Perceived Benefits and Harms of Involuntary Civil Commitment for Opioid
                        Use Disorder

Involuntary civil commitment (ICC) to treatment for opioid use disorder (OUD) prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and “on-demand” treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way.

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Civil commitment for opioid misuse: do short-term benefits outweigh long-term harms?

Journal of Medical Ethics ◽

10.1136/medethics-2020-107160 ◽

2021 ◽

pp. medethics-2020-107160

Author(s):

John C Messinger ◽

Daniel J Ikeda ◽

Ameet Sarpatwari

Keyword(s):

Civil Commitment ◽

Opioid Use Disorder ◽

Opioid Use ◽

Short Term ◽

Community Based ◽

Loss Of Life ◽

Severe Withdrawal ◽

The Usa ◽

Overdose Deaths

In response to a sharp rise in opioid-involved overdose deaths in the USA, states have deployed increasingly aggressive strategies to limit the loss of life, including civil commitment—the forcible detention of individuals whose opioid use presents a clear and convincing danger to themselves or others. While civil commitment often succeeds in providing short-term protection from overdose, emerging evidence suggests that it may be associated with long-term harms, including heightened risk of severe withdrawal, relapse and opioid-involved mortality. To better assess and mitigate these harms, states should collect more robust data on long-term health outcomes, decriminalise proceedings and stays, provide access to medications for opioid use disorder and strengthen post-release coordination of community-based treatment.

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Evidence-Based Treatment for Opioid Use Disorder

PsycEXTRA Dataset ◽

10.1037/e503952019-001 ◽

2018 ◽

Keyword(s):

Opioid Use Disorder ◽

Evidence Based ◽

Opioid Use ◽

Evidence Based Treatment

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Prior National Drug Abuse Treatment Clinical Trials Network (CTN) opioid use disorder trials as background and rationale for NIDA CTN-0100 “optimizing retention, duration and discontinuation strategies for opioid use disorder pharmacotherapy (RDD)”

Addiction Science & Clinical Practice ◽

10.1186/s13722-021-00223-z ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Matisyahu Shulman ◽

Roger Weiss ◽

John Rotrosen ◽

Patricia Novo ◽

Elizabeth Costello ◽

...

Keyword(s):

Clinical Trials ◽

Extended Release ◽

Primary Outcome ◽

Opioid Use Disorder ◽

Drug Abuse Treatment ◽

Opioid Use ◽

National Drug ◽

Retention In Treatment ◽

Abuse Treatment

AbstractOpioid use disorder continues to be a significant problem in the United States and worldwide. Three medications—methadone, buprenorphine, and extended-release injectable naltrexone,— are efficacious for treating opioid use disorder (OUD). However, the utility of these medications is limited, in part due to poor rates of retention in treatment. In addition, minimum recovery milestones and other factors that influence when and whether individuals can safely discontinue medications are unknown. The National Drug Abuse Treatment Clinical Trials Network (CTN) study “Optimizing Retention, Duration, and Discontinuation Strategies for Opioid Use Disorder Pharmacotherapy” (RDD; CTN-0100) will be among the largest clinical trials on treatment of OUD yet conducted, consisting of two phases, the Retention phase, and the Duration-Discontinuation phase. The Retention phase, open to patients initiating treatment, will test different doses and formulations of buprenorphine (standard dose sublingual, high dose sublingual, or extended-release injection), and a digital therapeutic app delivering contingency management and cognitive behavioral counseling on the primary outcome of retention in treatment. The Discontinuation phase, open to patients in stable remission from OUD and choosing to discontinue medication (including participants from the Retention phase or from the population of patients treated at the clinical site, referred by an outside prescriber or self-referred) will study different tapering strategies for buprenorphine (sublingual taper vs taper with injection buprenorphine), and a digital therapeutic app which provides resources to promote recovery, on the primary outcome of relapse-free discontinuation of medication. This paper describes how the RDD trial derives from two decades of research in the CTN. Initial trials (CTN-0001; CTN-0002; CTN-0003) focused on opioid detoxification, showing buprenorphine-naloxone was effective for detoxification, but that acute detoxification did not appear to be an effective treatment strategy. Trials on comparative effectiveness of medications for opioid use disorder (MOUD) (CTN-0027; CTN-0030; and CTN-0051) highlighted the problem of dropout from treatment and few trials defined retention on MOUD as the primary outcome. Long-term follow-up studies on those patient samples demonstrated the importance of long-term continuation of medication for many patients to sustain remission. Overall, these trials highlight the potential of a stable research infrastructure such as CTN to advance treatment effectiveness through a programmatic succession of large clinical trials.

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Patient Experiences with the Transition to Telephone Counseling during the COVID-19 Pandemic

Healthcare ◽

10.3390/healthcare9060663 ◽

2021 ◽

Vol 9 (6) ◽

pp. 663

Author(s):

Augustine W. Kang ◽

Mary Walton ◽

Ariel Hoadley ◽

Courtney DelaCuesta ◽

Linda Hurley ◽

...

Keyword(s):

Patient Outcomes ◽

Interrater Reliability ◽

Telephone Counseling ◽

Patient Experiences ◽

Opioid Use Disorder ◽

Opioid Use ◽

Therapeutic Experience ◽

Perceived Impact

Background: To identify and document the treatment experiences among patients with opioid use disorder (OUD) in the context of the rapid move from in-person to telephone counseling due to the COVID-19 pandemic. Methods: Participants (n = 237) completed a survey with open-ended questions that included the following domains: (1) satisfaction with telephone counseling, (2) perceived convenience, (3) changes to the therapeutic relationship, (4) perceived impact on substance use recovery, and (5) general feedback. Responses were coded using thematic analysis. Codes were subsequently organized into themes and subthemes (covering 98% of responses). Interrater reliability for coding of participants’ responses ranged from 0.89 to 0.95. Results: Overall, patients reported that telephone counseling improved the therapeutic experience. Specifically, 74% of respondents were coded as providing responses consistently indicating “positive valency”. “Positive valency” responses include: (1) feeling supported, (2) greater comfort and privacy, (3) increased access to counselors, and (4) resolved transportation barriers. Conversely, “negative valency” responses include: (1) impersonal experience and (2) reduced privacy. Conclusions: Telephone counseling presents its own set of challenges that should be investigated further to improve the quality of care and long-term patient outcomes.

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Championing Change to Save Lives: A Call to Action to Implement Reforms to Increase Use of Medications to Treat Opioid Use Disorder in Correctional Settings

Criminal Justice Review ◽

10.1177/0734016820981629 ◽

2020 ◽

pp. 073401682098162

Author(s):

Sonia L. Canzater ◽

Regina M. LaBelle

Keyword(s):

Standard Of Care ◽

Opioid Use Disorder ◽

Correctional Facilities ◽

Evidence Based ◽

Opioid Use ◽

Call To Action ◽

Evidence Based Treatment ◽

High Prevalence ◽

Correctional Settings ◽

Overdose Deaths

The disproportional rates of opioid use disorder (OUD) in U.S. correctional facilities make them prime intervention points to treat OUD utilizing medication to treat opioid use disorder (MOUD), the evidence-based clinical standard of care. MOUD has been shown to be effective to support recovery and reduce recurrence of OUD, overdose deaths, and recidivism for justice-involved persons both while incarcerated and once they reenter their communities. Despite the high prevalence, most jails and prisons do not offer MOUD. Litigation has spurred expanded access in more facilities, but widespread MOUD access can only become a reality through a comprehensive effort of corrections officials, medical experts, advocates, legislators, and other champions to raise awareness and affect ideological and policy change. It is a legal and ethical imperative that the lives of justice-involved persons not be jeopardized by the lack of evidence-based treatment for OUD in correctional settings.

