Effects of prenatal methadone and buprenorphine exposure on motivated responding for sucrose and gene expression in adult male and female rats

With increasing rates of opioid use disorder (OUD) and overdose deaths in the US, increased access to medications for OUD (MOUD) is paramount. Rigorous effectiveness evaluations of large-scale implementation initiatives using quasi-experimental designs are needed to inform expansion efforts. To evaluate a US Department of Veterans Affairs (VA) initiative to increase MOUD use in nonaddiction clinics. This quality improvement initiative used interrupted time series design to compare trends in MOUD receipt. Primary care, pain, and mental health clinics in the VA health care system (n = 35) located at 18 intervention facilities and nonintervention comparison clinics (n = 35) were matched on preimplementation MOUD prescribing trends, clinic size, and facility complexity. The cohort of patients with OUD who received care in intervention or comparison clinics in the year after September 1, 2018, were evaluated. The preimplementation period extended from September 1, 2017, through August 31, 2018, and the postimplementation period from September 1, 2018, through August 31, 2019. The multifaceted implementation intervention included education, external facilitation, and quarterly reports. The main outcomes were the proportion of patients receiving MOUD and the number of patients per clinician prescribing MOUD. Segmented logistic regression evaluated monthly proportions of MOUD receipt 1 year before and after initiative launch, adjusting for demographic and clinical covariates. Poisson regression models examined yearly changes in clinician prescribing over the same time frame. Overall, 7488 patients were seen in intervention clinics (mean [SD] age, 53.3 [14.2] years; 6858 [91.6%] male; 1476 [19.7%] Black, 417 [5.6%] Hispanic; 5162 [68.9%] White; 239 [3.2%] other race [including American Indian or Alaska Native, Asian, Native Hawaiian or other Pacific Islander, and multiple races]; and 194 [2.6%] unknown) and 7558 in comparison clinics (mean [SD] age, 53.4 [14.0] years; 6943 [91.9%] male; 1463 [19.4%] Black; 405 [5.4%] Hispanic; 5196 [68.9%] White; 244 [3.2%] other race; 250 [3.3%] unknown). During the preimplementation year, the proportion of patients receiving MOUD in intervention clinics increased monthly by 5.0% (adjusted odds ratio [AOR], 1.05; 95% CI, 1.03-1.07). Accounting for this preimplementation trend, the proportion of patients receiving MOUD increased monthly by an additional 2.3% (AOR, 1.02; 95% CI, 1.00-1.04) during the implementation year. Comparison clinics increased by 2.6% monthly before implementation (AOR, 1.03; 95% CI, 1.01-1.04), with no changes detected after implementation. Although preimplementation-year trends in monthly MOUD receipt were similar in intervention and comparison clinics, greater increases were seen in intervention clinics after implementation (AOR, 1.04; 95% CI, 1.01-1.08). Patients treated with MOUD per clinician in intervention clinics saw greater increases from before to after implementation compared with comparison clinics (incidence rate ratio, 1.50; 95% CI, 1.28-1.77). A multifaceted implementation initiative in nonaddiction clinics was associated with increased MOUD prescribing. Findings suggest that engagement of clinicians in general clinical settings may increase MOUD access.

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

Despite high rates of opioid use disorder (OUD) among patients admitted for acute inpatient psychiatric treatment, medications for opioid use disorder (MOUD) are not routinely prescribed in this setting. Dually diagnosed individuals are more likely to present to the mental health system for treatment than to substance use disorder programs; therefore, initiating MOUD in psychiatric units would increase treatment access. Following the implementation of a protocol to offer MOUD to patients admitted to psychiatric units, clinical staff perspectives were evaluated. Semistructured interviews were conducted with 15 staff members following protocol implementation in 2 psychiatric units. Interviews were inductively coded and thematically analyzed. Five themes emerged: (1) co-occurring OUD and psychiatric disorders are common in psychiatric units; (2) opioid withdrawal treatment during psychiatric admission is widely acceptable to staff, but support for maintenance treatment varies; (3) misconceptions regarding MOUD persist among staff; (4) patients with co-occurring disorders have complex psychosocial needs requiring multimodal treatment; (5) stigma can be a barrier to OUD treatment. Staff recognized the high prevalence of OUD in psychiatric units and the need for treatment. Despite some reluctance about MOUD initiation in this setting, MOUD remains the gold standard and should be available to patients with OUD wherever they seek medical care, consistent with a "No Wrong Door" approach. Improved education and multidisciplinary collaboration may increase staff acceptance of MOUD. Finally, MOUD initiation for dually diagnosed patients will be most successful when integrated within a multidisciplinary treatment model and coordinated community-based care.

