Substance use & addiction journal最新文献

American Indian/Alaska Native (AI/AN) individuals have the highest rates of opioid overdose mortality and chronic pain (CP) compared to other racial/ethnic groups in the United States. These individuals also report higher rates of pain anxiety and pain catastrophizing, which are both associated with poorer outcomes and risk for opioid misuse (OM) and opioid use disorder (OUD) among individuals with CP. Yet, no prior studies have examined rates of comorbid pain and OUD among AI/AN adults. This commentary describes an implementation research partnership of 3 AI/AN-serving clinics and a university team that utilizes an implementation hybrid type III design to examine the impact of implementation strategies on adoption and sustainability of evidence-based screening and brief intervention for CP and OM/OUD among AI/AN clients. As part of our community-engaged approach, we embrace both AI/AN models and Western models, and a collaborative board of 10 individuals guided the research throughout. We hypothesize that our culturally centered approach will increase rates of screening and brief intervention and improve identification of and outcomes among AI/AN clients with CP and OUD who receive treatment at participating sites. Each site convenes a workgroup to evaluate and set goals to culturally center screening and brief interventions for CP and OM/OUD. Data collected include deidentified electronic health records to track screening and brief interventions and rates of CP and OUD; provider and staff surveys beginning prior to implementation and every 6 months for 2 years; and a subset of clients will be recruited (N = 225) and assessed at baseline, 6, and 12 months to examine biopsychosocial and spiritual factors and their experiences with culturally centered screening and brief intervention. Cultural adaptations to the measures and screening and brief intervention as well as barriers and facilitators will be addressed. Recommendations for successful Tribal health clinic-university partnerships are offered.

Background: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies.

Methods: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups.

Results: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently).

Conclusions: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.

Background: Few patient-facing educational materials and interventions exist for the prevention of injection drug use-related infective endocarditis (IDU-IE). We developed a patient and clinician-informed website for patients about IDU-IE to promote education and prevention strategies.

Methods: This mixed-methods study integrated surveys and semi-structured interviews with patients and clinician to develop a patient website about IDU-IE. Patient participants included hospitalized adults with an opioid use disorder, history of injection drug use, and an injection drug use-related infection. Interprofessional healthcare clinicians including trainees participated. A baseline survey and semi-structured interviews were conducted with patients to understand knowledge of IDU-IE and preferences in educational materials content and format. Interviews were analyzed using rapid qualitative analysis. Results informed development of the patient website. Finally, patients and clinicians provided 2 rounds of survey feedback after reviewing the website, assessing the likelihood of using and recommending it to others, helpfulness of information in the website sections, and content satisfaction.

Results: Patient participants (n = 15) reported low baseline understanding of injection practice and risk of IDU-IE. After reviewing the website (n = 17), patients reported they were very likely to recommend the website as a reference for themselves (mean of 4.3; 4 = very likely) and for others (mean = 4.3). They found the following sections, on average, to be very helpful (4 = very helpful): complications from injection drug use (4.4), safer injection practice (4.4), and information about infective endocarditis (4.4). Patients on average were satisfied with the website content overall (4.8). Clinicians (n = 27) reported, on average, being very likely to recommend this website to a patient (4.4) and to use the website to counsel patients (4.1).

Conclusions: A patient and clinician-informed website on IDU-IE is acceptable for patients and clinicians to use as a patient education resource to help prevent IDU-IE-related harms.

Background: Addressing the negative impact of substance use disorders (SUDs) on individuals, families, and communities is a public health priority. Most treatments and interventions require engagement with a healthcare provider or someone who can offer recovery support. The need for interventions that facilitate self-management of relapse triggers at the moment they occur is also critical. Our study aimed to explore the user experience of individuals using a just-in-time smartphone episodic resonance breathing (eRPB) intervention to address stress, anxiety, and drug cravings.

Methods: We conducted an 8-week pilot study of the eRPB with 30 individuals in recovery from SUD. Data on 3 indicators of user experience-acceptability, appropriateness, and feasibility-were collected using survey questions (n = 30) and semi-structured interviews (n = 11). We performed univariate analysis on the survey data and deductive thematic analysis on the qualitative data.

Results: A majority of the survey respondents agreed that the application (app) was acceptable (> 77%), appropriate (> 82%), and feasible (> 89%). Several interview participants stated that the app helped them relax and manage stress and cravings and expressed appreciation for the simplicity of its design. Participants also reported barriers to feasibility (such as forgetting to use the app) and recommendations for improvement (such as the addition of motivational messages).

Conclusions: Our findings show that individuals in recovery from SUD had highly positive experiences with the eRPB app. A positive user experience may improve adherence to the intervention and, ultimately, the self-management of stress, anxiety, and craving relapse triggers.

Background: Opioid use disorder (OUD) has arguably the highest mortality rate of mental health conditions; opiate-related deaths are identified as the number one cause of accidental deaths in Canada and the United States. Specialized care for OUD is often described as lacking, fractured, and with frequent periods of disengagement. Digital health strategies may support connection to evidence-based resources even during periods of disengagement. However, sustained engagement in digital interventions remains a barrier, and as such, experts recommend using co-design approaches to develop interventions.

Methods: The current study outlines the results from a qualitative co-design project that engaged 6 lived experts and 8 clinical experts in a series of focus groups and interviews to adapt an existing intervention for use in OUD. Focus groups and interviews were recorded and transcribed before undergoing thematic analysis. This co-design process is the first stage of a larger project that will lead to the development of a novel digital health intervention for OUD populations.

Results: Transcripts underwent thematic analysis, and themes were divided into Crosscutting Themes, Feasibility and Engagement, and Specific Features. Each theme was divided into specific subthemes, which were reviewed by the design team and informed the design of the digital health platform. Key resulting directions included creating a psychologically safe digital space, curating resources for OUD as a multifaceted condition, and being mindful of barriers to implementation from both lived and clinical expert perspectives. Specific features are discussed in detail in the article.

Conclusion: Lived experts and clinicians strongly supported integrating digital tools into OUD care. Ongoing work is needed to better understand the role of technology in existing OUD structures as well as the implementation of key features such as digital peer support and creating effective and safe social connections. This study also validates co-design as an essential step in digital health development.

Background: Over 3 million Americans have an opioid use disorder (OUD), and only a fraction receive treatment. Public opinion is crucial in enacting evidence-based policies. Few studies have examined the public's perception of blame for the ongoing opioid overdose epidemic directed at distinct groups. We assessed US adults' perceived blameworthiness for the epidemic and examined factors that may influence the perceived blameworthiness.

Methods: We conducted a national survey in 2022 using the AmeriSpeak® panel to assess US adults' perception of blame toward individuals with an OUD and external contributors. Of the 3335 eligible panel members invited to participate, 1233 (37%) completed the survey. We developed a measure of knowledge and understanding of OUD, with a higher value indicating a greater understanding of the nature of OUD and recovery-including knowledge and beliefs on evidence-based treatment and relapse. We analyzed the relationships between sources of blame, knowledge, and understanding of OUD, and individual-level correlates.

Results: Higher score of knowledge and understanding of OUD was associated with lower odds of blaming individuals with OUD (odds ratio [OR] = 0.73, 95% confidence interval [CI] = [0.51, 1.05]) and greater odds of blaming external contributors: healthcare providers (OR = 1.49, 95% CI = [1.05, 2.12]), pharmaceutical companies (OR = 2.17, 95% CI = [1.50, 3.15]), and health insurance companies (OR = 1.42, 95% CI = [0.97, 2.09]). Those who are female, non-Hispanic White, Democrat, have higher education, or have friends or family who misused opioids tended to score higher in knowledge and understanding of OUD.

Conclusions: Perceived blameworthiness for the opioid overdose epidemic is related to knowledge and understanding of OUD. Public health campaigns with a bipartisan agenda to increase evidence-informed knowledge about OUD targeting people of color and with lower education may help reduce the blame toward people with an OUD, which in turn may increase support for evidence-informed policies.

Background: High-dose (≥24 mg) buprenorphine daily doses (BDD) may be important in treating patients with opioid use disorder (OUD) to improve retention and prevent overdose, particularly in the context of increased illicit fentanyl use. This study sought to: (1) identify trajectories for average BDD among patients initiating buprenorphine treatment for OUD and (2) assess patient characteristics associated with these identified trajectories.

Methods: Buprenorphine treatment episodes among patients in the US Veterans Healthcare Administration (VHA) from federal fiscal years 2006 to 2020 were identified. Group-based trajectory modeling (GBTM) was used to identify BDD trajectories based on weekly averages of BDD over the 180 days after buprenorphine episode initiation.

Results: A total of 79 303 buprenorphine treatment episodes among 44 583 patients were included in the analytic sample. GBTM identified 9 latent trajectories for BDD: (1) moderate dose, early discontinuation (10.1%), (2) moderate dose, delayed discontinuation (4.5%), (3) moderate dose, moderate-paced discontinuation (5.2%), (4) low-moderate dose, delayed discontinuation (7.0%), and (5) low-moderate dose, early discontinuation (21.1%), (6) low dose retention (9.6%), (7) low-moderate dose retention (16.7%), (8) moderate dose retention (18.6%), and (9) high dose retention (7.4%). Patient BDD can broadly be characterized as low [2-4 mg/day], low-moderate (6-8 mg/day), moderate (12-18 mg/day), and high dose (≥ 24 mg/day). Patients with episodes in the high BDD trajectory have the lowest social risk (eg, lowest rate of past-year history of homelessness) and the lowest diagnosed rate of physical and mental health-related comorbidities compared to those following other trajectories.

Conclusions: BDD ranges widely and patient characteristics are significantly different between those episodes following differing BDD trajectories. Future research on the association between BDD and subsequent patient outcomes (eg, overdose) needs to carefully consider these differences in baseline characteristics.

Buprenorphine is an effective medication for both opioid use disorder (OUD) and chronic pain (CP), but transitioning from full opioid agonists to buprenorphine, a partial opioid agonist, can be challenging. Preliminary studies suggest that low-dose buprenorphine initiation can overcome some challenges in starting treatment, but no randomized controlled trials have compared low-dose and standard buprenorphine initiation approaches regarding effectiveness and safety or examined implementation in hospital settings. In a pragmatic open-label hybrid type I effectiveness-implementation trial based in a single urban health system, 270 hospitalized patients with (a) CP and (b) OUD or opioid misuse are being randomized to buprenorphine treatment initiation using 5-day low-dose or standard initiation protocols. Outcomes include buprenorphine treatment uptake (primary), defined as receiving buprenorphine treatment 7 days after enrollment, and other OUD and pain outcomes at 1-, 3-, and 6-month follow-up (secondary). Data collection will also include safety measures, implementation of low-dose initiation protocols, patient acceptability, and cost-effectiveness. Comparing strategies in a randomized clinical trial will provide the most definitive data to date regarding the effectiveness and safety of low-dose buprenorphine initiation. The study will also provide important data on treating CP at a time that clinical guidelines are evolving to center buprenorphine as a preferred opioid for CP.

Background: A recent National Institute on Drug Addiction Call to Action focused on expanding methadone treatment access for individuals with opioid use disorder (OUD). One research priority identified was optimal educational and support structures, including training to provide methadone across multiple healthcare settings (e.g., primary care, opioid treatment programs [OTPs], pharmacies) and healthcare workers (HCWs) (e.g., providers, pharmacists). This scoping review sought to better understand HCWs' knowledge, attitudes, and stigma as it relates to methadone provision.

Methods: Four databases (PubMed, PsycInfo, CINAHL, Web of Science) were searched for publications between 2010 and 2022 using keywords-methadone, HCW, outpatient setting, knowledge, attitudes, and stigma, focusing on HCWs in general and pharmacists specifically.

Results: A total of 2,747 articles were identified and 14 met inclusion criteria for review. Settings included OTPs (n = 4), specialty addiction treatment clinics (n = 3), community pharmacies (n = 2), and multiple settings (n = 5). All articles (n = 14) examined methadone-related attitudes. Despite approval of methadone in 1972 to treat OUD, four articles illustrated continued methadone-related stigma held by HCWs. In response to COVID-19-related policy changes allowing methadone take-home flexibility, OTP clinicians expressed a range of attitudes concerning patient risk and potential program liability around diversion and misuse. One article assessing knowledge suggested that, even when most pharmacists correctly answered knowledge questions, a significant minority had misunderstandings that could undermine effective treatment.

Conclusions: Given the current imbalance between methadone treatment demand and availability, there is a critical need to expand outpatient methadone services. Pharmacists partnering with OTPs represent a logical but underutilized access point. We identified key areas to improve HCWs methadone-related knowledge, attitudes, and stigma. Future research should explore the impact of outpatient pharmacy-OTP and other expansion services, and systematic training, education, and evaluation of methadone-related understanding, including assessment tools to measure knowledge, attitudes, and stigma.

Background: Communities with robust recovery ecosystems could reduce negative outcomes associated with substance use disorders (SUDs) and facilitate the recovery process. This cross-sectional study examined the relationship between drug overdose mortality rates in the United States and the strength of county-level recovery ecosystems, as measured by the Recovery Ecosystem Index (REI).

Methods: The REI assesses the strength of county-level recovery ecosystems in the United States. Comprised of 14 indicators across 3 component classes, overall and component scores ranging from "one" (strongest) to "five" (weakest) were calculated for each county using standardized values of the indicators. County-level analyses included: (1) correlational analyses between drug overdose mortality rates (n = 2076) and REI scores (overall score and by component); and (2) quadrant analysis (n = 2076), dividing counties based on their drug overdose mortality rates and overall REI scores.

Results: Drug overdose mortality rates were inversely related to REI overall, SUD treatment component, and continuum of SUD support component scores, indicating that lower (stronger) scores corresponded to higher rates. Conversely, REI infrastructure and social component scores were positively related to rates. Counties were relatively evenly distributed across quadrants, with 26% (n = 537) with a strong REI score and high overdose mortality rate, 24% (n = 489) with a strong REI score and low overdose mortality rate, 20% (n = 409) with a weak REI and high overdose mortality rate, and 31% (n = 641) with a weak REI and low overdose mortality rate.

Conclusions: REI scores were generally inversely associated with drug overdose mortality rates in US counties, suggesting that communities have stronger recovery systems and services as the burden of SUD increases. Given relative variation in the scale of drug overdose mortality and strength of recovery ecosystems among counties, results could guide the identification of communities where the need for expanded recovery systems and services may be particularly critical.