Pain management after third molar extractions in adolescents: a qualitative study.

BACKGROUND: Understanding how adolescent patients make decisions about pain management after complex dental procedures could help reduce the use of opioid medications and the potential for future opioid misuse in this population. This qualitative study explores how adolescents manage pain, including how decision making with parents and providers affect their experience with opioid and non-opioid analgesics after third molar dental extractions. METHODS: We used a qualitative approach for the analysis of 30 telephone-based semi-structured interviews completed by 15 dyads between May and August 2019, which included 15 adolescents (15-17 years) who underwent a dental extraction, and a parent or guardian for each adolescent. The total sample included 30 participants. Interviews were conducted separately for patients and parents. De-identified interview transcripts were analyzed using qualitative analysis software using a directed content analysis approach. RESULTS: A total of 15 patient/parent dyads were interviewed. Key themes associated with pain management included sources of information, pain management behaviors engaged in by the adolescents and their caregivers, and the use of medication. In addition to conversations with their dental provider, most patients and their parents discussed pain management plans that included non-medication options, over-the-counter medications, and opioid medications to be taken as needed, which guided their post-extraction behaviors. All participants reported that the adolescent received an opioid prescription for post-extraction pain management, to be taken on an "as needed" basis, but most only took it the day of the extraction and up to 2 days following, usually based on the patient's reported pain levels and perceptions of over-the-counter medication adequacy. Participants said they did not receive guidance from their provider concerning disposal of unused opioid medications. CONCLUSIONS: Involving adolescents in the pain management decision making process and allowing them to carry out the plan with some caregiver support was acceptable and well executed following third molar extractions. Providers may have an opportunity to reduce the number of opioids prescribed, since respondents reported little to no use of opioids that they were prescribed. Providers should educate patients and their parents about safe disposal of opioids to mitigate the potential for diversion.

Patients with substance use disorders receiving continued care in skilled nursing facilities following hospitalization.

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Organizational Acceptability of Implementing SBIRT for Adolescents in Primary Care.

INTRODUCTION: Adolescent illicit drug, tobacco, and alcohol use can result in sudden and long-term negative health consequences. Primary care environments present the optimal opportunity for screening and brief interventions that target prevention and curtailing use. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a service delivery method that could potentially be well-integrated into primary care settings and used to serve a high volume of adolescents. Methods: This qualitative analysis of clinic staff interviews (N = 20), collected during a large cluster-randomized trial to implement two models of adolescent SBIRT, examined barriers and facilitating factors to overall acceptability of SBIRT. This study was conducted in a large, urban Federally Qualified Health Center (FQHC) at 7 sites throughout Baltimore City, Maryland, USA. Participants from each clinic included a range of various roles and responsibilities including: medical assistants (n = 3), nurses (n = 3), primary care providers (n = 4), behavioral health counselors (n = 4), and administrators (n = 6). Results: Results indicate both barriers and facilitating factors for acceptability of SBIRT in terms of (1) universal screening, (2) provider time demands, (3) behavioral health collaboration, and (4) behavioral health caseloads. Discussion: Universal screening was acceptable to participants across organizational roles, but brief interventions and referrals to treatment were found substantially less acceptable.

Until there's nothing left: Caregiver resource provision to youth with opioid use disorders.

Background and Aims: Despite the considerable literature associating certain characteristics of caregivers and family structures with risks of adolescent/young adult (youth) substance use, there has been little study of the role of caregivers in opioid use disorder (OUD) treatment outcomes. This qualitative study sought to understand and contextualize the factors that influenced the resources caregivers provided their youth after residential treatment. Methods: In order to improve understandings of the role caregivers play both during and after residential OUD treatment, 31 caregivers of youth who were in a residential substance use disorder treatment center were interviewed at baseline, three-months, and six-months following their youth's discharge. Results: This analysis focused on the provision of caregiver resources and identified three key influences - OUD understandings and expectations, relationships with youth, and the emotional toll on caregivers. This has important implications as residential treatment success rates are relatively low among this population. Conclusions: These findings suggest that engagement of caregivers and families in outpatient care following residential treatment could offer an important opportunity for interventions that promote youth recovery.

One million screened: Scaling up SBIRT and buprenorphine treatment in hospital emergency departments across Maryland.

