Perceptions of extended-release naltrexone, methadone, and buprenorphine treatments following release from jail

State-Mandated Opioid Use Disorder Treatment In Maryland Jails Helped Patients Recover Despite Gaps In Care

Providing medications for opioid use disorder (MOUD) reduces overdose risk after release from a carceral facility. In 2019, Maryland enacted a comprehensive law mandating that all jails provide all three forms of MOUD during incarceration and reentry support. The experiences of patients who received this care in jail have not been explored to date. We examined the perspectives of twenty-four people recently released from Maryland jails during the period January 2023-March 2024. Most participants noted an improvement in opioid addiction care in jail when compared with their previous jail stays. They praised jail-based MOUD and believed that receiving MOUD in custody helped reduce the risk for return to use, recidivism, and overdose death. However, participants described challenges in receiving timely care that led them to experience withdrawal in jail and ongoing stigma from jail staff. Addiction counseling in jail was desired but not always available. As more states seek to expand MOUD in jails, Maryland's experience provides a promising model but also reveals ongoing implementation challenges.

Outcomes following two models of treatment linkage facilitation for women with a history of OUD following jail release

INTRODUCTION

The Kentucky hub of the NIDA-funded Justice Community Opioid Innovation Network (JCOIN) examined implementation of a PreTreatment Telehealth model of assessment, both alone and in combination with Peer Navigation, to increase utilization of SUD treatment (including MOUD) among women with a history of OUD during community re-entry.

METHODS

Participants included women (N = 900) randomly selected, screened for OUD, consented, and randomized to two levels of intervention, as well as a comparison group of women in jail-based treatment. About 90 % of women who were released from jail were followed in the community 3 months post-release to assess treatment outcomes.

RESULTS

Findings indicated that almost half (44.2 %) of women entered SUD treatment during the 3 months post-release, and about one-fifth (22 %) entered MOUD treatment. In addition, days of substance use, including opioid use specifically, were significantly reduced among women who engaged with their Peer Navigator regularly in the community after jail release.

CONCLUSIONS

Study findings support the need for future research on treatment linkage facilitation for women that is not only tailored to their unique needs at re-entry, but also considers the systemic facilitating factors and barriers that may be associated with treatment utilization (including the limited use of MOUD during incarceration).

Community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated: a review of Wisconsin legislation and regulations

Opioid use disorder (OUD) is highly prevalent among jail and prison populations in the United States, including in Wisconsin. Medications for opioid use disorder (MOUD), including long-acting injectable naltrexone, are crucial in the treatment of OUD. These medications are especially important for individuals transitioning out of jail or prison and back into the community. Unfortunately, few individuals who were formerly incarcerated continue MOUD after reentry due to a variety of barriers. Wisconsin community pharmacists are highly accessible and uniquely positioned to provide care for this population, specifically by administering injectable naltrexone. However, community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated has not been previously explored. As a first step, this legislative and regulatory review aimed to identify Wisconsin statutes and administrative codes that may impact these services for this population. Two legal databases were searched to identify relevant Wisconsin statute and administrative code subsections. Overall, 24 statute subsections (from 7 chapters) and 31 administrative code subsections (from 12 chapters) were identified that (1) highlighted a need or potential role of community pharmacist-administered injectable naltrexone for individuals who were formerly incarcerated or (2) served as a potential barrier or facilitator to the availability, access, or use of these services. Future work should focus on helping community pharmacists leverage available resources and overcome existing legal barriers to providing or supporting MOUD services. Importantly, work should be done to ensure that individuals who were formerly incarcerated can be linked to these services upon reentry.

Barriers and facilitators to community pharmacist-provided injectable naltrexone for formerly incarcerated individuals during community reentry

Introduction

Medications for opioid use disorder (MOUD), including injectable naltrexone, are a key component in the treatment of opioid use disorder (OUD). These medications are especially important for individuals transitioning out of correctional facilities and back into their communities. Unfortunately, few formerly incarcerated individuals have access to MOUD upon reentry, incurring a 40-fold greater likelihood of overdose following release compared to the general population. In Wisconsin, community pharmacists have the authority to administer naltrexone injections. However, they have not been explored as a resource for improving access to this medication for this patient population.

Objective

As a first step, the goal of this study was to understand the barriers and facilitators impacting the use of community pharmacist-provided injectable naltrexone by formerly incarcerated individuals during community reentry period.

Materials and methods

The researcher conducted semi-structured interviews with 18 individuals representing five stakeholder groups, including four MOUD prescribers, three community pharmacists, four correctional staff, four community organization or non-profit staff, and three individuals or family members/caregivers of individuals with a history of OUD and incarceration. Deductive and inductive content analysis were used to identify barrier and facilitator categories across the five levels of the Socioecological Model.

Results

Overall, participants discussed factors at every level, and many barriers and facilitators confirmed findings from existing literature focused on MOUD access for formerly incarcerated individuals. Participants also identified factors more specific to community pharmacies, including 1) lack of interagency collaboration between pharmacists, prescribers, and correctional facilities and 2) lack of awareness of community pharmacist-provided injectable naltrexone services.

Conclusions

Future research should explore interventions to address the barriers identified in this study and improve connections between community pharmacists and formerly incarcerated individuals. This work can help ensure that these individuals are given the chance to successfully reintegrate into their communities.

Extended-Release Buprenorphine Could Overcome Barriers to Medical Treatment of Opioid Use Disorder in At-Risk Populations

Description This article discusses how monthly extended-release buprenorphine can be used to improve the treatment of opioid use disorder (OUD). In particular, the use of monthly extended-release buprenorphine holds promise for patients who have recently been released from jail or prison and are battling OUD, those who are unstable and continue to use opioids illicitly, patients who are experiencing homelessness while also struggling with OUD, and those who are stable and want to be weaned off buprenorphine.

Social Network Barriers to Extended-Release Naltrexone Within Rural Appalachia: Perspectives from Justice-Involved Clients and Clinicians

BACKGROUND

Extended-release naltrexone (XR-NTX, Vivitrol®) is an effective, but underutilized, evidence-based treatment for people with opioid use disorder (POUD) who are incarcerated. Networks of family, friends, and clinicians serve as social influencers of health behaviors, including XR-NTX initiation, and are especially salient in Appalachia.

OBJECTIVES

Using a triangulation of perspectives, this study examined concordance between the social network themes that emerged from qualitative interviews with clinicians and POUD social network findings.

METHODS

Audio-recorded qualitative interviews were conducted with all clinicians (n = 15) providing assessments and community-based treatment linkages to justice-involved POUDs in Kentucky's Appalachian counties. Two independent coders coded the transcribed interviews. Social network data were collected from POUDs who completed prison-based treatment programs and were recently released from prison (n = 52).

RESULTS

Three themes related to POUDs' social network barriers of XR-NTX emerged from the clinician interviews: (1) networks with limited knowledge of XR-NTX, (2) homophily in networks, and (3) limited support networks. From the perspective of the POUD, knowledge of XR-NTX was nonexistent within their networks, aligning with the clinician theme. Homophily was prevalent in some attributes (e.g., employment), but only 31.8% of POUD networks had used drugs, providing mixed support for this theme. In concordance with clinicians, POUDs received high levels of emotional support, but lacked instrumental, financial, and treatment support from networks.

CONCLUSIONS

The network characteristics of Appalachian POUDs recently released from prison create challenges associated with recovery, which may be addressed through network and educational interventions.

"Yeah, this is not going to work for me"-The impact of federal policy restrictions on methadone continuation upon release from jail or prison

INTRODUCTION

Individuals impacted by the criminal-legal system face increased risk of opioid overdose. Medications for opioid use disorder (MOUD) provide a life-saving intervention. Multiple barriers prevent access to MOUD, including federal policies regulating opioid treatment programs (OTPs). This study aims to identify how federal policy affects anticipated barriers to methadone treatment access at a high-risk time for opioid mortality: community re-entry after incarceration.

METHODS

The study used standard qualitative methods to conduct 40 in-depth-interviews with incarcerated individuals enrolled in the Rhode Island Department of Corrections MOUD treatment program. Semi-structured interviews took place between June and August 2018 and focused on participants' experiences with MOUD and anticipated treatment barriers upon re-entry. A deductive coding framework incorporating the SAMHSA "8-point" criteria for take-home methadone as the a priori codebook and additional identified barriers informed further inductive analysis.

RESULTS

Four themes emerged: (1) logistical hurdles such as transportation and clinic location impeded clinic access; (2) punitive measures within clinics, like dose reduction for rule infractions, discouraged treatment continuation; (3) the environment of methadone clinics often tempted return to use; (4) while the structured nature of methadone treatment provided accountability, it also posed challenges. Federal policies, particularly around daily dosing and "take-home" regulations, exacerbated barriers for those re-entering the community. State and clinic level policies, however, were also identified as direct or exacerbating barriers to treatment access.

