Retention Challenges in Opioid Use Disorder Treatment: The Role of Comorbid Psychological Conditions

COVID-19 Could Change the Way We Respond to the Opioid Crisis-for the Better.

Background:Of the over 20 million Americans reporting an opioid use disorder, only around 3 million report receiving treatment of any kind. The gold standard for opioid use disorder treatment is medication in combination with psychosocial support, but despite robust evidence supporting treatment, barriers are substantial and include limited insurance coverage, patient beliefs, ease of access, regulatory hurdles, and stigma. Although trained as medication experts, U.S. pharmacists are not routinely involved in opioid use disorder treatment and may represent an underutilized care team member.Objective:To explore U.S. pharmacy students’ perspectives on pharmacists as providers of methadone-based medications for opioid use disorder treatment.Methods:A qualitative design with focus groups of student pharmacists in a U.S. college of pharmacy in the Southeastern United States.Results:Over 2 months in 2020, three focus groups were conducted with 15 students in each group participating, and including second-, third-, and fourth-year student pharmacists. Three overarching themes emerged from the data: (1) student pharmacists desire exposure to therapeutic knowledge and lived experiences related to opioid use disorder and methadone treatment, (2) students perceive stigmatizing views held by practicing pharmacists toward opioid use disorder and methadone treatment, (3) pharmacists should play a role in methadone treatment.Conclusion:Student pharmacists desire an active and larger role in the care of patients managing opioid use disorder. Findings indicate these students perceive less stigma toward opioid use disorder than currently practicing pharmacists. Pharmacy curricula should emphasize stories of lived experiences of patients with opioid use disorder, therapeutic knowledge and guidelines related to medications for opioid use disorder, and the regulatory environment surrounding opioid use disorder treatment.

BackgroundConcurrent opioid and stimulant use is on the rise in North America. This increasing trend of use has been observed in the general population, and among people released from prison in British Columbia (BC), who face an elevated risk of overdose post-release. Opioid agonist treatment is an effective treatment for opioid use disorder and reduces risk of overdose mortality. In the context of rising concurrent stimulant use among people with opioid use disorder, this study aims to investigate the impact of stimulant use disorder on opioid agonist treatment dispensation following release from prison in BC.MethodsLinked health and corrections records were retrieved for releases between January 1st 2015 and December 29th 2018 (N = 13,380). Hospital and primary-care administrative health records were used to identify opioid and stimulant use disorder and mental illness. Age, sex, and health region were derived from BC’s Client Roster. Incarceration data were retrieved from provincial prison records. Opioid agonist treatment data was retrieved from BC’s provincial drug dispensation database. A generalized estimating equation produced estimates for the relationship of stimulant use disorder and opioid agonist treatment dispensation within two days post-release.ResultsCases of release among people with an opioid use disorder were identified (N = 13,380). Approximately 25% (N = 3,328) of releases ended in opioid agonist treatment dispensation within two days post-release. A statistically significant interaction of stimulant use disorder and mental illness was identified. Stratified odds ratios (ORs) found that in the presence of mental illness, stimulant use disorder was associated with lower odds of obtaining OAT [(OR) = 0.73, 95% confidence interval (CI) = 0.64–0.84)] while in the absence of mental illness, this relationship did not hold [OR = 0.89, 95% CI = 0.70–1.13].ConclusionsPeople with mental illness and stimulant use disorder diagnoses have a lower odds of being dispensed agonist treatment post-release compared to people with mental illness alone. There is a critical need to scale up and adapt opioid agonist treatment and ancillary harm reduction, and treatment services to reach people released from prison who have concurrent stimulant use disorder and mental illness diagnoses.