PURPOSE: Identification of problematic alcohol use and substance use in the population has been a clinical challenge, especially during the heightened years of the opioid epidemic. Bringing Screening, Brief Intervention, and Referral to Treatment (SBIRT) to scale in medical settings, such as hospital emergency departments (EDs) could facilitate broad identification of substance use disorders, timely delivery of brief interventions, and successful linkages to treatment. PROCEDURES: This large-scale data analysis pulled electronic health record (EHR) data from 23 hospitals in the state of Maryland for over 1 million patient visits between July 2014 and November 2018. FINDINGS: Of the 1,097,142 ED patients screened, 17.2% screened positive for problematic alcohol or any drug use in the previous 12 months. During this same period, 79,899 brief interventions were delivered, 15,961 referrals to outpatient treatment were made and 38.3% of those were successfully linked to treatment. Of the 950 patients exhibiting withdrawal symptoms, over two-thirds patients (70.1%; n = 666) were administered buprenorphine, 94.6% (n = 630) accepted a referral to buprenorphine treatment in the community, and 64.6% (n = 430) attended their first outpatient buprenorphine treatment visit. A total of 2382 patients presented to the ED with a suspected opioid overdose, over half were referred to the intervention program (53.8%) and 63.2% were successfully engaged by the PRCs in the ED. CONCLUSIONS: This analysis supports the scalability of SBIRT in hospital EDs and presents an implementation model that can be replicated in EDs nationwide.

Pharmacotherapy for opioid addiction in community corrections.

Pharmacotherapy for opioid addiction with methadone, buprenorphine, and naltrexone has proven efficacy in reducing illicit opioid use. These treatments are under-utilized among opioid-addicted individuals on parole, probation, or in drug courts. This paper examines the peer-reviewed literature on the effectiveness of pharmacotherapy for opioid addiction of adults under community-based criminal justice supervision in the US. Compared to general populations, there are relatively few papers addressing the separate impact of pharmacotherapy on individuals under community supervision. Tentative conclusions can be drawn from the extant literature. Reasonable evidence exists that illicit opioid use and self-reported criminal behaviour decline after treatment entry, and that these outcomes are as favourable among individuals under criminal justice supervision as the general treatment population. Surprisingly, there is no conclusive evidence regarding the extent to which pharmacotherapy impacts the likelihood of arrest and incarceration among individuals under supervision. However, given the proven efficacy of these three medications in reducing illicit opioid use and the evidence that, in the general population, methadone and buprenorphine treatment are associated with reduction in overdose mortality, the use of all three pharmacotherapies among patients under criminal justice supervision should be expanded while more data are collected on their impact on arrest and incarceration.

Treatment outcomes among a cohort of African American buprenorphine patients: Follow-up at 12 months.

BACKGROUND: Although buprenorphine/naloxone (bup/nal) is well-established as a safe and effective treatment for opioid use disorders (OUDs), there are few studies reporting 12-month outcomes of patients receiving bup/nal in formerly drug-free outpatient programs. OBJECTIVES: To examine 12-month outcomes by bup/nal treatment enrollment status among a cohort of African American patients enrolled in a clinical trial. METHODS: This analysis builds upon a randomized trial of 300 opioid-dependent African American bup/nal patients in two outpatient programs in Baltimore, MD. A subset of participants (N = 133, n = 47 female) were tracked for a 12-month follow-up interview. RESULTS: The participants receiving bup/nal at 12 months had significantly fewer opioid-positive urine screens (44% v. 73%) and days of self-reported heroin use (M [SE] = 1.13 [.34] v. 7.12 [1.44]) than the out-of-bup/nal-treatment group (both ps ≤ .001). Similarly, those receiving bup/nal reported significantly fewer days of cocaine use (M [SE] = 0.85 [0.23] v. 2.88[0.75]) and alcohol use (M [SE] = 1.44 [0.38] v. 3.69 [1.04]; both ps<.05). There were no significant differences related to criminal activity, quality of life, and most ASI composite scores. Models adjusting for the baseline value, prior treatment experience, and assigned study condition largely confirmed these findings, except that participants in treatment had fewer days of crime and higher psychological quality of life scores compared to those out-of-treatment. CONCLUSIONS: Those receiving bup/nal at 12 months had significantly lower rates of illicit opioid use than those who were not. Approaches to improve bup/nal treatment retention and reengagement of patients with OUD are needed.

