Patient and provider medication preferences affect treatment outcomes among adolescents and young adults with opioid use disorder.

BACKGROUND: The opioid epidemic in the United States has not spared youth or young adults, as evidenced by a six-fold increase in opioid use disorder (OUD) diagnoses in the last two decades. Given this dramatic rise, a call for greater uptake and accessibility of medications for opioid use disorder (MOUDs) among youth and young adults has ensued, resulting in an increasing number of MOUD treatment pathways for this vulnerable population. METHODS: This secondary data analysis seeks to characterize patient and provider preferences for MOUD treatment pathways, and test for associations between baseline MOUD treatment preferences and opioid use and treatment adherence outcomes. Participants included 288 youth and young adults (age 15-21 years), recruited from a residential treatment program in Maryland. The study assessed patient preferences at baseline (n = 253) and provider preferences at patient treatment discharge (n = 224). Mixed-effects negative binomial regression models were conducted for opioid use outcomes, and logistic regressions were conducted for treatment adherence outcomes. RESULTS: Results indicate that congruence of treatment with patients' (Incidence Rate Ratio [IRR] = 0.65) and providers' (IRR = 0.66) preferences was significantly associated with reduced self-reported days of opioid use in the past 90 days, but only for patients receiving extended-release naltrexone (XR-NTX). Results also indicated that patients were less likely to switch medication treatment pathways (e.g., from XR-NTX to buprenorphine, or vice versa) during follow-up if they received their preferred treatment at baseline, a finding which held true for both XR-NTX (Odds Ratio [OR] = 0.32) and buprenorphine (OR = 0.22). CONCLUSIONS: Receipt of MOUD congruent with patient and provider preferences was associated with reduced opioid use and greater treatment adherence in this sample of youth and young adults with OUD.

Linkage facilitation services for opioid use disorder: Taxonomy of facilitation practitioners, goals, and activities.

INTRODUCTION: This article proposes a taxonomy of linkage facilitation services used to help persons with opioid use disorder access treatment and recovery resources. Linkage facilitation may be especially valuable for persons receiving medication for opioid use disorder (MOUD) given the considerable barriers to treatment access and initiation that have been identified. The science of linkage facilitation currently lacks both consistent communication about linkage facilitation practices and a conceptual framework for guiding research. METHODS: To address this gap, this article presents a taxonomy derived from expert consensus that organizes the array of practitioners, goals, and activities associated with linkage services for OUD and related needs. Expert panelists first independently reviewed research reports and policy guidelines summarizing the science and practice of linkage facilitation for substance use disorders generally and OUD specifically, then met several times to vet the conceptual scheme and content of the taxonomy until they reached a final consensus. RESULTS: The derived taxonomy contains eight domains: facilitator identity, facilitator lived experience, linkage client, facilitator-client relationship, linkage activity, linkage method, linkage connectivity, and linkage goal. For each domain, the article defines basic domain categories, highlights research and practice themes in substance use and OUD care, and introduces innovations in linkage facilitation being tested in one of two NIDA-funded research networks: Justice Community Opioid Innovation Network (JCOIN) or Consortium on Addiction Recovery Science (CoARS). CONCLUSIONS: To accelerate consistent application of this taxonomy to diverse research and practice settings, the article concludes by naming several considerations for linkage facilitation workforce training and implementation.

State guidance and system changes related to COVID-19: Impact on opioid treatment programs.

