Sexually Transmitted Infection (STI) Incidence, STI Screening, and Human Immunodeficiency Virus Preexposure Prophylaxis Uptake in United States Veterans With Opioid Use Disorder in Long Island, New York.

Background: Opioid use disorder (OUD) confers increased risk of contracting bloodborne and sexually transmitted infections (STIs). Limited data exist on infectious disease screening and preexposure prophylaxis (PrEP) usage among United States Veterans (USVs) with OUD, including persons who inject drugs (PWID). This study aimed to evaluate the epidemiology of human immunodeficiency virus (HIV), hepatitis C virus (HCV), bacterial STIs, and PrEP uptake in USVs with OUD, including PWID. Methods: A retrospective chart review of USVs with OUD seeking care at Northport Veterans Affairs Medical Center between 2012 and 2022 was completed. Sociodemographics, HIV, HCV, STI testing rates and diagnosis, and PrEP uptake were compared between USVs, stratified by injection drug use history. Results: We identified 502 USVs with OUD; 43% had a history of injection drug use. Overall, 2.2% of USVs had HIV and 28.7% had HCV. An STI was diagnosed in 10% of USVs, most frequently syphilis (1.8%). PWID were more likely to be tested for HIV (93.5% PWID vs. 73.1% non-PWID; P < .001), HCV (95.8% PWID vs. 80.8% non-PWID; P < .001), and syphilis (80% PWID vs. 69.2% non-PWID; P = .006). Total gonorrhea and chlamydia testing rates were 31.9% and 33.7%, respectively, without difference between the groups. PrEP was prescribed in 1.2% of USVs. Conclusions: In USVs with OUD, gonorrhea and chlamydia screening occurred less frequently than syphilis, HCV, and HIV. PWID were more likely to be screened for HIV, HCV, and syphilis. PrEP uptake was low. Both PWID and non-PWID may benefit from increased STI screening and linkage to PrEP.

Successful administration of extended-release buprenorphine in the emergency department.

INTRODUCTION: The ongoing opioid epidemic in the United States has resulted in a substantial increase in overdose deaths and related morbidity and mortality. Given that emergency departments (ED) frequently serve as the initial point of contact for individuals experiencing opioid overdose or seeking treatment for opioid use disorder (OUD), ED clinicians have a pivotal role to play in providing prompt and effective treatment for OUD. While ED clinicians routinely administer sublingual and other transmucosal formulations of buprenorphine, extended-release buprenorphine (BUP-XR) remains underutilized in the ED. CASE REPORT: We present a case involving the successful administration of BUP-XR in the ED to a patient experiencing spontaneous opioid withdrawal. The patient tolerated test dosing of sublingual buprenorphine (BUP-SL) and subsequently received BUP-XR in the ED. Following this intervention, the patient was referred to the hospital-affiliated substance use disorder outpatient clinic, where he has since demonstrated successful follow-up and retention in treatment. CONCLUSION: Our report adds to the existing limited literature on the administration of BUP-XR in the ED and highlights the need for more comprehensive clinician teaching and guidance, as well as the establishment of in-hospital protocols for BUP-XR. Despite these challenges, our case indicates that initiating BUP-XR could be a viable and effective option for ED patients with OUD.

Study Protocol for the Opioid and Pain Treatment in Indigenous Communities Trial: A Systems Level Intervention for Enhanced Screening and Brief Intervention and Referral for Co-Occurring Chronic Pain and Opioid Use Disorder.

American Indian/Alaska Native (AI/AN) individuals have the highest rates of opioid overdose mortality and chronic pain (CP) compared to other racial/ethnic groups in the United States. These individuals also report higher rates of pain anxiety and pain catastrophizing, which are both associated with poorer outcomes and risk for opioid misuse (OM) and opioid use disorder (OUD) among individuals with CP. Yet, no prior studies have examined rates of comorbid pain and OUD among AI/AN adults. This commentary describes an implementation research partnership of 3 AI/AN-serving clinics and a university team that utilizes an implementation hybrid type III design to examine the impact of implementation strategies on adoption and sustainability of evidence-based screening and brief intervention for CP and OM/OUD among AI/AN clients. As part of our community-engaged approach, we embrace both AI/AN models and Western models, and a collaborative board of 10 individuals guided the research throughout. We hypothesize that our culturally centered approach will increase rates of screening and brief intervention and improve identification of and outcomes among AI/AN clients with CP and OUD who receive treatment at participating sites. Each site convenes a workgroup to evaluate and set goals to culturally center screening and brief interventions for CP and OM/OUD. Data collected include deidentified electronic health records to track screening and brief interventions and rates of CP and OUD; provider and staff surveys beginning prior to implementation and every 6 months for 2 years; and a subset of clients will be recruited (N = 225) and assessed at baseline, 6, and 12 months to examine biopsychosocial and spiritual factors and their experiences with culturally centered screening and brief intervention. Cultural adaptations to the measures and screening and brief intervention as well as barriers and facilitators will be addressed. Recommendations for successful Tribal health clinic-university partnerships are offered.

