Correlates of Opioid Abstinence in a 42-Month Posttreatment Naturalistic Follow-Up Study of Prescription Opioid Dependence

Effect of the Communities that HEAL intervention on receipt of behavioral therapies for opioid use disorder: A cluster randomized wait-list controlled trial

BACKGROUND

The U.S. opioid overdose crisis persists. Outpatient behavioral health services (BHS) are essential components of a comprehensive response to opioid use disorder and overdose fatalities. The Helping to End Addiction Long-Term® (HEALing) Communities Study developed the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths in 67 communities in Kentucky, Ohio, New York, and Massachusetts through the implementation of evidence-based practices (EBPs), including BHS. This paper compares the rate of individuals receiving outpatient BHS in Wave 1 intervention communities (n = 34) to waitlisted Wave 2 communities (n = 33).

METHODS

Medicaid data included individuals ≥18 years of age receiving any of five BHS categories: intensive outpatient, outpatient, case management, peer support, and case management or peer support. Negative binomial regression models estimated the rate of receiving each BHS for Wave 1 and Wave 2. Effect modification analyses evaluated changes in the effect of the CTH intervention between Wave 1 and Wave 2 by research site, rurality, age, sex, and race/ethnicity.

RESULTS

No significant differences were detected between intervention and waitlisted communities in the rate of individuals receiving any of the five BHS categories. None of the interaction effects used to test the effect modification were significant.

CONCLUSIONS

Several factors should be considered when interpreting results-no significant intervention effects were observed through Medicaid claims data, the best available data source but limited in terms of capturing individuals reached by the intervention. Also, the 12-month evaluation window may have been too brief to see improved outcomes considering the time required to stand-up BHS.

TRIAL REGISTRATION

Clinical Trials.gov http://www.

CLINICALTRIALS

gov: Identifier: NCT04111939.

Structural and social changes due to the COVID-19 pandemic and their impact on engagement in substance use disorder treatment services: a qualitative study among people with a recent history of injection drug use in Baltimore, Maryland

BACKGROUND

Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs.

METHODS

People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services.

RESULTS

The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors).

CONCLUSIONS

Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

BACKGROUND AND AIMS

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

METHODS

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

RESULTS

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

CONCLUSIONS

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

Role of Peer Coaches in Digital Interventions for MOUD Initiation and Maintenance

Millions of Americans suffer from opioid use disorder (OUD) in the United States, resulting in thousands of deaths. The ongoing opioid crisis necessitates novel approaches to reduce the morbidity and mortality associated with misusing opioids. Studies using peer support models show success in engaging persons living with OUD in initiating treatment and decreasing relapse. Although most studies have focused on patients in clinical settings, community studies integrating peer community leaders also show promise. This viewpoint paper explores the use of peer coaches in online interventions in the community setting.

The Protective Wall of Human Community: The New Evidence on the Clinical and Public Health Utility of Twelve-Step Mutual-Help Organizations and Related Treatments

Mutual-help organizations (MHOs) such as alcoholics anonymous (AA) are the most commonly sought source of help for alcohol and other drug (AOD) problems in the United States. Popularity, however, is not commensurate with efficacy; hence, following a call for more rigorous research on AA and 12-step treatments from the Institute of Medicine in 1990 a flurry of clinical trials, cost-effectiveness analyses, and mechanisms studies, have been published during the past 30 years. This body of work has now revealed the true clinical and public health utility attributable to these freely available resources in aiding addiction remission and recovery. AA, and possibly similar organizations, may be the closest thing public health has to a "free lunch" in terms of their ability to facilitate higher rates and longer durations of sustained remission while substantially reducing health care costs.

Innovating for real-world care: A systematic review of interventions to improve post-detoxification outcomes for opioid use disorder

BACKGROUND

Inpatient detoxification is a common health care entry point for people with Opioid Use Disorder (OUD). However, many patients return to opioid use after discharge and also do not access OUD treatment. This systematic review reports on the features and findings of research on interventions developed specifically to improve substance use outcomes and treatment linkage after inpatient detoxification for OUD.

METHODS

Of 6419 articles, 64 met inclusion criteria for the current review. Articles were coded on key domains including sample characteristics, study methods and outcome measures, bias indicators, intervention type, and findings.

RESULTS

Many studies did not report sample characteristics, including demographics and co-occurring psychiatric and substance use disorders, which may impact postdetoxification OUD treatment outcomes and the generalizability of interventions. Slightly more than half of studies examined interventions that were primarily medical in nature, though only a third focused on initiating medication treatment beyond detoxification. Medical and combination interventions that focused on initiating medications for OUD generally performed well, as did psychological interventions with one or more reinforcement-based components.

