Opioid Agonist Therapy Research Articles

Improving hospital-based opioid substitution therapy (iHOST): protocol for a mixed-methods evaluation

Background Opioid substitution therapy (also known as ‘opioid agonist therapy’ or ‘medication treatment of opioid use disorder’) is associated with improved health and social outcomes for people who use heroin and other illicit opioids. It is typically managed in the community and is not always continued when people are admitted to hospital. This causes opioid withdrawal, patient-directed discharge, and increased costs. We are establishing a project called iHOST (improving hospital opioid substitution therapy) to address these problems. This is an applied health research project in which we will develop and evaluate an intervention that aims to improve opioid substitution therapy in three acute hospitals in England. The intervention was developed in collaboration with stakeholders including people who use opioids, hospital staff, and other professionals who work with this group. It includes five components: (1) a card that patients can use to help hospital clinicians confirm their opioid substitution therapy, (2) a helpline for patients and staff, (3) an online training module for staff, (4) a clinical guideline for managing opioid withdrawal in hospital, and (5) ‘champion’ roles at each hospital. Methods We will do a mixed-methods study including a quasi-experimental quantitative study and a qualitative process evaluation. The primary outcomes for the quantitative study are patient-directed discharge and emergency readmission within 28 days. We will do a difference-in-difference analysis comparing changes in these outcomes for patients at iHOST sites with changes for patients at control hospitals. The process evaluation will use in-depth interviews, focus groups, and site observations with people who use opioids and staff. We will assess acceptability of the intervention, barriers and facilitators to implementation, and contextual factors impacting outcomes. Impact We anticipate that iHOST will improve care for hospital patients who use illicit opioids and/or are receiving community-based opioid substitution therapy. Depending on the results, we will promote the intervention at hospitals across the UK. Dissemination, including through publication, will inform hospital-based services for people who use drugs both in the UK and other countries.

Characteristics of attrition within the SuperMIX cohort of people who inject drugs: a multiple event discrete-time survival analysis

BackgroundCompared to the general population, people who inject drugs have poor health and wellbeing. Longitudinal studies can provide insight into factors driving these worse health outcomes but are subject to methodological challenges, such as cohort attrition. The aim of this study was to assess and characterise attrition in a prospective cohort of people who inject drugs in Victoria, Australia.MethodsUsing annually collected self-reported data from The Melbourne Injecting Drug User Cohort Study (SuperMIX) from September 2008 to January 2021, we estimated the incidence of participants being lost-to-follow-up (LTFU), with an episode of being LTFU defined as participants not undertaking a follow-up interview within two years of their last interview. We utilised a multiple event discrete-time survival analysis on participant period-observation data to estimate the associations between key factors and LTFU. Key areas of exposure measurement in analyses were sociodemographic, drug use and mental health.ResultsA total of n = 1328 SuperMIX participants completed a baseline interview, with n = 489 (36.8%) LTFU, i.e. not completing a follow-up interview in the following two years. Increased attrition was observed among SuperMIX participants who were: born outside Australia, younger than 30 years, reporting having completed fewer years of education, not residing in stable accommodation, not in stable employment and not on opioid agonist therapy (OAT).ConclusionsThe attrition rate of the SuperMIX cohort has largely been stable throughout the duration of the study. Higher attrition rates among individuals at greater sociodemographic disadvantage and not on OAT suggest that additional efforts are required to retain these participants. Findings also suggest that SuperMIX might not be capturing data on adverse health and wellbeing outcomes among subpopulations at high risk of harm.

Cost-Effectiveness of Treating Hepatitis C in Clients on Opioid Agonist Therapy in Community Pharmacies Compared to Primary Healthcare in Australia.

Meeting the World Health Organisation 2030 target of treating 80% of people with hepatitis C virus (HCV) in Australia requires accessible testing and treatment services for at-risk populations. Previous clinical trials, including those in Australia, have demonstrated the efficacy of outreach programmes to community pharmacies offering opioid agonist therapy (OAT). This analysis evaluates the potential cost-effectiveness of introducing an outreach programme in community pharmacies. Using a decision analytic model, we estimated the impact of adding a temporary hepatitis C outreach and treatment programme in community pharmacies to the standard treatment pathway available through general practice. We compared the expected number of tests, diagnoses, cures and costs occurring through the addition of this outreach and treatment programme to those expected through general practice alone over a 12-month time horizon. We examined costs from the perspective of the health system and conducted one-way and probabilistic sensitivity analyses to assess uncertainty in model parameters and test key assumptions. In the model adding the outreach programme pathway increased the number of tests from 4178 to 8737, the number of diagnoses from 615 to 1285 and the number of cures from 223 to 777 among people on OAT over a 12-month period. Each additional cure achieved through the addition of the outreach programme was estimated to incur $48,964 (AUD 2023) to the health system, with > 85% of these costs attributable to medication and dispensing expenses. The average cost per cure was estimated to be $49,152 through routine care and $49,018 in the outreach programme. Although outreach models of care incur large upfront costs, they can capture otherwise unreached populations and result in comparable or favourable cost per cure, due to higher levels of engagement and lower rates of loss to follow-up.

