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

Approved medications for opioid use disorder : current update

INTRODUCTION

Opioid use disorder (OUD) is recognized as a chronic, relapsing disorder with a high mortality and psychiatric and somatic comorbidity.

AREAS COVERED

Existing guidelines and meta-analyses on pharmacotherapy of opioid use disorder were reviewed. Opioid maintenance treatment (OMT) is the generally accepted first line treatment in OUD with oral methadone and buprenorphine being the gold standard. In recent years a number of novel opioids have been introduced into clinical practice including depot formulations of buprenorphine, retarded morphine and heroin (diacetylmorphine). The review refers to the different drugs available and gives an overview on clinical use, side effects, and efficacy in certain subgroups.

EXPERT OPINION

OMT is a success story with emerging new pharmacological options available. While oral methadone or buprenorphine still are the most suitable medications for many patients, depot formulations of buprenorphine may improve adherence and facilitate clinical management of many patients. Diacetylmorphine and retarded morphine are second line medications for treatment refractory patients. Future research may focus on responder characteristics for certain medications and efficacy in special subgroups as well as interaction of psychosocial and pharmacological treatments.

Pharmacological and behavioral pain treatment strategies for patients with opioid use disorder

INTRODUCTION

A critical challenge in providing effective medical care for individuals in opioid agonist treatment (OAT) for opioid use disorder is the effective management of acute and chronic pain. While pain commonly co-occurs with opioid use disorder, there is limited research to guide effective management of pain in this population.

AREAS COVERED

We first provide an overview of the etiology and treatment of acute and chronic pain, highlighting areas of complexity for patients receiving OAT. We then describe the search strategy, which involved a date-inclusive search for relevant terms in PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials. After summarizing the results of this search on the evidence for pharmacological and behavioral treatments of acute and chronic pain for individuals on OAT, we conclude with a discussion of these findings and a summarized expert opinion on the state of the evidence.

EXPERT OPINION

The evidence suggests that while research on effective treatment of acute and chronic pain in individuals in OAT is limited, promising work is ongoing to translate existing treatments, particularly behavioral treatments for chronic pain, to support this population. However, further research is warranted, particularly regarding pharmacological options.

Buprenorphine discontinuation and utilization of psychosocial services: a national study in the Veterans Health Administration

BACKGROUND

Longer duration of treatment with medication for opioid use disorder (MOUD) is associated with improved outcomes, but long-term retention remains a challenge. Research is needed to identify psychosocial interventions that support MOUD retention. To address this gap, we examined associations between a wide range of psychosocial services and buprenorphine treatment discontinuation across 18 months among a large cohort of Veterans initiating buprenorphine nationwide.

METHODS

We identified a cohort of patients with new buprenorphine initiation in 2017-2018 in Veterans Health Administration electronic health record data (N = 11,704). We examined prescription fills for up to 18 months after initiation. The primary outcome was first discontinuation of buprenorphine. We examined a variety of services, including psychotherapy in specialty substance use disorder (SUD) and mental health clinics, other healthcare services, and residential programs. To examine time-varying associations between psychosocial services and risk of discontinuation, we fit extended Cox regression models for each service separately and simultaneously.

RESULTS

Overall, 80.5% of patients discontinued buprenorphine at least once within 18 months. Risk of discontinuation was 18% (HR: 0.82, 95% CI: 0.77, 0.87) relatively lower following SUD psychotherapy and 26% (HR: 1.26, 95% CI: 1.15,1.39) higher following residential treatment.

CONCLUSIONS

Several services, including residential treatment, were associated with greater risk of subsequent buprenorphine discontinuation, whereas only SUD psychotherapy was consistently associated with lower risk of later discontinuation. These findings emphasize the need for future studies to increase understandings of beneficial and disruptive components of psychosocial services to improve treatment retention among patients receiving MOUD.

Exploring the Lived Experiences of Medication for Opioid use Disorder Treatment: A Qualitative Study among a Crowdsourced Convenience Sample

Given the effectiveness of medication for opioid use disorder (MOUD) and low engagement of treatment among people who use drugs (PWUD), it is important to better understand how to engage treatment clients with MOUD care. The current study aimed to achieve this goal by using qualitative methodology to characterize the MOUD treatment experiences. Participants (N = 52) were recruited for an online semi-structured interview. Qualitative analysis revealed varied treatment experiences, with the majority expressing irregular and intermittent MOUD treatment engagement. The therapeutic effects of MOUD in curbing withdrawal symptoms in conjunction with counseling services was frequently mentioned, as well as a preference for methadone maintenance treatment (MMT) to buprenorphine or naltrexone. Many participants described barriers to treatment and continuation of care, including failed drug screens for non-opioid drugs, perceived stigma, and physician-initiated discontinuation of treatment. The current study revealed that patients had favorable experiences with MOUD treatment, particularly when supplemented with counseling services.

A scoping review of interventions for engaging adolescents and young adults in opioid use disorder treatment across the care cascade

Background: A high number of adolescents and young adults engage in opioid misuse and/or meet criteria for opioid use disorder (OUD). Youth also experience worse treatment outcomes when compared to adult counterparts.Objectives: This scoping review aimed to identify and summarize existing interventions designed to increase engagement of youth across the OUD care cascade, as well as describe clinical and research implications.Methods: Peer-reviewed literature was searched using PubMed, PsycInfo, and Web of Science. Studies were eligible if they presented outcomes of an intervention focused on engaging adolescents and young adults (ages 12-25 years) in the OUD care cascade and were published in English.Results: Nine articles met inclusion criteria that described interventions for adolescents and young adults across engagement, initiation, and retention in the OUD care cascade. Several strategies were used in interventions, including behavioral health and integrated health services, contingency management, meaningful family involvement, assertive outreach, and provider trainings/consultation. Only one intervention has been tested with a randomized control trial.Conclusions: Due to small sample sizes and lack of control groups, findings from existing intervention studies do not indicate which strategies are most effective. Further research is urgently needed to develop and evaluate effective interventions for youth with OUD. Providers working with youth should implement services to meet youth's individual needs. Providers should consider utilizing integrated services and referrals to behavioral health, involving family in treatment, and use of contingency management and assertive outreach. Continuing education for providers on OUD treatment and developmental concerns is also crucially needed.

