Disparities in identification and treatment of opioid use disorder in primary care: A scoping review

Female, Hispanic, and Black patients with opioid use disorder (OUD) are less likely to receive OUD medication treatment than other patients. The PROUD (PRimary care Opioid Use Disorders treatment) trial demonstrated that implementation of primary care (PC) nurse care management increases OUD medication treatment compared with usual care (UC). This study assessed whether the PROUD intervention's effect differed across sex, race and ethnicity. Secondary analyses of cluster-randomized implementation trial. 12 PC clinics (2 per health system) in five states in the USA, randomized to UC or intervention, stratified by health system. PC patients 16-90 years old. Three strategies to implement office-based addiction treatment (OBAT) by nurse care managers: (1) full-time nurse salary; (2) nurse training and technical assistance from expert nurses at Boston Medical Center; (3) ≥3 PC providers willing to prescribe buprenorphine. Nurses were trained in the Massachusetts model of OBAT which includes lowering barriers to OUD treatment, assessing and educating patients, supporting initiation of medications for OUD and providing ongoing medical management, in collaboration with PC providers. The primary outcome was a clinic-level measure of OUD treatment defined as patient-years of OUD treatment per 10 000 PC patients based on orders and procedures for buprenorphine or extended-release naltrexone from electronic health records and insurance claims (hereafter 'OUD treatment'). The mean numbers of patients seen by intervention and UC clinics at baseline were 18 485 and 22 557, respectively. Female patients comprised 60% of the total PC population in intervention clinics and 64% in UC clinics; Asian, Black, Hispanic or smaller racial groups comprised 61% of the PC population in intervention clinics, and 70% in UC clinics. Compared with UC, the intervention increased OUD treatment for male patients [adjusted difference: 13.7 patient-years; 95% confidence interval (CI) = 5.8-21.7], but not female patients (2.9; 95% CI = -4.3 to 10.2); effect modification test, F (1,14) = 4.77; P = 0.046. Exploratory analyses suggest that differences in the intervention's effect on receipt of any OUD treatment in female and male patients, rather than differences in the duration of OUD treatment, may account for findings. There was no significant effect modification by race or ethnic group [effect modification test F (4,44) = 1.50; P = 0.218]. Primary care clinics that implement office-based addiction treatment by nurses increase patient-years of opioid use disorder (OUD) treatment in male but not female patients. Exploratory findings suggest that differences in the proportion of patients treated for OUD, rather than differences in the duration of OUD treatment, account for observed differences across groups.

We described Medicaid-insured women by receipt of perinatal opioid use disorder (OUD) treatment; and trends and disparities in treatment. Using 2007 to 2012 Medicaid Analytic eXtract data from 45 states and D.C., we identified deliveries among women with OUD. Regressions modeled the association between patient characteristics and receipt of any OUD treatment, medication for OUD (MOUD), and counseling alone during the perinatal period. Rates of any OUD treatment and MOUD for women with perinatal OUD increased over the study period, but trends differed by subgroup. Compared with non-Hispanic White women, Black and American Indian/Alaskan Native (AI/AN) women were less likely to receive any OUD treatment, and Black women were less likely to receive MOUD. Over time, the disparity in receipt of MOUD between Black and White women increased. Overall gains in OUD treatment were driven by improvements in perinatal OUD care for White women and obscured disparities for Black and AI/AN women.

BackgroundDirect acting antiretrovirals (DAA) are effective for individuals who are infected with chronic hepatitis C virus (HCV), yet many people go without access to these lifesaving treatments.Materials and methodsWe conducted a non-randomized study evaluating treatment data for patients in outpatient treatment for opioid use disorder (OUD) at a private clinic. Patients who were HCV-positive, had been in OUD treatment for at least 4 weeks, and engaged in integrated HCV treatment with DAA (co-located within their treatment for OUD) were compared to patients with HCV who only received OUD treatment. We evaluated HCV cure; OUD medication adherence, treatment utilization and retention; and illicit substance use for those engaged in treatment between 9/2016 and 1/2018.ResultsSeventy-four patients completed integrated HCV-OUD treatment with DAA, with 87.8% achieving cure. Of the 66 who completed treatment and were subsequently evaluated for sustained viral response 98.5% were cured. Patients who received integrated HCV and OUD treatment in our clinic, stayed in OUD treatment longer, demonstrated higher OUD medication adherence, and used less opioids or cocaine compared to HCV-infected patients (n = 572) being treated only for OUD.DiscussionWe have reported on a reproducible intervention that lends itself to outpatient OUD treatment. Analyses demonstrate the potential positive impact HCV treatment has on OUD recovery, including reduction in opioid and cocaine use and increased retention in careConclusionCo-locating HCV treatment with existing OUD treatment is feasible, effective, and demonstrates positive outcomes for the treatment of both conditions.

