Association of MOUD ECHO Participation on Expansion of Buprenorphine Prescribing in Rural Primary Care.

BACKGROUND: Lack of access to buprenorphine to treat Opioid Use Disorder is profound in rural areas where over half of small and remote rural counties have no buprenorphine prescriber. To increase prescribing, an online, Medication of Opioid Use Disorder (MOUD) Extensions for Community Healthcare Outcomes (ECHO) was developed that addressed known barriers to the startup and expansion of treatment. The objective of the present study was to determine the relationship between participating in MOUD ECHO sessions and prescribing of buprenorphine for OUD in rural primary care. METHODS: Using non-random, rolling-recruitment from Feb 2018 to October of 2021, all rural primary care clinics in New Mexico were contacted via phone call and fax to recruit providers (Physicians, Nurse Practitioners, and Physician Assistants) who had no or limited buprenorphine experience to enroll in this study. Participation in the MOUD ECHO was tracked across the 12 week series. Start-up and expansion of buprenorphine treatment was measured every 3 months for up to 2 years using 5 implementation benchmarks spanning training completion, obtaining licensure, prescribing and adding patients. Using a dose-response intention to treat type analysis, associations between number of sessions and benchmark achievement were analyzed using logistic regression. RESULTS: Eighty providers were enrolled, mostly female (66%) white (82%), non-Hispanic (82%), and mostly nurse practitioners (51%) or MDs (38%). Achievement of prescribing benchmarks at 6 months was significantly increased by attendance at MOUD ECHO sessions including obtaining training and licensure Odds Ratio (OR = 1.24; P = .001); starting to prescribe (OR = 1.31; P = .004), and adding patients (OR = 1.14; P = .025). CONCLUSIONS: This study provides compelling evidence that MOUD ECHO participation may significantly increase the number of providers implementing this treatment and adding patients onto their panels. The dose-response approach helps address current gaps in ECHO research that call for more rigorous examination of the ECHO model's impact on provider practice improvements.

Evaluation and guide for embedding opioid use disorder education in health professions' curricula.

BACKGROUND: Morbidity and mortality from Opioid Use Disorder is a health crisis in the United States. During the COVID-19 pandemic, there was a devastating increase of 38.4% in overdose deaths from the 12-month period leading up to June 2019 compared with the 12-month period leading up to May 2020, primarily driven by synthetic opioids. Buprenorphine is an effective medication for opioid use disorder but uptake is slow due in part to lack of provider knowledge, confidence, and negative attitudes/stigma toward patients with OUD. Addressing these barriers in academic training is a promising approach to building workforce able to effectively treat opioid use disorder. METHODS: Our university developed a training for pre-licensure physicians, physician assistants and psychiatric nurse practitioners that included the DATA Waiver training and a shadowing experience. Expected outcomes included improved knowledge, skills and attitudes about persons with OUD and buprenorphine treatment, plans to provide this treatment post-graduation, for pre-licensure learners to have completed all requirements to prescribe buprenorphine post-graduation, and for the training to be embedded into school's curricula. RESULTS: Results were positive overall including improved knowledge and attitudes toward persons with OUD, better understanding of the benefits of this treatment for patients, increased confidence and motivation to provide this treatment post-graduation. The training is now embedded in each program's graduation requirements. CONCLUSION: Developing a didactic and experiential training on buprenorphine treatment for opioid use disorder and embedding it into medical, physician assistant, and psychiatric nurse practitioner licensure programs can help prepare future providers to treat opioid use disorder in a range of settings. Key to replicating this program in other university settings is to engage faculty members who actively provide treatment to persons with OUD to ensure shadowing opportunities and serve as role models for learners.

Psychedelic Therapies at the Crossroads of Trauma and Substance Use: Historical Perspectives and Future Directions, Taking a Lead From New Mexico.

Post-traumatic stress disorder (PTSD), a common condition with potentially devastating individual, family, and societal consequences, is highly associated with substance use disorders (SUDs). The association between PTSD and SUD is complex and may involve adverse childhood experiences (ACEs), historical and multi-generational traumas, and social determinants of health as well as cultural and spiritual contexts. Current psychosocial and pharmacological treatments for PTSD are only modestly effective, and there is a need for more research on therapeutic interventions for co-occurring PTSD and SUD, including whether to provide integrated or sequential treatments. There is a current resurgence of interest in psychedelics as potential treatment augmentation for PTSD and SUDs with an appreciation of the risks in this target population. This paper reviews the historical perspective of psychedelic research and practices, as well as the intersection of historical trauma, ACEs, PTSD, and SUDs through the lens of New Mexico. New Mexico is a state with high populations of Indigenous and Hispanic peoples as well as high rates of trauma, PTSD, and SUDs. Researchers in New Mexico have been leaders in psychedelic research. Future directions for psychedelic researchers to consider are discussed, including the importance of community-based participatory approaches that are more inclusive and respectful of Indigenous and other minority communities.

Feasibility and acceptability of an online ECHO intervention to expand access to medications for treatment of opioid use disorder, psychosocial treatments and supports.