CONCLUSION

Significant hurdles persist for methadone access among individuals released from incarceration. Though the federal 8-point criteria have now been replaced with more flexible take-home policies, our findings highlight critical treatment barriers for individuals during the high-risk period of community re-entry. State and clinic level policies also exacerbate many of the barrier-driven themes identified in this analysis. Future work can explore how to best implement the identified benefits of a structured program without forcing the punitive measures that discourage treatment retention. Additional policy reform can help mitigate the effects of other social determinants of health (including transportation access). Ultimately, the many barriers to community methadone treatment retention also apply to individuals involved in the criminal legal system; they can be exacerbated at the federal, state, and clinic policy level.

Knowledge, experiences, and perceptions of medications for opioid use disorder among Black Kentuckians

BACKGROUND

Opioid overdoses have continued to increase at higher rates among Black Americans compared to people from other racial groups. Despite demonstrated effectiveness of MOUD in reducing risk of opioid overdose, Black Americans face decreased access to and uptake of MOUD. The current study aimed to examine the knowledge, perceptions, and experiences with MOUD among a sample of Black adults who use prescription opioids nonmedically in order to inform tailored efforts to improve MOUD uptake.

METHODS

Data were derived from a larger study assessing cultural and structural influences on drug use and drug treatment among people who use prescription opioids nonmedically. Semi-structured qualitative interviews were conducted with 34 Black men and women across four generational cohorts: born 1955-1969; 1970-1979; 1980-1994; and 1995-2001. Participant responses were analyzed using thematic analysis.

RESULTS

Nearly half of participants (44.1%) reported no knowledge or experience with MOUD. Among participants who had any knowledge about MOUD, four major themes regarding their perceptions emerged: MOUD Helps with Recovery; Not Needed for Level of Drug Use; Side Effects and Withdrawal; Equivalence with Illicit Drug Use. The majority reported negative perceptions of MOUD (52.6%), and the youngest cohort (born 1995-2001) had a higher proportion of negative perceptions (80%) relative to other age cohorts (born 1980-1994: 50%; 1970-1979: 75%; 1955-1969: 16.6%).

DISCUSSION

Findings indicate a significant knowledge gap and clear points of intervention for improving MOUD uptake. Interventions to improve communication of health information in ways that are culturally relevant and tailored by age group can be used in conjunction with efforts to improve MOUD access among Black individuals who use opioids nonmedically.

Patients with Opioid Use Disorder Choosing Treatment with Extended-Release Naltrexone: A 6-Month Naturalistic Study

INTRODUCTION

The treatment efficacy of extended-release naltrexone (XR-NTX) for opioid use disorder (OUD) has been demonstrated in several studies, but not in naturalistic settings where opioid agonist treatment (OAT) is freely accessible. This study aimed to examine the different treatment outcomes of XR-NTX in a setting where the participants freely chose XR-NTX as a treatment option instead of OAT.

METHODS

This was a 24-week open-label clinical prospective cohort study conducted in an outpatient setting at five hospitals in Norway. The study included 161 participants aged 18-65 years with OUD. Intramuscular injections of XR-NTX were administered every 4 weeks for 24 weeks. Measurements included retention in treatment, reasons for treatment discontinuation, days of use of opioids, other illicit substances and alcohol, level of heroin craving, treatment satisfaction, and adverse events (AEs).

RESULTS

Of 161 included participants, the mean age was 38 years, and 24% were women; 138 received at least one dose of the study medication (modified intention-to-treat [MITT] population), and mean time in treatment was 18.1 weeks (95% CI: 16.8-19.4). The majority of the MITT population (84; 60.9%) completed 24 weeks of treatment in the study. There was a significant decrease in the overall use of opioids (p < 0.001) and the use of alcohol, and other illicit substances were low. The participants generally reported high treatment satisfaction and low heroin cravings. Those who completed the 24 weeks of treatment reported significantly fewer days of opioid use (p < 0.001) and higher treatment satisfaction (p < 0.001) than those who discontinued treatment before 24 weeks. No serious AEs were directly related to XR-NTX use.

CONCLUSION

This study demonstrated high retention rates, decreased opioid use, and low use of other illicit substances and alcohol. Participants also reported low cravings for heroin and high treatment satisfaction. Completion of the full 24-week treatment resulted in lower opioid use and increased treatment satisfaction compared to those who discontinued treatment before 24 weeks. The observed higher retention and reduced opioid use, compared to other studies, may be attributed to participants' strong motivation for opioid abstinence facilitated by XR-NTX treatment.

Barriers and Facilitators to Community Pharmacist-Provided Injectable Naltrexone for Formerly Incarcerated Individuals During Community Reentry in Wisconsin

Medications for opioid use disorder (MOUD), including injectable naltrexone, are a key component in the treatment of opioid use disorder (OUD). These medications are especially important for individuals transitioning out of correctional facilities and back into their communities, as individuals receiving MOUD are 85% less likely to die due to drug overdose in the first month post-release and have a 32% lower risk of rearrest. Unfortunately, few formerly incarcerated individuals have access to MOUD upon reentry, incurring a 40-fold greater likelihood of overdose following release compared to the general population. While 84% of Wisconsin jails offering MOUD offer naltrexone, less than half provide linkage to community treatment for reentering individuals. In Wisconsin, community pharmacists have the authority to provide naltrexone injections. However, they have not been explored as a resource for improving access to this medication for formerly incarcerated individuals. As a first step, the goal of this study was to understand the barriers and facilitators impacting access to community pharmacist-provided injectable naltrexone for this patient population during community reentry period. The researcher conducted semi-structured interviews with 18 individuals representing five stakeholder groups. Deductive and inductive content analysis were used to identify barrier and facilitator categories across the five levels of the Socioecological Model. Overall, participants discussed factors at every level, and many barriers and facilitators confirmed findings from existing literature focused on MOUD access for formerly incarcerated individuals. Participants also identified factors more specific to community pharmacies, including 1) lack of interagency collaboration between pharmacists, prescribers, and correctional facilities and 2) lack of awareness of community pharmacist-provided MOUD services. Future research should explore interventions to address the barriers identified in this study and improve connections between community pharmacists and formerly incarcerated individuals. This work can help ensure that these individuals are given the chance to successfully reintegrate into society.

'Matters-of-concern' associated with discontinuation of long-acting injectable buprenorphine: Findings from a longitudinal qualitative study

BACKGROUND

Discontinuation of medications such as methadone and buprenorphine amongst patients receiving opioid agonist treatment (OAT) is an international phenomenon. Recent developments in OAT medication include depot-injections of buprenorphine. Circumstances underlying discontinuation of these new formulations of medication are not fully understood from a qualitative perspective.

METHODS

Data derive from a longitudinal qualitative study of patients' experience of long-acting injectable buprenorphine (LAIB), involving semi-structured telephone-interviews held at six-points in time. The relevant dataset for this article consists of 44 interview transcripts, generated from 8 participants who were each affected by discontinuation of LAIB prescriptions (during the first 12-months of treatment). Analyses sought to identify circumstances associated with LAIB discontinuation and data were further situated within a framework of 'evidence making intervention' and associated 'matters-of-concern'. Matters-of-concern relate to the ways in which an intervention is 'made' and constructed through engagement and practice, from the perspective of the recipient.

FINDINGS

In this study, participants experienced either 'discontinuation of LAIB prescriptions by treatment services' or patient-led 'opt-out' from treatment. Matters-of-concern underlying the former were associated with late attendance for scheduled appointments, non-prescribed substance use or receiving a custodial sentence. Matters-of-concern relating to patient-initiated discontinuation were associated with personal circumstances that affected treatment motivation, side-effects (of buprenorphine), a preference to resume heroin use, or because individual treatment goals had been achieved.

CONCLUSION

The assorted matters-of-concern that influence discontinuation of LAIB demonstrate that such OAT is complex and multi-faceted, is neither fixed nor stable, and does not generate universally shared outcome. Experiences of LAIB discontinuation are shaped by a wide range of social, temporal and treatment-related effects that include disconnected therapeutic alliance between patient and treatment providers. In order to maximise the benefits of LAIB it is necessary to develop meaningful therapeutic alliances (notwithstanding policy boundaries) to enable exploration of matters-of-concern during treatment.

Expanding access to Medication for Opioid Use Disorder (MOUD) in jails: A comprehensive program evaluation

INTRODUCTION

Individuals with opioid use disorder (OUD) transitioning from jails or prisons to the community are at high risk of overdose-related death shortly after release. Buprenorphine, methadone, and extended-release naltrexone are FDA-approved medications for opioid use disorder (MOUD) to reduce overdose risk and increase treatment engagement. Despite the evidence, many correctional facilities in the United States do not provide MOUD to their incarcerated population. Albany County Jail and Rehabilitative Services Center (ACCRSC) is a jail in New York State that provides comprehensive MOUD and overdose prevention services to all incarcerated individuals with OUD.

METHODS

MOUD program participants' data was collected during custody and after release to determine whether the program's primary goals of preventing overdose-related mortality and MOUD continuation after release were met. Other quality-of-life metrics were used for program improvements, such as program participants' physical and mental well-being, postrelease housing, employment, access to mental health services, and re-incarceration.

