Opioid use disorder treatment disruptions during the early COVID-19 pandemic and other emergent disasters: a scoping review addressing dual public health emergencies

"It didn't hurt me": patients' and providers' perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico

BACKGROUND

During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl-related overdose deaths and other drug-related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take-home-dose delivery.

METHODS

In-depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days.

RESULTS

Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take-home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes.

CONCLUSION

This study underscores the importance of insider perspectives on harm-reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.

Predictors of mental health among U.S. adults during COVID-19 early pandemic, mid- pandemic, and post-vaccine eras

BACKGROUND

A collective trauma like COVID-19 impacts individuals differently due to socio-contextual and individual characteristics. Younger adults, minorities, affiliates of certain political parties, and residents of some regions of the United States reported experiencing poorer mental health during the pandemic. Being diagnosed with COVID-19, or losing a friend/family to it, was related to more adverse mental health symptoms. While the negative impact of COVID-19 on health outcomes has been studied, mental health changes during this pandemic need further exploration.

METHODS

In a study of 8,612 U.S. households, using three surveys collected from a nationally representative panel between May 2020 and October 2021, using a repeated cross-sectional design, a linear mixed effect regression model was performed to investigate factors associated with the mental health status, based on the Mental Health Inventory-5, of individuals throughout different phases of the COVID-19 pandemic, and whether an improvement over time, especially after vaccines became available, was observed.

RESULTS

An overall improvement in mental health was observed after vaccines became available. Individuals with no COVID-related death in their household, those not wearing masks, those identifying as members of the Republican Party, race/ethnicities other than Asian, men, older adults, and residents of the South were less likely than others to report mental health challenges.

CONCLUSIONS

Our results highlight the need for widespread mental health interventions and health promotion to address challenges during the COVID-19 pandemic and beyond. Due to the worse mental health observed among Asians, younger adults, women, low-income families, those with a higher level of concern for COVID-19, people who lost someone to COVID-19, and/or individuals with histories of opioid use disorder and criminal legal involvement, over the period of this study, targeted attention needs to be given to the mental health of these groups.

"As long as that place stays open, I'll stay alive": Accessing injectable opioid agonist treatment during dual public health crises

BACKGROUND

Since the onset of the COVID-19 pandemic, overdose rates in North America have continued to rise, with more than 100,000 drug poisoning deaths in the past year. Amidst an increasingly toxic drug supply, the pandemic disrupted essential substance use treatment and harm reduction services that reduce overdose risk for people who use drugs. In British Columbia, one such treatment is injectable opioid agonist treatment (iOAT), the supervised dispensation of injectable hydromorphone or diacetylmorphine for people with opioid use disorder. While evidence has shown iOAT to be safe and effective, it is intensive and highly regimented, characterized by daily clinic visits and provider-client interaction-treatment components made difficult by the pandemic.

METHODS

Between April 2020 and February 2021, we conducted 51 interviews with 18 iOAT clients and two clinic nurses to understand how the pandemic shaped iOAT access and treatment experiences. To analyze interview data, we employed a multi-step, flexible coding strategy, an iterative and abductive approach to analysis, using NVivo software.

RESULTS

Qualitative analysis revealed the ways in which the pandemic shaped clients' lives and the provision of iOAT care. First, client narratives illuminated how the pandemic reinforced existing inequities. For example, socioeconomically marginalized clients expressed concerns around their financial stability and economic impacts on their communities. Second, clients with health comorbidities recognized how the pandemic amplified health risks, through potential COVID-19 exposure or by limiting social connection and mental health supports. Third, clients described how the pandemic changed their engagement with the iOAT clinic and medication. For instance, clients noted that physical distancing guidelines and occupancy limits reduced opportunities for social connection with staff and other iOAT clients. However, pandemic policies also created opportunities to adapt treatment in ways that increased patient trust and autonomy, for example through more flexible medication regimens and take-home oral doses.

CONCLUSION

Participant narratives underscored the unequal distribution of pandemic impacts for people who use drugs but also highlighted opportunities for more flexible, patient-centered treatment approaches. Across treatment settings, pandemic-era changes that increase client autonomy and ensure equitable access to care are to be continued and expanded, beyond the duration of the pandemic.

Increases in drug overdose deaths in Norway and the United States during the COVID-19 pandemic

INTRODUCTION

Little international comparative work exists describing pandemic-related spikes in overdose and related implications for drug and public health policy. We compared increases in overdose deaths during the pandemic in Norway and the United States, two countries in the top 10 for per-capita overdose mortality, yet with very different approaches to the pandemic, healthcare and drug policy.

METHODS

We examined monthly overdoses in 2020 versus baseline rates (the monthly average across 2017-2019). We compared excess overdose mortality to shifts in human mobility and social interaction, measured using cellphone-based mobility data, an indicator of the societal response to the pandemic.

