Characterization of peer support services for substance use disorders in 11 US emergency departments in 2020: findings from a NIDA clinical trials network site selection process.

INTRODUCTION: Emergency departments (ED) are incorporating Peer Support Specialists (PSSs) to help with patient care for substance use disorders (SUDs). Despite rapid growth in this area, little is published regarding workflow, expectations of the peer role, and core components of the PSS intervention. This study describes these elements in a national sample of ED-based peer support intervention programs. METHODS: A survey was conducted to assess PSS site characteristics as part of site selection process for a National Institute on Drug Abuse (NIDA) Clinical Trials Network (CTN) evaluating PSS effectiveness, Surveys were distributed to clinical sites affiliated with the 16 CTN nodes. Surveys were completed by a representative(s) of the site and collected data on the PSS role in the ED including details regarding funding and certification, services rendered, role in medications for opioid use disorder (MOUD) and naloxone distribution, and factors impacting implementation and maintenance of ED PSS programs. Quantitative data was summarized with descriptive statistics. Free-text fields were analyzed using qualitative content analysis. RESULTS: A total of 11 surveys were completed, collected from 9 different states. ED PSS funding was from grants (55%), hospital funds (46%), peer recovery organizations (27%) or other (18%). Funding was anticipated to continue for a mean of 16 months (range 12 to 36 months). The majority of programs provided "general recovery support (81%) Screening, Brief Intervention, and Referral to Treatment (SBIRT) services (55%), and assisted with naloxone distribution to ED patients (64%). A minority assisted with ED-initiated buprenorphine (EDIB) programs (27%). Most (91%) provided services to patients after they were discharged from the ED. Barriers to implementation included lack of outpatient referral sources, barriers to initiating MOUD, stigma at the clinician and system level, and lack of ongoing PSS availability due to short-term grant funding. CONCLUSIONS: The majority of ED-based PSSs were funded through time-limited grants, and short-term grant funding was identified as a barrier for ED PSS programs. There was consistency among sites in the involvement of PSSs in facilitation of transitions of SUD care, coordination of follow-up after ED discharge, and PSS involvement in naloxone distribution.

Opioid Overdose Hospitalizations During COVID-19: The Experience of Pennsylvania.

Objective: The COVID-19 pandemic placed extreme burden on hospitals, while opioid overdose is another challenging public health issue. This study aimed to examine the trends and outcomes of opioid overdose hospitalizations in Pennsylvania during 2018 to 2021. Design: We identified opioid overdose hospitalizations in the state of Pennsylvania using the state-wide hospital discharge database (PHC4) 2018 to 2021. We examined the number of opioid overdose hospitalizations, the corresponding mortality and discharges against medical advice comparing the pre-COVID period (2018-2019) and the COVID period (2020-2021). We also assessed what patient and hospital characteristics were associated with in-hospital death or leaving against medical advice. Results: A total of 13 446 opioid-related hospitalizations were identified in 2018 to 2021. Compared to pre-pandemic, a higher percentage of cases involving synthetics (17.0%vs 10.3%, P < .0001) were observed during COVID. After controlling for covariates, there was no significant difference in opioid overdose in-hospital deaths in the years 2020 to 2021 compared to 2018 to 2019 (OR = 0.846, 95% CI: 0.71-1.01, P = .065). The COVID period was significantly associated with more leaving against medical advice compared to years 2018 to 2019 (OR = 1.265, 95% CI: 1.11-1.44, P = .0003). Compared to commercial insurance, Medicaid insurance was associated with higher odds of both in-hospital death (OR = 1.383, 95% CI: 1.06-1.81, P = .0176) and leaving against medical advice (OR = 1.903, 95% CI: 1.56-2.33, P < .0001). Conclusion: There were no substantial changes in the number of overall opioid overdose cases and deaths at hospitals following the outbreak of COVID-19 in Pennsylvania. This observation suggests that an increased number of patients may have succumbed to overdoses outside of hospital settings, possibly due to a higher severity of overdoses. Further, we found that patients were more likely to leave against medical advice during the COVID-19 pandemic.