The objectives of the study were to provide a descriptive assessment of patient and hospital characteristics among individuals with an opioid use disorder (OUD) diagnosis in North Carolina and the seven western North Carolina counties and to identify rates of selected psychiatric/physical health outcomes associated with OUD and treatment gaps in medications for opioid use disorder (MOUD). Using the State Inpatient Database (SID), analyses were conducted to identify OUD and MOUD-related discharges between 2000 and 2020. Descriptive statistics and rates of OUD per 1000 discharges were calculated. Statistical significance for rates of OUD and non-OUD cases was determined using 95% confidence intervals. Variables indicating OUD diagnosis, MOUD participation, and comorbidities were identified. The seven selected counties in North Carolina had a total of 396,183 hospitalizations between 2000 and 2020. Apart from Macon County, the overall county-level prevalence rates of OUD were consistently higher than that of the state. Compared with North Carolina, the median hospital length of stay and hospital charges for OUD patients in the seven counties were consistently higher than those for non-OUD discharges. Significant MOUD treatment gaps were observed in the seven counties. The impact of the opioid epidemic is still pervasive in North Carolina, particularly in the seven western countries. The high rates of OUD and comorbid conditions in tandem with treatment shortages pose serious public health threats in these rural communities. Policies, funding, and programmatic efforts should prioritize the expansion of MOUD and other treatment efforts, including crisis services, harm reduction services, and recovery programs. Public health needs assessment that involves both patients and stakeholders should be carried out to deliver targeted health services and deploy necessary resources in this medically underserved region.

Rates of opioid use disorder (OUD) have increased in older adults (age ≥ 50). Medications for OUD (MOUD) treat OUD effectively; however, limited data exist on whether older adults with OUD are provided MOUD. Using 2016-2020 claims data from Medicare beneficiaries with a new episode of OUD, we calculated rates of MOUD initiation (first dispensing within 14 days of index event), engagement (dispensing of a second MOUD within 34 days of initiation), and retention (receiving MOUD consistently over 180 days). Among beneficiaries with qualifying index events (N = 40 336), 17%, 38%, and 45% were ages 20-49, 50-64, and ≥ 65, respectively. Five hundred and three beneficiaries with a qualifying index event (1.3%) initiated MOUD, 461 (1.1%) reached engagement, and 309 (0.8%) were retained. Multivariable logistic regressions showed older age was associated with reduced MOUD initiation (compared with those aged 20-49, adjusted odds ratios [aORs] were 0.79 [95% CI, 0.64-0.98] and 0.36 [95% CI, 0.25-0.51] for ages 50-64 and ≥65, respectively). Reduced MOUD initiation was associated with female sex (aOR = 0.74; 95% CI, 0.61-0.89) and increasing comorbidity score (aOR = 0.76 per 1-point increase; 95% CI, 0.72-0.80). These results suggest that in addition to general efforts to increase uptake of MOUD, age-specific strategies are needed.

“Sick and tired of being sick and tired”: Exploring initiation of medications for opioid use disorder among people experiencing homelessness

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

Methadone and buprenorphine are commonly prescribed during pregnancy to maintain recovery and prevent symptoms of withdrawal in women with opioid use disorder. Infants prenatally exposed to medications for opioid use disorder (MOUD), however, commonly show signs of neonatal opioid withdrawal syndrome (NOWS), which can include feeding-related issues like hyperphagia. To investigate the effects of prenatal MOUD exposure on feeding behavior, female Sprague-Dawley rats were implanted with osmotic minipumps filled with methadone, buprenorphine, or saline and subsequently mated. On postnatal day (PND) 1, buprenorphine- and methadone-exposed offspring weighed less than saline-exposed subjects. Throughout early postnatal development (PND2, 7, and 12), this reduction in weight persisted in buprenorphine, but not methadone, offspring. RNAscope in situ hybridization was then used to measure expression of genes in the nucleus accumbens (NAc) previously associated with hyperphagia in NOWS infants, including proopiomelanocortin (Pomc), neuropeptide Y2 receptors (Npy2r), and dopamine type 2 receptors (Drd2). Distinct developmental expression patterns were noted across the postnatal period, with few effects of MOUD; however, significantly lower Pomc expression was observed in methadone-exposed but not buprenorphine-exposed offspring. These findings demonstrate differential effects of methadone and buprenorphine on offspring development and gene expression, highlighting differences in offspring outcomes associated with these two MOUDs.