RESULTS

This study included 375 unique individuals who received MOUD treatment at the jail between January 19, 2019, and the end of December 2020, with 56.2 % continuing their treatment and 43.7 % initiating MOUD during custody. Among those who initiated MOUD at ACCRSC, 93.3 % were enrolled in buprenorphine. We identified eight program participant deaths after release within a year after incarceration. The average time between release and death was 233 days, with the shortest time between release and death being 107 days. We found that over half (53.6 %) of program participants using buprenorphine picked up their prescriptions after exiting ACCRSC. Among those who did not, nearly 16 % were unable to do so because they were transferred to another jail or prison that did not provide MOUD care. Overall, nearly 80 % of program participants who were transferred to another correctional facility could not continue their medication.

CONCLUSIONS

MOUD in correctional settings appears to reduce overdose deaths immediately after release. Administering buprenorphine and other types of MOUD in a jail setting has shown relatively high retention for people to fill their first prescription of buprenorphine outside the jail. To ensure high MOUD retention among incarcerated populations, all correctional facilities must provide MOUD care.

Access to medications for opioid use disorder for formerly incarcerated individuals during community reentry: a mini narrative review

Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of re-arrest and overdose during community reentry. Unfortunately, few formerly incarcerated individuals are able to access MOUD within the community, missing a critical tool for rehabilitation. A mini narrative review was conducted to highlight the published work that has been done to improve access to MOUD for formerly incarcerated individuals during reentry. The results yielded 15 records describing intervention evaluations, program descriptions, and research in progress. Most work is ongoing, showing promise that researchers have identified the importance of this problem. However additional research should be done to include other stakeholders and address the limitations of existing interventions and programs. Continued efforts can help ensure that formerly incarcerated individuals can safely and successfully reintegrate into society.

Cost-effectiveness of full and partial opioid agonists for opioid use disorder in outpatient settings: United States healthcare sector perspective

INTRODUCTION

Studies show that medications for opioid use disorder (MOUD) reduce illicit opioid use, emergency healthcare services, opioid-related overdose, and death. However, few studies have investigated the long-term cost-effectiveness of MOUD in office-based opioid treatment (OBOT) and opioid treatment program (OTP) settings. We aimed to estimate the cost, utility, quality-adjusted life years gained (QALYs), and incremental cost-effectiveness ratios (ICERs) of three MOUD compared to each other and counseling without medication from a US healthcare sector perspective.

METHODS

Our study developed a Markov model to conduct a cost-effectiveness analysis of counseling and three MOUD in the OBOT and OTP settings: sublingual buprenorphine/naloxone (BUPNX), buprenorphine extended-release (XR-BUP) injection, and oral methadone. The model included five health states representing combinations of receiving or off treatment while either using or not actively using illicit opioids, and death. The cycle length was one month; the time-horizon was ten years. The study obtained model inputs from systematic reviews of published literature and public data. A 3 % annual discount rate was applied to cost and utility calculation. The primary outcomes included total costs, life-years (LYs), QALYs, and ICERs. We also conducted a scenario analysis using a hypothetical OBOT outpatient setting with methadone.

RESULTS

In the base-case OBOT setting, the total costs and QALYs, respectively, were counseling $22,848, 5.60; BUPNX $29,875, 5.82; and XR-BUP $63,936, 5.87. ICERs were $32,345/QALY (BUPNX vs. counseling) and $625,858/QALY (XR-BUP vs BUPNX). In the OTP setting, the total costs of counseling, methadone, BUPNX, and XR-BUP were $20,124, $27,000, $33,500, and $75,272, respectively. QALYs of methadone were 5.86. QALYs of counseling, BUPNX, and XR-BUP remained the same as in the OBOT setting. Incremental ICERs were $26,714/QALY (methadone vs counseling) and $3,337,623/QALY (XR-BUP vs methadone). BUPNX was dominated by methadone. In the scenario analysis, BUPNX was also dominated by methadone.

CONCLUSIONS

Outpatient MOUD resulted in important gains in quality of life and life expectancy. In both OBOT and OTP settings, XR-BUP was not cost-effective. BUPNX was cost-effective in the OBOT setting, while it was dominated by methadone in the OTP setting. The cost-effectiveness of BUPNX and XR-BUP could be enhanced if the costs of these medications were reduced.

Prison Buprenorphine Implementation and Postrelease Opioid Use Disorder Outcomes

Importance

Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are uncommonly offered. In April 2019, the Massachusetts Department of Correction (MADOC), the state prison system, provided buprenorphine for incarcerated individuals in addition to previously offered injectable naltrexone.

Objective

To evaluate postrelease outcomes after buprenorphine implementation.

Design, Setting, and Participants

This cohort study with interrupted time-series analysis used linked data across multiple statewide data sets in the Massachusetts Public Health Data Warehouse stratified by sex due to differences in carceral systems. Eligible participants were individuals sentenced and released from a MADOC facility to the community. The study period for the male sample was January 2014 to November 2020; for the female sample, January 2015 to October 2019. Data were analyzed between February 2022 and January 2024.

Exposure

April 2019 implementation of buprenorphine during incarceration.

Main Outcomes and Measures

Receipt of MOUD within 4 weeks after release, opioid overdose, and all-cause mortality within 8 weeks after release, each measured as a percentage of monthly releases who experienced the outcome. Segmented linear regression analyzed changes in outcome rates after implementation.

Results

A total of 15 225 individuals were included. In the male sample there were 14 582 releases among 12 688 individuals (mean [SD] age, 35.0 [10.8] years; 133 Asian and Pacific Islander [0.9%], 4079 Black [28.0%], 4208 Hispanic [28.9%], 6117 White [41.9%]), a rate of 175.7 releases per month; the female sample included 3269 releases among 2537 individuals (mean [SD] age, 34.9 [9.8] years; 328 Black [10.0%], 225 Hispanic [6.9%], 2545 White [77.9%]), a rate of 56.4 releases per month. Among male participants at 20 months postimplementation, the monthly rate of postrelease buprenorphine receipt was higher than would have been expected under baseline trends (21.2% vs 10.6% of monthly releases; 18.6 additional releases per month). Naltrexone receipt was lower than expected (1.0% vs 6.0%; 8.8 fewer releases per month). Monthly rates of methadone receipt (1.4%) and opioid overdose (1.8%) were not significantly different than expected. All-cause mortality was lower than expected (1.9% vs 2.8%; 1.5 fewer deaths per month). Among female participants at 7 months postimplementation, buprenorphine receipt was higher than expected (31.6% vs 9.5%; 12.4 additional releases per month). Naltrexone receipt was lower than expected (3.4% vs 7.2%) but not statistically significantly different. Monthly rates of methadone receipt (1.1%), opioid overdose (4.8%), and all-cause mortality (1.6%) were not significantly different than expected.

Conclusions and Relevance

In this cohort study of state prison releases, postrelease buprenorphine receipt increased and naltrexone receipt decreased after buprenorphine became available during incarceration.

Provision of health care services related to substance use disorder in southern U.S. jails

INTRODUCTION

The U.S. jail population has more than tripled since the 1980s, and today, one out of every three incarcerated individuals is being held in a county or city jail. Substance use disorders (SUD) are overrepresented in incarcerated populations; however, little recent research has examined the availability and quality of SUD-related health care services in jail settings. Incarcerated individuals may engage with a variety of SUD-related health care services, including: screening and withdrawal management at entry, SUD treatment or other brief health care interventions while they are being held, and overdose prevention education and reentry planning at release.

METHODS

We conducted a thematic analysis of qualitative data from 34 interviews conducted with 38 personnel from a purposive sample of jails that varied in size and rurality within a five-state study area. The goals of the analyses were to: 1) describe jail health care services for SUD and barriers to service provision, 2) compare current practices to best practice recommendations, and 3) provide context by describing factors at the jail and community level that influence service provision, such as access to resources.

RESULTS

Interviewees described wide variability in both availability and comprehensiveness of SUD-related health care services. Most adhered to federal guidance for supervising withdrawal from alcohol and benzodiazepines, but not opioids. Medication for addiction treatment was most widely available for pregnant women and rarely for other individuals. Roughly one third of the jails in our sample provided behavioral group or individual therapy with a licensed counselor and roughly one quarter offered self-help groups. Very few jails provided comprehensive re-entry planning and support. Jail staff reported specific barriers to providing each type of service, as well as limiting contextual factors. Despite observed increases in case volume, jail health care staff did not necessarily receive any additional funding or staff members. Overall, lack of investment in mental and behavioral health care contributed to recidivism and feelings of hopelessness among staff.

CONCLUSIONS

This study identified several areas where jails could improve SUD-related health care services. Many of the barriers to improvement-organizational buy-in, cost/budgeting, staffing, logistics-were not under the control of health care staff. Implementing changes will require support from local governments, jails administrators, private health care companies, and other local health care providers.

