Journal of Addiction Medicine最新文献

Objectives: Buprenorphine and other medications for opioid use disorder (OUD) are recommended as standard of care in the treatment of OUD and are associated with positive health and addiction-related outcomes. Despite benefits, discontinuation is common, with half of patients discontinuing in the first year of treatment. Addressing OUD is a major clinical priority, yet little is known about the causes of medication discontinuation from the patient perspective.

Methods: From March 2021 to April 2022, we conducted qualitative interviews with patients who had discontinued buprenorphine for the treatment of OUD within the past 12 months. Eligible participants were selected from 2 Veterans Health Administration Health Care Systems in Oregon. Coding and analysis were guided by conventional qualitative content analysis.

Results: Twenty participants completed an interview; 90% were White and 90% were male, and the mean age was 54.2 years. Before discontinuation, participants had received buprenorphine for 8.3 months on average (range, 1-40 months); 80% had received buprenorphine for less than 12 months. Qualitative analysis identified the following themes relating to discontinuation: health system barriers (eg, logistical hurdles, rules and policy violations), medication effects (adverse effects; attributed adverse effects, lack of efficacy in treating chronic pain) and desire for opioid use. Patient description of decisions to discontinue buprenorphine could be multicausal, reflecting provider or system-level barriers in interaction with patient complexity or medication ambivalence.

Conclusions: Study results identify several actionable ways OUD treatment could be modified to enhance patient retention.

Objective: The medical community has become aware of its role in contributing to the opioid epidemic and must be part of its resolution. Recovery community centers (RCCs) represent a new underused component of recovery support.

Methods: This study performed an online national survey of all RCCs identified in the United States, and used US Census ZIP code tabulation area data to describe the communities they serve.

Results: Residents of areas with RCCs were more likely to be Black (16.5% vs 12.6% nationally, P = 0.005) and less likely to be Asian (4.7% vs 5.7%, P = 0.005), American Indian, or Alaskan Native (0.6% vs 0.8%, P = 0.03), or live rurally (8.5% vs 14.0%, P < 0.0001). More than half of RCCs began operations within the past 5 years. Recovery community centers were operated, on average, by 8.8 paid and 10.2 volunteer staff; each RCC served a median of 125 individuals per month (4-1,500). Recovery community centers successfully engaged racial/ethnic minority groups (20.8% Hispanic, 22.5% Black) and young adults (23.5% younger than 25 years). Recovery community centers provide addiction-specific support (eg, mutual help, recovery coaching) and assistance with basic needs, social services, technology access, and health behaviors. Regarding medications for opioid use disorder (MOUDs), RCC staff engaged members in conversations about MOUDs (85.2%) and provided direct support for taking MOUD (77.0%). One third (36.1%) of RCCs reported seeking closer collaboration with prescribers.

Conclusions: Recovery community centers are welcoming environments for people who take MOUDs. Closer collaboration between the medical community and community-based peer-led RCCs may lead to significantly improved reach of efforts to end the opioid epidemic.

Objectives: Long-term opioid therapy (LTOT) is potentially dangerous among patients with unhealthy alcohol use because of possible adverse interactions. We examined receipt of alcohol-related care among patients with unhealthy alcohol use receiving LTOT and without opioid receipt.

Methods: We use data collected from 2009 to 2017 in the Women Veterans Cohort Study, a national cohort of Veterans engaged in Veterans Health Administration care. We included patients who screened positive for unhealthy alcohol use (score ≥5) using the Alcohol Use Disorder Identification Consumption questionnaire. Our primary exposure was LTOT (receipt of prescribed opioids for ≥90 days) versus no opioid receipt at the time of the first positive Alcohol Use Disorder Identification Consumption. Our primary outcome was receipt of brief intervention within 14 days of positive alcohol screen. Unadjusted and 4 adjusted modified Poisson regression models assessed prevalence and relative rates (RRs) of outcomes.