Opioid and Non-Opioid Pharmacotherapy Use for Pain Management Among Privately Insured Pediatric Patients With Cancer in the United States.

BACKGROUND: This study examined the trends and patterns of opioid and non-opioid pharmacotherapy use among a large national sample of privately insured pediatric patients with cancer in the United States. MATERIALS AND METHODS: We identified pediatric (aged < 21) patients diagnosed with central nervous system (CNS), lymphoma, gonadal, leukemia, or bone cancer from MarketScan data 2005-2019. We examined the proportion of patients who filled a prescription for the following 5 types of pharmacotherapy: opioid, anticonvulsant, non-steroidal anti-inflammatory drug (NSAID), antidepressant, and muscle relaxant during active cancer treatment. We assessed the trends and patterns in pharmacotherapy using multivariable logistic regressions. RESULTS: Among 4174 patients included, 2979 (71%) had an opioid prescription; 746 (18%), 384 (9%), 202 (5%), and 169 (4%) had anticonvulsant, NSAID, antidepressant and muscle relaxant prescriptions, respectively. Multivariable logistic regression showed a nonlinear trend in the use of opioids among pediatric patients with cancer over time such that use slightly increased until 2012 (OR of 1.40 [95% CI, 1.12-1.73] for 2012 vs. 2006) but then decreased thereafter (OR of 0.51 [0.37-0.68] for 2018 vs. 2012). The use of anticonvulsants, NSAIDs, and muscle relaxants increased significantly linearly over time (all P < .005). CONCLUSION: There has been a downward trend in the use of opioids in recent years among pediatric patients with cancer and an upward trend in the use of non-opioid pharmacotherapy for pain management potentially as an alternative to opioids.

ASAM Clinical Considerations: Buprenorphine Treatment of Opioid Use Disorder for Individuals Using High-potency Synthetic Opioids.

ABSTRACT: Treatment of opioid use disorder (OUD) with buprenorphine has evolved considerably in the last decade as the scale of the OUD epidemic has increased along with the emergence of high-potency synthetic opioids (HPSOs) and stimulants in the drug supply. These changes have outpaced the development of prospective research, so a clinical consideration document based on expert consensus is needed to address pressing clinical questions. This clinical considerations document is based on a narrative literature review and expert consensus and will specifically address considerations for changes to the clinical practice of treatment of OUD with buprenorphine for individuals using HPSO. An expert panel developed 6 key questions addressing buprenorphine initiation, stabilization, and long-term treatment for individuals with OUD exposed to HPSO in various treatment settings. Broadly, the clinical considerations suggest that individualized strategies for buprenorphine initiation may be needed. The experience of opioid withdrawal negatively impacts the success of buprenorphine treatment, and attention to its management before and during buprenorphine initiation should be proactively addressed. Buprenorphine dose and dosing frequency should be individualized based on patients' treatment needs, the possibility of novel components in the drug supply should be considered during OUD treatment, and all forms of opioid agonist treatment should be offered and considered for patients. Together, these clinical considerations attempt to be responsive to the challenges and opportunities experienced by frontline clinicians using buprenorphine for the treatment of OUD in patients using HPSOs and highlight areas where prospective research is urgently needed.

COVID-19-related flexibility in methadone take-home doses associated with decreased attrition: Report from an opioid treatment program in central Pennsylvania.

