Integrated Hepatitis C-Opioid Use Disorder Care Through Facilitated Telemedicine: A Randomized Trial.

Importance: Facilitated telemedicine may promote hepatitis C virus elimination by mitigating geographic and temporal barriers. Objective: To compare sustained virologic responses for hepatitis C virus among persons with opioid use disorder treated through facilitated telemedicine integrated into opioid treatment programs compared with off-site hepatitis specialist referral. Design, Setting, and Participants: Prospective, cluster randomized clinical trial using a stepped wedge design. Twelve programs throughout New York State included hepatitis C-infected participants (n = 602) enrolled between March 1, 2017, and February 29, 2020. Data were analyzed from December 1, 2022, through September 1, 2023. Intervention: Hepatitis C treatment with direct-acting antivirals through comanagement with a hepatitis specialist either through facilitated telemedicine integrated into opioid treatment programs (n = 290) or standard-of-care off-site referral (n = 312). Main Outcomes and Measures: The primary outcome was hepatitis C virus cure. Twelve programs began with off-site referral, and every 9 months, 4 randomly selected sites transitioned to facilitated telemedicine during 3 steps without participant crossover. Participants completed 2-year follow-up for reinfection assessment. Inclusion criteria required 6-month enrollment in opioid treatment and insurance coverage of hepatitis C medications. Generalized linear mixed-effects models were used to test for the intervention effect, adjusted for time, clustering, and effect modification in individual-based intention-to-treat analysis. Results: Among 602 participants, 369 were male (61.3%); 296 (49.2%) were American Indian or Alaska Native, Asian, Black or African American, multiracial, or other (ie, no race category was selected, with race data collected according to the 5 standard National Institutes of Health categories); and 306 (50.8%) were White. The mean (SD) age of the enrolled participants in the telemedicine group was 47.1 (13.1) years; that of the referral group was 48.9 (12.8) years. In telemedicine, 268 of 290 participants (92.4%) initiated treatment compared with 126 of 312 participants (40.4%) in referral. Intention-to-treat cure percentages were 90.3% (262 of 290) in telemedicine and 39.4% (123 of 312) in referral, with an estimated logarithmic odds ratio of the study group effect of 2.9 (95% CI, 2.0-3.5; P < .001) with no effect modification. Observed cure percentages were 246 of 290 participants (84.8%) in telemedicine vs 106 of 312 participants (34.0%) in referral. Subgroup effects were not significant, including fibrosis stage, urban or rural participant residence location, or mental health (anxiety or depression) comorbid conditions. Illicit drug use decreased significantly (referral: 95% CI, 1.2-4.8; P = .001; telemedicine: 95% CI, 0.3-1.0; P < .001) among cured participants. Minimal reinfections (n = 13) occurred, with hepatitis C virus reinfection incidence of 2.5 per 100 person-years. Participants in both groups rated health care delivery satisfaction as high or very high. Conclusions and Relevance: Opioid treatment program-integrated facilitated telemedicine resulted in significantly higher hepatitis C virus cure rates compared with off-site referral, with high participant satisfaction. Illicit drug use declined significantly among cured participants with minimal reinfections. Trial Registration: ClinicalTrials.gov Identifier: NCT02933970.

Association of random and observed urine drug screening with long-term retention in opioid treatment programs.