Background: Buprenorphine combined with psychosocial support is the standard of care for treatment of opioid use disorder (OUD) in office-based primary care settings. However, uptake of this treatment has been slow due to a number of addressable barriers including providers' lack of training, staffing concerns, stigma and the need for ongoing support and consultation. This study examined acceptability and feasibility of an online Extensions for Community Healthcare Outcomes (ECHO) model intervention developed to support rural primary care clinics to expand treatment and is part of a larger study tracking the impact of participation in this ECHO on expansion of MOUD in rural primary care. Methods: We developed a comprehensive, 12-week online education and mentorship intervention using ECHO aimed at supporting the entire primary care clinic to start or expand treatment using MOUD, psychosocial treatments and recovery supports. We tracked participation and collected feedback using qualitative interviews and post-session questionnaires. Results: Sixty-seven primary care staff across 27 rural clinics in New Mexico participated in the study including 32 prescribers and 35 clinic support staff. Average participation was 4/12 sessions. Post-session questionnaires showed positive feedback, including that 95% or more respondents agreed or strongly agreed that the sessions were relevant and improved their confidence. Qualitative interview themes included strong endorsement of the ECHO curriculum. Clinical duties were the most common barrier to attending sessions. Conclusions: Engagement of 27 clinics, the range of staff and providers who participated, and positive feedback gathered through survey and qualitative interviews provide evidence of feasibility and acceptability of MOUD ECHO to support expansion of this treatment. However, barriers to participation present an important threat to feasibility. Understanding feasibility and acceptability is an important component of research on the impact of ECHO to expand MOUD treatment.

Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program.

Importance: The US opioid crisis was deemed a public health emergency in 2017. More than 130 individuals in the US die daily as a result of unintentional opioid overdose deaths. Objective: To measure use of take-home naloxone for overdose reversals performed by study participants with opioid use disorder receiving treatment at an opioid treatment program. Design, Setting, and Participants: In a year-long cohort study, between April 4, 2016, and May 16, 2017, 395 study participants enrolled at the University of New Mexico Addiction and Substance Abuse Opioid Treatment Program, an outpatient clinic treating substance use disorders. Inclusion criteria included all patients enrolled at University of New Mexico Addiction and Substance Abuse Opioid Treatment Program during the study enrollment period; positive history of opioid use disorder treated with methadone, buprenorphine, or naltrexone; and age 18 years or older. Exclusion criteria included allergy to naloxone and age younger than 18 years. The study closed 1 year after enrollment, on May 17, 2018. Data analysis was performed from May 2018 to July 2019. Exposure: Two doses of take-home naloxone combined with opioid overdose education were provided to study participants. Main Outcomes and Measures: The primary outcome was to measure the association of take-home naloxone with overdose reversals performed by patients with opioid use disorder enrolled in an opioid treatment program. Results: We enrolled 395 study participants (270 female [68.4%]; mean [SD] age, 35.4 [12.6] years; 260 [65.8%] with Hispanic white race/ethnicity) in the 1-year prospective trial. Sixty-eight female participants (25.2% of all female participants) were pregnant at the time of enrollment. Seventy-three of the 395 study participants (18.0%) performed 114 overdose reversals in the community. All community reversals were heroin related. Most study participants (86.8%) stated that the person on whom they performed an overdose reversal was a friend, relative, acquaintance, or significant other. In the year before enrollment, only 18 study participants (4.5%) had been prescribed naloxone. Conclusions and Relevance: Take-home naloxone as part of overdose education and naloxone distribution provided to patients in an opioid treatment program may be associated with a strategic targeted harm reduction response for reversing opioid overdose-related deaths. Policy makers may consider regulations to mandate overdose education and naloxone distribution in opioid treatment programs.

An Innovative Model for Naloxone Use Within an OTP Setting: A Prospective Cohort Study.

OBJECTIVES: Unintentional opioid overdose deaths are a public health crisis, and naloxone is the most effective harm reduction tool to curb many of these deaths. There is growing evidence that take-home naloxone can prevent opioid overdose in targeted populations. The goal of this study is to measure the opioid overdose reversal rate with take-home naloxone among participants with a diagnosis of opioid use disorder (OUD) in an opioid treatment program (OTP) setting. METHODS: Patients enrolled in an outpatient OTP program were eligible for this prospective cohort study between April 4, 2016 and July 4, 2016. Two hundred forty-four study participants received overdose education, instruction on how to use naloxone, and were provided with 2 doses of a take-home naloxone auto-injector kit. They were subsequently followed for 3 months. RESULTS: Thirty-one study participants reported overdose reversals using naloxone auto-injector kits on 38 community members. All overdose reversals were heroin-related. Eighty-seven per cent of the community members reversed with naloxone were friends or relatives of the study participants. CONCLUSIONS: This study validates that naloxone is not commonly used on the index study participant, but is often used on a secondary target among people who inject drugs. The large number of overdose reversals reported in this prospective study suggests that this novel model for naloxone use may be replicated at other OTP settings to reduce opioid overdose deaths.