Burden of opioid toxicity death in the fentanyl-dominant era for people who experience incarceration in Ontario, Canada, 2015-2020: a whole population retrospective cohort study

OBJECTIVES

To describe mortality due to opioid toxicity among people who experienced incarceration in Ontario between 2015 and 2020, during the fentanyl-dominant era.

DESIGN

In this retrospective cohort study, we linked Ontario coronial data on opioid toxicity deaths between 2015 and 2020 with correctional data for adults incarcerated in Ontario provincial correctional facilities.

SETTING

Ontario, Canada.

PARTICIPANTS

Whole population data.

MAIN OUTCOMES AND MEASURES

The primary outcome was opioid toxicity death and the exposure was any incarceration in a provincial correctional facility between 2015 and 2020. We calculated crude death rates and age-standardised mortality ratios (SMR).

RESULTS

Between 2015 and 2020, 8460 people died from opioid toxicity in Ontario. Of those, 2207 (26.1%) were exposed to incarceration during the study period. Among those exposed to incarceration during the study period (n=1 29 152), 1.7% died from opioid toxicity during this period. Crude opioid toxicity death rates per 10 000 persons years were 43.6 (95% CI=41.8 to 45.5) for those exposed to incarceration and 0.95 (95% CI=0.93 to 0.97) for those not exposed. Compared with those not exposed, the SMR for people exposed to incarceration was 31.2 (95% CI=29.8 to 32.6), and differed by sex, at 28.1 (95% CI=26.7 to 29.5) for males and 77.7 (95% CI=69.6 to 85.9) for females. For those exposed to incarceration who died from opioid toxicity, 10.6% died within 14 days of release and the risk was highest between days 4 and 7 postrelease, at 288.1 per 10 000 person years (95% CI=227.8 to 348.1).

CONCLUSIONS

The risk of opioid toxicity death is many times higher for people who experience incarceration compared with others in Ontario. Risk is markedly elevated in the week after release, and women who experience incarceration have a substantially higher SMR than men who experience incarceration. Initiatives to prevent deaths should consider programmes and policies in correctional facilities to address high risk on release.

"Just fighting for my life to stay alive": a qualitative investigation of barriers and facilitators to community re-entry among people with opioid use disorder and incarceration histories

BACKGROUND

During the period of community re-entry immediately following release from jail or prison, individuals with opioid use disorder (OUD) face structural barriers to successful re-entry and high risk of overdose. Few published studies investigate experiences in the immediate period (i.e., first 24 h) of re-entry among people with OUD.

AIM

To understand the barriers and facilitators to treatment and reintegration of people with OUD during the initial transition from carceral settings back into the community.

METHODS

From January-December 2017, we conducted 42 semi-structured qualitative interviews with patients with a history of incarceration who were receiving methadone at a not-for-profit, low-barrier opioid treatment program. Interviews probed participants' community re-entry experiences immediately following incarceration. Interviews were transcribed and analyzed using a Thematic Analysis approach.

RESULTS

The main themes described the experiences during the 24 h following release, reacclimating and navigating re-entry barriers, and re-entry preparedness and planning. Participants noted the initial 24 h to be a period of risk for returning to substance use or an opportunity to engage with OUD treatment as well as a tenuous period where many lacked basic resources such as shelter or money. When discussing the subsequent re-entry period, participants noted social challenges and persistent barriers to stable housing and employment. Participants overall described feeling unprepared for release and suggested improvements including formal transition programs, improved education, and support to combat the risk of overdose and return to substance use after incarceration.

CONCLUSIONS

In this study that qualitatively examines the experiences of people with incarceration histories and OUD enrolled in methadone treatment, we found that participants faced many barriers to community re-entry, particularly surrounding basic resources and treatment engagement. Participants reported feeling unprepared for release but made concrete suggestions for interventions that might improve the barriers they encountered. Future work should examine the incorporation of these perspectives of people with lived experience into the development of transition programs or re-entry classes.

Medications for opioid use disorder during incarceration and post-release outcomes

BACKGROUND

Continuation or initiation of MOUDs during incarceration could improve post-release outcomes by preventing return to opioid use and reducing risk of overdose. People with OUD involved in the criminal legal system are a vulnerable population, yet little research has comprehensively examined post-release outcomes associated with receiving MOUDs in jail and prison settings.

METHODS

The authors conducted a review of published peer-reviewed literature on post-release outcomes associated with the use of MOUDs in correctional settings to determine implications for further research and policy.

RESULTS

Results showed compelling evidence supporting the use of MOUDs for currently incarcerated populations, with almost all studies showing that MOUDs provided during incarceration increased community-based treatment engagement post-release. There is also evidence that initiating or continuing MOUDs during incarceration is associated with decreased opioid use and overdoses post-release, without increasing criminal involvement.

CONCLUSIONS

Findings indicate that forcing tapering and withdrawal during incarceration can have dire consequences upon release into the community. Initiating or continuing MOUDs during incarceration reduces the risk for opioid use and overdose upon release by maintaining opioid tolerance and increasing community treatment engagement.

"And Then COVID Hits": A Qualitative Study of How Jails Adapted Services to Treat Opioid Use Disorder During COVID-19

Background: Jails in Massachusetts are among the first nationwide to provide correctional populations with medications to treat opioid use disorder (MOUD). The COVID-19 pandemic caused jails to pivot and adapt MOUD programming. We aimed to identify adaptations and barriers to MOUD access that COVID-19 exacerbated or created, and document new elements that staff wish to sustain as COVID-19 recedes. Methods: We conducted semi-structured in-depth interviews and focus groups in 2020-2021 with 29 jail staff who implement MOUD programming in two Massachusetts jails. We conducted qualitative data analysis in Atlas.ti 8 using an inductive approach. Results: Participants shared that access to MOUD among correctional populations is understood by jail staff to be an essential health service. Thus, to facilitate continued access to MOUD, both during incarceration and also at community reentry, jail staff quickly implemented changes in MOUD regulations and dosing protocols and established telehealth capacity. Despite these program adaptations, participants identified how COVID-19 increased health and social needs among correctional populations, reduced availability of community-based healthcare and recovery-supportive services, and introduced new factors that could undermine recovery. Innovations that participants wished to sustain as COVID-19 receded included telehealth capacity, smaller-sized therapeutic groups, and application of a public health approach to treat opioid use disorder among correctional populations. Conclusions: During disruptive events, jails can adapt MOUD programming to ensure access for people living in jail and upon release. Findings identify factors for understanding the outcomes of jail-based MOUD programming during COVID-19 and highlight opportunities to improve service delivery after COVID-19.

Anticipated Barriers to Sustained Engagement in Treatment With Medications for Opioid Use Disorder After Release From Incarceration

BACKGROUND

Although the burden of opioid use disorder is disproportionately high among persons who are incarcerated, medications for opioid use disorder are often unavailable in correctional settings. The Rhode Island Department of Corrections provides all 3 classes of medications for opioid use disorder to clinically eligible persons who are incarcerated. Despite a decrease in fatal overdoses among persons with recent criminal legal system involvement since the program's implementation, barriers to continued engagement in treatment after release from incarceration still exist.

METHODS

We conducted 40 semistructured, qualitative interviews with people who were incarcerated and enrolled in the comprehensive medications for opioid use disorder program at the Rhode Island Department of Corrections. Analysis applied a general, inductive approach using NVivo 12.

RESULTS

Participants discussed barriers to treatment engagement before incarceration, as well as anticipated barriers to medications to treat opioid use disorder continuation after release from incarceration. Structural factors including housing, health insurance, transportation, and the treatment program structure, as well as social factors such as social support networks were perceived to influence retention in medications to treat opioid use disorder post-release.

CONCLUSION

Our findings suggest that people with opioid use disorder who are incarcerated encounter unique challenges upon community reentry. Addressing structural factors that pose barriers to post-release engagement is essential to sustaining retention. We recommend utilization of peer recovery specialists to alleviate some of the stress of navigating the structural barriers identified by participants.

Treatment Experiences for Patients Receiving Buprenorphine/Naloxone for Opioid Use Disorder: A Qualitative Study of Patients' Perceptions and Attitudes

Background: Although buprenorphine/naloxone has been demonstrated to be an effective treatment for patients with opioid use disorder (OUD), treatment retention has been a challenge. This study extends what is presently a limited literature regarding patients' experiences with this medication and the implications for treatment retention. Methods: The study was conducted as a qualitative investigation of patients in treatment for OUD at the time of the study. Forty-three patients (27 men, 15 women, mean age 34.7) were recruited from three clinical settings, a community health center, an academically-based treatment site, and an independent substance abuse treatment facility. Most patients had returned to use in the past after attempts to become abstinent. Results: Patients generally reported positive experiences with this medication noting it helped to reduce opioid cravings quickly. As important considerations for treatment retention, patients emphasized a firm commitment to achieving abstinence when beginning treatment and a prescriber who is informed about and attentive to their emotional state. Diverging attitudes did exist regarding treatment duration as some patients were accepting of long-term treatment while others desired a relatively brief option. Among patients who had returned to use, potentially important issues emerged pertaining to the absence of patient outreach for missed medication appointments and inadequate discharge planning following stays at rehabilitation facilities. Conclusions: While results regarding the importance of patient motivation and strong patient-prescriber relationships have been noted in previous studies, other findings regarding opportunities to improve patient outreach and coordination of care have received relatively less attention and warrant further consideration.