Results: Among eligible veterans, 6222 of 113,628 (5.5%) received LTOT at screening. Among patients receiving LTOT, 67.5% (95% confidence interval [CI], 66.3%-68.6%) had a documented brief intervention within 14 days of positive screen, compared with 70.1% (95% CI, 69.8%-70.4%) among patients without opioid receipt (RR, 0.96; 95% CI, 0.95-0.98; P < 0.001). Within adjusted models, the rate of brief intervention among patients receiving LTOT remained lower than patients without opioid receipt.

Conclusions: Among patients with unhealthy alcohol use, patients receiving LTOT had significantly lower rates of brief intervention receipt compared with those without opioid receipt, and they should be a focus for interventions to improve alcohol-related care and safer opioid prescribing.

Objectives: Substance use and pain are both growing public health concerns globally. Evidence suggests that individuals may use substances in order to self-medicate their pain. The Catastrophizing, Anxiety, Negative Urgency, and Expectancy model was developed to provide a theoretical foundation for the modifiable risk factors implicated in self-medication of pain with substance use. This study aimed to use the outcomes in the Catastrophizing, Anxiety, Negative Urgency, and Expectancy model to develop a brief clinical screening tool to identify individuals at risk for self-medication.

Methods: Participants (N = 520; M age = 38.8) were adults who endorsed the past three-month use of at least one substance and completed an online questionnaire. Logistic regression and receiver operator characteristic analyses were used to reduce the initial 104-item questionnaire to the items needed to achieve a minimum accuracy score of 0.95 and 0.90.

Results: A 14-item and a 7-item questionnaire were derived from the initial larger questionnaire. Both of these questionnaires were significantly correlated with the outcome variables and were significantly associated with health risk and percent of use because of pain. The R2 values between the 14- and 7-item versions were only significantly different for the percent of alcohol use because of pain.

Conclusions: The study provides two brief screening tools to screen for individuals at risk for self-medication of pain with substance use that can be easily implemented within clinical settings. Further, the screening tools provide insight into modifiable risk factors for self-medication and may also be valuable to monitor treatment response.

Objectives: Factors associated with treatment retention on medications for opioid use disorder (MOUD) in rural settings are poorly understood. This study examines associations between social determinants of health (SDoH) and MOUD retention among patients with opioid use disorder (OUD) in rural primary care settings.

Methods: We analyzed patient electronic health records from 6 rural clinics. Participants (N = 575) were adult patients with OUD and had any prescription for MOUD from October 2019 to April 2020. MOUD retention was measured by MOUD days and continuity defined as continuous 180 MOUD days with no more than a 7-day gap. Mixed-effect regressions assessed associations between the outcomes and SDoH (Medicaid insurance, social deprivation index [SDI], driving time from home to the clinic), telehealth use, and other covariates.

Results: Mean patient MOUD days were 127 days (SD = 50.7 days). Living in more disadvantaged areas (based on SDI) (adjusted relative risk [aRR]: 0.98; 95% confidence interval [CI], 0.98-0.99) and having more than an hour (compared with an hour or less) driving time from home to clinic (aRR: 0.95; 95% CI, 0.93-0.97) were associated with fewer MOUD days. Using telehealth was associated with more MOUD days (aRR: 1.23; 95% CI, 1.21-1.26). In this cohort, 21.7% of the participants were retained on MOUD for at least 180 days. SDoH and use of telehealth were not associated with having continuity of MOUD.

Conclusions: Addressing SDoH (eg, SDI) and providing telehealth (eg, improvements in public transportation, internet access) may improve MOUD days in rural settings.

