Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence

Empirically contrasting urine drug screening-based opioid use disorder treatment outcome definitions

BACKGROUND AND AIMS

A lack of consensus on the optimal outcome measures to assess opioid use disorder (OUD) treatment efficacy and their precise definition and computation has hampered the pooling of research data for evidence synthesis and meta-analyses. This study aimed to empirically contrast multiple clinical trial definitions of treatment success by applying them to the same dataset.

METHODS

Data analysis used a suite of functions, developed as a software package for the R language, to operationalize 61 treatment outcome definitions based on urine drug screening (UDS) results. Outcome definitions were derived from clinical trials that are among the most influential in the OUD treatment field. Outcome functions were applied to a harmonized dataset from three large-scale National Drug Abuse Treatment Clinical Trials Network (CTN) studies, which tested various medication for OUD (MOUD) options (n = 2492). Hierarchical clustering was employed to empirically contrast outcome definitions.

RESULTS

The optimal number of clusters identified was three. Cluster 1, comprising eight definitions focused on detecting opioid-positive UDS, did not include missing UDS in outcome calculations, potentially resulting in inflated rates of treatment success. Cluster 2, with the highest variability, included 10 definitions characterized by strict criteria for treatment success, relying heavily on UDS results from either a brief period or a single study visit. The 43 definitions in Cluster 3 represented a diverse range of outcomes, conceptualized as measuring abstinence, use reduction and relapse. These definitions potentially offer more balanced measures of treatment success or failure, as they avoid the extreme methodologies characteristic of Clusters 1 and 2.

CONCLUSIONS

Clinical trials using urine drug screening (UDS) for objective substance use assessment in outcome definitions should consider (1) incorporating missing UDS data in outcome computation and (2) avoiding over-reliance on UDS data confined to a short time frame or the occurrence of a single positive urine test following a period of abstinence.

Cognitive behavioral therapy for anxiety and opioid use disorder: Development and pilot testing

INTRODUCTION

Anxiety disorders are highly prevalent among people with opioid use disorder (OUD), and they have a negative impact on disorder course and treatment outcomes. The objective of this Stage 1 A/1B behavioral treatment development trial was to develop a novel cognitive-behavioral therapy (CBT) protocol for co-occurring anxiety disorders and OUD.

METHODS

Following a period of iterative manual development involving patient interviews and feedback from content experts, we tested a 12-session individual CBT protocol in a small, open pilot trial (N = 5). This was followed by a small, randomized controlled trial (N = 32), comparing the new protocol to 12 sessions of manualized Individual Drug Counseling. All participants also received medication for OUD.

RESULTS

Overall, support for feasibility and acceptability was strong, based on recruitment and retention rates and patient satisfaction ratings. Within-subjects results identified 11-point reductions in anxiety symptom severity (on a 0-56 point scale); these gains were sustained through 3 months of follow-up. However, these changes did not differ between randomized conditions. With respect to opioid outcomes, 85 % of participants were abstinent in the prior month at the end of treatment. Opioid use outcomes also did not differ by treatment condition.

CONCLUSIONS

These results support the feasibility and acceptability of a CBT protocol for co-occurring anxiety and OUD. However, in this small pilot trial results do not show an initial benefit over an evidence-based psychosocial treatment targeted to OUD alone, in combination with medication for OUD.

Psychotherapies in opioid use disorder: toward a step-care model

Opioid use disorder (OUD) is characterized by a lack of control in opioid use, resulting in psychological distress and deficits in interpersonal and social functioning. OUD is often associated with psychiatric comorbidities that increase the severity of the disorder. The consequences of OUD are dramatic in terms of increased morbi-mortality. Specific medications and psychotherapies are essential tools not only in the treatment of OUD but also in the prevention of suicide and overdoses. In our review, we assess the different types of psychotherapies (counseling, motivational interviewing, contingency management, cognitive-behavioral therapy, and dialectical-behavior therapy) that are delivered to opioid users, either associated or un-associated with OUD medications and/or medications for psychiatric disabilities. We describe the application of these therapies first to adult opioid users and then to adolescents. This work led us to propose a stepped-care model of psychotherapies for OUD which provided information to assist clinicians in decision-making regarding the selection of psychotherapeutic strategies according to patients' OUD severity.

Discontinuation of medication treatment for opioid use disorder after a successful course: The discontinuation phase of the CTN-0100 (RDD) trial

INTRODUCTION AND BACKGROUND

Buprenorphine, and extended-release naltrexone, are effective in decreasing opioid use, morbidity and mortality. The available evidence suggests that these medications should be used for long term treatment; however, patients often ask how long they need to be on medication, and whether it would be safe to discontinue. There are sparse data to guide us. The CTN-0100 trial will address this gap in our knowledge by studying participants who have decided to discontinue buprenorphine and extended-release naltrexone for OUD.

RESEARCH DESIGN AND METHODS

The trial is a multicenter, randomized, non-blinded study. Participants are stable adult volunteers, on sublingual buprenorphine, extended-release buprenorphine, or extended-release naltrexone, expressing an interest in discontinuing medication. Participants on buprenorphine must be stable for at least 1 year and participants on extended-release naltrexone must be stable for at least 6 months. Participants are engaged in the study for up to 96 weeks, including a flexible taper period, and are then transitioned to follow-up within the trial. All participants are randomly assigned to the study Medical Management (MM) or to MM plus Connections (CHESS health) digital smartphone application aimed at recovery and abstinence (MMD). Sublingual Buprenorphine participants are also randomized (2 × 2 design) to a taper using either sublingual or extended-release buprenorphine.

DISCUSSION/CONCLUSION

It is hoped that this trial will provide a rich source of data on management of patients discontinuing medication for opioid use disorder (MOUD) to inform future research and practice. The trial will shed light on which strategies are most likely to lead to long-term success (absence of relapse), and what participant characteristics distinguish those who can safely discontinue MOUD from those who remain at risk of relapse should they discontinue.

CLINICALTRIALS

gov Identifier: NCT04464980.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Multimodal Acute Pain Management in the Parturient with Opioid Use Disorder: A Review

The opioid epidemic in the United States has led to an increasing number of pregnant patients with opioid use disorder (OUD) presenting to obstetric units. Caring for this complex patient population requires an interdisciplinary approach involving obstetricians, anesthesiologists, addiction medicine physicians, psychiatrists, and social workers. The management of acute pain in the parturient with OUD can be challenging due to several factors, including respiratory depression, opioid tolerance, and opioid-induced hyperalgesia. Patients with a history of OUD can present in one of three categories: 1) those with untreated OUD; 2) those who are currently abstinent from opioids; 3) those being treated with medications to prevent withdrawal. A patient-centered, multimodal approach is essential for optimal peripartum pain relief and prevention of adverse maternal and neonatal outcomes. Medications for opioid use disorder (MOUD), previously referred to as medication-assisted therapy (MAT), include opioids like methadone, buprenorphine, and naltrexone. These are prescribed for pregnant patients with OUD, but appropriate dosing and administration of these medications are critical to avoid withdrawal in the mother. Non-opioid analgesics such as acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) can be used in a stepwise approach, and regional techniques like neuraxial anesthesia and truncal blocks offer opioid-sparing options. Other medications like ketamine, clonidine, dexmedetomidine, nitrous oxide, and gabapentinoids show promise for pain management but require further research. Overall, a comprehensive pain management strategy is essential to ensure the well-being of both the mother and the fetus in pregnant patients with OUD.