Barriers and facilitators to opioid agonist treatment (OAT) engagement among individuals released from federal incarceration into the community in Ontario, Canada

INTRODUCTION

Correctional populations with opioid use disorder experience increased health risks during community transition periods. Opioid Agonist Treatment (OAT) can reduce these risks, but retention is a key challenge. This study addresses a knowledge gap by describing facilitators and barriers to OAT engagement among federal correctional populations released into the community in Ontario, Canada.

METHODS

This article describes results from a longitudinal mixed-methods study examining OAT transition experiences among thirty-five individuals released from federal incarceration in Ontario, Canada. Assessments were completed within one year of participants' release. Data were thematically analyzed.

RESULTS

The majority (77%) of participants remained engaged in OAT, however, 69% had their release suspended and 49% returned to custody. Key facilitators for OAT engagement included flexibility, positive staff rapport, and structure. Fragmented OAT transitions, financial OAT coverage, balancing reintegration requirements, logistical challenges, and inaccessibility of 'take-home' OAT medications were common barriers.

CONCLUSIONS

Post-incarceration transition periods are critical for OAT retention, yet individuals in Ontario experience barriers to OAT engagement that contribute to treatment disruptions and related risks such as relapse and/or re-incarceration. Additional measures to support community OAT transitions are required, including improved discharge planning, amendments to OAT and financial coverage policies, and an expansion of OAT options.

Opioid agonist treatment take-home doses ('carries'): Are current guidelines resulting in low treatment coverage among high-risk populations in Canada and the USA?

Opioid agonist treatment (OAT) is the primary intervention for opioid use disorder (OUD) in Canada and the USA. Yet, a number of barriers contribute to sub-optimal treatment uptake and retention, including daily-supervised medication administration. Thus, clients are eventually granted access to take-home OAT doses (i.e., ‘carries’) to reduce this burden. However, this decision is based on physician discretion and whether patients can demonstrate stability in various life domains, many of which are inextricably linked to the social determinants of health (SDOH). Current Canadian and USA OAT carry guidance documents are not standardized and do not take the SDOH into consideration, resulting in the potential for inequitable access to OAT carries, which may be the case particularly among marginalized populations such as individuals with OUD who have been released from custody. This perspective article posits that current OAT guidelines contribute to inequities in access to OAT carries, and that these inequities likely result in disproportionately low coverage for OUD treatment among some high-risk groups, including individuals on release from incarceration in particular. Relevant impacts of COVID-19 and related policy changes are considered, and suggestions and recommendations to amend current OAT guidance documents are provided.

Patients' experiences of continued treatment with extended-release naltrexone: a Norwegian qualitative study

BACKGROUND

The opioid antagonist extended-release naltrexone (XR-NTX) in the treatment of opioid use disorder (OUD) is effective in terms of safety, abstinence from opioid use and retention in treatment. However, it is unclear how patients experience and adjust to losing the possibility of achieving an opioid effect. This qualitative study is the first to explore how people with opioid dependence experience XR-NTX treatment, focusing on the process of treatment over time.

METHODS

Using a purposive sampling strategy, semi-structured interviews were undertaken with 19 persons with opioid use disorder (15 men, four women, 22-55 years of age) participating in a clinical trial of XR-NTX in Norway. The interviewees had received at least three XR-NTX injections. Qualitative content analysis with an inductive approach was used.

FINDINGS

Participants described that XR-NTX treatment had many advantages. However they still faced multiple challenges, some of which they were not prepared for. Having to find a new foothold and adapt to no longer gaining an effect from opioids due to the antagonist medication was challenging. This was especially true for those struggling emotionally and transitioning into the harmful use of non-opioid substances. Additional support was considered crucial. Even so, the treatment led to an opportunity to participate in society and reclaim identity. Participants had strong goals for the future and described that XR-NTX enabled a more meaningful life. Expectations of a better life could however turn into broken hopes. Although participants were largely optimistic about the future, thinking about the end of treatment could cause apprehension.

CONCLUSIONS

XR-NTX treatment offers freedom from opioids and can facilitate the recovery process for people with OUD. However, our findings also highlight several challenges associated with XR-NTX treatment, emphasizing the importance of monitoring emotional difficulties and increase of non-opioid substances during treatment. As opioid abstinence in itself does not necessarily equal recovery, our findings underscore the importance of seeing XR-NTX as part of a comprehensive, individualized treatment approach.

TRIAL REGISTRATION

Clinicaltrials.gov # NCT03647774, first Registered: Aug 28, 2018.

Scoping review of interventions to link individuals to substance use services at discharge from jail

INTRODUCTION

Individuals with substance use disorders (SUD) must be linked to community-based SUD treatment and other services upon their release from jail, given their high service needs and risks for relapse, recidivism, and opioid-related overdose following release.

METHOD

This scoping review identified 14 studies (28 affiliated publications) that used experimental or quasi-experimental designs to evaluate jail re-entry interventions for individuals with SUD. The team coded intervention components, study characteristics, and study outcomes based on a service continuum for treatment linkage and retention and for post-release substance use and criminal justice outcomes.

RESULTS

This review included 4 randomized controlled trials (RCT) for linkage to treatment with medications for opioid use disorder (MOUD); 4 RCTs and 4 quasi-experimental studies for linkage to non-specific SUD treatment; and 2 RCTs for linkage to HIV + SUD services. Most studies (9/14) used case management and/or peer or patient navigation as the core intervention; 2 studies provided medical management for MOUD induction and/or facilitated referral to MOUD in the community; and 3 studies used motivational-based linkage interventions. A qualitative analysis of study outcomes found evidence to support the effectiveness of a diverse range of interventions to link individuals to community-based SUD treatment, MOUD, and other services at re-entry, but limited support for intervention effects on longer-term outcomes, including treatment retention, medication adherence, recidivism, and substance use.

CONCLUSION

Future controlled trials and implementation studies should help to unpack and examine core components of jail re-entry interventions and their successful implementation to enhance treatment retention and improve post-release outcomes.

Opioid agonist treatment (OAT) experiences and release plans among federally incarcerated individuals with opioid use disorder (OUD) in Ontario, Canada: a mixed-methods study

Background

Incarcerated populations experience an elevated prevalence of opioid use disorder (OUD). Federal correctional institutions in Canada have increasingly treated OUD among correctional populations via opioid agonist treatment (OAT) – an evidence based pharmacotherapy that works to reduce drug use and related health harms. However, there is limited evidence regarding incarcerated individuals’ experiences with institutional-based OAT, as well potential OAT-related community release prospects. This information is important for optimal treatment retention and improved health. To address this knowledge gap, we conducted a longitudinal follow-up study examining OAT-related experiences among federally incarcerated individuals before and after community release. This article focuses on the baseline (pre-release) data.

Methods

This mixed-methods study examined OAT-related experiences and release prospects among n = 46 individuals scheduled for community release, recruited from seven federal prisons located in Ontario, Canada. Participants underwent a comprehensive interviewer-administered on-site assessment, including quantitative and qualitative items. Assessment data was furthermore linked to administrative correctional data. Data were analyzed using thematic qualitative and descriptive quantitative approaches.

Results

Participants had complex histories with opioid use including related negative health outcomes. Experiences with institutional OAT were divergent and provision was not standardized; those with OAT engagement pre-admission did not experience many challenges, whereas those initiating OAT during incarceration experienced barriers such as treatment waitlists and adverse process experiences. Most participants expressed a preference for buprenorphine-naloxone over methadone, but described difficulties accessing it. Participants were keen to transition into community-based treatment, yet envisaged prospective barriers and facilitators concerning successful reintegration and treatment continuity.

Conclusions

Major barriers towards the current administration of OAT in federal correctional systems in Canada exist, including extensive waitlists, non-standardized practices, and challenges accessing preferred OAT formulations; this contributes to sub-optimal treatment. Eliminating waitlists, standardizing OAT provision, providing additional OAT options, and more comprehensive release planning may be essential for treatment retention and positive outcomes.

Opioid-specific medication-assisted therapy and its impact on criminal justice and overdose outcomes

Background

The overlap between justice system involvement and drug use is well-documented. Justice-involved people who misuse opioids are at high risk for relapse and criminal recidivism. Criminal justice policymakers consider opioid-specific medication-assisted therapies (MATs) one approach for improving outcomes for this population. More research is needed that explores the impacts of opioid-specific MATs for justice-involved people.

Objectives

This study sought to assess the effects of opioid-specific MAT for reducing the frequency and likelihood of criminal justice and overdose outcomes for current or formerly justice-involved individuals.

Search Methods

Records were searched between May 7, 2021 and June 23, 2021. We searched a total of sixteen proprietary and open access databases that included access to gray literature and conference proceedings. The bibliographies of included studies and relevant reviews were also searched.