RESULTS

Both the US and Norway saw large magnitude exacerbations in overdose mortality during the pandemic-related lockdowns, reaching 46.8% and 57.0% above baseline, respectively. Maximum increases occurred 2-3 months after peak reductions in mobility, suggesting lagged mechanisms. While overdose mortality returned to baseline relatively quickly in Norway, rates remained elevated in the US to the end of 2020.

CONCLUSIONS

Spikes in overdose mortality in both contexts may relate to disruptions in healthcare access and the drug supply becoming more potent. Norway's quicker return to baseline may reflect more robust access to harm reduction and addiction-related healthcare services. Nevertheless, it is notable that even in Norway - with universal access to high-quality services, low COVID-19 rates, and a highly effective public health infrastructure - a greater than 50% spike in overdose deaths was still seen at the onset of lockdown measures. This may have important implications for future pandemic and disaster planning.

A randomized, sham-controlled, quintuple-blinded trial to evaluate the NET device as an alternative to medication for promoting opioid abstinence

Background

There is an unmet need for non-medication approaches to illicit opioid discontinuation and relapse prevention. The NET (NeuroElectric Therapy) Device is a non-invasive, battery-operated, portable, re-useable device designed to deliver bilateral transcranial transcutaneous alternating current electrical stimulation, and is intended to treat opioid use disorder (OUD) without medication. The device is a CE-marked Class IIa, non-significant risk, investigational medical device.

Objective

This prospective trial (NRC021) tests the hypothesis that the NET Device provides safe and effective neurostimulation treatment for persons with OUD who express a desire to be opioid abstinent without medications for opioid use disorder (MOUD).

Methods

NRC021 is a randomized, parallel-group, sham-controlled, quintuple-blinded, single-site study. Persons with OUD entering a residential treatment facility for opioid detoxification are assigned to active or sham treatment (n = 50/group). Group assignment is stratified on presence of any current non-opioid substance use disorder and by sex. The biostatistician maintains the blinding so that the study sponsor, principal investigator, research assistants, treatment staff, and participants remain blinded. Following discharge from the inpatient facility, participants are assessed once weekly over 12 weeks for substance use (using timeline followback interview and video assessment of observed oral fluid sample provision and testing). The primary efficacy endpoint is each participant's overall percentage of weekly abstinence from illicit opioid use without use of MOUD. The secondary efficacy endpoint is each participant's percentage of non-opioid drug-free weeks. Safety outcomes are also measured.

Conclusion

NRC021 is designed to assess the efficacy of a novel non-medication treatment for OUD.

Clinical trial registration

ClinicalTrials.gov with the identifier NCT04916600.

Do buprenorphine doses and ratios matter in medication assisted treatment adherence?

Introduction

Buprenorphine (BUP), generally prescribed as buprenorphine/naloxone, is a key component of medication-assisted treatment (MAT) to manage opioid use disorder. Studies suggest higher doses of BUP increase treatment adherence. Routine urine drug screens (UDS) assist in monitoring MAT adherence via measurement of excreted BUP and its metabolite, norbuprenorphine (NBP). The clinical significance between BUP/NBP concentrations and their ratios for assessing adherence and substance use is not well-described.

Methods

We conducted a single-center, retrospective chart review of 195 clients age ≥18 years enrolled in a local MAT program from August 2017 to February 2021. Demographics, BUP doses, prescription history, and UDS results were collected. Participants were divided based on MAT adherence (<80% vs ≥80%) and median total daily dose (TDD) of BUP (≥16 mg vs <16 mg) in addition to pre- and post-COVID-19 cohorts.

Results

Median BUP/NBP urinary concentrations were significantly correlated with MAT adherence (P < .0001 for each) and a reduced percentage of positive UDS for opioids (P = .0004 and P < .0001, respectively) but not their ratios. Median TDD of BUP ≥16 mg (n = 126) vs <16 mg (n = 68) was not correlated with MAT adherence (P = .107) or incidence of nonprescription use (P = .117). A significantly higher incidence of UDS positive for opiates (P = .049) and alcohol (P = .035) was observed post-COVID-19.

Discussion

Clients appearing adherent to MAT who had higher concentrations of urinary BUP/NBP demonstrated a reduced incidence of opioid-positive UDS independent of the BUP dose prescribed. An increase in opioid- and alcohol-positive UDSs were observed during the COVID-19 pandemic.

Illicit Substance Use and the COVID-19 Pandemic in the United States: A Scoping Review and Characterization of Research Evidence in Unprecedented Times

We carried out a scoping review to characterize the primary quantitative evidence addressing changes in key individual/structural determinants of substance use risks and health outcomes over the first two waves of the COVID-19 pandemic in the United States (US). We systematically queried the LitCovid database for US-only studies without date restrictions (up to 6 August 2021). We extracted quantitative data from articles addressing changes in: (a) illicit substance use frequency/contexts/behaviors, (b) illicit drug market dynamics, (c) access to treatment and harm reduction services, and (d) illicit substance use-related health outcomes/harms. The majority of 37 selected articles were conducted within metropolitan locations and leveraged historical timeseries medical records data. Limited available evidence supported changes in frequency/behaviors/contexts of substance use. Few studies point to increases in fentanyl and reductions in heroin availability. Policy-driven interventions to lower drug use treatment thresholds conferred increased access within localized settings but did not seem to significantly prevent broader disruptions nationwide. Substance use-related emergency medical services’ presentations and fatal overdose data showed a worsening situation. Improved study designs/data sources, backed by enhanced routine monitoring of illicit substance use trends, are needed to characterize substance use-related risks and inform effective responses during public health emergencies.

