"They make it too hard and too many hoops to jump": system and organizational barriers to drug treatment during epidemic rates of opioid overdose.

INTRODUCTION: The United States is currently facing an opioid overdose crisis. Research suggests that multiple interventions are needed to reduce overdose deaths including increasing access and retention to medications to treat opioid use disorders (MOUD, i.e., methadone, buprenorphine, and naltrexone) and increasing the distribution and use of naloxone, a medication that can reverse the respiratory depression that occurs during opioid overdoses. However, barriers to MOUD initiation and retention persist and discontinuations of MOUD carry a heightened risk of overdose. Many times, MOUD is not sought as a first line of treatment by people with opioid use disorder (OUD), many of whom seek treatment from medically managed withdrawal (detox) programs. Among those who do initiate MOUD, retention is generally low. The present study examines the treatment experiences of people who use opioids in three states, Connecticut, Kentucky, and Wisconsin. METHODS: We conducted in-depth interviews with people who use opioids in a rural, urban, and suburban area of three states: Connecticut, Kentucky and Wisconsin. Data analysis was collaborative and key themes were identified through multiple readings, coding of transcripts and discussion with all research team members. RESULTS: Results reveal a number of systemic issues that reduce the likelihood that people initiate and are retained on MOUD including the ubiquity of detox as a first step in drug treatment, abstinence requirements and requiring patients to attend group treatment. MOUD-related stigma was a significant factor in the kinds of treatment participants chose and their experiences in treatment. CONCLUSIONS: Interventions to reduce MOUD stigma are needed to encourage MOUD as a first course of treatment. Eliminating abstinence-based rules for MOUD treatment may improve treatment retention and decrease overdose risk.

Potential Influences of the COVID-19 Pandemic on Drug Use and HIV Care Among People Living with HIV and Substance Use Disorders: Experience from a Pilot mHealth Intervention.

People living with HIV (PLWH) and substance use disorder (SUD) are particularly vulnerable to harmful health consequences of the global COVID-19 pandemic. The health and social consequences of the pandemic may exacerbate substance misuse and poor management of HIV among this population. This study compares substance use and HIV care before and during the pandemic using data collected weekly through an opioid relapse prevention and HIV management mobile-health intervention. We found that during the pandemic, PLWH and SUD have increased illicit substance use and contact with other substance-using individuals and decreased their confidence to stay sober and attend recovery meetings. The proportion of people missing their HIV medications also increased, and confidence to attend HIV follow-up appointments decreased. Optimal support for PLWH and SUD is critical during pandemics like COVID-19, as drug-related and HIV antiretroviral therapy (ART) non-adherence risks such as overdose, unsafe sexual behaviors, and transmission of infectious diseases may unfold.

RESUMEN: Personas con VIH y con trastornos por abuso de sustancias son más vulnerable a las consecuencias de la pandemia: COVID-19. Dentro estas poblaciones, las consecuencias sociales y de la salud, causadas por la pandemia, pueden exacerbar el mal uso de las sustancias, y la adherencia a los antiretrovirales. Este estudio compara el abuso de sustancias y el cuidado del VIH, antes y durante la pandemia, usando datos colectados semanal de otro programa que también investigo la prevención entre personas que han recaído con el uso de opioides y que tienen VIH. Nuestro análisis encuentra, que durante la pandemia, incrementaron el uso de sustancias ilícitas, y contacto con otras personas que usan sustancias, y perdieron la capacidad de mantenerse sobrios, y tambien dejaron de asistir reuniones de recuperación/apoyo. También, el porcentaje de personas con VIH no siguiendo con sus planes de tratamiento de VIH, incrementó; perdieron su motivacion en mantener sus citas médicos. Es muy crítico, durante una pandemia como COVID-19, tener recursos para personas que pertenecen a estas poblaciones, si no, casos de sobredosis, sexo sin protección y la transmisión de enfermedades infecciosas van a prevaler.

The effects of opioid policy changes on transitions from prescription opioids to heroin, fentanyl and injection drug use: a qualitative analysis.

BACKGROUND: Beginning in the 1990s, nonmedical use of prescription opioids (POs) became a major public health crisis. In response to rising rates of opioid dependence and fatal poisonings, measures were instituted to decrease the prescription, diversion, and nonmedical use of POs including prescription drug monitoring programs (PDMPs), pain clinic laws, prescription duration limits, disciplining doctors who prescribed an excessive number of POs, and the advent of abuse deterrent formulations of POs. This paper explores the unintended effects of these policies in the descriptions of why people who use opioids transitioned from PO to injection or heroin/fentanyl use. METHODS: We conducted 148 in-depth-interviews with people who use prescription opioids nonmedically, fentanyl or heroin from a rural, urban and suburban area in three states, Connecticut, Kentucky and Wisconsin. Interviews with people who use opioids (PWUO) focused on how they initiated their opioid use and any transitions they made from PO use to heroin, fentanyl or injection drug use. RESULTS: The majority of participants reported initiating use with POs, which they used for medical or nonmedical purposes. They described needing to take more POs or switched to heroin or fentanyl as their tolerance increased. As more policies were passed to limit opioid prescribing, participants noticed that doctors were less likely to prescribe or refill POs. This led to scarcity of POs on the street which accelerated the switch to heroin or fentanyl. These transitions likely increased risk of overdose and HIV/HCV infection. CONCLUSIONS: A careful analysis of how and why people say they transitioned from PO to heroin or fentanyl reveals many unintended harms of policy changes to prevent overprescribing and diversion. Results highlight the importance of mitigating harms that resulted from policy changes.