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

Opioids for persistent non-cancer pain: recommendations for clinical practice

BackgroundWhile buprenorphine/naloxone (B/N) is approved for opioid use disorder treatment, effective delivery of B/N comes with significant challenges. Most notably, many patients do not take medication daily as prescribed; this non-adherence worsens treatment outcomes, increases healthcare costs, and leads to persistent worries of diversion among providers and policymakers. The present study examines the feasibility, usability, and acceptability of MySafeRx—a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing designed to address the challenges of office-based opioid treatment (OBOT) with B/N.MethodsThe MySafeRx platform integrates electronic pill dispensers, text-messaging, and videoconferencing to provide supervised self-administration of medication and daily motivational coaching through an Android app interface. High-risk early adults (18–39 years old) who were enrolled in OBOT with B/N and had documented illicit opioid use in the past month during opioid agonist therapy (n = 12) participated in a 28-day single-arm observational study of the MySafeRx platform in addition to standard care.ResultsTwo-thirds of participants who completed the study achieved an average of > 5 days per week of supervised B/N self-administration. Visual confirmation of medication adherence was demonstrated for an average of 72% of study days among all participants. All participants achieved platform technical proficiency within 60 min, reporting good levels of usability and acceptability. Illicit opioid abstinence rates confirmed by urine toxicology increased by 53% during MySafeRx but fell 43% within 3 weeks post-intervention.ConclusionThe MySafeRx medication adherence and remote coaching mobile platform is acceptable and can be feasibly implemented in real-world opioid use disorder treatment settings during high-risk periods (i.e., initial stabilization, after illicit opioid lapse), resulting in reduced illicit opioid use; however, the effect did not last after intervention completion, suggesting longer duration or extended taper of program may be needed.ClinicalTrials.Gov NCT02942199 10/24/16 https://clinicaltrials.gov/ct2/show/NCT02942199

Integrated vs nonintegrated treatment for perinatal opioid use disorder: retrospective cohort study

Objectives:The PINPOINT (PaIn aNd oPiOId maNagemenT) intervention in Oregon aimed to support primary care clinics in applying evidence-based guidelines for pain management and opioid use disorder treatment. We evaluated the impact of this intervention on opioid use disorder treatment and overdose outcomes.Methods:Data from the voluntary Oregon All Payer All Claims datasets were integrated with several administrative datasets to create the Provider Results of Opioid Management and Prescribing Training dataset, which tracks clinical and prescribing activities at the provider level. We employed difference-in-differences models to assess the impact of PaIn aNd oPiOId maNagemenT enrollment on changes in opioid use disorder treatment and overdose outcomes. The intervention sample consisted of 289 primary care providers from clinics participating in PaIn aNd oPiOId maNagemenT, compared with 2000 control providers identified through administrative claims.Results:The difference-in-differences models indicated statistically significant associations between intervention enrollment and treatment with medications for opioid use disorder (incidence rate ratio [IRR] = 1.214, 95% confidence interval [CI] = 1.100-1.340), any substance use disorder treatment (IRR = 1.120, 95% CI = 1.070-1.172), and any outpatient opioid use disorder treatment (IRR = 1.102, 95% CI = 1.034-1.175) compared to controls. No statistically significant changes were observed in overall non-fatal drug overdoses, non-fatal opioid overdoses, and naloxone overdose reversals, though absolute event rates were low.Conclusions:We found that multi-faceted, evidence-based approaches to improve clinical practice in primary care settings were associated with increased treatment for opioid use disorder, however differences in overdose outcomes were not observed. Further research is needed to assess the scalability and clinical impact of these interventions across diverse care environments.

BackgroundFor people with opioid use disorder who are not responding to oral opioid agonist treatment, evidence supports the effectiveness of injectable opioid agonist treatment with injectable hydromorphone (an opioid analgesic) and diacetylmorphine (pharmaceutical grade heroin). While this treatment is effective at reducing illicit opioid use, concurrent cocaine use is prevalent. Dextroamphetamine (a central nervous system stimulant) has been found to be a safe and effective treatment for cocaine dependence among people receiving injectable opioid agonist treatment in Europe. We present the first report of dextroamphetamine prescribing offered for the treatment of stimulant use disorder among a patient receiving iOAT outside of a clinical trial. This case report can be used to inform clinical practice in the treatment of cocaine use disorder, an area where interventions are currently lacking.Case presentationDextroamphetamine was prescribed to a 51-year-old male who was diagnosed with concurrent opioid and stimulant use disorder in an injectable opioid agonist treatment clinic in Vancouver, Canada. He reported smoking crack cocaine daily for more than two decades and was experiencing health consequences associated with this use. He presented to his routine physician visit with the goal of reducing his cocaine use and was prescribed dextroamphetamine for the treatment of stimulant use disorder. After 4-weeks the patient was tolerating the medication with no observed adverse events and was achieving his therapeutic goal of reducing his cocaine use.ConclusionsDextroamphetamine can be prescribed to support patients with stimulant use disorder to reduce or stop their use of cocaine. The case demonstrated that when dextroamphetamine was prescribed, a significant reduction in cocaine use was experienced among a patient that had been regularly using cocaine on a daily basis for many years. Daily contact with care for the opioid medication promoted adherence to the stimulant medication and allowed for monitoring of dose and tolerance. Settings where patients are in regular contact with care such as oral and injectable opioid agonist treatment clinics serve as a suitable location to integrate dextroamphetamine prescribing for patients that use illicit stimulants to reduce use and associated harms.