Novel Therapeutic and Program-Based Approaches to Opioid Use Disorders

Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.

Retention and critical outcomes among new methadone maintenance patients following extended take-home reforms: a retrospective observational cohort study

Background

Approximately 1800 opioid treatment programs (OTPs) in the US dispense methadone to upwards of 400,000 patients with opioid use disorder (OUD) annually, operating under longstanding highly restrictive guidelines. OTPs were granted novel flexibilities beginning March 15, 2020, allowing for reduced visit frequency and extended take-home doses to minimize COVID exposure with great variation across states and sites. We sought to use electronic health records to compare retention in treatment, opioid use, and adverse events among patients newly entering methadone maintenance in the post-reform period in comparison with year-ago, unexposed, controls.

Methods

Retrospective observational cohort study across 9 OTPs, geographically dispersed, in the National Institute of Drug Abuse (NIDA) Clinical Trials Network. Newly enrolled patients between April 15 and October 14, 2020 (post-COVID, reform period) v. March 15-September 14, 2019 (pre-COVID, control period) were assessed. The primary outcome was 6-month retention. Secondary outcomes were opioid use and adverse events including emergency department visits, hospitalizations, and overdose.

Findings

821 individuals were newly admitted in the post-COVID and year-ago control periods, average age of 38.3 (SD 11.1), 58.9% male. The only difference across pre- and post-reform groups was the prevalence of psychostimulant use disorder (25.7% vs 32.9%, p = 0.02). Retention was non-inferior (60.0% vs 60.1%) as were hazards of adverse events in the aggregate (X2 (1) = 0.55, p = 0.46) in the post-COVID period. However, rates of month-level opioid use were higher among post-COVID intakes compared to pre-COVID controls (64.8% vs 51.1%, p < 0.001). Moderator analyses accounting for stimulant use and site-level variation in take-home schedules did not change findings.

Interpretation

Policies allowing for extended take-home schedules were not associated with worse retention or adverse events despite slightly elevated rates of measured opioid use while in care. Relaxed guidelines were not associated with measurable increased harms and findings could inform future studies with prospective trials.

Funding

USDHHSNIDACTNUG1DA013035-15.

Internal and Environmental Predictors of Physician Practice Use of Screening and Medications for Opioid Use Disorders

Medications for opioid use disorder (MOUD) remain highly inaccessible despite demonstrated effectiveness. We examine the extent of screening for opioid use and availability of MOUD in a national cross-section of multi-physician primary care and multispecialty practices. Drawing on an existing framework to characterize the internal and environmental context, we assess socio-technical, organizational-managerial, market-based, and state-regulation factors associated with the use of opioid screening and offering of MOUD in a practice. A total of 26.2% of practices offered MOUD, while 69.4% of practices screened for opioid use. Having advanced health information technology functionality was positively associated with both screening for opioid use and offering MOUD in a practice, while access to on-site behavioral clinicians was positively associated with offering MOUD in adjusted models. These results suggest that improving access to information and expertise may enable physician practices to respond more effectively to the nation's ongoing opioid epidemic.

Buprenorphine adherence and illicit opioid use among patients in treatment for opioid use disorder

Background: Buprenorphine is a partial mu opioid agonist medication that has been shown to decrease non-prescribed opioid use, cravings, and opioid related morbidity and mortality. There is an assumption that full adherence is needed to achieve ideal treatment outcomes, and that non-adherence is associated with ongoing opioid use. However, literature documenting the strength of that assertion is lacking.Objectives: Evaluate the association between daily buprenorphine adherence and illicit opioid use.Methods: Secondary analysis of a 12-week randomized controlled trial of adults with opioid use disorder who recently initiated buprenorphine. Weekly study visits included self-report of daily buprenorphine adherence over the past 7 days (Timeline Follow Back method) and urine drug tests (UDT). A log-linear regression model accounting for clustering by participant was used to assess the association between buprenorphine adherence and illicit opioid use. Buprenorphine adherence was measured as a continuous variable (0-7 days).Results: Among 78 participants (56 men, 20 women, 2 nonbinary) with 737 visits, full 7-day adherence was reported at 70% of visits. The predominant form of non-adherence was missed doses (92% of cases). Each additional day of adherence was associated with an 8% higher rate of negative UDT for illicit opioids (RR = 1.08; 95% CI:1.03-1.13, p = .0002).Conclusion: In this sample of participants starting buprenorphine, missed doses were not uncommon. Fewer missed days was significantly associated with a lower risk of illicit opioid use. These findings suggest that efforts to minimize the number of missed days of buprenorphine are beneficial for treatment outcomes.

Video-telecare collaborative pain management during COVID-19: a single-arm feasibility study

BACKGROUND

Chronic pain is among the most common conditions presenting to primary care and guideline-based care faces several challenges. A novel pain management program, Video-Telecare Collaborative Pain Management (VCPM), was established to support primary care providers and meet new challenges to care presented by the COVID-19 pandemic.

METHODS

The present single-arm feasibility study aimed to evaluate the feasibility and acceptability of VCPM and its components among U.S. veterans on long-term opioid therapy for chronic pain at ≥ 50 mg morphine equivalent daily dose (MEDD). VCPM consists of evidence-based interventions, including opioid reassessment and tapering, rotation to buprenorphine and monitoring, and encouraging behavioral pain and opioid-use disorder self-management.

RESULTS

Of the 133 patients outreached for VPCM, 44 completed an initial intake (33%) and 19 attended multiple VCPM appointments (14%). Patients were generally satisfied with VCPM, virtual modalities, and provider interactions. Nearly all patients who attended multiple appointments maintained a buprenorphine switch or tapered opioids (16/19; 84%), and buprenorphine switches were generally reported as acceptable by patients. Patients completing an initial intake with VCPM had reduced morphine equivalent daily dose after three months (means = 109 mg MEDD vs 78 mg), with greater reductions among those who attended multiple appointments compared to intake only (ΔMEDD = -58.1 vs. -8.40). Finally, 29 referrals were placed for evidence-based non-pharmacologic interventions.

CONCLUSION

Pre-defined feasibility and acceptability targets for VCPM and its components were broadly met, and preliminary data are encouraging. Novel strategies to improve enrollment and engagement and future directions are discussed.

"Come try it out. Get your foot in the door:" Exploring patient perspectives on low-barrier treatment for opioid use disorder

PURPOSE

Low-barrier treatment is an emerging strategy for opioid use disorder (OUD) care that prioritizes access to evidence-based medication while minimizing requirements that may limit treatment access in more traditional delivery models, particularly for marginalized patients. Our objective was to explore patient perspectives about low-barrier approaches, with a focus on understanding barriers to and facilitators of engagement from the patient point of view.

METHODS

We conducted semi-structured interviews with patients accessing buprenorphine treatment from a multi-site, low-barrier mobile treatment program in Philadelphia, PA from July-December 2021. We analyzed interview data using thematic content analysis and identified key themes.

RESULTS

The 36 participants were 58% male, 64% Black, 28% White, and 31% Latinx. 89% were enrolled in Medicaid, and 47% were unstably housed. Our analysis revealed three main facilitators of treatment in the low-barrier model. These included 1) program structure that met participant needs, such as flexibility, rapid medication access and robust case management services; 2) harm reduction approach that included acceptance of patient goals other than abstinence and provision of harm reduction services on-site; and 3) strong interpersonal connections with team members, including those with lived experience. Participants contrasted these experiences with other care they had received in the past. Barriers related to lack of structure, limitations of street-based care, and limited support for co-occurring needs, particularly mental health.