04 Care for adolescents with substance use: A national survey of paediatric hospitals

Abstract Background Substance use is a recognized Paediatric health care issue. More than 9 in 10 individuals receiving treatment for substance use disorders report that their first use of substances occurred by young adulthood. The Canadian Institute for Health Information reported that 5% of hospital stays among Canadian youth in 2017-2018 were related to harmful substance use. In a study of youth with a first-time emergency department visit for a mental health problem between 2010 and 2014, most visits were due to substance related disorders. Despite this, little is known about practices relating to substance use in children's hospitals. Objectives 1. To describe how adolescents who present to Paediatric hospitals with substance use disorders or substance-related health issues are identified, assessed, and treated. 2. To identify best-practices that can inform national standards of care. Design/Methods An online questionnaire was utilized to obtain information on: 1. Clinical practices in the emergency department, inpatient services and ICU; 2. Hospital policies and practice guidelines; and 3. Hospital and community programs and resources. Recruitment emails were sent to hospital leaders (CEO or equivalent) at all 13 Paediatric hospitals. Leaders were asked to identify one individual to complete the survey on behalf of their hospital with input from relevant stakeholders in the various clinical areas. The survey was developed iteratively by a national group of 9 adolescent medicine clinicians and 2 Paediatric trainees. The survey was piloted at a single Paediatric hospital and refined. The survey was administered via RedCap technology. Results Survey response rate was 70% (9/13 hospitals). The mean number of contributors to each survey was 9 (range of 1-35). Overall, few hospitals utilized best practices consistently. There was inconsistency in the use of validated screening tools, use of clinical practice guidelines for monitoring and ongoing care and prescribing of nicotine replacement therapy and opioid agonist therapy. These inconsistencies were noted within each clinical setting (emergency department, inpatient services, and ICU), across services in each hospital, and between hospitals. With respect to hospital services, 5/9 had some type of consult team related to substance use (e.g., adolescent medicine), 4/9 had specialized substance use outpatient services, and 2/9 offered partial hospitalization/day treatment for patients with substance use issues. Local community-based substance use resources were identified as insufficient to address needs by 8/9 hospitals. Conclusion Inconsistencies in the care of adolescents with substance use disorders or substance-related health issues highlights the need for national guidelines for Paediatric hospital-based assessment and care, and enhanced coordination between services and systems of care for this patient population.

Suicide in people prescribed opioid-agonist therapy in Scotland, United Kingdom, 2011-2020: A national retrospective cohort study.

Opioid dependence is associated with an increased risk of suicide. Drug-related mortality among people with opioid dependence in Scotland has more than tripled since 2010; less is known about changes in suicide risk. We aimed to determine if opioid agonist therapy (OAT) in Scotland is protective against suicide and to measure trends in suicide rates in those with opioid dependence over time. Retrospective cohort study. Scotland, UK. 46 453 individuals in Scotland who received at least one prescription for OAT between 2011 and 2020 with over 304 000 person-years (pys) of follow-up. We calculated standardised mortality ratios (SMR) using the age- and sex-specific suicide rates in Scotland for years 2011-2020. We fitted multivariable competing-risk regression models to estimate suicide rates by OAT exposure and to estimate trends over time, adjusting for potential confounders. There were 575 deaths classed as suicide among the cohort and the overall suicide rate was 1.89 (95% confidence interval [CI] = 1.74-2.05) per 1000 pys. Age and sex SMR for suicide was 7.05 times (95% CI = 6.50-7.65) higher than in the general population. After adjustment, OAT was shown to be highly protective against suicide, with rates more than three times greater (adjusted hazard ratio: 3.07; 95% CI = 2.60-3.62) off OAT compared with on OAT. Suicide rates decreased over time, falling from 2.57 (95% CI = 2.19-3.02) per 1000 pys in 2011-12 to 1.48 (95% CI = 1.21-1.82) in 2019-20. People with opioid dependence in Scotland appear to have a greater risk of suicide than the general population. Treatment is protective, with rates of suicide lower among those on opioid agonist therapy. Suicide rates have decreased over time, during a period in which drug-related death rates in Scotland have risen to globally high levels.

