Gender-specific predictors of methadone treatment outcomes among African Americans at an urban clinic

Inequities in the treatment of opioid use disorder: A scoping review

BACKGROUND

Given the lack of access to evidenced-based OUD treatment and the corresponding overdose crisis, researchers must evaluate and report health care inequities involving the treatment of OUD. Additionally, clinicians should be aware of these inequities in the treatment of patients.

METHODS

We carried out a scoping review of the literature regarding health inequities in treatment for OUD in July 2022. The study team retrieved articles published between 2016 and 2021 from MEDLINE and Ovid Embase. After authors received training, screening and data extraction were performed in masked, duplicate fashion. The team screened a total of 3673 titles and abstracts, followed by 172 articles for full-text review. The inequities that we examined were race/ethnicity, sex or gender, income, under-resourced/rural, occupational status, education level, and LGBTQ+. We used Stata 17.0 (StataCorp, LLC, College Station, TX) to summarize data and statistics of the studies within our sample.

RESULTS

A total of 44 studies evaluating inequities in OUD treatment met inclusion criteria. The most common inequity that studies examined was race/ethnicity (34/44 [77.27 %] studies), followed by under-resourced/rural (19/44 [43.18 %] studies), and sex or gender (18/44 [40.91 %] studies). LGBTQ+ (0/44 [0.0 %] studies) was not reported in the included studies. Our results indicate that many historically marginalized populations experience inequities related to access and outcomes in OUD treatment. The included studies in our scoping review occasionally demonstrated inconsistent findings.

CONCLUSIONS

Gaps exist within the literature on health inequities in treatment for OUD. The most examined inequities were race/ethnicity, under-resourced/rural and sex or gender, while studies did not examine LGBTQ+ status. Future research should aim to advance and supplement literature investigating health inequities in OUD treatment to ensure inclusive, patient-centered care.

Relapse risk revealed by degree centrality and cluster analysis in heroin addicts undergoing methadone maintenance treatment

BACKGROUND

Based on hubs of neural circuits associated with addiction and their degree centrality (DC), this study aimed to construct the addiction-related brain networks for patients diagnosed with heroin dependence undertaking stable methadone maintenance treatment (MMT) and further prospectively identify the ones at high risk for relapse with cluster analysis.

METHODS

Sixty-two male MMT patients and 30 matched healthy controls (HC) underwent brain resting-state functional MRI data acquisition. The patients received 26-month follow-up for the monthly illegal-drug-use information. Ten addiction-related hubs were chosen to construct a user-defined network for the patients. Then the networks were discriminated with K-means-clustering-algorithm into different groups and followed by comparative analysis to the groups and HC. Regression analysis was used to investigate the brain regions significantly contributed to relapse.

RESULTS

Sixty MMT patients were classified into two groups according to their brain-network patterns calculated by the best clustering-number-K. The two groups had no difference in the demographic, psychological indicators and clinical information except relapse rate and total heroin consumption. The group with high-relapse had a wider range of DC changes in the cortical-striatal-thalamic circuit relative to HC and a reduced DC in the mesocorticolimbic circuit relative to the low-relapse group. DC activity in NAc, vACC, hippocampus and amygdala were closely related with relapse.

CONCLUSION

MMT patients can be identified and classified into two subgroups with significantly different relapse rates by defining distinct brain-network patterns even if we are blind to their relapse outcomes in advance. This may provide a new strategy to optimize MMT.

Association between clinically recognized suicidality and subsequent initiation or continuation of medications for opioid use disorder

BACKGROUND

Among individuals with opioid use disorder (OUD), medications for OUD (MOUD) may lower suicide risk. Therefore, it is important that individuals with OUD and suicidality receive MOUD. This study examined associations between clinically recognized suicidality and subsequent initiation or continuation of MOUD among patients with OUD in the national Veterans Health Administration (VA).

METHODS

Electronic health record data were extracted for outpatients with OUD who received VA care 10/1/2016-7/31/2017. Suicidality was measured using diagnostic codes for suicidal ideation/attempt and patient record flags. Analyses were conducted separately among patients without prior-year MOUD receipt to examine MOUD initiation, and with prior-year MOUD receipt to examine MOUD continuation. Poisson regression models estimated likelihood of MOUD receipt in the following year for patients with prior-year suicidality relative to those without. Models were adjusted for sociodemographic and clinical characteristics.