CONCLUSIONS

This study provides key patient perspectives on low-barrier approaches for OUD treatment. Our findings can inform future program design to increase treatment access and engagement for individuals poorly served by traditional delivery models.

Use of a sequential multiple assignment randomized trial to test contingency management and an integrated behavioral economic and mindfulness intervention for buprenorphine-naloxone medication adherence for opioid use disorder

BACKGROUND

Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment.

METHODS

The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization.

CONCLUSIONS

This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04080180.

The effect of a methadone-initiated memory reconsolidation updating procedure in opioid use disorder: A translational study

Background

Opioid use disorder (OUD) is a chronic relapsing psychiatric disorder. An unconditioned stimulus (US)-triggers a memory reconsolidation updating procedure (MRUP) that has been developed and demonstrated its effectiveness in decreasing relapse to cocaine and heroin in preclinical models. However, utilizations of abused drugs as the US to initiate MRUP can be problematic. We therefore designed a translational rat study and human study to evaluate the efficacy of a novel methadone-initiated MRUP.

Methods

In the rodent study, male rats underwent heroin self-administration training for 10 consecutive days, and were randomly assigned to receive saline or methadone at 10 min, 1 h or 6 h before extinction training after 28-day withdrawal. The primary outcome was operant heroin seeking after reinstatement. In the human experimental study, male OUD patients were randomly assigned to get MRUP at 10 min or 6 h after methadone or methadone alone. The primary outcomes included experimental cue-induced heroin craving change, sustained abstinence and retention in the study at post intervention and the 5 monthly follow-up assessments. The secondary outcomes were changes in physiological responses including experimental cue-induced blood pressure and heart rate.

Findings

Methadone exposure but not saline exposure at 10 min or 1 h before extinction decreased heroin-induced reinstatement of heroin seeking after 28-day of withdrawal in rats (F _(8,80) = 8.26, p < 0.001). In the human study, when the MRUP was performed 10 min, but not 6 h after methadone dosing, the MRUP promoted sustained abstinence from heroin throughout 5 monthly follow-up assessments compared to giving methadone alone without MRUP (Hazard Ratio [95%CI] of 0.43 [0.22, 0.83], p = 0.01). The MRUP at 10 min, but not at 6 h after dosing also decreased experimental cue-induced heroin craving and blood pressure increases during the 6-month study duration (group × months × cue types, F _{(12, 63·3)} = 2.41, p = 0.01).

Interpretation

The approach of MRUP within about 1 to 6 h after a methadone dose potently improved several key outcomes of OUD patients during methadone maintenance treatment, and could be a potentially novel treatment to prevent opioid relapse.

Funding

National Natural Science Foundation of China (NO. U1802283, 81761128036, 82001400, 82001404 and 31671143) and Chinese National Programs for Brain Science and Brain-like Intelligence Technology (NO. 2021ZD0200800)

Opioid agonist treatment for people who are dependent on pharmaceutical opioids

BACKGROUND

There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin.  OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence.

SEARCH METHODS

We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods.

MAIN RESULTS

We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms.

AUTHORS' CONCLUSIONS

There is  very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

Gender differences among persons entering medication treatment for opioid use disorder in the community

BACKGROUND AND OBJECTIVES

We evaluated gender differences among persons initiating medications for opioid use disorder (MOUD).

METHODS

Analyses of baseline assessments for a study evaluating the impact of MOUD on outcomes included: demographics, DSM-5 diagnoses, depression severity, quality of life (QoL), and medication history (N = 125).

RESULTS

When compared to men, women had a greater prevalence of generalized anxiety and posttraumatic stress disorders; and worse psychological QoL. Women were less likely to be prescribed psychiatric medications.

DISCUSSION AND CONCLUSIONS

Women may benefit from tailored multidisciplinary programs with MOUD.

SCIENTIFIC SIGNIFICANCE

This study identified that women with OUD seeking MOUD in the community had greater sedative hypnotic nonprescribed medication use and psychiatric comorbidity than men, all of which can contribute to poorer retention on MOUD and higher risk of morbidity and mortality. Thus, concurrent psychiatric disorder screening and treatment integrated with MOUD may improve retention on MOUD, opioid relapse and overdose for women.

Pharmacotherapy of Opioid Use Disorder-Update and Current Challenges

The incidence of opioid use disorder (OUD) and overdose deaths is rising yearly within the United States. Many cases are associated with illicitly manufactured fentanyl use. In addition to offering patients medications for OUD (methadone, buprenorphine, and naltrexone), the approach to this epidemic should involve increasing provider awareness and education about substance use disorders, expanding urine toxicology screens to test for fentanyl, and using low-threshold treatment approaches.

Differences in buprenorphine treatment quality across physician provider specialties

BACKGROUND

The number and types of clinicians prescribing buprenorphine treatment for opioid use disorder (OUD) have increased over the past two decades, but there is little information on how potential indicators of quality of care to patients receiving buprenorphine vary by provider specialty.

METHODS

We used the Medicaid Analytic eXtract from 2009 to 2014 to identify buprenorphine treatment episodes. We assigned physician specialties to episodes based on whether an episode had at least one outpatient claim linked to specialists in addiction, behavioral health, opioid treatment program (OTP), pain, or primary care provider (PCP). We then used logistic regressions to estimate the association of linked physician specialty and achievement of the following process of care measures: at least 180-day duration, no co-occurring opioid analgesics, no co-occurring benzodiazepines, infectious disease screening, liver function test, drug and toxicology screenings, evaluation and management visits, and counseling.

RESULTS

Episodes linked to PCPs had significantly lower odds of achieving 180-day duration, an absence of opioid analgesics, an absence of benzodiazepines, drug and toxicology screenings, and counseling compared to addiction, behavioral health, and/or OTPs. Episodes linked to PCPs had significantly higher odds of undergoing infectious disease screenings, liver function tests, and evaluation and management visits compared to all specialty categories.

CONCLUSIONS

Episodes were more likely to achieve process of care measures related to the specialties of their physicians, but no specialty consistently demonstrated better performance compared to PCPs. Our findings highlight the need for models that can better integrate physical and behavioral health services for OUD treatment.

HIV clinic-based extended-release naltrexone versus treatment as usual for people with HIV and opioid use disorder: a non-blinded, randomized non-inferiority trial

BACKGROUND AND AIM

Opioid agonist medications for treatment of opioid use disorder (OUD) can improve human immunodeficiency virus (HIV) outcomes and reduce opioid use. We tested whether outpatient antagonist treatment with naltrexone could achieve similar results.

DESIGN

Open-label, non-inferiority randomized trial.

SETTING

Six US HIV primary care clinics.

PARTICIPANTS

A total of 114 participants with untreated HIV and OUD (62% male; 56% black, 12% Hispanic; positive for fentanyl (62%), other opioids (47%) and cocaine (60%) at baseline). Enrollment halted early due to slow recruitment.

INTERVENTION

HIV clinic-based extended-release naltrexone (XR-NTX; n = 55) versus treatment as usual (TAU) with buprenorphine or methadone (TAU; n = 59).

