Inpatient Opioid Use Disorder Treatment by Generalists is Associated With Linkage to Opioid Treatment Programs After Discharge

Abstract Background Opioid-related overdoses and harms have been declared a public health emergency in the United States, highlighting an urgent need to implement evidence-based treatments. Contingency management (CM) is one of the most effective behavioral interventions when delivered in combination with medication for opioid use disorder, but its implementation in opioid treatment programs is woefully limited. Project MIMIC (Maximizing Implementation of Motivational Incentives in Clinics) was funded by the National Institute on Drug Abuse to identify effective strategies for helping opioid treatment programs improve CM implementation as an adjunct to medication. Specific aims will test the impact of two different strategies on implementation outcomes (primary aim) and patient outcomes (secondary aims), as well as test putative mediators of implementation effectiveness (exploratory aim). Methods A 3-cohort, cluster-randomized, type 3 hybrid design is used with the opioid treatment programs as the unit of randomization. Thirty programs are randomized to one of two conditions. The control condition is the Addiction Technology Transfer Center (ATTC) Network implementation strategy, which consists of three core approaches: didactic training, performance feedback, and on-going consultation. The experimental condition is an enhanced ATTC strategy, with the same core ATTC elements plus two additional theory-driven elements. The two additional elements are Pay-for-Performance, which aims to increase implementing staff’s extrinsic motivations, and Implementation & Sustainment Facilitation, which targets staff’s intrinsic motivations. Data will be collected using a novel, CM Tracker tool to document CM session delivery, session audio recordings, provider surveys, and patient surveys. Implementation outcomes include CM Exposure (number of CM sessions delivered per patient), CM Skill (ratings of CM fidelity), and CM Sustainment (number of patients receiving CM after removal of support). Patient outcomes include self-reported opioid abstinence and opioid-related problems (both assessed at 3- and 6-months post-baseline). Discussion There is urgent public health need to improve the implementation of CM as an adjunct to medication for opioid use disorder. Consistent with its hybrid type 3 design, Project MIMIC is advancing implementation science by comparing impacts of these two multifaceted strategies on both implementation and patient outcomes, and by examining the extent to which the impacts of those strategies can be explained by putative mediators. Trial registration: This clinical trial has been registered with clinicaltrials.gov (NCT03931174). Registered April 30, 2019. https://clinicaltrials.gov/ct2/show/NCT03931174?term=project+mimic&draw=2&rank=1

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Neurocognitive, psychiatric, and substance use characteristics in a diverse sample of persons with OUD who are starting methadone or buprenorphine/naloxone in opioid treatment programs

Addiction Science & Clinical Practice ◽

10.1186/s13722-021-00272-4 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Travis M. Scott ◽

Julia Arnsten ◽

James Patrick Olsen ◽

Franchesca Arias ◽

Chinazo O. Cunningham ◽

...

Keyword(s):

Substance Use ◽

Learning And Memory ◽

Substance Use Disorders ◽

Neurocognitive Impairment ◽

Opioid Use Disorder ◽

Neurocognitive Functioning ◽

Treatment Programs ◽

Opioid Use ◽

Opioid Agonist ◽

Opioid Treatment

Abstract Background Medications for opioid use disorder such as opioid agonist treatment (OAT, including methadone, buprenorphine) are the gold standard intervention for opioid use disorder (OUD). Persons with OUD have high rates of neurocognitive impairment and psychiatric and substance use disorders, but few studies have examined these characteristics in diverse patients initiating OAT in opioid treatment programs (OTPs). Additionally, in these individuals, poor neurocognitive functioning and psychiatric/other substance use disorders are associated with poor OUD treatment outcomes. Given rapid changes in the opioid epidemic, we sought to replicate findings from our pilot study by examining these characteristics in a large diverse sample of persons with OUD starting OTP-based OAT. Methods Ninety-seven adults with OUD (M age = 42.2 years [SD = 10.3]; M education = 11.4 years [SD = 2.3]; 27% female; 22% non-Hispanic white) were enrolled in a randomized longitudinal trial evaluating methadone versus buprenorphine/naloxone on neurocognitive functioning. All participants completed a comprehensive neurocognitive, psychiatric, and substance use evaluation within one week of initiating OAT. Results Most of the sample met criteria for learning (79%) or memory (69%) impairment. Half exhibited symptoms of current depression, and comorbid substance use was highly prevalent. Lifetime cannabis and cocaine use disorders were associated with better neurocognitive functioning, while depression was associated with worse neurocognitive functioning. Conclusions Learning and memory impairment are highly prevalent in persons with OUD starting treatment with either methadone or buprenorphine/naloxone in OTPs. Depression and comorbid substance use are prevalent among these individuals, but neither impact learning or memory. However, depression is associated with neurocognitive impairment in other domains. These findings might allow clinicians to help persons with OUD starting OAT to develop compensatory strategies for learning and memory, while providing adjunctive treatment for depression. Trial Registration NCT, NCT01733693. Registered November 4, 2012, https://clinicaltrials.gov/ct2/show/NCT01733693.

