Pay for Performance and Treatment Outcome in Agonist Treatment for Opioid Use Disorder.

BACKGROUND AND OBJECTIVES: Pay for performance (P4P) models have become more popular in reimbursement for medical services, including treatment for substance use disorders. However, studies have not examined whether P4P has an impact on treatment outcome in the individual in opioid agonist treatment (OAT). Thus, the present study was conducted at the individual level, rather than the programmatic level, to determine whether meeting the P4P early engagement criteria (four services in the initial 14 days of treatment and/or eight services within the initial 30 days of treatment) resulted in reduced opioid, benzodiazepine, and cocaine use. METHODS: We performed a retrospective study of 63 patients enrolled in OAT for opioid use disorder. χ2 analyses were conducted crossing P4P early engagement criteria status and urine drug screen (UDS) results for opioid, cocaine, and/or benzodiazepine use at 6 and 12 months postadmission. Methadone dosage and treatment retention were also considered. The odds ratio was used to determine the directionality of significant results. RESULTS: Significant relationships were revealed between patients meeting 30-day P4P early engagement criteria and opioid negative UDS, and with retention in treatment at 6 and 12 months. Methadone dosage was significant at a 6-month follow-up. DISCUSSION AND CONCLUSIONS: Since significant associations between opioid use and P4P as well as opioid use and methadone dose were revealed, findings partially supported hypothesis. SCIENTIFIC SIGNIFICANCE: P4P and methadone dosage may have some benefit to individuals in OAT in attaining short-term abstinence from opioids. P4P may be less useful in helping individuals achieve abstinence from other substances of abuse. (Am J Addict 2020;00:00-00).

Alcohol and other drug use in older adults: results from a community needs assessment.

BACKGROUND: With the "Baby Boomer" generation reaching older adulthood, substance abuse treatment providers find themselves needing to address the unique needs of this population. Heavy drinking in adults ages 65 and over is strongly correlated with depression, anxiety, decreased social support, and poor health. However, while alcohol misuse has been shown to be predictive of a lower quality of life in older adults, the generalizability of these findings to urban dwelling, lower socioeconomic status individuals remains unclear. AIMS: To identify potential treatment needs of this population, a city-funded needs assessment was conducted. METHODS: Subjects were 249 individuals (44% male) who voluntarily completed measures of quality of life (QOL), depression, and substance abuse. Measures used included the Psychological General Well-Being Schedule, the Geriatric Depression Scale-15, and the Alcohol Use Disorders Identification Test (AUDIT). RESULTS: Alcohol or substance abuse was reported by over 20% of respondents, with 3.4% of respondents engaged in maladaptive alcohol use. Scores on the AUDIT were predictive of increased depression (r = - .209, p = .01), anxiety (r = - .201, p = .002), lower general well-being (r = - .154, p = .019), and decreased self-control (r = - .157, p = .017). DISCUSSION: A substantial percentage of the sample reported alcohol and substance misuse. Alcohol use was predictive of depression, global psychological distress, and decreased quality of life. CONCLUSIONS: This needs assessment reinforces findings from previous studies and addresses the added dimension of examining this in an urban, lower socioeconomic population.

Impact of cannabis use during stabilization on methadone maintenance treatment.

BACKGROUND AND OBJECTIVES: Illicit drug use, particularly of cannabis, is common among opiate-dependent individuals and has the potential to impact treatment in a negative manner. METHODS: To examine this, patterns of cannabis use prior to and during methadone maintenance treatment (MMT) were examined to assess possible cannabis-related effects on MMT, particularly during methadone stabilization. Retrospective chart analysis was used to examine outpatient records of patients undergoing MMT (n = 91), focusing specifically on past and present cannabis use and its association with opiate abstinence, methadone dose stabilization, and treatment compliance. RESULTS: Objective rates of cannabis use were high during methadone induction, dropping significantly following dose stabilization. History of cannabis use correlated with cannabis use during MMT but did not negatively impact the methadone induction process. Pilot data also suggested that objective ratings of opiate withdrawal decrease in MMT patients using cannabis during stabilization. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: The present findings may point to novel interventions to be employed during treatment for opiate dependence that specifically target cannabinoid-opioid system interactions.

The interaction of race and age in methadone treatment retention outcomes: A single-center analysis.