Opioids are associated with higher risk for ataxic breathing and sleep apnea. We conducted a systematic literature review and meta-analysis to assess the influence of long-term opioid use on the apnea-hypopnea and central apnea indices (AHI and CAI, respectively). A systematic review protocol (Cochrane Handbook guidelines) was developed for the search and analysis. We searched Embase, Medline, ACP Journal Club, and Cochrane Database up to November 2014 for three topics: (1) narcotics, (2) sleep apnea, and (3) apnea-hypopnea index. The outcome of interest was the variation in AHI and CAI in opioid users versus non-users. Two reviewers performed the data search and extraction, and disagreements were resolved by discussion. Results were combined by standardized mean difference using a random effect model, and heterogeneity was tested by χ(2) and presented as I(2) statistics. Seven studies met the inclusion criteria, for a total of 803 patients with obstructive sleep apnea (OSA). We compared 2 outcomes: AHI (320 opioid users and 483 non-users) and 790 patients with CAI (315 opioid users and 475 non-users). The absolute effect size for opioid use was a small increased in apnea measured by AHI = 0.25 (95% CI: 0.02-0.49) and a medium for CAI = 0.45 (95% CI: 0.27-0.63). Effect consistency across studies was calculated, showing moderate heterogeneity at I(2) = 59% and 29% for AHI and CAI, respectively. The meta-analysis results suggest that long-term opioid use in OSA patients has a medium effect on central sleep apnea.

The authors sought to characterize the 3-year prevalence of mental disorders and nonnicotine substance use disorders among male and female primary care patients with documented opioid use disorder across large U.S. health systems. This retrospective study used 2014-2016 data from patients ages ≥16 years in six health systems. Diagnoses were obtained from electronic health records or claims data; opioid use disorder treatment with buprenorphine or injectable extended-release naltrexone was determined through prescription and procedure data. Adjusted prevalence of comorbid conditions among patients with opioid use disorder (with or without treatment), stratified by sex, was estimated by fitting logistic regression models for each condition and applying marginal standardization. Females (53.2%, N=7,431) and males (46.8%, N=6,548) had a similar prevalence of opioid use disorder. Comorbid mental disorders among those with opioid use disorder were more prevalent among females (86.4% vs. 74.3%, respectively), whereas comorbid other substance use disorders (excluding nicotine) were more common among males (51.9% vs. 60.9%, respectively). These differences held for those receiving medication treatment for opioid use disorder, with mental disorders being more common among treated females (83% vs. 71%) and other substance use disorders more common among treated males (68% vs. 63%). Among patients with a single mental health condition comorbid with opioid use disorder, females were less likely than males to receive medication treatment for opioid use disorder (15% vs. 20%, respectively). The high rate of comorbid conditions among patients with opioid use disorder indicates a strong need to supply primary care providers with adequate resources for integrated opioid use disorder treatment.

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

Illicit drug use disorders are the most stigmatised health conditions worldwide, and stigma acts as a meaningful barrier to treatment entry and treatment provision. In the context of dramatically rising opioid-related harms, it is critical that we understand the drivers of stigma and how it affects opioid use disorder treatment and policy. The aim of this narrative review is to discuss how opioid-related stigma impacts treatment provision and harm reduction, and provide potential strategies to reduce stigma at a social and structural level. We used the Framework for Integrating Normative Influences on Stigma (FINIS) to identify sources of opioid-related stigma at the macro (structural stigma), meso (public stigma) and micro (internalised stigma) levels. Reducing stigma requires strategies that target multiple levels, however addressing inequity in the laws, regulations, and rules that segregate people with opioid and other substance use disorders from mainstream society is essential.

Racial‒Ethnic Disparities of Buprenorphine and Vivitrol Receipt in Medicaid

Specific polysubstance use patterns predict relapse among patients entering opioid use disorder treatment