Literature Collection

Importance: Retention in addiction treatment is associated with reduced mortality for individuals with opioid use disorder (OUD). Although clinical trials support use of OUD medications among youths (adolescents and young adults), data on timely receipt of buprenorphine hydrochloride, naltrexone hydrochloride, and methadone hydrochloride and its association with retention in care in real-world treatment settings are lacking. Objectives: To identify the proportion of youths who received treatment for addiction after diagnosis and to determine whether timely receipt of OUD medications is associated with retention in care. Design, Setting, and Participants: This retrospective cohort study used enrollment data and complete health insurance claims of 2.4 million youths aged 13 to 22 years from 11 states enrolled in Medicaid from January 1, 2014, to December 31, 2015. Data analysis was performed from August 1, 2017, to March 15, 2018. Exposures: Receipt of OUD medication (buprenorphine, naltrexone, or methadone) within 3 months of diagnosis of OUD compared with receipt of behavioral health services alone. Main Outcomes and Measures: Retention in care, with attrition defined as 60 days or more without any treatment-related claims. Results: Among 4837 youths diagnosed with OUD, 2752 (56.9%) were female and 3677 (76.0%) were non-Hispanic white. Median age was 20 years (interquartile range [IQR], 19-21 years). Overall, 3654 youths (75.5%) received any treatment within 3 months of diagnosis of OUD. Most youths received only behavioral health services (2515 [52.0%]), with fewer receiving OUD medications (1139 [23.5%]). Only 34 of 728 adolescents younger than 18 years (4.7%; 95% CI, 3.1%-6.2%) and 1105 of 4109 young adults age 18 years or older (26.9%; 95% CI, 25.5%-28.2%) received timely OUD medications. Median retention in care among youths who received timely buprenorphine was 123 days (IQR, 33-434 days); naltrexone, 150 days (IQR, 50-670 days); and methadone, 324 days (IQR, 115-670 days) compared with 67 days (IQR, 14-206 days) among youths who received only behavioral health services. Timely receipt of buprenorphine (adjusted hazard ratio, 0.58; 95% CI, 0.52-0.64), naltrexone (adjusted hazard ratio, 0.54; 95% CI, 0.43-0.69), and methadone (adjusted hazard ratio, 0.32; 95% CI, 0.22-0.47) were each independently associated with lower attrition from treatment compared with receipt of behavioral health services alone. Conclusions and Relevance: Timely receipt of buprenorphine, naltrexone, or methadone was associated with greater retention in care among youths with OUD compared with behavioral treatment only. Strategies to address the underuse of evidence-based medications for youths with OUD are urgently needed.

PURPOSE OF REVIEW: Opioid use disorder (OUD) remains a national epidemic with an immense consequence to the United States' healthcare system. Current therapeutic options are limited by adverse effects and limited efficacy. RECENT FINDINGS: Recent advances in therapeutic options for OUD have shown promise in the fight against this ongoing health crisis. Modifications to approved medication-assisted treatment (MAT) include office-based methadone maintenance, implantable and monthly injectable buprenorphine, and an extended-release injectable naltrexone. Therapies under investigation include various strategies such as heroin vaccines, gene-targeted therapy, and biased agonism at the G protein-coupled receptor (GPCR), but several pharmacologic, clinical, and practical barriers limit these treatments' market viability. This manuscript provides a comprehensive review of the current literature regarding recent innovations in OUD treatment.

IMPORTANCE: Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated. OBJECTIVE: To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD. DESIGN, SETTING, AND PARTICIPANTS: For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, 2020, asking PWUD about their substance use, substance use treatment, and interactions with the criminal legal system. Participants were recruited through respondent-driven sampling in 8 rural US regions. Respondents who were willing to recruit additional respondents from their personal networks were enrolled at syringe service programs, community support organizations, and through direct community outreach; these so-called seed respondents then recruited others. Of 3044 respondents, 2935 included participants who resided in rural communities and reported past-30-day injection of any drug or use of opioids nonmedically via any route. Data were analyzed from February 8, 2022, to September 15, 2023. EXPOSURE: Recent incarceration was the exposure of interest, defined as a report of incarceration in jail or prison for at least 1 day in the past 6 months. MAIN OUTCOMES AND MEASURES: The associations between PWUD who were recently incarcerated and main outcomes of treatment use and overdose were examined using logistic regression. RESULTS: Of 2935 participants, 1662 (56.6%) were male, 2496 (85.0%) were White; the mean (SD) age was 36 (10) years; and in the past 30 days, 2507 (85.4%) reported opioid use and 1663 (56.7%) reported injecting drugs daily. A total of 1224 participants (41.7%) reported recent incarceration, with a median (IQR) incarceration of 15 (3-60) days in the past 6 months. Recent incarceration was associated with past-6-month overdose (adjusted odds ratio [AOR], 1.38; 95% CI, 1.12-1.70) and recent SUD treatment (AOR, 1.62; 95% CI, 1.36-1.93) but not recent medication for opioid use disorder (MOUD; AOR, 1.03; 95% CI, 0.82-1.28) or currently carrying naloxone (AOR, 1.02; 95% CI, 0.86-1.21). CONCLUSIONS AND RELEVANCE: In this cross-sectional study of PWUD in rural areas, participants commonly experienced recent incarceration, which was not associated with MOUD, an effective and lifesaving treatment. The criminal legal system should implement effective SUD treatment in rural areas, including MOUD and provision of naloxone, to fully align with evidence-based SUD health care policies.

