Medication-assisted Treatment Research Articles

Information sharing to support care transitions for patients with complex mental health and social needs.

Patients with complex behavioral and mental health conditions require significant transitional care coordination. It is unclear how skilled nursing facilities (SNFs) that serve these patients engage in care transfer with hospitals, specifically whether they experience discrepancies in the type of information shared by hospital partners and/or use different approaches to secure needed information. Cross-sectional analysis of a national 2019-2020 SNF survey that collected information on transitional care practices with referring hospitals; respondents were directors of nursing services. We used chi-squared tests and descriptive statistics to characterize hospital information sharing practices experienced by facilities that accept complex patients (e.g., serious mental illness, substance use disorder, and/or medication assisted treatment), and to compare them to facilities that treat a less complex population. A total of 215 SNFs had sufficiently complete responses for inclusion in the analysis. Of these respondents, 57% accepted two or more types of patients with complex conditions of interest; these SNFs were more likely to be urban, for-profit, and serve more dual-eligible patients. SNFs accepting complex patients experience information sharing on par with other facilities, and are more likely to receive information on behavioral, social, mental, and functional status (25.41% vs. 12.90%; p=0.023). These facilities are also more likely to consistently use electronic methods (e.g., an online portal, shared electronic health record [EHR] access) to retrieve information from partner hospitals. SNFs accepting complex patients demonstrate some evidence of enhanced information retrieval via electronically mediated pathways. Overall, information sharing remains underdeveloped in this care context. Policymakers should continue to prioritize widespread digital infrastructure that supports post-acute care delivery.

The Federal Response to the Opioid Epidemic

The opioid epidemic has been a major public health crisis since the 1990s but was only declared a federal public health emergency in 2017. Since then, the federal government has increased funding to states for programs to address opioid use and overdose deaths. Despite the increased funding in the past five years, opioid-related overdose deaths continue to rise. The Substance Abuse and Mental Health Administration (SAMHSA) is the major federal agency responsible for allocating federal funds to opioid use disorder prevention, treatment, and personnel training programs. In 2021, SAMHSA allocated funding for opioid use disorder through eleven grant programs with a total of 330 grant awards, amounting to over $150 million. My analysis of 2021 SAMHSA grants aims to identify how funds for opioid use disorder are allocated, examine the relationship between opioid-related overdose deaths and the amount of funding allocated to states, and suggest potential gaps in funding. Ultimately, my research has found that treatment-focused programs were prioritized over prevention and education or training programs by SAMHSA funding. In 2021, treatment programs accounted for 223 of the 330 individual SAMHSA grant awards for opioid use disorder and 100% of grant awards received by nonprofit organizations. Medication-Assisted Treatment is the most commonly funded program among these grant awards. Additionally, states with a higher number of opioid-related overdose deaths are more likely to receive higher funding from SAMHSA grants (p<.001). Conversely, states with higher overdose death crude rates per 100,000 people did not receive adequate funding relative to the size of the population, creating gaps in accessibility to care. Additional gaps in opioid use disorder programs exist due to the downstream focus of funded interventions, neglecting upstream interventions. The data in my research are limited and therefore cannot draw broader conclusions as to how funding influences overdose deaths over time.

Pre-existing Opioid Use Worsens Outcomes in Patients With Diverticulitis.

Background and objective Diverticulitis occurs in 10-25% of patients with diverticulosis. Although opioids can decrease bowel motility, there is scarce data on the effect of chronic opioid use on the outcomes of diverticulitis. In this study, we aimed to explore the outcomes of diverticulitis in patients with pre-existing opioid use. Methods Data between 2008 and 2014 from the National Inpatient Sample (NIS) database was extracted using the International Classification of Diseases, 9th Revision (ICD-9) codes. Univariate and multivariate analyses were used to generate odds ratios (OR). Elixhauser Comorbidity Index (ECI) scores predicting mortality and readmission were calculated based on weighted scores from 29 different comorbidities. Scores were compared between the two groups using univariate analysis.Inclusion criteria included patients with a primary diagnosis of diverticulitis. Exclusion criteria included patients less than 18 years of age, and a diagnosis of opioid use disorder in remission. Studied outcomes included inpatient mortality, complications (including perforation, bleeding, sepsis event, ileus, abscess, obstruction, and fistula), length of hospital stay, and total costs. Results A total of 151,708 patients with diverticulitis and no active opioid use and 2,980 patients with diverticulitis and active opioid use were hospitalized in the United States from 2008 to 2014. Opioid users had a higher OR for bleeding, sepsis, obstruction, and fistula formation. Opioid users had a lower risk of developing abscesses. They had longer lengths of stay, higher total hospital charges, and higher Elixhauser readmission scores. Conclusion Hospitalized diverticulitis patients with comorbid opioid use are at an elevated risk of in-hospital mortality and sepsis. This could be attributed to complications from injection drug use predisposing opioid users to these risk factors. Outpatient providers caring for patients with diverticulosis should consider screening their patients for opioid use and try offering themmedication-assisted treatment to reduce their risk of poor outcomes.