MEASUREMENTS

Treatment group differences were compared for the primary outcome of viral suppression (HIV RNA ≤ 200 copies/ml) at 24 weeks and secondary outcomes included past 30-day use of opioids at 24 weeks.

FINDINGS

Fewer XR-NTX participants initiated medication compared with TAU participants (47 versus 73%). The primary outcome of viral suppression was comparable for XR-NTX (52.7%) and TAU (49.2%) [risk ratio (RR) = 1.064; 95% confidence interval (CI) = 0.748, 1.514] at 24 weeks. Non-inferiority could not be demonstrated, as the lower confidence limit of the RR did not exceed the pre-specified margin of 0.75 in intention-to-treat (ITT) analysis. The main secondary outcome of past 30-day opioid use was comparable for XR-NTX versus TAU (11.7 versus 14.8 days; mean difference = -3.1; 95% CI = -8.7, 1.1) in ITT analysis. Among those initiating medication, XR-NTX resulted in fewer days of opioid use compared with TAU in the past 30 days (6.0 versus 13.6, mean difference = -7.6; 95% CI = -13.8, -0.2).

CONCLUSIONS

A randomized controlled trial found supportive, but not conclusive, evidence that human immunodeficiency virus clinic-based extended-release naltrexone is not inferior to treatment as usual for facilitating human immunodeficiency virus viral suppression. Participants who initiated extended-release naltrexone used fewer opioids than those who received treatment as usual.

Systematic review and meta-analysis of changes in quality of life following initiation of buprenorphine for opioid use disorder

BACKGROUND

People with opioid use disorder (OUD) experience lower quality of life (QoL) than the general population, but buprenorphine treatment for OUD could help improve QoL of individuals with OUD. Thus, we conducted a systematic review and meta-analysis of the impact of buprenorphine on QoL among people with OUD.

METHODS

Seven databases were searched through August 2020. We included English-language studies with pre- and post- QoL assessments internationally. Standardized mean differences were calculated for five domains of QoL measures using a random effects model for correlated effect sizes with robust variance estimation. Meta-regression was used to assess variation in effect sizes based on QoL domain, treatment, and patient factors.

RESULTS

Twenty-one peer-reviewed studies from twelve countries were included. Only three studies included a no-treatment control group and five studies assigned groups using randomization. Improvements between baseline and follow-up were observed across all five domains of QoL measures (overall, physical, psychological, social, and environmental). The certainty of evidence was low for all domains of QoL, and very low for environmental QoL. We did not observe differences in the effect of buprenorphine on QoL by QoL domain, duration, dose, participant characteristics, or adjunctive counseling services.

CONCLUSIONS

Buprenorphine treatment likely improves overall, physical, psychological, and social QoL, and may improve environmental QoL, for individuals with OUD. Findings are limited by study quality, including lack of control groups and incomplete reporting. Future studies with more rigorous methods and comprehensive reporting are needed.

Medications for Opioid Use Disorder Do Help Patients

Much of the focus on the current opioid crisis remains on how we arrived here and who is to blame. Despite having effective treatments for the management of patients with opioid use disorder (OUD), rates of overdose deaths continue to increase. As such, the focus needs to shift to increasing access to medications for OUD and better incorporation of harm reduction strategies to decrease not just the mortality but also the morbidity associated with OUD and other substance use disorders. Unfortunately, significant barriers rooted in misunderstanding and bias still limit access and prevent patients with OUD from seeking and staying in treatment. Until these are overcome and medical practice changes, both physicians and patients will continue to struggle to overcome this problem.

Assessing Opioid Use Disorder Treatments in Trials Subject to Non-Adherence via a Functional Generalized Linear Mixed-Effects Model

The opioid crisis in the United States poses a major threat to public health due to psychiatric and infectious disease comorbidities and death due to opioid use disorder (OUD). OUD is characterized by patterns of opioid misuse leading to persistent heavy use and overdose. The standard of care for treatment of OUD is medication-assisted treatment, in combination with behavioral therapy. Medications for opioid use disorder have been shown to improve OUD outcomes, including reduction and prevention of overdose. However, understanding the effectiveness of such medications has been limited due to non-adherence to assigned dose levels by study patients. To overcome this challenge, herein we develop a model that views dose history as a time-varying covariate. Proceeding in this fashion allows the model to estimate dose effect while accounting for lapses in adherence. The proposed model is used to conduct a secondary analysis of data collected from six efficacy and safety trials of buprenorphine maintenance treatment. This analysis provides further insight into the time-dependent treatment effects of buprenorphine and how different dose adherence patterns relate to risk of opioid use.

Factors Associated with Long-Term Retention in Buprenorphine-Based Addiction Treatment Programs: a Systematic Review

BACKGROUND

The average length of buprenorphine treatment for opioid use disorder is less than 6 months.

OBJECTIVE

We conducted a systematic review to determine what factors were associated with longer retention in buprenorphine treatment.

DESIGN

We searched Medline, Embase, and Cochrane Database of Systematic Reviews in February 2018. Articles were restricted to randomized controlled trials on human subjects, written in English, which contained ≥ 24 weeks of objective data on retention in buprenorphine treatment.

MAIN MEASURES

We assessed whether dose of buprenorphine, treatment setting, or co-administration of behavioral therapy was associated with retention rates.

KEY RESULTS

Over 14,000 articles were identified. Thirteen articles (describing 9 studies) met inclusion criteria. Measures of retention varied widely. Three studies compared doses of buprenorphine between 1 and 8 mg and showed significantly higher rates of retention with higher doses (p values < 0.01). All other studies utilized buprenorphine doses between 8 and 24 mg daily, without comparison. No study found a significant difference in retention between buprenorphine alone and buprenorphine plus behavioral therapy (p values > 0.05). Initiating buprenorphine while hospitalized or within criminal justice settings prior to outpatient treatment programs was significantly associated with retention in buprenorphine treatment (p values < 0.01 respectively).

CONCLUSIONS

Setting of treatment initiation and a higher buprenorphine dose are associated with improved long-term treatment retention. More objective data on buprenorphine treatment programs are needed, including a standardized approach to defining retention in buprenorphine treatment programs.

REGISTRATION

This review was registered with PROSPERO (#CRD42019120336) in March 2019.

Onsite buprenorphine inductions at harm reduction agencies to increase treatment engagement and reduce HIV risk: Design and rationale

BACKGROUND

Despite dramatic increases in opioid use disorder (OUD) and overdose deaths, the U.S. has been unable to consistently deliver OUD treatment to those who need it. Syringe services programs (SSPs) can engage an out-of-treatment population of people with OUD that has elevated overdose risk. Buprenorphine treatment is safe and effective, and US regulations allow for prescribing from diverse locations, including SSPs. This study's objective is to test buprenorphine treatment initiation at SSPs. We hypothesize that offering onsite buprenorphine treatment initiation will improve OUD treatment engagement without reducing buprenorphine treatment effectiveness or safety.

METHODS

We will recruit 250 out-of-treatment SSP participants with OUD in a large urban area. Participants will be randomized to onsite buprenorphine treatment initiation or enhanced referral. Over 2 weeks, participants in the onsite treatment arm will see a buprenorphine provider twice at the SSP, receive weekly medication packs, and then their care will be transferred to a community health center for treatment continuation. In the control arm, within one week, participants will receive an appointment at the same community health center as in the intervention arm for buprenorphine initiation and continuation. Participants will be assessed with urine drug tests, questionnaires, and medical record review. The primary outcome will be engagement in buprenorphine treatment at 30 days. Secondary outcomes include buprenorphine diversion, opioid-free urine drug tests, and intervention cost-effectiveness.

