Literature Collection

Opioid use disorder continues to drive overdose deaths in many countries, including the United States. Illicit fentanyl and its analogues have emerged as key contributors to the complications and mortality associated with opioid use disorder. Medications for opioid use disorder treatment, such as methadone and buprenorphine, are safe and substantially reduce opioid use, infectious complications, and mortality risk, but remain underutilized. Polysubstance use and emerging substances such as xylazine and designer benzodiazepines create additional treatment challenges. Recent clinical and policy innovations in treatment delivery, including telemedicine, bridge clinics, and expanded models for accessing methadone have the potential to increase access to life-saving care for people living with opioid use disorder.

IMPORTANCE: People experiencing homelessness have been disproportionately affected by the opioid overdose crisis. To mitigate morbidity and mortality, several office-based addiction treatment (OBAT) programs designed for this population have been established across the US, but studies have not yet evaluated their outcomes. OBJECTIVE: To evaluate treatment retention and mortality in an OBAT program designed specifically for individuals experiencing homelessness with opioid use disorder (OUD). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted in the Boston Health Care for the Homeless Program (BHCHP). Participants included all adult patients (N = 1467) who had 1 or more OBAT program encounter at BHCHP from January 1 through December 31, 2018. Data analysis was conducted from January 13 to December 14, 2020. EXPOSURES: Sociodemographic, clinical, and addiction treatment-related characteristics were abstracted from the BHCHP electronic health record. MAIN OUTCOMES AND MEASURES: The primary outcome was all-cause mortality, identified by linkage to the Massachusetts Department of Public Health vital records. Multivariable Cox proportional hazards regression analyses were performed to evaluate baseline and time-varying variables associated with all-cause mortality. Secondary addiction treatment-related outcomes were abstracted from the electronic health record and included (1) BHCHP OBAT program retention, (2) buprenorphine continuation and adherence verified by toxicology testing, and (3) opioid abstinence verified by toxicology testing. RESULTS: Of 1467 patients in the cohort, 1046 were men (71.3%) and 731 (49.8%) were non-Hispanic White; mean (SD) age was 42.2 (10.6) years. Continuous retention in the OBAT program was 45.2% at 1 month, 21.7% at 6 months, and 11.3% at 12 months. Continuous buprenorphine adherence was 41.5% at 1 month, 17.6% at 6 months, and 10.2% at 12 months, and continuous opioid abstinence was 28.3% at 1 month, 6.1% at 6 months, and 2.9% at 12 months. The all-cause mortality rate was 29.0 deaths per 1000 person-years, with 51.8% dying from drug overdose. Past-month OBAT program attendance was associated with lower mortality risk (adjusted hazard ratio, 0.34; 95% CI, 0.21-0.55). CONCLUSIONS AND RELEVANCE: Mortality rates were high in this cohort of addiction treatment-seeking homeless and unstably housed individuals with OUD. Although continuous OBAT program retention was low, past-month attendance in care was associated with reduced mortality risk. Future work should examine interventions to promote increased OBAT attendance to mitigate morbidity and mortality in this vulnerable population.

Opiate addiction is a serious global health issue that profoundly impacts the welfare of populations around the world. Opioid addiction affects an estimated 1.9 million individuals in the United States alone, stimulating a rise in treatment options such as medication-assisted treatment with buprenorphine. When combined with counseling and relapse prevention groups, medication-assisted treatment has proven to be an effective office-based opioid treatment for opiate dependence. Office-based opioid treatment has broadened access to treatment of opioid dependence, has decreased the risk for overdose, and is effective for reducing cravings and opioid use at proper dosing levels. However, treatment retention and relapse remain significant challenges. The purpose of this study was to identify characteristics predictive of retention in treatment time of opioid-dependent individuals receiving office-based buprenorphine treatment. The records of individuals enrolled in a public health office buprenorphine clinic (n = 350) were analyzed to determine retention time in treatment and whether retention time varied by selected individual variables. Participants in the study had a cumulative predicted retention time on buprenorphine of 65% at 30 days, 35% at 6 months, 25% at 12 months, and 18% at 18 months.

OBJECTIVES: Healthcare professionals (HCPs) with opioid dependence are at risk for relapse and death, particularly in the first year of recovery; however, maintenance treatment with opioid agonists is controversial in this safety-sensitive group. We evaluated long-term safety, tolerability, and treatment outcomes of injectable, intramuscular, extended-release naltrexone (XR-NTX) in opioid-dependent HCPs. METHODS: This single-arm, multisite, open-label study was conducted in opioid-dependent HCPs who had been detoxified from opioids for at least 2 weeks. Subjects received monthly XR-NTX injections for up to 24 months, combined with counseling via intensive outpatient substance abuse treatment programs. Assessments included monthly urine opioid drug tests and routine safety assessments, along with a trimonthly short form (36) Health Survey, opioid craving questionnaire, and Treatment Satisfaction Questionnaire for Medication. RESULTS: Of 49 opioid-dependent HCPs screened, 38 enrolled and received at least 1 XR-NTX injection. Most were female (n = 31) and nurses or nursing assistants (n = 30). More than half (n = 21; 55.3%) received at least 12 injections. Seven discontinued due to adverse events (3 anxiety, 2 headache, 1 injection-site mass, 1 derealization). None experienced relapses to opioid dependence necessitating detoxification, overdose, or death during treatment. At 24 months, mean opioid craving fell by 45.2%, and short form (36) mental component scores improved by 31.1% from baseline and approached normal levels. Of 22 unemployed subjects at baseline, 45.5% improved employment status at 24 months. CONCLUSIONS: Long-term (2 years) XR-NTX was associated with no new safety concerns, and, compared with shorter-term studies in the general population, similar or better rates of retention, opioid-negative urines, opioid craving reduction, mental health functional quality of life improvement, and re-employment.