Opioid-Related Treatment Disparities Among Medicaid Enrollees in Indiana.

Health care disparities based on race/ethnicity and sex can be found in a variety of settings. Our aim is to determine if there are disparities in treatment provided to Indiana Medicaid enrollees who have medically documented opioid use. We used Medicaid reimbursement claims data to extract patients who were diagnosed with opioid use disorder (OUD) or had other medical event related to opioid use between January 2018 and March 2019. We used a two-proportion Z-test to verify the difference in the proportion of treatment provided between population subgroups. The study was approved by the Purdue University Institutional Review Board (2019-118). Over the study period, there were 52,994 Indiana Medicaid enrollees diagnosed with OUD or documentation of another opioid related event. Only 5.41% of them received at least one type of treatment service (detoxification, psychosocial, medication assisted treatment, or comprehensive). Although Medicaid began covering treatment services for enrollees with an OUD in Indiana at the start of 2018, very few received evidence-based services. Men and White enrollees with an OUD were in general more likely to receive services compared to women and non-White enrollees.

Emergency Department-Initiated Buprenorphine Treatment in a Population with a High Rate of Homelessness: An Observational Study

BackgroundBuprenorphine is an effective treatment for opioid use disorders. A previous randomized trial comparing emergency department (ED)-initiated buprenorphine to standard care showed dramatic improvement in follow-up. This is encouraging, but must be replicated to understand the generalizability of buprenorphine treatment. ObjectivesEvaluate the efficacy of an ED-initiated buprenorphine protocol similar to a previous randomized trial in a different population. MethodsThis ED-based descriptive study described the results of a project implementing an opioid use disorder treatment protocol that included buprenorphine. Patients with opioid use disorder were offered treatment with buprenorphine, a buprenorphine prescription whenever possible, and a follow-up visit to a clinic providing addiction treatment. The primary outcome was engagement in formal addiction treatment 30 days after the index visit. ResultsOf the 210 patients who accepted referral for outpatient medication-assisted treatment, 95 (45.2%) achieved the primary outcome. Two-thirds of these patients received a buprenorphine prescription at discharge; 40% were homeless. A regression analysis revealed one statistically significant predictor of the primary outcome: patients who were housed were 2.49 times more likely to engage in opioid use disorder treatment than patients who were homeless (p = 0.02). ConclusionsIn this descriptive study of an ED-initiated buprenorphine protocol, follow-up was less than that reported in a previous randomized controlled trial. Two important differences between our study and the randomized trial are the high rate of homelessness and the fact that not every patient received a prescription for buprenorphine. The efficacy of ED-initiated treatment may depend on certain population characteristics.

Changes and trends in medication-assisted treatment in Israel

BackgroundAs opioid prescription in Israel is increasing, there is a growing need for monitoring opioid use disorder and providing opioid agonist therapy. Our goal is to describe, sub-analyze, and identify obstacles in the treatment of opioid misuse in the Israeli medication assisted treatment centers.MethodsData on methadone, buprenorphine, and buprenorphine combined with naloxone for the indication of opioid addiction treatment for the period 2013–2020 were obtained from pharmaceutical companies that distribute them in Israel. Data on utilization of these drugs were also extracted from the database maintained by the Israel Ministry of Health's Pharmaceutical Administration Division. The data were converted to defined daily doses (DDD)/1000 inhabitants/day.ResultsThe number of patients receiving medication assisted treatment increased by 10% since 2013, with a shift from buprenorphine alone to buprenorphine/naloxone in government-run centers. Methadone remains the most popular maintenance drug.ConclusionsThe change in opioid maintenance prescription does not match the significant increase in opioid consumption. Optimization of treatment can be achieved by the creation of a comprehensive database, cooperation between healthcare organizations and the government and further development of non-stigmatic and accessible services.