Sustainability of opioid agonist therapy programmes in Belarus, the Republic of Moldova, Tajikistan and Ukraine in the context of transition from Global Fund support during 2020–2023

BackgroundMost national programmes of opioid agonist therapy (OAT) in Eastern Europe and Central Asia are at a critical juncture for building their sustainability due to decreasing support from the Global Fund and other international HIV funders. Therefore, it is timely to identify the status, trends, opportunities and risk factors of OAT preparedness in the face of donor transition.MethodsThe study assessed the OAT sustainability progress in 4 countries: Belarus, the Republic of Moldova, Tajikistan and Ukraine. The study used a comparative country case study design with qualitative methods and two data points in 2020 and 2022–2023. In total, 363 sources were reviewed and used, 83 interviews with key informants and 13 focus groups were conducted with clients, using a joint methodology and a defined Framework with three dimensions: ‘Policy & Governance’; ‘Finance & Resources’; and, ‘Services’.ResultsAll four countries have made improvements to increase OAT sustainability, though it varied. In 2022, Ukraine had a substantial degree of sustainability, followed by Belarus and Moldova with a moderate degree, while Tajikistan’s sustainability was at moderate-to-high risk. No country achieved a high degree of OAT sustainability in any of the three dimensions measured. However, a high degree of sustainability was reported for at least one indicator in Belarus, Moldova and Ukraine: ‘Medicines’; ‘Financial resources’; ‘Evidence and information systems’; ‘Service Accessibility’; or, ‘Service integration & quality’. On average, the greatest improvement between 2020 and 2022 was seen for ‘Availability & coverage’; ‘Financial resources’; ‘Service quality & integration’; and, ‘Service accessibility’. The highest risks across the countries, notably in Belarus and Tajikistan, were recorded for the indicator, ‘Availability and coverage’. Of concern is that the least progress, or even a decline, was found in ‘Human resources’.ConclusionsOAT sustainability in the 4 analysed countries remains at risk, despite progress in all countries. Managing HIV donor transition can have positive effects in addressing financial sustainability, especially inspired by Ukraine’s continued progress despite economic contraction and Russia’s invasion. More attention is needed to non-financial aspects of OAT sustainability in donor transition planning. The directions that could have multifaceted positive influence for OAT long-term resilience and scale up for impact on drug problems include decentralisation outside of health settings and broader drug treatment financial and management transformation, together with drug policy reforms. Thus far, viable solutions for sustainability of OAT in conflict areas appear unlikely. Building OAT resilience should remain high on the agenda of national stakeholders, technical partners and donors.

Health service utilization, substance use treatment response, and death in patients with opioid use disorder and comorbid hepatitis C findings from prospective cohort study with administrative database linkage

BackgroundAmong patients with opioid use disorder (OUD), high rates of overdose and death have been reported in subgroups with Hepatitis C Virus (HCV). Evidence on the comorbid effect of HCV on clinical and substance use trajectories has been limited by small sample sizes, short follow-up, and heavy reliance on administrative data which lacks granularity on important prognostic factors. Additionally, few studies include populations on substance use treatment. AimTo establish the impact of HCV exposure (antibody positivity) on health care utilization patterns, substance use treatment response, and death in a cohort of patients with OUD on opioid agonist therapy (OAT). MethodsThis multi-center prospective cohort study recruited adult patients with OUD on OAT from 57 substance use treatment centers in Ontario, Canada. The study collected substance use outcomes, and classified patients with ≥50 % positive opioid urine screens over one year of follow-up as having poor treatment response. Additional data obtained via linkage with ICES administrative databases evaluated the relationship between HCV status, healthcare service utilization, and death over 3 years of follow-up. Multiple logistic regression models established the adjusted impact of HCV on various outcomes. ResultsAmong recruited participants (n = 3430), 44.10 % were female with a mean age of 38.64 years (Standard deviation: 10.96). HCV was prevalent in 10.6 % of the cohort (n = 365). Methadone was used most often (83.9 %, n = 2876), followed by sublingual buprenorphine (16.2 %, n = 554). Over the three-year follow-up, 5.3 % of patients died (n = 181). Unadjusted results reveal rates of hospitalization (all-cause, mental-health related, critical care) and emergency department visits (mental health-related), were significantly higher among HCV patients. Associations diminished in adjusted models. Active injection drug use exhibited the highest predictive risk for all outcomes. ConclusionA high degree of acute physical and mental illness and its resulting health service utilization burden is concentrated among patients with OUD and comorbid HCV. Future research should explore the role for targeted interventions and how best to implement integrated healthcare models to better address the complex health needs of HCV populations who inject drugs.

