Hospital Addiction Medicine Consultation Service Orders and Outcomes by Patient Race and Ethnicity in an Urban, Safety-Net Hospital.

BACKGROUND: Hospital admissions involving substance use disorders are increasing and represent an opportunity to engage patients in substance use treatment. Addiction medicine consultation services improve access to medications for opioid use disorder (MOUD) and patient outcomes. However, as hospitals continue to adopt addiction medicine consultation services it is important to identify where disparities may emerge in the process of care. OBJECTIVE: To describe addiction medicine consultation service use by race and ethnicity as well as substance to identify opportunities to reduce substance use treatment disparities. DESIGN: Retrospective cohort study using 2016-2021 Electronic Health Record data from a large Midwest safety-net hospital. PARTICIPANTS: Hospitalized adults aged 18 or older, with one or more substance use disorders. MAIN MEASURES: Consultation orders placed, patient seen by consult provider, and receipt of MOUD by self-reported race. KEY RESULTS: Between 2016 and 2021, we identified 16,895 hospitalized patients with a substance use disorder. Consultation orders were placed for 6344 patients and 2789 were seen by the consult provider. Black patients were less likely (aOR = 0.58; 95% CI: 0.53-0.63) to have an addiction medicine consultation order placed and, among patients with a consultation order, were less likely (aOR = 0.74; 95% CI: 0.65-0.85) to be seen by the consult provider than White patients. Overall, Black patients with OUD were also less likely to receive MOUD in the hospital (aOR = 0.63; 95% CI: 0.50-0.79) compared to White patients. However, there were no differences in MOUD receipt among Black and White patients seen by the consult provider. CONCLUSIONS: Using Electronic Health Record data, we identified racial and ethnic disparities at multiple points in the inpatient addiction medicine consultation process. Addressing these disparities may support more equitable access to MOUD and other substance use treatment in the hospital setting.

In-Hospital Methadone Enrollment: a Novel Program to Facilitate Linkage from the Hospital to the Opioid Treatment Program for Vulnerable Patients with Opioid Use Disorder.

INTRODUCTION: Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. AIM: Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. SETTING: Seven hundred-bed university hospital in Aurora, CO. PROGRAM DESCRIPTION: A physician dually affiliated with a hospital's addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. PROGRAM EVALUATION METRICS: IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. RESULTS: Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients (n = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused (n = 43, 58.9% vs. n = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance (n = 53, 72.6% vs. n = 677, 40.1%), reported methamphetamine as their secondary substance (n = 27, 37.0% vs. n = 380, 22.5%), and reported they injected their primary substance (n = 46, 63.0% vs. n = 478, 28.3%). CONCLUSION: IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.

The Legal Landscape for Opioid Treatment Agreements.

Policy Points Opioid treatment agreements (OTAs) are controversial because of the lack of evidence that their use reduces opioid-related harms and the potential risks they pose of stigmatizing patients and undermining the clinician-patient relationship. Even so, their use is now required in most jurisdictions, and their use is influencing the outcomes of civil and criminal lawsuits. More research is needed to evaluate how OTAs are implemented given existing requirements. If additional research does not resolve the current level of uncertainty regarding OTA benefits, then policymakers in jurisdictions where they are required should consider eliminating OTA mandates or providing flexibility in the legal requirements to make room for clinicians and health care institutions to implement best practices. CONTEXT: Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids' risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in which the law permits flexibility for clinicians and health care institutions to adopt best practices. METHODS: We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. FINDINGS: Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions' requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts' reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. CONCLUSIONS: Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician-patient relationships and patient care within the bounds of relevant legal requirements and risks.

Examining changes in pain interference via pandemic-induced isolation among patients receiving medication for opioid use disorder: a secondary data analysis.