BACKGROUND: In the US, opioid treatment providers (OTPs) have wide latitude to perform urine drug screening (UDS) and discharge clients for positive results. OTP clients have identified randomized and directly observed UDS as potentially stigmatizing, but little research has examined the association between UDS modality and retention in OTPs. METHODS: This cross-sectional study uses the 2016-2017 NDATSS wave among OTPs that administered methadone. The exposure was a 4-level variable based on whether OTPs had a high percentage (≥ 90% of clients) who experienced randomized, observed, both, or neither modality of UDS. The outcome was the proportion of clients retained in treatment 1 year or longer (long-term retention). Analyses were conducted using fractional logit regression with survey weighting and presented as percentages and 95% confidence intervals. We also present how policies for involuntary clinic discharge modify these effects. RESULTS: 150 OTPs were eligible with a median of 310 clients. 40 (27%) OTPs did not highly utilize either randomized or observed UDS, 22 (15%) only highly utilized observed UDS, 42 (28%) only highly utilized randomized UDS and 46 (31%) utilized both practices on ≥ 90% of clients. Adjusted estimates for long-term retention ranged from 57.7% in OTPs that conducted both randomized and observed UDS on ≥ 90% of clients and 70.4% in OTPs that did not highly utilize these practices. Involuntary discharge may moderate this relationship. CONCLUSION: Findings showed an association between high utilization of randomized and observed UDS and decreased long-term retention, suggesting that UDS modality may impact long-term OTP retention.

Patient Perceptions of Integrating Meditation-based Interventions in Office-based Opioid Treatment with Buprenorphine: A Mixed-methods Survey.

INTRODUCTION: Recent findings support the provision of meditation-based interventions (MBIs) in primary care. However, the acceptability of MBI among patients prescribed medications for opioid use disorder (eg, buprenorphine) in primary care remains unclear. This study assessed experiences and preferences for adopting MBI among patients prescribed buprenorphine in office-based opioid treatment (OBOT). METHODS: This 23-item, semistructured cross-sectional survey was administered by study staff to patients enrolled in OBOT (N = 72) and consisted of demographic and clinical characteristics, perceptions, experiences with MBI, and preferred strategies to access MBI to support their treatment on buprenorphine. RESULTS: Most participants reported practicing at least 1 category of MBI (90.3%) on at least a daily (39.6%) or weekly (41.7%) basis including (1) spiritual meditation (eg, centering prayer; 67.7%); (2) nonmantra meditation (eg, comfortable posture; 61.3%); (3) mindfulness meditation (eg, mindfulness-based stress reduction; 54.8%); and (4) mantra meditation (eg, transcendental meditation; 29.0%). Interest in MBI was motivated by improving one's general health and well-being (73.4%), treatment outcomes with medications for OUD (eg, buprenorphine; 60.9%), and relationships with others (60.9%). Perceived clinical benefits of MBI included reduced anxiety or depression symptoms (70.3%), pain (62.5%), illicit substance or alcohol use (60.9%), cravings for illicit substances (57.8%), and opioid-related withdrawal symptoms (51.6%). CONCLUSIONS: Findings from this study indicate high acceptability for adopting MBI among patients prescribed buprenorphine in OBOT. Further research is needed to assess the efficacy of MBI to improve clinical outcomes among patients initiating buprenorphine in OBOT.

Nonopioid Substance Use among Patients Who Recently Initiated Office-based Buprenorphine Treatment.

OBJECTIVES: Medications for opioid use disorder (MOUDs) like buprenorphine are a first-line treatment for individuals who have opioid use disorder (OUD); however, these medications are not designed to impact the use of other classes of drugs. This descriptive study provides up-to-date information about nonopioid substance use among patients who recently initiated office-based buprenorphine treatment for OUD using data from 2 ongoing clinical trials. METHODS: The study sample was composed of 257 patients from 6 federally qualified health centers in the mid-Atlantic region who recently (i.e., within the past 28 days) initiated office-based buprenorphine treatment between July 2020 and May 2022. After the screening and informed consent processes, participants completed a urine drug screen and psychosocial interview as a part of the study baseline assessment. Descriptive analyses were performed on urine drug screen results to identify the prevalence and types of substances detected. RESULTS: More than half of participants provided urine specimens that were positive for nonopioid substances, with marijuana (37%, n = 95), cocaine (22%, n = 56), and benzodiazepines (11%, n = 28) detected with the highest frequencies. CONCLUSIONS: A significant number of participants used nonopioid substances after initiating buprenorphine treatment, suggesting that some patients receiving MOUDs could potentially benefit from adjunctive psychosocial treatment and supports to address their nonopioid substance use.