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Machine Learning Applied to Clinical Laboratory Data Predicts Patient-Specific, Near-Term Relapse in Patients in Medication for Opioid Use Disorder Treatment

10.1101/2020.08.10.20163881 ◽

2020 ◽

Author(s):

Paul Pyzowski ◽

Barbara Herbert ◽

Wasim Q. Malik

Keyword(s):

Addiction Treatment ◽

Clinical Laboratory ◽

Laboratory Data ◽

Opioid Use Disorder ◽

Data Driven ◽

Treatment Programs ◽

Patient Specific ◽

Opioid Use ◽

Disorder Treatment ◽

Near Term

We have developed a data-driven, algorithmic method for identifying patients in an outpatient buprenorphine program at high risk for relapse in the following seven days. This method uses data already available in clinical laboratory data, can be made available in a timely matter, and is easily understandable and actionable by clinicians. Use of this method could significantly reduce the rate of relapse in addiction treatment programs by targeting interventions at those patients most at risk for near term relapse.

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Telehealth for opioid use disorder treatment in low-barrier clinic settings: an exploration of clinician and staff perspectives

Harm Reduction Journal ◽

10.1186/s12954-021-00572-7 ◽

2021 ◽

Vol 18 (1) ◽

Author(s):

Shoshana V. Aronowitz ◽

Eden Engel-Rebitzer ◽

Abby Dolan ◽

Kehinde Oyekanmi ◽

David Mandell ◽

...

Keyword(s):

Harm Reduction ◽

The United States ◽

Opioid Use Disorder ◽

Treatment Programs ◽

Opioid Overdose ◽

Opioid Use ◽

Access To Treatment ◽

Provider Perspectives ◽

The Usa ◽

Disorder Treatment

Abstract Background The majority of individuals with opioid use disorder (OUD) face access barriers to evidence-based treatment, and the COVID-19 pandemic has exacerbated the United States (US) opioid overdose crisis. However, the pandemic has also ushered in rapid transitions to telehealth in the USA, including for substance use disorder treatment with buprenorphine. These changes have the potential to mitigate barriers to care or to exacerbate pre-existing treatment inequities. The objective of this study was to qualitatively explore Philadelphia-based low-barrier, harm-reduction oriented, opioid use disorder (OUD) treatment provider perspectives about and experiences with telehealth during the COVID-19 pandemic, and to assess their desire to offer telehealth to patients at their programs in the future. Methods We interviewed 22 OUD treatment prescribers and staff working outpatient programs offering OUD treatment with buprenorphine in Philadelphia during July and August 2020. All participants worked at low-barrier treatment programs that provide buprenorphine using a harm reduction-oriented approach and without mandating counseling or other requirements as a condition of treatment. We analyzed the data using thematic content analysis. Results Our analysis yielded three themes: 1/ Easier access for some: telehealth facilitates care for many patients who have difficulty attending in-person appointments due to logistical and psychological barriers; 2/ A layered digital divide: engagement with telehealth can be seriously limited by patients’ access to and comfort with technology; and 3/ Clinician control: despite some clinic staff beliefs that patients should have the freedom to choose their treatment modality, patients’ access to treatment via telehealth may hinge on clinician perceptions of patient “stability” rather than patient preferences. Conclusions Telehealth may address many access issues, however, barriers to implementation remain, including patient ability and desire to attend healthcare appointments virtually. In addition, the potential for telehealth models to extend OUD care to patients currently underserved by in-person models may partially depend on clinician comfort treating patients deemed “unstable” via this modality. The ability of telehealth to expand access to OUD care for individuals who have previously struggled to engage with in-person care will likely be limited if these patients are not given the opportunity to receive treatment via telehealth.

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Methadone initiation in a bridge clinic for opioid withdrawal and opioid treatment program linkage: a case report applying the 72-hour rule

Addiction Science & Clinical Practice ◽

10.1186/s13722-021-00279-x ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Jordana Laks ◽

Jessica Kehoe ◽

Natalija M. Farrell ◽

Miriam Komaromy ◽

Jonathan Kolodziej ◽

...

Keyword(s):

Methadone Treatment ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Withdrawal ◽

Treatment Programs ◽

Opiate Withdrawal ◽

Opioid Use ◽

Case Presentation ◽

Opioid Treatment ◽

Life Threatening

Abstract Background In the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h. Case presentation A 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later. Conclusions While patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.

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