National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness

State sequence analysis of daily methadone dispensing trajectories among individuals at United States opioid treatment programs before and following COVID-19 onset

BACKGROUND AND AIMS

US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates.

DESIGN

Retrospective chart review of electronic health records.

SETTINGS

Nine opioid treatment programs (OTPs) across nine US states.

PARTICIPANTS

Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376).

MEASUREMENTS

Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics.

FINDINGS

Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing.

CONCLUSION

Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

Illicit Substance Use and Treatment Access Among Adults Experiencing Homelessness

Importance

The lack of representative research on homelessness risks mischaracterizing and misrepresenting the prevalence of illicit substance use.

Objective

To estimate the population prevalence and patterns of illicit substance use, treatment, nonfatal overdose, and naloxone possession among people experiencing homelessness in 1 US state.

Design, Setting, and Participants

This representative survey study of adults experiencing homelessness from October 2021 to November 2022 in 8 California counties used multistaged probability-based sampling and respondent-driven sampling. Eligible individuals were 18 years or older and met the federal definition of homelessness.

Main Outcomes and Measures

The primary outcome measures included lifetime and past-6-month illicit substance use and substance type (methamphetamine, nonprescription opioids, or cocaine). Lifetime and current substance use treatment, unmet treatment need, types of treatments received, nonfatal overdose (lifetime and current episode of homelessness), and current possession of naloxone were measured. Population prevalence estimates with 95% Wald CIs were calculated using survey replicate weights.

Results

Of 3865 individuals approached, 3042 (79%) participated and an additional 158 participants were recruited through respondent-driven sampling. Among 3200 participants, the mean age was 46.1 (95% CI, 45.3-46.9) years, 67.3% (95% CI, 65.2%-69.3%) were cisgender male, and there were similar proportions of Black and African American, Hispanic and Latine, and White participants. Overall, an estimated 65.3% (95% CI, 62.2%-68.4%) of participants used illicit drugs regularly (≥3 times per week) in their lifetime; 41.6% (95% CI, 39.4%-43.8%) began using regularly before their first episode of homelessness and 23.2% (95% CI, 20.5%-25.9%) began using regularly after. In the past 6 months, an estimated 37.1% (95% CI, 32.9%-41.3%) of participants reported regular use of any drug; 33.1% (95% CI, 29.4%-36.7%) reported use of methamphetamines, 10.4% (95% CI, 7.9%-12.9%) reported use of opioids, and 3.2% (95% CI, 1.8%-4.6%) reported use of cocaine. In their lifetime, an estimated 25.6% (95% CI, 22.8%-28.3%) injected drugs and 11.8% (95% CI, 9.8%-13.8%) injected drugs in the past 6 months. Among those with any regular lifetime use, an estimated 6.7% (95% CI, 3.8%-9.5%) of participants were currently receiving treatment. Of those with any regular use in the last 6 months, an estimated 21.2% (95% CI, 17.9%-24.5%) reported currently wanting but not receiving treatment. An estimated 19.6% (95% CI, 17.4%-21.8%) of participants had a nonfatal overdose in their lifetime and 24.9% (95% CI, 21.3%-28.5%) currently possessed naloxone.

Conclusion and Relevance

In a representative study of adults experiencing homelessness in California, there was a high proportion of current drug use, history of overdose, and unmet need for treatment. Improving access to treatment tailored to the needs of people experiencing homelessness could improve outcomes.

Day-to-day discrimination and substance use treatment motivation among justice-involved adults experiencing homelessness

