Noninferiority Clinical Trial of Adapted START NOW Psychotherapy for Outpatient Opioid Treatment

Background

Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial.

Methods

Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens.

Results

137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder.

Conclusion

Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

Association Between Buprenorphine Dose and the Urine "Norbuprenorphine" to "Creatinine" Ratio: Revised

Background

Utilizing a 1-year chart review as the data, Furo et al. conducted a research study on an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio and found significant differences in the ratio among 8-, 12-, and 16-mg/day groups with an analysis of variance (ANOVA) test. This study expands the data for a 2-year chart review and is intended to delineate an association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratio with a higher statistical power.

Methods

This study performed a 2-year chart review of data for the patients living in a halfway house setting, where their drug administration was closely monitored. The patients were on buprenorphine prescribed at an outpatient clinic for opioid use disorder (OUD), and their buprenorphine prescription and dispensing information were confirmed by the New York Prescription Drug Monitoring Program (PDMP). Urine test results in the electronic health record (EHR) were reviewed, focusing on the "buprenorphine," "norbuprenorphine," and "creatinine" levels. The Kruskal-Wallis H and Mann-Whitney U tests were performed to examine an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio.

Results

This study included 371 urine samples from 61 consecutive patients and analyzed the data in a manner similar to that described in the study by Furo et al. This study had similar findings with the following exceptions: (1) a mean buprenorphine dose of 11.0 ± 3.8 mg/day with a range of 2 to 20 mg/day; (2) exclusion of 6 urine samples with "creatinine" level <20 mg/dL; (3) minimum "norbuprenorphine" to "creatinine" ratios in the 8-, 12-, and 16-mg/day groups of 0.44 × 10-4 (n = 68), 0.1 × 10-4 (n = 133), and 1.37 × 10-4 (n = 82), respectively; however, after removing the 2 lowest outliers, the minimum "norbuprenorphine" to "creatinine" ratio in the 12-mg/day group was 1.6 × 10-4, similar to the findings in the previous study; and (4) a significant association between buprenorphine dose and the urine "norbuprenorphine" to "creatinine" ratios from the Kruskal-Wallis test (P < .01). In addition, the median "norbuprenorphine" to "creatinine" ratio had a strong association with buprenorphine dose, and this association could be formulated as: [y = 2.266 ln(x) + 0.8211]. In other words, the median ratios in 8-, 12-, and 16-mg/day groups were 5.53 × 10-4, 6.45 × 10-4, and 7.10 × 10-4, respectively. Therefore, any of the following features should alert providers to further investigate patient treatment compliance: (1) inappropriate substance(s) in urine sample; (2) "creatinine" level <20 mg/dL; (3) "buprenorphine" to "norbuprenorphine" ratio >50:1; (4) buprenorphine dose >24 mg/day; or (5) "norbuprenorphine" to "creatinine" ratios <0.5 × 10-4 in patients who are on 8 mg/day or <1.5 × 10-4 in patients who are on 12 mg/day or more.

Conclusion

The results of the present study confirmed those of the previous study regarding an association between buprenorphine dose and the "norbuprenorphine" to "creatinine" ratio, using an expanded data set. Additionally, this study delineated a clearer relationship, focusing on the median "norbuprenorphine" to "creatinine" ratios in different buprenorphine dose groups. These results could help providers interpret urine test results more accurately and apply them to outpatient opioid treatment programs for optimal treatment outcomes.

