Perioperative Management of Patients on Medication for Opioid Use Disorder Undergoing Ambulatory Surgery

Methadone and buprenorphine discontinuation among postpartum women with opioid use disorder

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

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

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.

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.

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.

Differences in Mortality Among Infants With Neonatal Opioid Withdrawal Syndrome

Non-prescribing clinicians' treatment orientations and attitudes toward treatments for opioid use disorder: Rural differences

Opioid use and opioid use disorder (OUD) are prevalent among persons with legal system involvement. Medications for opioid use disorder (MOUD) are recommended for treatment, yet access is limited for legal-involved populations. In outpatient treatment settings, persons with legal-system involvement are less likely to receive MOUD. However, the influence of the type of legal system involvement on MOUD access is understudied. The purpose of this study was to examine if MOUD receipt differs by the type of legal system referral among adults referred to outpatient treatment by the legal system. Data came from the 2021-2022 Treatment Episode Dataset-Admissions (TEDS-A). The sample included 32,213 legal-involved adult admissions to outpatient treatment for primary opioid use. The independent variable was the type of legal system referral; court/diversionary program, probation or parole, prison, or other. The outcome was whether MOUD was included in the treatment plan. Covariates included the following sociodemographic, substance use, and treatment-related variables: sex, age, race/ethnicity, education, employment, living arrangement, prior substance use treatment, co-occurring mental disorder, type of opioid use, attendance of a substance use self-help group, outpatient treatment type, injection drug use, past-month arrest, and past-month opioid use frequency. Multivariable logistic regression was used to examine associations of referral type with MOUD, adjusting for sociodemographic, substance use, and treatment-related covariates. Compared to court/diversionary referral, probation or parole referral (AOR=0.80, 95% CI=0.76-0.85), prison referral (AOR=0.85, 95% CI=0.76-0.94) and other referral (AOR=0.42, 95% CI=0.39-0.46) were each associated with lower odds of MOUD when adjusting for covariates. Use of other opioid analgesics and synthetic opioids was associated with lower odds of MOUD than heroin use (AOR=0.48, 95% CI=0.46-0.51). MOUD access in the community varies by the type of legal system referral. To inform MOUD community linkage policies and practices, research is needed to identify gaps in referral processes for specific legal system institutions. Examining how opioid use behavior characteristics impact MOUD community linkage is an appropriate next step for future research.

Perspectives on medication for opioid use disorder (MOUD) access and service delivery among a community sample of people who use opioids in Los Angeles.

Thousands of pregnant people with opioid use disorder (OUD) enter US jails annually, yet their access to medications for OUD (MOUD) that meet the standard of care (methadone and/or buprenorphine) is unknown. To assess the availability of MOUD for the treatment of pregnant individuals with OUD in US jails. In this cross-sectional study, electronic and paper surveys were sent to all 2885 identifiable US jails verified in the National Jails Compendium between August 19 and November 7, 2019. Respondents were medical and custody leaders within the jails. The primary outcome was the availability of MOUD (methadone and/or buprenorphine) for the treatment of pregnant people with OUD in US jails. Availability of MOUD was assessed based on (1) continuation of MOUD for pregnant incarcerated individuals (if the individual was receiving MOUD before incarceration), with or without initiation of MOUD; (2) both initiation and continuation of MOUD for pregnant individuals; (3) only continuation of MOUD for pregnant individuals; and (4) management of opioid withdrawal for pregnant individuals. Secondary outcomes included MOUD availability during the postpartum period and logistical factors associated with the provision of MOUD. Multivariate logistic regression analysis was used to assess factors associated with MOUD availability during pregnancy. Among 2885 total surveys sent, 1139 (39.5%) were returned; of those, 836 surveys (73.4%; 29.0% of all surveys sent) could be analyzed, with similar proportions from metropolitan (399 jails [47.7%]) and rural (381 jails [45.6%]) settings. Overall, 504 jails (60.3%) reported that MOUD was available for medication continuation, with or without medication initiation, during pregnancy. Of those, 267 jails (53.0%; 31.9% of surveys included in the analysis) both initiated and continued MOUD, and 237 jails (47.0%; 28.3% of surveys included in the analysis) only continued MOUD; 190 of 577 jails (32.9%; 22.7% of surveys included in the analysis) reported opioid withdrawal as the only management for pregnant people with OUD. Among the 504 medication-providing jails, only 120 (23.8%) continued to provide MOUD during the postpartum period. Methadone was more commonly available at jails that only continued MOUD (84 of 123 jails [68.3%]), whereas buprenorphine was more commonly available at jails that both initiated and continued MOUD (73 of 119 jails [61.3%]). In an adjusted model, jails with higher odds of MOUD availability were located in the Northeast (odds ratio [OR], 10.72; 95% CI, 2.43-47.36) or metropolitan areas (OR, 1.92; 95% CI, 1.31-2.83), had private health care contracts (OR, 1.49; 95% CI, 1.03-2.14) and a higher number of women (≥70) reported in the female census (OR, 1.69; 95% CI, 1.02-2.80), and provided pregnancy testing within 2 weeks of arrival at the jail (OR, 2.66; 95% CI, 1.69-4.17). In this cross-sectional study, a substantial proportion of US jails did not provide access to MOUD to pregnant people with OUD. Although most jails reported continuing to provide MOUD to individuals who were receiving medication before incarceration, few jails initiated MOUD, and most medication-providing jails discontinued MOUD during the postpartum period. These results suggest that many pregnant and postpartum people with OUD in US jails do not receive medication that is the standard of care and are required to endure opioid withdrawal, signaling an opportunity for intervention to improve care for pregnant people who are incarcerated.