INTRODUCTION: In the United States, methadone treatment may only be provided through opioid treatment programs (OTPs), which operate under a complex system of federal and state regulations. During the pandemic, federal regulators relaxed several longstanding restrictions for OTPs by permitting expanded eligibility for take-home medication and allowing counseling and medication management through telehealth. The purpose of this study was to assess the guidance provided by states regarding the revised guidelines and efforts to protect staff and patients in response to the pandemic. METHODS: Between September and October of 2020, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Friends Research Institute, fielded a web-based qualitative survey of state opioid treatment authorities (SOTAs) across the United States, the District of Columbia, and Puerto Rico. The study conducted the survey prior to the availability of the COVID vaccines. It queried 42 SOTAs concerning state guidance provided to OTPs on treatment operations and practices for existing patients and new admissions; actions to protect staff and patients; changes in treatment need and operational capacity; and administrative practices regarding treatment. This study examines the responses of 42 SOTAs (65 %) who completed the survey. RESULTS: Using content analysis, responses to the survey indicate that most states provided guidance to OTPs in response to the revised federal regulations and the need to protect staff and patients. All respondents reported that their states permitted increased number of take-homes doses for existing patients (100 %) and most reported doing so for new admissions (69 %; N=29). Ninety-eight percent (98 %; N=41) reported permitting remote counseling for existing patients and 90 % (N=38) permitting this for new admissions. SOTAs reported providing guidance on staff safety, operational procedures, oversight, and reforming billing practices to align with new models of service delivery. CONCLUSIONS: SOTAs generally reported that federal guidance increased patient access, engagement, and retention. Increased take-home flexibilities were viewed as important for expanding access and continuity of treatment, with the majority of SOTAs stating that the revised treatment practices (e.g., expansion of telehealth, flexible medication dispensing practices) were beneficial. These regulatory flexibilities, many believe, promoted the continuation of treatment and successful patient outcomes during the pandemic.

Opioid treatment program culture and philosophy: Views of OTP staff and state officials on implementing interim methadone treatment.

INTRODUCTION: People seeking treatment at opioid treatment programs (OTPs) can face admission delays. Interim methadone (IM) treatment, an effective approach to expedite admissions when programs lack sufficient counseling staff, has been seldom implemented. A study of implementation facilitation to spur the use of IM was conducted among six OTPs and their state opioid treatment authorities (SOTAs) in four US states. Between study recruitment and launch, organizational changes at three OTPs eliminated their need for IM. Two OTPs' requests to their states to provide IM (one prior to study launch and one following launch) were deferred by the states due to internal issues that required resolution to comply with federal IM regulations. During the study, another OTP's delays resolved, and one OTP streamlined its admissions procedures. METHODS: Virtual interviews were conducted with 16 OTP staff and SOTAs from six OTPs in four US states following their participation in the parent study. Interviews focused on the feasibility and acceptability of the implementation intervention for IM. We analyzed data using a constant comparative approach. RESULTS: Two overarching themes emerged from the qualitative data with respect to the role that organizational culture plays in OTP staff views of efforts to implement interim methadone: (1) the contrasting views of interim methadone based on whether staff adopt a traditional treatment vs. harm reduction philosophy and (2) the importance of reconciling these philosophies in addressing the culture shift that would accompany the process of implementing IM. CONCLUSIONS: Organizational treatment philosophy and program culture emerged as important factors determining the OTPs' staff's willingness to adopt new approaches to expedite admissions. Participants noted a tension between traditional treatment and harm reduction philosophies that impacted their views of IM, in part based on when they entered the drug treatment field. While understanding and addressing treatment philosophy and organizational culture and willingness to change is of importance when implementing new approaches in OTPs, leadership at the state and OTP level are powerful drivers of change.

Polysubstance use and post-discharge mortality risk among hospitalized patients with opioid use disorder.