Prise en charge du trouble lié à l’usage d’opioïdes : mise à jour 2024 du guide de pratique clinique nationale

Contexte:

Dans un contexte où les pratiques et les politiques évoluent constamment, il est essentiel d’être à l’affût des plus récentes données scientifiques et de les intégrer afin d’optimiser la prise en charge des personnes atteintes d’un trouble lié à l’usage d’opioïdes. Cet article résume le nouveau guide de pratique clinique nationale de l’Initiative canadienne de recherche sur les impacts des substances psychoactives (ICRIS) sur la prise en charge clinique du trouble lié à l’usage d’opioïdes qui révise les recommandations de 2018.

Méthodes:

Aux fins de la mise à jour, nous avons suivi l’Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines et utilisé l’outil AGREE-REX (Appraisal of Guidelines REsearch and Evaluation—Recommendations EXcellence) pour assurer la qualité. Au terme d’une revue systématique de la littérature scientifique pertinente publiée entre le 1er janvier 2017 et le 14 septembre 2023, nous avons formulé et classé les nouvelles recommandations selon l’approche GRADE (Grading of Recommendations Assessment, Development, and Evaluation). Un comité multidisciplinaire national externe — auquel siégeaient notamment des personnes ayant un savoir expérientiel avec le trouble lié à l’usage d’opioïdes — a procédé à une évaluation, dont les résultats ont été pris en compte dans ce guide.

Recommandations:

Sur les 11 recommandations présentées dans le guide de 2018, 3 sont restées inchangées, et les 8 autres ont été mises à jour. Quatre d’entre elles ont été combinées en 1 seule, 1 a été scindée en 2, 1 est devenue une considération particulière et 2 ont fait l’objet d’une simple révision. Les principales modifications découlent de données probantes substantielles attestant que la méthadone et la buprénorphine ont une efficacité équivalente, notamment pour diminuer l’usage d’opioïdes et les effets indésirables, et sont donc maintenant toutes deux les options thérapeutiques privilégiées de première intention. La morphine orale à libération prolongée est recommandée comme une option de deuxième intention. Il est possible d’offrir des interventions psychosociales comme traitement complémentaire, mais cela ne devrait pas être obligatoire. Le présent guide de pratique clinique réitère l’importance d’éviter de prendre en charge le sevrage comme unique intervention et d’inclure des services de réduction des méfaits fondés sur des données probantes dans le continuum de soins.

Interprétation:

La mise à jour propose de nouvelles recommandations fondées sur les dernières données probantes en vue de normaliser la prise en charge du trouble lié à l’usage d’opioïdes. L’objectif est d’établir une assise solide sur laquelle les organismes provinciaux et territoriaux pourront bâtir leurs directives sur l’optimisation des soins.

An initial randomized controlled trial of a Combined Medication and Behavioral Activation Treatment (CoMBAT) for people with opioid use disorder

INTRODUCTION

Opioid use disorder is a chronic, relapsing disease and a major source of morbidity and mortality in the U.S. Medications for opioid use disorder (MOUD) have been shown to reduce opioid use; however, MOUD maintenance is often suboptimal. Depression is a well-documented risk factor for MOUD treatment disengagement; thus, behavioral interventions to address depression and support ongoing MOUD use in community settings are warranted.

METHODS

We evaluated the feasibility, acceptability, and preliminary efficacy of the CoMBAT (Combined Medication and Behavioral Activation Treatment) intervention via a pilot randomized controlled trial. We hypothesized that the CoMBAT intervention, which uses behavioral activation, motivational interviewing, and problem-solving techniques, would be feasible and acceptable to participants and decrease depression, increase goal-directed activity, improve MOUD care engagement, and reduce opioid use among adults with depressive symptoms who had a missed dose or clinical MOUD visit in the past 30 days. We enrolled 32 participants prescribed methadone or buprenorphine in the community; each received 2 health navigation and substance use counseling sessions (HN_SUC) before being randomized into (a) the 8-session CoMBAT intervention + HN_SUC + treatment as usual or (b) HN_SUC + treatment as usual only. The primary outcomes were intervention feasibility and acceptability. Preliminary efficacy measures included self-reported past-30-day MOUD doses and clinical visits, depressive symptoms, behavioral activation; and opioid-positive urinalysis; each assessed at baseline and 3- and 6-month follow-up visits.

RESULTS

The intervention was feasible (88 % of intervention sessions completed; 100 % retention at 6 months) and acceptable (86 % of intervention participants were satisfied/very satisfied with the intervention at 3-months; and intervention participants had a high level of alliance with their counselor at the mid-point: mean = 5.7 out of 7 [SD = 1.3] and end of their treatment: mean = 5.5 out of 7 [SD = 1.1]. At 6-months, intervention participants reported fewer missed MOUD doses and visits, less depressive symptoms, greater behavioral activation scores, and a lower percentage of opioid-positive toxicology screens relative to the control condition.

CONCLUSION

Findings provide evidence of intervention feasibility and acceptability and demonstrate initial efficacy for ongoing MOUD care engagement, depressive symptom reduction, increased behavioral activity, and reduced opioid use. Future intervention testing in a fully-powered efficacy trial is warranted.

Evaluating remyelination compounds for new applications in opioid use disorder management

Opioid use disorder (OUD) is associated with a reduction in brain white matter, affecting critical areas involved in decision-making, impulse control, and reward processing. The FDA has approved several drugs and natural compounds that enhance myelination, targeting oligodendrocyte progenitor cells (OPCs), directly enhancing oligodendrocyte (OL) function, or acting as cofactors for myelin production. This retrospective case study aimed to assess whether current clinical evidence supports the use of myelin-enhancing agents to promote remission in OUD. We evaluated a range of compounds with demonstrated effects on myelination, including muscarinic antagonists, cholesterol and lipid homeostatic agents, anti-aging drugs, immunomodulatory agents, anti-inflammatory medications, and others (25 medications in total), as well as 17 vitamins and supplements. Buprenorphine and methadone were used as positive controls. Sequential analyses were performed to identify individual drugs driving significant changes in remission rates (p ≤ 0.01; N ≥ 3,000) and their effects across age, sex, and Body Mass Index (BMI) categories. Three key findings emerged: (1) melatonin improved remission rates in males but showed no effect in females; (2) ibuprofen significantly increased remission rates, particularly in individuals aged 20-39 and 40-59 years; and (3) thiamin was associated with decreased remission rates in males and individuals with a BMI ranging from normal weight to obese. Additionally, buprenorphine and methadone were confirmed as effective in promoting remission. These findings highlight the importance of personalized medicine in treating OUD and suggest that further research is needed to explore individualized treatment strategies based on sex, age, and BMI.