Selection Criteria

Studies were eligible for inclusion in the review if they: (a) assessed the effects of opioid-specific MATs on individual-level criminal justice or overdose outcomes; included (b) a current or formerly justice-involved sample; and (c) a randomized or strong quasi-experimental design; and c) were published in English between January 1, 1960 and October 31, 2020.

Data Collection and Analysis

We used the standard methodological procedures as expected by The Campbell Collaboration.

Main Results

Twenty studies were included, representing 30,119 participants. The overall risk of bias for the experimental studies ranged from "some" to "high" and for quasi-experimental studies ranged from "moderate" to "serious." As such, findings must be interpreted against the backdrop of less-than-ideal methodological contexts. Of the 20 included studies, 16 included outcomes that were meta-analyzed using mean log odds ratios (which were reported as mean odds ratios). Mean effects were nonsignificant for reincarceration (odds ratio [OR] = 0.93 [0.68, 1.26], SE = .16), rearrest (OR = 1.47 [0.70, 3.07], SE = 0.38), and fatal overdose (OR = 0.82 [0.56, 1.21], SE = 0.20). For nonfatal overdose, the average effect was significant (OR = 0.41 [0.18, 0.91], SE = 0.41, p < 0.05), suggesting that those receiving MAT had nearly 60% reduced odds of a nonfatal overdose.

Implications for Policy Practice and Research

The current review supports some utility for adopting MAT for the treatment of justice-involved people with opioid addiction, however, more studies that employ rigorous methodologies are needed. Researchers should work with agencies to improve adherence to medication regimens, study design, and collect more detailed information on participants, their criminal and substance use histories, onset, and severity. This would help clarify whether treatment and control groups are indeed comparable and provide better insight into the potential reasons for participant dropout, treatment failure, and the occurrence of recidivism or overdose. Outcomes should be assessed in multiple ways, if possible (e.g., self-report and official record), as reliance on official data alone may undercount participants' degree of criminal involvement.

Perceptions and experiences toward extended-release buprenorphine among persons leaving jail with opioid use disorders before and during COVID-19: an in-depth qualitative study

BACKGROUND

Extended-release buprenorphine (XRB) offers a novel approach to sustained monthly treatment for people who use opioids in criminal justice settings (CJS). This study explores the experiences of adults receiving XRB as a jail-to-community treatment.

METHODS AND FINDINGS

In-depth qualitative interviews were conducted among adult participants with opioid use disorder (OUD; n  = 16) who were recently released from NYC jails and maintained on XRB after switching from daily sublingual buprenorphine (SLB). Interviews elaborated on the acceptability and barriers and facilitators of XRB treatment pre- and post-release. Interviews were audio recorded, transcribed, and analyzed for content related to factors influencing XRB treatment uptake and community reentry. Important themes were grouped into systems, medication, and patient-level factors. Key systems-level factors influencing initiation of XRB in jail included an alternative to perceived stigmatization and privacy concerns associated with daily in-jail SLB administration and less concerns with buprenorphine diversion. In-jail peer networks positively influenced participant adoption of XRB. XRB satisfaction was attributed to reduced in-jail clinic and medication administration visits, perceived efficacy and blockade effects upon the use of heroin/fentanyl following release, and averting the risk of criminal activities to fund opioid use. Barriers to retention included post-injection withdrawal symptoms and cravings attributed to perceived suboptimal medication dosing, injection site pain, and lack of in-jail provider information about the medication.

CONCLUSION

Participants were generally favorable to XRB initiation in jail and retention post-release. Further studies are needed to address factors influencing access to XRB in criminal justice settings, including stigma, ensuring patient privacy following initiation on XRB, and patient-, provider-, and correctional staff education pertaining to XRB. Trial Registration ClinicalTrials.gov Identified: NCT03604159.

The Role of Misinformation and Stigma in Opioid Use Disorder Treatment Uptake

Background: Deaths due to opioid overdose continue to rise in the United States. Despite availability of effective treatment for opioid use disorder, uptake is low among those who misuse opioids. Methods: This paper explores the role of misconception, stigma, and misinformation in influencing decisions to initiate medications for opioid use disorder among patients and providers. Conclusion: Misinformation about opioids has been prevalent among future healthcare providers and first responders as well as pharmaceutical companies, which may have implications for treatment. Among individuals with opioid use disorder, treatment uptake and adherence have been negatively affected by misconceptions about treatment efficacy and side effects, as well as stigma. We discuss the role of social media, education, and the community, in mitigating misinformation and addressing misconceptions about opioids and treatment options.

Medications for opioid use disorder in state prisons: Perspectives of formerly incarcerated persons

Background: Opioid use disorder (OUD) is common among incarcerated persons and risk of overdose and other adverse drug-related consequences is high after release. Recognizing their potential to reduce these risks, some correctional systems are expanding access to medication for opioid use disorder (MOUD). This study explored the experiences and perspectives of formerly incarcerated individuals on MOUD use while incarcerated and after release. Methods: We interviewed 53 individuals with self-reported OUD who were released from New Jersey state prisons. Interviews explored motivations to use MOUD while incarcerated and after release, and experiences with prison-based MOUD and transition to community-based care. We performed cross-case analysis to examine common and divergent perspectives across participants. Results: A common reason for accepting prerelease MOUD was recognition of its effectiveness in preventing drug use, overdose, and other drug-related consequences. Participants who chose not to use MOUD often were focused on being completely medication-free or saw themselves as having relatively low-risk of substance use after a prolonged period without opioid use. A few participants reported challenges related to prison-based MOUD, including logistical barriers, stigma, and once-daily buprenorphine dosing. Most participants effectively transitioned to community-based care, but challenges included insurance lapses and difficulty locating providers. Conclusions: Many formerly incarcerated persons with OUD recognize the value of MOUD in supporting recovery, but some hold negative views of MOUD or underestimate the likelihood that they will return to drug use. Patient education on risks of post-release overdose, the role of MOUD in mitigating risk, and MOUD options available to them could increase engagement. Participants' generally positive experiences with MOUD support the expansion of correctional MOUD programs.

The Predictive Value of Degree of Preference for Extended-Release Naltrexone for Treatment Adherence, Opioid Use, and Relapse

BACKGROUND

Extended-release naltrexone (XR-NTX) is effective for illicit opioid abstinence as an opioid maintenance treatment. To improve treatment outcomes, patient's preference for the modality of treatment is an important factor.

OBJECTIVES

We aimed to test the relationship between baseline preference for XR-NTX and adherence to treatment, use of illicit opioids, and risk of relapse.

METHODS

In an open-label, Norwegian clinical trial participants with opioid use disorder were randomized to either monthly injections with XR-NTX or daily sublingual buprenorphine-naloxone (BP-NLX) for 12 weeks. Subsequently, participants could continue with their preferred medication in a 36-week follow-up and in a prolonged period of 104 weeks.

RESULTS

Of 153 participants who completed detoxification, 72% were men, with a mean age of 36 years. Preference levels were similar across the randomized groups, with no significant associations between preference and adherence to treatment, opioid use, or relapse. The BP-NLX group had a significantly higher risk of first relapse to opioids than the XR-NTX group for all levels of preference (p < 0.001) and a significantly higher number of days of illicit opioid use. In the follow-up period, the adherence rate was twice as high among participants with the highest preference compared to participants with the lowest preference, both among those who switched to XR-NTX and those who continued (hazard ratio 2.2; 1.2-4.0, p = 0.013). Opioid use was significantly higher among participants who switched to XR-NTX with the lowest preference than the medium (p = 0.003) or the highest (p = 0.001) preference. The risk of relapse to opioids, however, was significantly higher among XR-NTX continuing participants with the lowest (p = 0.002) or the medium (p = 0.043) preference than those with the highest preference.

CONCLUSIONS

Individuals who matched with their preferred treatment used less illicit opioids than those who did not during short-term treatment. However, baseline preference for XR-NTX treatment primarily influenced longer term opioid use and treatment adherence.

'Not at all what I had expected': Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study

BACKGROUND

Extended-release naltrexone (XR-NTX), an opioid antagonist, has demonstrated equal treatment outcomes, in terms of safety, opioid use, and retention, to the recommended OMT medication buprenorphine. However, premature discontinuation of XR-NTX treatment is still common and poorly understood. Research on patient experiences of XR-NTX treatment is limited. We sought to explore participants' experiences with discontinuation of treatment with XR-NTX, particularly motivation for XR-NTX, experiences of initiation and treatment, and rationale for leaving treatment.

METHODS

We conducted qualitative, semi-structured interviews with participants from a clinical trial of XR-NTX. The study participants (N = 13) included seven women and six men with opioid dependence, who had received a minimum of one and maximum of four injections of XR-NTX. The study team analyzed transcribed interviews, employing thematic analysis with a critical realist approach.