Polysubstance use is becoming increasingly common and presents several harms. This study aimed to examine the association of comorbid cocaine, alcohol (binge drinking), and sedative use with mortality among hospitalized patients with opioid use disorder (OUD). A subsample of adult medical/surgical hospital patients with OUD who were seen by a hospital addiction consultation service in Baltimore City and enrolled in a randomized trial of a patient navigation intervention were included in this study (N = 314; 45 % female; 48 % White; mean age = 44). Death certificate data from the Maryland Division of Vital Records was used, covering 3.3-5.5 years post-discharge. Multivariable proportional hazards Cox regression and competing risks regression were used to estimate all-cause mortality and overdose mortality, respectively, as a function of concurrent use of cocaine, alcohol (binge drinking), and non-prescribed sedatives at baseline. In the 30 days prior to hospital admission, 230 (73 %) participants used cocaine, 64 (20 %) binge drank, and 45 (14 %) used non-prescribed sedatives. Nearly one-third (N = 98; 31 %) died during the observation period. Drug overdose caused 53 % (N = 52) of deaths. Older age (HR = 1.03 [1.01,1.05]; P = 0.001), less than high school education (HR = 0.36 [0.24,0.54]; P < 0.001), and past 30-day sedative use (HR = 2.05 [1.20,3.50]; P = 0.008) were significantly associated with all-cause mortality. The risk of overdose mortality was 62 % lower (HR = 0.38 [0.22,0.66]; P = 0.001) for those who completed high school. No other characteristics were significantly associated with overdose mortality. The concurrent use of opioids and sedatives increases the post-discharge mortality risk among hospitalized patients with OUD. Interventions are needed to prevent mortality among this high-risk population.

Impact of COVID-19-related methadone regulatory flexibilities: views of state opioid treatment authorities and program staff.

BACKGROUND: During the COVID-19 pandemic, federal regulations in the USA for methadone treatment of opioid use disorder (OUD) were temporarily revised to reduce clinic crowding and promote access to treatment. METHODS: As part of a study seeking to implement interim methadone without routine counseling to hasten treatment access in Opioid Treatment Programs with admission delays, semi-structured qualitative interviews were conducted via Zoom with participating staff (N = 11) in six OTPs and their State Opioid Treatment Authorities (SOTAs; N = 5) responsible for overseeing the OTPs' federal regulatory compliance. Participants discussed their views on the response of OTPs in their states to the pandemic and the impact of the COVID-related regulatory flexibilities on staff, established patients, and new program applicants. Interviews were audio recorded, transcribed, and a content analysis was conducted using ATLAS.ti. RESULTS: All SOTAs requested the blanket take-home exemption and supported the use of telehealth for counseling. Participants noted that these changes were more beneficial for established patients than program applicants. Established patients were able to obtain a greater number of take-homes and attend individual counseling remotely. Patients with limited resources had greater difficulty or were unable to access remote counseling. The convenience of intake through telehealth did not extend to new program applicants because the admission physical exam requirement was not waived. CONCLUSIONS: The experienced reflections of SOTAs and OTP providers on methadone practice changes during the COVID-19 pandemic offer insights on SAMHSA's proposed revisions to its OTP regulations. Trial registration Clinicaltrials.gov # NCT04188977.

Comparing outcomes of extended-release naltrexone in adolescents and young adults with opioid use disorder.

INTRODUCTION: Opioid use among youth is a public health concern in the United States, with >3300 overdose deaths occurring nationally each year. Unfortunately, youth in the United States are still prescribed medication for opioid use disorder (OUD) at a lower rate than their adult counterparts. METHODS: From 10/2013 to 01/2018, adolescents (ages 15-17; n = 25) and young adults (ages 18-21; n = 263) with moderate to severe OUD enrolled in the parent trial of extended-release naltrexone (XR-NTX; n = 82) versus treatment-as-usual (TAU; either buprenorphine maintenance [n = 94] or counseling without buprenorphine maintenance [n = 112]). The study assessed opioid use outcomes for adolescents vs. young adults using timeline follow-back self-report procedures at baseline and 3-/6-month follow-up assessments. Mixed-effects longitudinal and clustered panel regression models compared treatment effects over time of XR-NTX and TAU on opioid use outcomes in this secondary analysis. RESULTS: Though adolescent participants reported significantly less opioid use at baseline relative to their young adult counterparts (p < 0.05), the two age groups reported similar rates of opioid use throughout the intervention period. Additionally, both adolescents and young adults receiving XR-NTX evidenced lower rates of opioid use than those receiving TAU at all time points, and adolescents on XR-NTX were the only group who reduced their opioid use at all time points. Mixed-effects models indicated adolescents receiving XR-NTX demonstrated a 48 % lower rate of opioid use days [Incidence Rate Ratio (IRR) = 0.52; p = 0.020], while young adults receiving XR-NTX reported an estimated 26 % lower rate (IRR = 0.74; p = 0.009). CONCLUSIONS: Results indicate that adolescents respond favorably to XR-NTX relative to TAU for treatment of OUD, demonstrating similar outcomes to young adults.

