Examining Employment and Employment Barriers Among a Sample of Patients in Medication-Assisted Treatment in the United States

Using Science to Battle Stigma in Addressing the Opioid Epidemic: Opioid Agonist Therapy Saves Lives

Individuals with opioid use disorder (OUD) may experience worsening sleep quality over time, and a subset of individuals may have sleep disturbances that precede opioid use and do not resolve following abstinence. The purpose of the present study was to (1) collect retrospective reports of sleep across the lifespan and (2) identify characteristics associated with persistent sleep disturbance and changes in sleep quality in persons with OUD. Adults with OUD (n = 154) completed a cross-sectional study assessing current and past sleep disturbance, opioid use history, and chronic pain. Repeated-measures analysis of variance was used to examine changes in retrospectively reported sleep quality, and whether changes varied by screening positive for insomnia and/or chronic pain. Multivariate linear regression analyses were used to identify additional correlates of persistent sleep disturbance. Participants reported that their sleep quality declined over their lifespan. Changes in reported sleep over time varied based on whether the individual screened positive for co-occurring insomnia and/or chronic pain. In regression analyses, female sex (β = 0.16, P = .042), a greater number of treatment episodes (β = 0.20, P = .024), and positive screens for chronic pain (β = 0.19, P = .018) and insomnia (β=0.22, P = .013) were associated with self-reported persistent sleep disturbance. Only a portion of participants who screened positive for sleep disorders had received a formal diagnosis. OUD treatment providers should routinely screen for co-occurring sleep disturbance and chronic pain. Interventions that treat co-occurring OUD, sleep disturbance, and chronic pain are needed. Ellis JD, Mayo JL, Gamaldo CE, Finan PH, Huhn AS. Worsening sleep quality across the lifespan and persistent sleep disturbances in persons with opioid use disorder. J Clin Sleep Med. 2022;18(2):587-595.

Leveraging Telehealth in the United States to Increase Access to Opioid Use Disorder Treatment in Pregnancy and Postpartum During the COVID-19 Pandemic.

Stigma, Misunderstanding Among the Barriers to MAT Treatment

Objective:Opioid use disorder (OUD) has been declared a national public health emergency leading to increased enrollment in medication assisted treatment (MAT) programs. Cognitive deficits are seen among those with OUD which can persist even with MAT. Moreover, cognitive deficits predict poor community and treatment outcomes. Neuropsychological evaluations can identify, diagnose, and provide treatment recommendations, and are associated with improved outcomes in non-substance use patient populations. Yet, patients with OUD rarely undergo neuropsychological assessment when participating in opioid use treatment. Teleneuropsychology (TNP) may increase access to care but has not been evaluated with people with substance use disorders (SUDs). This project used a mixed-method design to evaluate the feasibility and impact of a pilot hybrid TNP service with new patients with OUDs entering a MAT program.Participants and Methods:Participants were >18 years old and new patients enrolling in MAT for OUD. Participants were excluded if they planned to move out of town within six months or were pending incarceration. Participants were identified by triage questions at MAT intake based on frequency of relevant co-occurring conditions indicating those with greatest need. Positively triaged individuals were referred to the TNP service which was conducted by a hybrid approach (i.e., patient presents to the clinic and is evaluated from a separate room using video-teleconferencing technology). We aimed to schedule participants within two-weeks of 30-days from intake to the MAT program. Consented participants completed questionnaires of feasibility and acceptability (e.g., satisfaction, usefulness) after undergoing a screening TNP evaluation and feedback of the results and recommendations. Participants also were invited to undergo a brief qualitative interview to further assess facilitators and barriers.Results:Of 57 individuals screened positive, 51 were referred, and 14 were reached to offer TNP. Ten (71.4%) agreed to the TNP evaluation and scheduled an appointment, though 50% had the first appointment scheduled within two weeks of 30-days after intake to MAT. Seven (70%) did not keep the first appointment (no show or cancellation) or were rescheduled due to clinic scheduling. Three were reached to reschedule. All three were unable to keep the appointment, but one did reschedule and keep the third appointment. Of the 4 who attended TNP, only 1 (25%) was within two weeks of 30-days after intake. Of those who attended the TNP appointment, 100% completed the protocol, 75% were satisfied with the evaluation overall, 75% found the evaluation useful, and 67% would recommend TNP to others (one participant did not respond to this question).Conclusions:Neuropsychological assessment may provide valuable information to improve treatment for those with OUDs. This pilot project revealed that individuals with OUDs can tolerate and are satisfied with a screening TNP evaluation and find the evaluation useful. The primary barrier was reaching referred patients. Treatment engagement among those with SUDs is a common challenge. Those with counselors who coordinated with the clinic schedulers were more likely to be reached and scheduled, suggesting support for regular case management. Other lessons learned and potential future steps are discussed.