Yoga and Physical Therapy for Chronic Pain and Opioid Use Disorder Onsite in an Opioid Treatment Program: A Randomized Controlled Trial.

BACKGROUND: There is a lack of integrated treatment for chronic pain and opioid use disorder (OUD). Yoga and physical therapy (PT) may improve pain and physical function of people living with (PLW) chronic low back pain (CLBP) and may also reduce opioid craving and use, but PLW with OUD face barriers to accessing these interventions. We hypothesize that compared to treatment as usual (TAU), providing yoga and PT onsite at opioid treatment programs (OTPs) will be effective at improving pain, opioid use, and quality of life among people with CLBP and OUD, and will be cost-effective. METHODS: In this hybrid type-1 effectiveness-implementation study, we will randomly assign 345 PLW CLBP and OUD from OTPs in the Bronx, NY, to 12 weeks of onsite yoga, onsite PT, or TAU. Primary outcomes are pain intensity, opioid use, and cost-effectiveness. Secondary outcomes include physical function and overall well-being. DISCUSSION: This trial tests an innovative, patient-centered approach to combined management for pain and OUD in real-world settings. We rigorously examine the efficacy of yoga and PT onsite at OTPs as nonpharmacologic, cost-effective treatments among people with CLBP and OUD who face barriers to integrated care.

Development of a Patient and Clinician Informed Website on Injection Drug Use Related Infective Endocarditis.

BACKGROUND: Few patient-facing educational materials and interventions exist for the prevention of injection drug use-related infective endocarditis (IDU-IE). We developed a patient and clinician-informed website for patients about IDU-IE to promote education and prevention strategies. METHODS: This mixed-methods study integrated surveys and semi-structured interviews with patients and clinician to develop a patient website about IDU-IE. Patient participants included hospitalized adults with an opioid use disorder, history of injection drug use, and an injection drug use-related infection. Interprofessional healthcare clinicians including trainees participated. A baseline survey and semi-structured interviews were conducted with patients to understand knowledge of IDU-IE and preferences in educational materials content and format. Interviews were analyzed using rapid qualitative analysis. Results informed development of the patient website. Finally, patients and clinicians provided 2 rounds of survey feedback after reviewing the website, assessing the likelihood of using and recommending it to others, helpfulness of information in the website sections, and content satisfaction. RESULTS: Patient participants (n = 15) reported low baseline understanding of injection practice and risk of IDU-IE. After reviewing the website (n = 17), patients reported they were very likely to recommend the website as a reference for themselves (mean of 4.3; 4 = very likely) and for others (mean = 4.3). They found the following sections, on average, to be very helpful (4 = very helpful): complications from injection drug use (4.4), safer injection practice (4.4), and information about infective endocarditis (4.4). Patients on average were satisfied with the website content overall (4.8). Clinicians (n = 27) reported, on average, being very likely to recommend this website to a patient (4.4) and to use the website to counsel patients (4.1). CONCLUSIONS: A patient and clinician-informed website on IDU-IE is acceptable for patients and clinicians to use as a patient education resource to help prevent IDU-IE-related harms.

Substance Use Disorder and Suicidal Ideation in Rural Maryland.