Health care use and cost of treatment for adolescents and young adults with opioid use disorder.

BACKGROUND: Few studies have examined the cost of medication for opioid use disorder (MOUD) with counseling for the adolescent and young adult population. This study calculated the health care utilization and cost of MOUD treatment, other substance use disorder treatment, and general health care for adolescents and young adults receiving treatment for opioid use disorder. METHODS: The study randomized youth ages 15 to 21 (N = 288) equally into the two study conditions: extended-release naltrexone (XR-NTX) or treatment as usual (TAU). While participants committed to treatment based on randomization the study observed considerable nonadherence to both randomized conditions. Instead of using the randomly assigned study conditions, we present descriptive costs by the type of MOUD treatment received: XR-NTX only, buprenorphine only, any other combination of MOUD treatments, and no MOUD. Health care use was aggregated over the 6-month period for each participant, and we calculated average/participant utilization for each treatment group. To determine participant costs, we multiplied the unit costs of health care services obtained from the literature by the reported amount of health care utilization for each participant. We then calculated the mean, standard error, median and IQR for MOUD costs, other substance use disorder treatment costs and general healthcare cost from the health care sector perspective. RESULTS: On average, participants in the XR-NTX only group received 2.6 doses of XR-NTX (equivalent to approximately 78 days of treatment). The buprenorphine only group had an average of 97 days of buprenorphine treatment. The XR-NTX only group had higher/patient costs compared to participants in the buprenorphine only group ($10,491 vs. $8765) and higher XR-NTX utilization would further increase costs. Participants in the any other MOUD combination group had the highest total costs ($14,627) while participants in the no MOUD group at the lowest ($3453). DISCUSSION: Our cost analysis calculates the real-world cost of MOUD treatment and, while not generalizable, provides policy makers an estimate of costs for adolescents and young adults. We found that participants in the XR-NTX only group received fewer days of medication compared to the buprenorphine only group, but their medication costs were higher due to the cost of XR-NTX injections. While the buprenorphine only group had the highest number of days of medication utilization of all the groups, the average number of days of medication utilization was considerably shorter than the six-month treatment period.

De-Implementing Opioids for Dental Extractions (DIODE): a multi-clinic, cluster-randomized trial of clinical decision support strategies in dentistry.

BACKGROUND: Opioid pain relievers are commonly prescribed following dental extractions, but evidence shows that non-opioid analgesics often provide adequate pain relief with fewer risks. The current study examined clinical decision support (CDS) as a tool for de-implementing opioid prescribing in dentistry. METHODS: This prospective, cluster-randomized trial examined CDS for dental pain management at 22 HealthPartners Dental Group clinics in Minnesota. Dental providers (n = 49) were randomized to deliver care using CDS, CDS with patient education materials (CDS-E), or standard practice (SP). Randomization was stratified by provider type (dentist vs. oral surgeon) and baseline opioid prescribing volume. Patient records of dental extractions were examined for January 2019 through May 2021, representing a 12-month baseline and 15-month intervention period (N = 12,924). Opioid prescription at the visit (no vs. yes) was the primary outcome. Data were analyzed using generalized linear mixed models, adjusting for patient sex and age, extraction complexity, and baseline prescribing strata (volume and provider type). RESULTS: Patients were 56.2% female, with a mean age of 46.7 (SD = 20.0) years. Providers were 8% oral surgeons, 57% female, and with a mean age of 43.7 (SD = 11.2) years. There were significant decreases in opioid prescribing during the study (P < 0.001), representing a continuation of pre-existing trends to reduce opioid prescribing in these dental practices. There were no significant differences in opioid prescribing between CDS and SP (OR = 1.29; 97.5% CI = 0.93, 1.79; P = 0.08), or CDS-E and SP arms (OR = 1.27; 97.5% CI = 0.86, 1.79; P = 0.18). The direction of the association favored greater reductions in opioid prescribing in the SP arm. Despite training and implementation support, utilization of the CDS was low, particularly among oral surgeons, who were significantly more likely than other dentists to prescribe opioids. Among non-oral surgeon providers with the opportunity to access it, CDS utilization was not significantly associated with opioid prescribing. CONCLUSIONS: Equipping dentists with CDS resources, whether alone or accompanied by patient education materials, did not accelerate reductions in opioid prescribing beyond those observed in standard practice. Strategies are needed to enhance CDS utilization for patient care and safety surrounding analgesia following dental extractions. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03584789.