Trajectory and progress of opioid agonist therapy programs in Kyrgyz Republic

Trajectory and progress of opioid agonist therapy programs in Kyrgyz Republic

Regimes of Drug Desires: Depot Buprenorphine as a Technology of Becoming

Long-acting injectable depot buprenorphine is the latest opioid agonist therapy to be offered in Australia. There has been increasing scholarly interest in the lived experience of this treatment; however, the current qualitative research on this issue is limited to reports on the benefits and challenges individuals experience during treatment. This study expands and complicates this body of work by delving into the social, affective, and material aspects of the depot buprenorphine experience. By applying a Deleuzo-Guattarian framework to the analysis of 40 semistructured, open-ended interviews conducted with individuals who were either currently receiving depot buprenorphine, were in the process of discontinuing, or had discontinued treatment, we argue that depot buprenorphine is a technology of becoming situated within regimes of desire. That is, depot buprenorphine is a catalyst of social, affective, and material changes that is realized and dwells within a set of cocreated assemblages comprised of human and other-than-human actors. According to the regimes of desire at work within these assemblages, individuals in treatment pass through a series of thresholds that mark their becoming into different kinds of persons. Four critical thresholds emerged in participants’ reports of depot buprenorphine: thresholds of geography, freedom, the body, and abstinence. These thresholds opened up radical new ways of being for participants, with some being more positive than others. We close by discussing the implications our findings have for the ongoing delivery of opioid agonist therapies in Australia and elsewhere.

The Gut-Brain Axis in Opioid Use Disorder: Exploring the Bidirectional Influence of Opioids and the Gut Microbiome-A Comprehensive Review.

Opioid Use Disorder is a chronic condition characterized by compulsive opioid use despite negative consequences, resulting in severe health risks such as overdose and contraction of infectious diseases. High dropout rates in opioid agonist therapy highlight the need for more effective relapse prevention strategies. Animal and clinical studies indicate that opioids influence gut microbiota, which in turn plays a critical role in addiction development and alters behavioral responses to opioids. This study provides a comprehensive review of the literature on the effects of opioids on the gut microbiome and explores the potential of microbiome manipulation as a therapeutic target in opioid addiction.

Trends in injectable buprenorphine prescribing in Canada: A descriptive analysis in five Canadian Provinces

BackgroundInjectable extended-release buprenorphine (BUP-ER) (Sublocade®) is a newer form of opioid agonist therapy (OAT) administered monthly. It was listed on formularies across Canada in February 2020, expanding the options for OAT across the country. This study describes rates of injectable BUP-ER uptake in five provinces to compare access to this novel medication across Canada. MethodsWe conducted a retrospective time-series analysis among individuals who received injectable BUP-ER in British Columbia, Alberta, Saskatchewan, Manitoba, and Ontario from February 1, 2020, to March 31, 2022. The primary outcome was the population-adjusted rate of injectable BUP-ER in each province, with secondary analyses exploring rates by urban/rural location, and the number of prescribers of injectable BUP-ER per 100,000 population. ResultsIn total, 6528 individuals were treated with injectable BUP-ER, with the majority in British Columbia (29.0 %) and Ontario (47.0 %). By March 2022, the rate of BUP-ER use was highest in British Columbia (16.6 per 100,000), and lowest in Ontario (9.1 per 100,000). The rate of BUP-ER use was higher in rural areas (15.5 per 100,000) compared to urban centres (10.6 per 100,000), and British Columbia had the highest rate of prescribers per 100,000 population (5.9) compared to Ontario (2.2), Alberta (2.3), Saskatchewan (3.4) and Manitoba (3.5) by the end of Q1–2022. ConclusionUptake of BUP-ER varied geographically since being approved by Health Canada. More rapid uptake in rural areas is reassuring and suggests that this form of OAT may be supporting treatment access to those with barriers to more traditional treatment formulations.