Background: Adults experiencing homelessness (AEH) disproportionately suffer from substance use disorders (SUD) and under-utilize SUD treatments compared with the general population. AEH with a recent history of justice involvement (AEH+J) face additional treatment barriers related to discrimination and criminal history.Objective: To describe types of discrimination that AEH+J experience and assess whether the type of discrimination experienced impacts motivation for SUD treatment by SUD severity.Methods: We analyzed data from 164 AEH+J (85% male, 54% non-Hispanic Black) from the Link2Care cohort. ANOVA and linear regression analyses tested for associations between discrimination type, SUD treatment motivation, and SUD severity. Multivariable linear regression models examined associations between discrimination types and SUD treatment motivation by SUD severity level.Results: The majority of AEH+J experienced discrimination (90%), primarily due to homeless status (27%) and race (27%). AEH+J with severe SUD had a significantly greater motivation for SUD treatment than those with mild/moderate disorders (mean difference: 7.34, p < .0001). Discrimination type was not directly associated with SUD severity or treatment motivation. However, among participants with severe SUD, AEH+J who experienced race-related discrimination had lower treatment motivation than those who did not experience discrimination (β = -6.17, p = .03).Conclusion: Results support allocating scarce publicly available SUD treatment resources to AEH+J with the greatest need and motivation to receive treatment. Results also highlight the importance of screening for discriminatory experiences, especially to those who primarily experience race-related discrimination, to improve motivation for SUD treatment among AEH+J with severe SUD.

Rural houselessness among people who use drugs in the United States: Results from the National Rural Opioid Initiative

BACKGROUND

Over the last two decades, houselessness and drug-related epidemics both have expanded from urban to rural regions across the United States (US). However, our understanding of the relationship between rural houselessness, drug use, and drug-related harms has not kept pace. The current study addresses this gap by describing houselessness among a large cohort of people who use drugs (PWUD) from rural communities across 10 states.

DESIGN

PWUD were recruited using modified chain-referral sampling for a cross-sectional survey capturing houselessness in the prior six months, drug use, drug-related harms, stigma, health service access, and sociodemographic characteristics. Using bivariate logistic regressions, we assessed associations between houselessness and participant characteristics. We also compare site-specific houselessness prevalence to Housing and Urban Development Point-in-Time (PIT) estimates, which are based on counts of sheltered and unsheltered people experiencing houselessness on a single night.

RESULTS

Among 3000 PWUD, 53.7 % reported experiencing houselessness. Houselessness was associated with multiple drug-related behaviors that increase the risk of overdose and acquisition of bloodborne infections. Houselessness prevalence was comparable and exceeded PIT estimates for several sites, even though study participants constituted <1 % of each site's adult population and were restricted to PWUD.

CONCLUSIONS

Our findings highlight that houselessness - historically considered an urban issue - is a significant public health concern for PWUD in rural areas. This demonstrates that addressing drug-related HIV, hepatitis C, and overdose epidemics, among others, in the rural US will require the provision of stable housing and harm reduction services as a pathway to treatment and recovery.

Health and Economic Outcomes of Offering Buprenorphine in Homeless Shelters in Massachusetts

Importance

Overdose is the leading cause of death among people experiencing homelessness (PEH), but engagement in medication treatment is low in this population. Shelter-based buprenorphine may be a strategy for increasing initiation and retention on lifesaving medications.

Objective

To estimate clinical outcomes and conduct an economic analysis of statewide shelter-based opioid treatment in Massachusetts.

Design, Setting, and Participants

This economic evaluation study in Massachusetts used a cohort state-transition simulation model. Two cohorts were modeled starting in 2013, including (1) a closed cohort of a fixed population of PEH with history of high-risk opioid use over their lifetimes and (2) an open cohort in which membership could change over time, allowing assessment of population-level trends over a 10-year period. Data analysis occurred from January 2023 to April 2024.

Exposures

Model exposures included (1) no shelter-based buprenorphine (status quo) and (2) offering buprenorphine in shelters statewide.

Main Outcomes and Measures

Outcomes included overdose deaths, quality-adjusted life-years (QALYs) gained, and health care and modified societal perspective costs. Sensitivity analyses were conducted on key parameters.

Results

In the closed cohort analysis of 13 800 PEH (mean [SD] age, 40.4 [13.1] years; 8749 male [63.4%]), shelter-based buprenorphine was associated with an additional 65.4 person-weeks taking buprenorphine over an individual's lifetime compared with status quo. Shelter-based buprenorphine was cost saving when compared with the status quo, with a discounted lifetime cost savings from the health sector perspective of $1300 per person, and 0.2 additional discounted QALYs per person and 0.9 additional life-years per person. In the population-level simulation, 254 overdose deaths were averted over the 10-year period with the shelter-based buprenorphine strategy compared with the status quo (a 9.2% reduction of overdose deaths among PEH in Massachusetts). Overdose-related and other health care utilization undiscounted costs decreased by $3.0 million and $66.4 million, respectively. Shelter-based opioid treatment generated $44.7 million in additional medication and clinical costs, but saved $69.4 million in overdose and other health costs.