Sustainability of Adolescent Screening and Brief Intervention Services in Primary Care After Removal of Implementation Supports.

OBJECTIVE: Although many health care organizations have sought to increase the integration of substance use services into clinical practice, such practice changes can prove difficult to sustain. METHOD: Seven primary care clinics participated in an implementation study of screening and brief intervention (BI) services for adolescent patients (ages 12-17). All sites delivered screening and brief advice (BA) for low-risk use using a uniform protocol. Clinics were randomized to deliver BI using generalist (provider-delivered) or specialist (behavioral health clinician-delivered) models. Implementation was facilitated by multiple supporting activities (e.g., trainings, local "champion," electronic health record [EHR] integration of screening and documentation, individualized feedback, project-specific materials, etc.). Data on the penetration of screening, BA, and BI delivery (N = 14,486 adolescent patient visits) were abstracted from the EHR for the 20-month implementation phase and a 12-month sustainability phase (during which implementation supports were removed). RESULTS: Penetration of screening continued to slowly increase across the implementation-to-sustainability phases (62% vs. 70%; p = .04). Although uptake during implementation was low for BA (29%) and BI (22%), there was no significant decrease in service provision during the sustainability phase. Although overall delivery of BI was significantly higher in generalist compared with specialist sites (p < .001), sustainability did not differ by generalist versus specialist conditions. There were considerable differences in penetration across clinic sites. CONCLUSIONS: Clinics sustained a high level of substance use screening. Uptake of intervention services was low but did not decrease further following the cessation of implementation supports. This study illustrates the challenges of successfully implementing and sustaining substance use services in adolescent primary care.

Providing substance use disorder treatment in correctional settings: knowledge gaps and proposed research priorities-overview and commentary.

This manuscript is the product of the authors' discussions, literature overview, and consultation with experts in the field, and identifies important gaps in the evidence base for substance use disorder (SUD) treatment effectiveness within criminal justice (CJ) settings. Lacking from the extant literature are longitudinal investigations of treatment related outcomes during and after incarceration. Such studies could provide rich contextual data about treatment delivery and effectiveness across the CJ continuum, and would provide important insight into individual characteristics (e.g., motivation, treatment modality preferences, treatment completion rates, etc.) as well as institutional and environmental factors (e.g., appropriate staffing, space limitations for individual treatment sessions, distribution of medications, etc.). We also identified the importance of reproducibility within CJ research, and the unfortunate reality of too many single studies conducted in single (or relatively few) correctional facilities. Some of this has been because the studies designed to produce that evidence are not prioritized for funding, which has continually placed researchers in a position where we cannot make firm conclusions or recommendations based on available evidence. The importance of replicating the foundational studies in this field cannot be overstated. We hope this article spurs other researchers to join in the healthy process of questioning the existing state of the CJ-based SUD treatment research, what should be re-examined, and how we can lay a stronger foundation for the future.

Characteristics and correlates of fentanyl preferences among people with opioid use disorder.