RESULTS

Among 20,085 patients with no prior-year MOUD, 12% had suicidality and 12% received MOUD in the following year. Suicidality was positively associated with MOUD initiation (adjusted incidence rate ratio [aIRR]: 1.15, 95% confidence interval [CI]: 1.04-1.28). Among 10,162 patients with prior-year MOUD, 9% had suicidality and 84% received MOUD in the following year. Suicidality was negatively associated with MOUD continuation (aIRR: 0.95, 95% CI 0.91-0.98).

CONCLUSIONS

Among VA patients with OUD, clinically recognized suicidality may increase likelihood of MOUD initiation but decrease likelihood of continuation. Efforts to increase initiation overall and to support retention for patients with suicidality are needed.

A scoping review of opioid harm reduction interventions for equity-deserving populations

Background

Morbidity and mortality associated with opioid use has become a North American crisis. Harm reduction is an evidence-based approach to substance use. Targeted harm reduction strategies that consider the needs of specific populations are required. The objective of this scoping review was to document the range of opioid harm reduction interventions across equity-deserving populations including racialized groups, Indigenous peoples, LGBTQIA2S+, people with disabilities, and women.

Methods

Ten databases were searched from inception to July 5th, 2021. Terms for harm reduction and opioid use formed the central concepts of the search. We included studies that: (1) assessed the development, implementation, and/or evaluation of harm reduction interventions for opioid use, and (2) reported health-related outcomes or presented perspectives that directly related to experiences receiving or administering harm reduction interventions, (3) were completed within an equity-deserving population and (4) were completed in New Zealand, Australia, Canada or the US. A knowledge map was developed a-priori based on literature outlining different types of harm reduction interventions and supplemented by the expertise of the research team.

Findings

12,958 citations were identified and screened, with 1373 reviewed in full-text screening. Of these, 15 studies were included in the final dataset. The most common harm reduction program was opioid agonist treatment (OAT) (n = 11, 73%). The remaining four studies included: overdose prevention; drug testing equipment; and outreach, peer support, and educational programs for safer use. Nine studies focused on women, primarily pregnant/post-partum women, three focused on Indigenous peoples, and three studies included racialized groups. No studies were identified that provided any information on persons with a disability or members of the LGBTQIA2S+ population.

Interpretation

The scant opioid specific harm reduction literature on equity-deserving populations to date has primarily focused on OAT programs and is focused primarily on women. There is a need for more targeted research to address the diverse social experiences of people who use drugs and the spectrum of harm reduction interventions that are needed. There is also a need to acknowledge the history of harm reduction as a drug-user activist movement aimed at challenging bio-medical paradigms of drug use. Further, there is a need to recognize that academic research may be contributing to health inequity by not prioritizing research with this lens.

Funding

This research was funded by the Canadian Institutes of Health Research.

Exposure to childhood trauma increases risk of opioid use disorder among people prescribed opioids for chronic non-cancer pain

BACKGROUND

Little is known about childhood trauma exposure and Opioid Use Disorder (OUD) among people prescribed opioids for chronic non-cancer pain (CNCP). We aimed to (1) describe childhood trauma exposure among this population, and (2) examine if childhood trauma exposure was an independent risk factor for OUD among people prescribed opioids for CNCP.

METHODS

This study used baseline data from 1514 people prescribed opioids for CNCP in Australia. We used latent class analysis to characterise participants by five indicators of childhood trauma exposure and logistic regression to characterise class membership. We used discrete-time survival analysis to determine whether there was an independent association between childhood trauma exposure and risk of OUD according to adjusted odds ratios (AOR).

RESULTS

We identified three classes of childhood trauma exposure: (1) 'low exposure' (n = 765; 54.0%), (2) 'emotional & sexual abuse' (n = 324; 22.9%), and (3) 'high all' (n = 329; 23.2%). 'Emotional & sexual abuse' or 'high all' childhood trauma exposure class membership was associated with higher rates of pain difficulties, mental disorders, and substance use disorders, compared to 'low exposure' class membership. After we adjusted for previously identified OUD risk factors, participants in the 'emotional & sexual abuse' (AOR 1.51; 95%CI 1.09-2.12; p = 0.016) and 'high all' (AOR 1.77; 95%CI 1.28-2.45; p = 0.001) childhood trauma exposure classes were at increased risk of OUD.

CONCLUSIONS

Among people prescribed opioids for CNCP, childhood trauma exposure was a common, independent risk factor for OUD. Availability of trauma-informed services for those prescribed opioids for CNCP may reduce risk of transition to OUD.

The "high cost of low living": Substance use recovery among older formerly homeless adults

BACKGROUND

The population of older homeless substance-using adults is growing considerably, and we sought to understand how such individuals gain control of problematic substance use amidst other life problems.