Conclusions and Relevance

In this economic evaluation of clinical and economic outcomes among PEH, shelter-based buprenorphine was associated with fewer overdose deaths and was cost saving. These findings suggest that broad rollout of shelter-based buprenorphine may be an important tool in addressing the overdose crisis.

Sex disparities in outcome of medication-assisted therapy of opioid use disorder: Nationally representative study

Question

The opioid epidemic causes massive morbidity, and males have substantially greater overdose mortality rates than females. It is unclear whether there are sex-related disparities at different stages in the trajectory of opioid use disorders, in "real world" settings.

Goal

To determine sex disparities in non-medical opioid use (NMOU) at the end of outpatient medication-assisted treatment (MAT), using nationally representative data.

Design

Observational epidemiological study of publicly funded outpatient MAT programs in the national "Treatment episode data set-discharges" (TEDS-D) for 2019.

Participants

Persons aged ≥18 in their first treatment episode, in outpatient MAT for use of heroin or other opioids (N=11,549). The binary outcome was presence/absence of NMOU.

Results

In univariate analyses, males had significantly higher odds of NMOU, compared to females (odds ratio=1.27; Chi2 [df:1]=39.08; uncorrected p<0.0001; p=0.0041 after Bonferroni correction). A multivariable logistic regression detected a male>female odds ratio of 1.19 (95%CI=1.09-1.29; p<0.0001), adjusting for socio-demographic/clinical variables. Several specific conditions were revealed in which males had greater odds of NMOU compared to females (e.g., at ages 18-29 and 30-39; corrected p=0.012, or if they used opioids by inhalation; corrected p=0.0041).

Conclusions

This nationally representative study indicates that males have greater odds of NMOU in their first episode of MAT, indicating more unfavorable outcomes. The study reveals specific socio-demographic and clinical variables under which this sex disparity is most prominent.

The Mobile Overdose Response Program: A mobile, low-threshold opioid use disorder treatment model in Philadelphia

INTRODUCTION

Low-threshold substance use treatment programs may help overcome barriers for marginalized individuals. The aims of this study were to 1) describe participant characteristics and treatment outcomes for a multi-site, Philadelphia-based mobile program providing street-based buprenorphine initiation, stabilization, and referral to ongoing care and 2) examine associations between patient characteristics and successful linkage.

METHODS

We conducted a retrospective cohort study of patients receiving buprenorphine through Prevention Point Philadelphia's mobile overdose response program from 9/2020-12/2021. We abstracted electronic medical record data, including patient characteristics, mobile program treatment, and care linkage. We used descriptive statistics to characterize the sample and assessed the association between patient characteristics and successful care linkage using multi-variable logistic regression.

RESULTS

Two hundred thirty-seven patients initiated buprenorphine in the program across six sites. Mean age was 46. Participants were majority men (67 %); 59 % identified as Black, 33 % identified as White, and 15 % reported Hispanic ethnicity. Most were publicly insured (74 %) and 30 % were unstably housed. Basedline engagement in primary care (32 %), psychiatric treatment (5 %), and counseling (2 %) were low. Most participants reported heroin or fentanyl use at intake (87 %), with high rates of IV drug use (37 %)., and co-occurring substance use and prior buprenorphine treatment experience were common.. 86 % completed ≥1 mobile follow-up visit, and 69 % completed ≥4 mobile program visits. 51 % of patients attended at least one visit at an outside site, and 30 % had ≥2 visits for buprenorphine prescriptions at an outside site. 35 % of the referrals were internal, meaning they went to University-based practices staffed by the mobile unit physicians. In a multivariable logistic regression model, internal referral was associated with significantly increased odds of effective care linkage (aOR 2.47, 95 % CI 1.20-5.09).

CONCLUSIONS

Targeted community outreach with low-threshold substance use care facilitated treatment access among marginalized individuals. Participants showed high levels of engagement with the mobile program, but rates of outside care linkage, while comparable to retention in other low-threshold models, were lower. The only predictor of effective care linkage was referral to brick-and-mortar clinics staffed by mobile unit physicians. These findings support the importance of outreach beyond traditional health care settings to engage high-risk patients with OUD.