OBJECTIVES: Early treatment drop-out is due to the unique interplay of the individual and their context, and is associated with overdose death. The objective of this project was to determine if age or race is associated with 6-month treatment retention outcome differences at a single-center opioid treatment program. METHODS: The study team performed a retrospective administrative database study from January 2014 to January 2017 using admission data with age and race as predictors of 6-month treatment retention outcomes. RESULTS: Of the 457 admissions, 114 were under the age of 30; however, only 4 % of these young adults were Black, Indigenous, and/or People of Color (BIPOC). While retention for BIPOC patients (62 %) was slightly higher than for White patients (57 %), this difference did not reach traditional levels of significance. CONCLUSIONS: Once BIPOC enter treatment, their treatment retention is similar to their White counterparts. Young adult BIPOC were less represented in the admission data, but treatment retention across racial groups was similar. An urgent need exists to determine the barriers and facilitators to treatment access among BIPOC young adults.

Medication Initiation, Patient-directed Discharges, and Hospital Readmissions Before and After Implementing Guidelines for Opioid Withdrawal Management.

OBJECTIVES: Rising rates of hospitalization for patients with opioid use disorder (OUD) result in high rates of patient-directed discharge (PDD, also called "discharge against medical advice") and 30-day readmissions. Interdisciplinary addiction consult services are an emerging criterion standard to improve care for these patients, but these services are resource- and expertise-intensive. A set of withdrawal guidelines was developed to guide generalists in caring for patients with opioid withdrawal at a hospital without an addiction consult service. METHODS: Retrospective chart review was performed to determine PDD, 30-day readmission, and psychiatry consult rates for hospitalized patients with OUD during periods before (July 1, 2017, to March 31, 2018) and after (January 1, 2019, to July 31, 2019) the withdrawal guidelines were implemented. Information on the provision of opioid agonist therapy (OAT) was also obtained. RESULTS: Use of OAT in patients with OUD increased significantly after guideline introduction, from 23.3% to 64.8% ( P < 0.001). Patient-directed discharge did not change, remaining at 14% before and after. Thirty-day readmissions increased 12.4% to 15.7% ( P = 0.05065). Receiving any OAT was associated with increased PDD and readmission, but only within the postintervention cohort. CONCLUSIONS: A guideline to facilitate generalist management of opioid withdrawal in hospitalized patients improved the process of care, increasing the use of OAT and decreasing workload on the psychiatry consult services. Although increased inpatient OAT has been previously shown to decrease PDD, in this study PDD and readmission rates did not improve. Guidelines may be insufficient to impact these outcomes.

The influence of intake urinalysis, psychopathology measures, and menstrual cycle phase on treatment compliance.

Drug abuse among women is a societal health problem which has received greater attention in recent years. Studies examining sex differences in drug abuse have shown consistent differences between males and females. In the current study, we retrospectively examined 75 treatment-seeking females to determine the relationships between intake measurements of psychopathology, intake urinalysis, menstrual cycle phase at admission, and treatment compliance. Our results support a relationship among these variables and a potential relationship between menstrual cycle phase and anxiety level is discussed. These results support the need for the development of individually tailored treatment programs.

Low dose naltrexone administration in morphine dependent rats attenuates withdrawal-induced norepinephrine efflux in forebrain.

