Implementation of Buprenorphine Services in NYC Syringe Services Programs: a qualitative process evaluation

Abstract Background Syringe services programs (SSPs) hold promise for providing buprenorphine treatment access to people with opioid use disorder (OUD) who are reluctant to seek care elsewhere. In 2017, the New York City Department of Health and Mental Hygiene (DOHMH) provided funding and technical assistance to nine SSPs to develop “low-threshold” buprenorphine services as part of a multipronged initiative to lower opioid-related overdose rates. The aims of this study were to 1) Describe characteristics of SSP-based buprenorphine services; and 2) Identify barriers to and facilitators of implementing SSP-based buprenorphine services. Methods We conducted 26 semi-structured qualitative interviews from April 2019 - November 2019 at eight SSPs in NYC that received funding and technical assistance from DOHMH. Interviews were conducted with three categories of staff: leadership (8 interviews); staff (11), and providers (6). We used thematic analysis to identify themes within pre-identified domains: program characteristics and barriers and facilitators to program implementation. We make recommendations for implementation based on our findings. Results Programs differed in their stage of development, location of services provided, and provider type, availability, and practices. Barriers to providing buprenorphine services at SSPs included gaps in staff knowledge and comfort communicating with participants about buprenorphine, difficulty hiring providers, managing tension between harm reduction and traditional OUD treatment philosophies, and financial constraints. Challenges also arose from serving a population with unmet psychosocial needs. Implementation facilitators included technical assistance from DOHMH, designated buprenorphine coordinators, offering other supportive services to participants, and telehealth to bridge gaps in provider availability. Key recommendations include: 1) health departments should provide support for SSPs in training staff, building health service infrastructure and developing policies and procedures, 2) SSPs should designate a buprenorphine coordinator and ensure regular training on buprenorphine for their frontline staff, and 3) providers should be selected or supported to use a harm reduction approach to buprenorphine treatment. Conclusions Despite encountering challenges, eight SSPs implemented buprenorphine services outside of conventional OUD treatment settings. Our findings have implications for health departments, SSPs, and other community organizations implementing buprenorphine services. Expansion of low-threshold buprenorphine services is a promising strategy to address the opioid overdose epidemic.

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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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Fentanyl analogue overdose: Key lessons in management in the synthetic opioid age

Journal of Opioid Management ◽

10.5055/jom.2019.0531 ◽

2019 ◽

Vol 15 (5) ◽

pp. 428-432

Author(s):

Amer Raheemullah, MD ◽

Neal Andruska, MD, PhD

Keyword(s):

Addiction Treatment ◽

Opioid Use Disorder ◽

Prescription Opioid ◽

Opioid Overdose ◽

Health Departments ◽

Opioid Use ◽

Public Health Departments ◽

Disorder Treatment ◽

Fentanyl Analogues ◽

Overdose Deaths

Fentanyl overdoses are growing at an alarming rate. Fentanyl is often mixed into heroin and counterfeit prescription opioid pills without the customer’s knowledge and only detected upon laboratory analysis. This is problematic because fentanyl analogues like carfentanil are 10,000 times more potent than morphine and pose new challenges to opioid overdose management. A 62-year-old male with an overdose from a rare fentanyl analogue, acrylfentanyl, was given two doses of intranasal 2 mg naloxone with improvements in respiratory rate. In lieu of more naloxone, his trachea was intubated and he was admitted to the intensive care unit. He subsequently developed ventilator-associated pneumonia and then a pulmonary embolism. He did not receive any opioid use disorder treatment and returned back to the emergency department with an opioid overdose 21 days after discharge.We are encountering an unprecedented rise in synthetic opioid overdose deaths as we enter the third decade of the opioid epidemic. Thus, it is imperative to be aware of the features and management of overdoses from fentanyl and its analogues. This includes protecting against occupational exposure, administering adequate doses of naloxone, and working with public health departments to respond to fentanyl outbreaks. Additionally, fentanyl overdoses represent a critical opportunity to move beyond acute stabilization, start buprenorphine or methadone for opioid use disorder during hospitalization, link patients to ongoing addiction treatment, and distribute naloxone into the community to help curb the overdose epidemic.

