Perceptions of COVID-19 risk during the pandemic: perspectives from people seeking medication for opioid use disorder

INTRODUCTION

The Coronavirus Disease 2019 (COVID-19) pandemic has had devastating consequences for persons with opioid use disorder (OUD). Yet, little is known about how people seeking treatment for OUD perceive the risks of COVID-19 and how their perception interplays with their health behaviours.

METHODS

In-depth interviews were conducted from September 2021 to March 2022 with 32 patients seeking medication treatment for OUD (MOUD) in Southern California. All interviews were conducted virtually and lasted between one and two hours. Interviews were recorded and transcribed verbatim. Two qualitative researchers independently conducted a content analysis of the transcripts to identify themes.

RESULTS

Three primary themes were identified: (1) perceptions and beliefs about COVID-19 susceptibility and severity; (2) perceptions of COVID-19 risk compared to substance use behaviours; and (3) vaccine hesitancy. Participants were mixed in their beliefs of susceptibility to contracting COVID-19 and the severity of the disease if contracted. Some participants reported taking precautions to mitigate their chances of acquiring COVID-19, and other participants reported that COVID was not a big concern as substance use took priority. For many of the participants, COVID-19 concerns were overshadowed by the risk of overdosing on substances and other risky substance use behaviour. Most of the participants (n = 23; 72%) had received at least one COVID-19 vaccine by the time of the interview, but over half (n = 19; 59%) expressed vaccine hesitancy. Vaccine hesitancy was driven by concerns about the unknown long-term side effects and potential interactions of the vaccine with MOUD.

CONCLUSIONS

Our study provides insight into COVID-19 prevention measures as well as vaccination perceptions and hesitancy among people who received treatment for OUD.Key messagesParticipants expressed diverse perceptions of the seriousness of COVID-19, with some taking precautions to mitigate their chances of acquiring COVID-19 and others perceiving that the risk of contracting COVID-19 was less than the risk of overdosing.Substance use, social isolation, vaccine hesitancy and COVID-19 risk behaviours should be studied as co-occurring phenomena that have potentially overlapping relationships that can influence behaviours that impact health and well-being.

Toward Critically Analyzing Whiteness in Immigrant Health

Assimilation theories dominate immigration scholarship to examine differential life chances, opportunities, and health of immigrants across three waves of immigrants in the United States. Assimilation theories are widely used in public health to explain the health status of immigrants despite the embedded White supremacist ideology while ignoring the role of whiteness. This article reviews and critiques assimilation theories to propose a critical analysis of whiteness in immigrant health scholarship. Critically analyzing whiteness in immigrant health studies allows us to recognize (a) the problematic framing of assimilation theories because of the theories' devotion to a White-European vision of upward mobility and a mainstream characterized as elite and White and (b) how a purportedly colorblind immigration law reinforces White supremacy through possessive investment in whiteness. To highlight whiteness in immigrant health, we examine the anti-immigration rhetoric and anti-immigrant policies and surveillance while providing implications for future research in the scholarship of immigrant health.

The impact of COVID-19 on substance use disorder treatment in California: Service providers' perspectives

Background

The COVID-19 pandemic has had a profound impact on the U.S. health care system, including addiction treatment. The objective of this study is to describe the impact of COVID on the delivery of treatment for substance use disorders (SUDs) from the perspectives of service providers.

Methods

Between May and September 2020, 61 service providers from 16 SUD treatment sites in California participated in virtual focus groups that lasted about an hour. We recorded the discussions and transcribed them verbatim. Two qualitative analysts independently conducted content analysis to identify themes from the transcripts.

Results

At the beginning of the pandemic, service providers observed a slight decrease in patient admissions, followed by an uptick in patient flow due to increased mental health issues, alcohol use, and relapse. Many of the clinics adopted flexible service delivery modes, such as curbside dosing and extended take-home medication, to enable social distancing in clinic settings. Approximately half of the clinic encounters offered telemedicime, and a considerable proportion of patients preferred to use telephone-based services rather than video-based services. Internet instability and technical difficulties limited the use of telemedicine among their patients.