Update on Barriers to Pharmacotherapy for Opioid Use Disorders.

PURPOSE OF REVIEW: The recent heroin and prescription opioid misuse epidemic has led to a sharp increase in the number of opioid overdose deaths in the USA. Notwithstanding the availability of three FDA-approved medications (methadone, buprenorphine, and naltrexone) to treat opioid use disorder, these medications are underutilized. This paper provides an update from the recent peer-reviewed literature on barriers to the use of these medications. FINDINGS: These barriers are interrelated and can be categorized as financial, regulatory, geographic, attitudinal, and logistic. While financial barriers are common to all three medications, other barriers are medication-specific. The adverse impact of the current opioid epidemic on public health can be reduced by increasing access to effective pharmacotherapy for opioid use disorder.

The concurrent validity of the Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale in adolescent patients in an urban federally qualified health center.

BACKGROUND: The Problem Oriented Screening Instrument for Teenagers (POSIT) substance use/abuse subscale has been validated with high school students, adolescents with criminal justice involvement, and adolescent substance use treatment samples using the Diagnostic and Statistical Manual of Mental Disorders (DSM)-III-R and DSM-IV. This study examines the concurrent validity of the POSIT's standard 17-item substance use/abuse subscale and a revised, shorter 11-item version using DSM-5 substance use disorder diagnoses. METHODS: Adolescents (N = 525; 93% African American, 55% female) 12-17 years of age awaiting primary care appointments at a Federally Qualified Health Center in Baltimore, Maryland completed the 17-item POSIT substance use/abuse subscale and items from a modified World Mental Health Composite International Diagnostic Interview corresponding to DSM-5 alcohol use disorder (AUD) and cannabis use disorder (CUD). Receiver operating characteristic curves, sensitivities, and specificities were examined with DSM-5 AUD, CUD, and a diagnosis of either or both disorders for the standard and revised subscales using risk cutoffs of either 1 or 2 POSIT "yes" responses. RESULTS: For the 17-item subscale, sensitivities were generally high using either cutoff (range: 0.79-1.00), although a cutoff of 1 was superior (sensitivities were 1.00 for AUD, CUD, and for either disorder). Specificities were also high using either cutoff (range: 0.81-0.95) but were higher using a cutoff of 2. For the 11-item subscale, a cutoff of 1 yielded higher sensitivities than a cutoff of 2 (ranges for 1 and 2: 0.96-1.00 and 0.79-0.86, respectively). Specificities for this subscale were higher using a cutoff of 2 (ranges for 1 and 2: 0.82-0.89 and 0.89-0.96, respectively). CONCLUSIONS: Findings suggest that the POSIT's substance use/abuse subscale is a potentially useful tool for screening adolescents in primary care for AUD or CUD using a cutoff of 1 or 2. The briefer, revised subscale may be preferable to the standard subscale in busy pediatric practices.

Confirmatory factor analysis of the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in community health center patients.

BACKGROUND AND OBJECTIVES: To investigate the factor structure of the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST). METHODS: Secondary analysis on an adult primary care sample (N = 2,599). RESULTS AND DISCUSSION: Factor analysis of the tobacco, alcohol, and cannabis items did not yield an acceptable oblique, three-factor solution, due in part to floor effects and limited variability. A short form comprises three items (past-3-month frequency of use, urge to use, and whether others have expressed concern for use), that showed good psychometrics. SCIENTIFIC SIGNIFICANCE: Supports the need for further investigation of the ASSIST factor structure and a short form. (Am J Addict 2016;25:259-263).

Community correctional agents' views of medication-assisted treatment: Examining their influence on treatment referrals and community supervision practices.