Network intervention analysis to assess the trajectory of change and intervention effects associated with the use of self-control training for ego depletion aftereffects

PURPOSE

The purpose of this study was to use the advanced technique of Network Intervention Analysis (NIA) to investigate the trajectory of symptom change associated with the effects of self-control training on youth university students' chronic ego depletion aftereffects.

METHODS

The nine nodes of chronic ego depletion aftereffects and integrated self-control training were taken as nodes in the network and analyzed using NIA. Networks were computed at the baseline, at the end of treatment, at 1-, 3-, 6-, 9- and 12-month follow up. 62 samples were recruited from universities and randomly divided into two groups. The sample ranged in age from 18 to 25 years and included both males and females.

RESULTS

Self-control training interventions directly improved the states of low self-efficacy, low adherence, and work burnout, as well as indirectly alleviated fatigue, emotional regulation disorders, and other issues. Follow-up surveys showed that the intervention not only had immediate effects but also had long-term effects.

CONCLUSION

These findings indicate that self-control training has a direct intervention effect on low self-efficacy, low adherence, and work burnout of youth university students' ego depletion aftereffects. This study is the first application of NIA in abnormal psychological state intervention research outside the field of mental disorder treatment. NIA is a promising method to evaluate the trajectories of intervention change and the direct and indirect effects of training interventions.

CLINICAL TRIAL REGISTRATION

No. KY20202063-F-2; date of approval: 10th December, 2020.

Association of Opioid Use Disorder-Related Service Trajectories during Pregnancy and Postpartum Health Service Use: A Group-Based Multitrajectory Modeling Study

OBJECTIVE

The aim of the study was to examine the relationship between opioid use disorder (OUD)-related service trajectories during pregnancy and postpartum emergency department (ED) and hospitalizations.

METHODS

We used the Merative MarketScan Commercial Claims and Encounters Database (2013-2021) to identify a cohort of pregnant individuals with OUD. We used group-based multitrajectory modeling to identify opioid-related treatment and service trajectories during pregnancy and examined their association with postpartum ED and hospital utilization.

RESULTS

Seven opioid-related treatment and service trajectories were identified in our cohort of 2,531 pregnant individuals with OUD. Compared to individuals initiating medications for OUD (MOUD) halfway through pregnancy but maintaining high adherence without ancillary services, those receiving only services throughout pregnancy had a higher risk of postpartum ED visits (HRED = 1.34). This latter group also faced significantly higher risks of postpartum hospitalizations, compared to adherent MOUD use (proportion of days covered ≥80%) alone, both throughout or in the latter half of pregnancy (HRHOS = 1.93; HRHOS = 1.60), and patients without MOUD or services (HRHOS = 1.43). Individuals initiating MOUD late in pregnancy with poor adherence and infrequent service use faced significantly higher risks of postdelivery hospitalization compared to consistent MOUD users throughout pregnancy (HRHOS = 2.33), or in the latter half, with or without services (HRHOS = 2.02; HRHOS = 1.93), and those not receiving MOUD or services (HRHOS = 1.73).

CONCLUSIONS

Adherent MOUD use either throughout pregnancy or the latter half of pregnancy, irrespective of other service use, was associated with better postpartum outcomes defined by fewer ED visits and hospitalizations.

Management of opioid use disorder: 2024 update to the national clinical practice guideline

BACKGROUND

In an evolving landscape of practices and policies, reviewing and incorporating the latest scientific evidence is necessary to ensure optimal clinical management for people with opioid use disorder. We provide a synopsis of the 2024 update of the 2018 National Guideline for the Clinical Management of Opioid Use Disorder, from the Canadian Research Initiative in Substance Matters.

METHODS

For this update, we followed the United States Institute of Medicine's Standards for Developing Trustworthy Clinical Practice Guidelines and used the Appraisal of Guidelines Research and Evaluation-Recommendation Excellence tool to ensure guideline quality. We carried out a comprehensive systematic literature review, capturing the relevant literature from Jan. 1, 2017, to Sept. 14, 2023. We drafted and graded recommendations according to the Grading of Recommendations, Assessments, Development and Evaluation approach. A multidisciplinary external national committee, which included people with living or lived experience of opioid use disorder, provided input that was incorporated into the guideline.

RECOMMENDATIONS

From the initial 11 recommendations in the 2018 guideline, 3 remained unchanged, and 8 were updated. Specifically, 4 recommendations were consolidated into a single revised recommendation; 1 recommendation was split into 2; another recommendation was moved to become a special consideration; and 2 recommendations were revised. Key changes have arisen from substantial evidence supporting that methadone and buprenorphine are similarly effective, particularly in reducing opioid use and adverse events, and both are now considered preferred first-line treatment options. Slow-release oral morphine is recommended as a second-line option. Psychosocial interventions can be offered as adjunctive treatment but should not be mandatory. The guideline reaffirms the importance of avoiding withdrawal management as a standalone intervention and of incorporating evidence-based harm reduction services along the continuum of care.

INTERPRETATION

This guideline update presents new recommendations based on the latest literature for standardized management of opioid use disorder. The aim is to establish a robust foundation upon which provincial and territorial bodies can develop guidance for optimal care.

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

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

Development and Evaluation of a Digital App for Patient Self-Management of Opioid Use Disorder: Usability, Acceptability, and Utility Study

BACKGROUND

Self-management of opioid use disorder (OUD) is an important component of treatment. Many patients receiving opioid agonist treatment in methadone maintenance treatment settings benefit from counseling treatments to help them improve their recovery skills but have insufficient access to these treatments between clinic appointments. In addition, many addiction medicine clinicians treating patients with OUD in a general medical clinic setting do not have consistent access to counseling referrals for their patients. This can lead to decreases in both treatment retention and overall progress in the patient's recovery from substance misuse. Digital apps may help to bridge this gap by coaching, supporting, and reinforcing behavioral change that is initiated and directed by their psychosocial and medical providers.

OBJECTIVE

This study aimed to conduct an acceptability, usability, and utility pilot study of the KIOS app to address these clinical needs.