The administration of low dose opioid antagonists has been explored as a potential means of detoxification in opiate dependence. Previous results from our laboratory have shown that concurrent administration of low dose naltrexone in the drinking water of rats implanted with subcutaneous morphine pellets attenuates behavioral and biochemical signs of withdrawal in brainstem noradrenergic nuclei. Noradrenergic projections originating from the nucleus tractus solitarius (NTS) and the locus coeruleus (LC) have previously been shown to be important neural substrates involved in the somatic expression of opiate withdrawal. The hypothesis that low dose naltrexone treatment attenuates noradrenergic hyperactivity typically associated with opiate withdrawal was examined in the present study by assessing norepinephrine tissue content and norepinephrine efflux using in vivo microdialysis coupled to high performance liquid chromatography (HPLC) with electrochemical detection (ED). The frontal cortex (FC), amygdala, bed nucleus of the stria terminalis (BNST) and cerebellum were analyzed for tissue content of norepinephrine following withdrawal in morphine dependent rats. Naltrexone-precipitated withdrawal elicited a significant decrease in tissue content of norepinephrine in the BNST and amygdala. This decrease was significantly attenuated in the BNST of rats that received low dose naltrexone pre-treatment compared to controls. No significant difference was observed in the other brain regions examined. In a separate group of rats, norepinephrine efflux was assessed with in vivo microdialysis in the BNST or the FC of morphine dependent rats or placebo treated rats subjected to naltrexone-precipitated withdrawal that received either naltrexone in their drinking water (5 mg/L) or unadulterated water. Following baseline dialysate collection, withdrawal was precipitated by injection of naltrexone and sample collection continued for an additional 4 h. At the end of the experiment, animals were transcardially perfused and the brains were removed for verification of probe placement. Low dose naltrexone pre-treatment significantly attenuated withdrawal-induced increases of extracellular norepinephrine in the BNST, with a smaller effect in the FC. These findings suggest that alterations in norepinephrine release associated with withdrawal may be attenuated in forebrain targets of noradrenergic brainstem neurons that may underlie reduced behavioral signs of withdrawal following low dose naltrexone administration.

Levels of spirituality and treatment outcome: a preliminary examination.

OBJECTIVE: The primary aim of this study was to examine whether admission differences in levels of spirituality predisposed alcohol-dependent individuals to favorable or unfavorable outcomes following admission to facilities that differed in the degree to which spirituality was emphasized. It was hypothesized that individuals whose admission level of spirituality was congruent with the treatment program's orientation and who as such were considered optimally placed (i.e., "matched") for treatment would evince better in-treatment outcomes. METHOD: Four hundred and five participants completed measures of spirituality and psychosocial well-being at intake and at end of treatment. RESULTS: In examining the entire sample, no matching effects were observed on discharge status, abstinence efficacy, or desire to drink. When analyses were restricted to those cases scoring in the upper or lower quartiles in spirituality, we observed a paradoxical effect, as individuals recording lower levels of spirituality at the less spiritual program evinced significantly poorer outcomes (i.e., less abstinence efficacy, greater desire to drink). CONCLUSIONS: These findings hint at the importance of spirituality in the environment of care, indicating that individuals low in spirituality were at risk for poorer outcomes, but exposure to a program that emphasized spirituality lowered that risk.

Psychological and physiological stress negatively impacts early engagement and retention of opioid-dependent individuals on methadone maintenance.

The present study investigated whether psychological and/or physiological measures of stress would impede induction onto methadone maintenance and predict early (<6 months) discontinuation. Compared with controls, opioid-dependent subjects displayed increased distress on the perceived stress scale (PSS) and post-traumatic stress disorder checklist (PCLC); 60% exhibited abnormal cortisol. Addiction severity index (ASI), drug-use, and stress indices explained between 17 and 37% of the variance in engagement including attendance, opioid abstinence, and methadone stabilization. Participants who discontinued treatment displayed poor engagement, abnormal cortisol, elevated withdrawal symptoms, higher distress, and increased ongoing opioid use versus compliant individuals. Discontinuation was initially related to drug-use severity; however, by 6 months, retention depended primarily upon cortisol abnormalities, which increased an individual's discontinuation risk by 7.7-fold. These findings support admission screening with the ASI/cortisol for drop out, and stress/drug-use indices for engagement that together may enable clinically-relevant early recognition and interventions for prevention of stress-induced relapse in opioid-dependent populations.

Serotonin transporter (5-HTT) gene polymorphisms and susceptibility to cocaine dependence among African-American individuals.

