Injectable Opioid Agonist Treatment Research Articles

Building Capacity for Injectable Diacetylmorphine and Hydromorphone for the Treatment of Opioid Use Disorder: Identifying Typical Doses

ABSTRACT Identifying typical doses of existing opioid use disorder medications, such as injectable opioid agonist treatment (iOAT), can support client and program needs, and potentially increase iOAT expansion. Longitudinal data from participants in a cohort study (n = 131), along with clinic dispensation records from August 2014 to April 2020, were used to examine physician prescribed as well as used doses of injectable diacetylmorphine and hydromorphone. Dosage groups, by medication and prescribed dose per session, were created for both hydromorphone and diacetylmorphine. A total of 534, 522 injections were registered during the study period among 129 participants. Mean received diacetylmorphine doses ranged from 106 to 989 mg per day, with most clients using 125–262 mg per session (mean 192.99 mg) and attending 2.40 sessions per day. Mean received hydromorphone doses ranged from 51.09 to 696.06 mg per day, with the majority using 88–154 mg per session (mean 121.32 mg; 2.43 sessions). Average daily doses remained stable overtime and, while mid-range doses were most typical, participants used the whole spectrum of allowable dose prescriptions. Evidence supporting typical doses of iOAT can be integrated into program planning to better allow providers and prescribers to anticipate program needs and engage in individualized care.

“I'm just searching to get better”: Constructions of treatment citizenship on injectable opioid agonist treatment

As part of the response to Canada's worsening overdose crisis driven by a toxic, adulterated drug supply, there has been increased attention to and expansion of drug treatment, options, including injectable opioid agonist treatment (iOAT). iOAT typically involves the, witnessed daily injection of opioids under healthcare provider supervision. There is a robust, evidence base on iOAT; however, there has been less focus on how people engage with this; treatment outside of clinical trials. This paper examines how people engage with iOAT programs, in expanded treatment settings in Canada, focusing on how the broader socio-structural context, shapes patient subjectivities in treatment. This study draws on critical ethnographic and community-based research approaches, conducted with people accessing four iOAT programs in Vancouver's Downtown Eastside; neighbourhood from May 2018 to November 2019. Data included in-depth baseline and followup, interviews and approximately 50 h of observation fieldwork conducted in one iOAT, program and with a subsample of participants in the surrounding neighbourhood. Analysis, leveraged the concepts of biological citizenship and structural vulnerability. This analysis characterized three narrative frames-regular long-term engagers, pain, patients, and sporadic and short-term engagers-through in-depth case presentations of participants with distinct types of engagement with iOAT programs. Participants within these, narrative frames described a dominant form of iOAT citizenship, an autonomous patient who, regularly engages in treatment and avoids pleasure. However, structural vulnerabilities, including, homelessness and housing instability, entrenched poverty, criminal-legal system engagement, and unmanaged pain, shaped the ability of participants to make claims to this normative model of citizenship. This study examined how structural vulnerabilities impact people's construction and ability to make iOAT citizenship claims. Findings point to the need for changes within and outside of iOAT programs, such as lower threshold treatment models, improved social services (e.g., secure housing), and pain management support.

Shared decision-making and client-reported dose satisfaction in a longitudinal cohort receiving injectable opioid agonist treatment (iOAT)