The recovery experiences of homeless service users with substance use disorder: A systematic review and qualitative meta-synthesis

BACKGROUND

The relationship between homelessness and substance use disorder (SUD) is layered and complex. Adults pursuing recovery while dealing with homelessness and SUD face many challenges. Little research has inspected qualitative first-person accounts of recovery in the context of homelessness and SUD, and few studies have employed conceptualisations of recovery beyond abstinence. In this systematic review study, we examine the qualitative literature on the recovery experiences of adult homeless service users with SUD.

METHODS

2,042 records were identified via database and secondary searching strategy. After title and abstract and full text screening, 15 eligible studies remained. Critical Appraisal Skills Programme quality appraisal criteria was used to assess potential bias in the studies. Meta-ethnography was employed to synthesise extracted data.

RESULTS

Four themes were generated from the extracted data: Two sides of the Service Coin; Navigating Relationships; Recovery Practices and Personal Attributes; and Housing as Foundational for Recovery.

CONCLUSION

Unconditional housing, a broad array of supports, opportunities to contribute to society, and family reunification supports all facilitate the development of recovery for adults with SUD experiencing homelessness. Implications for policy are discussed.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Treatment setting among individuals with opioid use and criminal legal involvement, housing instability, or Medicaid insurance, 2015-2021

Background

Individuals with criminal legal involvement (CLI), housing instability, or Medicaid insurance may experience barriers accessing substance use treatment in certain settings. Previous research has found individuals in these groups are less likely to receive medications for opioid use disorder (MOUD), but the role treatment setting may play in low rates of MOUD is unclear.

Methods

We conducted a cross-sectional study using nationally representative survey data from 2015 to 2021. We estimated the proportion of individuals who had CLI, housing instability, or Medicaid insurance who received substance use treatment in a variety of settings. We used multivariable logistic regressions to estimate the associations between group and the receipt of MOUD across treatment settings.

Results

Individuals with CLI, housing instability, or Medicaid insurance were more likely to receive substance use treatment in hospitals, rehabilitation, and mental health facilities compared with individuals not in these groups. However, all groups accessed substance use treatment in doctors' offices at similar rates. Treatment at a doctor's office was associated with the highest likelihood of receiving MOUD (aOR 4.73 [95% CI: 2.2.15-10.43]). Across multiple treatment settings, Individuals with CLI or housing instability were less likely to receive MOUD.

Conclusions

Individuals with CLI, housing instability, or Medicaid insurance are more likely to access substance use treatment at locations associated with lower rates of MOUD use. MOUD access across treatment settings is needed to improve engagement and retention in treatment for patients experiencing structural disadvantage or who have low incomes.

Impact of Medicaid expansion on inclusion of medications for opioid use disorder in homeless adults' treatment plans

INTRODUCTION

People experiencing homelessness (PEH) bear disproportionate opioid mortality. This article aims to determine how state Medicaid expansion under the Affordable Care Act impacted the inclusion of medications for opioid use disorder (MOUD) in treatment plans for housed versus homeless individuals.

METHODS

The Treatment Episodes Data Set (TEDS) provided data on 6,878,044 U.S. treatment admissions between 2006 and 2019. Difference-in-differences analysis compared MOUD treatment plans and Medicaid enrollment for housed versus homeless clients in states that did and did not expand Medicaid.

RESULTS

Medicaid expansion was associated with a 35.2 (95 % CI, 11.9 to 58.4) percentage point increase in Medicaid enrollment and an 8.51 (95 % CI, 1.13 to 15.9) percentage point increase in MOUD-inclusive treatment plans for housed and homeless clients alike. Yet the pre-existing MOUD disparity persisted, with PEH being 11.8 (95 % CI, -18.6 to -5.07) percentage points less likely to have MOUD-inclusive treatment plans.

CONCLUSIONS

Medicaid expansion may be an effective tool for increasing MOUD treatment plans for PEH in the 11 states that have not yet implemented the policy, but additional efforts to increase MOUD initiation for PEH will be necessary for closing their treatment gap.