FINDINGS

The research team identified three themes, and we present them as a chronological narrative: theme 1: Entering treatment - I thought I knew what I was going into; theme 2: Life with XR-NTX - I had something in me that I didn't want; and theme 3: Leaving treatment - I want to go somewhere in life. Patients' unfulfilled expectations of how XR-NTX would lead to a better life were central to decisions about discontinuation, including unexpected physical, emotional, or mental reactions as well as a lack of expected effects, notably some described an opioid effect from buprenorphine. A few participants ended treatment because they had reached their treatment goal, but most expressed disappointment about not achieving this goal. Some also expressed renewed acceptance of OMT. The participants' motivation for abstinence from illegal substances generally remained.

CONCLUSION

Our findings emphasize that a dynamic understanding of discontinuation of treatment is necessary to achieve a long-term approach to recovery: the field should understand discontinuation as a feature of typical treatment trajectories, and discontinuation can be followed by re-initiation of treatment.

Life satisfaction among individuals with opioid use disorder receiving extended-release naltrexone: A 12-week randomized controlled trial and a 36-week follow-up

INTRODUCTION

Life satisfaction (LS) in opioid-dependent individuals is lower than in the general population. This study aimed to explore changes in LS during short- and long-term treatment with extended-release naltrexone (XR-NTX).

METHODS

This open-label 12-week clinical trial randomized 159 participants to either monthly XR-NTX or daily buprenorphine-naloxone (BP-NLX). In a subsequent 36-week follow-up study on XR-NTX, participants either continued or switched to XR-NTX. The study collected data on the Temporary Satisfaction with Life (TSWL) and illicit opioid use every fourth week. The research team assessed changes in TSWL by a linear mixed model and growth mixture model. The study assessed relationship between opioid use and TSWL by a linear mixed model.

RESULTS

Change in LS differed significantly between the groups in both study periods. TSWL scores were significantly higher in the XR-NTX group at week 4 (p = 0.013) and week 8 (p = 0.002). In the follow-up period, the groups were significantly different only at week 16 (p = 0.031) and week 48 (p = 0.025), with the higher TSWL scores in the XR-NTX continued group. Increase in opioid use by one day was associated with a 0.12 point lower mean TSWL score. Both study periods identified groups with low and high LS levels. In the trial period, the TSWL scores exhibited a significant increase from baseline to week 12 in both groups, p < 0.001 and p = 0.011 in the low and high LS group, respectively. In the follow-up period, the TSWL scores exhibited a significant increase from week 16 to week 48 (p = 0.003) in the high LS group, while the low LS group showed persistently lower values throughout that period.

CONCLUSIONS

XR-NTX treatment given once monthly is associated with higher LS, as measured by TSWL, compared to daily use of BP-NLX. The majority of the participants had relatively low TSWL scores and did not report any change in TSWL during longer-term treatment. The study found a significant association between more frequent illicit opioid use and a low or decreased LS during follow-up.

Do out-of-pocket costs influence retention and adherence to medications for opioid use disorder?

BACKGROUND

Availability of medications for opioid use disorder (MOUD) has increased during the past two decades but treatment retention and adherence remain low. This study aimed to measure the impact of out-of-pocket buprenorphine cost on treatment retention and adherence among US commercially insured patients.

METHODS

Medical payment records from IBM MarketScan were analyzed for 6,439 adults age 18-64 years with commercial insurance who initiated buprenorphine treatment during January 1, 2016 to June 30, 2017. Regression models analyzed the relationship between patients' average daily out-of-pocket buprenorphine cost and buprenorphine retention (at least 80 % days covered by buprenorphine) at three different thresholds (180, 360, and 540 days) and adherence (the number of days of buprenorphine coverage) within each retention threshold. Models controlled for patient demographic and clinical characteristics including age, sex, presence of other substance use disorders, psychiatric and pain diagnoses, and receipt of prescription medications.

RESULTS

A one dollar increase in daily out-of-pocket buprenorphine cost was associated with a 12-14 % decrease in the odds of retention and a 5-8 % increase in the number of days without buprenorphine coverage during each analyzed retention threshold.

CONCLUSION

Recent policies have attempted to address supply-side barriers to MOUD treatment. This study highlights patient cost-sharing as a demand-side barrier to MOUD. While the average out-of-pocket buprenorphine cost is lower than two decades ago, this study suggests even at current levels such costs decrease retention and adherence among commercially insured patients. Efforts to address demand-side barriers could help maximize the health and social benefits of buprenorphine-based MOUD.

Opioid use disorder treatment for people experiencing homelessness: A scoping review

BACKGROUND

The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 2019 coronavirus disease pandemic. Existing, evidence-based treatment options for opioid use disorder (OUD) are broadly underutilized, particularly by people experiencing homelessness (PEH). PEH are also more likely to misuse and overdose on opioids. To better understand current gaps and disparities in OUD treatment experienced by PEH and efforts to address them, we synthesized the literature reporting on the intersection of housing status and OUD treatment.

METHODS

We conducted a scoping review of the literature from the electronic databases MEDLINE, Embase, PsycINFO, and Web of Science Core Collection. We included studies describing treatment-related outcomes specific to PEH and articles assessing OUD treatment interventions tailored to this population. Relevant findings were compiled via thematic analysis and narratively synthesized.

RESULTS

60 articles met our inclusion criteria, including 43 descriptive and 17 intervention-focused studies. These studies demonstrated that PEH experience more barriers to OUD treatment than their housed counterparts and access inpatient and detoxification treatment more commonly than pharmacotherapy. However, the reviewed literature indicated that PEH have similar outcomes once engaged in pharmacotherapy. Efficacious interventions for PEH were low-barrier and targeted, with housing interventions also demonstrating benefit.

CONCLUSIONS

PEH have diminished access to evidence-based OUD treatment, particularly medications, and require targeted approaches to improve engagement and retention. To mitigate the disproportionate opioid-related morbidity and mortality PEH experience, innovative, flexible, and interdisciplinary OUD treatment models are necessary, with housing support playing an important role.

Endogenous opiates and behavior: 2019

This paper is the forty-second consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2019 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

A systematic literature review of patient perspectives of barriers and facilitators to access, adherence, stigma, and persistence to treatment for substance use disorder

Introduction

The opioid crisis has left a devastating impact on the United States (U.S.) for over 20 years. The over-prescribing of opioid medications and availability of illicit opioids have contributed to the U.S. opioid epidemic. Given the complexity of the epidemic, substance use disorder, and its treatment, there is an urgent need for a thorough review of the qualitative literature which has captured the patient's experiences Such patient-derived qualitative data on lived experiences and perspectives may allow researchers, clinicians, and policy makers to glean new insights into addressing this epidemic.

Objectives

The objective of this paper is to present a systematic literature review of the existing U.S. qualitative research and provide a patient perspective on medications for opioid use disorder (MOUD), including barriers and facilitators to MOUD use.

Methods

In November 2019, four electronic databases (PubMed, CINAHL, Scopus, and Web of Science) were searched by a medical librarian using a combination of keywords, Medical Subject Headings (MeSH), and/or CINAHL subject headings. 8766 results were imported into EndNote, then duplicate records were removed, leaving a total of 4722 articles. The unique records were imported into Rayyan QCRI an online platform designed to expedite screening. Blinded screening was undertaken in duplicate by four reviewers. Two researchers abstracted all the articles and used thematic analysis.

Results

The screening in the abstract phase excluded 4681 results, leaving 41 studies for full-text screening to determine their eligibility for inclusion in the review. After screening, 21 articles were included in the study and the analysis is based on these articles Common themes across studies included stigmatization, perceived barriers to MOUD, and MOUD treatment deserts and provider shortages.

Conclusions

Qualitative research studies conducted to date have uncovered substantial MOUD treatment barriers which are both social and structural in nature. Such barriers to treatment may serve to exacerbate the current epidemic and must be taken into consideration in designing policy and treatment solutions for patients with OUD.

Does incarceration influence patients' goals for opioid use disorder treatment? A qualitative study of buprenorphine treatment in jail

BACKGROUND

Correctional facilities increasingly offer medications for opioid use disorder (OUD), including buprenorphine. Nevertheless, retention in treatment post-incarceration is suboptimal and overdose mortality remains high. Our objectives were to understand how incarcerated patients viewed buprenorphine treatment and identify modifiable factors that influenced treatment continuation post-release.

METHODS

We conducted semi-structured interviews with 22 men receiving buprenorphine treatment in an urban jail. Interviews were audio recorded, professionally transcribed, and analyzed using a grounded-theory approach. Team members constructed preliminary case memos from transcripts, and then interactively discussed themes within respective memos. We established participant 'typologies' by consensus.

RESULTS

Distinct typologies emerged based on participants' post-release treatment goals: (1) those who viewed buprenorphine treatment as a cure for OUD; (2) those who thought buprenorphine would help manage opioid-related problems; and (3) those who did not desire OUD treatment. Participants also described common social structural barriers to treatment continuation and community re-integration. Participants reported that post-release housing instability, unemployment, and negative interactions with parole contributed to opioid use relapse and re-incarceration.