Changes in drug poisoning mortality before and after the COVID-19 pandemic by occupation in Massachusetts

BACKGROUND

Incidence of drug poisoning deaths has increased during the coronavirus disease 2019 (COVID-19) pandemic. Previous research has established that risks differ for drug poisoning death according to occupation, and that workers also have a different risk for exposure to and death from COVID-19. This study sought to determine whether workers in certain occupations had drug poisoning mortality rates that increased in 2020 (the first year of the COVID-19 pandemic) compared to the average mortality rate for workers in those occupations during the previous 3 years.

METHODS

Death certificates of Massachusetts residents who died from drug poisonings in 2017-2020 were obtained. Average mortality rates of drug poisoning according to occupation during the 2017-2019 period were compared to mortality rates in 2020.

RESULTS

Between the 2017-2019 period and 2020, mortality rates of drug poisoning increased significantly for workers in three occupational groups: food preparation and serving; healthcare support; and transportation and material moving. In these occupations, most of the increases in 2020 compared to 2017-2019 occurred in months after COVID-19 pandemic cases and deaths increased in Massachusetts.

CONCLUSION

Mortality rates from drug poisonings increased substantially in several occupations in 2020 compared to previous years. Further research should examine the role of occupational factors in this increase in drug poisoning mortality rates during the COVID-19 pandemic. Particular attention should be given to determine the role that exposure to severe acute respiratory syndrome coronavirus 2, work stress, and financial stress due to job insecurity played in these increases.

Opioids in COVID-19: Two Sides of a Coin

Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics-possibly in higher doses than usual-which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: "Opioids", "COVID-19," "COVID-19 pandemic," "SARS-CoV-2," "Opioid use disorder," "Opioid dependence" and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic. Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug. Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.

Mal/adaptations: A qualitative evidence synthesis of opioid agonist therapy during major disruptions

BACKGROUND

Opioid agonist therapy (OAT) has been severely disrupted by the COVID-19 pandemic. The risks of opioid withdrawal, overdose, and diversion have increased, so there is an urgent need to adapt OAT to best support people who use drugs (PWUD). This review examines the views and experiences of PWUD, health care providers, and health system administrators on OAT during major disruptions to medical care to inform appropriate health system responses during the current pandemic and beyond.

METHODS

We conducted a systematic review and qualitative evidence synthesis. We searched three comprehensive datasets for qualitative and mixed-methods studies that examined OAT in the context of major disruptions such as natural disasters, and analyzed included studies using thematic analysis and the constant comparative method. We used conceptual frameworks of health systems resilience and adaptive systems to interpret our findings.

RESULTS

We included 10 studies published between 2002 and 2020 that examined OAT in the context of hurricanes, earthquakes, and terrorist attacks. We organized our results into three themes: uncertainty, inconsistency, and vulnerability; regulatory inflexibility; and lack of coordination. The highly regulated but poorly coordinated systems of OAT provision lacked flexibility to adapt to major disruptions, thereby manufacturing vulnerability for both PWUD and health workers.

CONCLUSIONS

OAT programs must be resilient and adaptable to face major disruptions while maintaining quality care. Our findings provide guidance to develop and implement innovative strategies that increase the adaptive potential of OAT programs while focusing on the needs of PWUD.

Experiences with take-home dosing in heroin-assisted treatment in Switzerland during the COVID-19 pandemic-Is an update of legal restrictions warranted?

Heroin-assisted treatment comprises the use of diacetylmorphine (pharmaceutical heroin) for individuals with severe opioid use disorder. In Switzerland, take-home doses in heroin-assisted treatment are more strictly regulated as compared to conventional opioid agonist treatment. In light of the COVID-19 pandemic, the Swiss Federal Council provisionally adapted its policy, allowing for longer prescriptions of take-home diacetylmorphine. Before the beginning of the pandemic, take-home doses only occurred in exceptional circumstances and under strict criteria for patient eligibility. Following the legislative adaptations, we critically revised our internal centre policies as well. We report our experiences with oral take-home diacetylmorphine from a Swiss outpatient university centre specialising in heroin-assisted treatment. An additional 45 patients received take-home doses following the first lockdown. While some patients wished to return to their previous treatment regimen, most patients managed their medication well and showed good adherence. We also noticed an increase of treatment admissions that are likely related to the relaxed regulations. Previously, the strict therapeutic framework of visiting a HAT centre twice a day for supervised dispensing seemed to have discouraged these individuals from seeking medical treatment. From a medical point of view, the politically driven restrictions on take-home doses in heroin-assisted treatment are questionable and do not support the goal of harm reduction.