BackgroundAcross different types of oral Opioid Agonist Treatment for people with Opioid Use Disorder, receiving a dose that meets their needs is associated with better outcomes. Evidence also shows patients are more likely to receive an “adequate dose” when their prescribers are involving them in decision making. Neither of these findings have been studied in the context of injectable Opioid Agonist Treatment, which is the purpose of this study.MethodsThis study was a retrospective analysis of an 18-month prospective longitudinal cohort study of 131 people receiving injectable Opioid Agonist Treatment. In the 18-month study, observations were collected every two months for one year, and then once more at 18 months. At 6 months, participants were asked whether their dose was satisfactory to them (outcome variable). Generalized Estimating Equations were used, to account for multiple observations from each participant. The final multivariate model was built using a stepwise approach.ResultsFive hundred forty-five participant-observations were included in the analysis. Participant-observations were grouped by “dose is satisfactory” and “wants higher dose”. From unadjusted analyses, participants were less likely to report being satisfied with their dose if they: were Indigenous, had worse psychological or physical health problems, had ever attempted suicide, were younger when they first injected any drug, were a current smoker, felt troubled by drug problems, gave their medication a lower “drug liking” score, and felt that their doctor was not including them in decisions the way they wanted to be. In the final multivariate model, all previously significant associations except for “current smoker” and “troubled by drug problems” were no longer significant after the addition of the “drug liking” score.ConclusionsPatients in injectable Opioid Agonist Treatment who are not satisfied with their dose are more likely to: be troubled by drug problems, be a current smoker, and report liking their medication less than dose-satisfied patients. Prescribers’ practicing shared decision-making can help patients achieve dose-satisfaction and possibly alleviate troubles from drug problems. Additionally, receiving a satisfactory dose may be dependent on patients being able to access an opioid agonist medication (and formulation) that they like.

High Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among Urban Syringe Service Program Participants.

Injectable opioid agonist treatment with hydromorphone (iOAT-H) is effective for persons who inject drugs (PWID) with opioid use disorder (OUD) but remains unavailable in the United States. Our objective was to determine interest in iOAT-H among syringe services program (SSP) participants. We recruited PWID with OUD from SSPs in New York City. Interest in iOAT-H was assessed on a 4-point scale. We compared participants who were and were not interested in iOAT-H regarding sociodemographic characteristics and self-reported variables (past 30 days): heroin use, public injection practices, and participation in illegal activity other than drug possession. Participants reported their preferred OUD treatment and reasons for these preferences. Of 108 participants, most were male (69%), Hispanic (68%), and median age was 42 years. The median number of prior OUD treatment episodes was 6 (interquartile range: 2-12). Most (65%) were interested in iOAT-H. Interested participants (vs not interested) reported, over the prior 30 days, greater heroin use days (mean, 26.4 vs 22.3), injecting in public more times (median, 15 vs 6), and a higher percentage having participated in illegal activity (40% vs 16%). Preferences for OUD treatment were: iOAT-H (43%), methadone (39%), and buprenorphine (9%). Participants who preferred iOAT-H to conventional OUD treatments reported preferring injection as a route of administration and that available OUD treatments helped them insufficiently. SSP participants with OUD reported high interest in iOAT-H. Participants had attempted conventional treatments but still used heroin almost daily. We identified PWID at risk for opioid-related harms who potentially could benefit from iOAT-H.

Exploring Patients’ Perceptions on Injectable Opioid Agonist Treatment: Influences on Treatment Initiation and Implications for Practice

Introduction: Injectable opioid agonist treatment (iOAT) with diacetylmorphine is an effective option for individuals previously considered non-responsive to opioid substitution treatment. Despite implementation in Canada and several European countries, relatively few eligible people choose to initiate iOAT. To better understand what encourages or deters prospective patients from initiating iOAT, the current study explores patients’ perceptions on iOAT and how these influence therapy initiation in practice. Methods: We conducted 34 semi-structured interviews with individuals currently in or eligible for iOAT in two German outpatient iOAT clinics. Transcripts were analysed following qualitative content analysis, with development of inductive categories and use of consensual coding. For member checking, we consulted individuals with lived experiences prior to data collection and publication. Results: Participants based their choice to initiate iOAT on the perceived implications of the treatment on one’s daily life and individual recovery. Participants were encouraged to initiate iOAT due to the therapy’s perceived potential in reducing cravings and substance use, its positive health consequences, and due to the image of iOAT as a path towards abstinence. Regarding deterring perceptions, participants feared a profound impairment of daily life due to factors such as the daily visits to the clinic, were concerned about whether iOAT would sufficiently promote or even impede one’s recovery, and described negative health effects. Conclusion: Perceptions found in this study profoundly influenced participants’ decisions on iOAT enrolment and contextualize the previous literature. The study reveals the dynamic coexistence of different perceptions about iOAT and sheds light on the inner-group stigmatization of iOAT. Practitioners and future research should acknowledge the complexities found in the current study in order to exploit the full potential of effective treatment modalities such as iOAT.