Medication Assisted Treatment Program Policies: Opinions of People in Treatment.

INTRODUCTION: Medication assisted treatment (MAT) for opioid use disorder (OUD) saves lives and enhances quality of life for people in recovery. However, only a small percentage of people eligible for MAT in the United States receive treatment, and among those who do seek treatment, retention is a challenge. This study aims to understand factors that help individuals enter and stay in MAT from the perspective of those in recovery. The patient perspective is vital in efforts to improve care delivery and best support individuals in treatment. METHODS: Survey development was driven by a review of current peer-reviewed literature plus information gained through 3 semi-structured interviews and follow-up discussions with 5 individuals who have lived experience in MAT, termed Participant Advisors. Survey questions focused in part on MAT participants' opinions relating to program policies such as drug testing, relapse protocols, duration of treatment, participant use of anti-anxiety medications and marijuana, and requirements for attendance in peer recovery groups such as Narcotics Anonymous and Alcoholics Anonymous. Responses were collected from West Virginia-based MAT programs from February through August 2021, with 1700 surveys distributed to 21 MAT programs. RESULTS: At the close of data collection, 225 survey responses, including over 500 free-text comments, were received (13.2% response rate). Most (n = 207, 95%) were currently in a MAT program and most (n = 187, 88.6%) reported using buprenorphine/naloxone for MAT, though participants reported having used other medications for treatment of OUD as well. Questions about how long a person should have MAT prescribed, how long they should be able to stay in treatment, whether they can use marijuana or anti-anxiety drugs while in treatment, and whether they should use a 12-step program generated mixed opinions. Findings strongly support consideration of individual situations and shared decision-making with providers.

Co-Constructing a Community-Based Telemedicine Program for People With Opioid Use Disorder During the COVID-19 Pandemic: Lessons Learned and Implications for Future Service Delivery.

The COVID-19 pandemic triggered unprecedented expansion of telemedicine, including in the delivery of opioid agonist treatment (OAT) for people with opioid use disorder (OUD). However, many people with OUD lack the technological resources necessary for remote care, have complex needs, and are underserved, with precarious access to mainstream services. To address the needs of these individuals, we devised a unique program to deliver OAT via telemedicine with the support of community outreach workers in Montreal (Quebec, Canada). The program was co-constructed by the service de médecine des toxicomanies of the Centre hospitalier de l'Université de Montréal (CHUM-SMT)-a hospital-based addiction medicine service-and CACTUS Montréal-a community-based harm reduction organization known and trusted by its clientele. All procedures were jointly developed to enable flexible and rapid appointment scheduling. CACTUS Montréal workers promoted the program, facilitated private on-site telemedicine connections to the CHUM-SMT, accompanied patients during web-based appointments if requested, and provided ongoing holistic support and follow-up. The CHUM-SMT offered individualized OAT regimens and other health services as needed. Overall, our experience as clinicians and community-based workers intimately involved in establishing and running this initiative suggests that participants found it to be convenient, nonjudgmental, and responsive to their needs, and that the implication of CACTUS Montréal was highly valued and integral to patient engagement and retention. Beyond the context of the COVID-19 pandemic, similar programs may present a flexible and accessible means to deliver alternative treatment options for people with OUD disengaged from traditional care, bridge gaps between communities and health providers, and improve access to care in rural or remote settings.

Blended smartphone intervention for patients in opioid maintenance treatment in Iran: protocol for a randomized controlled trial.

