Substance use patterns, sociodemographics, and health profiles of harm reduction service recipients in Burlington, Vermont.

BACKGROUND: Understanding current substance use practices is critical to reduce and prevent overdose deaths among individuals at increased risk including persons who use and inject drugs. Because individuals participating in harm reduction and syringe service programs are actively using drugs and vary in treatment participation, information on their current drug use and preferred drugs provides a unique window into the drug use ecology of communities that can inform future intervention services and treatment provision. METHODS: Between March and June 2023, 150 participants in a harm reduction program in Burlington, Vermont completed a survey examining sociodemographics; treatment and medication for opioid use disorder (MOUD) status; substance use; injection information; overdose information; and mental health, medical, and health information. Descriptive analyses assessed overall findings. Comparisons between primary drug subgroups (stimulants, opioids, stimulants-opioids) of past-three-month drug use and treatment participation were analyzed using chi-square and Fisher's exact test. RESULTS: Most participants reported being unhoused or unstable housing (80.7%) and unemployed (64.0%) or on disability (21.3%). The drug with the greatest proportion of participants reporting past three-month use was crack cocaine (83.3%). Fentanyl use was reported by 69.3% of participants and xylazine by 38.0% of participants. High rates of stimulant use were reported across all participants independent of whether stimulants were a participant's primary drug. Fentanyl, heroin, and xylazine use was less common in the stimulants subgroup compared to opioid-containing subgroups (p < .001). Current- and past-year MOUD treatment was reported by 58.0% and 77.3% of participants. Emergency rooms were the most common past-year medical treatment location (48.7%; M = 2.72 visits). CONCLUSIONS: Findings indicate high rates of polysubstance use and the underrecognized effects of stimulant use among people who use drugs-including its notable and increasing role in drug-overdose deaths. Crack cocaine was the most used stimulant, a geographical difference from much of the US where methamphetamine is most common. With the increasing prevalence of fentanyl-adulterated stimulants and differences in opioid use observed between subgroups, these findings highlight the importance and necessity of harm reduction interventions (e.g., drug checking services, fentanyl test strips) and effective treatment for individuals using stimulants alongside MOUD treatment.

Users' Acceptability and Perceived Efficacy of mHealth for Opioid Use Disorder: Scoping Review.

BACKGROUND: The opioid crisis continues to pose significant challenges to global public health, necessitating the development of novel interventions to support individuals in managing their substance use and preventing overdose-related deaths. Mobile health (mHealth), as a promising platform for addressing opioid use disorder, requires a comprehensive understanding of user perspectives to minimize barriers to care and optimize the benefits of mHealth interventions. OBJECTIVE: This study aims to synthesize qualitative insights into opioid users' acceptability and perceived efficacy of mHealth and wearable technologies for opioid use disorder. METHODS: A scoping review of PubMed (MEDLINE) and Google Scholar databases was conducted to identify research on opioid user perspectives concerning mHealth-assisted interventions, including wearable sensors, SMS text messaging, and app-based technology. RESULTS: Overall, users demonstrate a high willingness to engage with mHealth interventions to prevent overdose-related deaths and manage opioid use. Users perceive mHealth as an opportunity to access care and desire the involvement of trusted health care professionals in these technologies. User comfort with wearing opioid sensors emerged as a significant factor. Personally tailored content, social support, and encouragement are preferred by users. Privacy concerns and limited access to technology pose barriers to care. CONCLUSIONS: To maximize benefits and minimize risks for users, it is crucial to implement robust privacy measures, provide comprehensive user training, integrate behavior change techniques, offer professional and peer support, deliver tailored messages, incorporate behavior change theories, assess readiness for change, design stigma-reducing apps, use visual elements, and conduct user-focused research for effective opioid management in mHealth interventions. mHealth demonstrates considerable potential as a tool for addressing opioid use disorder and preventing overdose-related deaths, given the high acceptability and perceived benefits reported by users.

Emergency Department Peer Support Program and Patient Outcomes After Opioid Overdose.

Importance: Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking. Objective: To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization. Design, Setting, and Participants: This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023. Exposure: Hospital OORP implementation. Main Outcomes and Measures: The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access. Results: A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities. Conclusions and Relevance: In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.

Evaluation of heroin-assisted treatment in Norway: protocol for a mixed methods study.