Experiences of serious depression and serious anxiety among individuals receiving injectable opioid agonist treatment (iOAT)

BackgroundThis study aims to provide evidence of factors that impact participant reported serious depression and serious anxiety among individuals receiving injectable opioid agonist treatment (iOAT). MethodsData from an 18-month longitudinal retrospective cohort of individuals receiving iOAT was utilized. The outcomes of serious depression and serious anxiety were ascertained via self-report in the European Addiction Severity Index. Two Generalized Linear Mixed Models were formulated using Penalized Quasi-Likelihood method. ResultsAnalyses included 131 participants. Average age was 49.04 years, 31 % self-identified as female, and 30 % self-identified as Indigenous. Adjusted analysis identified the importance of poorer physical health (AOR:1.06; 95 % CI: 1.03, 1.08), illicit opioid use (AOR: 1.03; 95 %CI: 1.01, 1.06), emotional abuse (AOR: 2.01; 95 % CI: 1.17, 3.44), and social isolation (AOR: 1.95; 95 % CI: 1.06, 3.58) with serious depression. Adjusted analysis of serious anxiety identified associations with age (AOR: 0.95; 95 % CI: 0.92, 0.98), illicit benzodiazepine use (AOR:1.31 95 % CI: 1.06, 1.61), poorer physical health (AOR: 1.05; 95 % CI: 1.03, 1.07), and social problems (AOR: 2.09; 95 % CI: 1.18, 3.71). LimitationsGeneralizability of study findings may be limited given the criteria used to enroll participants and to define depression and anxiety. ConclusionDepression and anxiety are highly prevalent among clients receiving iOAT. While both disorders share several factors, there are distinct characteristics associated with each outcome. These include poorer physical health, experiences of abuse, illicit substance use, and social problems. Understanding factors that influence depression and anxiety in iOAT can assist providers in supporting iOAT clients' mental health and developing individualized care plans.

Characteristics, treatment patterns and retention with extended-release subcutaneous buprenorphine for opioid use disorder: A population-based cohort study in Ontario, Canada

BackgroundUptake and retention for opioid agonist treatment (OAT) remains low. Novel extended-release formulations may improve OAT accessibility by reducing the frequency of healthcare visits. Our aim was to examine uptake, characteristics, treatment patterns and retention of individuals initiating extended-release subcutaneous buprenorphine (BUP-ER), a monthly injectable OAT. MethodsWe conducted a population-based cohort study among adults aged 18+ initiated on BUP-ER between February 3, 2020 and March 31, 2022 in Ontario, Canada. Using administrative health data, we defined continuous BUP-ER use based on repeat injections within a 56-day period and used Kaplan-Meier curves to estimate time on treatment. Among new BUP-ER recipients, we described individual and prescriber characteristics, healthcare utilization and treatment patterns. Results2366 individuals initiated BUP-ER. The median time to BUP-ER discontinuation was 183 days (interquartile range: 66–428 days) and 52.0% of individuals were co-prescribed buprenorphine/naloxone at least once throughout the period of BUP-ER receipt. Among individuals who initiated on a dose of 300mg BUP-ER and had three or more injections, 18.8% continued to receive only 300mg doses (N=276 of 1470). Furthermore, 28.6% of those whose dose was reduced to 100mg (N=341 of 1194) had a subsequent dose increase to 300mg. ConclusionsOn average, people initiating BUP-ER discontinue within the first 6 months of treatment. While BUP-ER is likely providing an important OAT option, the high occurrence of discontinuation, supplementation with buprenorphine/naloxone, and frequent dose increases suggest inadequacy of current dosing recommendations among a proportion of individuals.