BACKGROUND: The pattern of substance use in Iran is characterized by a high prevalence of opioid use and opioid use disorder (OUD). Although opioid maintenance therapy (OMT) has been introduced in Iran, approximately 50% of people with opioid use disorder remain unreached. Moreover, psychosocial treatment of OUD and common mental health symptoms during OMT is limited. Digital interventions have been shown to improve psychological distress, depression, anxiety, and post-traumatic stress disorder symptoms. In addition, providing psychoeducation and risk reduction counseling to prevent communicable diseases like HIV and infectious hepatitis is common via the Internet. However, despite these promising advances, no smartphone intervention in OMT has been investigated for the treatment of OUD and common comorbid mental health symptoms. OBJECTIVE: We examine the effectiveness of adding a blended smartphone intervention based on community reinforcement approach, motivational interviewing- and cognitive behavioral therapy compared to OMT as usual that aims to improve OMT outcomes and addresses common mental health symptoms in OMT patients in Iran. METHOD: Adults with opioid dependence entering 8 treatment centers in Tehran, Iran will be randomly assigned to receive either OMT plus a smartphone intervention or OMT as usual. The primary outcomes will be the percentage of negative urine tests for illicit, non-prescribed use of opioids (opium, heroin, tramadol) and treatment retention. Secondary outcomes will include the longest period of abstinence from the illicit, non-prescribed use of opioids (opium, heroin, and tramadol) confirmed by urine samples, changes in communicable disease risk-taking behaviors, changes in stress and common mental health symptoms, and client satisfaction. Data analysis will follow the intention-to-treat principle and employ (generalized) linear mixed models. DISCUSSION: This study will provide substantial knowledge for designing effective blended interventions for OUD. Moreover, it will investigate if treatment retention and OMT-related outcomes and common mental health symptoms can be improved by adding a smartphone intervention to OMT. TRIAL REGISTRATION: https://en.irct.ir/trial/53578 .

Scaling and Sustaining Facilitated Telemedicine to Expand Treatment Access Among Underserved Populations: A Qualitative Study.

Background: Opioid treatment programs are an essential component of the management of opioid use disorder (OUD). They have also been proposed as "medical homes" to expand health care access for underserved populations. We utilized telemedicine as a method to increase access for hepatitis C virus (HCV) care among people with OUD. Methods: We interviewed 30 staff and 15 administrators regarding the integration of facilitated telemedicine for HCV into opioid treatment programs. Participants provided feedback and insight for sustaining and scaling facilitated telemedicine for people with OUD. We utilized hermeneutic phenomenology to develop themes related to telemedicine sustainability in opioid treatment programs. Results: Three themes emerged on sustaining the facilitated telemedicine model: (1) Telemedicine as a Technical Innovation in Opioid Treatment Programs, (2) Technology Transcending Space and Time, and (3) COVID-19 Disrupting the Status Quo. Participants identified skilled staff, ongoing training, technology infrastructure and support, and an effective marketing campaign as key to maintaining the facilitated telemedicine model. Participants highlighted the study-supported case manager's role in managing the technology to transcend temporal and geographical challenges for HCV treatment access for people with OUD. COVID-19 fueled changes in health care delivery, including facilitated telemedicine, to expand the opioid treatment program's mission as a medical home for people with OUD. Conclusions: Opioid treatment programs can sustain facilitated telemedicine to increase health care access for underserved populations. COVID-19-induced disruptions promoted innovation and policy changes recognizing telemedicine's role in expanding health care access to underserved populations. ClinicalTrials.gov Identifier: NCT02933970.

Differential effect of cannabis use on opioid agonist treatment outcomes: Exploratory analyses from the OPTIMA study.