BACKGROUND: Early in the pandemic, the United States population experienced a sharp rise in the prevalence rates of opioid use, social isolation, and pain interference. Given the high rates of pain reported by patients on medication for opioid use disorder (MOUD), the pandemic presented a unique opportunity to disentangle the relationship between opioid use, pain, and social isolation in this high-risk population. We tested the hypothesis that pandemic-induced isolation would partially mediate change in pain interference levels experienced by patients on MOUD, even when controlling for baseline opioid use. Such work can inform the development of targeted interventions for a vulnerable, underserved population. METHODS: Analyses used data from a cluster randomized trial (N = 188) of patients on MOUD across eight opioid treatment programs. As part of the parent trial, participants provided pre-pandemic data on pain interference, opioid use, and socio-demographic variables. Research staff re-contacted participants between May and June 2020 and 133 participants (71% response rate) consented to complete a supplemental survey that assessed pandemic-induced isolation. Participants then completed a follow-up interview during the pandemic that again assessed pain interference and opioid use. A path model assessed whether pre-pandemic pain interference had an indirect effect on pain interference during the pandemic via pandemic-induced isolation. RESULTS: Consistent with hypotheses, we found evidence that pandemic-induced isolation partially mediated change in pain interference levels among MOUD patients during the pandemic. Higher levels of pre-pandemic pain interference and opioid use were both significantly associated with higher levels of pandemic-induced isolation. In addition, pre-pandemic pain interference was significantly related to levels of pain interference during the pandemic, and these pain levels were partially explained by the level of pandemic-induced isolation reported. CONCLUSIONS: Patients on MOUD with higher use of opioids and higher rates of pain pre-pandemic were more likely to report feeling isolated during COVID-related social distancing and this, in turn, partially explained changes in levels of pain interference. These results highlight social isolation as a key risk factor for patients on MOUD and suggest that interventions promoting social connection could be associated with reduced pain interference, which in turn could improve patient quality of life. TRIAL REGISTRATION: NCT03931174 (Registered 04/30/2019).

Exceeding the guideline-recommended maximum daily dose of opioids for long-term treatment of non-cancer pain in Germany - a large retrospective observational study.

BACKGROUND: High-dose long-term opioid therapy (LTOT) has been associated with increased mortality and hospitalizations. Therefore, the evidence-based German guideline on LTOT for chronic non-cancer pain (CNCP) recommends to only exceed the maximum daily dose (MDD) of opioids in exceptional cases. This study aimed to determine the portion of LTOT patients who exceeded the guideline-recommended MDD and identify predictors of exceeding in administrative claims data. METHODS: The retrospective observational analysis of opioid prescriptions in patients receiving LTOT for CNCP was based on administrative claims by a large German statutory health insurance company. Patients with at least two quarters of opioid prescriptions between January 2018 and June 2019 were included and followed up for two years. Predictors were identified by logistic regression. In addition, the number of patients still in opioid therapy and the extent of exceeded MDDs were analyzed over time. RESULTS: The sample consisted of 113,475 patients. Overall, 10.5% of the patients exceeded the guideline-recommended MDD averaged over the observation period. Strong predictors for exceeding the MDD were receiving opioid prescriptions from > 7 physicians (OR = 7.66, p < .001), receiving predominantly strong opioids (OR = 6.79, p < .001) and receiving opioids for at least one year prior to inclusion (OR = 5.35, p < .001). Within the non-exceeding group, 28.1% discontinued opioid therapy. In contrast, 9.9% of patients in the exceeding group discontinued opioid therapy, whereas the vast majority remained on treatment until the end of the observation period. Furthermore, a slight increase in prescribed doses was observed over time. CONCLUSIONS: The results indicate that a moderate proportion of patients exceeded the guideline-recommended MDD. However, certain patient groups were more likely to receive high doses. This applied in particular to those who were already on treatment at the time of inclusion and continued to receive opioids until the end of the observation period. Further research should examine whether the continuous opioid therapy among the patients with exceeding the guideline-recommended MDD might be related to specific indications, a lack of therapeutic options or avoidance of withdrawal. TRIAL REGISTRATION: German Clinical Trials Register (drks.de/search/en). Identifier: DRKS00024854. Registered 28 April 2021.

Adoption of Electronic Health Record Among Substance Use Disorder Treatment Programs: Nationwide Cross-Sectional Survey Study.

