Addiction Medicine Practice-Based Research Network (AMNet): Assessment Tools and Quality Measures

Patient Engagement in and Adaptations to Delivery of Outpatient Care for Opioid Use Disorder During the COVID-19 Pandemic

OBJECTIVE

The authors investigated adaptations to outpatient care delivery and changes in treatment demand and engagement among patients receiving medications for opioid use disorder (MOUD) in the months after the declaration of the COVID-19 public health emergency in 2020.

METHODS

Data were collected through an online survey (June-November 2020) of outpatient MOUD prescribers. The survey obtained information on outpatient practices' adaptations to MOUD treatment and urine drug screening (UDS) and elicited provider views on the effects of the COVID-19 pandemic on patient demand for, and engagement in, treatment. Multivariable regression analyses were used to examine associations among practice characteristics, patient engagement, and service adaptations.

RESULTS

Of 516 respondents, 74% reported adaptations to MOUD delivery during the pandemic. Most respondents implemented virtual visits for initial (67%) and follow-up (77%) contacts. Prescribers of buprenorphine were more likely than those who did not prescribe the medication to report MOUD adaptations. Among respondents reporting any MOUD adaptation, 77% made adaptations to their UDS practices. Among 513 respondents who answered COVID-19-related questions, 89% reported that the pandemic had affected the treatment and engagement of their patients. Of these respondents, 30% reported increased difficulty with patient engagement, and 45% reported that their patients preferred virtual visits during this period, whereas 18% endorsed patient preference for in-person visits.

CONCLUSIONS

Telehealth and federal regulatory easements in response to the COVID-19 pandemic enabled providers to continue treating patients for opioid use disorder in 2020. The results suggest that care adaptations and changes in patient demand and engagement were common in the practices surveyed.

Tools to implement measurement-based care (MBC) in the treatment of opioid use disorder (OUD): toward a consensus

BACKGROUND

The prevalence and associated overdose death rates from opioid use disorder (OUD) have dramatically increased in the last decade. Despite more available treatments than 20 years ago, treatment access and high discontinuation rates are challenges, as are personalized medication dosing and making timely treatment changes when treatments fail. In other fields such as depression, brief measures to address these tasks combined with an action plan-so-called measurement-based care (MBC)-have been associated with better outcomes. This workgroup aimed to determine whether brief measures can be identified for using MBC for optimizing dosing or informing treatment decisions in OUD.

METHODS

The National Institute on Drug Abuse Center for the Clinical Trials Network (NIDA CCTN) in 2022 convened a small workgroup to develop consensus about clinically usable measures to improve the quality of treatment delivery with MBC methods for OUD. Two clinical tasks were addressed: (1) to identify the optimal dose of medications for OUD for each patient and (2) to estimate the effectiveness of a treatment for a particular patient once implemented, in a more granular fashion than the binary categories of early or sustained remission or no remission found in The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5).

DISCUSSION

Five parameters were recommended to personalize medication dose adjustment: withdrawal symptoms, opioid use, magnitude (severity and duration) of the subjective effects when opioids are used, craving, and side effects. A brief rating of each OUD-specific parameter to adjust dosing and a global assessment or verbal question for side-effects was viewed as sufficient. Whether these ratings produce better outcomes (e.g., treatment engagement and retention) in practice deserves study. There was consensus that core signs and symptoms of OUD based on some of the 5 DSM-5 domains (e.g., craving, withdrawal) should be the basis for assessing treatment outcome. No existing brief measure was found to meet all the consensus recommendations. Next steps would be to select, adapt or develop de novo items/brief scales to inform clinical decision-making about dose and treatment effectiveness. Psychometric testing, assessment of acceptability and whether the use of such scales produces better symptom control, quality of life (QoL), daily function or better prognosis as compared to treatment as usual deserves investigation.

Patient Reported Outcome and Experience Measures (PROMs and PREMs) in substance use disorder treatment services: A scoping review

BACKGROUND

Substance use disorders (SUD) pose significant challenges for healthcare systems, and there is a need to monitor the provision of effective, individualized care to persons accessing treatment. Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) are increasingly used in healthcare services to measure treatment outcomes and quality of care as perceived by patients, and to guide service improvement.

OBJECTIVES

This review aims to identify and characterize international developments regarding the use and systematic implementation of PROMs and PREMs in SUD treatment services.

METHODS

A scoping review was conducted searching multiple databases to identify studies on the use and routine implementation of PROMs and PREMs in SUD treatment services.

RESULTS

23 articles were selected, all dating from 2016 onwards. There was large variation in the patient-reported measures that were used, how they were developed and how and when patient-reported data were collected. Treatment providers identified leadership support, the presence of an integrated electronic patient record, and regular feedback to be the most important facilitators of successful implementation of patient-reported measures into clinical practice, whilst treatment dropout and burden to staff and patients were the most important barriers to consider.