"It's that longitudinal relationship that pays off": A qualitative study of internal medicine residents' perspectives on learning to prescribe buprenorphine

BACKGROUND

The opioid use disorder (OUD) epidemic is a national public health crisis. Access to effective treatment with buprenorphine is limited, in part because few physicians are trained to prescribe it. Little is known about how post-graduate trainees learn to prescribe buprenorphine or how to optimally train them to prescribe. We therefore aimed to explore the experiences and attitudes of residents learning to prescribe buprenorphine within two primary care-based opioid treatment models. Methods: We performed semi-structured interviews with second- and third-year internal medicine residents at an urban academic residency program. Participating residents practiced in clinics providing buprenorphine care using either a nurse care manager model or a provider-centric model. Subjects were sampled purposively to ensure that a diversity of perspectives were included. Interviews were conducted until theoretical saturation was reached and were analyzed using principles of thematic analysis. The research team developed a consensus code list. Each transcript was then independently coded by two researchers. The team then summarized each code and generated a set of themes that captured the main ideas emerging from the data. Results: We completed 14 interviews. Participants reported learning to prescribe buprenorphine through didactics, longitudinal outpatient prescribing, mentorship, and inpatient experiences. We characterized their attitudes toward patients with OUD, medication treatment of OUD, their own role in buprenorphine care, and future prescribing. Participants practicing in both clinical models viewed learning to prescribe buprenorphine as a normal part of their training and demonstrated positive attitudes toward buprenorphine prescribing. Conclusions: Longitudinal outpatient experiences with buprenorphine prescribing can prepare residents to prescribe buprenorphine and stimulate interest in prescribing after residency. Both nurse care manager and provider-centric clinical models can provide meaningful experiences for medical residents. Educators should attend to the volume of patients and inductions managed by each trainee, patient-provider continuity, and supporting trainees in the clinical encounter.

Launching a Medication-Assisted Treatment in an Outpatient Office-Based Practice

Background: Opioid use and overdose are escalating in the United States. Primary care providers are in a strategic position to assess patients for medication-assisted treatment (MAT). Objectives: To describe the implementation of MAT in an integrated primary care residency clinic and assess provider comfort levels with evaluating patients for high-risk opioid use, conduct crucial conversations about MAT treatment options and referral to MAT for evaluation and treatment. Methods: As part of a Primary Care Training and Enhancement grant through Health Resources and Services Administration, we used an implementation process to allow for optimal clinic flow. The process included assessment of patient populations, identifying a provider champion, organizing multidisciplinary team, engaging a practice facilitator, designing clinic model and infrastructure, creating the electronic health record order sets along with provider and staff training. Providers responded to brief questions to evaluate comfort levels in 3 domains: identifying high-risk opioid use, conducting crucial conversations about treatment options and referral to MAT for evaluation and treatment. Discussion: Incorporating MAT within an integrated primary care clinic and residency program with waiver training for residents was a successful and innovative program. The availability of MAT provided a solution for patients that could benefit from this type of treatment. MAT presence gave providers the opportunity to refer these patients for treatment that had not previously been as accessible. Conclusion: An integrated primary care practice with an embedded MAT can be successful with an organized structure to optimize clinic flow.

Impact of Office-based Opioid Treatment on Emergency Visits and Hospitalization in Adolescents with Opioid Use Disorder

OBJECTIVE

To determine if engagement in office-based opioid treatment decreases emergency department, urgent care visits, and hospitalizations for acute opioid-related events (OREs) among adolescents with opioid use disorder.

STUDY DESIGN

This retrospective cohort study identified all emergent and outpatient visits among adolescents, age 10-19 years, referred for office-based opioid treatment between January 1, 2006 and December 31, 2016. Patients were dichotomized into 2 cohorts: those who did and did not engage in office-based opioid treatment. The primary end point was the difference in the proportion of visits over the study period for acute OREs between cohorts and within the office-based opioid treatment cohort before and after referral. Secondary end points assessed change in the proportion of outpatient visits for treatment unrelated to opioid use disorder.