BACKGROUND: Opioid agonist treatment (OAT) for patients with opioid use disorder (OUD) has a convincing evidence base, although variable retention rates suggest that it may not be beneficial for all. One of the options to include more patients is the introduction of heroin-assisted treatment (HAT), which involves the prescribing of pharmaceutical heroin in a clinical supervised setting. Clinical trials suggest that HAT positively affects illicit drug use, criminal behavior, quality of life, and health. The results are less clear for longer-term outcomes such as mortality, level of function and social integration. This protocol describes a longitudinal evaluation of the introduction of HAT into the OAT services in Norway over a 5-year period. The main aim of the project is to study the individual, organizational and societal effects of implementing HAT in the specialized healthcare services for OUD. METHODS: The project adopts a multidisciplinary approach, where the primary cohort for analysis will consist of approximately 250 patients in Norway, observed during the period of 2022-2026. Cohorts for comparative analysis will include all HAT-patients in Denmark from 2010 to 2022 (N = 500) and all Norwegian patients in conventional OAT (N = 8300). Data comes from individual in-depth and semi-structured interviews, self-report questionnaires, clinical records, and national registries, collected at several time points throughout patients' courses of treatment. Qualitative analyses will use a flexible inductive thematic approach. Quantitative analyses will employ a wide array of methods including bi-variate parametric and non-parametric tests, and various forms of multivariate modeling. DISCUSSION: The project's primary strength lies in its comprehensive and longitudinal approach. It has the potential to reveal new insights on whether pharmaceutical heroin should be an integral part of integrated conventional OAT services to individually tailor treatments for patients with OUD. This could affect considerations about drug treatment even beyond HAT-specific topics, where an expanded understanding of why some do not succeed with conventional OAT will strengthen the knowledge base for drug treatment in general. Results will be disseminated to the scientific community, clinicians, and policy makers. TRIAL REGISTRATION: The study was approved by the Norwegian Regional Committee for Medical and Health Research Ethics (REK), ref.nr.:195733.

The dynamics of heroin and illicit opioid use disorder, casual use, treatment, and recovery: A mathematical modeling analysis.

A leading crisis in the United States is the opioid use disorder (OUD) epidemic. Opioid overdose deaths have been increasing, with over 100,000 deaths due to overdose from April 2020 to April 2021. This paper presents a mathematical model to address illicit OUD (IOUD), initiation, casual use, treatment, relapse, recovery, and opioid overdose deaths within an epidemiological framework. Within this model, individuals remain in the recovery class unless they relapse back to use and due to the limited availability of specialty treatment facilities for individuals with OUD, a saturation treatment function was incorporated. Additionally, a casual user class and its corresponding specialty treatment class were incorporated. We use both heroin and all-illicit opioids datasets to find parameter estimates for our models. Bistability of equilibrium solutions was found for realistic parameter values for the heroin-only dataset. This result implies that it would be beneficial to increase the availability of treatment. An alarming effect was discovered about the high overdose death rate: by 2046, the disorder-free equilibrium would be the only stable equilibrium. This consequence is concerning because it means the epidemic would end due to high overdose death rates. The IOUD model with a casual user class, its sensitivity results, and the comparison of parameters for both datasets, showed the importance of not overlooking the influence that casual users have in driving the all-illicit opioid epidemic. Casual users stay in the casual user class longer and are not going to treatment as quickly as the users of the heroin epidemic. Another result was that the users of the all-illicit opioids were going to the recovered class by means other than specialty treatment. However, the change in the relapse rate has more of an influence for those individuals than in the heroin-only epidemic. The results above from analyzing this model may inform health and policy officials, leading to more effective treatment options and prevention efforts.

State Medicaid Initiatives Targeting Substance Use Disorder in Criminal Legal Settings, 2021.