Background: Rural areas in the United States have been disproportionately burdened with high rates of substance use, mental health challenges, chronic stress, and suicide behaviors. Factors such as a lack of mental health services, decreased accessibility to public health resources, and social isolation contribute to these disparities. The current study explores risk factors to suicidal ideation, using emergency room discharge data from Maryland. Methods: The current study used data from the Healthcare Cost and Utilization Project (HCUP) State Emergency Department Databases (SEDD) from the State of Maryland. Logistic regression was used to assess the association between ICD-10 coded opioid use disorder, alcohol use disorder, cannabis use disorder, major depressive disorder, and the outcome variable of suicidal ideation discharge. We controlled for income, race, age, and gender. Results: Lifetime major depressive disorder diagnosis (odds ration [OR] = 79.30; 95% confidence interval [CI] 51.91-121.15), alcohol use disorder (OR = 6.87; 95% CI 4.97-9.51), opioid use disorder (OR = 5.39; 95% CI 3.63-7.99), and cannabis use disorder (OR = 2.67; 95% CI 1.37-5.18) were all positively associated with suicidal ideation. Conclusions: The study highlights the strong link between prior substance use disorder, depression, and suicidal ideation visit to the emergency room, indicating the need for prevention and intervention, particularly among those in rural areas where the burden of suicidal ideation and chronic stress are high. As health disparities between rural and urban areas further widened during the COVID-19 pandemic, there is an urgent need to address these issues.

Ibogaine administration following repeated morphine administration upregulates myelination markers 2', 3'-cyclic nucleotide 3'-phosphodiesterase (CNP) and myelin basic protein (MBP) mRNA and protein expression in the internal capsule of Sprague Dawley rats.

Ibogaine is a psychedelic alkaloid being investigated as a possible treatment for opioid use disorder. Ibogaine has a multi-receptor profile with affinities for mu and kappa opioid as well as NMDA receptors amongst others. Due to the sparsity of research into ibogaine's effects on white matter integrity and given the growing evidence that opioid use disorder is characterized by white matter pathology, we set out to investigate ibogaine's effects on two markers of myelination, 2', 3'-cyclic nucleotide 3'-phosphodiesterase (CNP) and myelin basic protein (MBP). Fifty Sprague Dawley rats were randomly assigned to five experimental groups of n = 10; (1) a saline control group received daily saline injections for 10 days, (2) a morphine control group received escalating morphine doses from 5 to 15 mg/kg over 10 days, (3) an ibogaine control group that received 10 days of saline followed by 50 mg/kg ibogaine hydrochloride, (4) a combination morphine and ibogaine group 1 that received the escalating morphine regime followed by 50 mg/kg ibogaine hydrochloride and (5) a second combination morphine and ibogaine group 2 which followed the same morphine and ibogaine regimen yet was terminated 72 h after administration compared to 24 h in the other groups. White matter from the internal capsule was dissected and qPCR and western blotting determined protein and gene expression of CNP and MBP. Morphine upregulated CNPase whereas ibogaine alone had no effect on CNP mRNA or protein expression. However, ibogaine administration following repeated morphine administration had an immediate effect by increasing CNP mRNA expression. This effect diminished after 72 h and resulted in a highly significant upregulation of CNPase protein at 72 h post administration. Ibogaine administration alone significantly upregulated protein expression yet downregulated MBP mRNA expression. Ibogaine administration following repeated morphine administration significantly upregulated MBP mRNA expression which increased at 72 h post administration resulting in a highly significant upregulation of MBP protein expression at 72 h post administration. These findings indicate that ibogaine is able to upregulate genes and proteins involved in the process of remyelination following opioid use and highlights an important mechanism of action of ibogaine's ability to treat substance use disorders.

Reconsidering the usefulness of long-term high-dose buprenorphine.