Design and implementation of a Type-2 hybrid, prospective randomized trial of opioid agonist therapies integration into primary care clinics in Ukraine

IntroductionUkraine has high HIV prevalence, concentrated among people who inject drugs (PWID), mostly of opioids. Maintenance on opioid agonist therapies (OAT) is the most effective evidence-based treatment for opioid use disorder. As PWID experience high morbidity and mortality from preventable and treatable non-communicable diseases, international agencies recommend integrating OAT into primary care centers (PCC). MethodsA randomized, type-2 hybrid implementation trial was carried out to compare outcomes of OAT integration in PCC to OAT delivery at specialty treatment centers (STC) – standard-of-care. Tele-education supporting PCC providers in managing OAT, HIV, tuberculosis and non-communicable diseases along with pay-for-performance incentives were used to facilitate implementation. Consenting patients underwent 1:2 randomization to either STC or PCC. Quality health indicators (QHIs), a composite percentage of recommended primary and specialty services accessed by patients (blood/urine tests, cancer screenings, etc.), were defined as efficacy outcomes and were assessed by participant self-report at baseline and every 6 months over 24 months and electronic chart reviews after the completion of the follow-up. The primary outcome is defined as the difference in composite QHI scores at 24 months, in which a repeated measures likelihood-based mixed model with missing at random assumptions will be used. Providers at PCC completed surveys at baseline, 12 and 24 months to assess implementation outcomes including changes in stigma and attitudes towards OAT and PWID. Preliminary resultsAmong the 1459 participants allocated to STC (N = 509) or PCC (N = 950), there were no differences in clinical and demographic characteristics. Self-reported prevalences were available for HIV (42 %), HCV (57 %), and prior tuberculosis (17 %). Study retention at 6, 12, 18, and 24 months was as 91 %, 85 %, 80 %, and 74 %, respectively. ConclusionPWID have a high prevalence of medical comorbidities and integrating OAT into primary care settings has the potential to improve the health of PWID. Findings from this study can help guide implementation of integrated care in Ukraine and throughout similar low-resource, high-burden countries in the Eastern European and Central Asian region.

Oxytocin Reduces Noradrenergic-Induced Opioid-Like Withdrawal Symptoms in Individuals on Opioid Agonist Therapy

BackgroundIntranasal administration of the neuropeptide oxytocin has been explored as a potential therapeutic agent for opioid use disorder (OUD). Oxytocin was effective in reducing stress and withdrawal symptoms in individuals with OUD. MethodThis phase 1 crossover, randomized, double-blind, placebo-controlled trial tested the safety, tolerability, and efficacy of intranasal oxytocin (80 international units) twice a day for 7 days in participants (n = 20) with OUD who were taking an opioid agonist therapy. In the laboratory, participants underwent opioid cue exposure paired with noradrenergic activation produced by yohimbine or placebo. Assessments included 1) subjective response: craving, withdrawal, anxiety, and stress; 2) biomedical markers: hypothalamic-pituitary-adrenal axis response (cortisol) and noradrenergic activation (α-amylase); and 3) safety measures: hemodynamics and adverse event evaluation. Generalized linear model with model-based estimator in the covariance matrix was used, with medication (oxytocin/placebo) and noradrenergic activation (yohimbine/placebo) as within-subject factors. ResultsOxytocin significantly reduced opioid-like withdrawal, anxiety symptoms, and cortisol levels elicited by cue exposure under noradrenergic activation produced by yohimbine. This effect was specific because oxytocin did not reduce craving, hemodynamics, or α-amylase levels increased by yohimbine administration. A single dose of yohimbine elicited the noradrenergic stimulation, and 7-day oxytocin administration was safe and well tolerated among individuals diagnosed with OUD and taking opioid agonist therapy. ConclusionThe findings of this study suggest that oxytocin alleviates opioid-like withdrawal symptoms and anxiety by modulating the hypothalamic-pituitary-adrenal axis.

