Faculty Bibliography

As the USA faces a worsening overdose crisis, improving access to evidence-based treatment for opioid use disorder (OUD) remains a policy priority. Federal regulatory changes in response to the COVID-19 pandemic substantially expanded flexibilities on take-home doses for methadone treatment for OUD. These changes have fuelled questions about the effect of new regulations on OUD outcomes and the potential effect on health of permanently integrating these flexibilities into treatment policy going forward. To aide US policy makers as they consider implementing permanent methadone regulatory changes, we conducted a review synthesising peer-reviewed research on the effect of the flexibilities of methadone take-home policies introduced during COVID-19 on methadone programme operations, OUD patient and provider experiences, and patient health outcomes. We interpret the findings in the context of the federal rule-making process and discuss avenues by which these findings can be incorporated and implemented into US policies on substance use treatment going forward.

BACKGROUND AND AIMS/OBJECTIVE:Individuals with opioid use disorder (OUD) suffer disproportionately from COVID-19. To inform clinical management of OUD patients, research is needed to identify characteristics associated with COVID-19 progression and death among this population. We aimed to investigate the role of OUD and specific comorbidities on COVID-19 progression among hospitalized OUD patients. DESIGN/METHODS:Retrospective cohort study of merged electronic health records (EHR) from five large private health systems SETTING: New York City, New York, USA, 2011-2021 PARTICIPANTS: Adults with a COVID-19 encounter and OUD or opioid overdose diagnosis between March 2020-February 2021 MEASUREMENTS: Primary exposure included diagnosis of OUD/opioid overdose. Risk factors included age, sex, race/ethnicity and common medical, substance use and psychiatric co-morbidities known to be associated with COVID-19 severity. Outcomes included COVID-19 hospitalization and subsequent intubation, acute kidney failure, severe sepsis and death. FINDINGS/RESULTS:Of 110,917 COVID-19+ adults, 1.17% were ever diagnosed with OUD/opioid overdose. OUD patients had higher risk of COVID-19 hospitalization (adjusted risk ratio [aRR]: 1.40 [95% confidence interval (CI) 1.33, 1.47]), intubation (adjusted aood ratio [aOR]: 2.05 [95% CI 1.74, 2.42]), kidney failure (aRR: 1.51 [95% CI 1.34, 1.70)), sepsis (aRR: 2.30 [95% CI 1.88, 2.81]), and death (aRR: 2.10 [95% CI 1.84, 2.40)]. Among hospitalized OUD patients, risks for COVID-19 outcomes included being male; older; of a race/ethnicity other than white, Black or Hispanic; and having co-morbid chronic kidney disease, diabetes, obesity or cancer. Protective factors included having asthma, hepatitis-C, and chronic pain. CONCLUSIONS:Opioid use disorder patients appears to have a substantial risk for COVID-19-associated morbidity and mortality, with particular comorbidities and treatments potentially moderating this risk.

BACKGROUND AND AIMS/OBJECTIVE:Opioid overdose is a leading cause of death during the immediate time after release from jail or prison. Most jails in the United States do not provide methadone and buprenorphine treatment for opioid use disorder (MOUD), and research in estimating its impact in jail settings is limited. We aimed to test the hypothesis that in-jail MOUD is associated with lower overdose mortality risk post-release. DESIGN, SETTING AND PARTICIPANTS/METHODS:Retrospective, observational cohort study of 15 797 adults with opioid use disorder who were released from New York City jails to the community in 2011-17. They experienced 31 382 incarcerations and were followed up to 1 year. MEASUREMENTS/METHODS:The primary outcomes were death caused by accidental drug poisoning and all-cause death. The exposure was receipt of MOUD (17 119 events) versus out-of-treatment (14 263 events) during the last 3 days before community reentry. Covariates included demographic, clinical, behavioral, housing, healthcare utilization, and legal characteristics variables. We performed multivariable, mixed-effect Cox regression analysis to test association between in-jail MOUD and deaths. FINDINGS/RESULTS:A majority were male (82%) and their average age was 42 years. Receiving MOUD was associated with misdemeanor charges, being female, injection drug use, and homelessness. During 1 year post-release, 111 overdose deaths occurred, and crude death rates were 0.49 and 0.83 per 100 person-years for in-jail MOUD and out-of-treatment groups, respectively. Accounting for confounding and random effects, in-jail MOUD was associated with lower overdose mortality risk (adjusted hazard ratio = 0.20, 95% CI = 0.08-0.46), and all-cause mortality risk (adjusted hazard ratio = 0.22, 95% CI = 0.11-0.42) for the first month post-release. CONCLUSIONS:Methadone and buprenorphine treatment for opioid use disorder during incarceration was associated with an 80% reduction in overdose mortality risk for the first month post-release.