Since the early 2000s Rhode Island has been among the states hardest hit by the opioid crisis. In response, the state has made it a priority to expand access to medication-assisted treatment (MAT) for opioid use disorder (OUD), which refers to the use of the FDA-approved medications methadone, buprenorphine, and/or naltrexone in conjunction with behavioral therapy. MAT is strongly supported by scientific evidence and endorsed by US public health officials and yet fails to reach many OUD patients. Using administrative data covering medical treatments and selected health outcomes for more than three-quarters of the Rhode Islanders covered by health insurance from mid-2011 through mid-2019, this report considers MAT’s efficacy in preventing opioid overdoses in Rhode Island and sheds light on the barriers to receiving MAT. The authors find evidence that MAT, as practiced in Rhode Island, appears to reduce the risk of opioid overdose: Among patients who had an initial (nonfatal) overdose, those who had received MAT in the preceding three months were less likely to experience a second overdose. In addition, federal policies that allowed a broader set of health-care providers to prescribe buprenorphine for OUD and enabled each prescriber to treat more patients with that drug are shown to have had some success in expanding the set of patients receiving MAT in Rhode Island.Unfortunately, we observe significant disparities in access to MAT across different groups within Rhode Island. Among individuals diagnosed with opioid dependence, those living in places with elevated poverty rates are less likely to receive buprenorphine, but they are also somewhat more likely to receive methadone. Because a treatment regimen involving methadone is much less convenient for the patient compared with one involving buprenorphine, ideally patients should have similar access to both drugs. Having Medicaid insurance as opposed to some other form of insurance is associated with a much greater chance of receiving methadone treatment, a finding that supports policies that would incentivize the expansion of Medicaid in states that have not yet done so. Women are somewhat less likely than men to receive either methadone or buprenorphine.This research demonstrates that recent federal policies helped to increase the number of Rhode Islanders who were prescribed buprenorphine for OUD. Raising patient-number limits enabled select prescribers to serve more patients and expand the total patient pool; however, more people could be helped if more prescribers took full advantage of their prescribing limits. This research and similar findings from other states reveal that the typical buprenorphine prescriber has a caseload that is well below the maximum number of patients they could treat. A separate policy that enabled mid-level practitioners (such as physician assistants) to train to prescribe buprenorphine was also found to draw in new patients, particularly those in high-poverty Zip codes. The research also underscores the urgency of helping more OUD patients receive methadone and/or buprenorphine treatment quickly following an overdose (in hospitals, for example) and to maintain that treatment over time for a sufficient duration.Some additional policies that could promote greater access to MAT include allowing pharmacists to prescribe buprenorphine, relaxing restrictions on the use of telehealth for obtaining buprenorphine prescriptions, and revisiting the rules about allowing take-home doses of methadone. Additional research is required on these interventions before specific recommendations can be made, but consideration of further policy adjustments is critically important given the ongoing scourge of opioid abuse and the proven ability of MAT to help those suffering from opioid use disorder. In response to the COVID-19 pandemic there has in fact been a temporary loosening of policies related to MAT in order to minimize patients’ exposure to the virus while helping them to get on or stay on medications, thus offering an opportunity to evaluate the efficacy and safety of the revised measures.

Racial inequities in opioid use disorder management: can the anesthesiologist improve outcomes?

