Focus on fentanyl in females: Sex and gender differences in the physiological and behavioral effects of fentanyl.

The prevalence of opioid use disorder and overdose continues to harm the U.S. population and is further exacerbated by the use of the synthetic opioid, fentanyl, and its analogs. Gender differences in the effects of fentanyl are not well understood. The present article reviews evidence for gender and sex differences in the physiological and behavioral effects of fentanyl in humans and animals. Biological sex seems to be a foundational driver in addiction vulnerability and affects mechanisms related to opioid use including fentanyl. Fentanyl has distinct pharmacodynamics and enhanced efficacy relative to other opioids that highlights the need to investigate how females may be uniquely altered by its use. Behavioral and physiological responses to fentanyl are found to differ by sex and gender in many cases, including outputs like affective symptoms, analgesia, tolerance, and withdrawal emphasizing the need for further research about the role of biological sex on fentanyl use.

Contextualizing medications for opioid use disorder and peer support service provision in the probation system with implementation science.

BACKGROUND: Medications for opioid use disorder (MOUD) is an evidence-based approach that reduces opioid-related mortality, particularly among criminal legal-involved persons who are at increased risk of adverse outcomes related to OUD. Implementing evidence-based approaches in the context of probation settings requires an in-depth understanding of specific contexts to improve intervention efficacy and effectiveness. Here, we use the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to understand implementation contexts for MOUD provision in the probation setting. METHODS: In-depth individual interviews were conducted with key programmatic stakeholders (treatment providers and probation staff involved in service provision for people on probation). The study examined stakeholder perspectives regarding MOUD and Peer Support Service (PSS) implementation among people who are involved in community supervision. Deductive and inductive thematic analysis was conducted, and subsequently the codes, subcodes, and themes were mapped onto the EPIS framework to better understand implementation contexts. RESULTS: We deduced key inner, outer, and bridging contexts that shape treatment service provision for individuals with OUD who are on probation. Inner contexts include a strong organizational climate that supports MOUD implementation and enthusiasm for peer support services. Outer contexts include difficulty navigating insurance among providers, treatment costs, and systemic stigma towards MOUD. Bridging contexts include a lack of collaboration/communication between relevant agencies (e.g., probation and courts). CONCLUSIONS: Findings indicate the implementation is complex and requires a coordinated effort between correctional systems, probation agencies, and community-based treatment providers.

Cognitive behaviour therapy as an evidence-based intervention for opioid use disorder: A systematic review.

Objective: To explore the effectiveness of cognitive behaviour therapy as an evidence-based intervention for patients with opioid use disorder and to estimate the effect of cognitive behaviour therapy in mental health care settings. METHODS: The systematic review was conducted from January to April 2023, and comprised search on Web of Science, PsycINFO, Medline, Embase, Google Scholar, Science Direct, PubMed, ClinicalTrials and OvidSP databases for experimental studies and randomised controlled trials related to opioid use disorders published in peer-reviewed English-language journals between December 2022 and April 2023. The studies' quality was assessed using the Modified Cochrane Collaboration risk of the bias assessment criteria. RESULTS: Of the 314 studies initially identified, 42(13%) were subjected to full-text assessment, and 10(23.8%) were analysed. There were 5(50%) studies done in the United States, 2(20%) in Iran, and 1(10%) each in Germany, China and England. All 10(100%) studies were randomised controlled trials with intervention-based cognitive behaviour therapy, and reported significant results in patients diagnosed with opioid use disorders. Conclusion: All the studies analysed were heterogeneous. Cognitive behaviour therapy had a short-term impact and remained influential in the long term as well in handling cognitive and behaviour setbacks among patients with opioid use disorders.

Opioid Risk Mitigation Practices of Interprofessional Oncology Personnel: Results From a Cross-Sectional Survey.