INTRODUCTION: Pennsylvania saw a dramatic increase in take-home doses of methadone after the COVID-19 pandemic-related relaxation in regulations. We evaluated whether pandemic-initiated relaxation in take-home methadone dose regulations was associated with changes in attrition and urine drug test (UDT) results at one outpatient opioid treatment program (OTP) among adult patients treated with methadone for opioid use disorder (OUD). METHODS: We analyzed aggregated, retrospective clinical practice data, using data abstracted from the OTP's electronic health record (EHR) on the number of patients treated with methadone, those allowed take-home doses, the number of take-home methadone doses dispensed, and the number and type of patient discharge ("attrition") from treatments for 12 months before (March 2019-February 2020; "pre-pandemic") and 12 months after (March 2020-February 2021; "pandemic") the regulatory changes took place. We also examined monthly aggregate data on the number of urine samples testing positive for amphetamines, cocaine, benzodiazepines or illicit opioids, and compared these findings between the pre-pandemic and pandemic periods. RESULTS: Pre-pandemic, 229 patients were treated with methadone, compared to 278 patients during the pandemic period. They received 11,047 and 28,563 take-home daily-doses of methadone (p < 0.0001) during each assessment period, respectively. All-cause treatment attrition (discharge from the program for any reason) decreased from 27.1 % in the pre-pandemic to 15.5 % in the pandemic period (p < 0.001). Compared to pre-pandemic, during the pandemic period the urine toxicology testing showed reduced positivity rates for cocaine (26.4 % vs 18.9 %, p < 0.001), and oxycodone and morphine (1.8 % vs 1.1 %, p < 0.019), and increased for fentanyl (24.0 % vs 30.5 %, p < 0.007), without statistically significant changes for benzodiazepines or amphetamines. CONCLUSIONS: The relaxation of regulations guiding take-home methadone doses accompanied reduced treatment attrition and favorable changes in urine toxicology results in one OTP. Allowing OTPs to apply flexible decisions regarding take-home methadone doses could improve treatment retention, outcomes, and, in turn, save lives.

Nutritional Status Differs by Prescription Opioid Use among Women of Reproductive Age: NHANES 1999-2018.

Prescription opioid use among pregnant women has increased in recent years. Prenatal exposure to opioids and poor nutrition can both negatively impact maternal-fetal outcomes. The objective of this study was to characterize the nutrition and health status of reproductive-age women taking prescription opioids, compared to women not taking opioids. Using NHANES 1999-2018 data, non-pregnant women aged 20-44 years were classified as taking a prescription opioid in the last 30 days (n = 404) or unexposed controls (n = 7234). Differences in anthropometric, cardiovascular, hematologic, and micronutrient status indicators between opioid-exposed and unexposed women were examined. Opioid-exposed women were older, had lower income and education, and were more likely to be non-Hispanic White, to smoke, and to have chronic health conditions compared to unexposed women. In unadjusted analyses, several nutrition and health markers were significantly different between opioid exposure groups. After controlling for covariates, women taking opioids had higher odds of Class II (OR = 1.6, 95% CI = 1.1-2.3) or III obesity (OR = 1.6, 95% CI = 1.1-2.5), and lower levels of serum folate, iron, and transferrin saturation. Reproductive-age women taking prescription opioids may be at risk for poorer nutritional and cardiometabolic health. Future research is needed to explore whether nutritional status impacts maternal-fetal outcomes for women exposed to opioids during pregnancy.

Disability-Adjusted Life-Years for Drug Overdose Crisis and COVID-19 Are Comparable During the Two Years of Pandemic in the United States.

OBJECTIVES: The drug overdose crisis with shifting patterns from primarily opioid to polysubstance uses and COVID-19 infections are 2 concurrent public health crises in the United States, affecting the population of sizes in different magnitudes (approximately < 10 million for substance use disorder [SUD] and drug overdoses vs 80 million for COVID-19 within 2 years of the pandemic). Our objective is to compare the relative scale of disease burden for the 2 crises within a common framework, which could help inform policy makers with resource allocation and prioritization strategies. METHODS: We calculated disability-adjusted life-years (DALYs) for SUD (including opioids and stimulants) and COVID-19 infections, respectively. We collected estimates for SUD prevalence, overdose deaths, COVID-19 cases and deaths, disability weights, and life expectancy from multiple publicly available sources. We then compared age distributions of estimated DALYs. RESULTS: We estimated a total burden of 13.83 million DALYs for SUD and drug overdoses and 15.03 million DALYs for COVID-19 in 2 years since March 2020. COVID-19 burden was dominated by the fatal burden (> 95% of total DALYs), whereas SUD burden was attributed to both fatal (53%) and nonfatal burdens (47%). The highest disease burden was among individuals aged 30 to 39 years for SUD (27%) and 50 to 64 years for COVID-19 (31%). CONCLUSIONS: Despite the smaller size of the affected population, SUD and drug overdoses resulted in comparable disease burden with the COVID-19 pandemic. Additional resources supporting evidence-based interventions in prevention and treatment may be warranted to ameliorate SUD and drug overdoses during both the pandemic and postpandemic recovery.

Patient- and Provider-Reported Experiences of a Mobile Novel Digital Therapeutic in People With Opioid Use Disorder (reSET-O): Feasibility and Acceptability Study.

BACKGROUND: Medications for the treatment of opioid use disorder, such as buprenorphine, are effective and essential for addressing the opioid epidemic. However, high dropout rates from medication remain a challenge. Behavioral treatment with contingency management and cognitive behavioral counseling has shown promise for improving the outcomes of buprenorphine treatment but is complicated to deliver. The delivery of behavioral treatment through technology-based platforms has the potential to make it more feasible for widespread dissemination. OBJECTIVE: reSET-O is a prescription digital therapeutic and a commercial adaptation of the Therapeutic Education System, an internet-based program with a Community Reinforcement Approach to cognitive behavioral therapy. It delivers cognitive behavioral therapy modules and contingency management rewards upon completion of modules and negative urine drug screens. This pilot study aims to assess the feasibility and acceptability of reSET-O in a community-based opioid treatment program with a Hub and Spoke model of care as part of a larger strategy to maintain individuals in treatment. Objective and qualitative results, as well as acceptability and likeability of reSET-O, were obtained from 15 individuals. METHODS: English-speaking individuals aged ≥18 years with a diagnosis of current opioid use disorder were recruited after being on buprenorphine for at least 1 week of treatment. Two 12-week prescriptions for reSET-O were written for the 24-week study. Patient reports of drug use and likeability scales of reSET-O were conducted at weeks 4, 8, 12, and 24 of the study. Qualitative interviews were also conducted. A total of 4 providers were recruited and provided feedback on the acceptability and feasibility of reSET-O. RESULTS: Of the 15 participants who participated in this pilot study, 7 (47%) completed 24 weeks, and 8 (53%) were unable to complete because of dropout after enrollment, attrition in treatment, or incarceration. An average of US $96 in contingency management rewards were earned by participants for the completion of modules for the duration of the pilot study. Participants' subjective feedback revealed that reSET-O was easy to use, enjoyable, and helped provide a safe space to admit recurring substance use. CONCLUSIONS: reSET-O was well accepted based on patient and provider feedback in this pilot study; however, adherence and retention in treatment remain areas for improvement. Randomized control trials are needed to assess whether retention of community-based buprenorphine treatment is enhanced through the use of technology-based behavioral interventions such as reSET-O.

Preparing for the future of medical education: A case series of traditional and virtual clinical rotations in addiction medicine spanning the COVID pandemic.

Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.

Research priorities for expanding access to methadone treatment for opioid use disorder in the United States: A National Institute on Drug Abuse Center for Clinical Trials Network Task Force report.

In the US, methadone treatment can only be provided to patients with opioid use disorder (OUD) through federal and state-regulated opioid treatment programs (OTPs). There is a shortage of OTPs, and racial and geographic inequities exist in access to methadone treatment. The National Institute on Drug Abuse Center for Clinical Trials Network convened the Methadone Access Research Task Force to develop a research agenda to expand and create more equitable access to methadone treatment for OUD. This research agenda included mechanisms that are available within and outside the current regulations. The task force identified 6 areas where research is needed: (1) access to methadone in general medical and other outpatient settings; (2) the impact of methadone treatment setting on patient outcomes; (3) impact of treatment structure on outcomes in patients receiving methadone; (4) comparative effectiveness of different medications to treat OUD; (5) optimal educational and support structure for provision of methadone by medical providers; and (6) benefits and harms of expanded methadone access. In addition to outlining these research priorities, the task force identified important cross-cutting issues, including the impact of patient characteristics, treatment, and treatment system characteristics such as methadone formulation and dose, concurrent behavioral treatment, frequency of dispensing, urine or oral fluid testing, and methods of measuring clinical outcomes. Together, the research priorities and cross-cutting issues represent a compelling research agenda to expand access to methadone in the US.

The opioid epidemic: Mobilizing an academic health center to improve outcomes.

Since 2000, opioid use disorder (OUD) has become an epidemic in the United States with more than 600,000 total deaths and a $51 billion annual cost. Patients with OUD require services from community-based organizations, local and state health departments, and health systems, all of which necessitate communication and collaboration among these groups to develop an effective strategy for diagnosis, treatment, and coordination of care. Academic health centers (AHCs) are poised to make significant contributions to the care of patients with OUD given in-house expertise across multiple medical specialties and the mission to care for patients in need. Despite the potential for AHCs to provide necessary services and address this public health crisis, progress has been slow. Many AHCs lack a clear roadmap for moving this agenda forward in their local regions. In response to rising deaths due to OUD, the authors' AHC undertook a significant redesign effort to facilitate the necessary processes and interdepartmental collaboration to provide patient-centered, comprehensive care for patients with OUD. In this article, using an organizational development framework (McKinsey 7S model), the authors describe their transformation process, and articulate strategies and potential barriers to implementing this framework. The goal of the article is to highlight the structural, procedural, and cultural changes that have occurred in one AHC so we can assist other AHCs in addressing the opioid epidemic.

Multi-model implementation of evidence-based care in the treatment of opioid use disorder in Pennsylvania.

Pennsylvania has the third highest rate of death due to drug overdose (44.3 per 100,000) in the country, which is significantly higher than the national rate. This continues to have drastic societal impact. Medication assisted treatment (MAT), which includes opioid agonist medications, is the gold standard in treatment for OUD; however, a significant gap remains between the number of individuals in need of treatment and the number of MAT providers. Penn State Health established a system to address the opioid epidemic through the Pennsylvania Coordinated Medication Assisted Treatment program utilizing lessons learned from existing validated models. Connecting primary care sites and hospital systems through a combination of Hub and Spoke, bridge clinic services provided at the Hub, peer recovery services, Project Extension for Community Health Outcomes (ECHO), and layered emergency department (ED) initiation of buprenorphine, this model is an innovative approach that addresses many known barriers to MAT treatment initiation. Early results within the first six months indicate significantly shortened wait time for patients seeking treatment, provision of waiver training to 70 local physicians to prescribe buprenorphine, and improved knowledge and ability to provide patient care for providers participating in our first Project ECHO cohort.

Combination Extended Smoking Cessation Treatment Plus Home Visits for Smokers With Schizophrenia: A Randomized Controlled Trial.

INTRODUCTION: The majority of people with schizophrenia have a diagnosis of tobacco dependence during their lifetime. A major obstacle to reducing the burden of cigarette smoking in this population is that these smokers have lower quit rates when undergoing standard treatment compared to smokers with no mental illness. We sought to determine if combination extended treatment (COMB-EXT) and home visits (HV) would lead to improved outcomes in smokers with schizophrenia. METHODS: Thirty-four cigarette smokers with schizophrenia completed either COMB-EXT with HV, COMB-EXT without HV, or treatment as usual (TAU) (random assignment). COMB-EXT consisted of group cognitive-behavioral therapy (CBT), bupropion, nicotine patch, and nicotine lozenge, which were initiated within 2 weeks and continued for 26 weekly visits. HV consisted of biweekly visits to the home with assessment of secondhand smoke (SHS) exposure and brief behavioral therapy with participants and others in the home environment. TAU consisted of group CBT plus serial single or combination medication trials as per standard care. RESULTS: Smokers with schizophrenia who received COMB-EXT (with or without HV) had greater reductions in cigarettes per day than those treated with TAU (both ps < .01). In addition, 7-day point prevalence abstinence rates for the three groups were 45%, 20%, and 8%, respectively, which was significantly higher for COMB-EXT plus HV than TAU (χ2(1) = 4.8, p = .03). Groups did not differ significantly in the number of adverse events, and HV were easily scheduled. CONCLUSION: COMB-EXT improves outcomes for smokers with schizophrenia. HV appeared to provide additional benefit for smoking cessation in this treatment-resistant population. IMPLICATIONS: The clear benefit found here of rapidly initiated, combination, extended treatment over TAU suggests that aggressive and extended treatment should be considered in clinical practice for smokers with schizophrenia. Furthermore, HV to address SHS exposure showed initial promise for assisting smokers with schizophrenia in maintaining abstinence, indicating that this intervention may be worthy of future research.

Criminal Charges Prior to and After Enrollment in Opioid Agonist Treatment: A Comparison of Methadone Maintenance and Office-based Buprenorphine.

BACKGROUND: Entry into methadone maintenance is associated with a reduction in criminal activity; less is known about the effects of office-based buprenorphine. OBJECTIVE: To compare criminal charges before and after enrollment in methadone maintenance or office-based buprenorphine. METHODS: Subjects were opioid-dependent adults who initiated either methadone maintenance (n = 252) or office-based buprenorphine (n = 252) between 2003 and 2007. Medical records were reviewed to gather demographic data and a state-maintained web-based database to collect data on criminal charges. Overall charges and drug charges in the 2 years prior to and after treatment enrollment were compared. Multivariable analysis was used to examine risk factors for charges after treatment enrollment. RESULTS: In the 2 years after enrolling in treatment, subjects receiving methadone had a significant decline in the proportion of subjects with any charges (49.6% vs. 32.5%, p < .001) or drug charges (25.0% vs. 17.5%, p = .015), as well as the mean number of cases (0.97 vs. 0.63, p = .002) and drug cases (0.38 vs. 0.23, p = .008), while those who initiated buprenorphine did not have significant changes in any of these measures. On multivariable analysis, the strongest predictor of criminal charges in the 2 years after treatment enrollment was prior charges (adjusted odds ratio 3.35, 95% confidence interval, 2.24-5.01). CONCLUSIONS: Enrollment in office-based buprenorphine treatment did not appear to have the same beneficial effect on subsequent criminal charges as methadone maintenance. If this observation is replicated in other settings, it may have implications for matching individuals to these treatment options.

Safety and effectiveness of a fixed-dose phenobarbital protocol for inpatient benzodiazepine detoxification.

Benzodiazepine dependence is a common problem. However, there is limited data on safe and effective detoxification protocols for benzodiazepine-dependent patients. We reviewed the medical records of 310 patients treated with a 3-day fixed-dose phenobarbital taper for benzodiazepine dependence over a 5-year period between 2004 and 2009. We recorded the incidence of seizures, falls, delirium, and emergency department (ED) visits or readmission to our institution within 30 days as markers for safety; we also recorded how many patients had doses held because of sedation. The taper was well tolerated, although one quarter of the patients had at least one dose held because of sedation. There were no seizures, falls, or injuries reported. Six percent had a readmission, and 7% had an ED visit at our institution within 30 days of discharge, but only 3 patients required readmission for withdrawal symptoms. Overall, this protocol appears to be safe and effective.