Barriers to drug treatment in police diversion programs and drug courts: A qualitative analysis.

Drug treatment courts and police diversion programs are designed to divert people away from incarceration and into drug treatment. This article explores barriers in linking people who use drugs (PWUD) into drug treatment facilities in urban, suburban, and rural areas of Connecticut, Kentucky, and Wisconsin. Between December 2018 and March 2020, study teams in the three states conducted in-depth, semistructured interviews with key informants involved in programs to divert PWUD from criminal justice involvement including police, lawyers, judges, and others who work in drug treatment courts, and substance use disorder treatment providers who received referrals from and worked with police diversion programs or drug courts. Police diversion programs and drug treatment courts showed intraprogram variation in the structure of their programs in the three states and in different counties within the states. Structural barriers to successfully linking PWUD to treatment included a lack of resources, for example, a limited number of treatment facilities available, difficulties in funding mandated treatment, particularly in Wisconsin where Medicaid expansion has not occurred, and PWUDs' need for additional services such as housing. Many police officers, judges, and others within drug treatment court, including drug treatment specialists, hold stigmatizing attitudes toward medications to treat opioid use disorder (MOUD) and are unlikely to recommend or actively refer to MOUD treatment. Drug courts and police diversion programs offer a welcome shift from prior emphases on criminalization of drug use. However, for such programs to be effective, more resources must be dedicated to their success. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The Role of Context in Integrating Buprenorphine into a Drop-In Center in Kampala, Uganda, Using the Consolidated Framework for Implementation Research.

BACKGROUND: Although Africa has long borne the brunt of the human immunodeficiency virus (HIV) epidemic, until recently, the continent has been considered largely free of illicit drug use and injection drug use in particular. In Uganda, the number of people who use or inject drugs (PWUD and PWID, respectively) has increased, and PWID are a key population at high risk for human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection. However, harm reduction practices, including providing clean injection equipment and medication-assisted treatment (MAT), have only recently been piloted in the country. This project aims to integrate buprenorphine into a harm reduction drop-in center (DIC). METHODS: The Consolidated Framework for Implementation Research was used to guide our preparations to integrate buprenorphine into existing practices at a harm reduction DIC. We conducted key informant interviews with members of a community advisory board and DIC staff to document this process, its successes, and its failures. RESULTS: Results indicate that criminalization of drug use and stigmatization of PWUD challenged efforts to provide buprenorphine treatment in less regulated community settings. CONCLUSIONS: DIC staff and their commitment to harm reduction and advocacy facilitated the process of obtaining necessary approvals.

A Mobile Health Intervention to Improve Hepatitis C Outcomes Among People With Opioid Use Disorder: Protocol for a Randomized Controlled Trial.

BACKGROUND: People who inject drugs are at a disproportionate risk for contracting hepatitis C virus (HCV). However, use of HCV prevention and treatment services remains suboptimal among people with substance use disorders due to various health system, societal, and individual barriers. Mobile health applications offer promising strategies to support people in recovery from substance use disorders. We sought to determine whether the Addiction-Comprehensive Health Enhancement Support System (A-CHESS), an existing mobile health application for opioid use disorder, could be adapted to improve HCV screening and treatment. OBJECTIVE: The goals of this paper are to describe: (1) the components and functionality of an HCV intervention incorporated into the existing A-CHESS system; and (2) how data are collected and will be used to evaluate HCV testing, linkage to care, and treatment. METHODS: People with recent opioid use were enrolled in a randomized controlled trial to test whether A-CHESS reduced relapse. We developed and implemented HCV intervention content within the A-CHESS platform to simultaneously evaluate whether A-CHESS improved secondary outcomes related to HCV care. All A-CHESS users received the HCV intervention content, which includes educational information, private messages tailored to an individual's stage of HCV care, and a public discussion forum. Data on patients' HCV risk behaviors and stage of care were collected through quarterly telephone interviews and weekly surveys delivered through A-CHESS. The proportion of people with opioid use disorder who are HCV untested, HCV-negative, HCV antibody-positive, or HCV RNA-positive, as well as linked to care, treated and cured at baseline is described here. The 24-month follow-up is ongoing and will be completed in April 2020. Survey data will then be used to assess whether individuals who received the HCV-enhanced A-CHESS intervention were more likely to reduce risky injection behaviors, receive HCV testing, link to medical care, initiate treatment, and be cured of HCV compared to the control group. RESULTS: Between April 2016 and April 2018, 416 individuals were enrolled and completed the baseline interview. Of these individuals, 207 were then randomly assigned to the control arm and 209 were assigned to the intervention arm. At baseline, 202 individuals (49%) self-reported ever testing HCV antibody-positive. Of those, 179 (89%) reported receiving HCV RNA confirmatory testing, 134 (66%) tested HCV RNA-positive, 125 (62%) were linked to medical care and 27 (13%) were treated and cured of HCV. Of the remaining 214 individuals who had never tested HCV antibody-positive, 129 (31%) had tested HCV antibody-negative within the past year and 85 (20%) had not been tested within the past year. CONCLUSIONS: The A-CHESS mobile health system allows for the implementation of a bundle of services as well as the collection of longitudinal data related to drug use and HCV care among people with opioid use disorders. This study will provide preliminary evidence to determine whether HCV-specific services embedded into the A-CHESS program can improve HCV outcomes for people engaged in addiction treatment. TRIAL REGISTRATION: ClinicalTrials.gov NCT02712034; https://clinicaltrials.gov/ct2/show/NCT02712034. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12620.