DISCUSSION

Our study will contribute to the growing literature on SSPs as a conduit to OUD treatment. SSPs hold promise to deliver needed care to people with OUD.

Prescribed opioid use is associated with increased all-purpose emergency department visits and hospitalizations in community-dwelling older adults in the United States

BACKGROUND

The geriatric and health characteristics of older adults make them more susceptible to the effects of opioids than younger groups. The number of older adults in the United States visiting the emergency department (ED) and overusing opioids has increased in recent years. Research examining their relationship is, however, limited.

METHODS

Using information from the 2020 National Health Interview Survey (NHIS), we included older adults aged 65 and older. To investigate the relationship between prescribed opioid use and 12-months ED visits and hospitalizations, linear regression and logistic regression models were built while adjusting for age, sex, ethnicity, education, employment, general health status, history of depression, and living arrangement.

RESULTS

Our study population consisted of 8,631 participants (mean age 74.3). Most of them were females (58.3%) and Caucasian (81.6%). About 16% of the participants used prescribed opioids over the past 12 months. Of the participants with prescribed opioid use, 65.1% of them did so to treat chronic pain. The adjusted regression models revealed that prescribed opioid use was independently and positively associated with 12-months ED visits (β = 0.22, 95% confidence interval [CI] 0.18, 0.26) and hospitalizations (Odds ratio [OR] = 3.78, 95% CI 3.29, 4.35). Other risk factors for 12-months ED visits and/or hospitalizations included advanced age, male gender, unemployment/retirement, African American ethnicity, living alone, fair or poor general health status, and history of depression.

DISCUSSIONS

Clinicians should screen older adults at high risk for ED visits and hospitalizations and explore multimodal pain management with them to help them reduce/stop using opioids. These efforts may decrease their chronic pain, opioid use, opioid use-related adverse health outcomes, ED visits, as well as hospitalizations.

Integrating Harm Reduction into Outpatient Opioid Use Disorder Treatment Settings : Harm Reduction in Outpatient Addiction Treatment

Opioid use disorder (OUD) is increasingly recognized as a chronic, relapsing brain disease whose treatment should be integrated into primary care settings alongside other chronic conditions. However, abstinence from all non-prescribed substance use continues to be prioritized as the only desired goal in many outpatient, primary care-based treatment programs. This presents a barrier to engagement for patients who continue to use substances and who may be at high risk for complications of ongoing substance use such as human immunodeficiency virus (HIV), hepatitis C virus (HCV), superficial and deep tissue infections, and overdose. Harm reduction aims to reduce the negative consequences of substance use and offers an alternative to abstinence as a singular goal. Incorporating harm reduction principles into primary care treatment settings can support programs in engaging patients with ongoing substance use and facilitate the delivery of evidence-based screening and prevention services. The objective of this narrative review is to describe strategies for the integration of evidence-based harm reduction principles and interventions into outpatient, primary care-based OUD treatment settings. We will offer specific tools for providers and programs including strategies to support safer injection practices, assess the risks and benefits of continuing medications for opioid use disorder in the setting of ongoing substance use, promote a non-stigmatizing program culture, and address the needs of special populations with ongoing substance use including adolescents, parents, and families.

A Facility-Wide Plan to Increase Access to Medication for Opioid Use Disorder in Primary Care and General Mental Health Settings

Background

The opioid epidemic in the United States has generated a pressing need to enhance access to medications for opioid use disorder (MOUD). This program description illustrates a quality-improvement effort to extend MOUD to primary care and general mental health clinics within the US Department of Veterans Affairs (VA) Connecticut Healthcare system (VACHS), and to examine barriers and facilitators to implementation of MOUD in target clinics.

Observations

As part of the national VA Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative to improve MOUD access, a VACHS team identified and resolved barriers to MOUD in target clinics. Key interventions were to obtain leadership support, increase waivered prescribers, and develop processes and tools to enhance prescribing. New initiatives included quarterly educational sessions, templated progress notes, and instant messaging for addiction specialist electronic consultations. MOUD receipt and prescriber characteristics were evaluated before and 1 year after implementation. There was a 4% increase in eligible patients receiving MOUD, from 552 (44%) to 582 (48%) (P = .04). The number of waivered prescribers increased from 67 to 131, and the number of buprenorphine prescribers increased from 35 to 52 over a 6-month span, and the percentage of health care practitioners capable of prescribing within the electronic health record increased from 75% to 89% (P = .01).

Conclusions

An interdisciplinary team approach to identifying and overcoming barriers to MOUD target clinics expands access. Key interventions include interdisciplinary leadership engagement, proactive education and incentivization of target prescribers, removal of procedural barriers, and development of tools to facilitate and support prescribing. These concrete interventions can help inform other institutions interested in expanding MOUD access.

Adjunct interventions to standard medical management of buprenorphine in outpatient settings: A systematic review of the evidence

BACKGROUND

A growing body of research has examined adjunctive interventions supportive of engagement and retention in treatment among patients receiving buprenorphine for opioid use disorder (OUD). We conducted a systematic review of the literature addressing the effect on key outcomes of adjunctive interventions provided alongside standard medical management of buprenorphine in outpatient settings.

METHODS

We included prospective studies examining adults receiving buprenorphine paired with an adjunctive intervention for the treatment of OUD in an outpatient setting. Data sources included Medline, Cochrane Central Register of Controlled Trials, CINAHL and PsycINFO from inception through January 2020. Two raters independently reviewed full-text articles, abstracted data and appraised risk of bias. Outcomes examined included abstinence, retention in treatment and non-addiction-related health outcomes.

RESULTS

The final review includes 20 manuscripts, 11 randomized control trials (RCTs), three secondary analyses of RCTs and six observational studies. Most studies examined psychosocial interventions (n = 14). Few examined complementary therapies (e.g., yoga; n = 2) or technological interventions (e.g., electronic pill dispensation; n = 3); one study examined an intervention addressing structural barriers to care (patient navigators; n = 1). Low risk of bias RCTs found no evidence that adding psychosocial interventions to buprenorphine treatment improves substance use outcomes.

CONCLUSIONS

Research is needed to identify adjunctive interventions with potential to support medication adherence and addiction-related outcomes for patients engaged in buprenorphine treatment. Data from clinical trials suggest that lack of ready access to psychosocial treatments should not discourage clinicians from prescribing buprenorphine.

Do people with opioid use disorder and posttraumatic stress disorder benefit from dding Individual opioid Drug Counseling to buprenorphine?

BACKGROUND AND PURPOSE

Large randomized trials have found that behavioral therapy for opioid use disorder (e.g., Individual Drug Counseling, Cognitive Behavioral Therapy for Opioid Use Disorder) does not improve buprenorphine maintenance outcomes, on average, for individuals with opioid use disorder. However, recent studies indicate that certain subgroups of patients may benefit from the addition of behavioral therapy to buprenorphine. In particular, people with more complex and severe psychosocial needs may benefit from the addition of behavioral therapy for opioid use disorder.

METHODS

In this study, we conducted a secondary analysis of a large, multi-site randomized trial (N = 357) of buprenorphine maintenance with and without individual Opioid Drug Counseling (ODC) for the treatment of opioid use disorder. We hypothesized that participants with posttraumatic stress disorder (PTSD) would benefit from the addition of ODC.