BACKGROUND: This study explored the risk mitigation practices of multidisciplinary oncology health-care personnel for the nonmedical use of opioids in people with cancer. METHODS: An anonymous, cross-sectional descriptive survey was administered via email to eligible providers over 4 weeks at The Ohio State University's Arthur G. James Cancer Hospital. The survey asked about experiences and knowledge related to opioid use disorders. RESULTS: The final sample of 773 participants included 42 physicians, 213 advanced practice providers (APPs consisted of advanced practice nurses, physician assistants, and pharmacists), and 518 registered nurses. Approximately 40% of participants responded feeling "not confident" in addressing medication diversion. The most frequent risk reduction measure was "Checking the prescription drug monitoring program" when prescribing controlled medications, reported by physicians (n = 29, 78.4%) and APPs (n = 164, 88.6%). CONCLUSION: People with cancer are not exempt from the opioid epidemic and may be at risk for nonmedical opioid use (NMOU) and substance use disorders. Implementing risk reduction strategies with every patient, with a harm reduction versus abstinence focus, minimizes harmful consequences and improves. This study highlights risk mitigation approaches for NMOU, representing an opportunity to improve awareness among oncology health-care providers. Multidisciplinary oncology teams are ideally positioned to navigate patients through complex oncology and health-care journeys.

Long-Term Prospects for Telemedicine in Opioid Use Disorder (OUD) Treatment: Results from a Longitudinal Survey of OUD Clinicians.

BACKGROUND: During the pandemic, there was a dramatic shift to telemedicine for opioid use disorder (OUD) treatment. Little is known about how clinician attitudes about telemedicine use for OUD treatment are evolving or their preferences for future use. OBJECTIVE: To understand OUD clinician views of and preferences regarding telemedicine. DESIGN: Longitudinal survey (wave 1, December 2020; wave 2, March 2022). SUBJECTS: National sample of 425 clinicians who treat OUD. MAIN MEASURES: Self-reported proportion of OUD visits delivered via telemedicine (actual vs. preferred), comfort in using video visits for OUD, impact of telemedicine on work-related well-being. KEY RESULTS: The mean reported percentage of OUD visits delivered via telemedicine (vs. in person) dropped from 56.9% in December 2020 to 41.5% in March 2022; the mean preferred post-pandemic percentage of OUD visits delivered via telemedicine was 34.8%. Responses about comfort in using video visits for different types of OUD patients remained similar over time despite clinicians having substantially more experience with telemedicine by spring 2022 (e.g., 35.8% vs. 36.0% report being comfortable using video visits for new patients). Almost three-quarters (70.9%) reported that most of their patients preferred to have the majority of their visits via telemedicine, and 76.7% agreed that the option to do video visits helped their patients remain in treatment longer. The majority (58.7%) reported that telemedicine had a positive impact on their work-related well-being, with higher rates of a positive impact among those who completed training more recently (68.5% of those with < 10 years, 62.1% with 10-19 years, and 45.8% with 20 + years, p < 0.001). CONCLUSIONS: While many surveyed OUD clinicians were not comfortable using telemedicine for all types of patients, most wanted telemedicine to account for a substantial fraction of OUD visits, and most believed telemedicine has had positive impacts for themselves and their patients.

Integrated Care Models: HIV and Substance Use.

PURPOSE OF REVIEW: Behaviors and practices associated with substance use contribute to lack of HIV virologic suppression and onward transmission. In the USA, many recent HIV outbreaks have been connected with substance use. Evidence-based strategies for integrating care of those at risk for and living with HIV and who use substances continue to evolve. This review, based on scientific and medical literature through March 2023, provides an overview and evaluation of initiatives for integrated care aimed to serve patients at risk for and with HIV and a substance use disorder. RECENT FINDINGS: Integrated care services can improve health outcomes for patients at risk for and with HIV and a substance use disorder; for instance, treatment for an opioid use disorder can help improve HIV viral suppression. Brick-and-mortar facilities can provide successful care integration with appropriate clinic leadership to support multidisciplinary care teams, up-to-date provider training, and sufficient pharmacy stock for substance use treatment. Delivering healthcare services to communities (e.g., mobile healthcare clinics and pharmacies, telehealth) may prove to be an effective way to provide integrated services for those with or at risk of HIV and substance use disorders. Incorporating technology (e.g., mobile phone applications) may facilitate integrated care. Other venues, including harm reduction programs and carceral settings, should be targets for integrated services. Venues providing healthcare should invest in integrated care and support legislation that increases access to services related to HIV and substance use.