Homelessness and Treatment Outcomes Among Black Adults With Opioid Use Disorder: A Secondary Analysis of X:BOT

OBJECTIVE

We sought to identify the sociodemographic and clinical characteristics associated with homelessnesss, and explore the relationship between homelessnesss and treatment outcomes among Black individuals.

METHODS

This is a secondary analysis of the subgroup of Black participants (n = 73) enrolled in "X:BOT," a 24-week multisite randomized clinical trial comparing the effectiveness of extended-release naltrexone versus sublingual buprenorphine-naloxone (n = 570). Outcomes included medication initiation, return to extramedical use of opioids assessed by both self-report and urine toxicology, and engagement in medications for opioid use disorder (MOUD) treatment at 28 weeks postrandomization. Descriptive statistics were performed.

RESULTS

Black participants were mostly unmarried and male, and about a third were aged 21-30 years. Among people experiencing homelessnesss, more were uninsured (45.5% [10/22] vs 19.6% [10/51]), unemployed (77.3% [17/22] vs 64.7% [33/51]), and reported alcohol (40.9% [9/22] vs 23.5% [12/51]) and sedative use (54.5% [12/22] vs 17.6% [9/51]) within the previous 30 days. Compared with housed Black individuals, a slightly higher proportion of Black individuals experiencing homelessnesss successfully initiated study medication (81.1% [18/22] vs 72.6% [37/51]); similar proportions returned to opioid use during the trial (68.2% [15/22] vs 68.6% [35/51]) and were engaged in MOUD at 28 weeks after trial entry (72.2% [13/18] vs 69.7% [23/33]) among participants located for follow-up.

CONCLUSIONS

These descriptive results among Black patients participating in a trial of MOUD suggest that efficacious MOUD is possible despite homelessnesss with additional clinical supports such as those provided by a clinical trial.

The role of polysubstance use on criminal justice involvement in the United States

PURPOSE OF REVIEW

Polysubstance use, broadly defined as using more than one type of substance, disproportionately impacts those involved in the criminal justice system (CJS). This review synthesizes recent findings on polysubstance use among those involved in the CJS and highlights areas of particular concern and interventions.

RECENT FINDINGS

We use 18 recent articles to identify the prevalence and types of criminal justice involvement and correlates of polysubstance use and criminal justice involvement. We highlight latent patterns of polysubstance use among various criminal justice populations (adults, pregnant women, and youth) and differential associations with adverse substance use and criminal justice outcomes. Lastly, we discuss substance use treatment in the justice system, the role of polysubstance use in treatment access and outcomes, and substance use-related services for previously incarcerated individuals reentering society.

SUMMARY

Current research provides further evidence of the syndemic nature of polysubstance use, criminal justice involvement, and adverse outcomes, which are complicated by significant barriers to accessing evidence-based treatment in justice settings. Yet, current research is limited due to methodological inconsistency and limited focus on the social determinants of health, racial/ethnic disparities, and interventions to increase treatment and reentry services.

The Future of the United States Overdose Crisis: Challenges and Opportunities

Policy Points People are dying at record numbers from overdose in the United States. Concerted action has led to a number of successes, including reduced inappropriate opioid prescribing and increased availability of opioid use disorder treatment and harm-reduction efforts, yet ongoing challenges include criminalization of drug use and regulatory and stigma barriers to expansion of treatment and harm-reduction services. Priorities for action include investing in evidence-based and compassionate policies and programs that address sources of opioid demand, decriminalizing drug use and drug paraphernalia, enacting policies to make medication for opioid use disorder more accessible, and promoting drug checking and safe drug supply.

A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States

BACKGROUND

Homelessness is an important social determinant of health (SDOH), impacting health outcomes for many medical conditions. Although homelessness is common among people with opioid use disorder (OUD), few studies systematically evaluate homelessness and other SDOH among people enrolled in standard of care treatment for OUD, medication for opioid use disorder (MOUD), or examine whether homelessness affects treatment engagement.

METHODS

Using data from the 2016 to 2018 U.S. Treatment Episode Dataset Discharges (TEDS-D), patient demographic, social, and clinical characteristics were compared between episodes of outpatient MOUD where homelessness was reported at treatment enrollment versus independent housing using pairwise tests adjusted for multiple testing. A logistic regression model examined the relationship between homelessness and treatment length and treatment completion while accounting for covariates.