Objective: To explore overall trends as well as racial/ethnic disparities in utilization of different telehealth modalities (telephone vs. televideo) at federally qualified health centers (FQHCs) during the COVID-19 pandemic. Methods: Using electronic health record data from a large New York-based FQHC system, we aggregated (separately) Behavioral Health and Family Practice visits per month occurring in-person, by telephone, or by televideo and graphed monthly trends in visits across the pre-pandemic, peak-pandemic, and post-peak-pandemic periods. We calculated fractions of visits conducted by modality for each patient demographic (race/ethnicity, primary language, age, gender, insurance type, and geography) and conducted bivariate assessments to test relationships between patient characteristics and modality. Results: Our data contained 121,072 unique patients and 811,105 visits overall. Telehealth use peaked in April 2020 but continued to account for a significant fraction of FQHC visits-nearly 25% (N = 4,908) of monthly Family Practice visits and a massive 98% (N = 14,173) of Behavioral Health visits as late as June 2021. Of all telehealth visits, nearly half were by telephone. Moreover, demographic factors differed between FQHC patients using telephone visits versus those using televideo: Black, non-English speaking, older, and Medicaid patients had significantly higher utilization of telephone visits than televideo visits (e.g., 25.9% of all Black patients' visits were via telephone vs. 17.1% via televideo; p < 0.001). In contrast, younger, Asian, and privately insured patients had significantly higher televideo visits. Conclusions: Our results suggest that telephone visits remain critical to the provision of health care for FQHC patients. They also suggest that disparities extend beyond the telehealth versus in-person dichotomy and inequities exist even within the type of telehealth used. This has implications for patient health, FQHC quality outcomes, as well as optimal Medicaid telehealth reimbursement policy.

BACKGROUND: Buprenorphine is an effective medication for opioid use disorder (MOUD) when offered in community-based settings, but evidence is limited for incarcerated populations, particularly in relation to recidivism. In Massachusetts, Franklin County jail (FCSO) was among the first to provide buprenorphine; adjacent Hampshire County jail (HCHC) offered it more recently. These jails present a natural experiment to determine whether outcomes are different between individuals who did and did not have the opportunity to receive buprenorphine in jail. METHODS: We examined outcomes of all incarcerated adults with opioid use disorder (n = 469) who did (FCSO n = 197) and did not (HCHC n = 272) have the opportunity to receive buprenorphine. The primary outcome was post-release recidivism, defined as time from jail exit to a recidivism event (incarceration, probation violation, arraignment). Using Cox proportional hazards models, we investigated site as a predictor, controlling for covariates. We also examined post-release deaths. RESULTS: Fewer FCSO than HCHC individuals recidivated (48.2% vs. 62.5%; p = 0.001); fewer FCSO individuals were re-arraigned (36.0% vs. 47.1%; p = 0.046) or re-incarcerated (21.3% vs. 39.0%; p < 0.0001). Recidivism risk was lower in the FCSO group (hazard ratio 0.71, 95% confidence interval 0.56, 0.89; p = 0.003), net of covariates (adjusted hazard ratio 0.68, 95% confidence interval 0.53, 0.86; p = 0.001). At each site, 3% of participants died. CONCLUSIONS: Among incarcerated adults with opioid use disorder, risk of recidivism after jail exit is lower among those who were offered buprenorphine during incarceration. Findings support the growing movement in jails nationwide to offer buprenorphine and other agonist medications for opioid use disorder.