State medical cannabis laws, currently in place in 39 states and Washington, DC, provide an avenue for therapeutic use of cannabis to manage chronic noncancer pain stemming from conditions such as arthritis and low back pain. These laws may also influence cannabis and opioid addiction and overdose, for example, if people substitute cannabis in place of opioids to manage pain. No studies, to our knowledge, have examined how state medical cannabis laws influence health care use related to addiction to or overdose from cannabis or opioids among people with chronic noncancer pain. We used a difference-in-differences design and augmented synthetic control analyses comparing changes in cannabis use disorder (CUD) and opioid use disorder (OUD) treatment and cannabis and opioid overdose-related health care use before and after medical cannabis law implementation among Medicare beneficiaries with chronic noncancer pain in seven states (Florida, Maryland, Minnesota, New Hampshire, New York, Oklahoma, and Pennsylvania) relative to changes in outcomes over the same period in 17 comparison states (Alabama, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Mississippi, Nebraska, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Virginia, Wisconsin, and Wyoming) without medical cannabis laws. State medical cannabis laws had an estimated average effect of less than 0.005 percentage points on the overall proportion of patients receiving any CUD or OUD treatment, less than 0.009 percentage points on the proportion of patients newly initiating CUD or OUD treatment, and less than 0.0005 percentage points on the proportion of patients receiving overdose-related health care for cannabis or opioid overdoses (p > 0.05 for all findings). Our study did not identify effects of state medical cannabis laws on health care use related to CUD or OUD treatment or overdose among Medicare beneficiaries younger than age 65 years with chronic noncancer pain.

Postpartum medication for opioid use disorder outcomes associated with prenatal treatment and neighborhood-level social determinants

To describe the effectiveness of medications for the treatment of opioid use disorder (OUD) and attention deficit/hyperactivity disorder (ADHD). Literature search of PubMed, Embase, Web of Science, CINAHL, Medline, PsycINFO, and Google Scholar was performed for studies published from inception to October 25, 2022. Studies were included if patients were diagnosed with OUD and ADHD and had pharmacotherapy for either condition. Abstracts, commentaries, reviews, case reports, case series, non-English articles, and animal studies were omitted. This review found 18 studies. Treatment of ADHD was evaluated for impact on ADHD and OUD outcomes, while treatment of OUD was evaluated for OUD-related outcomes. Outcomes assessed included markers for symptom intensity, adherence, and treatment failure. While results were mixed, treatment of ADHD was largely associated with improvements in ADHD severity and retention in OUD treatment programs. ADHD severity was associated with higher rates of illicit substance abuse and worse OUD-related outcomes. It could not be determined which medications for treatment of OUD should be prioritized. This review summarized key findings from studies that treated ADHD or OUD among dually diagnosed patients and highlighted methodological considerations for future research. Treatment of ADHD is warranted among patients with OUD and ADHD to improve retention in OUD treatment programs and reduce illicit substance abuse. Pharmacotherapy for the treatment of ADHD or OUD should continue to be determined based on patients' characteristics and the capabilities of the treatment program.