INTRODUCTION: Conflictual evidence exists regarding the effects of cannabis use on the outcomes of opioid agonist therapy (OAT). In this exploratory analysis, we examined the effect of recent cannabis use on opioid use, craving, and withdrawal symptoms, in individuals participating in a trial comparing flexible buprenorphine/naloxone (BUP/NX) take-home dosing model to witnessed ingestion of methadone. METHODS: We analyzed data from a multi-centric, pragmatic, 24-week, open label, randomized controlled trial in individuals with prescription-type opioid use disorder (n = 272), randomly assigned to BUP/NX (n = 138) or methadone (n = 134). The study measured last week cannabis and opioid use via timeline-follow back, recorded at baseline and every two weeks during the study. Craving symptoms were measured using the Brief Substance Craving Scale at baseline, and weeks 2, 6, 10, 14, 18 and 22. The study measured opioid withdrawal symptoms via Clinical Opiate Withdrawal Scale at treatment initiation and weeks 2, 4, and 6. RESULTS: The mean maximum dose taken during the study was 17.3 mg/day (range = 0.5-32 mg/day) for BUP/NX group and 67.7 mg/day (range = 10-170 mg/day) in the methadone group. Repeated measures generalized linear mixed models demonstrated that cannabis use in the last week (mean of 2.3 days) was not significantly associated with last week opioid use (aß ± standard error (SE) = -0.06 ± 0.04; p = 0.15), craving (aß ± SE = -0.05 ± 0.08, p = 0.49), or withdrawal symptoms (aß ± SE = 0.09 ± 0.1, p = 0.36). Bayes factor (BF) for each of the tested models supported the null hypothesis (BF < 0.3). CONCLUSIONS: The current study did not demonstrate a statistically significant effect of cannabis use on outcomes of interest in the context of a pragmatic randomized-controlled trial. These findings replicated previous results reporting no effect of cannabis use on opioid-related outcomes.

Use of a sequential multiple assignment randomized trial to test contingency management and an integrated behavioral economic and mindfulness intervention for buprenorphine-naloxone medication adherence for opioid use disorder.

BACKGROUND: Buprenorphine-naloxone is a medication shown to improve outcomes for individuals seeking treatment for opioid use disorder (OUD); however, outcomes are limited by low medication adherence rates. This is especially true during the early stages of treatment. METHODS: The present study proposes to utilize a sequential multiple assignment randomized trial design to compare two psychological interventions targeting buprenorphine-naloxone adherence: (1) contingency management (CM) and (2) brief motivational interviewing plus substance-free activities session plus mindfulness (BSM). Participants will be N = 280 adults who present to a university-based addictions clinic seeking treatment for OUD. Participants will be randomized to condition to receive 4 sessions of their assigned intervention (CM or BSM). Participants who are adherent, defined as attending physician appointments and having buprenorphine present in urine toxicology, will enter maintenance intervention for an additional 6 months. Those who are not adherent will be re-randomized to receive either the other intervention or both interventions. Follow-up will occur at 8 months post-randomization. CONCLUSIONS: This novel design will examine the benefit of sequential treatment decisions following non-adherence. The primary outcome of this study is buprenorphine-naloxone medication adherence, as assessed by physician visit attendance and presence of buprenorphine in urine. Results will elicit the relative efficacy of CM and BSM compared to one another and whether keeping the initial treatment approach when adding the alternative approach for initially non-adherent individuals is beneficial. TRIAL REGISTRATION: ClinicalTrials.gov NCT04080180.

Investigating the effect of zinc supplementation on probability of relapse and mental health in patients with opioid use disorder undergoing methadone maintenance treatment.

BACKGROUND: Considering different factors, such as high withdrawal rates in methadone maintenance treatment (MMT) programs alongside mental health (MH) problems appearing in patients with opioid use disorder and the lack of prior research on the effect of zinc supplementation in this respect, the present study aimed to investigate the effect of zinc supplementation on the probability of relapse (PoR) and MH problems in patients with opioid use disorder undergoing MMT. METHODS: For this purpose, a randomized controlled trial with a clinical basis was fulfilled on a total of 68 patients with opioid use disorder receiving MMT, allocated to two groups, viz. intervention, and control (each one consisting of 34 individuals). Then, the participants in the intervention group were given zinc supplements combined with methadone for three months, and the controls only took methadone, according to the treatment plan. The data were collected using the Relapse Prediction Scale (RPS) and the Depression, Anxiety, and Stress Scale 21 (DASS-21) before, one month after, and at the end of the intervention program. FINDINGS: Compared to the control group, the likelihood of drug use (p = 0.01), drug craving (p = 0.002), and the RPS total score (p = 0.002) in the intervention group was significantly lower. Moreover, the results revealed a significant decreasing trend in depression (p = 0.01), anxiety (p < 0.001), stress (p = 0.001), and the DASS-21 total score (p = 0.001) in the intervention. Compared to the control group, the DASS-21 total score (p < 0.001) in the intervention group was significantly lower. CONCLUSION: Accordingly, it was concluded that zinc supplementation could reduce the PoR and improve MH problems in patients with opioid use disorder experiencing MMT. However, further research is recommended to fill the gaps. TRIAL REGISTRATION: The research protocol has also been listed on the Iranian Registry of Clinical Trials (IRCT) with code no. IRCT2020050904736N1.

