Literature Collection

Background Medications for opioid use disorder (MOUD) such as buprenorphine is effective for treating opioid use disorder (OUD). START NOW (SN) is a manualized, skills-based group psychotherapy originally developed and validated for the correctional population and has been shown to result in reduced risk of disciplinary infractions and future psychiatric inpatient days with a dose response effect. We investigate whether adapted START NOW is effective for treating OUD in a MOUD office-based opioid treatment (OBOT) setting in this non-inferiority clinical trial. Methods Patients enrolled in once weekly buprenorphine/suboxone MOUD OBOT were eligible for enrollment in this study. Participants were cluster-randomized, individually-randomized, or not randomized into either START NOW psychotherapy or treatment-as-usual (TAU) for 32 weeks of therapy. Treatment effectiveness was measured as the number of groups attended, treatment duration, intensity of attendance, and overall drug use as determined by drug screens. Results 137 participants were quasi-randomized to participate in SN (n = 79) or TAU (n = 58). Participants receiving START NOW psychotherapy, when compared to TAU, had comparable number of groups attended (16.5 vs. 16.7, p = 0.80), treatment duration in weeks (24.1 vs. 23.8, p = 0.62), and intensity defined by number of groups attended divided by the number of weeks to last group (0.71 vs. 0.71, p = 0.90). SN compared to TAU also had similar rates of any positive drug screen result (81.0% vs. 91.4%, p = 0.16). This suggests that adapted START NOW is noninferior to TAU, or the standard of care at our institution, for treating opioid use disorder. Conclusion Adapted START NOW is an effective psychotherapy for treating OUD when paired with buprenorphine/naloxone in the outpatient group therapy setting. Always free and publicly available, START NOW psychotherapy, along with its clinician manual and training materials, are easily accessible and distributable and may be especially useful for low-resource settings in need of evidence-based psychotherapy.

BACKGROUND: Data on the predictors of nonmedical problems (NMP) in older adults attending the emergency department (ED) for low acuity conditions is lacking and could help rapid identification of patients with NMP and integration of these needs into care planning. OBJECTIVES: To determine the prevalence and predictors of NMP among older adults attending EDs for low acuity conditions. METHODS: Prospective cohort study in eight EDs (May-August 2021). We included cognitively intact ≥65 years old adults assigned a low triage acuity (3-5) using the CTAS. A questionnaire focusing on 11 NMP was administered. We used multiple logistic regression to identify predictors of NMP. RESULTS: Among the 1,061 participants included, the mean age was 77.1 ± 7.6, majority were female, and 41.6 % lived alone. At least one NMP was reported by 704 persons. Prevalence of each NMP: outdoor (41.1 %) and indoor (30.2 %) mobility issues, difficult access to dental care (35.1 %), transportation (4.1 %) and medication (5.4 %), loneliness (29.5 %), food insecurity (10.3 %), financial difficulties (9.5 %), unsafe living situation (4.1 %), physical/psychological violence (3.4 %), and abuse/neglect (3.3 %). Predictors of NMP were: age (OR 1.04 for each additional year), living alone (OR 2.20), pre-existing mental health conditions (OR 3.12), heart failure (OR 1.42), recent surgery/admission (OR 1.75), memory decline (OR 2.76), no family physician (OR 1.74) and consulting for a fall/functional decline (OR 2.48). CONCLUSIONS: Nonmedical problems are frequent among older adults. We need to implement holistic ED processes that integrate these problems into care planning.

OBJECTIVES: To investigate plasma levels of buprenorphine and norbuprenorphine and their relationship to respiratory depression. MATERIALS AND METHODS: Opioid-dependent subjects were randomized 2 : 1 to novel lyophilized rapid-disintegrating tablet ("bup-lyo") or standard sublingual buprenorphine tablet ("bup-SL"). Measurements included oximetry scores and linked plasma buprenorphine and norbuprenorphine levels. RESULTS: Respiratory depression (cumulative duration of SpO2 30 min) of buprenorphine and particularly with norbuprenorphine. A lower buprenorphine/norbuprenorphine ratio was predictive of respiratory depression. The mean (SD) observed ratio was significantly higher for "bup-lyo" (3.4 (2.8)) compared to "bup-SL" (1.7 (0.77)), p < 0.0001. CONCLUSION: Exploratory investigation found respiratory depression more strongly associated with norbuprenorphine than with buprenorphine. This accords with animal studies..

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.