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Problematisk opioidanvändning: om opioidrelaterade dödsfall och LARO i södra Sverige

10.24834/isbn.9789178772124 ◽

2021 ◽

Author(s):

◽

Lisa Andersson

Keyword(s):

Patient Choice ◽

Mortality Data ◽

Opioid Overdose ◽

Opioid Use ◽

Treatment Provider ◽

Opioid Substitution Treatment ◽

Treatment Providers ◽

National Mortality ◽

Choice Of Treatment ◽

Low Threshold

Problematic opioid use constitutes an extensive global problem. Correspondingly, opioid-related mortality is high and has increased in several Western countries, including Sweden, during the 2000s. In Sweden, the most effective treatment method, opioid substitution treatment (OST), was for a long time limited with respect to the number of patients. The treatment was also characterized by strict rules and conducted in a high-threshold manner, which has meant that it has not been fully appealing to people with problematic opioid use. Therefore, in Skåne County in southern Sweden, patient choice of treatment provider was introduced for OST in 2014 with the intention to increase the number of treatment places and strengthen patient empowerment. The overall aims of this thesis are (1) to investigate opioid-related deaths in Skåne with a focus on contact with care-providing authorities and in relation to increased access to OST, and (2) to examine patients’ and clinic managers’ attitudes towards the introduction of the patient choice reform for OST and their views of the reform's objectives of increased accessibility to OST and strengthening patients' empowerment and influence over their treatment. The four papers in this thesis are based on two research projects with various empiric material. Paper I and II are based on data on opioid overdose deaths from a period of two years before and two years following the introduction of the patient choice reform. Forensic data regarding the presence of various substances and which opioid caused the death, as well as demographic data and information on contact with care-providing authorities (health care, social services, and the Prison and Probation Service), were collected. Paper I examines clinical background and contact with care-providing authorities of opioid-related fatalities, as well as differences with regard to which opioid caused the death. Paper II examines the possible impact of the intervention on the development of opioid-related deaths in the region. National mortality data were also used in this study to investigate the development in Skåne compared to the rest of Sweden. The second research project focused on stakeholders’ views on the implementation of the patient choice reform. Paper III includes interviews with 33 OST patients, and paper IV consists of interviews with the managers of all OST clinics in Skåne. The results from paper I show that of the 180 deceased in opioid overdose included in the study, almost 90 per cent had been in contact with one of the examined care-providing authorities during the year prior to death. Few differences appeared with regard to which opioid contributed to the death. Paper II indicates that there has been no significant change in opioid-related deaths in Skåne after the patient choice reform and increased access to OST. An analysis on national mortality data however showed a significant yearly decrease in drug-related deaths in Skåne compared to other Swedish counties in the years following the reform (2015–2017). No change was noted in deaths related to methadone or buprenorphine in Skåne. The proportion of deaths among patients in OST increased after the introduction of the reform. The third paper indicates that patients in OST in Skåne have gained increased empowerment and influence over their treatment since the patient choice reform was introduced. Patients especially appreciated the knowledge that they could make an exit and change clinics if they so wished, even if they so far had chosen not to. In paper IV, the clinic managers were largely positive to the trend towards increased influence for patients over their treatment situation. They were more critical of the fact that there was no major differentiation between treatment providers, and that the competition that arose after the patient choice reform mainly was related to prescribing benzodiazepines. Conclusions drawn from the papers in this thesis include that patient choice of treatment provider can be viewed as a means of empowerment for patients in OST, which was regarded as positive by both patients and treatment providers. The limitations of such a system for providing OST that emerged were lack of diversity between clinics and that the competition between treatment providers largely comprised of differing views on the prescription of benzodiazepines. Further, improved access to low-threshold OST in Skåne was not associated with an increased overdose death-rate. The result that people who died from opioid overdose to a very large extent are known to society’s care-providing authorities suggests that there are considerable opportunities to reach people with problematic opioid use for therapeutic and harm reducing measures such as low-threshold OST and take-home naloxone.