Conclusion

COVID has been challenging for SUD treatment, but health care systems rapidly reacted with adjustments that may result in long-term changes in SUD service delivery. Telemedicine-based services have played a major role in ensuring uninterrupted patient care. Providers need organizational, technical, and logistical support to improve and sustain telemedicine services that increase access to quality care for their patients.

Patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD): Rationale, methodology, and preliminary results

BACKGROUND AND AIMS

As treatment for opioid use disorder (OUD) expands within general healthcare settings such as primary care, mechanisms to facilitate decision-making processes are increasingly necessary. Decision aids have the capacity to bolster existing resources in diverse treatment settings by increasing knowledge of treatment options and facilitating shared decision making. The aim of this study is to develop and test a patient decision aid for medication treatment for opioid use disorder (PtDA-MOUD) that assists individuals with OUD in making informed decisions about treatment at the time of initial clinical visit. Use of the PtDA-MOUD will be further tested in diverse treatment settings within the California Hub and Spoke System developed under the SAMHSA State Targeted Response to the Opioid Crisis grants.

METHODS

The PtDA-MOUD was iteratively developed with input from a scientific expert panel and both patient and provider focus groups, incorporating International Patient Decision Aid Standards. Thirty-six patients with OUD entering treatment pilot tested the PtDA and completed assessments, and results from clinical records were compared with matched controls who did not receive the PtDA. A clinical profile based on assessment data was created for use within the clinical visit.

RESULTS

The developed decision aid provides information on MOUD and captures patient characteristics relevant to medication treatment decisions. Feedback indicated that the PtDA-MOUD was feasible to implement and useful. Though the small sample size limited the ability to detect significant differences (p > .05), a greater number of individuals who reviewed the PtDA (37%) were inducted on MOUD than controls (11%) and received MOUD for more days (M = 14.0, SD = 24.7) than controls (M = 8.4; SD = 22.5). Moreover, the difference in means for days receiving MOUD had an approximately medium effect size (r = 0.25).

CONCLUSIONS

Patient perceptions of the decision aid were favorable and it showed promise as a tool in the OUD treatment process. Pilot testing results suggested preliminary positive effects on MOUD initiation. Future phases of this study will further investigate the usefulness of this tool. ClinicalTrials.govIdentifier:NCT03394261.

Assessment of medication for opioid use disorder as delivered within the Vermont hub and spoke system

Opioid overdose deaths in the United States have risen dramatically in the past decade. In response to this public health crisis, Vermont created an innovative system called the "hub-and-spoke" (H & S) system, initiated in January 2013. The H & S system has 7 regional "hubs" that offer methadone and buprenorphine, as well as intensive support, and 77 local "spokes" (primary care settings) that offer buprenorphine (and naltrexone to a much lesser extent). Questionnaires were administered to 80 participants in the H & S system (stratified by geographic region, treatment site, and gender) and 20 participants with opioid use disorder not currently in treatment. Data included demographics, drug and alcohol use; opioid use; injection use; education/employment; criminal justice involvement; family and relationship functioning; health and healthcare utilization; multiple areas of mental health functioning; opioid overdose; satisfaction with life areas; stigma; and perceived treatment effectiveness. In-treatment group participants reported use and functioning for the 90 days prior to the date of the interview (T₂) and, retrospectively, a comparable 90-day period prior to treatment entry (T₁). Out-of-treatment group participants were queried about functioning at the time of the interview (T₂) and 12 months earlier (T₁). Individuals not in treatment showed no meaningful changes in any domain from T₁ to T₂. Conversely, participants currently in treatment in the H & S system showed large reductions in substance use, overdoses, emergency department visits, police contacts, and family conflict, and improvements in mood and satisfaction with all areas of life, except work/school participation. Additionally, 85% of in-treatment participants reported 90-day abstinence from opioid use compared to 0% of out-of-treatment participants at T₂. These findings illustrate that medication for opioid use disorders, as delivered in the H & S system in Vermont, is highly effective for reducing opioid use and overdose and improving functioning in many life domains.