CONCLUSIONS

Research efforts to improve post-detoxification outcomes would benefit from clearer reporting of sample characteristics that are associated with treatment and recovery outcomes, including diagnostic comorbidities. Findings also support the need to identify ways to introduce medication for opioid use disorder (MOUD) and other effective treatments including reinforcement-based interventions during detoxification or soon after.

Patient Characteristics Associated with Opioid Abstinence after Participation in a Trial of Buprenorphine versus Injectable Naltrexone

Background and Objectives: Better understanding of predictors of opioid abstinence among patients with opioid use disorder (OUD) may help to inform interventions and personalize treatment plans. This analysis examined patient characteristics associated with opioid abstinence in the X:BOT (Extended-Release Naltrexone versus Buprenorphine for Opioid Treatment) trial. Methods: This post-hoc analysis examined factors associated with past-month opioid abstinence at the 36-week follow-up visit among participants in the X:BOT study. 428 participants (75% of original sample) attended the visit at 36 weeks. Logistic regression models were used to estimate the probability of opioid abstinence across various baseline sociodemographics, clinical characteristics, and treatment variables. Results: Of the 428 participants, 143 (33%) reported abstinence from non-prescribed opioids at the 36-week follow-up. Participants were more likely to be opioid abstinent if randomized to XR-NTX (compared to BUP-NX), were on XR-NTX at week 36 (compared to those off OUD pharmacotherapy), successfully inducted onto either study medication, had longer time on study medication, reported a greater number of abstinent weeks, or had longer time to relapse during the 24-week treatment trial. Participants were less likely to be abstinent if Hispanic, had a severe baseline Hamilton Depression Rating (HAM-D) score, or had baseline sedative use. Conclusions: A substantial proportion of participants was available at follow-up (75%), was on OUD pharmacotherapy (53%), and reported past-month opioid abstinence (33%) at 36 weeks. A minority of patients off medication for OUD reported abstinence and additional research is needed exploring patient characteristics that may be associated with successful treatment outcomes.

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).

Recovery From Opioid Problems in the US Population: Prevalence, Pathways, and Psychological Well-Being

OBJECTIVES

Research has enhanced our understanding of opioid misuse prevalence and consequences, but few studies have examined recovery from opioid problems. Estimating national recovery prevalence and characterizing individuals who have resolved opioid problems can inform policy and clinical approaches to address opioid misuse.

METHODS

We conducted a cross-sectional investigation of a nationally-representative sample of US adults who reported opioid problem resolution (OPI). For reference, OPI was compared with an alcohol problem resolution group (ALC). Analyses estimated OPI/ALC prevalence, differences in treatment/recovery service use, and psychological well-being, within 2 recovery windows: <1 year (early recovery) and 1 to 5 years (mid-recovery) since OPI/ALC problem resolution.

RESULTS

Of those who reported alcohol or drug use problem resolution, weighted problem resolution prevalence was 5.3% for opioids (early recovery 1.2%, mid-recovery 2.2%) and 51.2% for alcohol (early recovery 7.0%, mid-recovery 11.5%). In mid-recovery, lifetime use of formal treatment, pharmacotherapy, recovery support services, mutual help, and current pharmacotherapy were more prevalent in OPI than ALC. Service utilization did not differ between early-recovery OPI and ALC. Common services used by OPI included inpatient treatment (37.8%) and state/local recovery organizations (24.4%) in mid-recovery; outpatient treatment (25.7%) and recovery community centers (27.2%) in early recovery; Narcotics Anonymous (40.2%-57.8%) and buprenorphine-naloxone (15.3%-26.7%) in both recovery cohorts. Regarding well-being, OPI reported higher self-esteem than ALC in early recovery, and lower self-esteem than ALC in mid-recovery.

CONCLUSIONS

An estimated 1.2 million American adults report resolving an opioid problem. Given the service use outcomes and longer-term problem resolution of mid-recovery OPI, early-recovery OPI may require encouragement to utilize additional or more intensive services to achieve longer-term recovery. OPI beyond recovery-year 1 may need enhanced support to address deficient self-esteem and promote well-being.

