Faculty Bibliography

OBJECTIVE:This qualitative study identifies and describes experiences and challenges to retention of individuals with opioid use disorder (OUD) who participated in a low-threshold combined buprenorphine-peer support treatment program in Baltimore. METHODS:In-depth semi-structured interviews with staff and former clients of the Project Connections Buprenorphine Program (PCBP) (9 people) and focus group discussions with current and previous clients of PCBP (7 people) were conducted. Content analysis was used to extract themes regarding barriers to enrolling and remaining in, and transitioning from the program. RESULTS:Primary challenges identified by the participants included struggles with cravings and symptoms of withdrawal, comorbid mental health issues, criminal justice system involvement, medication stigma, and conflicts over level of flexibility regarding program requirements and the role of employment. CONCLUSIONS:This study identified several obstacles clients face when seeking care through a combined buprenorphine-peer support model. Findings highlight potential programmatic factors that can be improved and additional resources that may support treatment retention rates and better outcomes. Despite challenges, low-threshold and community-based programs can increase access to effective maintenance treatment for OUD, especially among vulnerable populations who may not have access to formal health services.

Buprenorphine is considered one of the most effective treatments for opioid use disorder and significantly reduces risk of overdose death. However, concerns about its diversion and misuse have often taken center stage in public discourse and in the design of practices and policies regarding its use. This has been to the detriment of many vulnerable patient populations, especially those involved in the criminal justice system. Policies that restrict access to buprenorphine in criminal justice and other settings due to concerns of diversion do not accurately reflect the relative risks and safety profile associated with it, creating unnecessary barriers that drive an illicit market of this much-needed medication. Although proper regulation of all controlled medications should be a priority, in most instances the benefits of buprenorphine highly outweigh its risks. In the midst of a national crisis, efforts should be focused on expanding, and not restricting, access to this lifesaving treatment.

OBJECTIVE:Understand how insurance impacts access to services among people who have injected drugs. METHODS:1748 adults who have injected drugs were assessed at twice-annual study visits between 2006 and 2017 (18,869 visits). Use of specialty substance use treatment, receipt of buprenorphine, and having a regular source of medical care were assessed for association with concurrent insurance coverage. Random intercept logistic regression was used to adjust for potential confounders. RESULTS:When participants acquired insurance, they were more likely to report specialty substance use treatment (aOR 2.0, 95% CI 1.6 to 2.5), a buprenorphine prescription (aOR 3.3, 95% CI 2.0 to 5.5), and a regular source of medical care (aOR 6.3, 95% CI 5.1 to 7.8). CONCLUSION/CONCLUSIONS:Insurance is associated with increased use of three important services for individuals who inject drugs. IMPLICATIONS/CONCLUSIONS:Expanding insurance may facilitate access to substance use treatment and other needed health services.

BACKGROUND:Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders. OBJECTIVE:This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use. METHODS:Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors. RESULTS:Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.

INTRODUCTION:Although prior clinical and population-based studies have demonstrated comorbidity between mood and alcohol use disorders (AUD), there is a paucity of research assessing whether mood disorders predict transition across stages of alcohol involvement. METHOD:Hypothesizing that mood disorders predict transition across sex-specific alcohol involvement stages, we used prospective data from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationally representative survey of US adults, which included male (n = 14,564) and female (n = 20,089) participants surveyed in 2001-2 and re-interviewed in 2004-5. Latent class (LCA) and latent transition analyses (LTA) were used to assess patterns of alcohol involvement in the US and the association of lifetime mood disorders at baseline with transition across stages of alcohol involvement during follow-up. RESULTS:A three-class model of AUD criteria was identified (No problems, Moderate problems and Severe problems) for both sexes. Positive cross-sectional associations between mood disorder and problem classes of alcohol involvement were found among both sexes, as were positive longitudinal associations. Propensity score adjustment mitigated the associations of baseline mood disorder with progressive transition for both sexes. However, among females, baseline mood disorder was consistently associated with reduction in remission from Severe to Moderate alcohol problems (aOR = 0.30, CI = 0.09-0.99, p = .048) over time. DISCUSSION:Our study provides evidence that mood disorders impact transition through stages of alcohol involvement and are most strongly associated with hindering remission among females. Findings advance our understanding of these comorbid relationships and have clinical implications for ongoing assessment of drinking patterns among individuals with mood disorders.