Knowledge of, and attitude towards, the treatment of hepatitis C in people who inject drugs

BackgroundDirect acting antivirals (DAAs) as a curative treatment of hepatitis C have been available for several years and have replaced interferon-containing therapies. However, treatment rates of people who inject drugs (PWID) are declining in Germany, putting the elimination of hepatitis C by 2030 at risk. This study aimed at elucidating the knowledge of, and attitude towards, hepatitis C treatment in a clinical sample of PWID.MethodsParticipants were recruited between February 2019 and October 2020 at two opioid agonist therapy (OAT) clinics and two in-patient drug detoxification wards. Based on the European Addiction Severity Index (Europ-ASI), a standardized interview focusing on: sociodemographic data, drug history, risky behavior, infection with hepatitis C virus (HCV) and HIV, and previous experience with HCV treatment was carried out. In addition, participants filled in a questionnaire evaluating 13 statements relating to HCV treatment (right/wrong) and 15 statements on their personal ‘pros and cons’ views to start such a treatment assessed with the means of a 6-point Likert scale.ResultsA total of 153 patients (average age 45 years, male 78%; 106 (69.3%) currently in opioid maintenance treatment, 47 (30.7%) currently admitted to an inpatient detoxification) with an opioid use disorder were investigated. All of them reported having injected drugs at least once in their lives; 97 participants (63.3%) stated that they had been previously diagnosed with HCV infection. Among them, 27/97 patients (27.8%) reported a previous treatment with interferon; 27/97 (27.8%) with DAAs; and 32/97 (33.0%) reported a currently active hepatitis C. Most patients knew about the availability and efficacy of DAAs. However, DAAs’ low rate of side effects, their short treatment duration, and their replacement of interferon, were not correctly evaluated by up to 50.3% of patients. 25–40% of 32 patients with currently active hepatitis C prioritized handling of social and other medical issues, e.g., reduction of heroin use, over treatment of hepatitis C.ConclusionsAlthough current levels of risky behavior have reportedly been reduced by active PWID over the past few years, educational and motivational interventions to increase hepatitis C treatment uptake should address the gaps in patients’ knowledge.

Barriers and Facilitators to Accessing Opioid Agonist Therapy for Street-involved Adolescents and Young Adults in Vancouver.

Opioid agonist therapy (OAT) remains the first-line therapy for people with opioid use disorder. Whereas overdose rates among adolescents and young adults (AYAs) remain high, little is known about their access to OAT. Therefore, we sought to evaluate factors that shape access to OAT among AYAs aged 14 to 26 years. Data were derived from the At-Risk Youth Study, a prospective cohort study that involves street-involved AYAs who use illicit substances in Vancouver, Canada. Generalized estimating equations were used to identify factors associated with OAT enrollment from September 2005 to October 2021. A total of 759 AYAs reported at least weekly opioid or OAT use, with a median age of 23 years and 65.7% self-identifying as male. At baseline, 147 participants (19.4%) were on OAT, and another 199 (26.2%) initiated OAT during study follow-up (median number of follow-up visits, 5 [Q1-Q3, 2.5-8]). In a multivariable analysis, being <19 years old (adjusted odds ratio [AOR], 0.40; 95% confidence interval [CI], 0.23-0.71), Indigenous ancestry (OR, 0.72; 95% CI, 0.52-1.00), homelessness (AOR, 0.65; 95% CI, 0.54-0.77), drug dealing (AOR, 0.73; 95% CI, 0.61-0.87), daily opioid use (AOR, 0.47; 95% CI, 0.40-0.55), and nonfatal overdose (AOR, 0.73; 95% CI, 0.60-0.89) were negatively associated with OAT use. This study identified a low rate of OAT access among AYAs. Adolescents and young adults were less likely to be on OAT if they were <19 years old, Indigenous, and possessed certain risk markers. These findings highlight the need for mitigation strategies to facilitate OAT access for this population and for additional harm reduction measures to support AYAs who do not want to use OAT.

Healthcare utilisation and associated costs for methadone versus buprenorphine recipients: Examination of interlinked primary and secondary care electronic health records in England.