Effectiveness of extended release naltrexone to reduce alcohol cravings and use behaviors during treatment and at follow-up

Changes in cravings to drink alcohol and alcohol use behaviors were examined among 337 patients who were administered extended-release naltrexone (XR-NTX) in conjunction with psychosocial treatment in community-based substance use disorder treatment programs. Cravings and use behaviors were assessed at multiple time points (baseline; weeks 1, 2, and 3 after the first dose; monthly after the first four assessments; and at 30- and 60-days after the last dose). A total of 863 doses (M=2.6, SD=1.8) were administered and the majority of patients (65%) took more than one dose. Alcohol craving scores decreased from 19 to 5.7 after the first dose of XR-NTX. Days of primary alcohol use at admission (M=10.5, SD=10.1) were reduced at discharge (M=to 1.2, SD=4.6). At the first follow-up, 79.8% reported no alcohol use and 77.8% reported no alcohol use at the second follow-up. The expected side effects were reported but the medication was well tolerated and there was no relationship between side effects and subsequent dose. Unexamined or unaccounted for variables (e.g., motivation, external pressures to remain in treatment) are "real world" consequences that may have impacted the outcome of this study. Results indicated that use of the antagonist medication XR-NTX may be related to significant decreases in alcohol craving and use while a patient is in treatment, as well as at 30- and 60-days after the final dose.

The Los Angeles County hub-and-provider network for promoting the sustained use of extended-release naltrexone (XR-NTX) in Los Angeles County (2010-2015)

Extended-release naltrexone (XR-NTX) is a medication-assisted treatment (MAT) that is used in conjunction with psychosocial treatment for substance use disorder. It is associated with a reduction in the number of days that patients use alcohol or opioids, in cravings and drug-seeking behaviors, and in healthcare utilization costs, as well as improved medication adherence rates for patients in substance use disorder (SUD) treatment programs and improved quality of life. Despite the clinical effectiveness of XR-NTX, its clinical use has been slow to develop. There is little research describing the utilization of XR-NTX over time at the treatment-system level and few documented attempts to promote MAT by creating a system to explicitly promote and sustain MAT use. This study examines changes between April 1, 2010, and March 30, 2015, in the utilization patterns of XR-NTX for SUDs as promoted and delivered in a system of "medication hubs," comprised of community providers and a medication coordinating center, and training efforts. This system was implemented as part of a large demonstration project that was designed to provide access to XR-NTX in Los Angeles County. Our findings indicated an increase in the initiation of XR-NTX (59% increase) and subsequent doses (89% increase) from Year 1 to Year 5 of the project (p<0.001). These findings suggest that it is possible to improve MAT utilization (in this case XR-NTX) through the use of a system of care that minimizes MAT payment issues for providers and patients, provides an infrastructure (medication hubs and SUD treatment providers), promotes system coordination, and educates providers.

Predictors of Continued Use of Extended-Released Naltrexone (XR-NTX) for Opioid-Dependence: An Analysis of Heroin and Non-Heroin Opioid Users in Los Angeles County

Extended-release naltrexone (XR-NTX) is associated with an increased number of opioid-free days, improved adherence rates in substance use disorder treatment programs, and reduced cravings and drug-seeking behaviors. There is little evidence on the predictive associations between baseline characteristics of opioid-dependent patients and XR-NTX utilization. Some studies have demonstrated better pharmacotherapy adherence and/or retention rates among non-heroin opioid users compared to heroin users. This study examines predictive associations between characteristics of patients and XR-NTX utilization, as well as participants' urge to use opiates. Our findings suggest that XR-NTX may contribute to decreases in urges to use among both heroin and non-heroin opioid users. Non-heroin opioid users and heroin users were retained in XR-NTX treatment for comparable periods of time. However, those who identified as homeless, injected opioids (regardless of opioid-type), or were diagnosed with a mental illness were less likely to be retained in treatment with XR-NTX.

An analysis of relapse prevention factors and their ability to predict sustained abstinence following treatment completion

BACKGROUND & OBJECTIVES

This study assessed the role of 14 specific relapse-prevention activities and their underlying factors in maintaining abstinence among subjects (N = 302) completing outpatient treatment for stimulant dependence.