BACKGROUND: Alcohol and opioid use disorders are common among adults under community supervision. Although several medications (medication-assisted treatment or MAT) are Food and Drug Administration (FDA)-approved to treat such disorders, they are underutilized with this population despite established effectiveness at decreasing substance use. This paper examines how community correctional agents' understanding of addiction and views of MAT influence their professional actions regarding addiction medications. METHODS: A total of 118 semistructured qualitative interviews were conducted with community correctional agents taking part in the CJ-DATS MATICCE implementation study across 20 parole/probation offices in 9 US states. Using grounded theory methodology and an iterative analytic approach, issues of role perception, views of MAT, current treatment referral, and community supervision practices were explored. RESULTS: Agents often had limited autonomy to make direct treatment referrals, regardless of their views of MAT, as they were required to follow court orders and their organization's policies and procedures. Within some organizations, community correctional agents held sufficient autonomy to make direct treatment referrals, with agents struggling to reconcile their desire to support their clients who needed MAT with concerns about the abuse potential of opioid agonist medications. Viewing MAT as a "treatment of last resort" was counterbalanced by the view that it was an effective evidence-based practice. Agents described how MAT impacted their ability to supervise clients and how their knowledge and understanding of MAT was directly influenced by watching their clients who were successful or unsuccessful on MAT. Even those agents who were more accepting of MAT were largely unsupportive of it long-term use. CONCLUSIONS: Community correctional agents' views of MAT were influenced by their understanding of addiction as well as their experiences supervising clients receiving treatment with medications, but whether or not MAT referrals were made was not always within their control.

Developing effective interorganizational relationships between community corrections and community treatment providers.

Weak service coordination between community corrections and community treatment agencies is a significant barrier in the diffusion of pharmacotherapy for treating opioid and alcohol use disorders. This analysis draws on qualitative interviews (n=141) collected in a multisite randomized trial to explore what probation/parole officers and treatment staff believe are the most critical influences on developing positive interorganizational relationships (IORs) between their respective agencies. Officers and treatment staff highlighted factors at both the individual and organizational level, with issues related to communication surfacing as pivotal. Findings suggest that future interventions consider developing shared interagency goals with input at all staff levels.

Reference periods in retrospective behavioral self-report: A qualitative investigation.

BACKGROUND: Self-report questions in substance use research and clinical screening often ask individuals to reflect on behaviors, symptoms, or events over a specified time period. However, there are different ways of phrasing conceptually similar time frames (eg, past year vs. past 12 months). METHODS: We conducted focused, abbreviated cognitive interviews with a sample of community health center patients (N = 50) to learn how they perceived and interpreted questions with alternative phrasing of similar time frames (past year vs. past 12 months; past month vs. past 30 days; past week vs. past 7 days). RESULTS: Most participants perceived the alternative time frames as identical. However, 28% suggested that the "past year" and "past 12 months" phrasings would elicit different responses by evoking distinct time periods and/or calling for different levels of recall precision. Different start and end dates for "past year" and "past 12 months" were reported by 20% of the sample. There were fewer discrepancies for shorter time frames. CONCLUSIONS: Use of "past 12 months" rather than "past year" as a time frame in self-report questions could yield more precise responses for a substantial minority of adult respondents. SCIENTIFIC SIGNIFICANCE: Subtle differences in wording of conceptually similar time frames can affect the interpretation of self-report questions and the precision of responses.

The Use of Technology in Participant Tracking and Study Retention: Lessons Learned From a Clinical Trials Network Study.

BACKGROUND: The growing use of newer communication and Internet technologies, even among low-income and transient populations, require research staff to update their outreach strategies to ensure high follow-up and participant retention rates. This paper presents the views of research assistants on the use of cell phones and the Internet to track participants in a multisite randomized trial of substance use disorder treatment. METHODS: Preinterview questionnaires exploring tracking and other study-related activities were collected from 21 research staff across the 10 participating US sites. Data were then used to construct a semistructured interview guide that, in turn, was used to interview 12 of the same staff members. The questionnaires and interview data were entered in Atlas.ti and analyzed for emergent themes related to the use of technology for participant-tracking purposes. RESULTS: Study staff reported that most participants had cell phones, despite having unstable physical addresses and landlines. The incoming call feature of most cell phones was useful for participants and research staff alike, and texting proved to have additional benefits. However, reliance on participants' cell phones also proved problematic. Even homeless participants were found to have access to the Internet through public libraries and could respond to study staff e-mails. Some study sites opened generic social media accounts, through which study staff sent private messages to participants. However, the institutional review board (IRB) approval process for tracking participants using social media at some sites was prohibitively lengthy. Internet searches through Google, national paid databases, obituaries, and judiciary Web sites were also helpful tools. CONCLUSIONS: Research staff perceive that cell phones, Internet searches, and social networking sites were effective tools to achieve high follow-up rates in drug abuse research. Studies should incorporate cell phone, texting, and social network Web site information on locator forms; obtain IRB approval for contacting participants using social networking Web sites; and include Web searches, texting, and the use of social media in staff training as standard operating procedures.