Studies indicate that the serotonin system, particularly the serotonin transporter (5-HTT), may modulate the central effects of cocaine. We investigated whether a polymorphism in the 5' promotor region (5-HTTLPR) of the 5-HTT gene confers susceptibility to cocaine dependence. One hundred and ninety-seven cocaine-dependent African-American subjects and 101 controls were studied. Polymerase chain reaction based genotyping of a biallelic repeat polymorphism in the 5' promotor region yielded 2 alleles containing 484 (S) and 528 bp (L) repeats, respectively. There were no significant differences between controls of European background (n = 40) and African-American controls (n = 61) in distribution of genotypes (European: LL = 32.5%, LS = 40.0%, SS = 27.5%; African-American: LL = 27.9%, LS = 57.4%, SS = 14.7%) (chi(2) = 3.60, df = 2, p = 0.16) or allele frequencies (European: L = 52.5%, S = 47.5%; African-American: L = 56.6%, S = 43.4%) (chi(2) = 2.21, df = 1, p = 0.13). When cocaine patients were compared to an ethnically diverse control group (n = 101), frequencies of the L variant (65.0%) were significantly higher while the S variant (35.0%) was less frequent among cocaine patients compared to controls (L = 53.9%, S = 46.1%) (chi(2) = 6.83, df = 1, p < 0.01). Similarly, there were more cocaine patients with the LL genotype (41.1%) and less with the SS genotype (11.2%) compared to controls (LL = 29.7%, SS = 21.8%) (chi(2) = 7.43, df = 2, p < 0.05). However, after restricting controls to African-American individuals only (n = 61), cocaine subjects and controls did not differ significantly with respect to genotype distribution (chi(2) = 4.24, df = 2, p = 0.12) or allele frequencies (chi(2) = 2.83, df = 1, p = 0.10). In conclusion, although comparisons with a heterogeneous control group indicated a possible association between allelic variants of 5-HTTLPR and cocaine dependence among African-American cocaine subjects, this relationship was not observed when the control group was limited to African-American people only. Our findings need to be confirmed on larger samples of ethnically matched individuals.

Gender differences in cue exposure reactivity and 9-month outcome.

Gender differences have been shown to be related to the course of cocaine dependence and treatment. While previous research has shown cue exposure procedures to be somewhat effective at reducing reactivity of substance dependent individuals to drug related stimuli, the few studies that have examined gender differences in craving and cue-reactivity have yielded equivocal results. We have recently demonstrated that an active cue-exposure procedure that featured cocaine-dependent individuals receiving immediate feedback about their level of physiological arousal following videotaped exposure to cocaine-related stimuli was capable of positively influencing in-treatment (helplessness, abstinence efficacy) as well as 9-month followup outcome (i.e., urinalysis) indices (Sterling, R., Gottheil, E., Murphy, J., & Weinstein, S. (2001). Cue exposure and abstinence efficacy. College on Problems of Drug Dependence, Phoenix, AZ, June 17, 2001). The purpose of the present study was to determine whether differential in-treatment or 9-month followup outcomes were obtained for male and female study participants. Subjects in this study were 81 individuals (47 male/34 female) who met DSM-IV criteria for cocaine dependence and who had consented to be randomly assigned to either the active cue-exposure or control conditions. Participants were compared along a myriad of pre-treatment, in-treatment, and 9-month followup measures. Other than males reporting more recent employment, there was no obvious systematic pattern of differences on pre-treatment indices. No gender differences in treatment retention were observed. With respect to 9-month followup, no gender differences on measures of addiction severity, psychological functioning, or urinalyses were noted. However males were more "cue-reactive" and more successful at establishing control over their reactivity to the cocaine stimuli. Additional research is needed to determine whether these differences in reactivity can be more clearly defined and utilized positively in a treatment setting.

The role and impact of gender and age on children's preferences for pediatricians.

OBJECTIVE: To determine the physician gender preferences of children and the consequences of meeting/not meeting children's preferences, both in their liking and feeling comfortable in talking with the pediatrician. METHODS: A convenience sample of 125 parent-child pairs completed surveys when coming for an outpatient visit to a university-sponsored, urban pediatric practice. RESULTS: Both adolescents and preadolescents (especially females) as young as 9 years of age expressed a gender preference for their physician. Meeting those preferences significantly affected how much children both liked and felt comfortable in talking with their physician. In young teen females, gender-preferred physicians are synonymous with gender-congruent physicians; yet although their preference for gender-congruent physicians increased in early adolescence, data indicated that their preference was often not met for several years to come. CONCLUSIONS: Liking and comfort with the pediatrician are not only desirable, but may also influence the doctor-patient relationship and young people's ability to develop health communication skills that they need as adults. These results, if validated, could also lead to a rethinking of parental dominance in the role of physician selection.

A Comparison of Medical Symptoms Reported by Cocaine-, Opiate-, and Alcohol-Dependent Patients.