The Impact of Injectable Opioid Agonist Treatment (iOAT) on Involvement in Criminalized Activities: A Secondary Analysis from a Clinical Trial in Vancouver, BC.

A significant portion of the economic consequences of untreated Opioid Use Disorder (OUD) relate to individuals' involvement in the criminal justice system. The present study uncovers if treatment with iOAT is related to the number of criminal charges amongst participants, what type of crime participants were involved in, and the frequency with which participants were victims of crime. This study contributes to the body of research on the effectiveness of iOAT reducing criminal involvement. This is a secondary analysis of police record data obtained from the Vancouver Police Department over a three-year period during the Study to Assess Longer-term Opioid Medication Effectiveness clinical trial. The data was obtained from participants (N = 192) enrolled in the trial through a release of information form. During the three-year period, most charges (45.6%) were property offences, and 25.5% of participants were victims of crime. Participants with no treatment prior to randomization into the SALOME trial were 2.61 (95% CI = 1.64-4.14) more likely to have been charged with a crime than during the iOAT state. IOAT can reduce individuals' involvement with the criminal justice system and is thus a crucial part of the continuum of care. Addiction should be conceptualized as a healthcare rather than criminal issue.

The mobilization of nurse-client therapeutic relationships in injectable opioid agonist treatment: Autonomy, advocacy and action

IntroductionInjectable opioid agonist treatment (iOAT) is an evidence-based treatment that serves an important minority of people with opioid use disorder who require specialized care. Unique to iOAT care is the consistency with which clients access treatment (up to three times daily), a condition that creates repeated opportunities for health care engagement. To date, no study has examined therapeutic relationships in this life saving, nurse-led treatment that can have lasting implications in the equitable delivery of other forms of addictions care. MethodsThis study used grounded theory to generate a dynamic framework for therapeutic relationship building in iOAT. Researchers collected semi-structured interviews from registered nurses working in iOAT sites (n=24) form January 2020 through June 2022. The study analyzed collected data through a constant comparative analysis; explored through open, axial, and selective coding; and assessed in a conditional relationship matrix. The team reviewed key findings with stakeholders through formalized processes of engagement to confirm saturation of coding categories. Throughout data collection and analysis, researchers integrated feedback from additional knowledge users and member checking. Reported findings adhered to the COREQ1 standardized checklist. ResultsWe identified five interrelated categories that created a distinct culture of care for iOAT nurses: Ways of Knowing, Personal Investment, Leveraging Empathy, Finding Flexibility, and Collaborating to Overcome. Through creating a safe, nonjudgmental environment, nurses establish therapeutic relationships that build trust to identify client needs outside of medication administration. In turn, nurses participate in team-based problem solving to advocate for client needs. If nurses cannot find flexibility within and outside of the health care system to improve client engagement, tensions can arise and therapeutic relationships can be strained. ConclusionsTherapeutic relationships are an integral part of building and maintaining trust with a population that has been precariously involved with other forms of health care. Nurses make a substantial effort to create a safe and nonjudgmental environment to manifest a culture of care that bridges client needs and program access. Without the expansion of access to iOAT programs and their embedded services, nurses are limited in their ability to provide individualized care for clients with diverse needs.

Benzodiazepine use, quality of life and psychiatric symptom burden in oral and injectable opioid agonist treatment: a cross-sectional study