OBJECTIVES: Fentanyl has come to dominate the U.S. illicit opioid supply. We aimed to characterize and examine correlates of preferences for fentanyl vs. other opioids among individuals starting OUD treatment. METHODS: We interviewed 250 adults initiating buprenorphine treatment with positive fentanyl toxicology at intake. We characterized opioid preferences and examined bivariate associations between opioid preference (preference for heroin, fentanyl, heroin-fentanyl mix, or other opioid) and sociodemographic characteristics, psychosocial factors, and substance use behaviors. We then used multinomial logistic regression to examine factors independently associated with fentanyl preferences. RESULTS: Over half (52.0 %) of participants preferred fentanyl (21.2 % fentanyl alone, 30.8 % heroin-fentanyl mix). In bivariate comparisons, participants who preferred fentanyl were a higher acuity group with respect to risks and problems in general. In the multinomial logistic regression, people who preferred fentanyl, either alone or mixed with heroin, used non-prescribed buprenorphine less in the 30 days preceding treatment entry compared to people who preferred heroin or other opioids (RRRalone= 0.88 [0.78, 0.99]; P = 0.037 and RRRmixed= 0.91 [0.84, 0.99]; P = 0.046). People who preferred fentanyl alone were also younger (RRR= 0.93 [0.90, 0.97]; P < 0.001) and more likely to have severe mental illness (RRR= 2.5 [1.1, 5.6]; P = 0.027) than people who prefer heroin or other opioids. CONCLUSIONS: Many people with OUD report preferring fentanyl. People who express preference for fentanyl differ substantively from those with other opioid preferences, and may be at elevated risk for poor health outcomes. Understanding preferences surrounding fentanyl could inform treatment and harm reduction interventions.

Examining the Effectiveness of the FaCES Adolescent SBIRT Intervention.

PURPOSE: The Facilitating Change for Excellence in SBIRT (FaCES) is a service package for adolescent primary care that was developed based on best practices and evidence, but was empirically untested. The aim of this study is to compare the FaCES intervention to treatment as usual (TAU) for rural adolescent primary care patients. METHODS: In this modified cluster-randomized stepped wedge design, providers who completed at least 20 adolescent TAU visits received training in the FaCES package in random order. Adolescent patients (N = 1,226) waiting for appointments were continuously recruited into the study and completed a baseline assessment before their scheduled appointment and an on-line 3-month follow-up. Participants received either FaCES or TAU, depending on whether their provider had been trained in FaCES. Due to COVID-19 disruptions, only 14 of the 29 providers were trained before study recruitment activities ceased. RESULTS: More than 80% of the sample indicated no prior use of tobacco, alcohol, or marijuana at study entry. The Arm × Time interaction failed to reach significance for the substance use outcomes considered. In the FaCES condition, the group with no prior use had an increased probability of substance use at 3-month follow-up, while the group reporting prior use had a decreased probability of use at follow-up. Participants who reported no use at baseline had an increased probability of use at follow-up, whether they received the FaCES intervention or TAU. DISCUSSION: This study was unable to demonstrate the effectiveness of FaCES. Findings suggest some natural movement in substance use risk over time.

Pain management after third molar extractions in adolescents: a qualitative study.

BACKGROUND: Understanding how adolescent patients make decisions about pain management after complex dental procedures could help reduce the use of opioid medications and the potential for future opioid misuse in this population. This qualitative study explores how adolescents manage pain, including how decision making with parents and providers affect their experience with opioid and non-opioid analgesics after third molar dental extractions. METHODS: We used a qualitative approach for the analysis of 30 telephone-based semi-structured interviews completed by 15 dyads between May and August 2019, which included 15 adolescents (15-17 years) who underwent a dental extraction, and a parent or guardian for each adolescent. The total sample included 30 participants. Interviews were conducted separately for patients and parents. De-identified interview transcripts were analyzed using qualitative analysis software using a directed content analysis approach. RESULTS: A total of 15 patient/parent dyads were interviewed. Key themes associated with pain management included sources of information, pain management behaviors engaged in by the adolescents and their caregivers, and the use of medication. In addition to conversations with their dental provider, most patients and their parents discussed pain management plans that included non-medication options, over-the-counter medications, and opioid medications to be taken as needed, which guided their post-extraction behaviors. All participants reported that the adolescent received an opioid prescription for post-extraction pain management, to be taken on an "as needed" basis, but most only took it the day of the extraction and up to 2 days following, usually based on the patient's reported pain levels and perceptions of over-the-counter medication adequacy. Participants said they did not receive guidance from their provider concerning disposal of unused opioid medications. CONCLUSIONS: Involving adolescents in the pain management decision making process and allowing them to carry out the plan with some caregiver support was acceptable and well executed following third molar extractions. Providers may have an opportunity to reduce the number of opioids prescribed, since respondents reported little to no use of opioids that they were prescribed. Providers should educate patients and their parents about safe disposal of opioids to mitigate the potential for diversion.