Self-Help Groups And Medication Use In Opioid Addiction Treatment: A National Analysis

Self-help groups and medications (buprenorphine, methadone, and naltrexone) both play important roles in opioid addiction treatment. The relative use of these two treatment modalities has not been characterized in a national study. Using national treatment data, we found that self-help groups were rarely provided in conjunction with medication treatment: Among all adult discharges from opioid addiction treatment in the period 2015-17, 10.4 percent used both self-help groups and medications, 29.2 percent used only medications, 29.8 percent used only self-help groups, and 30.5 percent used neither self-help groups nor medications. Use of self-help groups without medication is most common in residential facilities, among those with criminal justice referrals, and among uninsured or privately insured patients, as well as in the South and West regions of the US. These subgroups may be important targets for future efforts to identify and overcome barriers to medication treatment and create multimodal paths to recovery.

Online recovery support meetings can help mitigate the public health consequences of COVID-19 for individuals with substance use disorder

For people with current and remitted substance use disorder (SUD), the COVID-19 pandemic increases risk for symptom exacerbation and relapse through added stressors and reduced service access. In response, mutual-help groups and recovery community organizations have increased access to online recovery support meetings. However, rigorous studies examining online recovery support meeting participation to inform best practices have not yet been conducted. In the absence of such studies, a review of relevant literature, considered in context of potential barriers and drawbacks, suggests the risk-to-benefit ratio is favorable. Particularly given limited in-person SUD service access resulting from COVID-19 precautions, online recovery support meetings may help mitigate a key public health problem during an ongoing, public health pandemic.

Online digital recovery support services: An overview of the science and their potential to help individuals with substance use disorder during COVID-19 and beyond

Background

The COVID-19 pandemic and related social distancing public health recommendations will have indirect consequences for individuals with current and remitted substance use disorder (SUD). Not only will stressors increase risk for symptom exacerbation and/or relapse, but individuals will also have limited service access during this critical time. Individuals with SUD are using free, online digital recovery support services (D-RSS) that leverage peer-to-peer connection (i.e., social-online D-RSS) which simultaneously help these individuals to access support and adhere to public health guidelines. Barriers to SUD treatment and recovery support service access, however, are not unique to the COVID-19 epoch. The pandemic creates an opportunity to highlight problems that will persist beyond its immediate effects, and to offer potential solutions that might help address these long-standing, systemic issues. To help providers and other key stakeholders effectively support those interested in, or who might benefit from, participation in free, social-online D-RSS, this review outlines the following: 1) theories of expected therapeutic benefits from, and potential drawbacks of social-online D-RSS participation; 2) a typology that can be used to describe and classify D-RSS; 3) a D-RSS “case study” to illustrate how to apply the theory and typology; 4) what is known empirically about social-online D-RSS; and 5) whether and how to engage individuals with these online resources.

Method

Narrative review combining research and theory on both in-person recovery supports and social-online D-RSS.

Results

Studies examining in-person recovery support services, such as AA and other mutual-help organizations, combined with theory about how social-online D-RSS might confer benefit, suggest these digital supports may engage individuals with SUD and mobilize salutary change in similar ways. While people may use in-person and digital supports simultaneously, when comparing the two modalities, communication science and telemedicine group therapy data suggest that D-RSS may not provide the same magnitude of benefit as in-person services. D-RSS can be classified based on the a) type of service, b) type of platform, c) points of access, and d) organizations responsible for their delivery. Research has not yet rigorously tested the effectiveness of social-online D-RSS specifically, though existing data suggest that those who use these services generally find their participation to be helpful. Content analyses suggest that these services are likely to facilitate social support and unlikely to expose individuals to harmful situations.

Conclusions

When in-person treatment and recovery support services are limited, as is the case during the COVID-19 pandemic, expected therapeutic benefits and emerging data, taken together, suggest providers, mentors, and other community leaders may wish to refer individuals with current and remitted SUD to free, social-online D-RSS. Given the array of available services in the absence of best practice guidelines, we recommend that when making D-RSS referrals, stakeholders familiarize themselves with theorized benefits and drawbacks of participation, use a typology to describe and classify services, and integrate current empirical knowledge, while relying on trusted federal, academic, and national practice organization resource lists.

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Social-online, digital recovery support services (D-RSS) may address systemic service access barriers highlighted by COVID-19

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To aid provider and other stakeholder practices, we review relevant D-RSS theory and research

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Theory suggests D-RSS may mobilize salutary mechanisms of behavior change, though data also point to potential challenges

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Emerging D-RSS research is promising, though rigorous studies of their effectiveness have not yet been conducted

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The typology and resource lists from organizations provided here may be used for those who wish to make D-RSS referrals

Depression history as a predictor of outcomes during buprenorphine-naloxone treatment of prescription opioid use disorder

BACKGROUND

In the multi-site Prescription Opioid Addiction Treatment Study (POATS), the best predictor of successful opioid use outcome was lifetime diagnosis of major depressive disorder. The primary aim of this secondary analysis of data from POATS was to empirically assess two explanations for this counterintuitive finding.