Mixed Methods Evaluation of State Targeted Response to the Opioid Crisis in Ohio

Background: In 2017, the Substance Abuse and Mental Health Services Administration awarded State Targeted Response (STR) grants through the 21st Century Cures Act to help states address the opioid crisis. While there are publications that discuss how each state allocated their STR grant awards, there is a paucity of evaluations illustrating the impact of STR grant activities on clients of opioid use disorder (OUD) treatment, family members of persons living with OUD, community professionals whose work involves addressing OUD, as well as impacts on local communities. This longitudinal qualitative study assessed the impact of STR grant-funded projects on communities in Ohio particularly hard hit by the opioid epidemic. Methods: Data were collected through a mixed research methodology from November 2017 through April 2019. Epidemiologists conducted focus groups and administered surveys in 4 geographically different areas of the state. Study objectives included assessments of community messaging related to opioids, level of perceived stigma for OUD, knowledge of available services and processes for accessing them, and perception of community treatment service needs. Results: A total of 940 respondents participated in 3 cycles (6 months each) of focus groups. Key findings included increased naloxone knowledge and experience, increased proportion of persons living with OUD receiving medication-assisted treatment (MAT), and a 2.5 time increase in the number of reported positive observations of community change. While the level of perceived stigma for OUD remained consistent (moderate) throughout the study, respondents throughout cycles observed an increasing number of community approaches, such as public awareness campaigns and recovery rallies, to impart knowledge, change attitudes, and reduce stigma. Conclusion: Evaluations of STR funded activities and programs could help illustrate the value that additional funding might have over time in reducing stigma related to OUD and increasing knowledge of available treatment services in communities.

Latest MAT initiative in California will expand hub‐and‐spoke concept

California's latest effort to increase access to medication‐assisted treatment (MAT) to combat opioid use disorder will develop and implement a “hub and spoke” system designed to increase the number of prescribers of buprenorphine across the state.