Abstract: People with substance use disorders (SUDs) are increasingly admitted to general hospitals; however, many hospital systems lack both formal structures and skilled staff to provide high-quality care for inpatients with SUDs. Inpatient addiction consult services (ACSs), which are increasingly being implemented around the country, are an evidence-based strategy to add focused care for people with SUDs into the general medical setting. In 2018, New York City Health + Hospitals (H + H) launched an ACS program called Consult for Addiction Care and Treatment in Hospitals in six hospitals, supported by a team of addiction consult experts to deliver teaching and technical assistance (TTA) for the Consult for Addiction Care and Treatment in Hospitals ACSs. This commentary describes the TTA, which included site visits, introductory educational lectures, case conferences, ad hoc support, implementation assistance, and the creation of an addiction care guide. Similar TTA services could be used in the future when hospitals or systems want to launch novel clinical programs.

Objectives: Although methamphetamine use is common, the scope of methamphetamine use and outcomes for patients admitted to the hospital is unclear. This study aims to identify the prevalence of methamphetamine use from January 2012 to January 2022, coingestions, hospital course, and readmission rate of admitted patients.

Methods: This was a retrospective cohort study conducted on patients admitted to our center with the following inclusions: age older than 18 years, positive/"pending confirm" value for methamphetamine on urine drug screen, and/or an International Classification of Diseases , Tenth Revision , code related to stimulant use disorder as an active issue. Urine drug screen data are reported as methamphetamine +/- and polysubstance (PS) +/-. Patient demographics, admission diagnosis, and hospital course were extracted. Statistical tests used included t tests and Mann-Whitney U tests.

Results: A total of 19,159 encounters were included, representing 12,057 unique patients. The median (interquartile range) age was 43 (33-54) years. Of all encounters, 35.3% were methamphetamine + and PS -, and 46.3% were methamphetamine + and PS +. Hospitalizations increased from 883 in 2012 to 2532 in 2021. The median (IQR) hospital stay was 48 (48-120) hours. Of all encounters, 16.8% included an intensive care unit (ICU) admission, and the median ICU stay was 42 (21-87) hours. A total of 2988 patients (24.7%) were readmitted within the study period, and 4988 (71.5%) returned within 1 year of the previous encounter. In context of all emergency department admissions from 2013 to 2022, 13.1% had a urine drug screen + for methamphetamine.

Conclusions: Hospitalizations with recent methamphetamine use doubled at our institution from 2012 to 2022. In addition, 1 in 4 is readmitted (typically within 1 year), and a minority requires ICU care.

Objectives: Buprenorphine is not reliably stocked in many pharmacies, and pharmacy-level barriers may deter patients from opioid use disorder care. We surveyed all outpatient pharmacies in Philadelphia to describe variation in buprenorphine access and developed a map application to aid in identifying pharmacies that stock the medication.

Methods: Using a dataset from the Bureau of Professional and Occupational Affairs, we conducted a telephone survey of operating outpatient pharmacies (N = 422) about their buprenorphine stocking and dispensing practices. We used ArcGIS Pro 3.0.3 to join US Census Bureau ZIP code-level race and ethnicity data, conduct descriptive analyses, and create a map application.

Results: We collected data from 351 pharmacies (83% response rate). Two hundred thirty-eight pharmacies (68%) indicated that they regularly stock buprenorphine; 6 (2%) would order it when a prescription is sent. Ninety-one (26%) said that they do not stock or order buprenorphine, and 16 (5%) were unsure. We identified 137 "easier access" pharmacies (39%), meaning they regularly stock buprenorphine, dispense to new patients, and have no dosage maximums. Zip codes with predominantly White residents had a median (interquartile range) of 3 (2-4) "easier access" pharmacies, and those with predominantly Black residents a median (interquartile range) of 2 (1-4.5). Nine zip codes had no "easier access" pharmacies, and 3 had only one; these 3 zip codes are areas with predominantly Black residents.

Conclusions: Buprenorphine access is not equitable across Philadelphia and a quarter of pharmacies choose not to carry the medication. Our map application may be used to identify pharmacies in Philadelphia that stock buprenorphine.

Objectives: Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center-a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics.

Methods: SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively.

Results: SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch).

Conclusions: SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision.