Clinical Management of Opioid Withdrawal.

Appropriate clinical management of opioid withdrawal is a crucial bridge to long-term treatment for opioid use disorder (OUD), because it is a high-risk time for potential opioid overdose and relapse. We provide a narrative review of evidence-based opioid withdrawal management strategies applicable to a variety of treatment settings and geographies. The goals of opioid withdrawal management include relieving suffering associated with withdrawal, providing appropriate diagnosis and screening, engaging patients in initiation of OUD treatment, and using harm reduction strategies, all guided by a patient-centered approach to care. In addition, we discuss complex cases, relapse prevention strategies, and new developments in opioid withdrawal management.

Reimagining patient-centered care in opioid treatment programs: Lessons from the Bronx during COVID-19.

Opioid treatment programs (OTPs) operate within a rigid set of clinical guidelines and regulations that specify the number of required OTP visits for supervised administration of methadone. To ensure physical distancing in light of COVID-19, the federal government loosened regulations to allow for additional flexibility. As OTP providers in the Bronx, NY, caring for more than 3600 patients in the epicenter of both the overdose and COVID-19 pandemics, we describe how our clinical practice changed with COVID-19. We halted toxicology testing, and to promote physical distancing and prevent interruptions in access to treatment for medications for opioid use disorder (MOUD), we drastically increased unsupervised take-home doses of MOUD. Within two weeks, we reduced the proportion of patients with 5-6 OTP visits per week from 47.2% to 9.4%. To guide treatment decision-making, we shifted focus from toxicology tests to other patient-centered measures, such as engagement in care and patient goals. In the initial three months, our patients experienced six nonfatal overdoses, no fatal overdoses, and 20 deaths attributable to COVID-19. This experience provides an opportunity to re-imagine care in OTPs going forward. We advocate that OTPs rely less on toxicology testing and more on the other patient-centered measures to guide decisions about distribution of take-home doses of MOUD. To minimize financial risk to OTPs and facilitate their transition to a more flexible model of care, we advocate for the reassessment of OTP reimbursement models.

Abstinence-reinforcing contingency management improves HIV viral load suppression among HIV-infected people who use drugs: A randomized controlled trial.

BACKGROUND: HIV-infected people who use drugs (PWUD) have poor HIV outcomes. Few studies tested interventions to improve HIV outcomes among PWUD. Abstinence-reinforcing contingency management (CM) reduces drug use and could also improve HIV outcomes. METHODS: From 2012-2017, we conducted a randomized controlled trial testing whether a 16-week abstinence-reinforcing CM intervention improved HIV viral load (VL) among HIV-infected adults using opioids or cocaine. In the CM intervention, drug-free urines led to escalating value of vouchers ($2.50-$80/voucher, $1320 total maximum). In intention-to-treat mixed-effects linear and logistic regression analyses, we examined whether the CM intervention improved log10 VL (primary outcome), abstinence and antiretroviral adherence (secondary outcomes). RESULTS: Thirty-seven participants were randomized to the CM intervention and 36 to control. Median age was 49.2 years; most were male (61.6%) and non-Hispanic black (46.6%). In CM (vs. control) participants, mean reduction in log10 VL was greater (-0.16 log10 VL copies/mL per 4-week period; 95% CI: -0.29 to -0.03, p < 0.05). Over 16 weeks, CM participants had a mean reduction of 0.64 copies/mL in log10 VL greater than control participants. The CM intervention was not significantly associated with abstinence or adherence. CONCLUSIONS: This is the first study to demonstrate improvements in HIV VL via an abstinence-reinforcing CM intervention. Because the CM intervention did not significantly affect abstinence or adherence, the mechanism of its effect is unclear. To end the HIV epidemic, innovative strategies must address individuals with poor HIV outcomes. Abstinence-reinforcing CM may be one potential strategy to improve HIV outcomes among a select group of PWUD.

Teaching and assessing residents' skills in managing heroin addiction with objective structured clinical examinations (OSCEs).

BACKGROUND: Heroin-abusing patients present a significant challenge. Objective Structured Clinical Examinations (OSCEs) allow evaluation of residents' clinical skills. The objective of this study was to examine residents' OSCE performance assessing and managing heroin abuse. METHODS: Evaluation and comparison of heroin-specific communication, assessment, and management skills in a 5-station postgraduate year 3 (PGY3) substance abuse OSCE. Faculty used a 4-point Likert scale to assess residents' skills; standardized patients provided written comments. RESULTS: Two hundred sixty-five internal and family medicine residents in an urban university hospital participated over 5 years. In the heroin station, residents' skills were better (P < .001 for both comparisons) in communication (mean overall score: 316 ± 0.51) than in either assessment (mean overall score: 2.66 ± 0.60) or management (mean overall score: 2.50 ± 0.73). The mean score for assessing specific high-risk behaviors was lower than the mean overall assessment score (222 ± 1.01 vs. 2.74 ± .59; P < .0001), and the mean score for recommending appropriate harm reduction management strategies was lower than the mean overall management score (2.39 ± .89 vs. 2.54 ± .74; P < .005). Standardized patients' comments reflected similar weaknessess in residents' skills. CONCLUSIONS: Assessment and management of heroin abuse were more challenging for residents than general communication. Additional training is required for residents to assess and counsel patients about high-risk behaviors.