RESULTS

Logistic regression models indicated a significant PTSD by treatment condition interaction. Specifically, 67% of those with PTSD had a successful opioid use disorder treatment outcome when they were assigned to receive both ODC and buprenorphine, compared to a 36% response rate among those who received buprenorphine alone.

CONCLUSIONS

Although these results require replication, our findings provide initial indication that ODC is an important complement to buprenorphine maintenance treatment for people with co-occurring PTSD and opioid use disorder.

Association between Participation in Counseling and Retention in a Buprenorphine-Assisted Treatment Program for People Experiencing Homelessness with Opioid Use Disorder

The opioid epidemic is a public health crisis that disproportionately affects our unsheltered neighbors. Because medication-assisted treatment (MAT) is effective for preventing deaths from drug overdose and retention is associated with better health outcomes, there is a clear need for more research on factors impacting retention in care. This retrospective cohort analysis examines the relationship between attendance in counseling and retention on buprenorphine for three or more months for individuals experiencing homelessness being treated at a Federally Qualified Health Center (FQHC) and Public Health Service Act §330(h) Health Care for the Homeless Program grantee in San Diego County, California. The cohort included 306 adults experiencing homelessness who had at least one prescription for buprenorphine and participated in a MAT program between 2017 and 2019. The sample included 64.4% men, almost exclusively white, and 35% lived in a place not meant for human habitation. Of the sample, 97 patients were retained at 3 months and 209 were not. Results from a logistic regression model showed that counseling appointments were positively associated with retention at three months (OR = 1.57, p < 0.001). Findings from this study inform future MAT program design components for people experiencing homelessness.

Diversity inclusion in United States opioid pharmacological treatment trials: A systematic review

Pharmacological treatments for opioid use disorders (OUDs) may have mixed efficacy across diverse groups, i.e., sex/gender, race/ethnicity, and socioeconomic status (SES). The present systematic review aims to examine how diverse groups have been included in U.S. randomized clinical trials examining pharmacological treatments (i.e., methadone, buprenorphine, or naltrexone) for OUDs. PubMed was systematically searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The initial search yielded 567 articles. After exclusion of ineligible articles, 50 remained for the present review. Of the included articles, 14.0% (n = 7) reported both full (i.e., accounting for all participants) sex/gender and race/ethnicity information; only two of those articles also included information about any SES indicators. Moreover, only 22.0% (n = 11) reported full sex/gender information, and 42.0% (n = 21) reported full racial/ethnic information. Furthermore, only 10.0% (n = 5) reported that their lack of subgroup analyses or diverse samples was a limitation to their studies. Particularly underrepresented were American Indian/Alaska Native (AI/AN), Asian, Native Hawaiian/Other Pacific Islander (NH/OPI), and multiracial individuals. These results also varied by medication type; Black individuals were underrepresented in buprenorphine randomized controlled trials (RCTs) but were well represented in RCTs for methadone and/or naltrexone. In conclusion, it is critical that all people receive efficacious pharmacological care for OUDs given the ongoing opioid epidemic. Findings from the present review, however, support that participants from diverse or marginalized backgrounds are underrepresented in treatment trials, despite being at increased risk for disparities related to OUDs. Suggestions for future research are advanced. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Video directly observed therapy for patients receiving office-based buprenorphine - A pilot randomized controlled trial

BACKGROUND

We conducted a pilot study to assess feasibility of using video directly-observed therapy (DOT) for patients initiating buprenorphine to evaluate whether it is associated with better opioid use disorder (OUD) outcomes when compared to treatment-as-usual (TAU).

METHODS

Pilot randomized controlled trial of adult patients with OUD initiating buprenorphine treatment (n = 78) at two sites (Seattle, WA and Boston, MA) from January 2019 to May 2020. Intervention was video DOT using a HIPAA-compliant smartphone application to record taking daily buprenorphine. Study smartphones, text reminders to upload a video, and calendar summaries of video DOT adherence were provided. Main outcomes were 1) percentage of 12 weekly urine drug tests (UDT) negative for illicit opioids and 2) engagement in treatment at week 12 (i.e., having an active prescription for buprenorphine within the last 7 days).

RESULTS

Of 78 enrolled, 20 (26 %) were female; 29 (37 %) non-white; and 31 (40 %) homeless. The mean (standard deviation) percentage of doses confirmed by video was 31 % (34 %). In intention-to-treat analysis, the average percentage of weekly opioid negative UDT was 50 % (95 % CI: 40-63 %) in the intervention arm versus 64 % (95 % CI: 55-74 %) among controls; RR = 0.78 (95 % CI: 0.60-1.02, p = 0.07). Engagement at week 12 was 69 % (95 % CI: 56-86 %) v. 82 % (95 % CI: 71-95 %) in the intervention vs. TAU arms, respectively; RR = 0.84 (95 % CI: 0.65-1.10, p = 0.20).

CONCLUSIONS

The video DOT intervention did not result in improvements in illicit opioid use and treatment engagement compared to TAU. The study was limited by low rates of intervention use.

TRIAL REGISTRATION

ClinicalTrails.gov, NCT03779997, Registered on December 19, 2018.

Association of Counseling and Psychotherapy on Retention in Medication for Addiction Treatment Within a Large Medicaid Population

OBJECTIVES

Buprenorphine/naloxone is an effective medication for the treatment of opioid use disorder. Unlike methadone, which can only be dispensed in federally waived clinics and which must be combined with specific psychosocial treatment, buprenorphine can be dispensed by individual prescribers who have completed an 8-hour training program, with no requirement that patients receive concomitant psychotherapy. The objective of this study is to quantify the association of counseling and psychotherapy on retention in treatment. We also examine the effect of buprenorphine dosage on retention.

METHODS

We examined a cohort of 4987 members of a not-for-profit managed care organization serving Medicaid members in 41 counties in Pennsylvania. This cohort was selected from all members who had a full year without any medication for opioid use disorder followed by initiation of treatment with buprenorphine/naloxone in 2016 to 2017 and who remained Medicaid eligible for at least 80% of the following 2 years. Outcomes were estimated using inverse probability weighted propensity scores.

RESULTS

The addition of counseling and psychotherapy within the first 8 weeks of treatment was associated with greater total retention in treatment and there was a dose-response relationship. A 16 mg/d or greater dose of buprenorphine was also associated with greater retention.

CONCLUSIONS

These results provide support for an integrated approach to treating people with an opioid use disorder, through a combination of buprenorphine pharmacotherapy and targeted counseling and psychotherapy within the first 2 months of treatment.