BackgroundUse of benzodiazepines (BZD) in patients receiving opioid agonist treatment (OAT) is common and associated with a variety of negative health and social outcomes. This cross-sectional study investigates the impact of BZD use in OAT patients on their quality of life (QoL).MethodsA convenience sample of patients receiving oral OAT or heroin-assisted treatment in two outpatient centres in Basel, Switzerland was investigated. Participants (n = 141) completed self-report questionnaires on psychiatric symptoms and psychological distress (The Symptom Checklist 27, SCL-27), depressive state (German version of the Center for Epidemiological Studies Depression Scale), quality of life (Lancashire Quality of Life Profile, LQOLP) and use of BZD and other drugs (self-report questionnaire). Substance use was assessed by urine toxicology testing.ResultsIn bivariate analysis, total QoL scores were significantly lower for lifetime, current, and prolonged BZD users compared to participants without the respective use patterns. There was no significant relationship between BZD dose and QoL. In multivariable linear regression models controlling for psychiatric symptom load and depressive state, only lifetime use predicted lower QoL, whereas other BZD use patterns were not significantly associated.ConclusionsThe association of lower QoL and BZD use in OAT patients is strongly confounded by co-occurring depressive state and psychiatric symptoms. Careful diagnosis and treatment of co-occurring mental disorders in OAT is paramount to improve QoL in this patient population and may also help reduce BZD use.

Women's experiences in injectable opioid agonist treatment programs in Vancouver, Canada.

Injectable opioid agonist treatment (iOAT) has recently been expanded in some geographical contexts in Canada as part of a response to the escalating overdose crisis. Complex gendered dynamics, including power differentials, violence, and social norms, shape the overdose crisis and drug treatment programs which can adversely impact women's experiences. This qualitative study examines how social (e.g., gender, income, housing) and structural factors (e.g., program policies) impact women's experiences of iOAT. Qualitative interviews were completed with 16 women enrolled in four iOAT programs in Vancouver, Canada. Approximately 50 hours of ethnographic observations were conducted. Interview transcripts and ethnographic fieldnotes were analyzed using a critical feminist lens by applying the concepts of embodiment, relationality, and social control to understand women's engagement and self-reported treatment outcomes. Initial iOAT engagement was a relational process, including initiating treatment with a partner and engaging with iOAT to (re)build personal relationships. Relationships with iOAT providers, including flexibility and support with medication administration, were important to women, providing an affirming embodied experience and a greater sense of agency. However, program operations (e.g., mandated daily attendance, program crowding) incompatible with women's needs (e.g., employment) could undermine these positive experiences. Women's reported outcomes highlight a tension between achieving more agency and the constraints of intensive and stigmatized treatment. This study highlights how iOAT is both a source of care and control for women from a relational and embodied perspective. Findings underscore the need for gender-attentive and flexible drug treatment services to meet the varied needs of women and the importance of providing relational care for women accessing iOAT.

"They Talk to Me Like a Person" Experiences of People in an Injectable Opioid Agonist Treatment Program: A Qualitative Interpretive Description.

The aim of this study was to explore client experiences in a community-based injectable opioid agonist therapy (iOAT) program. The study occurred across two cities in Alberta, Canada. The research team conducted secondary interpretive description analysis on qualitative interview transcripts. Twenty-three iOAT clients were interviewed as part of a prior quality improvement initiative. Using secondary analysis of the transcripts, interviews were analyzed for themes, to create an understanding of clients' experiences. Participants accessed iOAT through other health services, for treatment of opioid use disorder. Participants reported that building trusting and supportive relationships with nurses was crucial to their success in the program. Through these relationships, participants experienced stopping and starting. They stopped behaviors such as illicit drug use, having withdrawal symptoms and anxiety, and prohibited income generation activities. They started taking care of themselves, accessing housing, increasing financial stability, receiving primary care, and connecting with friends and family. The global experience of iOAT was one of positive change for participants. The findings of this study are largely consistent with other published examples-iOAT programs create benefits for both clients and their communities. Although clients may join the program to access the hydromorphone, the relationships between staff and clients are the key driver of success.