Concurrent group treatment for hepatitis C: implementation and outcomes in a methadone maintenance treatment program.

Chronic hepatitis C virus (HCV) infection is highly prevalent among current and former drug users. However, the minority of patients enrolled in drug treatment programs have initiated HCV treatment. New models are needed to overcome barriers to care. In this retrospective study, we describe the implementation and outcomes of 42 patients treated in a concurrent group treatment (CGT) program. Patients participated in weekly provider-led group treatment sessions which included review of side effects; discussion of adherence and side effect management; administration of interferon injections; brief physical examination; and ended with brief meditation. Of the first 27 patients who initiated CGT, 42% achieved a sustained viral response. In addition, 87% (13/15) of genotype-1 infected patients treated with direct acting antiviral agent achieved an undetectable viral load at 24 weeks. The CGT model may be effective in overcoming barriers to treatment and improving adherence and outcomes among patients enrolled in drug treatment programs.

Evaluation of a substance use disorder curriculum for internal medicine residents.

Teaching about diagnosis, treatment, and sequelae of substance use disorders (SUDs) is insufficient in most Internal Medicine residency programs. To address this, the authors developed, implemented, and evaluated a novel and comprehensive SUD curriculum for first year residents (interns) in Internal Medicine, which anchors the ensuing 3-year longitudinal SUD curriculum. This intern curriculum includes didactic and experiential elements and allows skills practice. Topics include local epidemiology of substance abuse, neurobiology of SUDs, and screening, treatment, and referral. The entire curriculum is delivered over 7 hours during a month-long ambulatory rotation. Among 58 interns who have completed a pre-post evaluation of the curriculum, the majority reported an increased sense of responsibility for and confidence in treating patients with SUDs.

Teaching internal medicine resident physicians about Alcoholics Anonymous: a pilot study of an educational intervention.

Greater physician confidence in treating alcoholism is associated with a higher frequency of referring alcoholic patients for treatment, but many physicians have limited experience with Alcoholics Anonymous. We implemented a brief, didactic and experiential educational intervention about AA and evaluated its effect on knowledge and attitudes, using a before-after repeated measures study design. Thirty-six first-year internal medicine resident physicians received an educational intervention, which consisted of a 45-minute lecture about AA, a visit to an AA meeting, and a 30-minute debriefing session the next day. Residents' knowledge and attitudes were assessed by a brief written anonymous survey before and after the educational intervention. Residents reported increases in self-perceived knowledge about AA and had more favorable attitudes towards AA after the intervention. Our pilot study shows that a brief, didactic and experiential course can improve physician knowledge and attitudes about AA, and holds promise for improving physician interface with this commonly used intervention.

Teaching about Substance Abuse with Objective Structured Clinical Exams.

BACKGROUND: Although residents commonly manage substance abuse disorders, optimal approaches to teaching these specialized interviewing and intervention skills are unknown. OBJECTIVE: We developed a Substance Abuse Objective Structured Clinical Exam (OSCE) to teach addiction medicine competencies using immediate feedback. In this study we evaluated OSCE performance, examined associations between performance and self-assessed interest and competence in substance abuse, and assessed learning during the OSCE. DESIGN: Five-station OSCE, including different substance abuse disorders and readiness to change stages, administered during postgraduate year-3 ambulatory rotations for 2 years. PARTICIPANTS: One hundred and thirty-one internal and family medicine residents. MEASUREMENTS: Faculty and standardized patients (SPs) assessed residents' general communication, assessment, management, and global skills using 4-point scales. Residents completed a pre-OSCE survey of experience, interest and competence in substance abuse, and a post-OSCE survey evaluating its educational value. Learning during the OSCE was also assessed by measuring performance improvement from the first to the final OSCE station. RESULTS: Residents performed better (P<.001) in general communication (mean+/-SD across stations=3.12+/-0.35) than assessment (2.65+/-0.32) or management (2.58+/-0.44), and overall ratings were lowest in the contemplative alcohol abuse station (2.50+/-0.83). Performance was not associated with residents' self-assessed interest or competence. Perceived educational value of the OSCE was high, and feedback improved subsequent performance. CONCLUSIONS: Although internal and family medicine residents require additional training in specialized substance abuse skills, immediate feedback provided during an OSCE helped teach needed skills for assessing and managing substance abuse disorders.