Stepped Care for Opioid Use Disorder Train the Trainer (SCOUTT) initiative: Expanding access to medication treatment for opioid use disorder within Veterans Health Administration facilities

The US is confronted with a rise in opioid use disorder (OUD), opioid misuse, and opioid-associated harms. Medication treatment for opioid use disorder (MOUD)-including methadone, buprenorphine and naltrexone-is the gold standard treatment for OUD. MOUD reduces illicit opioid use, mortality, criminal activity, healthcare costs, and high-risk behaviors. The Veterans Health Administration (VHA) has invested in several national initiatives to encourage access to MOUD treatment. Despite these efforts, by 2017, just over a third of all Veterans diagnosed with OUD received MOUD. VHA OUD specialty care is often concentrated in major hospitals throughout the nation and access to this care can be difficult due to geography or patient choice. Recognizing the urgent need to improve access to MOUD care, in the Spring of 2018, the VHA initiated the Stepped Care for Opioid Use Disorder, Train the Trainer (SCOUTT) Initiative to facilitate access to MOUD in VHA non-SUD care settings. The SCOUTT Initiative's primary goal is to increase MOUD prescribing in VHA primary care, mental health, and pain clinics by training providers working in those settings on how to provide MOUD and to facilitate implementation by providing an ongoing learning collaborative. Thirteen healthcare providers from each of the 18 VHA regional networks across the VHA were invited to implement the SCOUTT Initiative within one facility in each network. We describe the goals and initial activities of the SCOUTT Initiative leading up to a two-day national SCOUTT Initiative conference attended by 246 participants from all 18 regional networks in the VHA. We also discuss subsequent implementation facilitation and evaluation plans for the SCOUTT Initiative. The VHA SCOUTT Initiative could be a model strategy to implement MOUD within large, diverse health care systems.

Acceptability and Feasibility of a Mobile Health Application for Video Directly Observed Therapy of Buprenorphine for Opioid Use Disorders in an Office-based Setting

INTRODUCTION/BACKGROUND

Video directly observed therapy (video-DOT) through a mobile health platform may improve buprenorphine adherence and decrease diversion. This pilot study tested the acceptability and feasibility of using this technology among patients receiving buprenorphine in an office-based setting.

METHODS

Participants were instructed to record videos of themselves taking buprenorphine. Data were collected from weekly in-person visits over a 4-week period; assessments included self-report of medication adherence, substance use, satisfaction with treatment and use of the application, and also urine drug testing. Open-ended questions at the final visit solicited feedback on patients' experiences using the mobile health application.

RESULTS

The sample consisted of 14 patients; a majority were male (86%) and White (79%). All participants except 1 (93%) were able to use the application successfully to upload videos. Among those who successfully used the application, the percentage of daily videos uploaded per participant ranged from 18% to 96%; on average, daily videos were submitted by participants 72% of the time. Most participants (10/14; 71%) reported being "very satisfied" with the application; of the remaining 4 participants, 2 were "satisfied" and 2 were "neutral." Participants reported liking the accountability and structure of the application provided and its ease of use. Negative feedback included minor discomfort at viewing one's self during recording and the time required.

CONCLUSIONS

Based on these results, use of a mobile health application for video-DOT of buprenorphine appears feasible and acceptable for patients who are treated in an office-based setting. Further research is needed to test whether use of such an application can improve treatment delivery and health outcomes.

Telehealth Approaches to Improve Opioid Use Care in Pregnancy

Although pharmacotherapy is the mainstay of treatment for opioid use disorder, the US faces a shortage of qualified pharmacotherapy providers, even in high-need areas. Telemedicine is a promising method of increasing the availability of opioid use disorder treatments, but several barriers must first be addressed before implementation. This article presents a case study of using telemedicine to provide pharmacotherapy in pregnancy, examines the barriers to providing pharmacotherapy via telemedicine, and proposes solutions to overcome these barriers.

New Approaches in Drug Dependence: Opioids

Purpose of Review

This article aims to provide an overview of standard and adjunctive treatment options in opioid dependence in consideration of therapy-refractory courses. The relevance of oral opioid substitution treatment (OST) and measures of harm reduction as well as heroin-assisted therapies are discussed alongside non-pharmacological approaches.

Recent Findings

Currently, recommendation can be given for OST with methadone, buprenorphine, slow-release oral morphine (SROM), and levomethadone. Heroin-assisted treatment using diamorphine shall be considered as a cost-effective alternative for individuals not responding to the afore-mentioned opioid agonists in order to increase retention and reduce illicit opioid use. The modalities of application and the additional benefits of long-acting formulations of buprenorphine should be sufficiently transferred to clinicians and the eligible patients; simultaneously methods to improve planning of actions and self- management need to be refined. Regarding common primary outcomes in research on opioid treatment, evidence of the effectiveness of adjunctive psychological interventions is scarce.

Summary

Maintaining a harm reduction approach in the treatment of opioid addiction, a larger range of formulations is available for the prescribers. Embedding the pharmacological, ideally individualized treatment into a holistic, structure-giving concept also requires a reduction of fragmentation of ancillary services available, drug policies, and treatment philosophies on a global scale.

Buprenorphine utilization among all Washington State residents' based upon prescription monitoring program data - Characteristics associated with two measures of retention and patterns of care over time

BACKGROUND

Opioid use disorder is a serious health condition for which buprenorphine is proven effective, yet providers substantially underutilize buprenorphine. We present two approaches to measuring treatment duration, factors associated with retention, and patterns of care.

METHODS

The study determined incident buprenorphine prescribing for all Washingtonians utilizing prescription monitoring program data from 2012 to 2019. The study calculated episode of care and cumulative time in care. Generalized linear models estimated associations among the length of the first episode of care and cumulative time in care with sex, age, and rurality. Cox proportional hazards models estimated the time to discontinuing buprenorphine for the first four episodes of care and time to discontinuing the last episode of care.

RESULTS

Mean and median duration of the first episode were 320 and 84 days, respectively, and for cumulative time in care 308 and 195 days. A minority of peoples' first episodes exceeded 180 days (37%). Being female and older were significantly associated with longer first episodes and cumulative time in care. Survival analyses indicated that the proportion of those still in care at 6, 12, and 24 months into their first episode of care declined for those with more than one episode of care; conversely the study found much smaller differences in retention for the last episode of care, indicating that many people were eventually able to be retained in care for longer periods of time.

CONCLUSION

Episodes of care and cumulative time on buprenorphine were both short compared to minimum quality recommendations of 180 days. Median cumulative time in care was double that of the first episode, highlighting that many people engage in subsequent episodes of substantial length. Episode of care and cumulative care analyses should inform states, payers, health care systems and providers in measuring and setting treatment duration goals.

Treatment of opioid use disorder in primary care

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.

Design and methods of a multi-site randomized controlled trial of an integrated care model of long-acting injectable buprenorphine with infectious disease treatment among persons hospitalized with infections and opioid use disorder

BACKGROUND

Hospitalization with co-occurring opioid use disorder (OUD) and infections presents a critical time to intervene to improve outcomes for these intertwined epidemics that are typically managed separately. A surge in life-threatening infectious diseases associated with injection drug use, including bacterial and fungal infections, HIV, and HCV accounts for substantial healthcare utilization, morbidity, and mortality. Infectious Disease (ID) specialists manage severe infections that require hospitalization and are a logical resource to engage patients in medication treatment for OUD (MOUD). An injectable long-acting monthly formulation of buprenorphine (LAB) has a potential advantage for initiating MOUD within hospital settings and bridging to treatment after discharge.

METHODS

A randomized multi-site trial tests a new model of care (ID/LAB) in which OUD and infections are managed by ID specialists and hospitalists using LAB coupled with referrals to community resources for long-term MOUD. A sample of 200 adults admitted to three U.S. hospitals for OUD and infections are randomly assigned 1:1 to ID/LAB or treatment as usual (TAU). The primary outcome measure is the proportion of patients enrolled in effective MOUD at 12 weeks after randomization. Secondary outcomes include relapse to opioid use, adherence to infectious disease treatment, infection morbidity and mortality, and drug overdose.

RESULTS

We describe the design, procedures, statistical analysis, and early implementation issues of this randomized trial.

