasing across North America.

Objective

To assess the risk of treatment discontinuation and mortality among individuals receiving buprenorphine/naloxone vs methadone for the treatment of opioid use disorder.

Design, Setting, and Participants

Population-based retrospective cohort study using linked health administrative databases in British Columbia, Canada. The study included treatment recipients between January 1, 2010, and March 17, 2020, who were 18 years or older and not incarcerated, pregnant, or receiving palliative cancer care at initiation.

Exposures

Receipt of buprenorphine/naloxone or methadone among incident (first-time) users and prevalent new users (including first and subsequent treatment attempts).

Main Outcomes and Measures

Hazard ratios (HRs) with 95% compatibility (confidence) intervals were estimated for treatment discontinuation (lasting ≥5 days for methadone and ≥6 days for buprenorphine/naloxone) and all-cause mortality within 24 months using discrete-time survival models for comparisons of medications as assigned at initiation regardless of treatment adherence ("initiator") and received according to dosing guidelines (approximating per-protocol analysis).

Results

A total of 30 891 incident users (39% receiving buprenorphine/naloxone; 66% male; median age, 33 [25th-75th, 26-43] years) were included in the initiator analysis and 25 614 in the per-protocol analysis. Incident users of buprenorphine/naloxone had a higher risk of treatment discontinuation compared with methadone in initiator analyses (88.8% vs 81.5% discontinued at 24 months; adjusted HR, 1.58 [95% CI, 1.53-1.63]), with limited change in estimates when evaluated at optimal dose in per-protocol analysis (42.1% vs 30.7%; adjusted HR, 1.67 [95% CI, 1.58-1.76]). Per-protocol analyses of mortality while receiving treatment exhibited ambiguous results among incident users (0.08% vs 0.13% mortality at 24 months; adjusted HR, 0.57 [95% CI, 0.24-1.35]) and among prevalent users (0.08% vs 0.09%; adjusted HR, 0.97 [95% CI, 0.54-1.73]). Results were consistent after the introduction of fentanyl and across patient subgroups and sensitivity analyses.

Conclusions and Relevance

Receipt of methadone was associated with a lower risk of treatment discontinuation compared with buprenorphine/naloxone. The risk of mortality while receiving treatment was similar for buprenorphine/naloxone and methadone, although the CI estimate for the hazard ratio was wide.

Controversies in Assessment, Diagnosis, and Treatment of Kratom Use Disorder

PURPOSE OF REVIEW

We apply the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria for substance use disorders (SUDs) to the herbal product kratom. Similarities and differences between kratom use disorder (KUD) and other SUDs are explored, along with assessment, diagnostic, and therapeutic recommendations for KUD.

RECENT FINDINGS

Literature reports of "kratom addiction" or KUD rarely specify the criteria by which patients were diagnosed. Individuals meeting DSM-5 KUD criteria typically do so via tolerance and withdrawal, using more than intended, and craving, not functional or ​psychosocial disruption, which occur rarely. Most clinicians who use medication to treat patients with isolated KUD select buprenorphine formulations, although there are no controlled studies showing that buprenorphine is safe or efficacious in this patient population. Diagnosis and treatment decisions for KUD should be systematic. We propose an algorithm that takes into consideration whether KUD occurs with comorbid opioid use disorder.

The fentanyl made me feel like I needed more methadone": changes in the role and use of medication for opioid use disorder (MOUD) due to fentanyl

BACKGROUND

Fentanyl and fentanyl analogues have disrupted the illicit drug supply through contamination of other substances (i.e., methamphetamine and cocaine) and replacement of heroin in illicit markets. Increasingly, they are contributing to opioid-overdose related deaths. The rapid and growing presence of fentanyl has led to gaps in research on the impact of this illicit market change on people who use drugs (PWUD). We sought to examine how the changing opioid market and growing fentanyl availability influences the role and use of medication for opioid use disorder (MOUD).

METHODS

Semi-structured qualitative interviews were conducted with a community recruited sample of PWUD (N = 22) in Los Angeles, California between September 2021 and April 2022. Interviews examined opioid use history, current opioid use behaviors and consumption patterns, and MOUD experiences and perceptions. Thematic analysis was used to systematically code and analyze textual interview data.

RESULTS

The following themes related to fentanyl use and MOUD emerged: (1) Use of deviated MOUD to address fentanyl contamination, (2) Changing perception of the effectiveness of MOUD on fentanyl, and (3) Regulatory limitations of MOUD for fentanyl use disorder.