BACKGROUND: Electronic health record (EHR) systems have been shown to be associated with improvements in care processes, quality of care, and patient outcomes. EHR also has a crucial role in the delivery of substance use disorder (SUD) treatment and is considered important for addressing SUD crises, including the opioid epidemic. However, little is known about the adoption of EHR in SUD treatment programs or the organizational-level factors associated with the adoption of EHR in SUD treatment. OBJECTIVE: We examined the adoption of EHR in SUD programs, with a focus on changes in adoption from 2014 to 2017, and identified organizational-level factors associated with EHR adoption. METHODS: We used data from the 2014 and 2017 National Drug Abuse Treatment System Surveys. Our analysis included 1027 SUD programs (531 in 2014 and 496 in 2017). We used chi-square and Mann-Whitney U tests for categorical and continuous variables, respectively, to assess changes in EHR adoption, technology use, program, and client characteristics. We also investigated differences in characteristics and barriers to adoption by EHR adoption status (adopted EHR vs had not adopted or were planning to adopt EHR). We then conducted multivariate logistic regressions to examine internal and external factors associated with EHR adoption. RESULTS: The adoption of EHR increased significantly from 57.6% (306/531) in 2014 to 69.2% (343/496) in 2017 (P<.001), showing that nearly one-third (153/496, 30.8%) of SUD programs had not yet adopted an EHR system by 2017. We identified a significant increase in technology use and ownership by a parent company (P=.01 and P<.001) and a decrease in the percentage of uninsured patients in 2017 (P<.001), compared to 2014. Our analysis further showed significant differences by adoption status for three major barriers to adoption: (1) start-up costs, (2) ongoing financial costs, and (3) privacy or security concerns (P<.001). Programs that used computerized scheduling (adjusted odds ratio [AOR] 3.02, 95% CI 2.23-4.09) and billing systems (AOR 2.29, 95% CI 1.62-3.25) were more likely to adopt EHR. Similarly, ownership type, such as private nonprofit (AOR 1.86, 95% CI 1.31-2.65) and public (AOR 2.14, 95% CI 1.27-3.67), or interest in participating in a patient-centered medical home (AOR 1.93, 95% CI 1.29-2.92), were associated with an increased likelihood to adopt EHR. Overall, SUD programs were more likely to adopt an EHR system in 2017 compared to 2014 (AOR 1.44, 95% CI 1.07-1.94). CONCLUSIONS: Our findings highlighted that SUD programs may be on track to achieve widespread EHR adoption. However, there is a need for focused strategies, resources, and policies explicitly designed to systematically address barriers and tackle obstacles to expanding the adoption of EHR systems. These efforts must be holistic and address factors at multiple organizational levels.

A Video-Observed Treatment Strategy to Improve Adherence to Treatment Among Persons Who Inject Drugs Infected With Hepatitis C Virus: Qualitative Study of Stakeholder Perceptions and Experiences.

BACKGROUND: Direct-acting antiviral medications have the potential to eliminate the hepatitis C virus (HCV) epidemic among people who inject drugs; yet, suboptimal adherence remains a barrier. Directly observed treatment (DOT), an effective strategy for optimizing adherence, has been frequently implemented in opioid treatment programs but less commonly in community health settings due to the heavy burden of daily visits. An alternative is video-observed therapy (VOT), which uses mobile health technology to monitor adherence. VOT has not been widely studied among people who inject drugs with HCV. OBJECTIVE: This qualitative study, part of a larger implementation evaluation, investigates stakeholder perceptions and experiences with VOT in Project HERO (Hepatitis C Real Outcomes), a multisite pragmatic trial testing treatment delivery models for people who inject drugs with HCV. Our goal was to understand the potential barriers and facilitators to the implementation of the VOT technology. METHODS: Qualitative interviews were conducted with 27 Project HERO study staff and 7 patients. Interviews focused on perceptions and experiences with the VOT app and barriers and facilitators to implementation. Team meeting minutes over the first 2 years of the project were transcribed. A coding system was developed and applied to the data. We summarized thematic data and compared participant perceptions to generate a close understanding of the data. RESULTS: Frequent barriers to VOT included mechanical failure, stolen or lost phones, and a steep learning curve for participants and study staff. In sites with older and less technically skilled participants, staff found it difficult to implement the VOT app. Research staff found that the routine monitoring of app use led to closer engagement with participants. This was both a benefit and a potential threat to the validity of this pragmatic trial. Patient participants reported mixed experiences. CONCLUSIONS: VOT may be a useful alternative to DOT for some patients, but it may not be feasible for all. Significant staff involvement may be required.