Costs and Implementation Effectiveness of Generalist Versus Specialist Models for Adolescent Screening and Brief Intervention in Primary Care.

OBJECTIVE: This study analyzed the marginal service and program costs, and conducted a cost-effectiveness analysis (CEA) of two models of implementation of adolescent substance screening, brief intervention, and referral to treatment (SBIRT). METHOD: SBIRT was implemented at seven clinics in a multisite, cluster-randomized trial, through a Specialist model (behavioral health counselor-delivered brief intervention), and a Generalist model (primary care provider-delivered brief intervention). The CEA calculated marginal costs using an activity-based costing methodology for direct SBIRT services, and effectiveness was measured by the proportion of brief interventions delivered among patients who screened positive for alcohol, tobacco, or other drugs. Site-level program costs comprised start-up and maintenance (training and technical assistance). Costs were estimated in 2017 U.S. dollars. RESULTS: The marginal cost of SBIRT per patient with a positive screen for brief intervention was $6.72 in the Specialist model and $6.05 in the Generalist model. Implementation effectiveness was 7.2% (SE = 2.9%) in the Specialist model and 37.7% (SE = 5.6%) in the Generalist model. The program costs to provide SBIRT for 1 year per site were $13,548 for the Specialist site and $12,081 for the Generalist. CONCLUSIONS: The Generalist model was more effective in implementing brief intervention and less expensive than the Specialist model. Results were robust to sensitivity analysis. Brief intervention delivered by primary care providers rather than by handoff to a behavioral health counselor may ensure greater penetration and a lower cost of these services in primary care settings.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization.

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Sexually Transmitted Infection Testing After Brief Intervention for Risk Behaviors in School-Based Health Centers.

PURPOSE: The initiation and escalation of substance use and sex behaviors is prevalent during adolescence. School-based health centers (SBHCs) are well-equipped to provide interventions for risky behaviors and offer sexually transmitted infection (STI) testing services. This study examined receipt of STI testing following brief intervention (BI) among sexually active adolescents. METHODS: This is a secondary analysis of data from a randomized trial comparing computer versus nurse practitioner-delivered BI approaches among adolescents (ages 14-18) with risky alcohol and/or cannabis use at two SBHCs within two urban high schools. Associations were examined among receipt of STI testing and participant characteristics, BI format, site, and frequency of substance use/sexual behaviors. RESULTS: Among sexually active participants (N = 254), 64.2% received STI testing at their SBHC within 6 months of receiving a BI. Participants receiving nurse practitioner-delivered BI had higher odds of getting STI testing than participants receiving computer-delivered BI (adjusted odds ratio 2.51, 95% confidence interval 1.41-4.47, p = .002). Other variables associated with STI testing in multivariable logistic regression included female sex (p = .001), being in a serious relationship (p = .018), and SBHC site (p < .001). Frequency of substance use and sexual risk behaviors were not independently associated with receipt of STI testing services. CONCLUSION: Sexually active adolescents who received in-person BI from a nurse practitioner were more likely to get STI testing than adolescents who received BI via computer. Nurse practitioners working in SBHCs can successfully engage adolescents in additional sexual health services subsequent to BI for risky behaviors.

Development and use of a checklist for the implementation of medication for opioid use disorder in jails.