To investigate associations of lifetime history of traumatic brain injury (TBI) with prescription opioid use and misuse among noninstitutionalized adults. Ohio Behavioral Risk Factor Surveillance System (BRFSS) participants in the 2018 cohort who completed the prescription opioid and lifetime history of TBI modules (n = 3448). Secondary analyses of a statewide population-based cross-sectional survey. Self-report of a lifetime history of TBI using an adaptation of the Ohio State University TBI-Identification Method. Self-report of past year: (1) prescription pain medication use (ie, prescription opioid use); and (2) prescription opioid misuse, defined as using opioids more frequently or in higher doses than prescribed and/or using a prescription opioid not prescribed to the respondent. In total, 22.8% of adults in the sample screened positive for a lifetime history of TBI. A quarter (25.5%) reported past year prescription opioid use, and 3.1% met criteria for prescription opioid misuse. A lifetime history of TBI was associated with increased odds of both past year prescription opioid use (adjusted odds ratio [AOR] = 1.52; 95% CI, 1.27-1.83; P < .01) and prescription opioid misuse (AOR = 1.65; 95% CI, 1.08-2.52; P < .05), controlling for sex, age, race/ethnicity, and marital status. Results from this study support the "perfect storm" hypothesis-that persons with a history of TBI are at an increased risk for exposure to prescription opioids and advancing to prescription opioid misuse compared with those without a history of TBI. Routine screening for a lifetime history of TBI may help target efforts to prevent opioid misuse among adults.

Polysubstance use and multimorbidity are the norm instead of exception with opioid and other substance use disorders. We must widen the focus of treatment, research, and policy from single substances to the full tapestry of polysubstance use and multimorbidity to help develop interdisciplinary approaches that mitigate their adverse consequences. Amid the persistent opioid addiction crisis in United States (US), Lin et al. [1] highlight the often under recognized fact that most patients who seek treatment for opioid use disorder (OUD) present with polysubstance use disorder (PSUD). In addition, PSUD is associated with a higher burden of psychiatric and medical comorbidity, transforming OUD and other substance use disorders (SUDs) into a “multimorbidity” state (multiple comorbidities interacting with each other in complex ways), exacerbating dysfunction and posing hydra-like treatment challenges [1-4]. Population-based studies from the United States and elsewhere have also shown a similarly high prevalence of PSUD among individuals with OUD and comorbidities among those with PSUD [3, 5]. The high prevalence of multimorbidity and PSUD among patients with OUD has several adverse implications, but its most tragic consequence is an increased risk of overdose deaths. Darke [6, 7] has pointed out that most heroin “overdose” deaths during the pre-fentanyl era were “underdose” deaths (low heroin metabolite levels on autopsy) fueled by high prevalence of polysubstance use and medical comorbidities. This pattern appears to continue even in the current fentanyl era [8] and with overdose deaths associated with prescribed opioids [9]. Case & Deaton [10] have also highlighted the synergistic role of drug and alcohol addictions and medical and psychiatric comorbidity in the sharp rise of excess suicide, cardiovascular, and overall mortality experienced by non-college educated Caucasian adults in the United States after 1990. In summary, multimorbidity (with PSUD at its foundation) appears to be a key factor that drives mortality risk among individuals with OUD (and other SUDs). It is well established that sustained buprenorphine and methadone treatment are associated with decreased overdose and overall mortality and better health outcomes [11]. Patients with PSUD have more severe clinical course of OUD and other SUDs [12], use treatment at higher rates than those with a single SUD [2], and PSUD has minimal adverse impact on buprenorphine treatment retention [13]. However, data provided by Lin et al. [1] illustrate that PSUD is associated with lower rate of initiation of buprenorphine treatment for OUD despite also being associated with a higher rate of engagement in SUD care. Long-acting injectable naltrexone, a seemingly less risky OUD medication treatment (albeit with poorer retention and without demonstrable association with decreased mortality) is used more among those with PSUD and multimorbidity [14-16]. Overdose prevention intervention efforts (such as naloxone) also appear to be deployed at a lower rate among patients with PSUD, despite the higher risk of overdose mortality among them [17]. The alarming treatment paradox of underutilization of life saving OUD treatments despite higher risk of mortality among those with OUD and multimorbidity might have several explanations. SUD has complex relationships with comorbidities that often create complicated clinical scenarios that are bewildering in their complexity to patients and providers [4]. For example, although SUD paradoxically predisposes individuals to chronic pain and worsens its clinical and treatment course rather than alleviating it, chronic pain has a reciprocal adverse exacerbating effect on SUD [4, 18]. The accompanying PSUD and multimorbidity then infuses an even greater relentlessness into the already fierce reciprocal relationship [4]. As Lin et al. point out [1], no treatment framework has emerged to guide management of complex clinical conditions involving OUD, PSUD, pain, psychiatric comorbidities, and its exacerbating functional consequences such as homelessness, incarceration, and suicide attempts. It has been suggested than an integrative approach to the management of multimorbidity by an interdisciplinary team may be more effective than one-by-one treatment of each individual SUD and each comorbidity by an independent specialist [4]. However, beyond the basic descriptive data, there is limited research to help guide such integrated treatment [2, 4]. The need for research on integrative treatment of multimorbidity in OUD (and other SUDs) care has become critical, because polysubstance use has become the norm instead of the exception, and the substance use patterns among patients with OUD have shifted from an exclusive addiction to prescription opioids to its concomitant use with heroin, much riskier opioid forms like fentanyl analogues and multiple other substances [19]. Hence, it is imperative that treatment development efforts, as well as research and policy interventions, widen their focus from multiple single substances to the full tapestry of polysubstance use and multimorbidity that underlies the current crisis in which opioids are just the tip of a much larger and intricately creviced iceberg. None.