OBJECTIVES/OBJECTIVE:There is a growing concern over the increased prevalence of fentanyl contaminated oxycodone pills, referred to as M30s. The current study is an examination of content on the Reddit social media site in order to understand the perceptions of and experiences with exposure to fentanyl contaminated M30 pills. METHODS:Data include subreddit posts collected from January 1, 2021, to July 28, 2021, from 71 drug-related subreddits using 34 fentanyl-related search terms. A random subsample of 500 posts was examined for thematic analysis. 226 (45.2%) of posts were determined to be relevant and included in the final sample. RESULTS:Over one-third (n = 85, 37.6%) of subreddit posts with mention of fentanyl were related to pressed M30 pills. Three emergent themes related to pressed M30 pills were identified: suspicion of contamination in oxycodone pills was pervasive (51.2%), composition of pills evoked anxiety (40%), and M30 mitigation and testing strategies (29.4%). CONCLUSIONS:Many persons on the online communities of Reddit who use drugs were aware of fentanyl contamination in the current pressed pill market. Reddit offered a space to network with others to discuss harm reduction strategies and anxieties surrounding the pervasiveness of fentanyl in the current drug market.

BACKGROUND:Substance use treatment and harm reduction services are essential components of comprehensive strategies for reducing the harms of drug use and overdose. However, these services have been historically siloed, and there is a need to better understand how programs that serve people who use drugs (PWUD) are integrating these services. In this study, we compared treatment and harm reduction services offered by a multistate sample of substance use service providers and assessed how well they align with characteristics and needs of clients they serve early in the COVID-19 pandemic. METHODS:We recruited a convenience sample of programs that deliver harm reduction and/or treatment services in ten US states. Program directors participated in a survey assessing the services offered at their program. We also recruited clients of these programs to participate in a survey assessing a range of sociodemographic and health characteristics, substance use behaviors, and health service utilization. We then cross-compared client characteristics and behaviors relative to services being offered through these programs. RESULTS:We collected and analyzed data from 511 clients attending 18 programs that we classified as either offering treatment with medications for opioid use disorder (MOUD) (N = 6), syringe service programs (SSP) (N = 8), or offering both MOUD and SSP (N = 4). All programs delivered a range of treatment and harm reduction services, with MOUD & SSP programs delivering the greatest breadth of services. There were discrepancies between services provided and characteristics and behaviors reported by clients: 80% of clients of programs that offered MOUD without SSP actively used drugs and 50% injected drugs; 40% of clients of programs that offered SSP without MOUD sought drug treatment services. Approximately half of clients were unemployed and unstably housed, but few programs offered direct social services. CONCLUSIONS:In many ways, existing programs are not meeting the service needs of PWUD. Investing in innovative models that empower clients and integrate a range of accessible and flexible treatment, harm reduction and social services can pave the way for a more effective and equitable service system that considers the long-term health of PWUD.

Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.