METHODS

We developed a unique, patient-centered computational software system (KIOS; Biomedical Development Corporation) to assist in managing OUD in an outpatient, methadone maintenance clinic setting. KIOS tracks interacting self-reported symptoms (craving, depressed mood, anxiety, irritability, pain, agitation or restlessness, difficulty sleeping, absenteeism, difficulty with usual activities, and conflicts with others) to determine changes in both the trajectory and severity of symptom patterns over time. KIOS then applies a proprietary algorithm to assess the individual's patterns of symptom interaction in accordance with models previously established by OUD experts. After this analysis, KIOS provides specific behavioral advice addressing the individual's changing trajectory of symptoms to help the person self-manage their symptoms. The KIOS software also provides analytics on the self-reported data that can be used by patients, clinicians, and researchers to track outcomes.

RESULTS

In a 4-week acceptability, usability (mean System Usability Scale-Modified score 89.5, SD 9.2, maximum of 10.0), and utility (mean KIOS utility questionnaire score 6.32, SD 0.25, maximum of 7.0) pilot study of 15 methadone-maintained participants with OUD, user experience, usability, and software-generated advice received high and positive assessment scores. The KIOS clinical variables closely correlated with craving self-report measures. Therefore, managing these variables with advice generated by the KIOS software could have an impact on craving and ultimately substance use.

CONCLUSIONS

KIOS tracks key clinical variables and generates advice specifically relevant to the patient's current and changing clinical state. Patients in this pilot study assigned high positive values to the KIOS user experience, ease of use, and the appropriateness, relevance, and usefulness of the specific behavioral guidance they received to match their evolving experiences. KIOS may therefore be useful to augment in-person treatment of opioid agonist patients and help fill treatment gaps that currently exist in the continuum of care. A National Institute on Drug Abuse-funded randomized controlled trial of KIOS to augment in-person treatment of patients with OUD is currently being conducted.

Efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT) in Individuals With Chronic Pain and Opioid Use Disorder: Protocol for a Randomized Clinical Trial of a Digital Cognitive Behavioral Treatment

BACKGROUND

Chronic pain is common among individuals with opioid use disorder (OUD) who are maintained on medications for OUD (MOUD; eg, buprenorphine or methadone). Chronic pain is associated with worse retention and higher levels of substance use. Treatment of individuals with chronic pain receiving MOUD can be challenging due to their increased clinical complexity. Given the acute and growing nature of the opioid crisis, MOUD is increasingly offered in a wide range of settings, where high-quality, clinician-delivered, empirically validated behavioral treatment for chronic pain may not be available. Therefore, digital treatments that support patient self-management of chronic pain and OUD have the potential for wider implementation to fill this gap.

OBJECTIVE

This study aims to evaluate the efficacy of Integrating the Management of Pain and Addiction via Collaborative Treatment (IMPACT), an interactive digital treatment program with asynchronous coach feedback, compared to treatment as usual (TAU) in individuals with chronic pain and OUD receiving MOUD.

METHODS

Adult participants (n=160) receiving MOUD and reporting bothersome or high-impact chronic pain will be recruited from outpatient opioid treatment programs in Connecticut (United States) and randomized 1:1 to either IMPACT+TAU or TAU only. Participants randomized to IMPACT+TAU will complete an interactive digital treatment that includes 9 modules promoting training in pain and addiction coping skills and a progressive walking program. The program is augmented with a weekly personalized voice message from a trained coach based on daily participant-reported pain intensity and interference, craving to use opioids, sleep quality, daily steps, pain self-efficacy, MOUD adherence, and engagement with IMPACT collected through digital surveys. Outcomes will be assessed at 3, 6, and 9 months post randomization. The primary outcome is MOUD retention at 3 months post randomization (ie, post treatment). Secondary outcomes include pain interference, physical functioning, MOUD adherence, substance use, craving, pain intensity, sleep disturbance, pain catastrophizing, and pain self-efficacy. Semistructured qualitative interviews with study participants (n=34) randomized to IMPACT (completers and noncompleters) will be conducted to evaluate the usability and quality of the program and its outcomes.

RESULTS

The study has received institutional review board approval and began recruitment at 1 site in July 2022. Recruitment at a second site started in January 2023, with a third and final site anticipated to begin recruitment in January 2024. Data collection is expected to continue through June 2025.

CONCLUSIONS

Establishing efficacy for a digital treatment for addiction and chronic pain that can be integrated into MOUD clinics will provide options for individuals with OUD, which reduce barriers to behavioral treatment. Participant feedback on the intervention will inform updates or modifications to improve engagement and efficacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05204576; https://clinicaltrials.gov/ct2/show/NCT05204576.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/54342.

Exploring user experiences of a text message-delivered intervention among individuals on opioid use disorder treatment in Kenya: A qualitative study

Opioid use disorder causes significant burden of disease and treatment comprises pharmacotherapy and psychosocial treatment. Cognitive behavioral therapy is an effective psychosocial intervention used in substance use disorders treatment and can be delivered using digital approach. There is limited use of digital treatment among individuals with opioid use disorder in Kenya. This study aimed to describe the experiences and feedback from participants with opioid use disorder enrolled in a text-message intervention in Kenya. Qualitative data was collected from participants in the intervention arm of a feasibility trial testing a text-message intervention based on cognitive behavioral therapy. Data was collected using open-ended questions in a questionnaire and structured in-depth interviews amongst those who received the intervention. Framework method was applied for analysis. Twenty-four participants (83.3% males) were enrolled with a mean age of 32.5 years (SD9.5). Five themes were identified namely: (1) Gain of cognitive behavioral therapy skills which included: identification and change of substance use patterns; drug refusal skills; coping with craving and self-efficacy; (2) Therapeutic alliance which included: development of a bond and agreement on treatment goals; (3) Feedback on intervention components and delivery such as: frequency, and duration of the text message intervention; (4) Challenges experienced during the intervention such as: technical problems with phones; and barriers related to intervention delivery; (5) Recommendations for improvement of intervention in future implementations. The findings demonstrated participants' satisfaction with intervention, gain of skills to change substance use patterns, highlighted challenges experienced and suggestions on improving the intervention among individuals with opioid use disorder. The feedback and recommendations provided by the participants can guide implementation of such interventions to allow acceptability, effectiveness and sustainability. Trial registration: This study was part of a randomized feasibility trial. Clinical trial registration: Pan African Clinical Trial Registry: Registration number: PACTR202201736072847. Date of registration: 10th January 2022.

