Housing for People with Substance Use Disorders: One Size Does Not Fit All Tenants-Assessment of 16 Housing Services and Suggestions for Improvement Based on Real World Experience.

Housing is an important factor for individuals addressing substance use disorders (SUD). This work compared aims and outcomes for new housing services and made suggestions for improvement. 16 new services were assessed over 6 months activity against factors identified as important. Services defined expected standards including (1) engagement with treatment for SUD, (2) restrictions on continuing substance use by tenants. After 6 months, 9 (56%) housing projects did not achieve planned standards and lowered criteria for inclusion. When setting up housing for people with SUD it is important to define clearly the nature of the intended service. Different types of housing programs in a network are needed to meet the evolving behaviour of tenants. One size does not fit all. Stable housing is important for people addressing SUD and these suggestions may increase the chance of providing a suitable foundation for people in need.

Addressing misuse and diversion of opioid substitution medication: guidance based on systematic evidence review and real-world experience.

BACKGROUND: Opioid dependence treatment, comprising opioid substitution treatment (OST) and psychosocial intervention, is accepted to improve outcomes in opioid addiction for both the individual and public health. OST medication such as methadone or buprenorphine may be misused or diverted. This results in failure to recover from addiction, increased crime and the spread of blood-borne viruses. Worldwide, attempts to address misuse and diversion have been proposed and implemented with varying impact. METHODS: A structured, expert-led process recommended the most impact. As an initial step, a broad range of strategies were defined, and a systematic review of published literature identified 37 highly relevant sources of evidence. Experts reviewed this evidence and ranked the list of strategies for effectiveness and ease of implementation, based on their clinical experience. RESULTS/CONCLUSIONS: Three groups of strategies to address misuse or diversion are defined, depending on impact (effectiveness and ease of implementation). Preferred strategies include the promotion of access to treatment and the use of product formulations less likely to be misused. However, additional data and innovative approaches to address this complex problem are needed.

The Impact of Misuse and Diversion of Opioid Substitution Treatment Medicines: Evidence Review and Expert Consensus.

BACKGROUND/AIMS: Opioid substitution treatment (OST) improves outcomes in opioid dependence. However, controlled drugs used in treatment may be misused or diverted, resulting in negative treatment outcomes. This review defines a framework to assess the impact of misuse and diversion. METHODS: A systematic review of published studies of misuse and diversion of OST medicines was completed; this evidence was paired with expert real-world experience to better understand the impact of misuse and diversion on the individual and on society. RESULTS: Direct impact to the individual includes failure to progress in recovery and negative effects on health (overdose, health risks associated with injecting behaviour). Diversion of OST has impacts on a community that is beyond the intended OST recipient. The direct impact includes risk to others (unsupervised use; unintended exposure of children to diverted medication) and drug-related criminal behavior. The indirect impact includes the economic costs of untreated opioid dependence, crime and loss of productivity. CONCLUSION: While treatment for opioid dependence is essential and must be supported, it is vital to reduce misuse and diversion while ensuring the best possible care. Understanding the impact of OST misuse and diversion is key to defining strategies to address these issues.

Prolonged-Release Buprenorphine Therapy in Opioid Use Disorder Can Address Stigma and Improve Patient Quality of Life.

Treatment for opioid use disorder (OUD) including opioid agonist therapy (OAT) is effective. Medication with the oral administration of methadone and buprenorphine has well-known limitations (establishing consistent optimal dosing levels, misuse, diversion, and accidental exposure). Treatment may require attendance at treatment services for collection and consumption of medication; this is associated with stigma and discrimination. Novel therapeutic options include approved, injectable, prolonged-release buprenorphine (PRB) products providing consistently optimal drug levels and less frequent dosing. This work assesses the lived experience of persons currently engaged in OUD therapy to define the potential value of novel therapeutic options in order to inform treatment decisions. One hundred and twenty-two people engaged with treatment services participated in this assessment. Seventy-two percent of participants believed that novel therapeutic options would improve quality of life and 67% stated it would reduce stigma and discrimination. Participants were neither concerned about the efficacy of (net score negative 30%), or lack of control over (net score negative 36%) treatment, nor about reduced contact with treatment services (net score negative 11%). Results from this assessment indicate that the provision of choice including novel therapeutic options is likely to improve quality of life and reduce the stigma of persons with OUD.

Patient-Reported Outcomes, Experiences and Satisfaction with Weekly and Monthly Injectable Prolonged-Release Buprenorphine.