Opioid use and COVID-19: a secondary analysis of the impact of relaxation of methadone take-home dosing guidelines on use of illicit opioids.

Background: An exemption to existing U.S. regulation of methadone maintenance therapy after the onset of the COVID-19 pandemic permitted increased take-home doses beginning March 2020.Objectives: We assessed the impact of this exemption on opioid use.Methods: A pre/post study of 187 clients recruited from an OTP who completed a survey and consented to share their urine drug testing (UDT) data. Use of fentanyl, morphine, hydromorphone, codeine, and heroin was assessed via UDT. Receipt of take-home methadone doses was assessed from clinic records for 142 working days pre- and post-COVID exemption. Analysis was conducted using a linear regression model to assess the association between increased take-home doses and use of illicit opioids.Results: In the pre- vs. post-COVID-19 SAMHSA exemption periods, 26.2% vs. 36.3% of UDTs were positive for 6-acetylmorphine respectively, 32.6% vs. 40.6% positive for codeine, 34.2% vs 44.2% positive for hydromorphone, 39.5% vs. 48.1% positive for morphine, 8.0% vs. 14.4% positive for fentanyl (p-value < .001). However, in the unadjusted descriptive data, when grouped by change in substance use, those clients who experienced a decrease in the use of morphine, codeine, and heroin post-COVID-19 were given significantly more take-home doses than the groups that had no change or an increase in the use of these substances. In the adjusted model, there was no significant relationship between change in opioid use and increased receipt of take-home methadone doses.Conclusions: Although take-home doses post-COVID-19 nearly doubled, this increase was not associated with a significant change in use of illicit opioids.

A realist review of best practices and contextual factors enhancing treatment of opioid dependence in Indigenous contexts.

OBJECTIVES: The objective of this study was to examine international literature to identify best practices for treatment of opioid dependence in Indigenous contexts. METHODS: We utilized a systematic search to identify relevant literature. The literature was analysed using a realist review methodology supported by a two-step knowledge contextualization process, including a Knowledge Holders Gathering to initiate the literature search and analysis, and five consensus-building meetings to focus and synthesize relevant findings. A realist review methodology incorporates an analysis of the complex contextual factors in treatment by identifying program mechanisms, namely how and why different programs are effective in different contexts. RESULTS: A total of 27 sources were identified that met inclusion criteria. Contextual factors contributing to opioid dependence described in the literature often included discussions of a complex interaction of social determinants of health in the sampled community. Twenty-four articles provided evidence of the importance of compassion in treatment. Compassion was evidenced primarily at the individual level, in interpersonal relationships based on nonjudgmental care and respect for the client, as well as in more holistic treatment programs beyond biophysical supports such as medically assisted treatment. Compassion was also shown to be important at the structural level in harm reduction policies. Twenty-five articles provided evidence of the importance of client self-determination in treatment programs. Client self-determination was evidenced primarily at the structural level, in community-based programs and collaborative partnerships based in trust and meaningful engagement but was also shown to be important at the individual level in client-directed care. Identified outcomes moved beyond a reduction in opioid use to include holistic health and wellness goals, such as improved life skills, self-esteem, feelings of safety, and healing at the individual level. Community-level outcomes were also identified, including more families kept intact, reduction in drug-related medical evacuations, criminal charges and child protection cases, and an increase in school attendance, cleanliness, and community spirit. CONCLUSIONS: The findings from this realist review indicate compassion and self-determination as key program mechanisms that can support outcomes beyond reduced incidence of substance use to include mitigating systemic health inequities and addressing social determinants of health in Indigenous communities, ultimately healing the whole human being.

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

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

Scaling and Sustaining Facilitated Telemedicine to Expand Treatment Access Among Underserved Populations: A Qualitative Study.