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A review of the evidence to explain pharmacological basis of injection (ab)use of buprenorphine–naloxone tablets

Journal of Opioid Management ◽

10.5055/jom.2021.0651 ◽

2021 ◽

Vol 17 (7) ◽

pp. 141-152

Author(s):

Tamoud Modak, MD, DM ◽

Siddharth Sarkar, MD, MRCPsych ◽

Yatan Pal Singh Balhara, MD

Keyword(s):

Public Health Problem ◽

Opioid Use Disorder ◽

Critical Examination ◽

Evidence Based ◽

Major Public Health Problem ◽

Opioid Use ◽

Evidence Based Treatment ◽

Opioid Replacement Therapy ◽

Pharmacological Basis

Opioid use disorder is a major public health problem, and opioid replacement therapy with buprenorphine (BPN) is a clinically effective and evidence-based treatment for it. To deter misuse of the tablet through the injecting route, BPN coformulated with naloxone (BNX) in 4:1 ratio is available in many countries. Despite this, significant diversion and injecting use of the BNX combination has been reported from across the world. In this article, the pharmacological properties of BPN and BNX and the evidence for their diversion are reviewed. Also, a critical examination is made of the evidence supporting the role of naloxone in reducing the agonist effects of BPN when used through the injecting route. Based on this evidence, a hypothesis explaining the continued diversion of BNX has been proposed.

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Patient and Clinician Perspectives on Adolescent Opioid Use Disorder Treatment During a Pandemic: One Step Back, but Two Forward? (Preprint)

10.2196/preprints.23463 ◽

2020 ◽

Author(s):

Samuel W Stull ◽

Erin R McKnight ◽

Andrea E Bonny

Keyword(s):

The United States ◽

Opioid Use Disorder ◽

Drop Out ◽

Mobile Technologies ◽

Opioid Use ◽

The Face ◽

One Step ◽

Clinician Perspectives ◽

Receive Treatment

UNSTRUCTURED Opioid use disorder (OUD) is one of the most pressing public health problems in the United States and is highly prevalent among adolescents and young adults (AYAs). However, only a small percentage of AYAs with OUD ever receive treatment. Further, among those that do receive treatment, a substantial proportion of patients continue to struggle with OUD, and many prematurely drop out of treatment. These challenges have only been heightened in the face of the COVID-19 pandemic, but greater utilization of telehealth and mobile technologies by OUD patients may help counter these barriers, which ultimately may improve AYA OUD treatment in the postpandemic period. This viewpoint presents the perspective of a person in OUD recovery using online and mobile technology to support his own OUD recovery combined with thoughts from two clinicians supporting AYAs with OUD. Their perspectives may provide insights to help counter COVID-19–related consequences and offer clues to improving AYA OUD treatment in the long term.

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Implementing a Low-threshold Audio-only Telehealth Model for Medication-assisted Treatment of Opioid Use Disorder at a Community-based Non-profit Organization in Washington, D.C.

10.21203/rs.3.rs-915722/v1 ◽

2021 ◽

Author(s):

Ellis Jaewon Yeo ◽

Hannah Kralles ◽

David Sternberg ◽

Dana McCullough ◽

Ajetha Nadanasabesan ◽

...

Keyword(s):

Patient Characteristics ◽

The United States ◽

Opioid Use Disorder ◽

Retention Rates ◽

People Who Use Drugs ◽

Opioid Use ◽

Treatment Access ◽

Community Based ◽

Medication Assisted Treatment ◽

Low Threshold

Abstract BackgroundThe COVID-19 pandemic has had especially devastating effects on people who use drugs. Due to pandemic protocols in the United States, medication-assisted treatment (MAT) regulations became more flexible, permitting our community-based nonprofit organization to transition its low-threshold MAT clinic to an audio-only telehealth model of care in 2020. Case PresentationThis case study describes our transition from a low-threshold community-based in-person MAT clinic to an audio-only telehealth model. We extracted data from electronic health records to describe patient characteristics and to calculate treatment retention rates. We measure the success of our intervention relative to published retention rates, both overall as well as for in-person and telehealth care. ConclusionsLow-threshold medication-assisted treatment in the care of people with opioid use disorder is essential to increasing treatment access and continuity. We found that an audio-only telehealth model was viable. Although we had decreased retention rates following the transition to an audio-only telehealth model, our rates remained excellent compared to published values for in-person MAT care. We call for advocacy and regulations to support continued use of telehealth services throughout and beyond the COVID-19 pandemic.

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