Objectives. To document state Medicaid pre- and postrelease initiatives for individuals in the criminal legal system with substance use disorder (SUD). Methods. An Internet-based survey was sent in 2021 to Medicaid directors in all 50 US states and the District of Columbia to determine whether they were pursuing initiatives for persons with SUD across 3 criminal legal settings: jails, prisons, and community corrections. A 90% response rate was obtained. Results. In 2021, the majority of states did not report any targeted Medicaid initiatives for persons with SUD residing in criminal legal settings. Eighteen states and the District of Columbia adopted at least 1 Medicaid initiative for persons with SUD across the 3 criminal legal settings. The most commonly adopted initiatives were in the areas of medication for opioid use disorder treatment and Medicaid enrollment. Out of 24 possible initiatives for each state (8 initiatives across 3 criminal legal settings), the 2 most commonly adopted were (1) provision of medication treatment of opioid use disorder before release from criminal legal settings (16 states) and (2) facilitation of Medicaid enrollment through suspension rather than termination of Medicaid enrollment upon entry to a criminal legal setting (14 states). Initiatives pertaining to Medicaid SUD care coordination were adopted by the fewest (9) states. Conclusions. In 2021, states' involvement in Medicaid SUD initiatives for criminal legal populations remained low. Increased adoption of Medicaid SUD initiatives across criminal legal settings is needed, especially knowing the high rate of overdose mortality among this group. (Am J Public Health. 2024;114(5):527-530. https://doi.org/10.2105/AJPH.2024.307604).

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

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

Integrated exercise program in opioid agonist therapy clinics and effect on psychological distress: study protocol for a randomized controlled trial (BAReAktiv).

BACKGROUND: Substance use disorder is associated with unhealthy lifestyle choices, resulting in adverse social and health consequences. People with opioid use disorder receiving opioid agonist therapy, in particular, have high morbidity and reduced quality of life. Physical activity is recommended as an adjunctive treatment for people with substance use disorder, but there is minimal evidence from randomized controlled trials on the effects of this among people with substance use disorder receiving opioid agonist therapy. METHODS: BAReAktiv is a multicentre randomized controlled trial. The study aims to recruit 324 patients receiving opioid agonist therapy (parallel groups randomized 1:1 to integrated exercise intervention or control, superiority trial). A 16-week group-based integrated exercise intervention with workouts twice a week. The exercise program consists of endurance and resistance training. The target group will be patients 18 years and older receiving opioid agonist therapy in outpatient clinics in several centers in Western Norway. The primary outcome of the study is the effect on psychological distress measured by Hopkins' symptom checklist with ten items. Secondary outcome measures include physical functioning assessed with a 4-min step test, activity level, fatigue symptoms, quality of life, and changes in inflammation markers. This study will provide improved knowledge on the effects of an integrated exercise program in opioid agonist therapy. DISCUSSION: Systematically integrating exercise programs for people receiving opioid agonist therapy could lead to a shift towards a stronger focus on health behaviors in outpatient care. Integrating exercise could benefit patient recovery and reduce disease burden. Further scale-up will be considered if the provided exercise program is safe and effective. TRIAL REGISTRATION: ClinicalTrials.gov. NCT05242848. Registered on February 16, 2022.

Co-delivery of HIV pre-exposure prophylaxis (PrEP) and HIV testing among publicly insured adolescents and young adults (AYA) receiving medication for opioid use disorder (MOUD).

BACKGROUND: Low rates of HIV pre-exposure prophylaxis (PrEP) prescribing contribute to the disproportionate burden of HIV in the United States. Among adolescent and young adults (AYA) with opioid use disorder, HIV testing and PrEP co-prescription rates are poorly characterized. METHODS: We performed a retrospective analysis involving deidentified data from Philadelphia's Medicaid beneficiaries ages 16-29 years who were prescribed medication for opioid use disorder (MOUD) from 2015 to 2020 and continuously Medicaid-enrolled for ≥6 months prior to that prescription. After identifying the presence of a qualifying diagnosis signifying a PrEP indication, we examined the outcome of appropriate PrEP co-prescriptions and HIV testing using generalized estimating equations (GEE) modeling. RESULTS: We identified 795 AYA Medicaid beneficiaries with 1269 qualified treatment episodes. We calculated a PrEP prescribing rate of 29.47 per 1000 person-years among AYA receiving MOUD. The HIV testing rate was 63.47 per 1000 person-years among AYA receiving MOUD. GEE modeling revealed that individuals receiving methadone were more likely (aOR=2.62, 95% CI=1.06-6.49) to receive HIV testing within 6 months after a PrEP-qualifying diagnosis compared to those receiving other MOUD medications. Those who only saw outpatient behavioral health providers were less likely (aOR=0.48, 95% CI=0.24-0.99) to have received an HIV test within 6 months after the PrEP-qualifying diagnosis compared to those receiving inpatient behavioral health services. CONCLUSIONS: Co-prescription of PrEP and HIV testing among AYA receiving MOUD was rare in this large urban publicly insured population. Interventions are needed to increase HIV prevention services for this key population of AYA at risk for HIV infection.