CDC Issues New Opioid Prescribing Guideline

Back to table of contents Previous article Next article Clinical & ResearchFull AccessCDC Issues New Opioid Prescribing GuidelineTerri D'ArrigoTerri D'ArrigoSearch for more papers by this authorPublished Online:12 Jan 2023https://doi.org/10.1176/appi.pn.2023.02.2.12AbstractThe new guideline emphasizes flexibility and addresses challenges that arose after the 2016 guideline was released.Late last year the Centers for Disease Control and Prevention (CDC) released a new guideline for prescribing opioids that includes updated and expanded recommendations for health professionals who provide pain care for adult outpatients with short- and long-term pain.The guideline is meant to address challenges that developed in the wake of the 2016 guideline and to add more flexibility in opioid prescribing.“Of particular concern, some policies purportedly drawn from the 2016 CDC Opioid Prescribing Guideline have been notably inconsistent with it and have gone well beyond its clinical recommendations,” the 2022 guideline states. “Such misapplication includes extension to patient populations not covered in the 2016 CDC Opioid Prescribing Guideline (e.g., cancer and palliative care patients), rapid opioid tapers and abrupt discontinuation without collaboration with patients, rigid application of opioid dosage thresholds, application of the guideline’s recommendations for opioid use for pain to medications for opioid use disorder treatment (previously referred to as medication assisted treatment), duration limits by insurers and pharmacies, and patient dismissal and abandonment.”The 2022 guideline addresses the following:Determining whether to initiate opioids for pain.Selecting opioids and determining opioid dosages.Deciding duration of initial opioid prescription and conducting follow-up.Assessing risk and addressing potential harms of opioid use.The guideline also supports the development and promotion of evidence-based treatments to manage pain and expands recommendations for tapering opioids for patients already receiving opioid therapy.The guideline should not be used as an inflexible standard of care or rigid policy or law, says Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H.According to Christopher M. Jones, Pharm.D., Dr.P.H., M.P.H., acting director of CDC’s National Center for Injury Prevention and Control, the guideline includes new structural elements that make it very clear that the guideline is a clinical tool to support individualized care and should not be used as an inflexible standard of care or rigid policy or law.Patients who have been taking opioids long term for chronic pain who appear unstable or show a decrease in function should be thoroughly evaluated for opioid use disorder, says Andrew J. Saxon, M.D.“To emphasize flexibility and encourage individualized care in using the new guideline, we have highlighted overarching principles of safe and effective pain treatment rather than focusing on specific dosage thresholds,” Jones told Psychiatric News. “For example, we do not include a specific days supply recommendation or morphine milligram equivalent dose … like was done with the 2016 guideline.”The guideline also addresses opioid prescribing for various populations that are often represented in psychiatric practice.“Of particular note for addiction psychiatrists, general psychiatrists, and others working with patients who have substance use disorders or mental disorders, we have expanded the evidence base around the use of opioid pain medication and other pain treatments and risk mitigation and treatment strategies in certain groups, like older adults and pregnant people, and in people with conditions posing special risks, such as those with a history of substance use disorder and mental health issues,” Jones said.Andrew J. Saxon, M.D., the director of the Center of Excellence in Substance Addiction Treatment and Education at the VA Puget Sound Health Care System and a former member of APA’s Council on Addiction Psychiatry, stressed the importance of evaluating patients who have been taking opioids long term (prescribed opioids continuously for more than 90 days).“Patients currently on long-term opioid therapy for chronic pain who appear unstable or show a decrement in function should be thoroughly evaluated for opioid use disorder,” Saxon said. “If they have opioid use disorder, they should be transitioned from opioid therapy to medication for opioid use disorder, typically buprenorphine, though it could be methadone if an Opioid Treatment Program is available and the patient is amenable. If the patient does not have opioid use disorder or refuses medication for opioid use disorder, a careful clinical decision will need to be made regarding continuation of opioids versus tapering, with very careful monitoring in either case.” ■Resource“CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022” ISSUES NewArchived

Placental volume in pregnant women with opioid use: prenatal MRI assessment

Objective Opioid use in pregnant women is a growing public health concern and is shown to be associated with lower infant birth weights. Placental volume changes in prior studies correlated with various maternal and fetal conditions. We aimed to identify differences between placental volumes in pregnant women with opioid use, and control pregnant women without drug use. Methods We prospectively recruited 27 healthy pregnant women and 17 pregnant women with opioid use disorder who were on medication-assisted treatment (MAT). All women underwent placenta/fetal MRI at 27–39 weeks gestation on a 3 Tesla MR scanner. Placental volumes were measured in a blinded fashion using a previously validated technique. Multiple linear regression was used to identify associations of placental volume with multiple maternal and fetal clinical factors. The significance threshold was set at p < .05. Results Placental volume was significantly associated with gestational age at MRI (p < .0001), fetal sex (p = .027), MAT with smoking (p = .0008), MAT with polysubstance use (p = .01), and maternal BMI (p = .032). Placental volume was not associated with opioid MAT alone in our cohort. Conclusion For pregnant women on medication-assisted treatment for opioid use disorder, there was no significant difference in placental volume compared to healthy pregnant women. However, concomitant smoking and polysubstance use in the setting of medication-assisted treatment may be detrimental to placental health. To our knowledge, this is the first study assessing placental volume in opioid use on prenatal MRI. These results support the benefit of medication-assisted treatment during pregnancy; however additional studies are needed to further elucidate the impact of opioid use on placental and fetal development and postnatal outcomes.

A Better Life: Factors that Help and Hinder Entry and Retention in MAT from the Perspective of People in Recovery.