Suicidal thoughts and behaviors in patients with chronic pain, with and without co-occurring opioid use disorder.

BACKGROUND: Individuals with chronic pain and a co-occurring substance use disorder present higher risk of suicide, but the individual and joint impacts of chronic pain and substance use disorders on suicide risk are not well defined. The objective of this study was to exam the factors associated with suicidal thoughts and behaviors in a cohort of patients with chronic non-cancer pain (CNCP), with or without concomitant opioid use disorder (OUD). DESIGN: Cross sectional cohort design. SETTING: Primary care clinics, pain clinics, and substance abuse treatment facilities in Pennsylvania, Washington, and Utah. SUBJECTS: In total, 609 adults with CNCP treated with long-term opioid therapy (>/= 6 months) who either developed an OUD (cases, n = 175) or displayed no evidence of OUD (controls, n = 434). METHODS: The predicted outcome was elevated suicidal behavior in patients with CNCP as indicated by a Suicide Behavior Questionnaire-Revised (SBQ-R) score of 8 or above. The presence of CNCP and OUD were key predictors. Covariates included demographics, pain severity, psychiatric history, pain coping, social support, depression, pain catastrophizing and mental defeat. RESULTS: Participants with CNCP and co-occurring OUD had an increased odds ratio of 3.44 in reporting elevated suicide scores as compared to participants with chronic pain only. Multivariable modeling revealed that mental defeat, pain catastrophizing, depression, and having chronic pain, and co-occurring OUD significantly increased the odds of elevated suicide scores. CONCLUSIONS: Patients with CNCP and co-morbid OUD are associated with a 3-fold increase in risk of suicide.

Association of globalization with the burden of opioid use disorders 2019. A country-level analysis using targeted maximum likelihood estimation.

BACKGROUND: The "opioid crisis" has been responsible for hundreds of thousands deaths in the US, and is at risk of dissemination worldwide. Within-country studies have demonstrated that the rise of opioid use disorders (OUD) is linked to increased access to opioid prescriptions and to so-called "diseases of despair". Both have been related to the emergence of globalization policies since the 1980s. First, globalized countries have seen a reorganization of healthcare practices towards quick and easy answers to complex needs, including increased opioid prescriptions. Second, despair has gained those suffering from the mutations of socio-economic systems and working conditions that have accompanied globalization policies (e.g. delocalization, deindustrialization, and the decline of social services). Here, using data with high quality ratings from the Global Burden of Disease database, we evaluated the country-based association between four levels of globalization and the burden of OUD 2019. RESULTS: The sample included 87 countries. Taking into account potential country-level confounders, we found that countries with the highest level of globalization were associated with a 31% increase in the burden of OUD 2019 compared to those with the lowest level of globalization (mean log difference: 0.31; 95%CI, 0.04-0.57; p = 0.02). Additional analyses showed a significant effect for low back pain (mean log difference: 0.07; 95%CI, 0.02-0.12; p = 0.007). In contrast, despite sharing some of the risk factors of OUD, other mental and substance use disorders did not show any significant relationship with globalization. Finally, socio-cultural de jure globalization, which compiles indicators related to gender equality, human capital and civil rights, was specifically associated with the burden of OUD (mean log difference: 0.49; 95%CI: 0.23,0.75; p < 0.001). CONCLUSIONS: These findings suggest that OUD may have inherent underpinnings linked to globalization, and more particularly socio-cultural aspects of globalization. Key factors may be increased rights to access prescriptions, as well as increased feelings of despair related to the erosion of local cultures and widening educational gaps.

Social and structural determinants of recovery: The impact of race.

Relapse rates for substance use disorders (SUDs) after treatment are as high as 50%. Evidence suggests that social and structural determinants of recovery influence these outcomes. Important domains to consider include economic stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context are the major domains of social determinants of health. All these factors influence people's ability to reach their highest health potential. However, race and racial discrimination often compound the negative effects of these factors on substance use treatment outcomes. Moreover, research is urgently needed to examine the specific mechanisms through which these issues influence SUD and SUD outcomes.

Hospital adoption of harm reduction and risk education strategies to address substance use disorders.