Impact of comorbid opioid use disorder and major depressive disorder on healthcare utilization outcomes in patients with peripheral artery disease: A National Readmission Database analysis.

BACKGROUND: Prior research has demonstrated that individuals with peripheral artery disease (PAD) often have comorbid opioid use disorder (OUD) and major depressive disorder (MDD), with limited data regarding their impact on readmission outcomes, length of stay, and cost. This study aimed to investigate these healthcare utilization outcomes in patients with PAD who have comorbid OUD and MDD. METHODS: Data were obtained from the National Readmission Database from 2011 through 2018. The study population included all hospitalizations with PAD as the primary or secondary diagnosis, from which hospitalizations with OUD and MDD were extracted using appropriate ICD-9/10 diagnosis codes. Primary outcomes were 30-day and 90-day readmission, total cost, and total length of stay within the calendar year. We created hierarchical multivariable logistic regression models examining OUD with and without MDD, with a random effect for healthcare facility location. RESULTS: From 2011 to 2018, 13,265,817 weighted admissions with PAD were identified. These admissions were segmented into four categories: No OUD/No MDD (12,056,466), OUD/No MDD (323,762), No OUD/MDD (867,641), and OUD/MDD (17,948). The group with No OUD/No MDD was used as the reference group for all subsequent comparisons. Regarding 30-day and 90-day readmissions, patients with OUD/MDD had odds of 1.14 (95% CI 1.10, 1.18) and 1.09 (95% CI 1.06, 1.13), respectively. Patients with OUD/No MDD bore the highest median cost of $64,354 (IQR $30,797-137,074), and patients with OUD/MDD marked the lengthiest median stay of 6.01 days (IQR 2.01-13.30). CONCLUSION: This study found a significant association between these comorbidities and outcomes and therefore calls for targeted interventions and pain management strategies.

A qualitative study to determine perspectives of clinicians providing telehealth opioid use disorder treatment.

BACKGROUND: Telehealth-only medication for opioid use disorder (teleMOUD) treatment with buprenorphine was first made possible in the United States during the COVID-19 Public Health Emergency. As a result, several large provider groups now treat opioid use disorder (OUD) patients in nearly every state using telehealth. This study evaluates the perceptions and experiences of providers working almost exclusively in a teleMOUD program. METHODS: Qualitative interviews were conducted with 18 providers (physicians, physician assistants and nurse practitioners) using a semi-structured interview guide. Interviews were recorded, transcribed and reviewed. After reviewing the transcripts, a codebook was developed, interviews were coded, and coded excerpts were analyzed for key themes. RESULTS: Inductive codes were used to organize provider responses and included patient-level codes, provider-level codes, and telehealth environment codes. For providers, there are benefits of a flexible and less stressful working environment, which contribute to a higher quality of life. Providers also expressed mixed feelings regarding professional identity and focusing specifically on OUD, differences in relationships with colleagues, and challenges related to policy changes and ambiguities. For patients, providers perceived greater access, less stigma, more convenience, and a unique provider-patient relationship compared to in-person treatment. These themes affect providers and patients on multiple levels of the social-ecological model. CONCLUSIONS: Multiple themes emerged in this study. This work is amongst the first to describe perspectives of providers working in the nascent teleMOUD setting, and can inform initiatives to improve provider wellness, provider retention, and quality of care for patients treated in the setting.

Effect of a Co-Located Bridging Recovery Initiative on Hospital Length of Stay Among Patients With Opioid Use Disorder: The BRIDGE Randomized Clinical Trial.