Opioid addiction and opioid-related overdoses and deaths are serious public health problems nationally and in West Virginia, in particular. Medication-assisted treatment (MAT) is an effective yet underutilized treatment for opioid use disorder (OUD). Research examining factors that help individuals succeed in MAT has been conducted from provider and program perspectives, but little research has been conducted from the perspective of those in recovery. This study, co-developed with individuals in recovery, took place in West Virginia-based MAT programs using an exploratory sequential mixed methods approach. The survey was open February through August 2021. Data were analyzed late 2021 through mid 2022. Respondents experienced many barriers to MAT entry and retention, including community bias / stigma, lack of affordable programming, and lack of transportation. Respondents sought MAT primarily for personal reasons, such as being tired of being sick, and tired of having to look for drugs every day. As one respondent shared, " I wanted to better my life, to get it under control." Programs and policies should make it easy for individuals to enter treatment when ready, through affordable and accessible treatment options, reduced barriers to medications, focused outreach and education, individualized care, and reduced stigmatization.

Strategies to recruit rural primary care providers to implement a medication for opioid use disorder (MOUD) focused integrated care model.

Access to providers and programs that provide medications for opioid use disorder (MOUD) remains a systemic barrier for patients with opioid use disorder (OUD), particularly if they live in rural areas. The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) addressed this problem with a multisystem partnership that recruited, trained, and supported rural primary care providers to provide MOUD and implement an integrated care model (ICM) for patients with OUD. Given the demonstrated efficacy of Project RAMP, this article summarizes our recruitment strategies, including feasibility concerns for further expansion into other regions. The approach for recruiting implementation sites included two phases: partner outreach and site identification. Once recruited, the Systems Transformation Framework guided planning and implementation activities. Recruitment and implementation activities were assessed with implementation trackers and evaluated by providers via key informant interviews (KIIs). Project RAMP recruited 26 primary care practices from 13 counties, including nine health systems and two private practice groups-exceeding the original target of 24 sites. There was a median of 49 days from first contact to project onboarding. A total of 108 primary care practices spanning 22 health systems declined participation. Findings from the KIIs highlighted the value of engaging PCPs by connecting to a shared vision (i.e., improving the quality of patient care) as well as addressing perceived participation barriers (e.g., offering concierge technical assistance to address lack of training or resources). Findings highlight how successful recruitment activities should leverage the support of health system leadership. Findings also emphasize that aiding recruitment and engagement efforts successfully addressed prescribers' perceived barriers to providing MOUD as well as facilitating better communication among administrators, PCPs, behavioral health professionals, care managers, and patients.Plain Language Summary: Opioid use disorder (OUD) is one of the leading causes of preventable illness and death. The standard of care for OUD is the provision of medications for opioid use disorder (MOUD) and the application of an integrative integrated care model (ICM) where behavioral health is blended with specialized medical services. Unfortunately, access to providers and healthcare facilities that provide MOUD or apply an ICM remains a systemic barrier for patients with OUD, particularly if they live in rural areas. Although there is no one-size-fits-all approach to implementing MOUD in primary care, findings from Project The Rural Access to Medication Assisted Treatment (MAT) in Pennsylvania Project (Project RAMP) highlight strategies that may improve future MOUD and ICM implementation efforts in similar rural contexts. Specifically, future efforts to increase MOUD capacity by recruiting new providers should be prepared to leverage health system leadership, address provider barriers via training and expert consultation, and facilitate connections to local behavioral health providers. This approach may be helpful to others recruiting health systems and primary care practices to implement new care models to use MOUD in treating patients with OUD.

Building a community of experts in medication-assisted treatment (MAT) using the Project ECHO© model.

Project Extension for Community Healthcare Outcomes (ECHO) utilizes telemedicine to connect a multidisciplinary team of experts with a -network of primary care physicians to enable rapid dissemination of evidence-based -guidelines and practices at scale. In this study, the Project ECHO model disseminated the Arizona Pain and Addiction Curriculum to providers in rural Arizona with the goal to educate providers on medication-assisted treatment (MAT). Participants engaged in biweekly, virtual teleECHO sessions, and post-session surveys were used to collect data on provider satisfaction, self-efficacy, knowledge, barriers to change, and changes in practice behavior. Between February 2020 and November 2020, the MAT-ECHO program hosted 20 teleECHO sessions (N = 20) with 255 unique participating providers and delivered 877 learning hours. Analysis of a 6-month post-ECHO survey (N = 13) demonstrated that teleECHO sessions had broad geographic outreach. Participants had an average of 12 years of experience, 38 percent held NP/PA professional degrees, and 54 percent practiced in opioid treatment program settings. Assessment of job satisfaction and well-being revealed overall improved satisfaction among the small cohort of nonwaivered respondents (N = 8), except for meeting patient's needs. MAT-waivered respondents reported no post-session changes. Data from this study demonstrated that teleECHO sessions were well attended, consisted of a diverse cohort with various degrees, and had broad geographic outreach; hence, the utilization of the teleECHO model has the potential to reach rural providers and subsequently increase the availability and -efficacy of MAT in rural America.