Personally-tailored opioid-overdose and medication for opioid use disorder (MOUD) education (TOME) significantly increases MOUD and overdose knowledge in peripartum individuals: Results from a randomized controlled pilot trial.

Serious injection-related infections (SIRIs) cause significant morbidity and mortality. Medication for opioid use disorder (MOUD) improves outcomes but is underused. Understanding MOUD treatment after SIRIs could inform interventions to close this gap. To examine rehospitalization, death rates, and MOUD receipt for individuals with SIRIs and to assess characteristics associated with MOUD receipt. This retrospective cohort study used the Massachusetts Public Health Data Warehouse, which included all individuals with a claim in the All-Payer Claims Database and is linked to individual-level data from multiple government agencies, to assess individuals aged 18 to 64 years with opioid use disorder and hospitalization for endocarditis, osteomyelitis, epidural abscess, septic arthritis, or bloodstream infection (ie, SIRI) between July 1, 2014, and December 31, 2019. Data analysis was performed from November 2021 to May 2023. Demographic and clinical factors potentially associated with posthospitalization MOUD receipt. The main outcome was MOUD receipt measured weekly in the 12 months after hospitalization. We used zero-inflated negative binomial regression to examine characteristics associated with any MOUD receipt and rates of treatment in the 12 months after hospitalization. Secondary outcomes were receipt of any buprenorphine formulation, methadone, and extended-release naltrexone examined individually. Among 8769 individuals (mean [SD] age, 43.2 [12.0] years; 5066 [57.8%] male) who survived a SIRI hospitalization, 4305 (49.1%) received MOUD, 5919 (67.5%) were rehospitalized, and 973 (11.1%) died within 12 months. Of those treated with MOUD in the 12 months after hospitalization, the mean (SD) number of MOUD initiations during follow-up was 3.0 (1.7), with 956 of 4305 individuals (22.2%) receiving treatment at least 80% of the time. MOUD treatment after SIRI hospitalization was significantly associated with MOUD in the prior 6 months (buprenorphine: adjusted odds ratio [AOR], 16.51; 95% CI, 13.81-19.74; methadone: AOR, 28.46; 95% CI, 22.41-36.14; or naltrexone: AOR, 2.05; 95% CI, 1.56-2.69). Prior buprenorphine (incident rate ratio [IRR], 1.17; 95% CI, 1.11-1.24) or methadone (IRR, 1.89; 95% CI, 1.79-2.01) use was associated with higher treatment rates after hospitalization, and prior naltrexone use (IRR, 0.86; 95% CI, 0.77-0.95) was associated with lower rates. This study found that in the year after a SIRI hospitalization in Massachusetts, mortality and rehospitalization were common, and only half of patients received MOUD. Treatment with MOUD before a SIRI was associated with posthospitalization MOUD initiation and time receiving MOUD. Efforts are needed to initiate MOUD treatment during SIRI hospitalizations and subsequently retain patients in treatment.