METHODS

We examined what broader dimensions might subsume the 14 items constituting the Drug Avoidance Activities checklist (Farabee et al. J Subst Abuse Treat 2002;23:343-350), and how well these derived factors predicted concurrent drug use at baseline and again 3 and 12 months later.

RESULTS

Although four factors were identified consistently for the three time points, only avoidance strategies had sufficient internal consistency to be retained for further analysis. Controlling for age, gender, and ethnicity, the avoidance subscale was a significant predictor of UA results at all time periods: a one-point increase in the avoidance strategies scale was associated with an 86% increase in odds of a negative UA at baseline (OR = 1.86, 95% CI = 1.37-2.53, p < .001), a 77% increase at 3-month follow-up (OR = 1.77, CI = 1.37-2.29, p < .001), and a 37% increase at 12-month follow-up (OR = 1.37, CI = 1.04-1.81, p = .026).

CONCLUSIONS

Although correlations of individual items with UA results showed statistically significant (p < .05) results for 8 of 14 items at one or more observation points, avoidance-related behaviors showed the strongest associations with sustained abstinence.

Utilization, measurement, and funding of recovery supports and services

An environmental survey was conducted regarding substance abuse recovery supports and services (RSS) delivered across California, where these services are offered, and by whom. Inquiries were made regarding RSS measurement efforts, funding mechanisms, and technical assistance needs. A survey was disseminated to all 57 administrators of county alcohol and other drug or behavioral departments. Results indicate that 62% (23 of 37) of responding counties offer RSS. Overall, certified addiction counselors (CACs) were the staff most utilized to provide RSS, followed by peers, clinicians, and volunteers. Among recovery-community organizations (RCOs), peers, volunteers, and CACs were the most utilized staff. Sober living homes were the most prevalent type of RCO, followed by recovery centers, faith-based/recovery ministries, and recovery schools. Forty-five percent of counties reported funding RSS; 37.8% collect data. RSS may provide valuable support services for individuals recovering from alcohol/drug use; however, the field must further define RSS and develop measurement strategies to justify RSS funding.

A comparison of four telephone-based counseling styles for recovering stimulant users

The continuing development and refinement of empirically supported interventions to increase participation in posttreatment care and promote sustained abstinence from illicit drug use is a priority for the addictions field. The purpose of this study was to assess the combined and relative effectiveness of four types of counseling styles, delivered by telephone, relative to a no call control condition. Stimulant users (N = 302) were randomized to one of four low-cost, telephone support protocols (unstructured/nondirective, unstructured/directive, structured/nondirective, structured/directive) or a standard referral to aftercare without telephone counseling (control). All of the study participants were nearing the completion of (or had completed) an intensive phase of structured, outpatient stimulant abuse treatment. Drug use and aftercare participation were assessed at 3 and 12 months following randomization. Intent-to-treat analyses showed no significant time-by-group interactions for these primary outcomes. Subsequent analyses, however, revealed a significant difference between the aggregated call groups and the control group at the time of the 3-month follow-up. The mean ASI drug use severity composite score for subjects in the call conditions declining from .058 at baseline to .048 at 3 months, whereas the no call/control group average score increased from .053 to .062 (χ (1) = 4.95, p = .026). A similar-and slightly stronger-effect was found when the study sample was restricted to those reporting any use during the month prior to the baseline interview (n = 152). This study provides modest support for the telephone-based counseling approaches strategies examined in this project. Subsequent research will assess interactions between patient characteristics and counseling styles, and improved identification of which treatment graduates might be more likely to benefit from this type of continuing support. (PsycINFO Database Record (c) 2013 APA, all rights reserved).

Sex under the influence of drugs or alcohol: common for men in substance abuse treatment and associated with high-risk sexual behavior

Sex under the influence of drugs or alcohol is associated with high-risk sexual behavior. Heterosexual men (n = 505) in substance abuse treatment completed a computer-administered interview assessing sexual risk behaviors. Most men (73.3%) endorsed sex under the influence in the prior 90 days, and 39.1% endorsed sex under the influence during their most recent sexual event. Sex under the influence at the most recent event was more likely to involve anal intercourse, sex with a casual partner, and less condom use. Patients might benefit from interventions targeting sexual behavior and substance use as mutual triggers. (Am J Addict 2010;00:1-9).

