Substance use & addiction journal最新文献

Dual diagnoses of psychosis and drug or alcohol problems (DDp) are prevalent, high-cost presentations, reliably associated with poorer outcomes and greater difficulty engaging with mental health services compared to either condition alone or other mental health problems. Engagement difficulties restrict access to recommended care that could improve outcomes, and thus are a priority treatment target. Contingency management (financial incentives for positive health behaviours, CM), peer support, and text messaging each improve engagement for psychosis or drug/alcohol problems. Despite the high potential to improve engagement and thus clinical and economic outcomes in DDp, their combined impact remains unevaluated in this poorly treated and hard-to-reach population. We plan a confirmatory trial to test, for the first time, the impact on engagement in DDp of adding CM to usual care alongside text message reminders and peer support. Methodological innovation is required to ensure adequate rates of recruitment, retention, and outcome completion; as well as standardised delivery of interventions, particularly CM, which will be delivered by peer support workers, and will target attendance, to improve engagement in recommended treatments. We comment here on the protocol for CoMPEERS (ISRCTN90137206), a study to test the feasibility of progressing this novel design to a full trial.

Individuals with opioid misuse (OM) or opioid use disorder (OUD) frequently have co-occurring chronic pain (CP). Services for these chronic conditions are commonly siloed in specialty treatment programs with few empirically demonstrated integrated interventions for patients with OM/OUD+CP. This manuscript describes the Tailored Retention and Engagement for Effective-integrated Treatment of OUD and Pain (TREETOP) engagement clinical trial protocol testing the effectiveness of a pain self-management (PSM) intervention at improving outcomes for patients with OM/OUD+CP in the context of primary care settings. This is a multisite hybrid type-1 effectiveness-implementation clinical trial (n = 228) wherein stratified equal randomization is used to assign participants to either PSM or usual care. The PSM intervention is novel because it was tailored to patients with OM/OUD+CP and is delivered remotely by a trained interventionist over ten 1-hour sessions. All study activities are conducted virtually, and follow-up study visits occur at 3-, 6- and 9-months. Enhanced technology-based recruitment strategies are used to boost accrual. The primary outcome is reduction in pain interference (PROMIS SF v1.0-Pain Interference 4a) at 3-months and secondary outcomes include pain self-efficacy (PSEQ), medications for opioid use disorder engagement and illicit drug use (Modified ASI). The supplemental protocol provides in-depth information on the study design and methods. Implementation measures are specific to this trial, which are crucial for the understanding and advancement of the uptake of evidence-based practices into everyday care. As part of the HEAL initiative^® funded Integrative Management of Chronic Pain and OUD for Whole Recovery (IMPOWR) network, this randomized controlled trial will determine the effectiveness of an integrated PSM intervention for patients with OM/OUD+CP, which has the potential to broadly reach under-served populations given its remote delivery and linkage with primary care settings.

Background: Federal rules governing opioid treatment programs (OTPs)-altered during and in the aftermath of the COVID-19 public health emergency-granted OTPs greater flexibility in clinical care (eg, take-home methadone doses, telehealth). Revised rules have not appeared to impact patient safety and were largely welcomed by patients and clinicians. Despite this, OTPs varied in adoption, and some have returned to pre-pandemic practice. In this qualitative study, we examined variation in clinical practices across U.S. Department of Veterans Affairs (VA) OTPs following the opportunity for reform, as well as the beliefs and perspectives of OTP administrators that may shed light on variability in decisions to adopt programmatic changes.

Methods: We contacted OTP administrators (medical directors, program managers) at all 33 VA OTPs nationally. We conducted semi-structured interviews from September 2023 to June 2024. Data were analyzed using an inductive-deductive analytic approach employing the framework method. Transcripts were coded and charted into a framework matrix that included site characteristics, clinical practices and requirements, and summaries of domains developed during the coding stage, allowing for comparison across sites.

Results: Administrators from 28/33 VA OTPs completed interviews. Participants described diverse clinic policies regarding take-home schedules, frequency and response to toxicology testing, and requirements to attend groups. Telehealth utilization increased in almost all locations. Decisions to adopt more flexible clinical requirements appeared to reflect differential perceptions of patient and community risks and beliefs about the effects of the regulations on the therapeutic environment. While leaders appreciated the opportunity to individualize treatment, they also expressed a need for guidance to ensure consistent, equitable care.

Conclusions: This study reveals variation in OTP clinical practice across VA in the wake of regulatory reform. To inform decision-making in the new regulatory environment, research examining the effects of OTP clinical practices on patient engagement, retention, and quality of care should be prioritized.

Background: To expand access to buprenorphine treatment for opioid use disorder (OUD), the X-waiver requirement was removed in January 2023. This study examined changes in OUD diagnosis and buprenorphine prescribing before and after waiver elimination.

Methods: We conducted a retrospective analysis using TriNetX electronic health record data (EHR) on adults with OUD during the waiver-required (2021-2022) and elimination (2023-2024) periods. Logistic regression estimated the likelihood of new OUD diagnoses and buprenorphine initiation, adjusting for demographic and clinical characteristics.

Results: Among 1 041 754 adults with an OUD diagnosis (516 508 in the waiver-required and 525 246 in the waiver-elimination periods), 295 675 participants (146 904 in the waiver-required and 148 771 in the waiver-elimination periods) had a new OUD diagnosis recorded. Among those with a new OUD diagnosis, buprenorphine was prescribed to 27 665 (18.8%) participants in the waiver-required and 29 223 (19.6%) participants in the waiver-elimination periods. Those in the waiver-elimination period, compared to those in the waiver-required period, were 2% less likely to receive a new OUD diagnosis (adjusted odds ratio [aOR] = 0.98, 95% confidence interval [CI]: 0.97, 0.98) and 14% more likely to have buprenorphine initiated (aOR = 1.14, 95% CI: 1.12, 1.16).

Conclusion: In this retrospective analysis of a large EHR dataset, we found that following the elimination of the X-waiver, the incidence of new OUD diagnoses declined by 2%, while subsequent buprenorphine initiation increased by 14%. These findings highlight the impact of regulatory changes on buprenorphine prescribing and underscore the need for continued efforts to reduce barriers to this life-saving treatment for OUD.

Background: Peer workers in the substance use and recovery field draw from their lived experience in recovery to provide services to individuals seeking treatment for substance use disorder. Little is known about the benefits and challenges of peer work in rural settings and in leadership positions. This study explores how lived experience shapes the perceptions and actions of directors of recovery community centers (RCCs) in rural areas, focusing on the link between lived experience and stigma, client challenges, and attitudes toward medications for opioid use disorder (MOUD).

Methods: We conducted semi-structured interviews with 11 directors at RCCs in rural Georgia, United States, from August to November 2024 to understand their lived experience, community stigma, client challenges, and attitudes toward MOUD. Thematic analysis was employed to develop themes related to lived experience and service delivery.

Results: Themes included links between lived experience and reducing rural community stigma by recovering out loud, forming partnerships to overcome client challenges, facilitating community awareness of the RCC, and connecting to clients through empathy. Regarding MOUD attitudes, directors generally expressed positive sentiments toward this recovery pathway, but some interviewees shared negative perceptions and complex MOUD-related lived experiences. Both lived experience and education/training shaped these attitudes.

Conclusions: Peer leaders can enhance recovery support services in rural areas through their lived experience representation, though this approach may introduce challenges. Recovery services should consider these peers an asset while providing them with education and training on evidence-based practices.

Background: Individuals involved in the criminal-legal system, particularly those incarcerated in prisons, are highly impacted by the opioid epidemic. Individuals from rural areas who are incarcerated may face disparate access to naloxone, the agent used to reverse opioid-induced respiratory depression. This objective of this study was to describe pre-incarceration possession of naloxone among rural and urban individuals incarcerated in state prisons.

Methods: As part of the Geographic variation in Addiction Treatment Experiences study, data were collected from adults incarcerated and released from 14 Kentucky state prisons. Eligible individuals had a history of opioid use disorder and had participated in prison-based substance use disorder treatment. Structured surveys were conducted from June 2021 to March 2024 (n = 393). Two dependent variables, lifetime and recent possession of naloxone in the 6 months prior to incarceration, were measured. Then, 2 multivariate logistic regression models were estimated to examine associations between rurality, demographic characteristics, and opioid-related measures on these 2 dependent variables.

Results: About 56% of the sample had personally experienced opioid overdose. Prior to incarceration, 47% had ever possessed naloxone and 36% reported recent possession of naloxone. Rural individuals were significantly less likely than urban individuals to report lifetime naloxone possession (odds ratio [OR] = 0.58, 95% CI = 0.35-0.96, P = .04) and recent naloxone possession (OR = 0.56, 95% CI = 0.33-0.97, P = .04).

Conclusions: In this sample recruited from Kentucky prisons, many individuals had experienced an overdose prior to incarceration, but few had naloxone. Given the significant disparities between rural and urban individuals in naloxone possession prior to incarceration, greater access to naloxone at prison release and in communities is urgently needed.

Background: Patients with substance use disorders are often seen by primary care and other frontline clinicians, yet gaps in knowledge, skills, and competing demands limit clinicians' ability to provide evidence-based care. A safety-net system developed a message-based intervention ("Chat") within the electronic health record for clinicians to pose addiction-related queries and receive guidance from addiction medicine experts. We describe the characteristics of Chat queries and the early implementation-related outcomes of the Chat.

Methods: We conducted a multi-method evaluation describing the characteristics of Chat queries and cross-sectional surveys of clinicians and addiction experts assessing implementation-related outcomes. Chat characteristics included volume, response time, and nature of the queries. Implementation outcomes included reach (proportion using the Chat), implementation (responsiveness and helpfulness of responses), usability (System Usability Scale), and acceptability, appropriateness, and feasibility (Acceptability of Intervention Measure, Intervention Appropriateness Measure, and Feasibility of Intervention Measure).

Results: Over 6 months, 84 queries were placed; 98% were answered, with an average response time of 4 (SD 19) minutes; 90% of responses occurred in <15 minutes. We surveyed 218 clinicians (60 responses, 28% response rate) and 28 addiction medicine experts (21 response, 75% response rate) with access to the Chat. Among clinicians, 68% (n = 41) were aware of the Chat, and 40% (n = 24) used it. Average usability scores were 87 (SD 11) among clinicians and 87 (SD 10) among experts, indicating excellent usability. Clinicians rated acceptability, appropriateness, and feasibility highly (average scores 4.5, 4.4, and 4.4, respectively). Key barriers include clinicians relying on other in-clinic support and addiction experts citing insufficient knowledge.

Conclusion: The Chat is a pragmatic, usable, and near real-time peer-to-peer solution to support primary care clinicians while they provide care to patients who use substances. The Chat may improve the provision of evidence-based care and can be implemented in systems with existing addiction medicine expertise.

Background: Opioid use disorder (OUD) during pregnancy is a leading contributor to peripartum morbidity and mortality, with overdose deaths rising significantly in recent years. Despite the identification of various factors associated with overdose events, including social, demographic, psychiatric, and neonatal outcomes, the relative contributions of these factors to peripartum overdose history (or lack thereof) remain unclear. Thus, this study aims to characterize factors associated with lifetime opioid-involved overdose events among currently pregnant individuals receiving buprenorphine (BUP) treatment for OUD.

Methods: Treatment-seeking pregnant individuals with an estimated gestational age of 6 to 30 weeks were enrolled in a large multisite randomized controlled trial evaluating 2 BUP formulations for OUD. Participant baseline demographic, substance use, and mental health data were collected using validated measures, and random forest modeling identified key factors associated with lifetime opioid overdose events.

Results: The 140 pregnant participants (M_age = 31.2 years, SD = 4.7; 87.1% White) reported an average of 8.7 years (SD = 5.8) of opioid use, with 92.1% endorsing lifetime prescription opioid use and 82.9% reporting heroin use. The average lifetime number of nonfatal opioid overdose events was 4.8 (SD = 12.1); an overdose was reported by 55% of the sample (n = 77). Random forest analysis (area under the receiver operating characteristic curve = 0.797) incorporating sociodemographic, substance use, and mental health characteristics found that the most important factors associated with lifetime overdose events were, in order, lifetime heroin use, trauma exposure, reliance on partners or parents for financial support, depressive symptoms, and lifetime cocaine use.

Conclusions: These findings underscore the critical need to address substance use, co-occurring mental health, and socioeconomic challenges that are associated with previous opioid overdose. Identifying and targeting key modifiable overdose risk factors can inform the development of tailored interventions to improve outcomes for this population.

Background: Past studies have shown a large percentage of college health providers (CHPs) feel responsible yet unprepared to address prescription stimulant misuse (PSM) and prescription stimulant diversion (PSD). As such, the authors developed a theory-guided, universal curriculum for CHPs to more confidently address PSM and PSD among their student populations. The purpose of the current study was to refine the curriculum using a multistep approach and assess the impact on providers' PSM and PSD knowledge, attitudes, norms, barriers, and self-efficacy.

Methods: The initial version of the curriculum was reviewed for content validity by 2 content/curriculum experts. Next, 5 students reviewed a revised version of the curriculum for face validity. The authors further refined the curriculum using the Delphi technique; specifically, a geographically diverse sample of 28 CHPs rated the appropriateness and clarity of each topic within each objective of the curriculum. Next, staff (N = 27) at 1 student health center received the training and completed a pre-post assessment to evaluate impact on knowledge, attitudes, norms, barriers, and self-efficacy. Quantitative (eg, means, medians, paired t-tests) and qualitative feedback were reviewed to guide refinement. These activities were completed between August 2023 and August 2024.

Results: The criteria for content and face validity were met based on the reviews by curriculum experts and students, respectively. The Delphi technique required 2 rounds. All discussion topics had median and mode scores that reflected appropriateness and clarity. Pre-post assessment of the training showed significant improvements in CHPs knowledge, norms, self-efficacy, implementation barriers, and confidence to overcome barriers related to addressing PSM and PSD.

Conclusions: A multistep process produced a comprehensive and theory-guided curriculum. Curriculum receipt resulted in improvements in multiple domains. Next steps include using an experimental design to test the impact of an intervention based on this training on student behavior, as well as digitizing and disseminating the training.

Medical hospitalizations are common among people with substance use disorders (SUD) and represent important opportunities for engagement, treatment initiation, and linkage to follow-up care. However, hospitalizations are also destabilizing events marked by an elevated risk of death and readmission in the period immediately following hospital discharge. There is currently no consensus on the best way to support patients with SUD as they transition from the hospital to follow-up care in the community after discharge. Care transitions span multiple care settings and are influenced by a wide array of medical, psychosocial, and environmental factors. Given their complexity, it is crucial to engage a diverse array of partners to collaboratively set research priorities, define outcomes, and design interventions to improve care in this area. Key partners include people with lived substance use experience, hospital-based clinicians, social workers, addiction specialists, peer navigators, primary care clinicians, and more. A community-engaged research framework is essential to promote equitable contribution from this diverse group of collaborators. In this article, we share our protocol for a community engagement project called COmmunity Network to Navigate and Enhance Care Transitions and describe how we integrated core principles of community-engaged research into its design.