Literature Collection

IMPORTANCE: Addiction treatment rapidly transitioned to a primarily telehealth modality (telephone and video) during the COVID-19 pandemic, raising concerns about disparities in utilization. OBJECTIVE: To examine whether there were differences in overall and telehealth addiction treatment utilization after telehealth policy changes during the COVID-19 pandemic by age, race, ethnicity, and socioeconomic status. DESIGN, SETTING, AND PARTICIPANTS: This cohort study examined electronic health record and claims data from Kaiser Permanente Northern California for adults (age ≥18 years) with drug use problems before the COVID-19 pandemic (from March 1, 2019, to December 31, 2019) and during the early phase of the COVID-19 pandemic (March 1, 2020, to December 31, 2020; hereafter referred to as COVID-19 onset). Analyses were conducted between March 2021 and March 2023. EXPOSURE: The expansion of telehealth services during COVID-19 onset. MAIN OUTCOMES AND MEASURES: Generalized estimating equation models were fit to compare addiction treatment utilization during COVID-19 onset with that before the COVID-19 pandemic. Utilization measures included the Healthcare Effectiveness Data and Information Set of treatment initiation and engagement (including inpatient, outpatient, and telehealth encounters or receipt of medication for opioid use disorder [OUD]), 12-week retention (days in treatment), and OUD pharmacotherapy retention. Telehealth treatment initiation and engagement were also examined. Differences in changes in utilization by age group, race, ethnicity, and socioeconomic status (SES) were examined. RESULTS: Among the 19 648 participants in the pre-COVID-19 cohort (58.5% male; mean [SD] age, 41.0 [17.5] years), 1.6% were American Indian or Alaska Native; 7.5%, Asian or Pacific Islander; 14.3%, Black; 20.8%, Latino or Hispanic; 53.4%, White; and 2.5%, unknown race. Among the 16 959 participants in the COVID-19 onset cohort (56.5% male; mean [SD] age, 38.9 [16.3] years), 1.6% were American Indian or Alaska Native; 7.4%, Asian or Pacific Islander; 14.6%, Black; 22.2%, Latino or Hispanic; 51.0%, White; and 3.2%, unknown race. Odds of overall treatment initiation increased from before the COVID-19 pandemic to COVID-19 onset for all age, race, ethnicity, and SES subgroups except for patients aged 50 years or older; patients aged 18 to 34 years had the greatest increases (adjusted odds ratio [aOR], 1.31; 95% CI, 1.22-1.40). Odds of telehealth treatment initiation increased for all patient subgroups without variation by race, ethnicity, or SES, although increases were greater for patients aged 18 to 34 years (aOR, 7.17; 95% CI, 6.24-8.24). Odds of overall treatment engagement increased (aOR, 1.13; 95% CI, 1.03-1.24) without variation by patient subgroups. Retention increased by 1.4 days (95% CI, 0.6-2.2 days), and OUD pharmacotherapy retention did not change (adjusted mean difference, -5.2 days; 95% CI, -12.7 to 2.4 days). CONCLUSIONS: In this cohort study of insured adults with drug use problems, there were increases in overall and telehealth addiction treatment utilization after telehealth policies changed during the COVID-19 pandemic. There was no evidence that disparities were exacerbated, and younger adults may have particularly benefited from the transition to telehealth.

BACKGROUND: Treatment for opioid use disorder involving opioid-based pharmacotherapies is considered most effective when accompanied by psychosocial interventions. Peer-led support groups are widely available and have been described by many as fundamental to the recovery process. However, some individuals using medications face stigma in these settings, which can be contradictory and counterproductive to their recovery. METHODS: This paper describes the development of the "Ability, Inspiration and Motivation" or "AIM" group, an alternative peer support group that aims to remove medication stigma from peer recovery. Qualitative interviews with staff, peers, and clients of a community-based buprenorphine treatment program were used to establish the core components of the curriculum to support client needs. RESULTS: Staff, peers, and clients of the buprenorphine program indicated a need and desire to establish a peer recovery group that recognizes persons on medication as being in recovery and destigmatizes use of medication to treat opioid addiction. A respectful environment, holistic perspective on health, spirituality, sharing, and celebration were all established as necessary pillars of the AIM group curriculum. CONCLUSIONS: The community-based effort to establish and develop the AIM group demonstrates that combining the strengths of a peer support with evidence-based medication treatment is both possible and desirable. Shifting the culture of peer recovery groups to support the use of medications may have implications for improving treatment retention and should be considered as a potential strategy to reduce the burden of the opioid epidemic.

Patients with opioid use disorder are at a high risk of overdose. To minimize that risk, a program offering intranasal naloxone rescue kits was piloted at a Veterans Administration Hospital. The purpose of this study was to characterize veterans who accepted these potentially lifesaving kits. Retrospective medical chart review of 158 veterans with opioid use disorder receiving treatment on either the inpatient psychiatry detoxification units or outpatient methadone maintenance setting who were offered overdose education and naloxone rescue kits. One hundred and ten of 158 veterans (70%) accepted overdose education and naloxone rescue. Overall, they had a mean age of 39.1 years and averaged 12.7 years of opioid use. In the prior month, they averaged 14.3 days of heroin use; they used alone 48.5% of the time. They estimated an average of 2.8 accidental overdoses over their lifetimes. There were few significant differences between those who accepted and those who declined with regard to demographic and clinical variables. However, significantly higher percentages of outpatients accepted overdose education and naloxone rescue compared to inpatients (89% versus 63%, p = 0.003, Chi-square); the odds of acceptance were increased four-fold when offered to outpatients. Outpatients were nearly a decade older, with more years of opioid use (19.0 versus 11.0), but with less utilization of inpatient services in the prior year (all p < 0.05). The main finding was that 70% of veterans accepted overdose education and naloxone rescue, but significantly higher proportions of outpatients were more receptive than inpatients (89% versus 63%, p = 0.003). Efforts to increase overdose education and naloxone rescue acceptance in all settings are encouraged.

CONTEXT: The United States is in the midst of an opioid overdose epidemic. Opioids killed more than 28 000 people in 2014, more than any year on record. One approach to addressing this growing epidemic is Opioid Overdose Education and Naloxone Distribution (OEND) training. Little is known about these programs' participants and their effectiveness across different demographic groups. OBJECTIVES: To examine (1) whether knowledge and attitudes improved over the course of the training programs; (2) whether training outcomes differ by demographics; and (3) what overdose experiences do attendees have, and whether those experiences influence their knowledge and attitudes. DESIGN: A pre- and posttest survey was used to collect data on participants' demographics, overdose experiences, and opioid overdose knowledge and attitudes. SETTING: Surveys that took place at community-wide OEND programs were offered throughout Erie County, New York, during October and November 2015. PARTICIPANTS: Community members who elected to attend the training programs, were at least 18 years of age, spoke English, and were willing and able to participate were included in the sample (N = 198). INTERVENTION: N/A. MAIN OUTCOME MEASURE: The Opioid Overdose Knowledge and Attitudes Scale. RESULTS: Knowledge and attitude scores significantly improved from pre- to posttest assessments, increasing by 23.1% and 15.4%, respectively (Ps < .001). There were significant demographic differences in knowledge and attitudes at the pretest assessment, but these differences were ameliorated by the OEND program and did not persist at posttest assessment. In addition, 62.9% of participants had never experienced, witnessed, or known someone who had overdosed. CONCLUSION: Results indicate that OEND programs are effective at improving knowledge and attitudes toward opioid overdose. These results indicate that OEND programs are not reaching the highest risk individuals but are instead attracting concerned family and significant others. Future programs should focus on reaching current opioid users, overdose victims, and their families to ensure OEND programs are reaching the target audiences.

Background: As overdose remains a major public health concern in the United States, it is important to understand the experiences people who inject drugs (PWID) have with overdose. Past experiences during such emergencies are an important determinant of future behavior, including help seeking, which can be lifesaving. Methods: We explored experiences with overdose, using data from 21 in-depth interviews collected from PWID in a rural county in West Virginia (Cabell County). We used an iterative, modified constant comparison approach to synthesize resulting interview data. Results: Participants reported pervasive experiences with overdose, including through their own personal overdose experiences, witnessing others overdose, and losing loved ones to overdose fatalities. Experiencing emotional distress when witnessing an overdose was common among our participants. Many participants reported regularly carrying naloxone and using it to reverse overdoses. Multiple participants described believing the myth that people grow immune to naloxone over time. Concerns about the presence of fentanyl in drugs were also common, with many participants attributing their own and others' overdoses to fentanyl. Conclusions: Our findings have important implications for naloxone access and education, as well as policies and practices to encourage help seeking during overdose events among rural PWID. Participant concerns about fentanyl in the drug supply highlight the need for access to drug checking technologies.