Are DEA-waivered buprenorphine prescribers colocated with behavioral health clinicians?

BACKGROUND AND OBJECTIVES

Medication for opioid use disorder (MOUD) in primary care includes a combination of medication, behavioral therapy, and/or other psychosocial services. This study assessed rates of colocation between waivered prescribers and behavioral health clinicians across the United States to understand if rates varied by provider type and geographic indicators.

METHODS

Data from the DEA-Drug Addiction Treatment Act of 2000 provider list as of March 2022 and the National Plan and Provider Enumeration System's National Provider Identifier database were gathered, cleaned, and formatted in Stata. Data were geocoded with ESRI StreetMap® database and ArcGIS software. Covariates at individual, county, and state levels were examined and compared. Chi-square statistics and a mixed-effects logistic regression were analyzed.

RESULTS

The sample (N = 71, 292 prescribers) included physicians (64%), nurse practitioners (29%), and physician assistants (7%). About 48% of prescribers were colocated with a behavioral health clinician. Physicians were the least likely to be colocated (47%), but differences between provider types were modest. We observed significant geographic differences in provider colocation by provider type. Mixed effects logistic regression identified significant predictors of colocation at individual, county, and state levels.

DISCUSSION AND CONCLUSIONS

Optimally distributing the workforce providing MOUD is necessary to broadly ensure the provision of comprehensive MOUD care based on practice guidelines.

SCIENTIFIC SIGNIFICANCE

Less than half of all waivered prescribers, outside of hospitals, are colocated with behavioral health clinicians. Findings offer greater clarity on where integrated MOUD is occurring, among which types of providers, and where it needs to be expanded to increase MOUD uptake.

Outcomes Associated with Treatment with and Without Medications for Opioid Use Disorder

There is limited research on outcomes for patients who start treatment for opioid use disorder (OUD) with only psychosocial treatment compared to those who initiate treatment with either medications for OUD (MOUD) or the combination of psychosocial treatment and MOUD. Cox proportional hazards regression was used on a database of individuals with commercial health insurance or Medicare Advantage to estimate the associations of treatment type with opioid overdose and self-harm (separately). Logistic regression was used to estimate the association of treatment type with prescription opioid fill following treatment initiation. Relative to patients who initiated treatment with only psychosocial treatment, patients who also initiated treatment with MOUD had lower risk of having an overdose inpatient or emergency department (ED) encounter, a self-harm inpatient or ED encounter, and a prescription opioid filled following treatment initiation. Starting treatment with MOUD was associated with better patient outcomes than initiating treatment with only psychosocial treatment.

Economic Evaluation of Extended-Release Buprenorphine for Persons With Opioid Use Disorder

Importance

In 2017, the US Food and Drug Administration (FDA) approved a monthly injectable form of buprenorphine, extended-release buprenorphine; published data show that extended-release buprenorphine is effective compared with no treatment, but its current cost is higher and current retention is lower than that of transmucosal buprenorphine. Preliminary research suggests that extended-release buprenorphine may be an important addition to treatment options, but the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine remains unclear.

Objective

To evaluate the cost-effectiveness of extended-release buprenorphine compared with transmucosal buprenorphine.

Design, Setting, and Participants

This economic evaluation used a state transition model starting in 2019 to simulate the lifetime of a closed cohort of individuals with OUD presenting for evaluation for opioid agonist treatment with buprenorphine. The data sources used to estimate model parameters included cohort studies, clinical trials, and administrative data. The model relied on pharmaceutical costs from the Federal Supply Schedule and health care utilization costs from published studies. Data were analyzed from September 2021 to January 2023.

Interventions

No treatment, treatment with transmucosal buprenorphine, or treatment with extended-release buprenorphine.

Main Outcomes and Measures

Mean lifetime costs per person, discounted quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs).

Results

The simulated cohort included 100 000 patients with OUD receiving (61% male; mean [SD] age, 38 [11] years) or not receiving medication treatment (58% male, mean [SD] age, 48 [18] years). Compared with no medication treatment, treatment with transmucosal buprenorphine yielded an ICER of $19 740 per QALY. Compared with treatment with transmucosal buprenorphine, treatment with extended-release buprenorphine yielded lower effectiveness by 0.03 QALYs per person at higher cost, suggesting that treatment with extended-release buprenorphine was dominated and not preferred. In probabilistic sensitivity analyses, treatment with transmucosal buprenorphine was the preferred strategy 60% of the time. Treatment with extended-release buprenorphine was cost-effective compared with treatment with transmucosal buprenorphine at a $100 000 per QALY willingness-to-pay threshold only after substantial changes in key parameters.

Conclusions and Relevance

In this economic evaluation of extended-release buprenorphine compared with transmucosal buprenorphine for the treatment of OUD, extended-release buprenorphine was not associated with efficient allocation of limited resources when transmucosal buprenorphine was available. Future initiatives should aim to improve retention rates or decrease costs associated with extended-release buprenorphine.

Opioid use disorder treatment and the role of New Jersey Medicaid policy changes: perspectives of office-based buprenorphine providers

Background: In the US, seventy percent of drug-related deaths are attributed to opioids. In response to the ongoing opioid crisis, New Jersey's (NJ) Medicaid program implemented the MATrx model to increase treatment access for Medicaid participants with opioid use disorder (OUD). The model's goals include increasing the number of office-based treatment providers, enhancing Medicaid reimbursement for certain treatment services, and elimination of prior authorizations for OUD medications.Objectives: To explore office-based addiction treatment providers' experiences delivering care in the context of statewide policy changes and their perspectives on treatment access changes and remaining barriers.Methods: This qualitative study used purposive sampling to recruit office-based New Jersey medications for opioid use disorder (MOUD) providers . Twenty-two providers (11 females, 11 males) discussed treatment experiences since the policy changes in 2019, including evaluations of the current state of OUD care in New Jersey and perceived outcomes of the MATrx model policy changes.Results: Providers reported the MOUD climate in NJ improved as Medicaid implemented policies intended to reduce barriers to care and increase treatment access. Elimination of prior authorizations was noted as important, as it reduced provider burden and allowed greater focus on care delivery. However, barriers remained, including stigma, pharmacy supply issues, and difficulty obtaining injectable or non-generic medication formulations.Conclusion: NJ policies may have improved access to care for Medicaid beneficiaries by reducing barriers to care and supporting providers in prescribing MOUD. Yet, stigma and lack of psychosocial supports still need to be addressed to further improve access and care quality.