BACKGROUND:The United States overdose crisis continues unabated. Despite efforts to increase capacity for treating opioid use disorder (OUD) in the U.S., how actual treatment receipt compares to need remains unclear. In this cross-sectional study, we estimate progress in addressing the gap between OUD prevalence and OUD treatment receipt at the national and state levels from 2010 to 2019. METHODS:We estimated past-year OUD prevalence rates based on the U.S. National Survey on Drug Use and Health (NSDUH), using adjustment methods that attempt to account for OUD underestimation in national household surveys. We used data from specialty substance use treatment records and outpatient pharmacy claims to estimate the gap between OUD prevalence and number of persons receiving medications for opioid use disorder (MOUD) during the past decade. RESULTS:Adjusted estimates suggest past-year OUD affected 7,631,804 individuals in the U.S. in (2,773 per 100,000 adults 12+), relative to only 1,023,959 individuals who received MOUD (365 per 100,000 adults 12+). This implies approximately 86.6% of individuals with OUD nationwide who may benefit from MOUD treatment do not receive it. MOUD receipt increased across states over the past decade, but most regions still experience wide gaps between OUD prevalence and MOUD receipt. CONCLUSIONS:Despite some progress in expanding access to MOUD, a substantial gap between OUD prevalence and treatment receipt highlights the critical need to increase access to evidence-based services.

BACKGROUND:Until recently, few carceral facilities offered medications for opioid use disorder (MOUD). Although more facilities are adopting MOUD, much remains to be learned about addressing implementation challenges related to expansion of MOUD in carceral settings and linkage to care upon re-entry. This is particularly important in jails, where individuals cycle rapidly in and out of these facilities, especially in jurisdictions beginning to implement bail reform laws (i.e., laws that remove the requirement to pay bail for most individuals). Increasing access to MOUD in these settings is a key unexplored challenge. METHODS:In this qualitative study, we interviewed staff from county jails across New Jersey, a state that has implemented state-wide efforts to increase capacity for MOUD treatment in jails. We analyzed themes related to current practices used to engage individuals in MOUD while in jail and upon re-entry; major challenges to delivering MOUD and re-entry services, particularly under bail reform conditions; and innovative strategies to facilitate delivery of these services. RESULTS:Jail staff from 11 New Jersey county jails participated in a baseline survey and an in-depth qualitative interview from January-September 2020. Responses revealed that practices for delivering MOUD varied substantially across jails. Primary challenges included jails' limited resources and highly regulated operations, the chaotic nature of short jail stays, and concerns regarding limited MOUD and resources in the community. Still, jail staff identified multiple facilitators and creative solutions for delivering MOUD in the face of these obstacles, including opportunities brought on by the COVID-19 pandemic. CONCLUSIONS:Despite challenges to the delivery of MOUD, states can make concerted and sustained efforts to support opioid addiction treatment in jails. Increased use of evidence-based clinical guidelines, greater investment in resources, and increased partnerships with health and social service providers can greatly improve reach of treatment and save lives.

OBJECTIVE:Polysubstance use may complicate treatment outcomes for individuals who use opioids. This research aimed to examine the prevalence of polysubstance use in an opioid use disorder treatment trial population and polysubstance use's association with opioid relapse and craving. METHODS:This study is a secondary data analysis of individuals with opioid use disorder who received at least one dose of medication (n = 474) as part of a 24-week, multi-site, open label, randomized Clinical Trials Network study (CTN0051, X:BOT) comparing the effectiveness of extended-release naltrexone versus buprenorphine. Models examined pretreatment polysubstance use and polysubstance use during the initial 4 weeks of treatment on outcomes of relapse by week 24 of the treatment trial and opioid craving. RESULTS:Polysubstance use was generally not associated with treatment outcomes of opioid relapse and craving. Proportion of days of pretreatment sedative use was associated with increased likelihood of opioid relapse (OR: 1.01, 95 % CI: 1.00-1.02). Proportion of days of cocaine use during the initial 4 weeks of treatment was associated with increased likelihood of opioid relapse (OR: 1.05, 95 % CI: 1.01-1.09) but this effect was no longer significant once the potential of confounding by opioid use was considered. Sedative use during initial 4 weeks of treatment was associated with increased opioid craving (b: 0.77, 95 % CI: 0.01-1.52). The study found no other significant relationships. CONCLUSIONS:In the current study population, polysubstance use was only marginally associated with 24-week treatment outcomes.