Ovarian function and its manipulation in the tammar wallaby, Macropus eugenii

This study aimed to develop a superovulation protocol for the monovulatory tammar wallaby (Macropus eugenii), and examined the regulation of ovarian activity which leads to alternate ovulation in this marsupial. The most effective stimulatory treatment was 20 I.U. pregnant mare serum gonadotrophin (PMSG) given intramuscularly (i.m.) 20 days after the activation of an oestrous cycle by the removal of a sucking pouch young (RPY). Bromocriptine treatment was given at the time of RPY if the animal was in early seasonal quiescence. Mating had generally occurred when animals were examined 2 days after PMSG treatment on the morning of Day 22 RPY. Ovulation occurred only if the animal was treated on Day 22 or 23 (i.e. 2 or 3 days after PMSG) with gonadotrophin releasing hormone (GnRH) to induce a luteinizing hormone (LH) surge. Three 30-micrograms injections of GnRH (in 0.2 mL olive oil) were delivered as i.m. injections at 3-h intervals. Radioimmunoassay confirmed that the PMSG dose used did not elevate circulating steroid hormone concentrations beyond those found in normal cycles and that the GnRH protocol led to an LH surge of at least 6 h. Although multiple ovulation was achieved, the number of ovulations was low (2 or 3 per female). A major factor influencing the low ovulation rate was that generally only one ovary responded. Fertilized eggs and cleaving embryos were obtained. However, the fertility of induced ovulations has not yet been examined systematically. Laparoscopic examination through successive natural cycles confirmed that follicle growth and ovulation in the tammar wallaby alternates between the right and left ovary. Inhibition of follicle development in the corpus luteum (CL)-bearing ovary was also seen in females treated with the exogenous gonadotrophin (PMSG/GnRH) superovulation protocol. Follicle development was inhibited during the first half of the cycle in the non-CL-bearing ovary and during the entire cycle in the CL-bearing ovary. This inhibition seemed to occur at the follicular level because exogenous gonadotrophin was unable to initiate a response during periods of inhibition and the response to gonadotrophin differed in the two ovaries. The number of follicles growing in the non-CL-bearing ovary in response to an exogenous gonadotrophin stimulus was inversely related to the weight of the growing CL for the first 19 days after RPY.(ABSTRACT TRUNCATED AT 400 WORDS)

A simple glycerol-based freezing protocol for the semen of a marsupial Trichosurus vulpecula, the common brushtail possum

Frozen storage of semen and embryos is now a well established part of the breeding of many eutherian mammals but it has not been applied to marsupials. This paper reports the first successful technique for the frozen preservation of marsupial spermatozoa. Semen was collected by electroejaculation under anaesthesia from a pool of five brushtail possums. The ejaculated semen was diluted 1:1 with Krebs Henseleit Ringer, centrifuged at 800 g for 5 min, resuspended in the test cryoprotectant media at 1, 2 and 5 x 10(6) spermatozoa mL-1 and 7, 10.5, 14 and 17.5% glycerol and then drawn up into 0.25 mL plastic straws. The spermatozoa were rapidly frozen in the vapour phase, 6 cm above liquid nitrogen, for 30 min before the straws were plunged into the liquid. Sperm motility was assessed blind for coded straws by phase-contrast microscopy on a warmed stage (35 degrees C), before freezing and after rapid thawing in a water bath at 37 degrees C (10 s). The highest recovery of both percentage motility (around 50-60%) and progressive motility (around 0.5-1 unit lower than prefreeze) occurred when spermatozoa were frozen and thawed in the presence of 17.5% glycerol. Recovery of motility was greater at the higher sperm concentrations (2 and 5 x 10(6) mL-1). There was no evidence of acrosomal damage or loss after freezing and thawing in high concentrations of glycerol. The only defect detected in spermatozoa subjected to the protocol was a variable tendency to bending of the neck region. This ranged from heads inclined at a slight angle to the tail through to complete flexure.(ABSTRACT TRUNCATED AT 250 WORDS)