INTRODUCTION: Prolonged-release buprenorphine (PRB), administered by weekly or monthly injection, for opioid dependence (OD) treatment offers the potential to address some limitations of oral therapy including stigma, difficulty in achieving consistent appropriate dosing, risk of diversion of medications, risk of overdose, and continuing use of other drugs. Patient-reported outcomes (PRO) and experiences are important in the evaluation of OD therapy success. This work aimed to document PRO during PRB therapy to guide future treatment decision-making. METHODS: Qualitative interviews were completed with people on PRB OD treatment. Twenty individuals from four treatment services in England and Wales were asked to participate. A structured interview was developed guided by a person with OD lived experience. Interviews were transcribed, coded and analyzed using iterative categorization. RESULTS: Fifteen of 20 individuals approached agreed to participate, and 14 completed interviews. The average age of participants was 42 (range 33-54) years, 13 males and 1 woman, the history of problematic opioid use was 14 years (3-25 years), time in treatment was 7 years (1-20 years), and duration on treatment with PRB was 4 months (range 1-8 months). Participants reported treatment experiences leading to coding of 277 unique comments: therapy effectiveness (77% indicated a benefit of, or satisfaction with, PRB therapy, 7% neutral/general, 16% indicated concern or questions about PRB therapy), convenience (81% benefit, 7% neutral/general, 12% concern), and overall satisfaction (81% benefit, 3% neutral/general, 16% concern). Reported benefits include cravings reduction of 10 (71%), self-care improvement of 10 (71%), relationships improvement of 9 (64%), resources management of 6 (43%), positive outlook on life of 12 (86%). Participants reported a range of positive personal experiences; challenges reported included temporary injection discomfort at treatment initiation. DISCUSSION: In this small, focused population, there was generally a positive level of treatment satisfaction with PRB. These experiences provide insights to explain potential treatment benefit to others and are useful in guiding therapy choices for others in the future.

COVID19 pandemic and people with opioid use disorder: innovation to reduce risk.

The Covid-19 pandemic is creating a vast and growing number of challenges for all. People with a history of opioid use disorder (OUD) also may be exposed to additional risks. Piedmont one of the areas most severely affected by the Covid-19 pandemic, with large numbers of people infected and related mortality. In the region, specialists responsible for OUD care identified the risk that the existing care system exposed patients to. Teams designed and implemented innovation approaches to enable continuation of care and reduce the inherent system risk to patients with OUD.

OUD Care Service Improvement with Prolonged-release Buprenorphine in Prisons: Cost Estimation Analysis.

BACKGROUND: In prisons in England, integrated treatment for opioid use disorder (OUD) is accessible and effective, commonly based on daily supervised consumption of methadone. Treatment limitations (inadequate dosing, nonengagement with care, stigma, diversion and bullying) are noted. Flexible dose, injectable prolonged-release buprenorphine (PRB) which removes the need for daily dispensing and supervision is suggested for prisoner care. This work aimed to predict the difference in costs of current standard of care vs partial introduction of PRB. METHODS: A predictive model of compared costs for the provision of OUD care in the prison setting in England evaluated current standard of care (all receive methadone) with a future situation of 30% of prisoners electing to use a monthly dose of PRB. Evidence describing costs to deliver OUD care for 150 prisoners (pharmacotherapy, direct service, indirect health care, indirect security costs) were collected, including assumptions describing how care would be delivered. Evidence sources include national data sources, scientific literature and from experience in the prison health care setting. RESULTS: For a representative standard prison population requiring OUD care of 150 prisoners in England PRB introduction is associated with a predicted reduction in direct and indirect costs of OUD care. Annual OUD care costs for current standard of care were £0.6M; with 30% PRB costs reduced by £8665, more than 3000 hours of staff time is saved. Sensitivity analyses showed greater adoption of PRB resulted in further cost reduction. CONCLUSION: PRB can address limitations of OUD care in prisons and improve outcomes. Introduction does not increase cost of care in this predictive analysis. PRB may lead the transformation of prisoner OUD care.

Standards for opioid use disorder care: An assessment of Nordic approaches.

AIMS: Outcomes in opioid use disorder (OUD) in Nordic countries have improved with integrated treatment and harm-reduction programmes. Approaches and the standard of care are different across the region. Evidence of treatment needs and current approaches are defined from evidence to inform development of a common standard. METHOD: Evidence of population sizes and treatment approach collected. Common standards for care (harm reduction, pharmacotherapy, psychology/social therapy) defined for each country. RESULTS: Evidence defines number in treatment; potential population needing treatment not defined for all countries. Populations sizes, treatment access (ratio in treatment programme compared to total country population) defined: Sweden 4,000 in OUD care (access ratio 40); Finland 3,000 (55); Norway 8,000 (154); Denmark 7,500 (132). Approach to treatment similar: integrated treatment programmes standard. Care provided by specialists in outpatient clinics/primary care; secondary care/inpatient services are available. Harm reduction is limited in Sweden but available and more accessible elsewhere. Treatment entry criteria: access relatively unlimited in Norway and Denmark, more limited in Finland and Sweden. Standards of care defined: easy access to high-quality services, individual planning, care not limited by time, management of relapse, education for patients, continuous engagement, holistic approach including management of comorbidities, needle equipment programmes without limit, treatment in prisons as community. CONCLUSION: There are opportunities to improve OUD care in the Nordics. Policy makers and clinicians can advance OUD care and share common success factors. Collaborative work across the Nordic countries is valuable. Further research in clinical practice development can yield important results for the benefit of patients with OUD.

