Community pharmacy-based injectable naltrexone service delivery models and best practices

BACKGROUND

Opioid use disorder (OUD) is a major public health issue in the United States. Medications for OUD (MOUD), which combines the use of approved medications with counseling and behavioral therapies, represents an evidence-based approach to treat individuals living with an OUD. However, MOUD has not kept up with increased demand and new treatment approaches are needed. One approach is injectable naltrexone, an approved and effective MOUD treatment, provided by pharmacists, who are more geographically accessible and have legal authority to administer it in some states.

OBJECTIVES

To explore how different community pharmacists provide injectable naltrexone treatment and identify best practices.

METHODS

An exploratory sequential mixed-methods design was used to investigate pharmacy-based naltrexone injection practices, involving a pharmacist questionnaire and interviews with pharmacists, prescribers, and community stakeholders. An inductive/iterative content analysis approach, guided by an initial straw model, was used to identify and explore conceptual categories for the interviews.

RESULTS

The final sample included 68 pharmacy surveys and 14 total interviews with pharmacists (n = 9), prescribers (n = 3), and community stakeholders (n = 2). Pharmacies providing naltrexone injections reported administering over 700 injections in the past year. Interviews revealed benefits and barriers to pharmacist-provided injections and the importance of the prescriber-pharmacist relationship in OUD treatment. Three pharmacy treatment delivery models were identified, compared to the initial straw model, and informed development of a best practices checklist for community pharmacies interested in establishing or expanding a naltrexone injection service.

CONCLUSIONS

The study demonstrates how community pharmacies developed and implemented a naltrexone injection service. Pharmacists' and prescribers' feedback clearly suggests an untapped interest, as well as resources, in realizing pharmacists' roles as providers of injectable naltrexone treatment. Implementation research could inform the development and evaluation of an intervention based on these best practices to further explore the utility of community pharmacy-based naltrexone injection services.

A randomized comparison of extended-release naltrexone with or without patient navigation vs enhanced treatment-as-usual for incarcerated adults with opioid use disorder

The high prevalence of opioid use among justice-involved adults make jails an exceptional setting to initiate opioid use disorder (OUD) treatment, but optimal strategies for delivering these interventions are still not well understood. The objective of this study was to conduct a randomized controlled trial to assess the effectiveness of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc) alone or in conjunction with patient navigation (XR-NTX + PN) for jail inmates with OUD. We randomized a sample of 135 sentenced jail inmates with moderate to severe OUD to (1) XR-NTX only; (2) XR-NTX + PN; or (3) enhanced treatment-as-usual (ETAU) with drug education, each initiated prior to release from jail. We scheduled follow-up data assessments at 1, 3, 6, and 12 months post-release. Primary outcomes were opioid use (based on Timeline Followback Interview and Addiction Severity Index) and meeting CIDI DSM-5 criteria for OUD 6 months postrelease. We also measured treatment adherence, HIV risk, and recidivism. XR-NTX participants received a mean of 2.26 of 7 possible injections compared to XR-NTX + PN participants, who received a mean of 2.93 injections (Cohen's d = 0.33, 95% CI: -0.09 to 0.74). Thirty-six percent of patients in XR-NTX + PN attended at least one postrelease PN session. We found no significant differences by study condition six months after release from jail for the primary outcomes of any opioid use (ETAU: 17%, XR-NTX: 16%, XR-NTX + PN: 29%) and past 30-day OUD (ETAU: 8%, XR-NTX: 11%, XR-NTX + PN: 10%). Secondary outcomes of rearrest and HIV risk also were similar across groups, with the exception of lower sex-related HIV risk among those in the XR-NTX condition at 12 months. This study did not show superior outcomes of XR-NTX or XR-NTX + PN with regard to opioid use or recidivism outcomes, relative to ETAU. It did, however, highlight the difficulties with adherence to XR-NTX and PN interventions in OUD patients initiating treatment in jail.

Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort

BACKGROUND AND AIMS

Despite the growing opioid overdose crisis, medication treatment for opioid use disorder remains uncommon. The comparative effectiveness of buprenorphine and naltrexone treatment in reducing overdose and the comparative risks of discontinuing treatment in the real world, remain uncertain. Our aim was to examine the effectiveness of medications for opioid use disorder in preventing opioid-related overdose.

DESIGN

Retrospective cohort study SETTING: United States.

PATIENTS

46,846 commercially insured individuals diagnosed with opioid use disorder and initiating medication treatment between 2010 and 2016.

MEASUREMENTS

Opioid-related overdose identified by International Classification of Diseases, Ninth and Tenth Revisions.

FINDINGS

In our sample, 1386 individuals were prescribed extended-release injectable naltrexone (median filled prescriptions = 9 months), 7782 were prescribed oral naltrexone (5 months), and 40,441 were prescribed buprenorphine (19 months) at least once during follow-up. Individuals receiving buprenorphine therapy were at significantly reduced risk of opioid-related overdose compared to no treatment (adjusted hazard ratio (HR) = 0.40, 95% CI 0.35-0.46), while a significant association was not observed in extended-release injectable (HR = 0.74, 95% CI 0.42-1.31) or oral (HR = 0.93, 95% CI 0.71-1.22) naltrexone. We found no association with opioid overdose within four weeks of discontinuation of any medication.

CONCLUSION

Among commercially-insured patients who initiate medications for opioid use disorder, buprenorphine, but not naltrexone, was associated with lower risk of overdose during active treatment compared to post-discontinuation. More research is needed to understand the benefits and risks unique to each treatment option to better tailor therapies to patients with opioid use disorder.

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.

Injectable pharmacotherapy for opioid use disorders (IPOD)

BACKGROUND

Despite the growing prevalence of opioid use among offenders, pharmacotherapy remains an underused treatment approach in correctional settings. The aim of this 4-year trial is to assess the clinical utility, effectiveness, and cost implications of extended-release naltrexone (XR-NTX, Vivitrol®; Alkermes Inc.) alone and in conjunction with patient navigation for jail inmates with opioid use disorder (OUD).

METHODS

Opioid-dependent inmates will be randomly assigned to one of three treatment conditions before being released to the community to include: 1) XR-NTX only; 2) XR-NTX plus patient navigation (PN), and 3) enhanced treatment-as-usual (ETAU) with drug education and a community treatment referral. Before release from jail, participants in the XR-NTX and XR-NTX plus PN conditions will receive their first XR-NTX injection. Those in the XR-NTX plus PN condition also will meet with a patient navigator. Participants in both XR-NTX conditions will be scheduled for medical management sessions twice monthly for months 1-3, monthly medical management sessions for months 4-6, with monthly injections for 5months post-release (which, given the pre-release injection, results in a 6-month medication phase). Follow-up data collection will occur at 1, 3, 6, and 12months post release.

RESULTS

We discuss the study's rationale, aims, methods, and anticipated findings. The primary outcome is the presence of a DSM 5 OUD diagnosis 1year after randomization (6months after the end of the active treatment phase).

DISCUSSION

We hypothesize that providing XR-NTX prior to release from jail will be particularly beneficial for this extremely high-risk population by reducing opioid use, associated criminal behavior, and injection-related disease risk. ClinicalTrials.Gov: NCT02110264.