Importance: Co-located bridge clinics aim to facilitate a timely transition to outpatient care for inpatients with opioid use disorder (OUD); however, their effect on hospital length of stay (LOS) and postdischarge outcomes remains unclear. Objective: To evaluate the effect of a co-located bridge clinic on hospital LOS among inpatients with OUD. Design, Setting, and Participants: This parallel-group randomized clinical trial recruited 335 adult inpatients with OUD seen by an addiction consultation service and without an existing outpatient clinician to provide medication for OUD (MOUD) between November 25, 2019, and September 28, 2021, at a tertiary care hospital affiliated with a large academic medical center and its bridge clinic. Intervention: The bridge clinic included enhanced case management before and after hospital discharge, MOUD prescription, and referral to a co-located bridge clinic. Usual care included MOUD prescription and referrals to community health care professionals who provided MOUD. Main Outcomes and Measures: The primary outcome was the index admission LOS. Secondary outcomes, assessed at 16 weeks, were linkage to health care professionals who provided MOUD, MOUD refills, same-center emergency department (ED) and hospital use, recurrent opioid use, quality of life (measured by the Schwartz Outcome Scale-10), overdose, mortality, and cost. Analysis was performed on an intent-to-treat basis. Results: Of 335 participants recruited (167 randomized to the bridge clinic and 168 to usual care), the median age was 38.0 years (IQR, 31.9-45.7 years), and 194 (57.9%) were male. The median LOS did not differ between arms (adjusted odds ratio [AOR], 0.94 [95% CI, 0.65-1.37]; P = .74). At the 16-week follow-up, participants referred to the bridge clinic had fewer hospital-free days (AOR, 0.54 [95% CI, 0.32-0.92]), more readmissions (AOR, 2.17 [95% CI, 1.25-3.76]), and higher care costs (AOR, 2.25 [95% CI, 1.51-3.35]), with no differences in ED visits (AOR, 1.15 [95% CI, 0.68-1.94]) or deaths (AOR, 0.48 [95% CI, 0.08-2.72]) compared with those receiving usual care. Follow-up calls were completed for 88 participants (26.3%). Participants referred to the bridge clinic were more likely to receive linkage to health care professionals who provided MOUD (AOR, 2.37 [95% CI, 1.32-4.26]) and have more MOUD refills (AOR, 6.17 [95% CI, 3.69-10.30]) and less likely to experience an overdose (AOR, 0.11 [95% CI, 0.03-0.41]). Conclusions and Relevance: This randomized clinical trial found that among inpatients with OUD, bridge clinic referrals did not improve hospital LOS. Referrals may improve outpatient metrics but with higher resource use and expenditure. Bending the cost curve may require broader community and regional partnerships. Trial Registration: ClinicalTrials.gov Identifier: NCT04084392.

A patient activation intervention in primary care for patients with chronic pain on long term opioid therapy: results from a randomized control trial.

BACKGROUND: Given significant risks associated with long-term prescription opioid use, there is a need for non-pharmacological interventions for treating chronic pain. Activating patients to manage chronic pain has the potential to improve health outcomes. The ACTIVATE study was designed to evaluate the effectiveness of a 4-session patient activation intervention in primary care for patients on long-term opioid therapy. METHODS: The two-arm, pragmatic, randomized trial was conducted in two primary care clinics in an integrated health system from June 2015-August 2018. Consenting participants were randomized to the intervention (n = 189) or usual care (n = 187). Participants completed online and interviewer-administered surveys at baseline, 6- and 12- months follow-up. Prescription opioid use was extracted from the EHR. The primary outcome was patient activation assessed by the Patient Activation Measure (PAM). Secondary outcomes included mood, function, overall health, non-pharmacologic pain management strategies, and patient portal use. We conducted a repeated measure analysis and reported between-group differences at 12 months. RESULTS: At 12 months, the intervention and usual care arms had similar PAM scores. However, compared to usual care at 12 months, the intervention arm demonstrated: less moderate/severe depression (odds ratio [OR] = 0.40, 95%CI 0.18-0.87); higher overall health (OR = 3.14, 95%CI 1.64-6.01); greater use of the patient portal's health/wellness resources (OR = 2.50, 95%CI 1.42-4.40) and lab/immunization history (OR = 2.70, 95%CI 1.29-5.65); and greater use of meditation (OR = 2.72; 95%CI 1.61-4.58) and exercise/physical therapy (OR = 2.24, 95%CI 1.29-3.88). At 12 months, the intervention arm had a higher physical health measure (mean difference 1.63; 95%CI: 0.27-2.98). CONCLUSION: This trial evaluated the effectiveness of a primary care intervention in improving patient activation and patient-reported outcomes among adults with chronic pain on long-term opioid therapy. Despite a lack of improvement in patient activation, a brief intervention in primary care can improve outcomes such as depression, overall health, non-pharmacologic pain management, and engagement with the health system. TRIAL REGISTRATION: The study was registered on 10/27/14 on ClinicalTrials.gov (NCT02290223).