Background: Hospitals are well-positioned to integrate harm reduction into their workflow. However, the extent to which hospitals across the United States are adopting these strategies remains unknown.Objectives: To assess what factors are associated with hospital adoption of harm reduction/risk education strategies, and trends of adoption across time.Methods: We constructed a dataset marking implementation of harm reduction/risk education strategies for a 20% random sample of nonprofit hospitals in the U.S (n = 489) using 2019-2021 community health needs assessments (CHNAs) and implementation strategies obtained from hospital websites. We used two-level mixed effects logistic regression to test the association between adoption of these activities and organizational and community-level variables. We also compared the proportion of hospitals that adopted these strategies in the 2019-2021 CHNAs to an earlier cohort (2015-2018.)Results: In the 2019-2021 CHNAs, 44.7% (n = 219) of hospitals implemented harm reduction/risk education programs, compared with 34.1% (n = 156) in the 2015-2018 cycle. In our multivariate model, hospitals that implemented harm reduction/risk education programs had higher odds of having adopted three or more additional substance use disorder (SUD) programs (OR: 10.5: 95% CI: 5.35-20.62), writing the CHNA with a community organization (OR: 2.14; 95% CI: 1.15-3.97), and prioritizing SUD as a top three need in the CHNA (OR: 2.63; 95% CI: 1.54-4.47.)Conclusions: Our results suggest that hospitals with an existing SUD infrastructure and with connections to community are more likely to implement harm reduction/risk education programs. Policymakers should consider these findings when developing strategies to encourage hospital implementation of harm reduction activities.

Evaluation of a Primary Care-Based Multidisciplinary Transition Clinic for Patients Newly Initiated on Buprenorphine in the Emergency Department.

BACKGROUND: Care transitions represent vulnerable events for patients newly initiating medications for opioid use disorder (MOUD). Multidisciplinary primary care-based transition clinics may improve care linkage and retention in MOUD treatment. Additionally, these interventions may help primary care clinicians (PCPs) overcome barriers to adopting MOUD into practice. In this evaluation, we assessed the impact of a primary care-based transition clinic for patients newly initiating buprenorphine for opioid use disorder (OUD) in the emergency department. METHODS: We conducted a retrospective program evaluation within a single academic health system involving adults who newly initiated buprenorphine for OUD through an emergency department-based program and were referred to follow up in either a dedicated multidisciplinary primary care-based transition clinic (SPARC) vs referral to usual primary care (UPC). We performed descriptive analyses comparing patient demographics, referral volume, linkage to care, treatment retention, and markers of high-quality care between the 2 groups. A log-rank test was used to determine the difference in probabilities of retention between SPARC and UPC over 6 months. RESULTS: Over 12 months, the number of referrals to SPARC was greater than to UPC (N = 64 vs N = 26). About 58% of patients referred to SPARC attended an initial visit vs 38% referred to UPC. Treatment retention was consistently greater in SPARC than UPC (1 m: 90% vs 60%; 3 m: 76% vs 40%; 6 m: 60% vs 30%). Markers of care quality including naloxone provision (100% vs 80%) and infectious screening (81% vs 40%) were greater in SPARC clinic. SPARC was associated with a statistically significant increased probability of retention in treatment as compared to UPC (P < .01). CONCLUSIONS: In this observational evaluation, a primary care-based multidisciplinary transition clinic for patients initiating buprenorphine MOUD was associated with expanded access to longitudinal OUD treatment and superior linkage to care, retention in care, and quality of care compared to referral to usual primary care. Further research using a more rigorous research design is required to further evaluate these findings.

Primary care provider confidence in addressing opioid use disorder: A concept analysis.