Clients’ experiences on North America’s first take-home injectable opioid agonist treatment (iOAT) program: a qualitative study

BackgroundTo support public health measures during the COVID-19 pandemic, oral opioid agonist treatment (OAT) take-home doses were expanded in Western countries with positive results. Injectable OAT (iOAT) take-home doses were previously not an eligible option, and were made available for the first time in several sites to align with public health measures. Building upon these temporary risk-mitigating guidelines, a clinic in Vancouver, BC continued to offer two of a possible three daily doses of take-home injectable medications to eligible clients. The present study explores the processes through which take-home iOAT doses impacted clients’ quality of life and continuity of care in real-life settings.MethodsThree rounds of semi-structured qualitative interviews were conducted over a period of seventeen months beginning in July 2021 with eleven participants receiving iOAT take-home doses at a community clinic in Vancouver, British Columbia. Interviews followed a topic guide that evolved iteratively in response to emerging lines of inquiry. Interviews were recorded, transcribed, and then coded using NVivo 1.6 using an interpretive description approach.ResultsParticipants reported that take-home doses granted them the freedom away from the clinic to have daily routines, form plans, and enjoy unstructured time. Participants appreciated the greater privacy, accessibility, and ability to engage in paid work. Furthermore, participants enjoyed greater autonomy to manage their medication and level of engagement with the clinic. These factors contributed to greater quality of life and continuity of care. Participants shared that their dose was too essential to divert and that they felt safe transporting and administering their medication off-site. In the future, all participants would like more accessible treatment such as access longer take-home prescriptions (e.g., one week), the ability to pick-up at different and convenient locations (e.g., community pharmacies), and a medication delivery service.ConclusionsReducing the number of daily onsite injections from two or three to only one revealed the diversity of rich and nuanced needs that added flexibility and accessibility in iOAT can meet. Actions such as licencing diverse opioid medications/formulations, medication pick-up at community pharmacies, and a community of practice that supports clinical decisions are necessary to increase take-home iOAT accessibility.

Changes in daily dose in open-label compared to double-blind: The role of clients’ expectations in injectable opioid agonist treatment

IntroductionThough double-blind studies have indicated that hydromorphone and diacetylmorphine produce similar effects when administered through injectable opioid agonist treatment (iOAT) programs, participant preferencemay influence some aspects of medication dispensation such as dose. MethodsThis is a retrospective longitudinal analysis. Participants (n = 131) were previously enrolled in a double-blind clinical trial for iOAT who continued to receive treatment in an open-label follow up study. Data includedmedication dispensation records from 2012 to 2020. Using linear regression and paired t-tests, average daily dose totals of hydromorphone and diacetylmorphine were examined comparatively between double-blind and open-label periods. A subgroup analysis explored dose difference by preference using the proxy, blinding guess, a variable used to facilitate the measurement of treatment masking during the clinical trial by asking which medication the participant thought they received. ResultsDuring the open-label period, participants prescribed diacetylmorphine received49.5 mg less than during the double-blind period (95% CI −12.6,-86.4).Participants receiving hydromorphone did not see a significant dose decrease. Participants who guessed they received hydromorphone during the clinical trial, but learned theywere on diacetylmorphine during the open-label period, saw adecrease in total daily dose of 78.3 mg less (95% CI −134.3,–22.4) during the open-label period. ConclusionIf client preference is consideredin the treatment of chronic opioid use disorder, clients may be able to better moderate their dose to suit their individual needs. Together with their healthcare providers, clientscan participate in their treatment trajectories collaboratively to optimize client outcomes and promote person-centeredtreatment options.

“As long as that place stays open, I’ll stay alive”: Accessing injectable opioid agonist treatment during dual public health crises