Opioid and cocaine abuse are major public health burdens. Existing medications for opioid use disorder are limited by abuse liability and side effects, whereas no treatments are currently approved in the United States for cocaine use disorder. Dopamine D3 receptor (D3R) antagonists have shown promise in attenuating opioid and cocaine reward and mitigating relapse in preclinical models. However, translation of D3R antagonists to the clinic has been hampered by reports that the D3R antagonists GSK598,809 (5-(5-((3-((1S,5R)-1-(2-fluoro-4-(trifluoromethyl)phenyl)-3-azabicyclo[3.1.0]hexan-3-yl)propyl)thio)-4-methyl-4H-1,2,4-triazol-3-yl)-4-methyloxazole) and SB-277,011A (2-(2-((1r,4r)-4-(2-oxo-2-(quinolin-4-yl)ethyl)cyclohexyl)ethyl)-1,2,3,4-tetrahydroisoquinoline-6-carbonitrile) have adverse cardiovascular effects in the presence of cocaine. Recently, we developed two structurally novel D3R antagonists, R-VK4-40 and R-VK4-116, which are highly selective for D3R and display translational potential for treatment of opioid use disorder. Here, we tested whether R-VK4-40 ((R)-N-(4-(4-(2-Chloro-3-ethylphenyl)piperazin-1-yl)-3-hydroxybutyl)-1H-indole-2-carboxamide) and R-VK4-116 ((R)-N-(4-(4-(3-Chloro-5-ethyl-2-methoxyphenyl)piperazin-1-yl)-3-hydroxybutyl)-1H-indole-2-carboxamide) have unwanted cardiovascular effects in the presence of oxycodone, a prescription opioid, or cocaine in freely moving rats fitted with surgically implanted telemetry transmitters. We also examined cardiovascular effects of the D3R antagonist, SB-277,011A, and L-741,626 (1-((1H-indol-3-yl)methyl)-4-(4-chlorophenyl)piperidin-4-ol), a dopamine D2 receptor-selective antagonist, for comparison. Consistent with prior reports, SB-277,011A increased blood pressure, heart rate, and locomotor activity alone and in the presence of cocaine. L-741,626 increased blood pressure and heart rate. In contrast, R-VK4-40 alone dose-dependently reduced blood pressure and heart rate and attenuated oxycodone-induced increases in blood pressure and oxycodone or cocaine-induced increases in heart rate. Similarly, R-VK4-116 alone dose-dependently reduced cocaine-induced increases in blood pressure and heart rate. These results highlight the safety of new D3R antagonists and support the continued development of R-VK4-40 and R-VK4-116 for the treatment of opioid and cocaine use disorders. SIGNIFICANCE STATEMENT: Opioid and cocaine abuse are major public health challenges and new treatments that do not adversely impact the cardiovascular system are needed. Here, we show that two structurally novel dopamine D3 receptor antagonists, R-VK4-40 and R-VK4-116, do not potentiate, and may even protect against, oxycodone- or cocaine-induced changes in blood pressure and heart rate, supporting their further development for the treatment of opioid and/or cocaine use disorders.

The opioid crisis has devasted individuals, families, and communities in the United States and abroad. Improving opioid use disorder (OUD) treatment requires a nuanced understanding of the risk factors associated with the onset of OUD, and barriers to successful, long-term recovery. Women and men might have several unique risk factors for initiating opioid use, progressing from non-medical opioid use to OUD, and experiencing negative OUD treatment outcomes. These unique risk factors are best understood by examining sex as a biological variable and gender as a social construct in persons with OUD. Toward this end, the research reviewed in this chapter includes sex-based biological factors that affect opioid use, such as neurohormonal interactions with the endogenous opioid system and sex-based differences in neural development, as well as gender-based societal influences that can lead to OUD and potentially stymie attempts at treatment, such as traditional gender roles within the family unit and stigma surrounding OUD treatment. Factors that encompass the intersection of sex and gender are also discussed in the context of OUD treatment, including co-morbid mental health conditions, chronic pain, and response to medications for OUD (MOUD). Building on the preclinical and clinical research on these topics, future studies should aim to optimize pharmacotherapeutic approaches within subpopulations of women and men with OUD, develop strategies to better engage women and men with childcare responsibilities in OUD treatment, and reduce stigma associated with living with OUD and seeking treatment for OUD.

To determine how the rise of telehealth during the COVID-19 pandemic impacted Medicaid enrollees' access to opioid use disorder (OUD) treatment. Electronic health records from Northwestern Medicine, a large midwestern academic health system, from January 1, 2019 to December 31, 2021. The exposure was the expansion of telehealth services during the COVID-19 pandemic. A difference-in-differences design was used to determine the impact of telehealth on the probability of receiving any OUD care, any in-person OUD care, and any telehealth OUD care in a month. The study included Medicaid and privately insured patients older than 18 years of age, diagnosed with OUD, who had any encounter with the Northwestern Medicine system. All outpatient visits with OUD as the primary diagnosis were included in the analysis. There were 486 individuals in the sample and 17,496 person-month observations. After the onset of the COVID-19 pandemic, Medicaid enrollees are 4.5 percentage points (percentage change, 43.7%; 95% confidence interval [CI] 8.7 to 0.3 percentage points; p = 0.035) less likely to receive any OUD care in a month, relative to privately insured patients. While no statistically significant differences in the likehood of receiving in-person OUD care were detected between the groups after exposure, we did observe that Medicaid enrollees are 3.6 percentage points (percentage change 64.2%; 95% CI 6.0 to 1.1 percentage points; p = 0.004) less likely to receive any telehealth OUD care in a month relative to privately insured patients. While those with private insurance were able to maintain OUD treatment during the pandemic by supplementing in-person care with telehealth, Medicaid enrollees experienced a drop in overall OUD treatment rates due to lower telehealth use. The rise of telehealth for OUD treatment might contribute to widening care gaps for Medicaid enrollees.