Making community pharmacies psychologically informed environments (PIE): a feasibility study to improve engagement with people using drug services in Scotland.

This developmental study tested the feasibility of training pharmacy staff on the psychologically informed environments (PIE) approach to improve the delivery of care. Community pharmacies provide key services to people who use drugs (PWUD) through needle exchange services, medication-assisted treatment and naloxone distribution. PWUD often have trauma backgrounds, and an approach that has been demonstrated to work well in the homeless sector is PIEs. Bespoke training was provided by clinical psychologists and assessed by questionnaire. Staff interviews explored changes made following PIE training to adapt the delivery of care. Changes in attitude of staff following training were assessed by questionnaire. Peer researchers interviewed patient/client on observed changes and experiences in participating pharmacies. Staff interviews were conducted six months after training to determine what changes, if any, staff had implemented. Normalisation process theory (NPT) provided a framework for assessing change. Three pharmacies (16 staff) participated. Training evaluation was positive; all participants rated training structure and delivery as 'very good' or 'excellent'. There was no statistically significant change in attitudes. COVID-19 lockdowns restricted follow-up data collection. Staff interviews revealed training had encouraged staff to reflect on their practice and communication and consider potentially discriminatory practice. PIE informed communication skills were applied to manage COVID-19 changes. Staff across pharmacies noted mental health challenges for patients. Five patients were interviewed but COVID-19 delays in data collection meant changes in delivery of care were difficult to recall. However, they did reflect on interactions with pharmacy staff generally. Across staff and patient interviews, there was possible conflation of practice changes due to COVID-19 and the training. However, the study found that training pharmacy teams in PIE was feasible, well received, and further development is recommended. There was evidence of the four NPT domains to support change (coherence, cognitive participation, collective action and reflexive monitoring).

Comparisons of stress-related neuronal activation induced by restraint in adult male rat offspring with prenatal exposure to buprenorphine, methadone, or morphine.

Prenatal opioid exposure may impede the development of adaptive responses to environmental stimuli by altering the stress-sensitive brain circuitry located at the paraventricular nucleus of the hypothalamus (PVH) and locus coeruleus (LC). Corticotropin-releasing factor (CRF) released from neurons in the PVH has emerged as a key molecule to initiate and integrate the stress response. Methadone (Meth) and buprenorphine (Bu) are two major types of synthetic opioid agonists for first-line medication-assisted treatment of opioid (e.g., morphine, Mor) use disorder in pregnant women. No studies have compared the detrimental effects of prenatal exposure to Meth versus Bu on the stress response of their offspring upon reaching adulthood. In this study, we aimed to compare stress-related neuronal activation in the PVH and LC induced by restraint (RST) stress in adult male rat offspring with prenatal exposure to the vehicle (Veh), Bu, Meth, or Mor. CFos-immunoreactive cells were used as an indicator for neuronal activation. We found that RST induced less neuronal activation in the Meth or Mor exposure groups compared with that in the Bu or Veh groups; no significant difference was detected between the Bu and Veh exposure groups. RST-induced neuronal activation was completely prevented by central administration of a CRF receptor antagonist (α-helical CRF9-41, 10 μg/3 μL) in all exposure groups, suggesting the crucial role of CRF in this stress response. In offspring without RST, central administration of CRF (0.5 μg/3 μL)-induced neuronal activation in the PVH and LC. CRF-induced neuronal activation was lessened in the Meth or Mor exposure groups compared with that in the Bu or Veh groups; no significant difference was detected between the Bu and Veh exposure groups. Moreover, RST- or CRF-induced neuronal activation in the Meth exposure group was comparable with that in the Mor exposure group. Further immunohistochemical analysis revealed that the Meth and Mor exposure groups displayed less CRF neurons in the PVH of offspring with or without RST compared with the Bu or Veh groups. Thus, stress-induced neuronal activation in the PVH and LC was well preserved in adult male rat offspring with prenatal exposure to Bu, but it was substantially lessened in those with prenatal exposure to Meth or Mor. Lowered neuronal activation found in the Meth or Mor exposure groups may be, at least in part, due to the reduction in the density of CRF neurons in the PVH.