Practical steps to improve chronic hepatitis C treatment in people with opioid use disorder.

OBJECTIVES: People with a history of injecting drugs have high prevalence of hepatitis C virus (HCV) infection, and many have opioid use disorder (OUD). Modern HCV therapies with improved efficacy and tolerability are available, but access is often limited for this group, who may be underserved for health care and face social inequity. This work develops practical steps to improve HCV care in this population. METHODS: Practical steps to improve HCV care in OUD populations were developed based on clinical experience from Spain, structured assessment of published evidence. RESULTS: Options for improving care at engagement/screening stages include patient education programs, strong provider-patient relationship, peer support, and adoption of rapid effective screening tools. To facilitate work up/treatment, start options include simplified work up process, integration of HCV and OUD care, and continuous psychosocial support prior, during, and after HCV treatment. CONCLUSION: It is important to plan on local basis to set up a joint integrated approach between specific drug treatment services and local points of HCV care. The elements for a specific integrated program should be chosen from options identified, including education services, peer input, organization to make HCV screening and treatment easier by co-location of services, and wider access to prescribing direct-acting antiviral (DAA) therapy.

Current and future options for opioid use disorder: a survey assessing real-world opinion of service users on novel therapies including depot formulations of buprenorphine.

PURPOSE: Integrated treatment for opioid use disorder (OUD) includes opioid agonist therapy (OAT) such as methadone and buprenorphine with well-evidenced benefits. Treatment with typical existing oral medications is associated with burdens and limits to successful outcomes (frequent dosing, attendance for collection/consumption, difficulty in achieving optimal dosing, misuse, diversion, accidental exposure, and stigma from the treatment process). Novel medications include injected depot formulations with less frequent administration, providing consistent drug levels after dosing. This survey assesses the opinion of those with OUD treatment services lived experience to inform future medication choices. PATIENTS AND METHODS: A survey of people with experience of OUD pharmacotherapy - the treatment system - was completed. Participants reviewed statements describing elements of OUD care using 7-point Likert scales to indicate their level of agreement or disagreement. Data were assessed using descriptive analysis. RESULTS: In total, 35 people (16 in treatment; 19 with previous history of treatment) completed the survey. Average drug-use duration, 20 years, commonly included injected opioids. The majority agreed treatment was effective, but not tailored to their individual needs and limited normal day-to-day activities. Opinions on novel depot medications included the following: agreement on its potential to make life easier, reduce stigma, free-up time for preferred activities. Participants did not report concerns over the effectiveness and safety of depot medications, nor about reduced contact with treatment services that could be associated with less frequent dosing. CONCLUSION: This survey provides a useful initial record of the opinions of people experienced in OUD treatment services on novel depot medications, which may result in important benefits. Care providers and policy makers should continue to work with those with lived experience to understand the specific opportunity provided by such innovation.

Principles for managing OUD related to chronic pain in the Nordic countries based on a structured assessment of current practice.

BACKGROUND: Long-term use of opioid analgesics (OA) for chronic pain may result in opioid use disorder (OUD). This is associated with adverse outcomes for individuals, families and society. Treatment needs of people with OUD related to chronic pain are different compared to dependence related to use, and also injection, of illicit opioids. In Nordic countries, day-to-day practical advice to assist clinical decision-making is insufficient. AIM: To develop principles based on expert clinical insights for treatment of OUD related to the long-term use of OA in the context of chronic pain. METHODS: Current status including an assessment of barriers to effective treatment in Finland, Denmark, Iceland, Norway, Sweden was defined using a patient pathway model. Evidence to describe best practice was identified from published literature, clinical guidelines and expert recommendations from practice experience. RESULTS: Availability of national treatment guidelines for OUD related to chronic pain is limited across the Nordics. Important barriers to effective care identified: patients unlikely to present for help, healthcare system set up limits success, diagnosis tools not used, referral pathways unclear and treatment choices not elucidated. Principles include the development of a specific treatment pathway, awareness/ education programs for teams in primary care, guidance on use of diagnostic tools and a flexible treatment plan to encourage best practice in referral, treatment assessment, choice and ongoing management via an integrated care pathway. Healthcare systems and registries in Nordic countries offer an opportunity to further research and identify population risks and solutions. CONCLUSIONS: There is an opportunity to improve outcomes for patients with OUD related to chronic pain by developing and introducing care pathways tailored to specific needs of the population.