Opium tincture versus methadone for opioid agonist treatment: a randomized controlled trial.

AIM: To test if opium tincture (OT) was non-inferior to methadone in retaining participants in opioid agonist treatment (OAT). DESIGN: A Phase III, multi-centre, parallel-group, non-inferiority, double-blind randomized controlled trial with an allocation ratio of 1:1. Participants were provided treatment and followed for a period of 85 days. SETTING: Four OAT clinics in Iran. PARTICIPANTS: Two hundred and four participants with opioid use disorder [mean age (standard deviation) = 37.4 (9.3); female 11.3%] recruited between July 2017 and January 2018. INTERVENTIONS: Participants were assigned to either OT (102) or methadone (102) using a patient-centred flexible dosing strategy. MEASUREMENTS: Treatment retention over 85 days was the primary outcome. Self-reported opioid use outside treatment and occurrence of adverse events (AEs) were the secondary outcomes. FINDINGS: Remaining in treatment at the end of the follow-up were 68.6% in the methadone arm and 59.8% in the OT arm. The relative retention rate of methadone to OT was 1.15 (0.97, 1.36) in both intent-to-treat and per-protocol analyses; non-inferiority was not supported statistically, as the upper bound of the confidence interval exceeded our pre-specified non-inferiority margin (1.25). Opioid use outside treatment was reported by 30.3% of OT (n = 152) and 49.4% of methadone (n = 168) patients, a difference in proportions of -19%: 90% confidence interval (-28%, -10%). The total count of AEs in the OT arm (22 among nine individuals) was significantly higher (P = 0.04) than that in the methadone arm (three among two individuals). Nausea was the most common side effect. CONCLUSION: While this study could not conclude the non-inferiority of opium tincture (OT) to methadone for retaining patients in opioid agonist treatment, OT retained 60% of participants to end of follow-up (85 days) and was superior to methadone in reducing self-reported opioid use outside treatment.

Case series on treatment of dependence to Kamini Vidrawan Ras with opioid substitution therapy.

INTRODUCTION: A cohort of clients was recognised attending an addiction medicine clinic with similar presentations of opioid dependence from use of a rarely known Ayurvedic medication in a specific ethnic community. This retrospective case series was completed to promote wider recognition and further understanding of dependence on Kamini Vidrawan Ras (Kamini). METHODS: A retrospective file audit of the electronic medical record for clients of an addiction medicine outpatient clinic with a history of dependent use of Kamini identified 12 clients meeting inclusion criteria. RESULTS: All 12 clients were male, aged 27-41 years, all but one of north Indian origin, predominantly employed and predominantly (but not exclusively) without significant other substance use history. All 12 clients were treated with opioid substitution therapy. DISCUSSION AND CONCLUSIONS: This case series highlights an opioid dependence syndrome resulting from use of an Ayurvedic medicine by men from a specific area of India, highlighting a potential adverse effect of traditional medicines in ongoing use by migrant and ethnic populations that have emigrated to Australia.

Treatment retention, return to use, and recovery support following COVID-19 relaxation of methadone take-home dosing in two rural opioid treatment programs: A mixed methods analysis.