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Drug Use, Homelessness and Health: Responding to the Opioid Overdose Crisis with Housing and Harm Reduction Services

10.21203/rs.3.rs-507032/v1 ◽

2021 ◽

Author(s):

katrina milaney

Keyword(s):

Drug Use ◽

Harm Reduction ◽

Housing Instability ◽

Opioid Overdose ◽

Opioid Use ◽

Chi Square ◽

Increased Risk ◽

Reported Data ◽

Structural Inequities ◽

Hospital Use

Abstract Background Canada is in the midst of an opioid overdose crisis and Alberta has one of the highest opioid use rates across the country. Populations made vulnerable through structural inequities who also use opioids, such as those who are unstably housed, are at an increased risk of experiencing harms associated with opioid use. The main purpose of this study was to explore if there was an association between unstable housing and hospital use for people who use opioids. Methods Analysis utilized self-reported data from the Alberta Health and Drug Use Survey which surveyed 813 Albertans in three cities. Hospital use was modeled using a logistic regression with our primary variable of interest being housing unstable status. Chi square tests were conducted between hospital use and variables associated with demographics, characteristics of drug use, health characteristics, and experiences of receiving services to establish model inclusion. Results Results revealed a significant association between housing instability and hospital use.with unstably housed individuals twice as likely torequire hospital care. Conclusions Results highlight the importance of concurrently addressing housing instability alongside the provision of harm reduction services such assafe supply and supervised consumption sites. These findings have significant implications for policy and policymakers during the opioid overdose epidemic, and provide a foundation for future areas of research.

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Commentary: Applying the Community Partners in Care Approach to the Opioid Crisis

Ethnicity & Disease ◽

10.18865/ed.28.s2.381 ◽

2018 ◽

Vol 28 (Supp) ◽

pp. 381-388

Author(s):

Kenneth B. Wells ◽

Katherine E. Watkins ◽

Brian Hurley ◽

Lingqi Tang ◽

Felica Jones ◽

...

Keyword(s):

Working Group ◽

Technical Assistance ◽

Opioid Use ◽

Learning Collaborative ◽

Treatment Access ◽

Community Partners ◽

Stakeholder Support ◽

Care Approach ◽

Individual Program ◽

Stakeholder Input

Background: Given national concern over rising mortality from opioid use disorders (OUD) and challenges to increasing OUD treatment access, a coalition approach may hold promise to improve access and outcomes for diverse populations. We present considerations of a community-partnered working group on adapting the Community Partners in Care (CPIC) study and coalition approach to OUD.Method: During January 2016 through January 2017, academic, provider, consumer and policy stakeholders reviewed options to adapt CPIC’s Resources for Services (RS) for individual program technical assistance and Community Engagement and Planning (CEP) for coalition support to OUD treatments, integrating stakeholder input into design options with estimated sample sizes.Findings: The working group recommended Community Reinforcement and Family Treatment (CRAFT) as a stakeholder-support intervention to facilitate uptake and adherence to Medications for Addiction Treatment (MAT). Recommended implementation interventions for MAT/CRAFT were expert technical assistance supplemented by organizational readiness, and CEP for coalition support with a Learning Collaborative. Power estimation suggests that to compare implementation intervention effects on abstinence would require a somewhat larger enrolled sample and 3-4 times the screening sample as CPIC, and for mortality, at least 5-10 times the enrolled sample as CPIC.Discussion: Stakeholders viewed the CPIC design and interventions as feasible and acceptable as community-wide approaches for addressing the opioid epidemic, but comparing impacts on mortality would require large, multi-site trials. Ethn Dis. 2018;28(Suppl 2):381-388; doi:10.18865/ed.28.S2.381.

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2900. High Rates of Experienced and Witnessed Opioid Overdose in PWID Receiving HCV Treatment: Data From the ANCHOR Study

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz359.178 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S83-S83

Author(s):

Elana S Rosenthal ◽

Laura Nussdorf ◽

Aaron D’Amore ◽

Christopher Brokus ◽

Rachel Silk ◽

...

Keyword(s):