Engaging the Great Circle: a qualitative study of the Confederated Tribes of Grand Ronde's mobile medication unit

BACKGROUND: The Confederated Tribes of the Grand Ronde Community of Oregon began a Mobile Medication Unit (MMU) as part of their Great Circle Recovery Opioid Treatment Program (OTP) to address elevated rates of opioid use disorder (OUD) among American Indians and Alaska Natives in Oregon. The MMU provides methadone or buprenorphine for individuals with OUD, enrolled in the OTP, who are living either on the reservation or in surrounding rural communities. An implementation study describes the service through document review and qualitatively assesses patient and staff experiences and the perceived barriers and facilitators to mobile services. METHODS: Semi-structured qualitative interviews with patients (n = 11), MMU staff (n = 5), and the state opioid treatment authority (n = 1) gathered details on the initiative's development and operations. Provider interviews probed implementation experiences. Patient interviews focused on their experiences with the MMU and staff, changes in quality of life and recommendations for enhancing treatment. Interviews were transcribed and analysed using a Thematic Analysis approach. RESULTS: Staff themes identified two driving forces (i.e. staff desire for an inclusive approach to wellness that is accessible to all community members; the catalysts for the MMU), two steps toward MMU development (i.e. Tribal approvals and support; the construction and maintenance of community relationships) and two perspectives on MMU implementation and impact (i.e. initial implementation barriers; facilitators and observations of how the MMU reduced stigma associated with agonist therapy). Patients' themes noted the MMU's professional and 'caring' environment, accessible rural locations and general suggestions including culturally responsive ancillary services. CONCLUSION: The Great Circle MMU enhanced access to opioid agonist therapy for people with OUD (i.e. American Indians/Alaska Natives, and non-natives) living in rural communities. The Confederated Tribes of Grand Ronde operates the first Tribally owned OTP MMU, grounded in cultural humility and committed to Tribal members and the great circle of the larger community.

A Harm Reduction Framework for Integrated Treatment of Co-Occurring Opioid Use Disorder and Trauma-Related Disorders.

The opioid epidemic has exposed a gulf in mental health research, treatment, and policy: Most patients with comorbid trauma-related disorder (TRD) and opioid use disorder (OUD) (TRD + OUD) remain undiagnosed or unsuccessfully treated for the combination of TRD symptoms and opioid use. TRD treatments tend to be psychotherapies that are not accessible or practical for many individuals with TRD + OUD, due to TRD treatment models not systematically incorporating principles of harm reduction (HR). HR practices prioritize flexibility and unequivocally improve outcomes and save lives in the treatment of OUD. Considering the urgent need to improve TRD + OUD treatment and outcomes, we propose that the OUD and TRD fields can be meaningfully reconciled by integrating HR principles with classic phasic treatment for TRD. Adding a "prestabilization" phase of treatment for TRD - largely analogous to the precontemplation Stage of Change - creates opportunities to advance research, clinical practice, and policies and potentially improve patient outcomes.

Mobile resonance frequency breathing smartphone application to support recovery among people with opioid use disorder: Study protocol for feasibility study.