RESULTS

There were 188 238 eligible treatment episodes. Homelessness was reported in 17 158 episodes (8.7%). In pairwise analysis, episodes involving homelessness were significantly different from those involving independent living on most demographic, social, and clinical characteristics, with significantly greater social vulnerability in most SDOH variables (P's < .05). Homelessness was significantly and negatively associated with treatment completion (coefficient = -0.0853, P < 0.001, 95% CI = [-0.114, -0.056], OR = 0.918) and remaining in treatment for greater than 180 days (coefficient = -0.3435, P < 0.001, 95% CI = [-0.371, -0.316], OR = 0.709) after accounting for covariates.

CONCLUSIONS

Patients reporting homelessness at treatment entry in outpatient MOUD in the U.S. represent a clinically distinct and socially vulnerable population from those not reporting homelessness. Homelessness independently predicts poorer engagement in MOUD confirming that homelessness may be an independent predictor for MOUD treatment discontinuation nationally.

Homelessness and Gender: Differences in Characteristics and Comorbidity of Substance Use Disorders at Admission to Services

Background: Substance use disorders and homelessness are two closely related behavioral health issues. This study examines associations between homelessness and severity of substance use disorder (SUD) characteristics (inclusive of alcohol and other legal and illegal drugs) and presence of mental health comorbidity among individuals entering treatment for SUD. We also examine differences in SUD and mental health comorbidity by gender within a sample of clients experiencing homelessness upon admission to treatment. Methods: Using the 2017 Treatment Episodes Data Set, we used logistic regression models to examine the association between homelessness and indicators of severity (e.g., frequency of use, route of transmission) and the presence of mental health conditions, and to examine the association between gender and these dependent variables among only individuals experiencing homelessness at treatment admission. Results: After controlling for covariates, homelessness is significantly associated with increased odds of cocaine and methamphetamine use compared to all other substances, higher frequency of use, younger age of first use, use of more substances, injection drug use, and co-occurring mental health conditions. Female gender is inversely associated with younger age at first use and highly associated with co-occurring mental health conditions among those experiencing homelessness at admission to treatment. Conclusions: Individuals experiencing homelessness enter substance use services with different characteristics of substance use disorders, different patterns of use, and with higher rates of mental health comorbidity. Within homeless admissions, women have significant differences in substance use and higher likelihood of mental health comorbidity than men. Future research should focus on the specific treatment needs of individuals experiencing homelessness, and how the combination of homelessness and gender affects barriers and challenges to treatment.

Trends In The Use Of Treatment For Substance Use Disorders, 2010-19

Rapidly rising drug overdose rates in the United States during the past decade underscore the need to increase access to treatment among people with substance use disorders (SUDs). We analyzed trends in the use of treatment services among people with SUDs during the period 2010-19, using data from the National Survey on Drug Use and Health. Compared with 2013, outpatient visits for general health in the prior year increased 3.6 percentage points by the 2017-19 period. Use of any SUD treatment in the prior year remained unchanged, but treatment use among people involved in the criminal legal system increased by about 6.2 percentage points by the end of the study period. Among those receiving SUD treatment, there was a 14.9-percentage-point increase in having treatment paid for by Medicaid between 2010-13 and 2017-19. Although access to general medical care and insurance coverage have improved for people with SUD, our study findings underscore the importance of renewed efforts to increase the use of SUD treatment.

Opioid Use Disorder and Racial/Ethnic Health Disparities: Prevention and Management

PURPOSE OF REVIEW

This review aims to summarize risks and disparities associated with the prevalence and treatment of opioid use disorder in the perioperative and long-term setting, as well as evidence-based treatment and prevention targeted toward specific vulnerable populations.