Nurse-Sensitive Indicators in the Care of Individuals With Opioid Use Disorder.

Patients with opioid use disorder (OUD) seek care in primary care settings where nurses support the provision of medication-assisted treatment. Office-based opioid treatment (OBOT) that includes buprenorphine hydrochloride administration under the supervision of a nurse for stabilization and maintenance therapy has the potential to improve outcomes for patients with OUD in primary care settings. However, the first step is to determine if OBOT nurses provide nurse-sensitive care, which consists of activities that have been shown to make a difference in patient outcomes. Content analysis of 368 nursing notes from 100 patients enrolled in an OBOT program in an urban hospital-based primary care clinic was conducted. Data were analyzed descriptively according to quantity and qualitatively according to the content. Entries indicative of care coordination and transition management were extracted. Seven content categories within care coordination were identified, including harm reduction, medication management, symptom management, communication between providers, promoting adherence, self-management goal setting, and patient education. Four areas within transition management were identified including supporting connections to resources, referrals for care, medication reconciliation, and communication with other facilities. Care coordination was documented more frequently than transition management. The presence of nurse-sensitive indicators provides evidence for and distinguishes the role of the nurse in OUD care.

Psychotherapies Used in the Treatment of Substance Use Disorder: A Narrative Review

Drug addiction is a serious social, economic, and health issue that persists worldwide. However, the efforts and certain measures taken to curb this problem seem to be counterproductive. The high addiction relapse rates and rising number of addiction cases show the requirement for proper treatment. In general, a variety of evidencebased treatment interventions for drug addiction are available. However, the gap between the availability of evidence-based therapies and their limited implementation in practice has yet to be bridged. As recommended by previous studies, psychotherapy (‘Talk therapy’), pharmacotherapy (medication-assisted treatment), alone or in combination, can be used to treat drug addiction, with the capability of resolving the high relapse rate. This article provides an overview of the evidence for, and clinical application of, psychotherapeutic approaches used in the treatment of Substance Use Disorders (SUD). Given the scope of the literature, this review will focus on the psychotherapeutic approaches used in the treatment of illicit drug use disorders, including addictive pharmaceutics, while excluding legal drugs like alcohol and nicotine. Cognitive-Behavioural Therapy (CBT), Contingency Management interventions (CM), Community reinforcement approach, Motivational enhancement therapy, 12-step facilitation therapy, family therapy, and Multisystem Therapy (MST) are some of the most prevalent evidence-based psychotherapeutic approaches currently in practice. Evidence suggests that the combination of different psychotherapies with other treatment interventions is expected to improve treatment outcomes.

INFORMATION SHARING TO SUPPORT CARE TRANSITIONS FOR PATIENTS WITH COMPLEX MENTAL AND BEHAVIORAL HEALTH NEEDS

Abstract Information sharing practices between hospitals and skilled nursing facilities (SNFs) are insufficient to effectively support patient handoffs. Information needs are even greater for SNFs that admit patients with complex behavioral needs. It is unclear whether these needs have prompted hospital investment in enhanced information sharing with these SNFs, and what strategies these facilities are using to meet informational needs. We use data from a 2019 nationally representative SNF survey (N=265, response rate 53%) designed to gather information on information sharing practices with hospital partners. 122 SNFs (57% of respondents) report accepting at least two of the following complex conditions: serious mental illness, substance use disorder, or medication assisted treatment. Using logistic regression models that adjust for facility ownership and rurality, SNFs that accept complex patients are significantly more likely to receive information on behavioral, mental, and functional status compared to facilities who accept none or only one type of complex patient (odds ratio=2.42; p=0.023). Unadjusted models indicate that facilities that accept complex patients lag in IT-facilitated access to hospital information, and report more difficulty securing timely access to information. The significance of these findings do not persist after adjustment, suggesting structural differences in the types of SNFs that hospitals are partnering with to improve information sharing. We conclude that while SNFs that accept complex patients are mostly keeping pace or even doing slightly better in terms of access to hospital information that supports transitional care, further investment is needed to improve hospital information sharing behaviors.