More evidence for patterns of healthcare utilisation and associated costs among people receiving opioid agonist therapy (OAT) is needed. We investigated primary and secondary healthcare usage and costs among methadone and buprenorphine recipients in England. We conducted a cohort study using the Clinical Practice Research Datalink GOLD and Aurum databases of patients who were prescribed OAT between 1 January 2007 and 31 July 2019. The cohort was linked to Hospital Episode Statistics admitted patient care, outpatient and emergency department data, neighbourhood- and practice-level Index of Multiple Deprivation quintiles and mortality records. Negative binomial regression models were applied to estimate weighted rate ratios (wRR) of healthcare utilisation. Total and mean costs were calculated using Unit Costs of Health and Social Care and the National Healthcare Service Payment by Results National Tariffs. Among 12,639 patients observed over 39,016 person-years, we found higher rate of hospital admissions (wRR 1.18; 1.08-1.28) among methadone compared with buprenorphine recipients. The commonest hospital discharge diagnoses among methadone patients were infectious diseases (19.2%), mental and behavioural disorders (17.0%) and drug-related poisoning (16.5%); the three commonest among buprenorphine patients were mental and behavioural diseases (21.5%), endocrine (13.8%) and genitourinary system diseases (13.1%). Methadone patients had similar mean costs compared with buprenorphine patients (cost difference: £539.01; 432.11-1006.69). Differences in healthcare utilisation frequency for methadone versus buprenorphine recipients were observed. The differences in associated costs were mainly driven by hospital admissions. These findings offer valuable insights for optimising care strategies and resource allocation for OAT recipients.

Latine perspectives on the impact of family, perceptions of medication, health systems, incarceration, and housing on accessing opioid agonist therapy: A thematic analysis

IntroductionOpioid-related overdose deaths rates among Latine individuals are increasing rapidly and, in Massachusetts, have exceeded rates among non-Hispanic White individuals. Yet Latine individuals are less likely to receive opioid agonist therapies (OAT) methadone and buprenorphine, which have been demonstrated to prevent opioid deaths. Amid climbing Latine overdose rates, we lack qualitative data from Spanish-speaking people who use opioids about their views on and access to OAT. In this paper, we sought to assess variables affecting Latine individuals' initiation of OAT. MethodsWe conducted 21 semi-structured interviews – half in Spanish – with Latine-identifying individuals recruited from four locations–three residential treatment sites and one city shelter–in Boston offering services to people who use drugs. We utilized thematic analysis to identify barriers and facilitators to starting and continuing OAT. ResultsThe following themes – which cut across individual-, interpersonal-, and systems-level variables – emerged as core considerations shaping Latine participants' OAT engagement: (1) family, (2) medication desirability and accessibility, (3) health care resources, (4) housing stability, and (5) incarceration. First, family members were prominent interpersonal influences on participants' treatment decisions. For some participants, family introduced participants to opioids at young ages and later supported them in recovery. Second, engagement with OAT was shaped by individual-level opinions on the medications as well as by systems-level experiences with trying to access the medications. Participants identified benefits and drawbacks of methadone versus buprenorphine, with greater access difficulties for methadone. Third, the health care setting in Boston provided notable systems-level facilitators to OAT access, including outreach workers, Medicaid, and Spanish-speaking providers. Fourth, housing instability impeded some from accessing OAT while motivating others to initiate the medications. Finally, incarceration created systems-level barriers to OAT engagement. Most participants had been incarcerated in jail or prison but did not have access to OAT during incarceration or during their transition back to the community. ConclusionsApproaches to increase OAT engagement among Latine individuals should consider integrating family into recovery pathways, tailoring information in Spanish, developing bilingual/bicultural staffing, ensuring supportive insurance coverage systems, addressing housing needs, and making OAT available for individuals involved in the legal system.

Non-injection drug use among incarcerated people in Iran: Findings from three consecutive national bio-behavioral surveys

BackgroundPrisons often serve as high-risk environments for drug use, and incarcerated people are at a high risk for substance use-related mental and physical harms. This study aimed to determine the prevalence of non-injection drug use inside the prison and its related factors among incarcerated people in Iran.MethodsWe utilized data from three national bio-behavioral surveillance surveys conducted among incarcerated people in Iran in 2009, 2013, and 2017. Eligibility criteria were being ≥ 18 years old, providing informed consent, and being incarcerated for over a week. Overall, 17,228 participants across all surveys were recruited through a multi-stage random sampling approach. Each participant underwent a face-to-face interview and HIV test. The primary objective of the study was to assess self-reported non-injection drug use within the prison environment within the last month. A multivariable logistic regression model was built to determine associated covariates with drug use inside prison and an adjusted odds ratio (aOR) with 95% confidence intervals (CI) were reported.ResultThe prevalence of non-injection drug use inside the prison was 24.1% (95% CI 23.5, 24.7) with a significant decreasing trend (39.7% in 2009, 17.8% in 2013, 14.0% in 2017; p-value < 0.001). Overall, 44.0% of those who used drugs were also receiving opioid agonist therapy (OAT) and we noted that in 2017, 75.1% of those on OAT used stimulants. In the multivariable logistic regression model, the year of interview (2013: aOR = 1.43 and 2009: aOR = 5.60), younger age (19–29: aOR = 1.14 and 30–40: aOR = 1.37), male sex (aOR = 3.35), < high school education (aOR = 1.31), having a history of previous incarceration (aOR = 1.26), and having a history of lifetime HIV testing (aOR = 1.76) were significantly and positively associated with recent non-injection drug use inside the prison.ConclusionsApproximately one in four incarcerated people in Iran reported drug use within the last month inside prisons. While a declining trend in non-injection drug use was noted, substantial gaps persist in harm reduction programs within Iranian prisons. In particular, there is a pressing need for improvements in drug treatment programs, focusing on the integration of initiatives specifically designed for people who use stimulants.