While long-term medication-assisted treatment (MAT) using methadone or buprenorphine is associated with significantly lower all-cause mortality for individuals with opioid use disorder (OUD), periods of initiating or discontinuing treatment are associated with higher mortality risks relative to stable treatment. This study aimed to identify the OUD treatment durations necessary for the elevated mortality risks during treatment transitions to be balanced by reductions in mortality while receiving treatment. Simulation model based on a compartmental model of OUD diagnosis, MAT receipt and all-cause mortality among Veterans with OUD in the United States Veterans Health Administration (VA) in 2017-2018. We simulated methadone and buprenorphine treatments of varying durations using parameters obtained through calibration and published meta-analyses of studies from North America, Europe and Australia. United States. Simulated cohorts of 10 000 individuals with OUD. All-cause mortality over 12months. Receiving methadone for 4months or longer or buprenorphine for 2months or longer resulted in 54 [95% confidence interval (CI)=5-90] and 65 (95% CI=21-89) fewer deaths relative to not receiving MAT for the same duration, using VA-specific mortality rates. We estimated shorter treatment durations necessary to achieve net mortality benefits of 2months or longer for methadone and 1month or longer for buprenorphine, using non-VA population literature estimates. Sensitivity analyses demonstrated that necessary treatment durations increased more with smaller mortality reductions on treatment than with larger relative risks during treatment transitions. Short periods (<6months) of treatment with either methadone or buprenorphine are likely to yield net mortality benefits for people with opioid use disorder relative to receiving no medications, despite periods of elevated all-cause mortality risk during transitions into and out of treatment. Retaining people with opioid use disorder in treatment longer can increase these benefits.