BACKGROUND: Experiencing drug cravings is an aspect of substance use disorders that frequently compromises the recovery efforts of people who use drugs. Most treatment approaches that address drug cravings either involve cognitive strategies or medication. Few interventions directly address the physiological aspects of craving, such as increased heart rate. Previous research has demonstrated that slow-paced breathing may be effective in managing drug cravings by manipulating an individual's heart rate. The purpose of this paper is to describe a study protocol for an intervention that offers resonance frequency breathing training for managing cravings via a smartphone application (app). METHODS: This trial is registered in ClinicalTrials.gov (Identifier: NCT05830773). The intervention focuses on persons in recovery from opioid use disorder who receive services from the Texas Health and Human Service Commission Recovery Support Services division. Participants will be trained to use Camera Heart Rate Variability (CHRV), a resonance frequency breathing app. The CHRV app measures heart rate and the volumetric variations of blood circulation. When experiencing stress, anxiety, or cravings, participants will use the app to practice breathing exercises. Participants (N = 60) will also complete surveys at baseline, 4 weeks, and 8 weeks; the survey questions, covers demographic characteristics, personal trauma history, substance use experience, and utilization of substance use treatment services. The surveys will also include psychosocial measures of craving, stress, and anxiety to allow the study team to assess changes between baseline and study completion. Participants who complete the full 8-week intervention will be invited to participate in a 30-minute interview about their experience with the app. Interviews will provide details on implementation outcomes, including acceptability, appropriateness, and feasibility. CONCLUSION: Many evidence-based interventions for opioid use require interpersonal communication with individuals in one's recovery network. However, individuals may be unable to engage others in their recovery network in the moments when they are experiencing cravings or stress- and anxiety-related triggers. Therefore, recovery support interventions that emphasize individual self-management of cravings, stress, and anxiety when they occur can empower individuals in recovery and enhance existing interventions.

Effects of the Connections program on return-to-custody, mortality and treatment uptake among people with a history of opioid use: Retrospective cohort study in an Australian prison system.

BACKGROUND AND AIMS: Connections is a voluntary health program that facilitates access to opioid agonist treatment (OAT) and social services for people with opioid use exiting prison. This study aimed to measure the effectiveness of Connections in reducing recidivism and improving health outcomes for people with a history of opioid use on leaving prison. DESIGN: Retrospective cohort study with quasi-random allocation to the program. SETTING: Public adult prisons in New South Wales, Australia, 2008-2015. PARTICIPANTS: Adults released from custody with a history of opioid use. Of 5549 eligible releasees, 3973 were allocated to Connections and 1576 to treatment-as-usual. MEASUREMENTS: Outcomes were return-to-custody, all-cause mortality, and OAT participation. FINDINGS: Regression analyses on an intention-to-treat basis, and adjusting for baseline propensity scores, comparing patients allocated to Connections versus treatment-as-usual showed no difference in rates of return-to-custody within 2 years (hazard ratio [HR]: 1.01; 95% confidence interval [CI]: 0.92 -1.12). Patients allocated to the Connections program were more likely to access OAT (odds ratio [OR]: 1.21; 95% CI: 1.06-1.39) and had lower mortality within 28 days of release (0.25% vs. 0.66%; HR: 0.38; 95% CI: 0.14-1.03). Differences in mortality did not persist beyond 28 days. Subgroup analyses showed that allocation to Connections was associated with higher risk of return-to-custody within 28 days for Aboriginal and/or Torres Strait Islander (Indigenous) and female releasees. CONCLUSIONS: The Connections program for people with opioid use exiting prison did not reduce the likelihood of return-to-custody but did facilitate opioid agonist treatment participation on release from prison.

Suicide within 1 year of non-fatal overdose: Risk factors and risk reduction with medications for opioid use disorder.

OBJECTIVE: Individuals with substance use disorders and overdoses have high risk of suicide death, but evidence is limited on the relationship between interventions following the initial overdose and subsequent suicide death. METHODS: National Medicare data were used to identify Medicare disability beneficiaries (MDBs) with inpatient or emergency care for non-fatal opioid overdoses from 2008 to 2016. Data were linked with National Death Index (NDI) to obtain dates and causes of death for the sample. Cox proportional hazards models estimated the associations between exposure to interventions (mechanical ventilation, MOUD) and suicide death. RESULTS: The sample (n = 81,654) had a suicide rate in the year following a non-fatal overdose of 566 per 100,000 person-years. Post-overdose MOUD was associated with an adjusted hazard ratio of 0.20 (95%CI: 0.05,0.85). Risk of suicide was elevated for those whose initial overdoses required mechanical ventilation as part of the treatment (aHR: 1.86, 95%CI:[1.48,2.34]). CONCLUSIONS: The year following a non-fatal opioid overdose is a very high-risk period for suicide among MDBs. Those receiving MOUD had an 80% reduction in the hazards of suicide, while those whose overdose treatment involved mechanical ventilation had 86% higher hazards of death by suicide. Our findings highlight the importance of psychiatric intervention in this high-risk population. Efforts are needed to initiate and retain more patients in MOUD.