Primary care providers (PCPs) are well-positioned to provide care for opioid use disorder (OUD), yet very few address OUD regularly. One contributing factor may be PCPs' lack of confidence in their ability to effectively treat OUD. Evidence demonstrates that clinician confidence in home care and hospital settings is associated with improved care delivery and patient outcomes. However, a conceptual definition of PCP confidence in addressing OUD has yet to be established. The aim of this concept analysis is to enhance conceptual understanding of PCP confidence in addressing OUD and inform future measurement strategies. Following Walker and Avant's method of concept analysis, PubMed, PsycINFO, and Google Scholar were searched in October 2021. Manuscripts were included if they referenced confidence in relation to PCPs who provide care to adult patients with OUD. Studies conducted outside the US and not published in English were excluded. The search resulted in 18 studies which were synthesized to conceptualize PCP confidence in addressing OUD. Defining attributes include self-efficacy, experience, and readiness to address OUD. These attributes may be influenced by organizational culture, training, support, and resources. Consequences of PCP confidence addressing OUD may include improved patient outcomes, improved delivery of and access to OUD care, and PCP attitude changes. This concept analysis-which grounds the concept of PCP confidence in addressing OUD in the theoretical and empirical literature-lays the framework for future measurement of the concept. This represents a critical first step towards developing strategies to enhance PCP confidence in addressing OUD.

High Satisfaction with Patient-Centered Telemedicine for Hepatitis C Virus Delivered to Substance Users: A Mixed-Methods Study.

Background: While telemedicine may increase health care access for vulnerable populations, data are limited on whether people with opioid use disorder (PWOUD) are satisfied with telemedicine. We assessed PWOUD satisfaction with telemedicine and identified factors that increase telemedicine satisfaction. Methods: We conducted a mixed-methods study among hepatitis C virus (HCV)-infected persons enrolled at 12 opioid treatment programs (OTPs) throughout New York State. Participants successfully completed HCV treatment either through telemedicine integrated into OTPs (N = 238) or through offsite referral (N = 106). We evaluated Patient Satisfaction Questionnaire (PSQ) response scores at the initial and final health care encounters and subsequently interviewed telemedicine study participants (N = 25) to assess their experiences with telemedicine. Results: All participants (N = 344) successfully completed HCV treatment. We observed no differences in PSQ scores between telemedicine and in-person encounters (98.3% and 98.7% of telemedicine participants provided PSQ scores of satisfied or highly satisfied at each timepoint, respectively). Study participants indicated that attributes associated with high telemedicine encounter satisfaction included: (1) communicating study information, (2) gaining trust, and (3) delivering patient-centered care. Participants weighted "General Satisfaction" and "Time Spent with Doctor" higher than "Accessibility and Convenience," and female participants were significantly more satisfied than males. Satisfaction with health care delivery among all participants increased significantly comparing timepoints. Conclusions: Participants were highly satisfied with HCV telemedicine encounters equivalent to in-person encounters. Communication augments trust facilitating delivery of patient-centered care through telemedicine. Participants value empathy and trust with providers over accessibility and convenience. In summary, PWOUD are highly satisfied with the facilitated telemedicine model and value empathetic and trusting providers. ClinicalTrials.gov Identifier: NCT02933970.

Perspectives Regarding Medications for Opioid Use Disorder Among Individuals with Mental Illness.

Most people with co-occurring opioid use disorder (OUD) and mental illness do not receive effective medications for treating OUD. To investigate perspectives of adults in a publicly-funded mental health system regarding medications for OUD (MOUD), we conducted semi-structured telephone interviews with 13 adults with OUD (current or previous diagnosis) receiving mental health treatment. Themes that emerged included: perceiving or using MOUDs as a substitute for opioids or a temporary solution to prevent withdrawal symptoms; negative perceptions about methadone/methadone clinics; and viewing MOUD use as "cheating". Readiness to quit was important for patients to consider MOUDs. All participants were receptive to discussing MOUDs with their mental health providers and welcomed the convenience of receiving care for their mental health and OUD at the same location. In conclusion, clients at publicly-funded mental health clinics support MOUD treatment, signaling a need to expand access and build awareness of MOUDs in these settings.

Influences on advance practice nursing education to prescribe medications for opioid use disorder.