An individual-based dynamic model to assess interventions to mitigate opioid overdose risk

BackgroundIllicit opioid overdose continues to rise in North America and is a leading cause of death. Mathematical modeling is a valuable tool to investigate the epidemiology of this public health issue, as it can characterize key features of population outcomes and quantify the broader effect of structural and interventional changes on overdose mortality. The aim of this study is to quantify and predict the impact of key harm reduction strategies at differing levels of scale-up on fatal and nonfatal overdose among a population of people engaging in unregulated opioid use in Toronto.MethodsAn individual-based model for opioid overdose was built featuring demographic and behavioural variation among members of the population. Key individual attributes known to scale the risk of fatal and nonfatal overdose were identified and incorporated into a dynamic modeling framework, wherein every member of the simulated population encompasses a set of distinct characteristics that govern demographics, intervention usage, and overdose incidence. The model was parametrized to fatal and nonfatal overdose events reported in Toronto in 2019. The interventions considered were opioid agonist therapy (OAT), supervised consumption sites (SCS), take-home naloxone (THN), drug-checking, and reducing fentanyl in the drug supply. Harm reduction scenarios were explored relative to a baseline model to examine the impact of each intervention being scaled from 0% use to 100% use on overdose events.ResultsModel simulations resulted in 3690.6 nonfatal and 295.4 fatal overdoses, coinciding with 2019 data from Toronto. From this baseline, at full scale-up, 290 deaths were averted by THN, 248 from eliminating fentanyl from the drug supply, 124 from SCS use, 173 from OAT, and 100 by drug-checking services. Drug-checking and reducing fentanyl in the drug supply were the only harm reduction strategies that reduced the number of nonfatal overdoses.ConclusionsWithin a multi-faceted harm reduction approach, scaling up take-home naloxone, and reducing fentanyl in the drug supply led to the largest reduction in opioid overdose fatality in Toronto. Detailed model simulation studies provide an additional tool to assess and inform public health policy on harm reduction.

Federal opioid agonist therapy policy: interrupted time series analysis of the impact of the methadone exemption removal across eight provinces in Canada

BackgroundFederal deregulation of opioid agonist therapies are an attractive policy option to improve access to opioid use disorder care and achieve widespread beneficial impacts on growing opioid-related harms. There have been few evaluations of such policy interventions and understanding effects can help policy planning across jurisdictions.MethodsUsing health administrative data from eight of ten Canadian provinces, this study evaluated the impacts of Health Canada’s decision in May 2018 to rescind the requirement for Canadian health professionals to obtain an exemption from the Canadian Drugs and Substance Act to prescribe methadone for opioid use disorder. Over the study period of June 2017 to May 2019, we used descriptive statistics to capture overall trends in the number of agonist therapy prescribers across provinces and we used interrupted time series analysis to determine the effect of this decision on the trajectories of the agonist therapy prescribing workforces.ResultsThere were important baseline differences in the numbers of agonist therapy prescribers. The province with the highest concentration of prescribers had 7.5 more prescribers per 100,000 residents compared to the province with the lowest. All provinces showed encouraging growth in the number of prescribers through the study period, though the fastest growing province grew 4.5 times more than the slowest. Interrupted time series analyses demonstrated a range of effects of the federal policy intervention on the provinces, from clearly positive changes to possibly negative effects.ConclusionsFederal drug regulation policy change interacted in complex ways with provincial health professional regulation and healthcare delivery, kaleidoscoping the effects of federal policy intervention. For Canada and other health systems such as the US, federal policy must account for significant subnational variation in OUD epidemiology and drug regulation to maximize intended beneficial effects and mitigate the risks of negative effects.