Chronic hepatitis C and individuals with a history of injecting drugs in Spain: population assessment, challenges for successful treatment.

In Spain, there is a need to improve chronic hepatitis C care among people who inject drugs (PWID). Injecting drug use is an important risk behaviour for hepatitis C virus (HCV) infection. Review of 28 sources of the relevant published literature mapped the size of the addiction-HCV population in Spain. Experts in opioid use disorder (OUD) treatment in Spain completed a consensus to define the population size, HCV prevalence and access or barriers to hepatitis C treatment for PWID populations. In Spain, over 300 000 individuals have a lifetime history of injecting drugs. Currently, 150 000 individuals in Spain have OUD; many have injected drugs. Each year, 80 000 individuals engage with treatment services for OUD. A proportion of this group continues to inject drugs. There is a high HCV prevalence in PWID - estimates of 60-80% in Spain. Uptake of hepatitis C therapy in PWID in Spain is limited; barriers include awareness of treatment pathways, advocacy for regular screening and effective joint care. There is an urgent need to address barriers to effective hepatitis C care for PWID in Spain. Practical and specific strategies including peer-led solutions, patient buddy systems and joint working models at the local level can make important short-term differences.

Are we ready to treat hepatitis C virus in individuals with opioid use disorder: assessment of readiness in European countries on the basis of an expert-generated model.

Individuals with a history of injecting drugs have a high prevalence of chronic hepatitis C (HCV) infection. Many have a history of opioid use disorder (OUD). Despite novel treatments with improved efficacy and tolerability, treatment is limited in the group. A faculty of experts shared insights from clinical practice to develop an HCV care-readiness model. Evidence and expert knowledge was collected. Ten experts developed a model of three factors (with measures): 'healthcare engagement', 'guidance' and 'place'. Overall, 40-90% of individuals with OUD engage with drug treatment services. Ten of 12 HCV guidelines provided specific advice for the OUD population. Ten of 12 OUD care guidelines provided useful HCV care advice. In 11 of 12 cases, location of HCV/drug treatment care was in different places. This readiness assessment shows that there are important limitations to successful HCV care in OUD. Specific actions should be taken: maintain/increase access to OUD treatment services/opioid agonist therapy, updating HCV guidance, locate care in the same place and allow wider prescribing of anti HCV medicines.

Recommendations for buprenorphine and methadone therapy in opioid use disorder: a European consensus.

INTRODUCTION: Management of patients with opioid use disorder (OUD) commonly includes opioid agonist therapy (OAT) as a part of an integrated treatment plan. These interventions are associated with proven benefits to the individual and society. Areas covered: The use of methadone and buprenorphine within an integrated treatment plan in the management of patients with OUD: this work provides consensus recommendation on pharmacotherapy in OUD to assist clinicians with practical decision making in this field. Expert opinion: Pharmacotherapy is recommended as part of an integrated OUD treatment approach with psychosocial interventions, with the goal of reducing risks of illicit opioid use, overdose mortality, infection with HIV or HCV, improving health, psychological and social outcomes. Access to OAT should be prioritised in the treatment of OUD. Treatment choices in OUD pharmacotherapy should be based on the needs of the individual and characteristics of medications. Recommendations for choices of OAT are based on clinical efficacy, safety, patient preference, side effects, pharmacological interactions, quality of life, dose titration potential and outcomes (control craving, ongoing opioids consumption or other drugs, and potentially psychiatric comorbidities). Special groups, pregnant women, prisoners, patients with mental health problems have specific needs which must be addressed with expert input.

Buprenorphine dosing choices in specific populations: review of expert opinion.

INTRODUCTION: Treatment of opioid dependence with buprenorphine improves outcomes. Typical dosing ranges for all patients from clinical evidence and as defined in the product information are wide. For specific groups with complex clinical scenarios, there is no clear consensus on dosing choices to achieve best possible outcomes. AREAS COVERED: The doses of buprenorphine used in 6 European countries was reviewed. A review of published evidence supported rapid induction with buprenorphine and the benefits of higher doses but did not identify clearly useful guidance on dosing choices for groups with complex clinical scenarios. An expert group of physicians with experience in addiction care participated in a discussion meeting to share clinical practice experience and develop a consensus on dosing choices. EXPERT OPINION: There was general agreement that treatment outcomes can be improved by optimising buprenorphine doses in specific subgroups. Specific groups in whom buprenorphine doses may be too low and who could have better outcomes with optimised dosing were identified on the basis of clinical practice experience. These groups include people with severe addiction, high tolerance to opioids, and psychiatric comorbidities. In these groups it is recommended to review dosing choices to ensure buprenorphine dosing is sufficient.