CONCLUSIONS

PWUD described several repertoires for adjusting to changes in the illicit market of opioids. Clinicians treating PWUD should ask about recent fentanyl use prior to starting MOUD to account for increased tolerance to opioids. Harm reduction strategies such as naloxone kits, safe supply, and supervised consumption facilities can all prevent overdose deaths due to fentanyl.

Recent Opioid Use Impedes Range Adaptation in Reinforcement Learning in Human Addiction

BACKGROUND

Drugs like opioids are potent reinforcers thought to co-opt value-based decisions by overshadowing other rewarding outcomes, but how this happens at a neurocomputational level remains elusive. Range adaptation is a canonical process of fine-tuning representations of value based on reward context. Here, we tested whether recent opioid exposure impacts range adaptation in opioid use disorder, potentially explaining why shifting decision making away from drug taking during this vulnerable period is so difficult.

METHODS

Participants who had recently (<90 days) used opioids (n = 34) or who had abstained from opioid use for ≥ 90 days (n = 20) and comparison control participants (n = 44) completed a reinforcement learning task designed to induce robust contextual modulation of value. Two models were used to assess the latent process that participants engaged while making their decisions: 1) a Range model that dynamically tracks context and 2) a standard Absolute model that assumes stationary, objective encoding of value.

RESULTS

Control participants and ≥90-days-abstinent participants with opioid use disorder exhibited choice patterns consistent with range-adapted valuation. In contrast, participants with recent opioid use were more prone to learn and encode value on an absolute scale. Computational modeling confirmed the behavior of most control participants and ≥90-days-abstinent participants with opioid use disorder (75%), but a minority in the recent use group (38%), was better fit by the Range model than the Absolute model. Furthermore, the degree to which participants relied on range adaptation correlated with duration of continuous abstinence and subjective craving/withdrawal.

CONCLUSIONS

Reduced context adaptation to available rewards could explain difficulty deciding about smaller (typically nondrug) rewards in the aftermath of drug exposure.

Attitudes and Intentions toward Use of HIV Pre-Exposure Prophylaxis (PrEP) among Adults Receiving Treatment for Opioid Use

Background: Although pre-exposure prophylaxis (PrEP) prevents HIV, little is known about PrEP awareness and factors associated with intention to take PrEP among people with opioid use disorder (OUD). Methods: HIV-negative adults recruited from an outpatient treatment program in Cincinnati, Ohio completed self-administered surveys. Items derived from literature and health behavioral theory included demographics, sexual and drug use behaviors, HIV prevention practices, PrEP knowledge, and attitudes toward PrEP. Primary outcomes were 1) intention to ask a clinician about PrEP and 2) intention to accept PrEP if recommended by a clinician. Outcomes were dichotomized into higher vs. lower intention for analyses in logistic regression models. Results: Among 198 participants, 60.3% reported past injection drug use. Among 58 participants (29.3%) meeting criteria for PrEP, 24% were aware of PrEP, 15.5% had discussed it with a clinician, and 5% had taken it. Factors associated with intention to ask a clinician about PrEP included being somewhat confident about consistent condom use (p < 0.01), motivation to comply with normative beliefs (p < 0.01), and reporting that PrEP fits very well (p < 0.01) and is easy to fit (p < 0.01) into current prevention practices. Factors associated with intention to accept PrEP if recommended by a clinician included motivation to comply with normative beliefs (p < 0.01) and PrEP being easy to fit into current prevention practices (p < 0.01). Conclusion: Among participants meeting indications for PrEP, only 24% were aware of it and few had taken it. Interventions that normalize PrEP and target incorporating PrEP into current prevention practices may improve uptake among individuals with OUD.

Impact of Medication-Based Treatment on Health Care Utilization Among Individuals With Opioid Use Disorder

OBJECTIVE

This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health.

METHODS

This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics.

RESULTS

Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services.

CONCLUSIONS

These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.