BackgroundSince the onset of the COVID-19 pandemic, overdose rates in North America have continued to rise, with more than 100,000 drug poisoning deaths in the past year. Amidst an increasingly toxic drug supply, the pandemic disrupted essential substance use treatment and harm reduction services that reduce overdose risk for people who use drugs. In British Columbia, one such treatment is injectable opioid agonist treatment (iOAT), the supervised dispensation of injectable hydromorphone or diacetylmorphine for people with opioid use disorder. While evidence has shown iOAT to be safe and effective, it is intensive and highly regimented, characterized by daily clinic visits and provider–client interaction—treatment components made difficult by the pandemic.MethodsBetween April 2020 and February 2021, we conducted 51 interviews with 18 iOAT clients and two clinic nurses to understand how the pandemic shaped iOAT access and treatment experiences. To analyze interview data, we employed a multi-step, flexible coding strategy, an iterative and abductive approach to analysis, using NVivo software.ResultsQualitative analysis revealed the ways in which the pandemic shaped clients’ lives and the provision of iOAT care. First, client narratives illuminated how the pandemic reinforced existing inequities. For example, socioeconomically marginalized clients expressed concerns around their financial stability and economic impacts on their communities. Second, clients with health comorbidities recognized how the pandemic amplified health risks, through potential COVID-19 exposure or by limiting social connection and mental health supports. Third, clients described how the pandemic changed their engagement with the iOAT clinic and medication. For instance, clients noted that physical distancing guidelines and occupancy limits reduced opportunities for social connection with staff and other iOAT clients. However, pandemic policies also created opportunities to adapt treatment in ways that increased patient trust and autonomy, for example through more flexible medication regimens and take-home oral doses.ConclusionParticipant narratives underscored the unequal distribution of pandemic impacts for people who use drugs but also highlighted opportunities for more flexible, patient-centered treatment approaches. Across treatment settings, pandemic-era changes that increase client autonomy and ensure equitable access to care are to be continued and expanded, beyond the duration of the pandemic.

How injectable opioid agonist treatment (iOAT) care could be improved? service providers and stakeholders’ perspectives

Background Addressing inadequacies in the implementation of existing evidence-based approaches into practice, such as injectable opioid agonist treatment (iOAT), is imperative for the management of opioid use disorder. With the expansion of iOAT, stakeholder perspectives are needed to inform program optimization. This study aimed to understand stakeholder and provider perspectives on iOAT care and how it can be improved to better meet service users’ needs. Methods Semi-structured interviews (n = 11), email correspondence (n = 2), a focus group (n = 4), and one regional meeting were conducted with iOAT stakeholders to receive feedback on how iOAT can better meet service users’ needs. Qualitative analysis employed a thematic and interpretive description approach to identify key themes, presented as a thematic summary. Results Stakeholder narratives highlight the importance they attribute to client autonomy, individualized care, tensions between providers and the system (policies, governing structures, etc., that establish, facilitate and determine how iOAT is delivered in Canada) as well as power dynamics between providers and service users. Conclusion IOAT providers and stakeholders surveyed in this study are committed to seeing the needs of service users met but often feel constrained by system-level regulations that influence power dynamics between providers and service users. Findings underline pragmatic suggestions to advance person-centered care as a way to make iOAT accessible and individualized.

Feasibility of Testing Client Preferences for Accessing Injectable Opioid Agonist Treatment (iOAT): A Pilot Study.

Injectable opioid agonist treatment (iOAT) is an effective treatment for opioid use disorder (OUD). To our knowledge, no research has systematically studied client preferences for accessing iOAT. Incorporating preferences could help meet the heterogenous needs of clients and make addiction care more person-centred. This paper presents a pilot study of a best-worst scaling (BWS) preference elicitation survey that aimed to assess if the survey was feasible and accessible for our population and to test that the survey could gather sound data that would suit our planned analyses. Current and former iOAT clients (n = 18) completed a BWS survey supported by an interviewer using a think-aloud approach. The survey was administered on PowerPoint, and responses and contextual field notes were recorded manually. Think-aloud audio was recorded on Audacity. Clients' feedback fell into five categories: framing of the task, accessibility, conceptualization of attributes and levels, formatting, and behaviour predicting questions. Survey repetitiveness was the most consistent feedback. The data simulation showed that 100 responses should provide an adequate sample size. This pilot demonstrates the type of analysis that can be done with BWS in our population, suggests that such analysis is feasible, and highlights the importance of the interviewer and participant working side-by-side throughout the task.