Criminal justice system (CJS) involvement is common among individuals with opioid use disorder (OUD), yet limited research examines retention in medications for OUD (MOUD) within community settings. This study assessed whether CJS involvement predicted retention on buprenorphine/naloxone and explored related demographic and clinical factors. A retrospective cohort included adults (n = 367) enrolled in a low-barrier outpatient MOUD program in Texas (January 2022-April 2024). CJS involvement was identified from program records. Retention was measured as the number of continuous days with buprenorphine/naloxone prescriptions. Analyses used univariate tests, logistic regression, and nonparametric kernel regression. Nearly one-quarter (24.8%) were CJS-involved. Retention at 180 days was similar between CJS and non-CJS groups (38%). CJS participants initiated substance use earlier and reported higher heroin and injection drug use. Behavioral health sessions were associated with both CJS involvement (OR = 1.10, p ≤ 0.001) and longer retention (β = 10.81 days/session, p = 0.001). With comprehensive, low-barrier services, individuals involved with CJS achieved MOUD retention comparable to their peers. Early behavioral health engagement was a strong predictor of retention, suggesting a key intervention point to enhance outcomes and advance equity for justice-involved populations.

Medication-based treatment among rural, primary care patients diagnosed with opioid use disorder and alcohol use disorder

Toxicity of agents used for opioid withdrawal: a case-based approach.

Background In the United States (US) when opioid use disorder (OUD) is treated with medication assisted treatment (MAT), many patients in MAT will relapse into active opioid use during the recovery process. About 23% drop out of treatment within 3 months, and 40-50% drop out within 6 months of MAT start. Using the Anderson and Newman (2005) Framework for Health Services Utilization, 27 variables reflecting predisposing, enabling, and need factors were used to examine the impact on the number of days patients were retained in treatment. Methods One MAT clinic in rural Michigan used random sample of archival records (n = 390) OUD patients (DSM-V-TR code 304.00, ICD-10 code F11.20) between Jan. 1, 2014 and Nov. 21, 2018 with prescribed buprenorphine as part of MAT program. The first set of linear regressions (backward elimination) defined significant variables for each factor, and the final model included significant variables to predict length of retention in MAT. Results The first step identified legal issues (predisposing), MSHN insurance, distance to clinic, ability to drive, mental health diagnosis, and homelessness (enabling factors); Zung self-reporting depression score, starting dose, past suicide attempt, Hep-C status, and method of use (needs factor) as statistically significant to be used in the final model, controlling for age and gender. Starting dose (unstandardized b = 136.8, 95%CI 98.0, 175.6), driving license (b = 68.3, CI 13.2, 123.4), distance to clinic (b=-1.1, CI -2.2, -0.5) had statistical impact on the length of stay in MAT. Discussion This case study identified enabling factors (starting dose and access to clinic) affecting length of participation in MAT. Other factors warranting provider attention were identified for rural OUD patients. Conclusions Evidence based guidelines for starting doses are needed to increase MAT effectiveness. MAT services should consider distance to clinic as a factor of successful treatment. Key messages Evidence based guidelines for starting doses are needed to increase MAT effectiveness. Opiood treatment services should consider distance to clinic as a factor of successful treatment.

Background: Opioid use disorder (OUD) is increasingly prevalent in North America. Methadone Maintenance Treatment (MMT) is an opioid substitution therapy used to relieve symptoms of withdrawal, and to manage OUD symptoms. Despite MMT’s overall effectiveness, individual treatment outcomes vary, and little research explores why these differences exist. Objectives: Considering the association between genetic vulnerability, including family factors, and substance use disorders (SUDs), this study investigated the relationship between family factors and treatment outcomes in individuals with OUD receiving MMT. Patients and Methods: This cross-sectional study included a sample of 973 adult patients with OUD in MMT. Family factors were defined as number of relatives with an SUD, and their degree of genetic relatedness to the proband. Patient-related outcomes were determined by measuring illicit opioid and non-opioid use during MMT. Results: A significant association was found between number of family members with an SUD and the proband’s illicit opioid use (OR = 1.08, 95% CI = 1.01, 1.16; P = 0.03). No significant association was found between genetic relatedness and the proband’s illicit opioid and non-opioid use, nor between number of family members with an SUD and the proband’s non-opioid use. Conclusions: These results suggest a role of shared familial environmental factors in OUD treatment outcomes. Specifically, OUD patients with a family history of substance use are at higher risk of relapse during MMT. Based on these findings, healthcare providers should consider stratifying their OUD patients based on family history of SUDs, and providing additional support to those with a positive history to improve their MMT outcomes.