Staff Views of Acceptability and Appropriateness of a Computer-Delivered Brief Intervention for Moderate Drug and Alcohol Use.

The use of computers for identifying and intervening with stigmatized behaviors, such as drug use, offers promise for underserved, rural areas; however, the acceptability and appropriateness of using computerized brief intervention (CBIs) must be taken into consideration. In the present study, 12 staff members representing a range of clinic roles in two rural, federally qualified health centers completed semi-structured interviews in a qualitative investigation of CBI vs. counselor-delivered individual brief intervention (IBI). Thematic content analysis was conducted using a constant comparative method, examining the range of responses within each interview as well as data across interview respondents. Overall, staff found the idea of providing CBIs both acceptable and appropriate for their patient population. Acceptability by clinic staff centered on the ready availability of the CBI. Staff also believed that patients might be more forthcoming in response to a computer program than a personal interview. However, some staff voiced reservations concerning the appropriateness of CBIs for subsets of patients, including older patients, illiterate individuals, or those unfamiliar with computers. Findings support the potential suitability and potential benefits of providing CBIs to patients in rural health centers.

Changes in Quality of Life following Buprenorphine Treatment: Relationship with Treatment Retention and Illicit Opioid Use.

Studies of substance abuse treatment outcomes that give priority to cessation of all drug use may obscure other tangible benefits of treatment that are important to patients. The aim of this study was to examine the association between changes in quality of life (QoL) and: (1) retention in treatment; and (2) opioid use as measured by self-report and urine testing. Participants were 300 African American men and women starting outpatient buprenorphine treatment. Participants completed assessments at baseline, three and six months consisting of the World Health Organization's Quality of Life brief scale, Addiction Severity Index, and urine testing for opioids. There were statistically significant increases over time across all four QoL domains: physical, psychological, environmental, and social. Self-reported frequency of opioid use was negatively associated with psychological QoL, but opioid urine test results were not significantly associated with any QoL domains. Continued treatment enrollment was significantly associated with higher psychological QoL and environmental QoL. Patients entering buprenorphine treatment experience improvements in QoL, which are amplified for patients who remain in treatment. Point-prevalence opiate urine test results obtained at each assessment were not associated with any of the QoL domains and may not accurately reflect improvements perceived by patients receiving buprenorphine treatment.

The CRAFFT cut-points and DSM-5 criteria for alcohol and other drugs: a reevaluation and reexamination.

BACKGROUND: The CRAFFT, previously validated against DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnostic criteria, is the most widely used screening instrument for alcohol and other substance misuse in adolescents. The present secondary analysis study sought to compare the CRAFFT with the new DSM-5 diagnostic criteria in order to assess the CRAFFT's psychometric properties and determine the optimal cut-point for identifying adolescents in need of further assessment. METHODS: Participants were primary care patients aged 12-17 (N = 525) who were recruited while waiting for a medical appointment in an urban federally qualified health center in Baltimore, Maryland, USA. Participants were administered the CRAFFT and the Composite International Diagnostic Interview, second edition, modified to include the new DSM-5 craving item. The authors examined the performance of the CRAFFT in identifying any problem use (defined as 1 or more DSM-5 criteria) and any DSM-5 substance use disorder (2 or more DSM-5 criteria) for alcohol or drugs other than tobacco. The authors examined sensitivity, specificity, and receiver operating characteristic areas under the curve (AUC) to determine the optimal CRAFFT cut-point(s) for predicting any problem use and any DSM-5 substance use disorder (SUD). RESULTS: Examining the CRAFFT as a continuous measure, AUC values were 0.93 for problem use or higher and 0.97 for DSM-5 SUD. Consistent with previously recommended cut-points for the CRAFFT, the cut-point of 2 performed optimally for identifying adolescents both exhibiting problem use of alcohol or drugs and meeting DSM-5 SUD criteria for alcohol or other drugs. CONCLUSIONS: Despite changes in the DSM substance use diagnostic criteria, the CRAFFT continues to demonstrate excellent sensitivity and specificity at its established cut-point of 2. Additional studies examining the CRAFFT in light of the new DSM-5 diagnostic criteria with more diverse populations are warranted.