Buprenorphine has been successfully used for decades in the treatment of opioid use disorder, yet there are complexities to its use that warrant attention to maximize its utility. While the package insert of the combination product buprenorphine\naloxone continues to recommend a maximum dose of 16 mg daily for maintenance, the emergence of fentanyl and synthetic analogs in the current drug supply may be limiting the effectiveness of this standard dose. Many practitioners have embraced and appropriately implemented novel practices to mitigate the sequelae of our current crisis. It has become common clinical practice to stabilize patients with 24 - 32 mg of buprenorphine daily at treatment initiation. Many of these patients, however, are maintained on these high doses (>16 mg/d) indefinitely, even after prolonged stability. Although this may be a necessary strategy in the short term, there is little evidence to support its safety and efficacy, and these high doses may be exposing patients to more complications and side effects than standard doses. Commonly known side effects of buprenorphine that are likely dose-related include hyperhidrosis, sedation, decreased libido, constipation, and hypogonadism. There are also complications related to the active metabolite of buprenorphine (norbuprenorphine) which is a full agonist at the mu opioid receptor and does not have a ceiling on respiratory suppression. Such side effects can lead to medical morbidity as well as decreased medication adherence, and we, therefore, recommend that after a period of stabilization, practitioners consider a trial of decreasing the dose of buprenorphine toward standard dose recommendations. Some patients' path of recovery may never reach this stabilization phase (i.e., several months of adherence to medications, opioid abstinence, and other clinical indicators of stability). Side effects of buprenorphine may not have much salience when patients are struggling for survival and safety, but for those who are fortunate enough to advance in their recovery, the side effects become more problematic and can limit quality of life and adherence.

Disparities in Access to Highly Rated Skilled Nursing Facilities Among Medicare Beneficiaries With Opioid Use Disorder.

OBJECTIVES: To investigate disparities in admissions to highly rated skilled nursing facilities (SNFs) between Medicare beneficiaries with and without opioid use disorder (OUD). DESIGN: Nationwide, retrospective observational cohort. SETTING AND PARTICIPANTS: Medicare Fee-for-Service beneficiaries aged ≥18 years admitted to SNFs following hospitalization during 2016-2020 (n = 30,922 with OUD and n = 137,454 without OUD). METHODS: Data used were 100% Medicare inpatient claims, nursing home administrative databases, and Nursing Home Compare. We identified hospitalized patients with and without OUD and matched them on age, sex, Part D low-income subsidy (LIS), and residential county. We compared the overall and component (quality, staffing, and health inspections) star ratings of SNFs that beneficiaries entered. Beneficiary-level regression models were conducted adjusting for race and ethnicity, Medicare-Medicaid dual status, comorbidity score, hospital length of stay, and state and year fixed effects. RESULTS: The overall study sample had a mean (SD) age of 71.4 (11.4) years, 63.9% were female, and 57.4% had LIS. Among beneficiaries with OUD, 50.3% entered SNFs with above-average (4 or 5) overall rating compared with 51.3% among those without OUD. Distributions of above-average ratings among beneficiaries with and without OUD were as follows: 63.9% vs 62.2% for quality, 32.8% vs 34.9% for health inspections, and 46.2% vs 45.0% for staffing, respectively. Adjusted regression models indicated that beneficiaries with OUD were less likely to be admitted to facilities with above-average overall (OR 0.90, 95% CI 0.87-0.92), health inspection (OR 0.90, 95% CI 0.88-0.92), and staffing (OR 0.91, 95% CI 0.89-0.94) ratings compared with beneficiaries without OUD, whereas quality (OR 0.98, 95% CI 0.94-1.01) ratings did not differ. CONCLUSIONS AND IMPLICATIONS: Despite mixed results on component ratings, our findings suggest a concerning disparity in the overall quality of SNFs admitting Medicare beneficiaries with OUD. Enhancing equitable access to high-quality SNF care for individuals with OUD is imperative amid rising demand and legal protections under the American Disabilities Act.

Predictors of persistent opioid use in Australian primary care: A retrospective cohort study, 2018-2022.

OBJECTIVE: To examine the predictors of persistent opioid use ('persistence') in people initiating opioids for non-cancer pain in Australian primary care. DESIGN: A retrospective cohort study. SETTING: Australian primary care. SUBJECTS: People prescribed opioid analgesics between 2018-2022, identified through the Population Level Analysis and Reporting (POLAR) database. METHODS: Persistence was defined as receiving opioid prescriptions for at least 90 days with a gap of less than 60 days between subsequent prescriptions. Multivariable logistic regression was used to examine the predictors of persistent opioid use. RESULTS: The sample consisted of 343,023 people initiating opioids for non-cancer pain; of these, 16,527 (4.8%) developed persistent opioid use. Predictors of persistence included older age (≥75 vs 15-44 years: Adjusted odds ratio: 1.67, 95% CI: 1.58-1.78), concessional beneficiary status (1.78, 1.71-1.86), diagnosis of substance use disorder (1.44, 1.22-1.71) and chronic pain (2.05, 1.85-2.27), initiation of opioid therapy with buprenorphine (1.95, 1.73-2.20) and long-acting opioids (2.07, 1.90-2.25), provision of higher quantity of opioids prescribed at initiation (total OME of ≥ 750mg vs < 100mg: 7.75, 6.89-8.72), provision of repeat/refill opioid prescriptions at initiation (2.94, 2.77-3.12), and prescription of gabapentinoids (1.59, 1.50-1.68), benzodiazepines (1.43, 1.38-1.50) and z-drugs (e.g., zopiclone, zolpidem; 1.61, 1.46-1.78). CONCLUSIONS: These findings add to the limited evidence of individual-level factors associated with persistent opioid use. Further research is needed to understand the clinical outcomes of persistent opioid use in people with these risk factors to support the safe and effective prescribing of opioids.