OBJECTIVES: In March 2020, the Substance Abuse and Mental Health Services Administration permitted Opioid Treatment Programs (OTPs) to relax restrictions on take-home methadone and promoted telehealth to minimize potential exposures to COVID-19. We assessed the effects of COVID-19-related changes on take-home methadone dosing in two OTPs serving five rural Oregon counties. METHODS: We used a mixed-methods convergent design. The OTPs extracted urine drug test (UDT) results, take-home methadone regimens, and treatment retention from the electronic health record (EHR) for patients (n = 377). A mixed-effects negative binomial regression model assessed patient-level differences in take-home doses before and after the COVID-19 policy changes and the associations with treatment discontinuation, and UDT positivity. Semi-structured qualitative interviews (n = 32) explored patient reactions to increased take-home dosing and reduced clinic visits to provide context for quantitative findings. RESULTS: The number of take-home doses increased in the post-COVID-19 period for patients engaged in treatment for more than 180 days (median: 8 vs 13 take-home doses per month, p = 0.011). Take-homes did not increase for patients with fewer days of treatment. Each percentage point increase in take-home dosing above what would be expected without COVID-19 policy changes was negatively associated with the percent of UDT positive for opioids (B = -0.12, CI [-0.21, -0.04], p = 0.005) and the probability of treatment discontinuation (aOR = 0.97, CI [0.95, 0.99], p = 0.003). Qualitative analysis revealed three themes explaining how increased take-home dosing supported recovery: 1) value of feeling trusted with increased responsibility; 2) reduced travel time permitted increased employment and recreation; and 3) reduced exposure to individuals less stable in recovery and potential triggers. CONCLUSIONS: Take-home methadone dose relaxations were associated with increased methadone take-home doses, improved retention, and decreased UDT opioid positive results among clinically stable patients. Qualitative findings suggest that fewer take-home restrictions are feasible and desirable and do not pose safety or public health harms.

Multidisciplinary treatment of opioid use disorder in primary care using the collaborative care model.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Successful engagement in buprenorphine treatment among hospitalized patients with opioid use disorder and trauma.

BACKGROUND: The opioid epidemic continues to cause significant morbidity and mortality. Although there are effective medications for opioid use disorder (OUD), a minority of patients receive these treatments. OUD is common among patients hospitalized for traumatic injury and hospitalization could be an opportunity to initiate medications and link to ongoing buprenorphine care. METHODS: This retrospective cohort study based on electronic health record review included patients who were: (1) hospitalized between January 1, 2018 and June 30, 2019, (2) age ≥18 years, (3) seen by an Addiction Medicine Consult Service, and (4) initiated on buprenorphine with plans for continuation post-discharge. Descriptive statistics identified differences between trauma and non-trauma groups and regression analysis identified predictors of 30 day buprenorphine follow up. RESULTS: Of 197 eligible patients, 60 (30.5 %) were hospitalized for traumatic injuries. Compared to non-trauma patients, trauma patients were younger, more likely to be employed, more likely to report using cannabis and tobacco, less likely to have recently injected drugs, and hospitalized longer. Among patients with follow-up data available (n = 147), 63.2 % of trauma patients were seen within 30 days, compared to 48.2 % of non-trauma patients (p = 0.16). There were no significant differences between the two groups with regards to urine drug test results or acute care utilization in the follow-up period. CONCLUSIONS: Among hospitalized patients with OUD who initiate buprenorphine, those who were hospitalized for trauma were at least as likely to link to out-patient treatment. Trauma admissions represent an important opportunity for diagnosing and linking patients with OUD to buprenorphine treatment.

The impact of medical school education on the opioid overdose crisis with concurrent training in naloxone administration and MAT.