METHODS

The POATS study was a national, 10-site randomized controlled trial (N = 360 enrolled in the 12-week buprenorphine-naloxone maintenance treatment phase) sponsored by the NIDA Clinical Trials Network. We evaluated how the presence of a history of depression influences opioid use outcome (negative urine drug assays). Using adjusted logistic regression models, we tested the hypotheses that 1) a reduction in depressive symptoms and 2) greater motivation and engagement in treatment account for the association between depression history and good treatment outcome.

RESULTS

Although depressive symptoms decreased significantly throughout treatment (p <.001), this improvement was not associated with opioid outcomes (aOR = 0.98, ns). Reporting a goal of opioid abstinence at treatment entry was also not associated with outcomes (aOR = 1.39, ns); however, mutual-help group participation was associated with good treatment outcomes (aOR = 1.67, p <.05). In each of these models, lifetime major depressive disorder remained associated with good outcomes (aORs = 1.63-1.82, ps = .01-.055).

CONCLUSIONS

Findings are consistent with the premise that greater engagement in treatment is associated with good opioid outcomes. Nevertheless, depression history continues to be associated with good opioid outcomes in adjusted models. More research is needed to understand how these factors could improve treatment outcomes for those with opioid use disorder.

Outcomes in Long-term Opioid Tapering and Buprenorphine Transition: A Retrospective Clinical Data Analysis

Background

There are significant medical risks of long-term opioid therapy (LTOT) for chronic pain. Consequently, there is a need to identify effective interventions for the reduction of high-dose full-agonist opioid medication use.

Methods

The current study details a retrospective review of 240 patients with chronic pain and LTOT presenting for treatment at a specialty opioid refill clinic. Patients first were initiated on an outpatient taper or, if taper was not tolerated, transitioned to buprenorphine. This study analyzes potential predictors of successful tapering, successful buprenorphine transition, or failure to complete either intervention and the effects of this clinical approach on pain intensity scores.

Results

One hundred seven patients (44.6%) successfully tapered their opioid medications under the Centers for Disease Control and Prevention guideline target dose (90 mg morphine-equianalgesic dosage), 45 patients (18.8%) were successfully transitioned to buprenorphine, and 88 patients (36.6%) dropped out of treatment: 11 patients during taper, eight during buprenorphine transition, and 69 before initiating either treatment. Conclusions. Higher initial doses of opioids predicted a higher likelihood of requiring buprenorphine transition, and a co-occurring benzodiazepine or z-drug prescription predicted a greater likelihood of dropout from both interventions. Patterns of change in pain intensity according to treatment were mixed: among successfully tapered patients, 52.8% reported greater pain and 23.6% reported reduced pain, whereas 41.8% reported increased pain intensity and 48.8% reported decreased pain after buprenorphine transition. Further research is needed on predictors of treatment retention and dropout, as well as factors that may mitigate elevated pain scores after reduction of opioid dosing.

Buprenorphine Treatment for Opioid Use Disorder in Community-Based Settings: Outcome Related to Intensity of Services and Urine Drug Test Results

Background and Objectives

Variables contributing to the outcome of buprenorphine treatment for opiate use disorder have been studied, including patient characteristics and the treatment approach applied. It is also valuable to study the types of clinical facilities that can affect outcome.

Methods

We evaluated patients (N = 20 993) in 573 facilities where buprenorphine was prescribed. Urine drug test results were analyzed for those (N = 13 281) who had buprenorphine prescribed at least twice in the period January 2015 through June 2017. Facilities were divided into three categories: medication management (MM) only, limited psychosocial (LP) therapy, and recovery‐oriented (with more extensive counseling and a 12‐step orientation) (RO).

Results

Urine drug tests negative for other opioids at the time of the second buprenorphine prescription were 34% for MM, 56% for LP, and 62% for RO (P < .001). A comparison was made between the most recent and the established patients at the facilities. The decrement in urinalyses positive for other opioids in this latter comparison was 3% for MM, 7% for LP, and 23% for RO (P < .001).

Discussion and Conclusions

In a large sample of community settings, buprenorphine patients’ urinalyses positive for opioids can vary considerably across treatment facilities, and more intensive recovery orientation may yield a better outcome in terms of secondary opioid use.

Scientific Significance

The majority of buprenorphine patients are treated in community facilities. It is important that research be done by facility type in such settings in order to plan for optimal treatment. (© 2020 The Authors. The American Journal on Addictions published by Wiley Periodicals, Inc.;00:00–00)