Substance abuse is frequently associated with adverse medical consequences. The differences in medical symptoms reported by 101 alcohol-, 113 cocaine-, and 107 opiate-dependent individuals receiving outpatient treatment were studied using a 134-item questionnaire (MILCOM). Data analysis revealed interesting and unexpected findings, with cocaine patients reporting the fewest total symptoms among the three groups. Moreover, cocaine patients reported significantly fewer CNS and musculoskeletal symptoms compared to both alcohol and opiate patients and significantly fewer GI and urinary symptoms than the alcohol but not the opiate patients. In addition, there were sex- and race-related differences in the pattern of symptoms reported. Women reported significantly more CVS, mood, nose/throat, CNS, skin, and GI symptoms than men. Similarly, Caucasians reported significantly more mood, CNS, nose/throat, head/neck, musculoskeletal, and GI symptoms than African-Americans. The study highlights the influence of drug of choice, gender, and race on medical needs of substance-abusing persons.

Is exposure to an effective contingency management intervention associated with more positive provider beliefs?

This study empirically examined opinions of treatment providers regarding contingency management (CM) programs while controlling for experience with a specific efficacious CM program. In addition to empirically describing provider opinions, we examined whether the opinions of providers at the sites that implemented the CM program were more positive than those of matched providers at sites that did not implement it. Participants from 7 CM treatment sites (n = 76) and 7 matched nonparticipating sites (n = 69) within the same nodes of the National Institute of Drug Abuse Clinical Trials Network completed the Provider Survey of Incentives (PSI), which assesses positive and negative beliefs about incentive programs. An intent-to-treat analysis found no differences in the PSI summary scores of providers in CM program versus matched sites, but correcting for experience with tangible incentives showed significant differences, with providers from CM sites reporting more positive opinions than those from matched sites. Some differences were found in opinions regarding costs of incentives, and these generally indicated that participants from CM sites were more likely to see the costs as worthwhile. The results from the study suggest that exposing community treatment providers to incentive programs may itself be an effective strategy in prompting the dissemination of CM interventions.

Using buprenorphine to treat opioid-dependent university students: opportunities, successes, and challenges.

OBJECTIVE: : The objective of this study was to characterize a population of opioid-dependent university students who were treated with buprenorphine, describe their treatment outcome, and discuss challenges the authors faced in working with this population in the setting of a university counseling center. METHODS: : We conducted a retrospective chart review of 27 opioid-dependent university students treated with buprenorphine at the university's counseling center. RESULTS: : Students were predominantly white (85%, n = 23), male (63%, n = 17), average age of 22 years with an average of 33.4 ± 28.79 months (range = 4 to 132) opioid use before presentation. By self-report, 17 (63.0%) students reported heroin use, 9 (33.3%) students reported prescription opioid use, and 1 (3.7%) student reported use of both. Fifteen (56%) reported intravenous use. Treatment retention was high with students receiving an average of 12.00 + 11.49 months treatment (range = 1 to 36). During the course of treatment, 81% of all submitted urine drug screens were negative for opioids, 83.1% were negative for cocaine, 90.7% were negative for illicit (nonprescribed) benzodiazepines, and 59.1% were negative for marijuana. The average buprenorphine dose was 13.8 ± 5.69 mg (range = 4 to 24 mg). No serious adverse effects occurred. In working with this population, we found that continued marijuana use, engagement in treatment, financial concerns, and decision making around family involvement were ongoing challenges. CONCLUSIONS: : Opioid-dependent university students are a unique group of substance users. Our results indicate that they can be safely and effectively treated with buprenorphine in a university counseling center.

Contribution of limbic norepinephrine to cannabinoid-induced aversion.