BACKGROUND: Opioid misuse is a major public health concern in the United States. Opioid agonist medications are evidence-based treatments for opioid use disorders (OUD) that can be prescribed by advance practice registered nurses (APRNs) with prescriptive authority and appropriate training. PURPOSE: Article examines factors influencing preparation to provide medications for opioid use disorder (MOUD) in APRN education. METHODS: Data from semi-structured interviews addressing the role of education in preparing APRNs to provide MOUD were grouped into key themes using thematic analysis. Data were collected in a mixed methods study in four states with high opioid overdose deaths whose main findings were previously published. FINDINGS: Two overarching themes emerged: "addressing attitudes" and "curriculum change." Sub-themes include affective barriers to providing OUD treatment; motivation to respond to the OUD crisis; and attitude change through experience with MOUD. DISCUSSION AND CONCLUSION: APRNs can play a key role in reducing the harms caused by OUD. Attention to attitudinal issues, such as stigma, toward people using opioids is important in educating APRNs about providing MOUD.

National Prevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018.

BACKGROUND: Acute healthcare utilization attributed to alcohol use disorders (AUD) and other substance use disorders (SUD) is rising. OBJECTIVE: To describe the prevalence and characteristics of emergency department (ED) visits and hospitalizations made by adults with AUD or SUD. DESIGN, SETTING, AND PARTICIPANTS: Observational study with retrospective analysis of the National Hospital Ambulatory Medical Care Survey (2014 to 2018), a nationally representative survey of acute care visits with information on the presence of AUD or SUD abstracted from the medical chart. MAIN MEASURES: Outcome measured as the presence of AUD or SUD. KEY RESULTS: From 2014 to 2018, the annual average prevalence of AUD or SUD was 9.4% of ED visits (9.3 million visits) and 11.9% hospitalizations (1.4 million hospitalizations). Both estimates increased over time (30% and 57% relative increase for ED visits and hospitalizations, respectively, from 2014 to 2018). ED visits and hospitalizations from individuals with AUD or SUD, compared to individuals with neither AUD nor SUD, had higher percentages of Medicaid insurance (ED visits: AUD: 33.1%, SUD: 35.0%, neither: 24.4%; hospitalizations: AUD: 30.7%, SUD: 36.3%, neither: 14.8%); homelessness (ED visits: AUD: 6.2%, SUD 4.4%, neither 0.4%; hospitalizations: AUD: 5.9%, SUD 7.3%, neither: 0.4%); coexisting depression (ED visits: AUD: 26.3%, SUD 24.7%, neither 10.5%; hospitalizations: AUD: 33.5%, SUD 35.3%, neither: 13.9%); and injury/trauma (ED visits: AUD: 51.3%, SUD 36.3%, neither: 26.4%; hospitalizations: AUD: 31.8%, SUD: 23.8%, neither: 15.0%). CONCLUSIONS: In this nationally representative study, 1 in 11 ED visits and 1 in 9 hospitalizations were made by adults with AUD or SUD, and both increased over time. These estimates are higher or similar than previous national estimates using claims data. This highlights the importance of identifying opportunities to address AUD and SUD in acute care settings in tandem with other medical concerns, particularly among visits presenting with injury, trauma, or coexisting depression.

Collaborative health systems ECHO: The use of a tele-education platform to facilitate communication and collaboration with recipients of state targeted response funds in Pennsylvania.

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Perceptions and experiences of patients attending an opioid substitution clinic in South Africa.

Background: Opioid substitution therapy (OST) is endorsed as the recommended treatment for opioid use disorders. Opioid substitution therapy is not widely used in South Africa, so little is known about its perceived clinical utility in this setting. There is also a paucity of qualitative research that explores the subjective experiences of patients using OST. Aim: To explore patients' perceptions and experiences attending a South African OST outpatient clinic (OST-OC). Setting: The OST-OC at Stikland Psychiatric Hospital, Cape Town, South Africa. Methods: We conducted a qualitative study using semi-structured interviews with eight participants who had been attending the OST-OC for at least 6 months. Transcripts were analysed using Atlas.ti software and thematic content analysis was used to identify themes. Results: Patients stated that OST helped them to regain and maintain a stable lifestyle. Autonomy and agency, the therapeutic relationship and family support were perceived as contributing to successful patient outcomes. The preference for methadone and buprenorphine treatment depended on individual experiences. Patients valued kindness from staff members but reported that improved interactions with some nonclinical staff could better facilitate treatment. Challenges experienced included stigma and cost. Conclusions: This study offers insights about OST that are pertinent to low- and middle-income countries. Reducing the cost of OST, collaborative decision-making between staff and patients, and a non-judgemental attitude by clinical staff were recognised as important factors for optimised service delivery. Contribution: Understanding patients' experiences of OST in a South African setting will allow for future policy development for the treatment of opioid use disorders in similar settings locally and abroad.