Back to table of contents Previous article Next article Clinical & ResearchFull AccessDocument Provides Inpatient Guidelines for Medication Treatment of Opioid Use DisorderAbhisek Chandan Khandai, M.D., Josie Francois, M.D.Abhisek Chandan KhandaiSearch for more papers by this author, M.D., Josie FrancoisSearch for more papers by this author, M.D.Published Online:21 Dec 2022https://doi.org/10.1176/appi.pn.2023.01.1.39AbstractA new resource document will help strengthen psychiatrists’ capabilities to be team leaders in the treatment of hospitalized patients with opioid use disorder. This article is one of a series coordinated by APA’s Council on Consultation-Liaison Psychiatry and the Academy of Consultation-Liaison Psychiatry.The prevalence, morbidity, mortality, and costs of opioid use disorder have dramatically increased over the past 20 years. While there are several effective and evidence-based medications for opioid use disorder (MOUD), less than 20% of Americans with opioid use disorder receive MOUD. The inpatient general hospital setting represents a critical point of access to MOUD, given the significant medical comorbidities of patients with opioid use disorder and the increased time to engage patients in treatment, better monitoring capabilities, and opportunities to reduce the monetary impact of the disorder on the health care system.Psychiatrists are an integral part of the hospital treatment team. However, they are often excluded for many reasons, including stigma toward opioid use disorder, lack of consultation-liaison (C-L) psychiatry services, and discomfort with managing opioid use disorder.To help address this care gap, APA’s Council on C-L Psychiatry, in collaboration with the Council on Addiction Psychiatry, convened a multispecialty expert workgroup to prepare a resource document related to the medication treatment of patients with opioid use disorder. The workgroup discussed several barriers to medication treatment and factors limiting the involvement of psychiatrists in the treatment of opioid and other substance use disorders in the inpatient hospital setting. Among the barriers they identified were stigma associated with substance use disorders (SUD) and a knowledge gap among psychiatrists regarding SUD treatment. The workgroup then created a resource document that seeks to address these barriers and guide general psychiatrists.The document includes an overview of OUD and its management in adults, explores the pharmacology of MOUD, describes barriers to care and specialty-specific concerns, and provides approaches to reducing stigma. The resource document also compares current medications to treat patients with opioid use disorder (naltrexone, buprenorphine, and methadone), walks psychiatrists through the medications’ initiation and titration in the general hospital setting, and provides recommendations on how to transition patients taking these medications from inpatient to outpatient settings.The resource guide is designed to educate and empower psychiatrists to take a larger role in MOUD in the general hospital setting to save more lives at reduced cost. Psychiatrists are in a strong position to oversee the use of MOUD in hospital settings and are best equipped to lead MOUD treatment and reduce stigma, given our relative expertise in the area of SUDs, comorbid psychiatric illnesses, and harm reduction strategies. As such, it is important that psychiatrists stay up to date on evidence-based MOUD and work with other specialties to promote psychiatric involvement in the care of those with opioid use disorder in the general hospital setting. ■Resource Document on the Treatment of Opioid Use Disorder in the General HospitalAbhisek Chandan Khandai, M.D., is a consultation-liaison psychiatry attending at UT Southwestern Medical Center and a member of APA’s Committee on Consultation-Liaison Psychiatry.Josie Francois, M.D., is a first-year psychiatry resident at Brigham and Women’s Hospital. ISSUES NewArchived

Buprenorphine/naloxone has been shown to be an effective treatment of opioid use disorder. According to the Canadian National clinical practice guideline on the management of opioid use disorders, given the superior safety profile of buprenorphine/naloxone and its potential for flexible take-home dosing in comparison to other opioid agonist medication it is strongly recommended to initiate opioid agonist treatment with buprenorphine/naloxone as the preferred first-line treatment when possible. Due to its pharmacological properties induction can be challenging, requiring the cessation of all opioids for a certain amount of time to avoid the risk of precipitated withdrawal symptoms. For this reason, buprenorphine/naloxone is not initiated for the treatment of opioid use disorder in critically ill patients where continuous infusion of opioids are required for maintenance of sedation resulting in a missed opportunity for first line treatment of that patient's opioid use disorder. We present a case of a 29-year-old female with opioid use disorder admitted for infective endocarditis and septic shock requiring intubation for hypoxic respiratory failure secondary to bilateral lung septic emboli with a high opioid debt requiring higher than typical doses of fentanyl and dexmedetomidine infusions to maintain sedation with clinical objective sign of inadequate treatment of her pain and opioid withdrawal. She was successfully started on buprenorphine/naloxone using a rapid micro-induction technique that did not cause precipitated withdrawal or require cessation of her fentanyl infusion. This case illustrates a new method for starting buprenorphine/naloxone in a critically ill intubated patient, where buprenorphine/naloxone was never a consideration in this specific patient population. This method can be used to minimize barriers to opioid agonist therapy in intubated patients.