"Canada is in the midst of an opioid crisis, making it important to disseminate standardized approaches and evidence-based recommendations for managing opioid use disorder. Opioid Agonist Treatment: A Synthesis of Canadian Guidelines for Treating Opioid Use Disorder is a national clinical guideline that harmonizes existing provincial and national guidelines, evidence-based practices and expert opinions into one document aimed at providing consistent and high-quality care to people with opioid use disorder. Opioid agonist therapy is the most effective treatment option for opioid use disorder, ideally combined with behavioural and social supports. It can stabilize the cycle of intoxication and withdrawal, reduce opioid cravings and block the intoxicating effects of other short-acting opioids, including fentanyl. People who are maintained on opioid agonist therapy typically experience improved health and social functioning and reduced risk of overdose. CAMH worked with subject matter experts and medical regulatory authorities across Canada to reach consensus on recommendations from existing guidelines. The aim of this unified guideline is to standardize expectations for Canadian prescribers, but not to replace any adopted guidelines. Please consult your professional regulatory body for specific guidance in your jurisdiction."--

INTRODUCTION: Although many drugs are implicated in the crisis, opioids and concomitant sedatives are associated with increased overdose risk in both rural and urban communities. Individuals in rural areas are up to 5-fold more likely to experience adverse outcomes related to opioids. The primary objective of this study was to evaluate concomitant use of opioid and benzodiazepine prescriptions in Texas, compare metropolitan and rural differences, and use these data to inform clinicians and to help develop harm reduction strategies. METHODS: Prescribing data were extracted from the Texas Prescription Drug Monitoring Program (PDMP) public use data file, the statewide monitoring program administered by the Texas State Board of Pharmacy. An overlapping drug combination prescription day was defined as any day in which a patient had at least one of the overlapping drug types-eg, opioid + benzodiazepine, opioid + benzodiazepine + carisoprodol. RESULTS: In Texas, 47.4 percent of the counties with the highest number of overlapping days (per patient) bordered other states. Providers who practice in rural areas prescribe opioid and benzodiazepine medications with 8.2 more overlapping days per quarter. DISCUSSION: Taking both opioid and benzodiazepine prescriptions is associated with increased overdose risk. Opioid prescription data provide a distinct view into the opioid epidemic that allows all states and counties to view the trends of opioid utilization. There are only a few studies using PDMP data to compare urban and rural trends. CONCLUSIONS: Rural patients had more benzodiazepine and opioid days overlap than urban patients. The prevalence is higher among older adults and providers who practice in rural areas (average 8.2 more days per quarter). Our findings in Texas indicate a trend downward in overlap for both rural and urban areas over the last year of measurement. However, rural areas are still significantly higher.

Using the social determinants of health (SDOH) framework, the current study aimed to examine opioid literacy and the role of SDOH on opioid literacy. This study used a cross-sectional survey design to collect self-reported data from people living in four rural Alabama counties affected by the opioid crisis. Participants reported moderate levels of opioid knowledge. There were no significant predictors of general knowledge. For opioid overdose knowledge, the strongest individual predictors were educational level (Bachelor's degree) and self-rated financial strain, which contributed to higher scale scores. For the models evaluating opioid overdose response knowledge, the strongest individual predictors were minority status (inverse), self-rated mental health, and interpersonal safety. Our findings indicate that SDOH, such as financial strain and interpersonal safety, are significantly linked to opioid literacy. Educational efforts to enhance opioid literacy, proper usage, and management in rural counties should consider SDOH factors. Findings further outline the team's integrative approach to developing intervention strategies for opioid treatment and recovery that can benefit the northwest Alabama community and beyond. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 52-59.].

INTRODUCTION: Fatal overdoses from opioids increased four-fold from 1999 to 2009, and they are now the leading cause of death among Americans under 50. Legislation has been passed by every state to increase access to naloxone but dispensing by community pharmacies remains low. OBJECTIVES: The objective of this study was to pilot test a proactive opioid overdose counseling intervention and a passive naloxone intervention, and the implementation strategies developed to support their delivery, in rural community pharmacies on relevant implementation outcomes. METHODS: The interventions, implementation strategies, and the overall pilot study approach were developed in a collaborative partnership with a regional supermarket pharmacy chain. They selected 2 rural pharmacies to participate in the pilot study and 2 non-intervention pharmacies to serve as comparison sites. Two interventions were pilot tested in the 2 intervention pharmacies: 1)a proactive opioid overdose counseling intervention and 2) a passive naloxone intervention. An explanatory sequential mixed-methods design was utilized to evaluate adoption, feasibility, acceptability, and appropriateness outcomes after the 3-month observation period. RESULTS: Between the 2 intervention pharmacies, 130 patients received the opioid overdose counseling intervention. 44 (33.8%) were prescribed and dispensed naloxone. Zero naloxone prescriptions were written or dispensed at the comparison pharmacies. Interviews with pharmacy staff found the interventions to be feasible, acceptable, and appropriate in their settings. CONCLUSION: This small scale pilot study in partnership with a regional supermarket pharmacy chain had positive results with a third of patients who received the opioid overdose counseling intervention being dispensed naloxone. However, the majority of patients did not receive naloxone indicating additional revisions to the intervention components and/or implementation strategies are needed to improve the overall impact of the interventions.