RECENT FINDING

There are significant demographic disparities in pain management and development and management of OUD in the chronic and surgical setting. While White patients traditionally receive more pain management, they are also at higher risk of developing OUD. Hispanic and Latin populations have the largest proportion of youth with OUD and often lack culturally appropriate translation services that allow for effective treatment. Native Americans have the second highest rate of OUD and often receive care in communities and healthcare settings that lack funding and resources to combat OUD. African Americans tend to suffer from the criminalization of OUD and are less able to seek treatment due to this, and furthermore, often lack community services that would benefit them. Additional vulnerable populations include homeless individuals that lack access to healthcare or health insurance. In addition, incarcerated individuals often lack access to naloxone and suffer from high rates of fatal overdose soon after being released to the community. People in rural settings lack needle-exchange programs and community-based interventions/support groups. Patients in the perioperative setting lack standard screening and pain management protocols. Interventions targeted toward each appropriate group can help decrease the rate of OUD and improve its treatment, and overarching interventions such as protocols, targeted funding, education and regulation can combat OUD for all populations.

Outcomes of a NYC Public Hospital System Low-Threshold Tele-Buprenorphine Bridge Clinic at 1 Year

Background: This study evaluated clinical outcomes of a low barrier tele-buprenorphine bridge program for NYC residents with opioid use disorder (OUD) at 1 year during the coronavirus disease 2019 (COVID-19) pandemic. Methods and materials: This retrospective analysis of the NYC Health + Hospitals (NYC H + H) Virtual Buprenorphine Clinic registry assessed baseline demographic and clinical characteristics, rates of referrals to community treatment, and induction-related adverse events among city residents with OUD, from March 2020 to the end of March 2021. Results: The program enrolled 199 patients, of whom 62.3% were provided same-day visits (n = 124). Patients were enrolled in the program for a median of 14 days (range 0-130 days). Referrals sources included hospital and clinic staff (n = 83, 47.7%), word of mouth (n = 30, 17.2%), and correctional health or reentry services (n = 30, 17.2%). Induction-related adverse events were mostly limited to precipitated withdrawal symptoms (n = 21, 5%). Roughly half of patients were referred to community treatment (n = 109, 54.8%) and of those 51.4% (n = 56/109) completed at least one visit in community treatment. Discussion: Our experience indicates that a low threshold tele-buprenorphine bridge program in place of a safe and feasible approach to facilitating entry in community treatment for underserved people who use opioids in a large metropolitan area.

Homelessness and publicly funded substance use disorder treatment in California, 2016-2019: Analysis of treatment needs, level of care placement, and outcomes

INTRODUCTION

Both homelessness and substance use have increased in recent years. People experiencing homelessness (PEH) are at increased risk for health problems and early mortality, both of which can be exacerbated by substance use disorders (SUD). Specialty SUD treatment is likely needed to address substance use among PEH, and more than 232,000 PEH received treatment from U.S. publicly funded SUD programs in 2015. The objective of this paper is to develop a better understanding of the SUD services that PEH receive in publicly funded treatment programs by (1) describing the characteristics and needs of the PEH population served in publicly funded SUD treatment programs, compared to non-PEH populations; (2) determining if differences exist in treatment placement (level of care) for PEH and non-PEH; and (3) gauging how successful programs are in treating PEH compared to non-PEH.

METHODS

Observational study using a two-way fixed effect model to determine associations among homelessness, retention, and outcomes among Medicaid beneficiaries receiving SUD treatment in California from 2016 to 2019 (n = 638,953). The study team used ordinary least squares (OLS) regression to measure the degree to which homelessness was associated with baseline characteristics, SUD services received, and treatment outcomes.

RESULTS

PEH were significantly more likely than non-PEH to be having methamphetamine or heroin as their primary substance. PEH had greater frequency of primary substance use prior to entering treatment, greater ER and hospital utilization, more criminal justice involvement, and greater prevalence of mental health diagnoses and unemployment. PEH were 9.82% more likely than non-PEH to receive residential treatment and 7.11% less likely than non-PEH to receive treatment intensive outpatient modalities. Homelessness was associated with an 11.90% decrease in retention, and a 19.40% decrease in successful discharge status. These trends were consistent across outpatient, intensive outpatient, and residential modalities.

CONCLUSIONS

Developing SUD treatment capacity and housing supports can improve treatment outcomes for PEH. Potential strategies to improve SUD services for PEH include providing more contingency management, opioid pharmacotherapies, programming designed to treat individuals with co-occurring mental health disorders, and resources for housing options that can support PEH in their recovery.