RATIONALE: The cannabinoid system has risen to the forefront in the development of novel treatments for a number of pathophysiological processes. However, significant side effects have been observed in clinical trials raising concerns regarding the potential clinical utility of cannabinoid-based agents. Understanding the neural circuits and neurochemical substrates impacted by cannabinoids will provide a better means of gaging their actions within the central nervous system that may contribute to the expression of unwanted side effects. OBJECTIVES: In the present study, we investigated whether norepinephrine (NE) in the limbic forebrain is a critical determinant of cannabinoid receptor agonist-induced aversion and anxiety in rats. METHODS: An immunotoxin lesion approach was combined with behavioral analysis using a place conditioning paradigm and the elevated zero maze. RESULTS: Our results show that the non-selective CB1/CB2 receptor agonist, WIN 55,212-2, produced a significant place aversion in rats. Further, NE in the nucleus accumbens was critical for WIN 55,212-2-induced aversion but did not affect anxiety-like behaviors. Depletion of NE from the bed nucleus of the stria terminalis was ineffective in altering WIN 55,212-2-induced aversion and anxiety. CONCLUSIONS: These results indicate that limbic, specifically accumbal, NE is required for cannabinoid-induced aversion but is not essential to cannabinoid-induced anxiety.

Cannabinoids and novelty investigation: influence of age and duration of exposure.

Administration of the synthetic cannabinoid receptor agonist WIN 55,212-2 has been shown to increase indices of noradrenergic activity. Neuroanatomical, neurochemical and behavioral studies have provided evidence supporting a marked impact of cannabinoids on the rat coeruleo-cortical pathway. As activity of this pathway is implicated in setting specific attentional modes, the present study assessed the influence of acute and repeated systemic administration of WIN 55,212-2 on novelty investigation in adolescent and adult male rats by using the hole board behavioral paradigm. Animals were individually acclimated to the hole board for 10-min sessions over 3 days, and novel objects were introduced on the fourth day. Novelty-seeking behavior was measured by comparison of the average number of return visits to a hole containing a novel object versus the average number of return visits to an empty hole. While attenuation of novelty preference was observed in adult rats acutely treated with WIN 55,212-2, both acutely treated adolescent groups retained their preference for novelty. All groups treated with repeated administration of either drug or vehicle demonstrated novelty preference, and no differences were found in the measure of novelty investigation between the groups. Furthermore, this study reproduced findings showing significant differences in locomotor activity that did not coincide with differences in novelty-seeking behavior. These data thus suggest a complex effect of CB1 receptor modulation on novelty preference in the male rat that is modulated by age and treatment.

A retrospective case control study of alcohol relapse and spiritual growth.

In the context of an NIAAA/Fetzer Institute-funded study designed to look at the impact of spirituality in an inpatient alcohol treatment, this retrospective case control study investigated whether spiritual growth occurred during an inpatient phase of treatment for alcohol dependence, the degree to which spiritual gains (if noted) would be maintained at follow-up, and whether spiritual growth would be associated with follow-up sobriety. To accomplish this goal, thirty-six individuals who reported relapsing to alcohol at three-month follow-up were compared with thirty-six matched controls who reported abstinence at follow-up. Spiritual development and change was assessed via a set of six measures. Paired t-tests revealed that spiritual growth occurred across all measures during the treatment phase. Repeated measures analysis of variance (ANOVA) indicated that this growth was maintained at three-month follow-up. Two-way repeated measures ANOVA revealed that while non-relapsers maintained spiritual growth over the course of four weeks of treatment and in the three-month period following treatment, renewed alcohol use was associated with decreased spirituality.

Relationship between tobacco smoking and medical symptoms among cocaine-, alcohol-, and opiate-dependent patients.

Despite widespread use of tobacco by alcohol and drug abusers, the medical effects of smoking remain understudied among such individuals. We investigated the relationship between tobacco smoking and medical symptoms among 87 cocaine-, 98 opiate- and 81 alcohol-dependent individuals receiving outpatient treatment. Smoking status was assessed and medical symptoms were recorded using a standardized 134-item self-report instrument (MILCOM). Almost 79% of patients were tobacco smokers. Analysis of variance revealed a main effect of tobacco smoking on medical symptoms. Smokers reported significantly more symptoms on the total scale as well as on the respiratory, cardiovascular, gastrointestinal, and nose/throat subscales compared to non-smokers. Furthermore, we found a significant interaction between tobacco smoking and substance abuse with respect to medical symptoms. While opiate and alcohol patients who smoked reported more symptoms than those who did not, unexpectedly, cocaine users who smoked reported fewer symptoms than those who did not smoke. While the findings support the link between smoking and medical problems among substance abusers, these effects do not seem to be uniform across various substances of abuse. In particular, cocaine patients seem to be affected differently than alcohol and opiate patients.