Striatal resting-state connectivity after long-term diacetylmorphine treatment in opioid-dependent patients.

New treatment approaches for opioid-dependent patients include injectable opioid agonist treatment with diacetylmorphine. While evidence has shown beneficial clinical effects of diacetylmorphine, it is still not clear how long-term diacetylmorphine treatment affects the brain and whether functional brain changes are accompanied by clinical improvements. Therefore, this prospective case-control study focuses on long-term effects of diacetylmorphine on resting-state functional connectivity. We included opioid-dependent patients (N = 22, age range 33-58, 16 males) treated with diacetylmorphine and healthy controls (N = 9, age range 27-55, 5 males) that underwent two MRI assessments approximately nine years apart. For the patients, the assessments took part shortly after the diacetylmorphine intake to be able to explore changes in resting-state functional connectivity in brain regions related to the stage of binge and intoxication (caudate, putamen, nucleus accumbens). A cluster in the right superior frontal gyrus was detected, showing over nine years an increase in functional connectivity originating from the left caudate and the left accumbens in patients but not in healthy controls. These connectivity changes in patients were related to the duration of the diacetylmorphine treatment at the follow-up, indicating smaller increases in functional connectivity with longer treatment duration (r = 0.63, P < 0.01). These results suggest that long-term diacetylmorphine treatment in opioid-dependent patients increases fronto-striatal connections, an effect that is linked to the duration of the treatment duration. Future research needs to further address the wide-ranging effects of diacetylmorphine on brain functioning and deepen the understanding of their clinical relevance.

Treatment History and Interest in Injectable Opioid Agonist Treatment With Hydromorphone Among People Who Inject Drugs.

Injectable opioid agonist treatment (iOAT) is a novel approach to treating opioid use disorder (OUD) that is typically reserved for treatment-experienced persons who inject drugs (PWID) with long-standing OUD. This study examined PWID's past OUD treatment histories and their attitudes toward iOAT with hydromorphone. This cross-sectional study recruited syringe services program participants with OUD in New York City. Participants self-reported past OUD care episodes (detoxification; outpatient, inpatient, or medication treatment; or mutual aid groups) and current interest in iOAT with hydromorphone (assessed on a 4-point scale with 3 or 4 considered "interested"). Participants with 2 or more treatment episodes in the past 5 years were considered treatment-experienced. We examined whether the number of past care episodes was associated with interest in iOAT. Of 108 PWID, most participants were male (68.5%) and Hispanic (68.5%) with a mean age of 43 years (±10.8). Nearly all (98.1%) had severe OUD and had received past OUD care (96.3%), with the mean number of care episodes being 17.4 (SD, ±15.9). Most participants (59.8%) were treatment-experienced. Interest in iOAT with hydromorphone was high (64.8%), but there was no significant association between total past care episodes and expressing interest in iOAT (odds ratio, 1.02; 95% confidence interval, 0.99-1.05). Participants were highly treatment-experienced, and iOAT interest was high regardless of prior OUD treatment. New OUD treatment options, such as iOAT with hydromorphone, would be welcomed by PWID whose OUD has not remitted with conventional treatment as well as other PWID.

Diacetylmorphine for Adults With Opioid Dependence

&#x0D; Injectable diacetylmorphine might provide more benefits and lower costs compared with oral methadone maintenance therapy in patients with severe opioid use disorder.&#x0D; The Canadian Research Initiative in Substance Misuse guideline recommends that both injectable diacetylmorphine and hydromorphone should be considered as treatment options for individuals with severe, treatment-refractory opioid use disorder and ongoing illicit injection opioid use, and that the injectable opioid agonist treatment should have an end date to transition to an oral opioid agonist treatment.&#x0D; No recent studies on the clinical effectiveness of diacetylmorphine for injection in comparison with methadone or buprenorphine were identified.&#x0D; No cost-effectiveness studies of injectable diacetylmorphine compared with buprenorphine were identified.&#x0D;