Patient perspectives on buprenorphine/naloxone: a qualitative study of retention during the starting treatment with agonist replacement therapies (START) study.

This study examines the barriers and facilitators of retention among patients receiving buprenorphine/naloxone at eight community-based opioid treatment programs across the United States. Participants (n = 105) were recruited up to three and a half years after having participated in a randomized clinical trial comparing the effect of buprenorphine/naloxone and methadone on liver function. Semi-structured interviews were conducted with 67 patients provided with buprenorphine/naloxone who had terminated early and 38 patients who had completed at least 24 weeks of the trial. Qualitative data were analyzed using the constant comparison method. Barriers to buprenorphine/naloxone retention that emerged included factors associated with: (1) the design of the clinical trial; (2) negative medication or treatment experience; and (3) personal circumstances. The facilitators comprised: (1) positive experience with the medication; (2) personal determination and commitment to complete; and (3) staff encouragement and support. The themes drawn from interviews highlight the importance of considering patients' prior experience with buprenorphine/naloxone and methadone, medication preference, personal circumstances, and motivation to abstain from illicit use or misuse of opioids, as these may influence retention. Ongoing education of patients and staff regarding buprenorphine/naloxone, especially in comparison to methadone, and support from staff and peers are essential.

Treatment Outcomes of African American Buprenorphine Patients by Parole and Probation Status.

This secondary analysis compared outcomes of African-American adults newly-admitted to buprenorphine treatment who were on parole and probation to patients who were not under criminal justice supervision. Buprenorphine patients (N=300) were randomly assigned to receive either Intensive Outpatient Treatment (IOP) or Standard Outpatient Treatment (OP) treatment and were assessed at baseline, 3- and 6-months. There were no differences between groups in treatment retention. Among probationers/parolees, IOP was associated with lower 3-month treatment retention compared to OP, but among participants not on probation/parole the relationship was reversed (p=.004). Both conditions showed significant declines in heroin and cocaine use, illegal activity, and in meeting DSM-IV criteria for opioid and cocaine dependence. Probationers/parolees reported lower frequency of illegal activities at 3-months compared to non-probationers/parolees (p=.007). Buprenorphine treatment should be made more widely available to individuals on parole/probation as they respond as well to treatment as patients not supervised by the criminal justice system.

State guidance and system changes related to COVID-19: Impact on opioid treatment programs.

INTRODUCTION: In the United States, methadone treatment may only be provided through opioid treatment programs (OTPs), which operate under a complex system of federal and state regulations. During the pandemic, federal regulators relaxed several longstanding restrictions for OTPs by permitting expanded eligibility for take-home medication and allowing counseling and medication management through telehealth. The purpose of this study was to assess the guidance provided by states regarding the revised guidelines and efforts to protect staff and patients in response to the pandemic. METHODS: Between September and October of 2020, The National Association of State Alcohol and Drug Abuse Directors (NASADAD) and Friends Research Institute, fielded a web-based qualitative survey of state opioid treatment authorities (SOTAs) across the United States, the District of Columbia, and Puerto Rico. The study conducted the survey prior to the availability of the COVID vaccines. It queried 42 SOTAs concerning state guidance provided to OTPs on treatment operations and practices for existing patients and new admissions; actions to protect staff and patients; changes in treatment need and operational capacity; and administrative practices regarding treatment. This study examines the responses of 42 SOTAs (65 %) who completed the survey. RESULTS: Using content analysis, responses to the survey indicate that most states provided guidance to OTPs in response to the revised federal regulations and the need to protect staff and patients. All respondents reported that their states permitted increased number of take-homes doses for existing patients (100 %) and most reported doing so for new admissions (69 %; N=29). Ninety-eight percent (98 %; N=41) reported permitting remote counseling for existing patients and 90 % (N=38) permitting this for new admissions. SOTAs reported providing guidance on staff safety, operational procedures, oversight, and reforming billing practices to align with new models of service delivery. CONCLUSIONS: SOTAs generally reported that federal guidance increased patient access, engagement, and retention. Increased take-home flexibilities were viewed as important for expanding access and continuity of treatment, with the majority of SOTAs stating that the revised treatment practices (e.g., expansion of telehealth, flexible medication dispensing practices) were beneficial. These regulatory flexibilities, many believe, promoted the continuation of treatment and successful patient outcomes during the pandemic.