Background: Opioid treatment programs are an essential component of the management of opioid use disorder (OUD). They have also been proposed as "medical homes" to expand health care access for underserved populations. We utilized telemedicine as a method to increase access for hepatitis C virus (HCV) care among people with OUD. Methods: We interviewed 30 staff and 15 administrators regarding the integration of facilitated telemedicine for HCV into opioid treatment programs. Participants provided feedback and insight for sustaining and scaling facilitated telemedicine for people with OUD. We utilized hermeneutic phenomenology to develop themes related to telemedicine sustainability in opioid treatment programs. Results: Three themes emerged on sustaining the facilitated telemedicine model: (1) Telemedicine as a Technical Innovation in Opioid Treatment Programs, (2) Technology Transcending Space and Time, and (3) COVID-19 Disrupting the Status Quo. Participants identified skilled staff, ongoing training, technology infrastructure and support, and an effective marketing campaign as key to maintaining the facilitated telemedicine model. Participants highlighted the study-supported case manager's role in managing the technology to transcend temporal and geographical challenges for HCV treatment access for people with OUD. COVID-19 fueled changes in health care delivery, including facilitated telemedicine, to expand the opioid treatment program's mission as a medical home for people with OUD. Conclusions: Opioid treatment programs can sustain facilitated telemedicine to increase health care access for underserved populations. COVID-19-induced disruptions promoted innovation and policy changes recognizing telemedicine's role in expanding health care access to underserved populations. ClinicalTrials.gov Identifier: NCT02933970.

Scaling a Behavioral Health Home Delivery Model to Special Populations.

The present project utilized a Learning Collaborative (LC) to disseminate the Behavioral Health Home Plus (BHHP) physical-behavioral health integration model to providers serving two behavioral health populations at risk for adverse health conditions: youth psychiatric residential treatment facilities (five sites) and adult opioid treatment providers (seven sites). Following the positive results of a randomized controlled trial utilizing an LC to implement two behavioral health home models in community mental health provider organizations serving adults with serious mental illness, Community Care Behavioral Health Organization facilitated integration of the models to scale health and wellness supports to additional behavioral health care delivery settings. This paper presents provider results focused on BHHP implementation training, LC implementation, physical health and wellness promotion within sites, and BHHP model sustainment plans. Provider self-reported data indicate that the LC approach is a successful tool for integrating and sustaining BHHP model components in routine care.

Facilitating factors and barriers for use of medications to treat opioid use disorder (MOUD) among justice-involved individuals in rural Appalachia.

The purpose of this qualitative study is to assess facilitating factors and barriers for medications to treat opioid use disorder (MOUD) initiation among justice-involved individuals in one rural Appalachian community, as well as how those factors may differ across the three types of Food and Drug Administration (FDA) approved medications. Qualitative interviews were conducted with rural justice-involved individuals (N = 10) with a history of opioid use in the target community. Overall, participants demonstrated knowledge of the different types of MOUD and their pharmacological properties, but limited overall health literacy around opioid use disorder and MOUD treatment. Treatment access was hampered by transportation, time burdens, and costs. Findings call for research into improving health literacy education, training, and resources to decrease stigma and increase access to MOUD, particularly in light of the ongoing opioid crisis. State policies also need to increase access to all FDA medications among justice-involved individuals, as well as supporting a care continuum from facility entry, release, and community re-entry.

Race-based differences in drug use prior to onset of opioid use disorder.

Rates of opioid use disorder (OUD) have increased dramatically over the past two decades, a rise that has been accompanied by changing demographics of those affected. Early exposure to drugs is a known risk factor for later development of opioid use disorder; but how and whether this risk factor may differ between racial groups is unknown. Our study seeks to identify race differences in self-report of current and past substance use in OUD-diagnosed treatment-seeking individuals. Patients (n = 157) presenting for methadone maintenance treatment at a racially diverse urban opioid treatment program were approached and consented for study involvement. Participants were administered substance use history questionnaires and urine drug screening at intake. Chi-square, t-tests, and rank-sum were used to assess race differences in demographic variables. Logistic and linear regressions assessed the relationship between race and substance use for binary and continuous variables, respectively. 61% of the population identified as Black and 39% as White. Black participants were significantly older; age was thus included as a covariate. Logistic regressions demonstrated that despite similar urine toxicology at intake, White participants were significantly more likely to report having used prescription opioids and psychedelic, stimulant, and sedative substance classes prior to their first use of non-pharmaceutical opioids. Compared to Black participants, White treatment-seeking OUD-diagnosed individuals reported using a wider range of substances ever and prior to first use of non-pharmaceutical opioids. There were no differences, however, in presentation for OUD treatment, suggesting different pathways to OUD, which may carry important clinical implications.

A Taxonomy of Hospital-Based Addiction Care Models: a Scoping Review and Key Informant Interviews.

