Literature Collection

AIMS: American deaths from opioid overdose now approach 50,000 annually. While evidence shows that medications for addiction treatment (MAT) save lives, retaining patients in MAT programs is challenging. The U.S. Agency for Healthcare Research and Quality, on behalf of the U.S. Department of Health and Human Services, commissioned a rapid evidence review on the effectiveness of interventions to promote a broader understanding of the published literature on MAT retention among adults with opioid use disorder (OUD). METHODS: We searched MEDLINE and the Cochrane Library from February 12, 2009, through June 16, 2019, for systematic reviews (SRs) and randomized controlled trials (RCTs). We summarized evidence for six retention intervention types: care settings/services/logistical support, contingency management, health information technology (IT), extended-release (XR) medication-based treatment, psychosocial support, and financial support. Our primary outcome was retention, defined as continued medication engagement for at least 3 months after MAT initiation. Secondary outcomes included mortality and harms. FINDINGS: Key findings from 2 SRs and 39 primary studies include: 1. Most studies of MAT for OUD do not focus on retention as the primary outcome, are small (e.g., one to two trials per intervention), and have design flaws. 2. Care setting interventions that initiated MAT in soon-to-be-released incarcerated patients improved retention following release. 3. Contingency management improved retention when combined with antagonist MAT, but not with agonist forms of MAT. Applicability, however, may be limited due to implementation challenges. 4. Preliminary trials suggest that retention in MAT supported with health IT approaches may be no worse than in-person approaches. 5. Early studies suggest no difference in retention with XR-buprenorphine in either injectable or implant formulations compared with daily buprenorphine. There were conflicting results with XR-naltrexone injection compared with daily buprenorphine. 6. The addition of psychosocial interventions did not improve retention; however, many studies included some form of counseling in the control groups, potentially obscuring evidence of effectiveness. Harms were infrequently reported across studies except in studies of XR formulations. Similarly, few studies reported whether participant characteristics influenced retention. CONCLUSIONS: While patients who receive longer-term treatment with MAT have improved outcomes, fewer than half of the identified studies measured treatment retention as a primary outcome. Limited evidence suggests criminal justice prerelease MAT initiation and the use of contingency management for patients on antagonist forms of MAT may aid retention. XR and daily buprenorphine formulations appear to be equivalent for treatment retention and comparisons of XR-naltrexone versus daily buprenorphine showed conflicting results. Integrating MAT treatment with medical and social services and the use of health IT did not change retention. Some studies were conducted outside of the United States, where policies and practices differ, focused on highly selected populations and/or conditions that are not fully representative of the spectrum of OUD, or were studied in situations that may not be easily implemented in real-world conditions. There is a critical need for studies that use standardized definitions of retention, include measures of harms as well as benefits, and reflect the full spectrum of real-life conditions.

Objectives: Drug overdose (OD) deaths have been increasing over the past 20 years. Although risk factors for drug OD have been identified in adult populations, less is known about risk factors for OD in young people. The aim of this review is to systematically examine the literature to identify risk factors for drug OD specific to young people, including adolescents and young adults. Methods: Our initial PubMed search identified 4001 articles. Included were cross-sectional and longitudinal cohort studies published in English that compared young people who experienced a drug OD to those who did not. Review articles, meta-analyses, case-reports, editorials, epidemiological studies, and qualitative studies were excluded. Two investigators reviewed the full texts of all relevant articles and extracted data on sample demographics, prevalence of OD, and correlates associated with OD. Results: Twelve relevant studies were identified reflective of a sample of 5020 unique individuals with an age range of 14-30 years, and a mean age range of 20.2-26 years. The lifetime prevalence of OD in these young people ranged from 24% to 48%. Substance use characteristics most often associated with OD included injection drug, opioid, and tranquilizer use. Polysubstance use was also found to be strongly associated with OD in three studies. Other replicated risk factors for OD in young people included histories of psychopathology, incarceration, unstable housing, and witnessing an OD. Conclusion: Opioid, tranquilizer, and injection drug use have been identified as risk factors for OD in both younger and older adult populations. Risk factors that emerged as noteworthy predictors of OD in young people specifically include polysubstance use, psychiatric comorbidity, unstable housing, and witnessing an OD. There remains a paucity of literature on drug OD risk factors in young people, with little information regarding medical and treatment history risk factors.