The Evaluation of a Clinical Decision Support Tool Using Natural Language Processing to Screen Hospitalized Adults for Unhealthy Substance Use: Protocol for a Quasi-Experimental Design.

Automated and data-driven methods for screening using natural language processing (NLP) and machine learning may replace resource-intensive manual approaches in the usual care of patients hospitalized with conditions related to unhealthy substance use. The rigorous evaluation of tools that use artificial intelligence (AI) is necessary to demonstrate effectiveness before system-wide implementation. An NLP tool to use routinely collected data in the electronic health record was previously validated for diagnostic accuracy in a retrospective study for screening unhealthy substance use. Our next step is a noninferiority design incorporated into a research protocol for clinical implementation with prospective evaluation of clinical effectiveness in a large health system. This study aims to provide a study protocol to evaluate health outcomes and the costs and benefits of an AI-driven automated screener compared to manual human screening for unhealthy substance use. A pre-post design is proposed to evaluate 12 months of manual screening followed by 12 months of automated screening across surgical and medical wards at a single medical center. The preintervention period consists of usual care with manual screening by nurses and social workers and referrals to a multidisciplinary Substance Use Intervention Team (SUIT). Facilitated by a NLP pipeline in the postintervention period, clinical notes from the first 24 hours of hospitalization will be processed and scored by a machine learning model, and the SUIT will be similarly alerted to patients who flagged positive for substance misuse. Flowsheets within the electronic health record have been updated to capture rates of interventions for the primary outcome (brief intervention/motivational interviewing, medication-assisted treatment, naloxone dispensing, and referral to outpatient care). Effectiveness in terms of patient outcomes will be determined by noninferior rates of interventions (primary outcome), as well as rates of readmission within 6 months, average time to consult, and discharge rates against medical advice (secondary outcomes) in the postintervention period by a SUIT compared to the preintervention period. A separate analysis will be performed to assess the costs and benefits to the health system by using automated screening. Changes from the pre- to postintervention period will be assessed in covariate-adjusted generalized linear mixed-effects models. The study will begin in September 2022. Monthly data monitoring and Data Safety Monitoring Board reporting are scheduled every 6 months throughout the study period. We anticipate reporting final results by June 2025. The use of augmented intelligence for clinical decision support is growing with an increasing number of AI tools. We provide a research protocol for prospective evaluation of an automated NLP system for screening unhealthy substance use using a noninferiority design to demonstrate comprehensive screening that may be as effective as manual screening but less costly via automated solutions. ClinicalTrials.gov NCT03833804; https://clinicaltrials.gov/ct2/show/NCT03833804. DERR1-10.2196/42971.

Association of medication-assisted treatment and short acting opioids with newborn head circumference and birth weight.

We compared the association of methadone, buprenorphine, and short-acting opioid exposure with newborn head circumference (HC) and birth weight (BW), and evaluated gestational age (GA) as a mediator. We included newborns born 2013-2018 identified by neonatal abstinence syndrome diagnosis code (N = 572) and birthday-matched unexposed controls (N = 571). Linear regressions of opioid exposure with HC and BW controlled for tobacco, marijuana, cocaine, gabapentin, cesarean section, Medicaid, and newborn sex, with mediation analysis by GA. Methadone was associated with 0.81 cm lower HC (95% CI = -1.22, -0.40) and 0.23 kg lower BW (95% CI = -0.35, -0.10) with approximately 24% and 41% mediated by GA, respectively. Buprenorphine and short acting opioids were not associated with HC or BW. Methadone exposed newborns have smaller HC and lower BW not fully attributable to younger GA, suggesting a direct effect of methadone on intrauterine growth. Exploration of potential developmental consequences of this is urgently needed.