Neuronal apoptosis induced by morphine withdrawal is mediated by the p75 neurotrophin receptor.

Morphine withdrawal evokes neuronal apoptosis through mechanisms that are still under investigation. We have previously shown that morphine withdrawal increases the levels of pro-brain-derived neurotrophic factor (BDNF), a proneurotrophin that promotes neuronal apoptosis through the binding and activation of the pan-neurotrophin receptor p75 (p75NTR). In this work, we sought to examine whether morphine withdrawal increases p75NTR-driven signaling events. We employed a repeated morphine treatment-withdrawal paradigm in order to investigate biochemical and histological indicators of p75NTR-mediated neuronal apoptosis in mice. We found that repeated cycles of spontaneous morphine withdrawal promote an accumulation of p75NTR in hippocampal synapses. At the same time, TrkB, the receptor that is crucial for BDNF-mediated synaptic plasticity in the hippocampus, was decreased, suggesting that withdrawal alters the neurotrophin receptor environment to favor synaptic remodeling and apoptosis. Indeed, we observed evidence of neuronal apoptosis in the hippocampus, including activation of c-Jun N-terminal kinase (JNK) and increased active caspase-3. These effects were not seen in saline or morphine-treated mice which had not undergone withdrawal. To determine whether p75NTR was necessary in promoting these outcomes, we repeated these experiments in p75NTR heterozygous mice. The lack of one p75NTR allele was sufficient to prevent the increases in phosphorylated JNK and active caspase-3. Our results suggest that p75NTR participates in the neurotoxic and proinflammatory state evoked by morphine withdrawal. Because p75NTR activation negatively influences synaptic repair and promotes cell death, preventing opioid withdrawal is crucial for reducing neurotoxic mechanisms accompanying opioid use disorders.

Prevalence and Medication Treatment of Opioid Use Disorder Among Primary Care Patients with Hepatitis C and HIV.

BACKGROUND: Hepatitis C and HIV are associated with opioid use disorders (OUD) and injection drug use. Medications for OUD can prevent the spread of HCV and HIV. OBJECTIVE: To describe the prevalence of documented OUD, as well as receipt of office-based medication treatment, among primary care patients with HCV or HIV. DESIGN: Retrospective observational cohort study using electronic health record and insurance data. PARTICIPANTS: Adults ≥ 18 years with ≥ 2 visits to primary care during the study (2014-2016) at 6 healthcare systems across five states (CO, CA, OR, WA, and MN). MAIN MEASURES: The primary outcome was the diagnosis of OUD; the secondary outcome was OUD treatment with buprenorphine or oral/injectable naltrexone. Prevalence of OUD and OUD treatment was calculated across four groups: HCV only; HIV only; HCV and HIV; and neither HCV nor HIV. In addition, adjusted odds ratios (AOR) of OUD treatment associated with HCV and HIV (separately) were estimated, adjusting for age, gender, race/ethnicity, and site. KEY RESULTS: The sample included 1,368,604 persons, of whom 10,042 had HCV, 5821 HIV, and 422 both. The prevalence of diagnosed OUD varied across groups: 11.9% (95% CI: 11.3%, 12.5%) for those with HCV; 1.6% (1.3%, 2.0%) for those with HIV; 8.8% (6.2%, 11.9%) for those with both; and 0.92% (0.91%, 0.94%) among those with neither. Among those with diagnosed OUD, the prevalence of OUD medication treatment was 20.9%, 16.0%, 10.8%, and 22.3%, for those with HCV, HIV, both, and neither, respectively. HCV was not associated with OUD treatment (AOR = 1.03; 0.88, 1.21), whereas patients with HIV had a lower probability of OUD treatment (AOR = 0.43; 0.26, 0.72). CONCLUSIONS: Among patients receiving primary care, those diagnosed with HCV and HIV were more likely to have documented OUD than those without. Patients with HIV were less likely to have documented medication treatment for OUD.