RESULTS

Four hundred five emergent and outpatient visits were identified: 285 (70.4%) in the office-based opioid treatment cohort and 120 (29.6%) in the non-office-based opioid treatment cohort. After office-based opioid treatment engagement, 27.8% of visits in the office-based opioid treatment cohort were for acute OREs vs 80.8% in the non-office-based opioid treatment cohort (OR, 0.092; 95% CI, 0.052-0.160; P < .001). Outpatient visits in the office-based opioid treatment cohort were 10.9 times that of non-office-based opioid treatment (OR, 10.9; 95% CI, 6.23-19.16; P < .001). Within the office-based opioid treatment cohort, emergent visits decreased from 76.1% to 27.8% (OR, 0.121; 95% CI, 0.070-0.210; P < .001) and the odds of outpatient services was 8.3 times more after engagement (OR, 8.27; 95% CI, 4.78-14.4, P < .001).

CONCLUSIONS

The absolute decrease in emergent visits for acute OREs was 53% in adolescents engaged in office-based opioid treatment, representing a relative decrease of 65.6% compared with adolescents not engaged. An analysis of visits before and after office-based opioid treatment demonstrated similar decreases, suggesting that office-based opioid treatment has a significant impact in decreasing acute OREs in the adolescent population.

Lacking evidence for the association between frequent urine drug screening and health outcomes of persons on opioid agonist therapy

BACKGROUND

Opioid agonist therapy (OAT) is a first-line treatment for opioid use disorder (OUD); however, the efficacy and role of urine drug screening (UDS) in OAT has received little research attention. Prior evidence suggests that UDS frequency reflects philosophy and practice context rather than differences in patient characteristics or clinical need. Therefore, we reviewed the literature on the effect of and recommendations for the frequency of UDS on health outcomes for persons with OUD who receive OAT.

METHODS

We searched Medline and EMBASE for articles published from 1995-2017. Search results underwent double, independent review with discrepancies resolved through discussion with a third reviewer, when necessary. Additional articles were identified through snowball searching, hand searching (Google Scholar), and expert consultation. The Cochrane tool was used to assess risk of bias.

RESULTS

Of the 60 potentially eligible articles reviewed, only one three-arm randomized open-label trial, comparing weekly and monthly UDS testing with take-home OAT doses, met our inclusion criteria.

CONCLUSIONS

Our review identified an urgent gap in research evidence underpinning an area of clinical importance and that is routinely reported by patients as an area of concern.

Training in office-based opioid treatment with buprenorphine in US residency programs: A national survey of residency program directors

BACKGROUND

The prevalence of opioid use disorder (OUD) has increased sharply. Office-based opioid treatment with buprenorphine (OBOT) is effective but often underutilized because of physicians' lack of experience prescribing this therapy. Little is known about US residency training programs' provision of OBOT and addiction medicine training.

METHODS

The authors conducted a survey of residency program directors (RPDs) at all US residency programs in internal medicine, family medicine, and psychiatry to assess the frequency with which their residents provide care for OUD, presence and features of curricula in OBOT and addiction medicine, RPDs' beliefs about OBOT, and potential barriers to providing OBOT training.

RESULTS

The response rate was 49.5% (476 of 962). Although 76.9% of RPDs reported that residents frequently manage patients with OUD, only 23.5% reported that their program dedicates 12 or more hours of curricular time to addiction medicine, 35.9% reported that their program encourages/requires training in OBOT, and 22.6% reported that their program encourages/requires obtaining a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. Most RPDs believe that OBOT is an important treatment option for OUD (88.1%) and that increased residency training in OBOT would improve access to OBOT (73.7%). The authors also found that programs whose RPD had favorable views of OBOT were more likely to provide OBOT and addiction medicine training. Psychiatry programs were most likely to provide OBOT training and their RPDs most likely to have beliefs about OBOT that were positive. Commonly cited barriers to implementing OBOT training include a lack of waivered preceptors (76.9%), competing curricular priorities (64.1%), and a lack of support (social work and counseling) services (54.0%).

CONCLUSIONS

Internal medicine, family medicine, and psychiatry residents often care for patients with OUD, and most RPDs believe that increased residency training in OBOT would increase access to this treatment. Yet, only a minority of programs offer training in OBOT.