CONCLUSIONS

Study findings will provide insight into the feasibility and effectiveness of integrated treatment of OUD and serious infections and have the potential to reduce morbidity and mortality in this vulnerable population.

Perceived social support in patients with chronic pain with and without opioid use disorder and role of medication for opioid use disorder

BACKGROUND

A significant predictor of treatment outcomes for patients with chronic non-cancer pain (CNCP) and opioid use disorder (OUD) is the degree and quality of social support they receive. Specifically, in patients with CNCP and on long-term opioid therapy, the development of OUD tends to be associated with losses in social support, while engagement in treatment for OUD improves support networks. Delivery of the evidence-based OUD treatment medications, methadone and buprenorphine, occurs in clinical environments which patently differ with respect to social support resources. The aims of this study were to describe perceived social support in patients with CNCP without OUD (no-OUD), with OUD and on buprenorphine (OUD-BP), and with OUD and on methadone (OUD-methadone).

METHODS

Using the Duke Social Support Index (DSSI), perceived social support in a sample of Caucasian patients with CNCP and on opioid therapy was compared between no-OUDs (n = 834), OUD-methadone (n = 83) and OUD-BP (n = 99) therapy. Average DSSI scores were compared across groups and a linear regression model computed to describe association between group and perceived social support.

RESULTS

No difference was observed in DSSI scores between no-OUDs and OUD-methadone, however scores were lower among OUD-BP participants than those receiving methadone (x = -5.2; 95% CI: -7.5, -2.9) and (x = -6.5, 95% CI: -8.2, -4.9).

CONCLUSIONS

Patients with CNCP and OUD on methadone therapy endorse levels of social support comparable to those without OUD, however those on buprenorphine therapy report significantly less support, bringing implications for OUD treatment outcomes.

"It's way more than just writing a prescription": A qualitative study of preferences for integrated versus non-integrated treatment models among individuals with opioid use disorder

Background

Increasingly, treatment for opioid use disorder (OUD) is offered in integrated treatment models addressing both substance use and other health conditions within the same system. This often includes offering medications for OUD in general medical settings. It remains uncertain whether integrated OUD treatment models are preferred to non-integrated models, where treatment is provided within a distinct treatment system. This study aimed to explore preferences for integrated versus non-integrated treatment models among people with OUD and examine what factors may influence preferences.

Methods

This qualitative study recruited participants (n = 40) through Craigslist advertisements and flyers posted in treatment programs across the United States. Participants were 18 years of age or older and scored a two or higher on the heroin or opioid pain reliever sections of the Tobacco, Alcohol, Prescription Medications, and Other Substances (TAPS) Tool. Each participant completed a demographic survey and a telephone interview. The interviews were coded and content analyzed.

Results

While some participants preferred receiving OUD treatment from an integrated model in a general medical setting, the majority preferred non-integrated models. Some participants preferred integrated models in theory but expressed concerns about stigma and a lack of psychosocial services. Tradeoffs between integrated and non-integrated models were centered around patient values (desire for anonymity and personalization, fear of consequences), the characteristics of the provider and setting (convenience, perceived treatment effectiveness, access to services), and the patient-provider relationship (disclosure, trust, comfort, stigma).

Conclusions

Among this sample of primarily White adults, preferences for non-integrated versus integrated OUD treatment were mixed. Perceived benefits of integrated models included convenience, potential for treatment personalization, and opportunity to extend established relationships with medical providers. Recommendations to make integrated treatment more patient-centered include facilitating access to psychosocial services, educating patients on privacy, individualizing treatment, and prioritizing the patient-provider relationship. This sample included very few minorities and thus findings may not be fully generalizable to the larger population of persons with OUD. Nonetheless, results suggest a need for expansion of both OUD treatment in specialty and general medical settings to ensure access to preferred treatment for all.

Impact of Continuing Care on Recovery From Substance Use Disorder

Continuing care is widely believed to be an important component of effective treatment for substance use disorder, particularly for those individuals with greater problem severity. The purpose of this review was to examine the research literature on continuing care for alcohol and drug use disorders, including studies that addressed efficacy, moderators, mechanisms of action, and economic impact. This narrative review first considered findings from prior reviews (published through 2014), followed by a more detailed examination of studies published more recently. The review found that research has generally supported the efficacy of continuing care for both adolescents and adults, but the picture is complex. Reviews find relatively small effects when results from individual studies are combined. However, continuing care of longer duration that includes more active efforts to keep patients engaged may produce more consistently positive results. Moreover, patients at higher risk for relapse may benefit to a greater degree from continuing care. Several newer approaches for the provision of continuing care show promise. These include incentives for abstinence and automated mobile health interventions to augment more conventional counselor-delivered interventions. Primary care can be used to provide medications for opioid and alcohol use disorders over extended periods, although more research is needed to determine the optimal mix of behavioral treatments and other psychosocial services in this setting. Regardless of the intervention selected for use, the status of most patients will change and evolve over time, and interventions need to include provisions to assess patients on a regular basis and to change or adapt treatment when warranted.

Evidence-Based Treatment of Young Adults With Substance Use Disorders

In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among adolescents and young adults, in this special article, we review principles of care related to SUD treatment of young adults. SUDs are most commonly diagnosed during young adulthood, but most of the evidence guiding the treatment of this population has been obtained from older adult study participants. Extrapolating evidence from older populations, the expert group asserted the following principles for SUD treatment: It is important that clinicians who work with young adults effectively identify and address SUD to avert long-term addiction and its associated adverse health outcomes. Young adults receiving addiction treatment should have access to a broad range of evidence-based assessment, psychosocial and pharmacologic treatments, harm reduction interventions, and recovery services. These evidence-based approaches should be tailored to young adults' needs and provided in the least restrictive environment possible. Young adults should enter care voluntarily; civil commitment to treatment should be a last resort. In many settings, compulsory treatment does not use evidence-based approaches; thus, when treatment is involuntary, it should reflect recognized standards of care. Continuous engagement with young adults, particularly during periods of relapse, should be considered a goal of treatment and can be supported by care that is patient-centered and focused on the young adult's goals. Lastly, substance use treatments for young adults should be held to the same evidence and quality standards as those for other chronic health conditions.

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

BACKGROUND

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD.

METHODS

A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used.

RESULTS

Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only.

CONCLUSIONS

This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions.

TRIAL REGISTRATION

PROSPERO registration CRD42018090761.

A Community Responds to the COVID-19 Pandemic: a Case Study in Protecting the Health and Human Rights of People Who Use Drugs

Effective responses to a global pandemic require local action. In the face of a pandemic or similar emergencies, communities of people who use drugs face risks that result from their ongoing drug use, reduced ability to secure treatment for drug use and correlated maladies, lack of access to preventive hygiene, and the realities of homelessness, street-level policing, and criminal justice involvement. Herein, we document the efforts of a coalition of people who use drugs, advocates, service providers, and academics to implement solutions to reduce these risks at a municipal and state level focusing on New Haven and the State of Connecticut. This coalition identified the communities at risk: active users needing access to harm reduction services, persons in treatment needing access to their medications, the homeless and marginally housed needing improved hygiene, people engaged in sex work, and the incarcerated needing release from custody. The section describing each of the risks demonstrates how the coalition acted preemptively at early stages of the pandemic, ahead of official initiatives, to develop ameliorative risk reduction solutions. Outcomes discussed include instances in which obstacles were overcome or still remain.