Harm Reduction ◽

Opioid Use Disorder ◽

Morbidity And Mortality ◽

Opioid Overdose ◽

Opioid Use ◽

Hcv Treatment ◽

Single Center Study ◽

Treatment Data ◽

Evidenced Based ◽

Chronic Hcv

Abstract Background People who inject drugs (PWID) have significant morbidity and mortality associated with hepatitis C (HCV); however, harms associated with ongoing injecting drug use (IDU)—such as opioid overdose—may pose a more imminent risk, and often are not addressed as part of HCV treatment. Naloxone distribution is a simple, evidenced-based strategy to reduce mortality associated with opioid overdose. Methods ANCHOR is a single-center study embedded in an urban harm-reduction program evaluating treatment of HCV in PWID with chronic HCV, opioid use disorder (OUD), and IDU. Participants received HCV treatment and were offered collocated buprenorphine. At each study visit, patients self-reported experienced and witnessed overdose and were offered naloxone. Results The 100 enrolled participants are predominantly male (75%), median 57 years, black (93%) and inject opioids at least daily (58%). At baseline, 65% had ever experienced overdose, 91% had ever witnessed an overdose, and 35% had ever administered naloxone. Between day 0 and week 48, 15 patients (15%) experienced overdose; of which, 4 (4%) were fatal. The rate of experienced overdose was 15 overdoses per 100 person-years. In addition, 59 (59%) patients witnessed at least one overdose between day 0 and week 48. Seventy-three patients were dispensed naloxone at least once, and of those who witnessed an overdose, 48 (81%) administered naloxone. Nineteen (40%) patients who administered naloxone had never used naloxone before starting HCV treatment. Conclusion PWID with HCV, OUD, and ongoing IDU have high rates of personal and witnessed overdose during and after HCV treatment. Dispensing naloxone at HCV-related visits is highly acceptable among PWID, and results in high rates of naloxone utilization. To reduce morbidity and mortality in patients and their communities, ID providers should complement treatment of infections by prescribing naloxone for patients with OUD, ideally as part of a comprehensive package of harm reduction and OUD treatment. Disclosures All Authors: No reported Disclosures.

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“They’re not doing enough.”: women’s experiences with opioids and naloxone in Toronto

Substance Abuse Treatment Prevention and Policy ◽

10.1186/s13011-021-00360-3 ◽

2021 ◽

Vol 16 (1) ◽

Author(s):

Emilie R. Macleod ◽

Iren Tajbakhsh ◽

Sarah Hamilton-Wright ◽

Nancy Laliberte ◽

Jessica L. Wiese ◽

...

Keyword(s):

Harm Reduction ◽

Thematic Analysis ◽

Qualitative Interviews ◽

Opioid Overdose ◽

Opioid Use ◽

Community Partner ◽

Research Knowledge ◽

Women’S Experiences ◽

Opioid Crisis ◽

Women's Experiences

Abstract Background Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women’s experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women’s experiences and perspectives on the opioid crisis in Ontario, Canada’s most populous province, since the opioid crisis began in 2010. Objective Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs. Methods We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study’s community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government’s responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data. Results Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government’s response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing. Conclusions Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.

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The impact of the opioid crisis on U.S. state prison systems

Health & Justice ◽

10.1186/s40352-021-00143-9 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Christy K. Scott ◽

Michael L. Dennis ◽

Christine E. Grella ◽

Allison F. Mischel ◽

John Carnevale

Keyword(s):

United States ◽

Criminal Justice ◽

Technical Assistance ◽

Sampling Strategy ◽

The United States ◽

Opioid Overdose ◽

Opioid Use ◽

State Prison ◽

Prison Systems ◽

The Impact

Abstract Background Prior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD). Methods A stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance. Results MOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications. Conclusion Study findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

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Opportunities to Offer Harm Reduction to People who Inject Drugs During Infectious Disease Encounters: Narrative Review

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa503 ◽

2020 ◽

Vol 7 (11) ◽

Author(s):

Alyssa M Peckham ◽

Erika H Young

Keyword(s):

Harm Reduction ◽

People Who Inject Drugs ◽

Opioid Use Disorder ◽

Opioid Use ◽

Postexposure Prophylaxis ◽

Treatment Access ◽

Clinical Encounters ◽

Exposure Prophylaxis ◽

Improve Patient ◽

Major Target

Abstract Increased rates of overdose (OD) and blood-borne infections have been associated with injection drug use (IDU). This increasing overlap between IDU-related infectious diseases (ID) is a byproduct of the opioid OD crisis, especially with the transition to synthetic opioids with faster onset and shorter duration leading to potentially more frequent injections. ID specialists are uniquely positioned to positively impact the opioid OD crisis by capitalizing on opportunistic moments of engagement during clinical encounters with people who inject drugs (PWID). Harm reduction services should therefore be expanded and offered to PWID in ID settings to reduce rates of OD, infection, and hospitalization. Major target areas include (1) teaching and distribution of materials related to safer injection practice such as sterile injection supplies, fentanyl test strips, and naloxone; (2) increased screening and access to pre-exposure prophylaxis and postexposure prophylaxis; and (3) initiation of medications for opioid use disorder. Incorporating these strategies in various treatment settings can expand treatment access, improve patient outcomes, and reduce stigma associated with IDU.

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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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