Methods: Data were collected in an NIMH-funded study in which four in-depth interviews were conducted over 18 months with formerly homeless adults living in permanent supportive housing. The study subsample was comprised of 15 predominantly African American individuals over age 45 who were in recovery for at least six months. Cross-case analyses used a template approach followed by inductive sub-theme analyses.

Results: Three themes drawn from the literature yielded seven sub-themes as follows. Theme #1: Acute life stressors: (a) "substance use as primary"; (b) "acute life events and substance use"; (c) "incarceration as turning point." Theme #2: Attributions of recovery: (a) "quitting as personal decision"; (b) "I just got to stay on top of it"; Theme #3: Social relationships: (a) "I have associates, not friends"; (b) "taking a cautious approach."

Conclusion: Participants viewed substance use as the primary problem in their lives despite other adversity. Recovery was viewed as a personal decision, but maintaining recovery involved positive social relationships. Policies and practices related to recovery should address the complexities of lives-as-lived.

Treatment Outcomes Among Black Adults Receiving Medication for Opioid Use Disorder

Largely due to structural racism, Black people with substance use disorder have worse outcomes than their White counterparts. The opioid epidemic has amplified these racial disparities. Little is known about strengths that buffer against the systemic issues that disproportionately impact Black adults with opioid use disorder (OUD), particularly those receiving buprenorphine for OUD. The objectives of this study are to (1) assess psychosocial and clinical predictors of OUD outcomes and (2) explore differences in OUD outcomes by gender among a sample of Black adults receiving buprenorphine. This is a secondary data analysis of a cross-sectional survey and medical record review with a convenience sample recruited from an addiction medicine clinic. Analyses included Black participants who provided at least one urine drug test during the study period (n = 98). Prospective 6-month OUD outcomes (treatment retention, substance use recurrence, and buprenorphine continuation) were abstracted from the medical record. Univariate analyses explored differences by gender. Multivariate regressions assessed predictors of OUD outcomes. Participants were 53% women and middle-aged (47 ± 12 years). The majority (59%) had been in treatment for at least 1 year at study enrollment. Substance use recurrence was common, but many individuals remained in treatment. OUD outcomes did not differ by gender. Older age and absence of injection opioid use history were significant predictors of treatment retention and buprenorphine continuation. When provided access to high-quality treatment, Black adults with OUD demonstrate positive outcomes. Addressing structural racism and developing culturally informed treatment interventions are necessary to improve access to high-quality care for this community.

Opioid prescribing and opioid-overdose deaths in Michigan: Urban-rural comparisons and changes across 2013-2017

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Examined opioid prescribing and opioid-overdose death rates in Michigan counties.

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Conducted urban-rural county comparisons and tested for changes across 2013–2017.

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Higher rates of overdose deaths in urban, and higher rates of prescribing in rural.

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Opioid-overdose death rates rose in both urban and rural counties across 2013–2017.

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Opioid prescribing rates did not change in urban or rural counties across 2013–2017.

Background

Opioid-overdose deaths and opioid prescriptions have increased substantially within the past decade, leading to examinations of urban-rural differences for these opioid-related outcomes, and whether annual trends differ by urban-rural status. Most investigations have examined differences using national data, whereas few studies have identified patterns in hard-hit regions. Therefore, we examined urban-rural differences for opioid-related outcomes in Michigan, a state with overdose death and prescribing rates above the national average.

Methods

This study used county-level public data on opioid prescribing and opioid-overdose death rates in Michigan. Bivariate and joinpoint regression analyses tested for annual differences and annual changes in opioid-related outcomes across 2013–2017. Rural Urban Continuum Codes classified urban-rural county status.

Results

Bivariate analyses demonstrated that urban counties had consistently higher opioid-overdose death rates than rural, whereas rural counties had consistently higher opioid prescribing rates than urban. Joinpoint regression (2013–2017) revealed opioid-overdose death rates increased in urban (Annual Percent Change = 25.0%, p = .001) and rural counties (Annual Percent Change = 21.7%, p = .002), though no changes for opioid prescribing rates were observed among urban or rural counties.

Conclusions

Our study highlights nuanced urban-rural patterns in Michigan, a hard-hit state, compared to trends in national data. Both urban and rural counties experienced rising rates of opioid-overdose deaths, and rural counties experienced higher opioid prescribing rates than urban. Though urban counties experienced higher opioid-overdose death rates than rural, the rise in both county types was similar. Future research directions, implications for public health, and healthcare policy recommendations are discussed.