CONCLUSIONS

PROMs and PREMs are increasingly used in SUD treatment services, but guidance is needed to support researchers and clinicians in selecting and implementing valid, meaningful, and comparable measures if we want to understand the effects of PROM and PREM data collection and feedback on treatment quality and results.

Towards shortening the Brief Addiction Monitor-Revised (BAM-R)

Introduction

The Brief Addiction Monitor-Revised (BAM-R) is a widely used, 17-item assessment of substance use, risk, and protective factors associated with recovery from substance use disorders. Despite wide adoption in the U.S. Department of Veterans Affairs (VA) and recommendations for use in measurement-based care (MBC), administration may not be feasible in many MBC settings due to time constraints. The purpose of this study was to derive a shortened version of the BAM-R for use in fast-paced healthcare settings.

Methods

BAM-R data from 32,002 Veterans were obtained through the VA's Corporate Data Warehouse. We used logistic regression models to identify items for removal based on prediction of two clinical outcomes (90-day substance use disorder (SUD) treatment retention and 12-month mortality) and item-level sensitivity to change during substance use treatment.

Results

Although no intake BAM-R items predicted SUD treatment retention or mortality, effect sizes for item-level sensitivity to change during substance use treatment varied from small to large. Seven items were judged as relevant for MBC of SUD. Among all BAM-R items, Heavy Alcohol Use, Self-Help, Drug Use, Craving, and Mood items demonstrated the greatest magnitude of sensitivity to change.

Conclusions

Although additional research is recommended before a shortened BAM-R can be implemented in non-specialty MBC settings, we identified 5 BAM-R items with perceived clinical utility and scores that demonstrated evidence of sensitivity to change. Shortening the BAM-R increases feasibility of use, though more work is needed to optimize measurement for SUD MBC.

Longitudinal associations between pain and substance use disorder treatment outcomes

INTRODUCTION

Pain is commonly reported among those in treatment for substance use disorders (SUD) and is associated with poorer SUD treatment outcomes. The current study examined the trajectory of pain over the course of SUD treatment and associations with substance use outcomes.

METHODS

This observational study included adults seeking treatment for alcohol, cannabis, or opioid use disorders (N = 811). Participants completed a battery of assessments at treatment admission, 30 days post admission, and at discharge, including measures of demographics, pain, quality of life, abstinence self-efficacy, and craving.

RESULTS

Analyses indicated linear reductions in pain intensity and interference over time. Significant interactive effects were observed for opioid use disorder (OUD) and time, such that participants with OUD had greater reductions in pain intensity and interference over time compared to those without OUD. Elevated pain intensity was associated with negative treatment outcomes, including reduced quality of life and abstinence self-efficacy, and greater craving and negative affect.

CONCLUSIONS

Reductions in pain occur over the course of SUD treatment, particularly for those with OUD. Greater pain was also associated with adverse SUD treatment outcomes. Results suggest that treatment and associated abstinence may be beneficial for those with co-occurring pain and SUD, highlighting an additional benefit of improving access to SUD treatment for patients and health care systems. Future research should replicate these findings among diverse samples and further characterize the trajectory of pain during and after SUD treatment.

The opioid use disorder core outcomes set (OUD-COS) for treatment research: findings from a Delphi consensus study

BACKGROUND AND AIM

There is no gold-standard and considerable heterogeneity in outcome measures used to evaluate treatments for opioid use disorder (OUD) along the opioid treatment cascade. The aim of this study was to develop the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder core outcomes set (OUD-COS).

DESIGN

Four-round, e-Delphi expert panel consensus study and plenary research group discussion and targeted consultation.

SETTING

United States.

PARTICIPANTS

A panel of 25 members including clinical practitioners, clinical researchers and administrative staff from the CTN, the network's affiliated clinical and community sites and the NIDA Centre for the CTN.

MEASUREMENTS

From a pool of 24 candidate items in four domains (biomedical/disease status; behaviors, symptoms and functioning; opioid treatment cascade; and morbidity and mortality), the panel completed an on-line questionnaire to rank items with defined specification on a 9-point scale for importance, with a standard 70% consensus criterion.

FINDINGS

After the fourth round of the questionnaire and subsequent discussion, consensus was reached for five outcomes: two patient-reported (global impression of improvement and incident non-fatal overdose); one clinician-reported (illicit/non-medical drug toxicology); and two from administrative records (duration of treatment and fatal opioid poisoning).

CONCLUSIONS

An e-Delphi consensus study has produced the US National Institute on Drug Abuse (NIDA) National Drug Abuse Treatment Clinical Trials Network opioid use disorder core outcomes set (version 1) for opioid use disorder treatment efficacy and effectiveness research.