The COVID-19 pandemic catalyzed a rapid shift in healthcare delivery towards telehealth services, impacting patient care, including opioid use disorder (OUD) treatment. Regulatory changes eliminated the in-person evaluation requirement for buprenorphine treatment, encouraging adoption of telehealth. This study focused on understanding experiences of primary care providers in predominantly rural areas who used telehealth for OUD treatment during the pandemic. Semi-structured interviews were conducted with 22 primary care providers. Participants practiced in 13 rural and 9 urban counties in Kentucky and Arkansas. Data were analyzed using conventional content analysis. The pandemic significantly impacted healthcare delivery. While telehealth was integrated for behavioral health counseling, in-person visits remained crucial, especially for urine drug screenings. Telehealth experiences varied, with some facing technology issues, while others found it efficient. Telehealth proved valuable for behavioral health counseling and sustaining relationships with established patients. Patients with OUD faced unique challenges, including housing, internet, transportation, and counseling needs. Stigma surrounding OUD affected clinical relationships. Building strong patient-provider relationships emerged as a central theme, emphasizing the value of face-to-face interactions. Regarding buprenorphine training, most found waiver training helpful but lacked formal education. This research offers vital guidance for improving OUD treatment services, especially in rural areas during crises like the COVID-19 pandemic. It highlights telehealth's value as a tool while acknowledging its limitations. The study underscores the significance of strong patient-provider relationships, the importance of reducing stigma, and the potential for training programs to elevate quality of care in OUD treatment.

Issue/problem Management of patients with opioid use disorder commonly includes opioid agonist therapy as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society. Treatment choices in opioid use disorder pharmacotherapy should be based on the needs of the individual and characteristics of medications. Description of the problem The aim was to present the use of pharmacotherapy in the treatment of opioid use disorder in family medicine practice in Zagreb. We collected data from 30 family physician practices, on patients treated for opioid use disorder. We analyzed the epidemiological characteristics of the patient, the diagnosis according to ICD X rev., as well as the frequency of the medication use and the duration of the treatment. Results Data about 100 patients treated for opioid use disorder were obtained, (88% men and 12% women). The average age of the patients was 37.9 years. From all patients, 31% had dg. F.60, 22% had dg. F19, 15% had dg. F32, 3% had dg. F29. 19% of patients was HCV positive. 62%of patients were treated with buprenorphine and 38% with methadone. In 5% of patients buprenorphine was only medication in therapy. 53% of patients with buprenorphine use diazepam, 30% use buprenorphine with antidepressant, and 12% use diazepam and antidepressant with buprenorphine. All patients who are on methadone therapy are using some other medication in therapy. Methadone is commonly prescribed in combination with diazepam and antidepressant (55%). The following combination is methadone and diazepam (34%), a combination of methadone, antipsychotics and pregabalin (7%) and a combination of methadone, antidepressants and antipsychotics (4%). The average duration of treatment for opiate addicts is 11.9 years. Lessons Patients who use buprenorphine in the treatment of opioid use disorder have less need for additional medication in therapy than patients who use methadone. Key messages Patients who use buprenorphine in the treatment of opioid use disorder have less need for additional medication in therapy than patients who use methadone. Treatment choices in opioid use disorder pharmacotherapy should be based on the needs of the individual and characteristics of medications.

Familial perceptions of appropriate treatment types and goals for a family member who has opioid use disorder

In response to rising numbers of opioid overdose deaths, primary care providers have been called on to play a greater role in delivering buprenorphine treatment for opioid use disorder. However, policy makers and providers have raised concerns that expanding treatment access may reduce treatment quality and that primary care providers are not well equipped to deliver buprenorphine treatment. We investigated two research questions in response to these concerns: How did buprenorphine treatment use and quality change in North Carolina Medicaid from 2014 to 2017, and how did buprenorphine treatment quality differ between primary care providers and specialists in North Carolina Medicaid during this period? We measured buprenorphine treatment quality as patients' retention in treatment and providers' adherence to treatment guidelines. We found that the number of enrollees receiving medication treatment for opioid use disorder increased substantially, but the percentage of enrollees with the disorder receiving treatment remained low. The quality of buprenorphine treatment increased during the study period, and primary care providers provided care of comparable or higher quality compared with that of other providers. Treatment quality for buprenorphine treatment is improving, but there remains room for improvement in both use and quality. Our results support the role of primary care providers in expanding treatment for opioid use disorder.