Medicaid enrollment varies considerably among states. This study examined the association of Medicaid enrollment with the use of substance health services in the longitudinal National Epidemiologic Survey on Alcohol and Related Conditions of 2001-2005. Instrumental variable methods were used to assess endogeneity of individual-level Medicaid enrollment using state-level data as instruments. Compared to the uninsured, Medicaid covered adults were more likely to use substance use disorder treatment services over the next three years. States that have opted to expand Medicaid enrollment under the Affordable Care Act will likely experience further increases in the use of these service over the coming years.

OBJECTIVES:To present and discuss recent patterns of prescription opioid sales throughout Brazil. METHODS:We graphed linear trends of opioid prescriptions sold from registered pharmacies across Brazil from 2009 to 2015. We then calculated the change in rate of prescriptions sold per 1000 persons in 2015 compared with 2009. RESULTS:Opioid sales increased across Brazil from 1 601 043 prescriptions in 2009 to 9 045 945 prescriptions in 2015, corresponding to a 465% increase in 6 years. The largest absolute increase was for codeine products (rate ratio (RR) = 5.30; 95% confidence interval [CI] = 5.29, 5.31), accounting for more than 98% of prescriptions in both years. Oxycodone had the largest relative increase (RR = 11.39; 95% CI = 11.19, 11.59), and fentanyl products had the smallest absolute and relative increase (RR = 2.91; 95% CI = 2.78, 3.03). CONCLUSIONS:Given rapid increases in opioid sales across Brazil, it is critical to introduce effective prescribing and monitoring methods that allow patients to access necessary medications without escalating risk of opioid misuse and related consequences. Careful surveillance of supply and subsequent outcomes are needed to prevent the development of another devastating opioid epidemic in the Americas.

BACKGROUND:Most recent research on adolescent drug use has focused on alcohol, tobacco, and marijuana. Less is known about the recent epidemiology of adolescent cocaine use, which has serious health consequences. PURPOSE:To describe recent trends in cocaine use by U.S. high school students, and identify differences in lifetime and repeated use across sex and racial/ethnic groups. METHODS:We used data from the national Youth Risk Behavior Surveys (YRBS) from 1999 to 2015. We estimated the prevalence of lifetime cocaine use (LCU) and repeated lifetime cocaine use (RLCU) across years by race/ethnicity and sex and tested for linear and quadratic trends. RESULTS:The prevalence of LCU decreased from 1999 to 2015 (9.54%-5.19%). RLCU also decreased (5.13%-2.84%). Despite the overall decline, LCU and RLCU both rose between 2009-2015 (LCU:2.78%-5.19%, RLCU:1.58%-2.84%). Boys had higher rates of LCU and RLCU than girls (LCU:6.42% vs 4.65%; RLCU:3.69% vs 2.18%). American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, and Hispanic adolescents had the highest overall prevalence of LCU. Black adolescents' LCU patterns differed from other racial/ethnic groups. The prevalence of LCU among Black boys increased over time, while the prevalence for Black girls remained consistently low. CONCLUSIONS:Adolescent cocaine use is less common today than in the 1990s. However, rates of adolescent cocaine use have risen across all racial/ethnic groups in the past few years. Public health efforts should address at risk groups with particularly high or rising rates of cocaine use.

BACKGROUND:Treatment for opioid use disorder involving opioid-based pharmacotherapies is considered most effective when accompanied by psychosocial interventions. Peer-led support groups are widely available and have been described by many as fundamental to the recovery process. However, some individuals using medications face stigma in these settings, which can be contradictory and counterproductive to their recovery. METHODS:This paper describes the development of the "Ability, Inspiration and Motivation" or "AIM" group, an alternative peer support group that aims to remove medication stigma from peer recovery. Qualitative interviews with staff, peers, and clients of a community-based buprenorphine treatment program were used to establish the core components of the curriculum to support client needs. RESULTS:Staff, peers, and clients of the buprenorphine program indicated a need and desire to establish a peer recovery group that recognizes persons on medication as being in recovery and destigmatizes use of medication to treat opioid addiction. A respectful environment, holistic perspective on health, spirituality, sharing, and celebration were all established as necessary pillars of the AIM group curriculum. CONCLUSIONS:The community-based effort to establish and develop the AIM group demonstrates that combining the strengths of a peer support with evidence-based medication treatment is both possible and desirable. Shifting the culture of peer recovery groups to support the use of medications may have implications for improving treatment retention and should be considered as a potential strategy to reduce the burden of the opioid epidemic.