Quality of life of patients treated with opium tincture or methadone: A randomized controlled trial

OBJECTIVE

Quality of life (QoL) is an increasingly recognized patient-centered treatment outcome in individuals with opioid use disorder. There is a gap in literature on the impact of opium tincture (OT) on patients' QoL compared to standard treatment options such as methadone. This study aimed to compare the QoL of participants with opioid use disorder receiving OAT using OT or methadone and identify the factors associated with their QoL during treatment.

METHODS

The opium trial was a multicenter non-inferiority randomized clinical trial in four private OAT outpatient clinics in Iran. The study assigned patients to either OT (10 mg/ml) or methadone sirup (5 mg/ml) for a follow-up of 85 days. QoL was assessed using the brief version of the World Health Organization Quality of Life instrument (WHOQOL- BREF).

RESULTS

A total of 83 participants, 35 (42.2%) in the OT arm and 48 (57.8%) in the methadone arm, completed the WHOQOL-BREF in full and were included in the primary analysis. The mean score of patients' QoL showed improvement compared to baseline, but differences were not statistically significant between OT and methadone arms (p = 0.786). Improvements were mainly observed within the first 30 days of receiving treatment. Being married and lower psychological distress were associated with an improved QoL. Within the social relationships domain, male gender showed significantly higher QoL compared to females.

CONCLUSION

OT shows promise as an OAT medication, comparable to methadone in improving patients' QoL. There is a need to incorporate psychosocial interventions to further sustain and improve the QoL in this population. Identifying other social determinants of health which affect QoL and the cultural adaptation of assessments for individuals from various ethnocultural backgrounds are critical areas of inquiry.

Eliminate the buprenorphine DEA X waiver: Justification using a policy analysis approach

INTRODUCTION

Drug overdoses have reached a historic milestone of over 100,000 deaths in a single year, 75,673 related to opioids. The acceleration in opioid-related deaths coupled with stark health inequities demands a close examination of opioid use disorder (OUD) treatment barriers and swift consideration of policy changes.

DESIGN

The aim of this buprenorphine policy analysis is to summarize existing buprenorphine barriers and present policy solutions to improve access and actualize the contributions of Advanced Practice Registered Nurses (APRNs).

METHODS

The policy analysis follows five sequential steps: (1) defining the problem, (2) identifying key stakeholders, (3) assessing the landscape of relevant policies, (4) describing viable policy options, and (5) making final recommendations.

RESULTS

Although there are laudable efforts to improve buprenorphine access, such as the new buprenorphine guidelines issued in April 2021, without larger-scale changes to federal, state, and scope of practice laws, overdose rates will continue to rise. We recommend a multipronged policy approach to improve buprenorphine treatment access, including eliminating the DEA X waiver, improving OUD education, and adopting full practice authority for APRNs in all states.

CONCLUSION

Incremental change is no longer sufficient to address opioid overdose deaths. Bolder and coordinated policy action is possible and necessary to empower the full clinical workforce to apply evidence-based life-saving treatments for OUD. The critical contributions of nurses in advancing equitable access to OUD care are emphasized in the National Academy of Medicine's Report, Future of Nursing: Charting a Path to Achieve Health Equity. Nurses are named as instrumental in improving buprenorphine access. Policy changes that acknowledge and build on evidence-based treatment expansion strategies are sorely needed.

CLINICAL RELEVANCE

One of the most robust tools to combat opioid overdose deaths is buprenorphine, a partial opioid agonist, and gold standard medication treatment for OUD, but only 5% of the prescribing workforce possess the required Drug Enforcement Agency (DEA) X waiver. A growing body of evidence demonstrates that Advanced Practice Registered Nurses are accelerating the growth in waiver update and buprenorphine use, despite the considerable barriers and limitations described in this policy analysis.

To Prescribe or Not to Prescribe?: Barriers and Motivators for Progressing Along Each Stage of the Buprenorphine Training and Prescribing Path

This study aimed to identify the strongest barriers and motivators associated with each step toward buprenorphine prescribing (1. obtaining a waiver, 2. beginning to prescribe, and 3. prescribing to more people) among a sample of Missouri-based medical professionals (N = 130). Item weights (number of endorsements times mean rank of the item's importance) were calculated based on their responses. Across groups, lack of access to psychosocial support services, need for higher levels of care, and clinical complexity were strong barriers. Among non-prescribers (n = 57, 46.3%), administrative burden, potential of becoming an addiction clinic, and concern about misuse and diversion were most heavily weighted. Among prescribers (n = 66, 53.7%), patients' inability to afford medications was a barrier across phases. Prominent motivators among all groups were the effectiveness of buprenorphine, improvement in other health outcomes, and a personal interest in treating addiction. Only prescribers reported the presence of institutional support and mentors as significant motivators.

Digital interventions for opioid use disorder treatment: A systematic review of randomized controlled trials

INTRODUCTION

Opioid use disorders are associated with a high burden of disease and treatment gap. Digital interventions can be used to provide psycho-social treatment for opioid use disorders, as an alternative to or together with face-to-face interventions. This review aimed to assess the application and effectiveness of digital interventions to treat opioid use disorder globally.

METHODS

The study team searched four electronic databases (PubMed, Psych INFO, Web of Science and Cochrane Central register of controlled trials). The inclusion criteria were: randomized controlled trials, assessment for opioid use before and at least once following intervention, and use of digital interventions. The primary outcomes were opioid use and/or retention in treatment, with data being summarized in tables and a narrative review presented.

RESULTS

The initial database search yielded 3542 articles, of which this review includes 20. Nineteen were conducted among adults in the United States. The digital interventions used included web-based, computer-based, telephone calls, video conferencing, automated self-management system, mobile applications and text messaging. They were based on therapeutic education systems, community reinforcement approaches, cognitive behavior therapy, relapse prevention, brief interventions, supportive counselling and motivational interviewing. The studies had mixed findings; of the 20 studies, 10 had statistically significant differences between the treatment groups for opioid abstinence, and four had significant differences for treatment retention. Comparisons were difficult due to varying methodologies. Participants rated the interventions as acceptable and reported high rates of satisfaction.

CONCLUSION

The use of digital interventions for opioid use disorder treatment was acceptable, with varying levels of effectiveness for improving outcomes, which is influenced by participant and intervention delivery factors. Further studies in different parts of the world should compare these findings, specifically in low- and middle-income countries.

Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines

BACKGROUND

Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.

OBJECTIVE

Evaluate the quality and content of existing guidelines for OUD treatment and management.

DATA SOURCES

OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines.

STUDY SELECTION

Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults.

DATA EXTRACTION

We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.

DATA SYNTHESIS

Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal.

CONCLUSIONS

Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

Impact of the COVID-19 pandemic on the prevalence of opioid agonist therapy discontinuation in Ontario, Canada: A population-based time series analysis

BACKGROUND

We assessed the impact of COVID-19, which includes the declaration of a state of emergency and subsequent release of pandemic-specific OAT guidance (March 17, 2020 to March 23, 2020) on the prevalence of OAT discontinuation.

METHODS

We conducted a population-based time series analysis using interventional autoregressive integrated moving average models among Ontario residents who were stable (>60 days of continuous use) and not yet stable on OAT. Specifically, we examined whether COVID-19 impacted the weekly percentage of individuals who discontinued OAT, overall and stratified by treatment type (methadone vs. buprenorphine/naloxone). Additionally, we compared demographic characteristics and patient outcomes among people stable on OAT who discontinued treatment during (March 17, 2020 to November 30, 2020) and prior (July 3, 2019 to March 16, 2020) to the pandemic.

RESULTS

The weekly prevalence of OAT discontinuation across the study period ranged between 0.6% and 1.1%, among those stable on treatment compared to 7.3% and 16.6%, among those not stable on treatment. Following COVID-19, there was no significant change in the percentage of Ontarians who discontinued OAT, regardless of whether they were stabilized on treatment. Among those stable on OAT, a similar proportion of patients restarted therapy and experienced opioid-related harm following an OAT discontinuation. However, mortality following OAT discontinuation must be noted, as approximately 1.4% and 0.8% of people who discontinued methadone and buprenorphine/naloxone respectively, died within 30 days of discontinuation.

CONCLUSIONS

Trends in the prevalence of OAT discontinuation did not significantly change during the first eight months of the COVID-19 pandemic.

Jail-based treatment for opioid use disorder in the era of bail reform: a qualitative study of barriers and facilitators to implementation of a state-wide medication treatment initiative

Background

Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge.

Methods

In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services.

Results

Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January–September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails’ limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic.

Conclusions

Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.

Supplementary information

The online version contains supplementary material available at 10.1186/s13722-022-00313-6.

Relative effectiveness of medications for opioid-related disorders: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

Several pharmacotherapeutic interventions are available for maintenance treatment for opioid-related disorders. However, previous meta-analyses have been limited to pairwise comparisons of these interventions, and their efficacy relative to all others remains unclear. Our objective was to unify findings from different healthcare practices and generate evidence to strengthen clinical treatment protocols for the most widely prescribed medications for opioid-use disorders.

METHODS

We searched Medline, EMBASE, PsycINFO, CENTRAL, and ClinicalTrials.gov for all relevant randomized controlled trials (RCT) from database inception to February 12, 2022. Primary outcome was treatment retention, and secondary outcome was opioid use measured by urinalysis. We calculated risk ratios (RR) and 95% credible interval (CrI) using Bayesian network meta-analysis (NMA) for available evidence. We assessed the credibility of the NMA using the Confidence in Network Meta-Analysis tool.

RESULTS

Seventy-nine RCTs met the inclusion criteria. Due to heterogeneity in measuring opioid use and reporting format between studies, we conducted NMA only for treatment retention. Methadone was the highest ranked intervention (Surface Under the Cumulative Ranking [SUCRA] = 0.901) in the network with control being the lowest (SUCRA = 0.000). Methadone was superior to buprenorphine for treatment retention (RR = 1.22; 95% CrI = 1.06-1.40) and buprenorphine superior to naltrexone (RR = 1.39; 95% CrI = 1.10-1.80). However, due to a limited number of high-quality trials, confidence in the network estimates of other treatment pairs involving naltrexone and slow-release oral morphine (SROM) remains low.

CONCLUSION

All treatments had higher retention than the non-pharmacotherapeutic control group. However, additional high-quality RCTs are needed to estimate more accurately the extent of efficacy of naltrexone and SROM relative to other medications. For pharmacotherapies with established efficacy profiles, assessment of their long-term comparative effectiveness may be warranted.

TRIAL REGISTRATION

This systematic review has been registered with PROSPERO (https://www.crd.york.ac.uk/prospero) (identifier CRD42021256212).

Medication for opioid use disorder in the Arab World: A systematic review

BACKGROUND

Opioid use disorder (OUD) is a global public health concern. The standard of care for OUD involves treatment using medications such as buprenorphine, methadone, or naltrexone. No known review exists to assess the contextual factors associated with medication for opioid use disorder (MOUD) in the Arab World. This systematic review serves as an implementation science study to address this research gap and improve the uptake of MOUD in the Arab World.

METHODS

Systematic searches of Medline, PsycINFO, and EMBASE, and a citation analysis, were used to identify peer-reviewed articles with original data on MOUD in the Arab World. Quality assessment was conducted using the CASP appraisal tools, and main findings were extracted and coded according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework.

RESULTS

652 research articles were identified, and 10 met inclusion criteria for final review. Four studies considered health-systems aspects of MOUD administration, such as cost-effectiveness, the motivations for and impact of national MOUD policies, the types of social, political, and scientific advocacy that led to the adoption of MOUD in Arab countries, and the challenges limiting its wide-scale adoption in the Arab World. Six papers considered MOUD at individual and group patient levels by evaluating patient quality of life, addiction severity, patient satisfaction, and patient perspectives on opioid agonist therapy.

CONCLUSION

Despite financial and geographic barriers that limit access to MOUD in the Arab World, this review found MOUD to be cost-effective and associated with positive health outcomes for OUD patients in the Arab World. MOUD can be successfully established and scaled to the national level in the Arab context, and strong coalitions of health practitioners can lobby to establish MOUD programs in Arab countries. Still, the relative novelty of MOUD in this context precludes an abundance of research to address its long-term delivery in the Arab World.