Special considerations in managing pain and psychosocial distress in patients with opioid use disorder and cancer: the role of the supportive care and psycho-oncology interdisciplinary team.

People with a substance use disorder (SUD) have shortened lifespans due to complications from their substance use and challenges engaging with traditional health care settings and institutions. This impact on life expectancy is especially prominent in patients with co-occurring SUDs and cancer, and often has a much worse prognosis from the cancer than a similar patient without a SUD. Palliative care teams are experts in serious illness communication and symptom management and have become increasingly embedded in the routine care of patients with cancer. We argue that the skill set of palliative care teams is uniquely suited for addressing the needs of this oft marginalized group. We provide a comprehensive review of tools for addressing these needs, including medications that can both treat pain and opioid use disorder (OUD), and highlight psychosocial approaches to treating patients with OUD and cancer in a way that is respectful and effective. Using a trauma informed framework, we focus on the application of harm reduction principles from addiction medicine and the principles of clear communication, accompaniment, and emotional presence from palliative care to maximize support. We also focus on ways to reduce stigma in the delivery of care, by providing language that reduces barriers and increases patient engagement. Finally, we describe a clinic embedded within our institution's cancer center which aims to serve patients with cancer and SUDs, built on the framework of harm reduction, accompaniment and trauma informed care (TIC). Overall, we aim to provide context for addressing the common challenges that arise with patients with cancer and OUD, including the direct impact of psychosocial stress on substance use and cancer treatment, delays in disease directed treatment that can potentially impact further treatment options and outcomes, challenging pain management due to greater opioid debt, and potential loss of primary coping mechanism through substance use in the face of potential terminal diagnosis.

Association of economic and racial segregation with restricted buprenorphine dispensing in U.S. community pharmacies.

Background: Timely and reliable dispensing of buprenorphine is critical to accessing treatment for opioid use disorder (OUD). Racial and ethnic inequities in OUD treatment access are well described, but it remains unclear if inequities persist at the point of dispensing. Methods: We analyzed data from a U.S. telephone audit that measured restricted buprenorphine dispensing in community pharmacies, defined as inability to fill a buprenorphine prescription requested by a "secret shopper." Using the Index of Concentration at the Extremes (ICE), we constructed county-level measures of racial, ethnic, economic, and racialized economic (joint racial and economic segregation) segregation. Logistic regression models evaluated the association of ICE measures and restricted buprenorphine dispensing, adjusting for county type (urban vs. rural) and pharmacy type (chain vs. independent). Results: Among 858 pharmacies surveyed in 473 counties, pharmacies in the most ethnically segregated and economically deprived counties had 2.66 times the odds (95 % CI: 1.41, 5.17) of restricting buprenorphine dispensing, compared to pharmacies in the most privileged counties after adjustment. Pharmacies in counties with high racialized economic segregation (quintile 2 and 3) also had higher odds of restricting buprenorphine dispensing (aOR 3.09 [95 % CI 1.7, 5.59]; aOR 2.11 [95 % CI 1.17, 3.98]). Similar associations were observed for economic segregation (aOR: 2.18 [95 % CI: 1.21, 3.99]), but not ethnic (0.59 [0.34, 1.05]) or racial (0.61 [0.35, 1.07]) segregation alone. Conclusions: Restricted buprenorphine dispensing was most pronounced in socially and economically disadvantaged communities, potentially exacerbating gaps in OUD treatment access. Policy interventions should target both prescribing and dispensing capacity to advance pharmacoequity.