Background: In light of short lengths of stay and proximity to communities of release, jails are well-positioned to intervene in opioid use disorder (OUD). However, a number of barriers have resulted in a slow and limited implementation. Methods: This paper describes the development and testing of a Medication for Opioid Use Disorder (MOUD) Implementation Checklist developed as part of a Building Bridges project, a two-year planning grant which supported 16 US jail systems as they prepared to implement or expand MOUD services. Results: Although initially developed to track changes within sites participating in the initiative, participants noted its utility for identifying evidence-based benchmarks through which the successful implementation of MOUDs could be tracked by correctional administrators. Conclusions: The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports. Plain Language Summary: People incarcerated in jails are more likely to have opioid use disorder than the general population. Despite this, jails in the United States (U.S.) often offer limited or no access to Medication for Opioid Use Disorder (MOUD). The Building Bridges project was designed to address this gap in 16 U.S. jail systems as they prepared to implement or expand MOUD services. This article addresses the use of a MOUD checklist that was initially designed to help the jails track changes toward evidence-based benchmarks. The findings suggest that this checklist can both help guide and illustrate progress toward vital changes facilitated through established processes and supports.

Opioid agonist treatment initiation and linkage for hospitalized patients seen by a substance use disorder consultation service.

Background: Facilitating opioid agonist treatment (OAT) for opioid use disorder (OUD) is an important role of hospital substance use disorder (SUD) consultation services. In the NavSTAR trial, hospital patients receiving SUD consultation who were randomly assigned to patient navigation services for 3 months post-discharge had fewer readmissions compared to usual care. Methods: This secondary analysis examined hospital-based OAT initiation (pre-randomization) and community-based OAT linkage (post-discharge) among NavSTAR trial participants with OUD (N=314). Associations between OAT initiation and linkage, and patient demographics, housing status, comorbid SUD diagnoses, recent substance use, and study condition were examined using multinomial and dichotomous logistic regression. Results: Overall, 57.6% initiated OAT during hospitalization (36.3% methadone, 21.3% buprenorphine). Compared to participants not initiating OAT, participants who received methadone were more likely to be female (Relative Risk Ratio [RRR]=2.05, 95% CI=1.11, 3.82, p=0.02), while participants who received buprenorphine were more likely to report homelessness (RRR=2.57, 95% CI=1.24, 5.32, p=0.01). Compared to participants initiating methadone, participants initiating buprenorphine were more likely to be non-White (RRR=3.89; 95% CI=1.55, 9.70; p=0.004) and to report prior buprenorphine treatment (RRR=2.57; 95% CI=1.27, 5.20; p=0.009). OAT linkage within 30-days post-discharge was associated with hospital-based buprenorphine initiation (Adjusted Odds Ratio [AOR]=3.86, 95% CI=1.73, 8.61, p=0.001) and patient navigation intervention (AOR=2.97, 95% CI=1.60, 5.52, p=0.001). Conclusions: OAT initiation differed by sex, race, and housing status. Hospital-based OAT initiation and patient navigation were independently associated with linkage to community-based OAT. Hospitalization is a reachable moment to begin OAT to alleviate withdrawal and facilitate treatment continuity post-discharge.

Post-residential treatment outpatient care preferences: Perspectives of youth with opioid use disorder.

INTRODUCTION: We know little about what youth with opioid use disorders (OUD) think about outpatient substance use treatment and 12-step meetings following discharge from residential substance use treatment. This study explores youths' preferences between intensive outpatient treatment (IOP) and community-based 12-step groups. METHOD: The study recruited youth (n = 35) from a larger randomized trial (N = 288) that examined the effectiveness of extended-release naltrexone versus treatment-as-usual. This study asked the youth to participate in semi-structured qualitative interviews at baseline, 3 months, and 6 months post-residential treatment discharge. Qualitative interviews probed youths' key decision points during the six-months following residential treatment for OUD, including medication and counseling, and 12-step continuation in the community. RESULTS: Qualitative analyses revealed three overarching themes related to youths' preferences for either IOP or 12-step meetings: structure of recovery support, mechanisms of accountability, and relationships. CONCLUSION: Despite varying preferences, this analysis highlights the complexity of benefits that youth report receiving from each approach. Research has yet to determine the degree to which these approaches are complementary or supplementary for this population.