Integrating peer support services into primary care-based OUD treatment: Lessons from the Penn integrated model

Opioid use disorder (OUD) is a major public health emergency in the United States. In 2020, 2.7 million individuals had an OUD. Medication for opioid use disorder is the evidence-based, standard of care for treating OUD in outpatient settings, especially buprenorphine because it is effective and has low toxicity. Buprenorphine is increasingly prescribed in primary care, a setting that provides greater anonymity and convenience than substance use disorder treatment centers. Yet two-thirds of people who begin buprenorphine treatment discontinue within the first six months. Treatment dropout elevates the risks of return to use, infections, higher levels of medical care and related costs, justice system involvement, and death. One promising form of retention support is peer service programs. Peers combine their lived experience of substance use and recovery with formal training to help patients engage and persist in OUD treatment. They provide a range of services, including health education, encouragement and empathy, coping skills, recovery modeling, and concrete assistance in overcoming the situational barriers to retention. However, guidance is needed to define the peer role in primary care, the specific tasks peers should perform, the competencies those tasks require, training and professional development needs, and peer performance standards. Guidance also is needed to integrate peers into the care team, allocate and coordinate responsibilities among care team members, manage peer operations and workflow, and facilitate effective team communication. Here we describe a peer support program in the University of Pennsylvania Health System (UPHS or Penn Medicine) network of primary care practices. This paper details the program's core components, values, and activities. We also report the organizational challenges, unresolved questions, and lessons for the field in administering a peer support program to meet the needs of patients served by a large, urban medical system with an extensive suburban and rural catchment area. CLINICAL TRIALS REGISTRATION: www.clinicaltrials.gov registration: NCT04245423.

Coverage of the opioid crisis in national network television news from 2000-2020: A content analysis

Background: News coverage has both negatively and positively influenced public awareness and perceptions surrounding the opioid crisis. This study aimed to describe and analyze national network television news framing of the scope and impact of the opioid crisis in the United States. Methods: We performed a retrospective content analysis on national network television evening news segments covering the opioid crisis from 1/2000 to 8/2020, which were obtained from the Vanderbilt Television News Archive. The database was queried for: opioid epidemic, oxycontin, heroin, fentanyl, and naloxone. Two independent reviewers quantitatively coded segment characteristics, including theme, geographic location, opioids mentioned, strategies for combatting the epidemic discussed, interviews conducted, and patient demographics. Changes in segment characteristics over time were analyzed using chi-square analyses and Fisher's exact tests. Results: News segments (N = 191) most commonly provided an overview of the epidemic (55.5%) and/or conveyed personal stories (40.3%). Prescription opioids (59.7%) and heroin (62.8%) were more often referenced than fentanyl (17.8%); the focus on heroin peaked in 2011-2015 (84.8%), while references to fentanyl significantly increased over time (p = 0.021). The most frequently interviewed people included patients with opioid use disorder (OUD) (47.1%), healthcare providers (36.7%), family members/friends (31.9%), and law enforcement (30.9%). Most of the featured patients with OUD were male (63.0%), white (88.4%), and young (< 40 years) adults (77.9%). Coverage of the crisis peaked in 2016. Conclusions: Evening news segments' emphasis on personal stories, while emotionally compelling, came at the cost of thematically-framed coverage that may improve public understanding of the complexities of the epidemic. The depiction of primarily white, young adult patients with OUD revealed a need for a greater emphasis in the news on underrepresented minorities and older adults, as these populations face additional stigma and disparities in OUD treatment initiation and retention.

Patient Characteristics Associated with Opioid Abstinence after Participation in a Trial of Buprenorphine versus Injectable Naltrexone

Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.

Retention in care for persons with opioid use disorder transitioning from sublingual to injectable buprenorphine

INTRODUCTION

In the current overdose epidemic, effective treatments for opioid use disorders (OUD), including innovations in medication delivery such as extended-release formulations, have the potential to improve treatment access and reduce treatment discontinuation. This study assessed treatment retention in a primary care-based, extended-release buprenorphine program.

METHODS

The study recruited individuals (n = 92) who transitioned from sublingual buprenorphine to extended-release buprenorphine (BUP-XR) in 2018-2019. The study defined the primary outcome, treatment retention, as three or more consecutive, monthly BUP-XR injections following the transition to BUP-XR in this retrospective chart review.

RESULTS

Participants' mean age was 38 years old and 67% were male. The average duration of sublingual buprenorphine prior to transition was 17.1 (±28.1) months. Three months after transition, 48% of extended-release buprenorphine patients had discontinued BUP-XR treatment. Persons with chronic pain were more likely, and those who had used heroin in the past month less likely to continue BUP-XR. Mean months on sublingual buprenorphine prior to BUP-XR initiation was 24.3 (±32.5) months for people who received 3+ post-induction injections compared to only 8.9 (±19.5) months for those who did not (p = .009).

CONCLUSIONS

Extended-release buprenorphine discontinuation was high in a real-world setting. Retention continues to represent a major obstacle to treatment effectiveness, and programs need interventions with even newer MOUD formulations.