BACKGROUND: There is pressing need to improve hospital-based addiction care. Various models for integrating substance use disorder care into hospital settings exist, but there is no framework for describing, selecting, or comparing models. We sought to fill that gap by constructing a taxonomy of hospital-based addiction care models based on scoping literature review and key informant interviews. METHODS: Methods included a scoping review of the literature on US hospital-based addiction care models and interventions for adults, published between January 2000 and July 2021. We conducted semi-structured interviews with 15 key informants experienced in leading, implementing, evaluating, andpracticing hospital-based addiction care to explore model characteristics, including their perceived strengths, limitations, and implementation considerations. We synthesized findings from the literature review and interviews to construct a taxonomy of model types. RESULTS: Searches identified 2,849 unique abstracts. Of these, we reviewed 280 full text articles, of which 76 were included in the final review. We added 8 references from reference lists and informant interviews, and 4 gray literature sources. We identified six distinct hospital-based addiction care models. Those classified as addiction consult models include (1) interprofessional addiction consult services, (2) psychiatry consult liaison services, and (3) individual consultant models. Those classified as practice-based models, wherein general hospital staff integrate addiction care into usual practice, include (4) hospital-based opioid treatment and (5) hospital-based alcohol treatment. The final type was (6) community-based in-reach, wherein community providers deliver care. Models vary in their target patient population, staffing, and core clinical and systems change activities. Limitations include that some models have overlapping characteristics and variable ways of delivering core components. DISCUSSION: A taxonomy provides hospital clinicians and administrators, researchers, and policy-makers with a framework to describe, compare, and select models for implementing hospital-based addiction care and measure outcomes.

Support for evidence-informed opioid policies and interventions: The role of racial attitudes, political affiliation, and opioid stigma.

Political affiliation, racial attitudes, and opioid stigma influence public support for public health responses to address opioid use disorders (OUD). Prior studies suggest public perceptions of the opioid epidemic are less racialized and less politically polarized than were public perceptions of the crack cocaine epidemic. Analyzing a cross-sectional, nationally representative sample (n = 1161 U.S. adults) from the October 2020 AmeriSpeak survey, we explored how political affiliation, racial attitudes (as captured in the Color-Blind Racial Attitudes Scale [CoBRAS]), and OUD stigma were associated with respondents' expressed views regarding four critical domains. Respondents with unfavorable attitudes towards Black Americans were less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and distributing naloxone for overdose prevention. Democratic Party affiliation was associated with greater support for all three of the above measures, and increased support for mandatory treatment, which may be seen as a substitute for more punitive interventions. Black respondents were also less likely to support expanding Medicaid funding, increasing government spending to provide services for people living with OUD, and of distributing naloxone. Our finding suggest that negative attitudes towards African-Americans and political differences remain important factors of public opinion on responding to the OUD epidemic, even after controlling for opioid stigma. Our findings also suggest that culturally-competent dialogue within politically conservative and Black communities may be important to engage public support for evidence-informed treatment and prevention.

Functional Impairment and Cognitive Symptoms Among People with HIV Infection on Chronic Opioid Therapy for Pain: The Impact of Gabapentin and Other Sedating Medications.

Gabapentin is associated with dizziness, falls, and somnolence yet commonly prescribed to people with HIV (PWH) treated with chronic opioid therapy (COT). Physical function and cognition are understudied when prescribed together. Among PWH on COT, we evaluated whether co-prescribed gabapentin is associated with (a) functional impairment; (b) trouble thinking clearly; and (c) difficulty controlling drowsiness using logistic regression models adjusted for prescribed opioid dose, other (non-gabapentin) sedating medication, substance use disorder, and mental/physical health indicators in a cross-sectional study. Among 166 participants, 40% were prescribed gabapentin, 41% reported functional impairment, 41% trouble thinking clearly, and 38% difficulty controlling drowsiness. Gabapentin co-prescribed with COT was significantly associated with trouble thinking clearly but not with functional impairment or difficulty controlling drowsiness. Clinicians should be cognizant of potential problems with thinking clearly when co-prescribing gabapentin and opioid medication.

Pronounced Regional Disparities in United States Methadone Distribution.