Transcranial Photobiomodulation Therapy as an Intervention for Opioid Cravings and Depression: A Pilot Cohort Study.

Introduction: The opioid crisis, a declared national health emergency, has prompted the exploration of innovative treatments to address the pervasive issues of opioid cravings and associated depression. Aims: This pilot cohort study investigated the efficacy of transcranial Photobiomodulation (tPBM) therapy using the SunPowerLED helmet to alleviate these symptoms in individuals undergoing treatment for opioid addiction at a rehabilitation center in West Virginia. Methods: Employing a quasi-experimental design, this study enrolled participants into two groups: one receiving tPBM therapy alongside standard care and a control group receiving standard care alone. The helmet features include the following: total wavelength = 810 nm, total irradiance = 0.06 W/cm2 (60 m W/cm2), and total fluence = 172.8J/cm2. Results: The results of the Wilcoxon signed-rank tests for within-group analysis and Mann-Whitney U tests for between-group comparisons revealed statistically significant reductions in the intensity (W = 7.36, p = 0.012), time (W = 6.50, p = 0.015), frequency (W = 6.50, p = 0.010), and total scores of opioid cravings (W = 7.50, p = 0.009), as well as improvements in depression symptoms (W= 8.00, p = 0.005) within the PBM group compared to the non-PBM group. Discussion: These findings suggest that transcranial PBM therapy could be a promising noninvasive intervention for reducing opioid cravings and depressive symptoms in individuals with opioid use disorder, warranting further investigation through larger randomized controlled trials.

Prevalence of problematic pharmaceutical opioid use in patients with chronic non-cancer pain: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Chronic non-cancer pain (CNCP) is one of the most common causes of disability globally. Opioid prescribing to treat CNCP remains widespread, despite limited evidence of long-term clinical benefit and evidence of harm such as problematic pharmaceutical opioid use (POU) and overdose. The study aimed to measure the prevalence of POU in CNCP patients treated with opioid analgesics. METHOD: A comprehensive systematic literature review and meta-analysis was undertaken using MEDLINE, Embase and PsycINFO databases from inception to 27 January 2021. We included studies from all settings with participants aged ≥ 12 with non-cancer pain of ≥ 3 months duration, treated with opioid analgesics. We excluded case-control studies, as they cannot be used to generate prevalence estimates. POU was defined using four categories: dependence and opioid use disorder (D&OUD), signs and symptoms of D&OUD (S&S), aberrant behaviour (AB) and at risk of D&OUD. We used a random-effects multi-level meta-analytical model. We evaluated inconsistency using the I2 statistic and explored heterogeneity using subgroup analyses and meta-regressions. RESULTS: A total of 148 studies were included with > 4.3 million participants; 1% of studies were classified as high risk of bias. The pooled prevalence was 9.3% [95% confidence interval (CI) = 5.7-14.8%; I2 = 99.9%] for D&OUD, 29.6% (95% CI = 22.1-38.3%, I2 = 99.3%) for S&S and 22% (95% CI = 17.4-27.3%, I2 = 99.8%) for AB. The prevalence of those at risk of D&OUD was 12.4% (95% CI = 4.3-30.7%, I2 = 99.6%). Prevalence was affected by study setting, study design and diagnostic tool. Due to the high heterogeneity, the findings should be interpreted with caution. CONCLUSIONS: Problematic pharmaceutical opioid use appears to be common in chronic pain patients treated with opioid analgesics, with nearly one in 10 experiencing dependence and opioid use disorder, one in three showing signs and symptoms of dependence and opioid use disorder and one in five showing aberrant behaviour.

Physician's Attitudes Toward Patients With Opioid Use Disorder and Use of Medications for Opioid Use Disorder Vary by Training.

OBJECTIVES: This study compared whether different addiction treatment educational experiences were associated with physicians' attitudes toward patients with opioid use disorder (OUD) and perceived efficacy of medications for opioid use disorder (MOUD). METHODS: Ohio physicians (n = 2757) with and without a waiver to prescribe buprenorphine (Drug Addiction Treatment Act 2000 [DATA 2000] waiver) were surveyed regarding their attitudes toward treating patients with OUD and on the effectiveness of MOUD. We divided physicians into 3 groups: physicians with DATA 2000 waivers, non-waivered physicians with experiential training, and non-waivered physicians without experiential training. We defined experiential training as educational experience directly working with individuals with OUD including those in recovery. Analysis of variance was used to detect statistically significant group differences. RESULTS: We found significant main effect differences in attitudes toward patients with OUD and perceived efficacy of MOUD between groups (P ≤ .01) for all but one attitude. Post hoc comparisons revealed waivered physicians had the most favorable attitudes. Among physicians without a waiver, those with experiential training had significantly more favorable attitudes toward treating OUD and perceived MOUD to be more effective, including items such as "OUD are treatable illnesses" and "medication assisted treatment is a crucial part of treatment for OUD." CONCLUSION: The results suggest that physicians with DATA 2000 waiver and experiential training, as compared to physicians without either a waiver or experiential training in OUD, are associated with less stigmatizing views of treating patients with OUD and prescribing MOUD. While legislation in December 2022 eliminated DATA 2000 waiver training requirement, these findings suggest an ongoing need for training opportunities.

Default mode network aberrance in subjects of alcohol and opioid use disorders during working memory task: An exploratory EEG microstates study.

Background: Aberrance in switching from default mode network (DMN) to fronto-parietal network (FPN) is proposed to underlie working memory deficits in subjects with substance use disorders, which can be studied using neuro-imaging techniques during cognitive tasks. The current study used EEG to investigate pre-stimulus microstates during the performance of Sternberg's working memory task in subjects with substance use disorders. Methods: 128-channel EEG was acquired and processed in ten age and gender-matched subjects, each with alcohol use disorder, opioid use disorder, and controls while they performed Sternberg's task. Behavioral parameters, pre-stimulus EEG microstate, and underlying sources were analyzed and compared between subjects with substance use disorders and controls. Results: Both alcohol and opioid use disorder subjects had significantly lower accuracy (P < 0.01), while reaction times were significantly higher only in subjects of alcohol use disorder compared to controls (P < 0.01) and opioid use disorder (P < 0.01), reflecting working memory deficits of varying degrees in subjects with substance use disorders. Pre-stimulus EEG microstate revealed four topographic Maps 1-4: subjects of alcohol and opioid use disorder showing significantly lower mean duration of Map 3 (visual processing) and Map 2 (saliency and DMN switching), respectively, compared to controls (P < 0.05). Conclusion: Reduced mean durations in Map 3 and 2 in subjects of alcohol and opioid use disorder can underlie their poorer performance in Sternberg's task. Furthermore, cortical sources revealed higher activity in both groups of substance use disorders in the parahippocampal gyrus- a hub of DMN; superior and middle temporal gyri associated with impulsivity; and insula that maintains balance between executive reflective system and impulsive system. EEG microstates can be used to envisage neural underpinnings implicated for working memory deficits in subjects of alcohol and opioid use disorders, reflected by aberrant switching between neural networks and information processing mechanisms.

Perioperative Management of Buprenorphine at an Urban Academic Medical Center.

INTRODUCTION: Buprenorphine is a partial mu opioid receptor agonist with high affinity to its receptor, which raises concerns of blocking or displacing full opioid agonists when used during the perioperative period of surgical patients. However, buprenorphine itself has high analgesic potency and discontinuing buprenorphine may lead to suboptimal pain control and risk for opioid use disorder relapse. There is limited data for the continuation of buprenorphine perioperatively. METHODS: This study is a retrospective cohort study of adult surgical patients taking buprenorphine for opioid use disorder at an urban, teaching, level 1 trauma center. Patients were split into two groups based on whether buprenorphine was continued (n = 46) or held (n = 28) within the first 48 h after surgery. RESULTS: Those who had buprenorphine continued in the first 48 h postoperatively required half the dose of nonbuprenorphine opioids compared to those who had buprenorphine held (113.25 versus 255.75 oral morphine equivalents, P = 0.0040). Both groups had a similar level of analgesia and incidence of adverse events. Nearly all patients who continued buprenorphine in the first 48 h postoperatively were discharged on this agent, while only half of patients who had buprenorphine held were restarted on it at discharge (92.68% versus 56.52%, P = 0.0013). CONCLUSIONS: This present study found lower nonbuprenorphine opioid requirements in patients with continued versus held perioperative buprenorphine use with no difference in degree of analgesia.

Patterns and Outcomes of Opioid Use Before and After Hospitalization for Critical Illness: A Population-Based Cohort Study.

Background: Hospitalization represents a major access point for prescription opioids, yet little is known regarding patterns and outcomes of opioid exposures before and after hospitalization for critical illness. Methods: This is an observational, population-based cohort study of adults (≥18 years) hospitalized for critical illness from 2010 to 2019. Multivariable models assess associations between opioid exposures prior to hospitalization, classified according to the Consortium to Study Opioid Risks and Trends, and posthospitalization opioid exposures and clinical outcomes through 1-year posthospitalization. Results: Of 11 496 patients, 6318 (55%) were men with a median age of 66 (51, 79) years and 40% (n = 4623) surgical admissions. Prehospitalization opioid availability included 8449 (73%) none, 2117 (18%) short-term, 471 (4%) episodic, and 459 (4%) long-term. Thirty-nine percent (4144/10 708) of hospital survivors were discharged with opioids, with higher prescribing rates for surgical admissions (55%). Greater preadmission opioid exposures were associated with higher prevalent opioid availability at 1 year (odds ratio [95% confidence interval] 24.1 [18.3-31.8], 9.42 [7.18-12.3], and 2.55 [2.08-3.12] for long-term, episodic, and short-term exposures, respectively, vs none, P < .001). Greater preadmission opioid exposures were associated with longer hospitalizations (1.13 [1.04-1.23], 1.15 [1.06-1.25], and 1.08 [1.04-1.13] multiplicative increase in geometric mean, P < .001), more readmissions (hazard ratio [HR] 2.08 [1.74-2.49], 1.88 [1.56-2.26], and 1.48 [1.33-1.64], P < .001), and higher 1-year mortality (HR 1.59 [1.28-1.98], 1.75 [1.41-2.18], and 1.49 [1.32-1.69], P < .001). Similar associations were observed across surgical and nonsurgical admissions. Conclusions: Prehospitalization opioid exposures in survivors of critical illness are associated with clinical outcomes through 1 year and may serve as important prognostic markers.

Implementation of medication for opioid use disorder treatment during a natural disaster: The PROUD-LA study.

BACKGROUND: The impacts of climate change-related extreme weather events (EWEs) on Medication for Opioid Use Disorders (MOUD) implementation for Medicaid beneficiaries are relatively unknown. Such information is critical to disaster planning and other implementation strategies. In this study we examined implementation determinants and strategies for MOUD during EWEs. METHODS: The Louisiana-based Community Resilience Learning Collaborative and Research Network (C-LEARN) utilized Rapid Assessment Procedures-Informed Community Ethnography (RAPICE), involving community leaders in study design, execution, and data analysis. We conducted qualitative semi-structured interviews with 42 individuals, including MOUD Medicaid member patients and their caregivers, healthcare providers and administrators, and public health officials with experience with climate-related disasters. We mapped key themes onto updated Consolidated Framework for Implementation Research domains. RESULTS: MOUD use is limited during EWEs by pharmacy closures, challenges to medication prescription and access across state lines, hospital and clinic service limits, overcrowded emergency departments, and disrupted communications with providers. MOUD demand simultaneously increases due to the stress associated with displacement, resource loss, the COVID-19 pandemic, and social determinants of health. Effective implementation strategies include healthcare system disaster plans with protocols for clear and regular patient-provider communication, community outreach, additional staffing, and virtual delivery of services. Providers can also increase MOUD access by having remote access to EHRs, laptops and contact information, resource lists, collaborative networks, and contact with patients via call centers and social media. Patients can retain access to MOUD via online patient portals, health apps, call centers, and provider calls and texts. The impact of EWEs on MOUD access and use is also influenced by individual characteristics of both patients and providers. CONCLUSIONS: The increasing frequency and severity of climate-related EWEs poses a serious threat to MOUD for Medicaid beneficiaries. MOUD-specific disaster planning and use of telehealth for maintaining contact and providing care are effective strategies for MOUD implementation during EWEs. Potential considerations for policies and practices of Medicaid, providers, and others to benefit members during hurricanes or major community stressors, include changes in Medicaid policies to enable access to MOUD by interstate evacuees, improvement of medication refill flexibilities, and incentivization of telehealth services for more systematic use.