The Student Osteopathic Medical Association (SOMA) Overdose Prevention Task Force (OPTF) was created with a vision to reduce overdose deaths around the country through osteopathic medical student action and advocacy. With the medical understanding that opioid overdose is a public health crisis and that there are knowledge deficits within patient populations subject to possible overdose and use disorders, our aim is to increase medical education and training within the medical community, starting at the medical student level. Our focus at this time is to create training and distribution programs for naloxone, to advocate for effective Good Samaritan Laws in states where they are lacking, and to increase access to medication-assisted treatments (MAT) in the communities that need them most. Foundational to the mission of the OPTF is education of the general public and medical communities on harm reduction practices and reducing the stigma surrounding substance use. Student leaders are strategically dispersed nationally over 40 campuses to achieve these goals.

Six-month retention and changes in quality of life and substance use from a low-threshold methadone maintenance therapy programme in Durban, South Africa.

BACKGROUND: Emerging data points to a potential heroin use epidemic in South Africa. Despite this, access to methadone maintenance therapy and other evidence-based treatment options remains negligible. We aimed to assess retention, changes in substance use and quality of life after 6 months on methadone maintenance therapy provided through a low-threshold service in Durban, South Africa. METHODS: We enrolled a cohort of 54 people with an opioid use disorder into the study. We reviewed and described baseline socio-demographic characteristics. Baseline and 6-month substance use was assessed using the World Health Organization's Alcohol Smoking and Substance Use Involvement Screening Test (ASSIST) and quality of life, using the SF-12. We compared changes at 6 months on methadone to baseline using the Wilcoxon signed rank test and paired-tests for the ASSIST and SF-12 scores, respectively. McNemar's test was used for comparisons between paired results of categorical variables relating to injecting frequency. RESULTS: The majority of the participants were young, Black African males, with a history of drug use spanning over 10 years. Retention after 6 months was 81%. After 6 months, the median heroin ASSIST score decreased from 37 to 9 (p < 0.0001) and the cannabis ASSIST score increased from 12.5 to 21 (p = 0.0003). The median mental health composite score of the SF-12 increased from 41.4 to 48.7 (p = 0.0254). CONCLUSIONS: Interim findings suggest high retention, significant reductions in heroin use and improvements in mental health among participants retained on methadone maintenance therapy for 6 months. Further research into longer term outcomes and the reasons contributing to these changes would strengthen recommendations for the scale-up of methadone maintenance therapy in South Africa.

Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder.

Importance: Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. Objective: To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and Participants: This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. Exposures: One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and Measures: Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. Results: A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and Relevance: Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.

Characteristics of Office-Based Buprenorphine Prescribers for Medicare Patients.

INTRODUCTION: Opioid use disorder (OUD) is a major and growing public health concern, and Medicare patients have nearly double the proportion of OUD prevalence compared with those with commercial insurance. This study examines provider-level characteristics to delineate the wide variation behind buprenorphine provision, which is the mainstay of medication-assisted treatment for OUD. METHODS: Using Medicare Part D Public Use Files claims data from 2013 to 2016 in all states, we assessed prescribing patterns of buprenorphine formulations for the specialties of family medicine, internal medicine, psychiatry, and general practice. We incorporated data from 2013 to 2016 American Medical Association Physician Masterfile to model various provider- and area-level characteristics as predictors of buprenorphine prescriber status. RESULTS: Family medicine and internal medicine comprise nearly two-thirds of the outpatient buprenorphine prescriber population for Medicare beneficiaries. Yet, both specialties also have the lowest proportion of active buprenorphine prescribers compared with psychiatrists and general practitioners. Additional characteristics associated with buprenorphine provision include male sex, osteopathic training, Northeast region, US undergraduate medical education, more years in practice, and a higher proportion of dual-eligible patients. CONCLUSIONS: Primary care specialties, such as family medicine and internal medicine, currently comprise a significant majority of the US buprenorphine prescriber population for Medicare beneficiaries. Future policies should target specific demographics to enable greater patient access from physicians who are characteristically less likely to prescribe buprenorphine to increase overall capacity.