OBJECTIVES: The majority of patients seeking medical care for chronic pain consult a primary care physician (PCP). Because systemic opioids are commonly prescribed to patients with chronic pain, PCPs are attempting to balance the competing priorities of providing adequate pain relief while reducing risks for opioid misuse and overdose. It is important for PCPs to be aware of pain management strategies other than systemic opioid dose escalation when patients with chronic pain fail to respond to conservative therapies and to initiate a multimodal treatment plan. METHODS: The Medline database and evidence-based treatment guidelines were searched to identify publications on intrathecal (IT) therapy for the management of chronic pain. Selection of publications relevant to PCPs was based on the authors' clinical and research expertise. RESULTS: IT administration delivers analgesic medication directly into the cerebrospinal fluid, avoiding first-pass effect and bypassing the blood-brain barrier, thereby requiring lower medication doses. Morphine, a micro-opioid receptor agonist, and ziconotide, a non-opioid, selective N-type calcium channel blocker, are the only analgesics approved by the US Food and Drug Administration to treat chronic refractory pain by the IT route. Patients who are potential candidates for IT therapy may benefit from evaluation by an interventional pain physician. PCPs can play an important role in patient selection and referral for IT therapy and provide ongoing collaborative care for patients receiving IT therapy, including monitoring for efficacy and adverse events and facilitating communication with the treating specialist. CONCLUSIONS: Collaboration between PCPs and pain specialists may improve outcomes of and patient satisfaction with IT therapy and other interventional treatments.

OBJECTIVE: Effective treatments for opioid use disorder exist, but rural areas of the United States have a shortage of services offering such treatments. Physician bias toward patients with opioid use disorder can also limit care access, but no studies have assessed whether physician bias is a more acute barrier in rural compared with urban communities. METHODS: In total, 408 board-certified physicians in Ohio, a state with a high rate of opioid overdoses, completed an online survey examining perspectives on clinical care for patients who misuse opioids. Respondents with missing county-level data were excluded, leaving a total sample of 274. The authors used t tests to determine rural-urban differences in bias, key predictors of bias, and availability of opioid services. Multivariable regression modeling was used to estimate rural-urban differences in bias independent of key bias predictors. RESULTS: Physicians in rural areas (N=37) reported higher levels of bias toward patients with opioid use disorder than did their urban counterparts (N=237). This difference remained statistically significant even after accounting for known bias predictors and physician specialty. Physicians specializing in addiction medicine reported lower bias than did physicians not working in this specialty. CONCLUSIONS: Given existing disparities in harm reduction and addiction treatment services in rural areas, increased physician bias in counties lacking these services suggests that rural patients with opioid use disorder face numerous challenges to finding effective treatment. Bias reduction interventions should target health care professionals in rural communities where such efforts may have the most pronounced impact on improving health care access.

Background: Opioids accounted for 75% of drug overdoses in the United States in 2020, with rural states particularly impacted by the opioid crisis. While medication assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD; and (2) evaluate the role of specific OpitMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention. Methods: We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence. Discussion: This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone appbased interventions. Trial registration: ClinicalTrials.gov identifier: NCT05336188, registered March 21, 2022, https://clinicaltrials.gov/ct2/show/NCT05336188.

BACKGROUND: Opioids accounted for 75% of drug overdoses in the USA in 2020, with rural states particularly impacted by the opioid crisis. While medication-assisted treatment (MAT) with Suboxone remains one of the more efficacious treatments for opioid use disorder (OUD), approximately 40% of people receiving Suboxone for outpatient MAT for OUD (MOUD) relapse within the first 6 months of treatment. We developed the smartphone app-based intervention OptiMAT as an adjunctive intervention to improve MOUD outcomes. The aims of this study are to (1) evaluate the efficacy of adjunctive OptiMAT use in reducing opioid misuse among people receiving MOUD and (2) evaluate the role of specific OptiMAT features in reducing opioid misuse, including the use of GPS-driven just-in-time intervention. METHODS: We will conduct a two-arm, single-blind, randomized controlled trial of adults receiving outpatient MOUD in the greater Little Rock AR area. Participants are English-speaking adults ages 18 or older recently enrolled in outpatient MOUD at one of our participating study clinics. Participants will be allocated via 1:1 randomized block design to (1) MOUD with adjunctive use of OptiMAT (MOUD+OptiMAT) or (2) MOUD without OptiMAT (MOUD-only). Our blinded research statistician will evaluate differences between the two groups in opioid misuse (as determined by quantitative urinalysis conducted by clinical lab staff blinded to group membership) during the 6-months following study enrolment. Secondary analyses will evaluate if OptiMAT-usage patterns within the MOUD+OptiMAT group predict opioid misuse or continued abstinence. DISCUSSION: This study will test if adjunctive use of OptiMAT improve MOUD outcomes. Study findings could lead to expansion of OptiMAT into rural clinical settings, and the identification of OptiMAT features which best predict positive clinical outcome could lead to refinement of this and similar smartphone app-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT05336188 , registered March 21, 2022.