Evaluating how has care been affected by the Ontario COVID-19 Opioid Agonist Treatment Guidance: Patients' and prescribers' experiences with changes in unsupervised dosing

BACKGROUND

The COVID-19 pandemic has exacerbated the opioid crisis. Opioid-related deaths have increased and access to treatment services, including opioid agonist treatment (OAT), has been disrupted. The Ontario COVID-19 OAT Treatment Guidance document was developed to facilitate access to OAT and continuity of care during the pandemic, while supporting physical distancing measures. In particular, the Guidance expanded access to unsupervised OAT dosing. It is important to evaluate the changes in unsupervised OAT dosing after the release of the Ontario COVID-19 OAT Guidance based on patients' and prescribers' reports.

METHOD

Online questionnaires were developed collaboratively with people with lived and living expertise, prescribers, clinical experts, and researchers. Patients (N = 402) and prescribers (N = 100) reported their experiences with changes in unsupervised dosing during the first six months of the pandemic.

RESULTS

Many patients (57%) reported receiving additional unsupervised OAT doses (i.e., take away doses). Patients who received additional unsupervised doses were not significantly more likely to report adverse health outcomes compared to patients who did not receive additional unsupervised doses. Patients with additional unsupervised doses and prescribers agreed that changes in OAT care were positive (e.g., reported an improved patient-prescriber relationship and more openness between patient and prescriber). Prescribers and some patients reported the need for continued flexibility in unsupervised doses after the pandemic restrictions lift.

CONCLUSIONS

Results support the need to re-evaluate historical approaches to OAT care delivery, particularly unsupervised doses. It is crucial to implement policies, regulations, and supports to reduce barriers to OAT care during the pandemic and once the pandemic response restrictions are eased. Flexibility in OAT care delivery, particularly unsupervised dosing, will be key to providing patient-centred care for persons with opioid use disorder.

Exploring the experiences of clients receiving opioid use disorder treatment at a methadone clinic in Kenya: a qualitative study

BACKGROUND

Assessing the experiences of individuals on methadone treatment is essential to help evaluate the treatment program's effectiveness. This study aimed to explore the experiences of patients receiving methadone treatment at a clinic in Nairobi, Kenya.

METHOD

This study employed an exploratory qualitative study design. Through purposive sampling, participants were enrolled from individuals attending a methadone clinic for at least 2 years. Semi-structured individual interviews were used to collect data on substance use and experience before methadone treatment and experiences after starting methadone treatment, including benefits and challenges. Interviews were transcribed, and NVIVO 12 software was used to code the data using the preidentified analytical framework. Thematic analyses were utilized to identify cross-cutting themes between these two data sets. Seventeen participants were enrolled.

RESULTS

Seventeen participants were enrolled comprising 70% males, with age range from 23 to 49 years and more than half had secondary education. The interview data analysis identified four themes, namely: (a) the impact of opioid use before starting treatment which included adverse effects on health, legal problems and family dysfunction; (b) learning about methadone treatment whereby the majority were referred from community linkage programs, family and friends; (c) experiences with care at the methadone treatment clinic which included benefits such as improved health, family reintegration and stigma reduction; and (d) barriers to optimal methadone treatment such as financial constraints.

CONCLUSION

The findings of this study show that clients started methadone treatment due to the devastating impact of opioid use disorder on their lives. Methadone treatment allowed them to regain their lives from the adverse effects of opioid use disorder. Additionally, challenges such as financial constraints while accessing treatment were reported. These findings can help inform policies to improve the impact of methadone treatment.

Influence of Prolonged Serotonin and Ergovaline Pre-Exposure on Vasoconstriction Ex Vivo

Ergot alkaloid mycotoxins interfere in many functions associated with serotonergic neurotransmitters. Therefore, the objective was to evaluate whether the association of serotonin (5-hydroxytryptamine, 5-HT) and ergot alkaloids during a 24 h pre-incubation could affect the vascular contractile response to ergot alkaloids. To evaluate the effects of 24 h exposure to 5-HT and ergot alkaloids (ergovaline, ERV), two assays were conducted. The first assay determined the half-maximal inhibitory concentration (IC₅₀) following the 24 h pre-exposure period, while the second assay evaluated the effect of IC₅₀ concentrations of 5-HT and ERV either individually or in combination. There was an interaction between previous exposure to 5-HT and ERV. Previous exposure to 5-HT at the IC₅₀ concentration of 7.57 × 10⁻⁷ M reduced the contractile response by more than 50% of control, while the exposure to ERV at IC₅₀ dose of 1.57 × 10⁻¹⁰ M tended to decrease (p = 0.081) vessel contractility with a response higher than 50% of control. The 24 h previous exposure to both 5-HT and ERV did not potentiate the inhibitory response of blood vessels in comparison with incubation with each compound alone. These results suggest receptor competition between 5-HT and ERV. More studies are necessary to determine the potential of 5-HT to treat toxicosis caused by ergot alkaloids.

The "black box" of treatment: Patients' perspective on what works in opioid maintenance treatment for opioid dependence

BACKGROUND

A lack of conceptual modeling of how the components of opioid maintenance treatment (OMT) for opioid dependence (OD) work causes it to occasionally be labeled the "black-box" of treatment. This study had a two-fold objective: First, to analyze which factors related to OMT for OD contribute to the abstinence of problematic use of non-prescribed opioids and sustain recovery, from the patients' perspective; second, to understand which changes OMT produced in the individuals' lives might significantly contribute to relapse prevention.

METHODS

We used qualitative methods of design, inquiry, and analysis from a convenience sample of 19 individuals in a Swedish treatment setting.

RESULTS

All the participants reported previous cycles of problematic use of non-prescribed opioids and other non-prescribed psychoactive substances, treatment, abstinence, recovery, and relapse before starting the current OMT program. During the pre-treatment stage, specific events, internal processes, and social environments enhanced motivation toward abstinence and seeking treatment. During the treatment stage, participants perceived the quality of the human relationships established with primary social groups as important as medication and the individual plan of care in sustaining recovery. From the participants' perspective, OMT was a turning point in their life course, allowing them a sense of self-fulfillment and the reconstruction of personal and social identity. However, they still struggled with the stigmatization produced by a society that values abstinence-oriented over medication-assisted treatments.

CONCLUSION

OMT is not an isolated event in individuals' lives but rather a process occurring within a specific social context. Structural factors and the sense of acceptance and belonging are essential in supporting the transformation. Treatment achievements and the risk for relapse vary over time, so the objectives of the treatment plan must account for characteristics of the pre-treatment stage and the availability and capacity of individuals to restructure their social network, besides the opioid maintenance treatment and institutional social care.