Objectives Limited research has addressed racial/ethnic disparities in receiving medications for opioid use disorder (MOUD) and treatment outcomes. This study examined racial/ethnic differences in receiving MOUD and treatment completion among women of reproductive age with opioid use disorder (OUD). Methods This study utilized data from the 2010–2019 Treatment Episode Data Set (TEDS). The analytic sample consisted of 209,521 women of reproductive age (18–49 years old). Results Overall, MOUD receipt was low for all racial/ethnic groups, with Hispanic and Black women being more likely to receive MOUD than White women. Receipt of MOUD ranged from 18.3% for White women to 21.9% for Hispanic women. Black and Hispanic women had lower odds of completing any treatment for OUD than White women. The rates of OUD treatment completion increased over time (2010 to 2019) for White and Black women, with a small decrease for Hispanic women. For all groups, treatment completion rates without MOUD were higher than those with MOUD. Conclusions Racial/ethnic disparities exist in the receipt of any OUD treatment, receipt of MOUD, and completion of treatment. Monitoring disparities and designing programs to maximize successful receipt and completion of MOUD is necessary for improving intervention efforts for women of reproductive age.

Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose “never” or “always” for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.

Pregnant people in U.S. jails experience high rates of opioid use disorder (OUD), yet access to medications for opioid use disorder (MOUD) remains inconsistent. This mixed-methods study examines how jail policies, treatment infrastructure, and political context shape MOUD provision for pregnant incarcerated individuals. We conducted a secondary analysis of a national survey of 2885 U.S. jails (analytic sample = 836). Logistic regression models assessed associations between MOUD provision and telemedicine capacity, community MOUD availability, state Medicaid expansion, and 2020 presidential voting outcomes. Qualitative responses characterized barriers to care. Findings confirm that MOUD access for pregnant incarcerated individuals remains limited and structurally patterned. Fewer than half of jails continued methadone or buprenorphine for pregnant individuals already in treatment, and initiation was uncommon. MOUD provision was more likely in Democrat-won states, jails with telemedicine capacity, and jails located in communities with MOUD providers, while limited community availability reduced odds of provision. Qualitative themes highlighted restrictive jail policies, provider discretion, diversion concerns, and misconceptions regarding fetal harm. These findings underscore persistent structural barriers to evidence-based perinatal OUD treatment in carceral settings and highlight the importance of telemedicine expansion, community treatment capacity, and standardized correctional policies to advance perinatal health equity.

Transitions of care between jail-based medications for opioid use disorder and ongoing treatment in the community: A retrospective cohort study

Factors associated with receipt of medication for opioid use disorder among pregnant individuals entering treatment programs in the U.S.

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

BackgroundThe Veterans Health Administration has made strides to improve access to medications for opioid use disorder overall. However, quality improvement methods to assess treatment gaps may not sufficiently detect differences in medication access by intersecting patient factors, which may have multiplicative rather than additive effects. This study aimed to determine whether race/ethnicity and legal involvement interact in receipt of medications for opioid use disorder among Veterans Health Administration patients.MethodsUsing national electronic health record data from Fiscal Years 2021–2022, we examined the receipt of medications for opioid use disorder among veterans diagnosed with opioid use disorder who received healthcare at Veterans Health Administration facilities (n = 65,883). We conducted a mixed effects multivariable logistic regression model to examine an interaction effect of race/ethnicity and legal involvement with receipt of any medications for opioid use disorder, both unadjusted and adjusted for patient and facility characteristics.ResultsIn an adjusted logistic regression model, the interaction effect indicated that non-Hispanic Black veterans with legal involvement had the lowest odds of medications for opioid use disorder receipt compared to non-Hispanic White veterans without legal involvement (adjusted odds ratio = 0.67, 95% confidence interval = 0.59–0.77, p <.0001). Non-Hispanic American Indian/Alaska Native patients without legal involvement (adjusted odds ratio = 0.85, 95% confidence interval = 0.73–0.99, p =.04) also had lower odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement. Non-Hispanic White veterans with legal involvement (adjusted odds ratio = 1.07, 95% confidence interval = 1.01–1.14, p =.03) had higher odds of receipt of medications for opioid use disorder compared to non-Hispanic White patients without legal involvement.ConclusionsVeterans Health Administration quality improvement efforts should monitor interacting racial and legal status factors and understand and address patient, clinical, and regulatory barriers to medications for opioid use disorder among Black veterans with legal involvement.