CONCLUSION

Participants had different goals for post-release buprenorphine treatment continuation, but their prior experiences suggested that social structural issues would complicate these plans. Incarceration can intensify marginalization, which when combined with heightened legal supervision, reinforced cycles of release, relapse, and re-incarceration. Participants valued buprenorphine treatment, but other structural and policy changes will be necessary to reduce incarceration-related inequities in opioid overdose mortality.

Strategies to improve implementation of medications for opioid use disorder reported by veterans involved in the legal system: A qualitative study

BACKGROUND

Veterans involved in the legal system have a high risk of overdose mortality but limited utilization of medications for opioid use disorder (MOUD). To increase the use of MOUD in Veterans Health Administration (VHA) facilities and reduce overdose mortality, the VHA should incorporate strategies identified by legal-involved veterans to improve quality of care and ensure that their patients' experiences are integrated into care delivery. This study aims to determine strategies to increase use of MOUD from the perspective of legal-involved veterans with a history of opioid use or opioid use disorder (OUD).

METHODS

Between February 2018 and March 2019, we conducted semistructured interviews with 18 veterans with a history of opioid use or OUD and legal involvement (15 men and 3 women; mean age 41, standard deviation 13, range 28-61). Veterans were from 9 geographically dispersed United States VHA facilities. The study analyzed verbatim transcripts using the framework method. The primary focus was themes that represented legal-involved veteran-identified strategies to improve the use of MOUD.

RESULTS

The 18 veterans interviewed had legal involvement directly related to their opioid use and most (n = 15; 83%) had previously used MOUD. Veteran-identified strategies to improve access to and use of MOUD included: (1) VHA should provide transportation or telehealth services; (2) legal agencies should increase access to MOUD during incarceration; (3) the VHA should reduce physician turnover; (4) the VHA should improve physician education to deliver compassionate, patient-centered treatment; (5) the VHA should improve veteran education about MOUD; and (6) the VHA should provide social support opportunities to veterans.

CONCLUSIONS

Legal-involved veterans provided strategies that can inform and expand MOUD to better meet their needs and the treatment needs of all patients with OUD. The VHA should consider incorporating these strategies into care, and should evaluate their impact on patients' experience, initiation of and retention on medications, and overdose rates.

Adaptation of a standard extended-release naltrexone (XR-NTX) protocol for rural re-entering offenders with OUD

BACKGROUND

Despite a growing body of empirical support for the effectiveness of extended-release naltrexone (XR-NTX) to reduce opioid relapse among people with opioid use disorder (OUD) transitioning from a correctional facility to the community, continuity of care following release remains challenging. This paper describes a research-based adaptation of a state's standard of care XR-NTX protocol using the ADAPT-ITT framework for delivery in a non-traditional, non-treatment, community criminal justice setting (P&P office), as well as the expansion of services by a local Federally Qualified Health Center (FQHC) provider who would, for the first time, be going to the jail and P&P office to provide XR-NTX and related treatment.

METHOD

The present study focuses on the first seven phases (Assessment through Training) of the ADAPT-ITT framework in the adaptation of the Department of Corrections (DOC) protocol in preparation for a pilot trial for induction in a rural jail and during the transition to a rural community. Expert clinical review and focus groups with key stakeholders in criminal justice supervision and the local providers in the FQHC informed the needed adaptations to the existing XR-NTX protocol for initiation at the jail and ongoing administrations in the community.

RESULTS

Findings from stakeholder focus groups, study team review, topical expert review, and a theater test suggested that there were critical adaptations needed in both content and context at the patient and clinic level.

CONCLUSION

Health and justice officials should consider the need to tailor and adapt evidence-based approaches for real-world locations that high-risk, justice-involved individuals visit in order to reduce barriers and increase access to critically needed treatment for OUD.

Kentucky Women's Justice Community Opioid Innovation Network (JCOIN): A type 1 effectiveness-implementation hybrid trial to increase utilization of medications for opioid use disorder among justice-involved women

The opioid crisis has disproportionately affected women, but research on approaches to increase initiation of medications for opioid use disorder (MOUD) among women is limited. The Kentucky Justice Community Opioid Innovation Network (JCOIN) will implement a type 1 hybrid effectiveness and implementation trial to examine an innovative MOUD pretreatment model using telehealth (alone and in combination with peer navigators) for justice-involved women in transition from jail to the community. The overall goal of the project is to increase initiation and maintenance of MOUD among high-risk justice-involved women during community reentry to reduce opioid relapse and overdose. This project and other studies through the JCOIN network have the potential to significantly impact the OUD treatment field by contributing empirical evidence about the effectiveness and implementation of innovative technologies to increase initiation and maintenance of MOUD during a critical, high-risk time of community reentry among vulnerable, justice-involved individuals in both urban and nonurban communities.

Patients' perspectives on initiating treatment with extended-release naltrexone (XR-NTX)

BACKGROUND

The National Drug Abuse Treatment Clinical Trials Network (CTN) multisite comparative-effectiveness study ("X:BOT") by Lee et al. (2018) found that, once initiated, extended-release naltrexone (XR-NTX) is as similarly safe and effective as sublingual buprenorphine-naloxone (BUP-NX) for the treatment of opioid use disorder (OUD). However, the detoxification hurdle makes XR-NTX much more difficult to initiate than BUP-NX. This hurdle highlights the need to better understand how patients transition from active opioid use to XR-NTX treatment.

OBJECTIVE

To explore patient-identified barriers and facilitators to initiating antagonist treatment (XR-NTX) within the context of an inpatient hospital setting and to reflect postdischarge experiences of those who did and did not initiate XR-NTX treatment.

METHOD

We used a convenience sampling strategy to identify study candidates, with the intention of recruiting approximately an equal number of medication-initiated and noninitiated patients. Study participants (N = 14) included 13 males and 1 female with OUD randomized to the XR-NTX arm of the X:BOT study at 1 of the 8 study sites. Seven participants in this sample initiated XR-NTX treatment, and seven did not. Each participant completed one semistructured qualitative interview. We analyzed transcripts using deductive and inductive approaches to conventional content analysis.

RESULTS

Although the majority of participants viewed opioid blockade, once-monthly dosing, and no dependence or withdrawal as favorable attributes of XR-NTX, participant ambivalence and lack of familiarity with antagonist treatment were barriers to treatment initiation. The long duration of action and the perceived "commitment" to the medication (e.g., "At the time, a month sounded like a year") compounded the patients' concerns and ambivalence. The majority of those who initiated XR-NTX described it as an effective treatment for OUD, with treatment satisfaction and sustained abstinence emerging as central themes among this population. Some participants who did not successfully initiate XR-NTX expressed regret and a willingness to try XR-NTX in the future.

CONCLUSION

Achieving full opioid detoxification is one, but not the only, barrier to initiating treatment with XR-NTX. Additional participant-identified barriers to XR-NTX initiation include fears and ambivalence regarding antagonist treatment. Once initiated, participants perceive XR-NTX to be an effective treatment for maintaining abstinence from opioids. XR-NTX appealed to participants due to the autonomy it affords with once-monthly dosing and no physical dependence.

Reducing overdose after release from incarceration (ROAR): study protocol for an intervention to reduce risk of fatal and non-fatal opioid overdose among women after release from prison

BACKGROUND

Drug overdose is the leading cause of death after release from prison, and this risk is significantly higher among women compared to men. Within the first 2 weeks after release, the risk of death from drug overdose is 12.7 times higher than the general population, with risk of death further elevated among females. Although female inmates have higher rates of opioid use disorder and post-release overdose fatality, justice-involved women are under-represented in studies of medications for opioid use disorder. The Reducing Overdose After Release from Incarceration (ROAR) pilot intervention and evaluation (recruitment June 2019 through December 2020) aims to reduce opioid overdose among women released to the community following incarceration in state prison. The evaluation further assesses induction, acceptance and effectiveness of extended release naltrexone in a female post-prison population.

METHODS/DESIGN

In the week prior to their release, female adults in custody with moderate to severe opioid use disorder start treatment with extended release naltrexone, an injectable opioid antagonist that blocks the effects of opioids for up to 1 month. All ROAR participants receive training to use naloxone rescue kits and are provided nasal naloxone at release. Ongoing support from a certified recovery mentor to facilitate sustained engagement with treatment for substance use disorders begins in the month prior to release from prison and continues for 6 months in community. We evaluate the association between ROAR participation and the primary outcome of opioid overdose. Using administrative data provided by the Oregon Department of Corrections and the Oregon Health Authority, we compare the odds of overdose among ROAR participants versus a comparison group of females released from prison during the study period. Evaluation activities in community includes survey and qualitative interviews for 6 months post release, as well as a review of clinic records to assess retention on medication among the pilot cohort (N = 100).

DISCUSSION

ROAR is a collaboration between Oregon's public health, criminal justice, and medical communities. The ROAR intervention and evaluation provide critical information on improving interventions to prevent opioid overdose and improve retention on treatment in community in an overlooked, high-risk population: incarcerated women re-entering the community.

TRIAL REGISTRATION

Clinical Trials.gov TRN: NCT03902821 .