BACKGROUND: Methadone is an evidence-based treatment for opioid use disorder (OUD) and pain management. Methadone for OUD may be difficult for some patients to access, particularly those in rural areas. OBJECTIVE: The purpose of this study was to characterize methadone distribution patterns between 2017 and 2019 across the United States. METHODS: The US Drug Enforcement Administration's Automated Reports and Consolidated Ordering System was used to acquire the number of opioid treatment programs (OTPs) per state and methadone distribution weight in grams. Methadone distributions by weight, corrected for state population and number of OTPs, were compared from 2017 to 2019 between states, within regions, and nationally. RESULTS: The national distribution of methadone increased +12.3% for OTPs but decreased -34.6% for pain. Whereas all states saw a decrease in pain distribution, the Northeast showed a significantly smaller decrease than all other regions. Additionally, the majority of states experienced an increase in distribution for OTPs, and most states demonstrated a relatively stable or increasing number of OTPs, with an +11.5% increase nationally. The number of OTPs per 100K state population ranged from 2.1 in Rhode Island to 0.0 in Wyoming. CONCLUSION AND RELEVANCE: Although methadone distribution for OUD was increasing in the United States, the pronounced regional disparities identified warrant further consideration to improve patient access to this evidence-based pharmacotherapy, particularly in the Midwest and West regions. Greater implementation of telehealth and involvement of primary care into opioid treatment practice offer possible solutions to eliminating geographical treatment barriers.

Identifying the Physical and Mental Healthcare Needs of Opioid Treatment Program Clients.

Background: Individuals with opioid use disorder (OUD) often have significant medical and behavioral health needs that are unaddressed. Opioid treatment programs (OTP) are uniquely positioned to provide integrated services for OUD, physical and mental health but are underutilized for this purpose. This study aims to describe the physical and mental healthcare needs of OTP clients in order to inform integrated care implementation in OTPs. Method: OTP clients (n = 1261) in an integrated care program in the Bronx borough of New York City were assessed for mental health symptoms (e.g., anxiety, depression), chronic disease indicators (e.g., blood pressure, cholesterol), and general functioning (e.g., capability of managing healthcare needs). Results: Symptoms of anxiety, post-traumatic stress, and depression were common. Self-reported health status and level of functioning were generally poor. Heavy smoking and obesity were the most frequent physical health risks. Other chronic disease indicators (e.g., blood pressure) showed 25-46% may be at risk. Sixty percent had multiple mental health risks and 85% had multiple physical health risks. Older clients had a higher rate of hypertension and diabetes risk than younger clients. Conclusions: Integrated care programs in OTPs must be prepared to address and coordinate care for chronic mental and physical health conditions in addition to OUD.

Spatial and Nonspatial Factors Associated with Access to Medication for Opioid Use Disorder among Pregnant Women in Massachusetts.

INTRODUCTION: In Massachusetts, one-third of pregnant women with opioid use disorder (OUD) do not receive medications for OUD (MOUD), such as buprenorphine and methadone. Research has demonstrated that broadly, access to medications differs by location and by socioeconomic and geographic characteristics of communities, but a comprehensive understanding at the micro-level is lacking. This study aims to identify and characterize access to MOUD treatment among pregnant women in Massachusetts. METHODS: We used enhanced two-step floating catchment area analyses, which incorporated supply and demand measures, as well as local drive-time, to determine spatial accessibility to MOUD. We used four publicly available data sources to calculate geographic accessibility to MOUD. We then merged the resulting accessibility indices with data from the American Community Survey to statistically analyze ZIP Code Tabulation Area (ZCTA) characteristics that were associated with geographic accessibility to MOUD among the study population. RESULTS: We calculated access to 258 opioid (methadone and/or buprenorphine) treatment programs and 2,585 buprenorphine-waivered prescribers among 74,969 pregnant women during the period 2016-2020 in 448 ZCTAs (N = 537 ZCTAs). ZCTAs with lower accessibility to both types of MOUD were concentrated in Western Massachusetts. Central Massachusetts had poor accessibility to buprenorphine providers. Accessibility was greater in ZCTAs that were nonmetropolitan, that had higher minority status and langauge vulnerability, and that had less extreme concentration of privilege. CONCLUSIONS: There is a need to improve MOUD access overall, and to enhance access to both types of medications, so pregnant women can choose the one that works best for them.