Faculty Bibliography

OBJECTIVES/OBJECTIVE:The purpose of this study was to assess the feasibility and clinical impact of telemedicine-based opioid treatment with buprenorphine-naloxone following the Coronavirus disease 2019 pandemic. METHODS:Participants included in this retrospective analysis consisted of adult New York City residents with opioid use disorder eligible for enrollment in the NYC Health+Hospitals Virtual Buprenorphine Clinic between March and May 2020 (n = 78). Follow-up data were comprised of rates of retention in treatment at 2 months, referrals to community treatment, and induction-related events. RESULTS:During the initial 9 weeks of clinic operations, the clinic inducted 78 patients on to buprenorphine-naloxone and completed 252 visits. Patient referrals included non-NYC Health + Hospitals (n = 22, 28.2%) and NYC Health + Hospitals healthcare providers (n = 17, 21.8%), homeless shelter staff (n = 13, 16.7%), and the NYC Health + Hospitals jail reentry program in Rikers Island (n = 11, 14.1%). At 8 weeks, 42 patients remained in care (53.8%), 21 were referred to a community treatment program (26.9%), and 15 were lost to follow-up (19.2%). No patients were terminated from care due to disruptive behavior or suspicions of diversion or misuse of Buprenorphine. Adverse clinical outcomes were uncommon and included persistent withdrawal symptoms (n = 8, 4.3%) and one nonfatal opioid overdose (0.5%). CONCLUSIONS:Telemedicine-based opioid treatment and unobserved home induction on buprenorphine-naloxone offers a safe and feasible approach to expand the reach of opioid use disorder treatment, primary care, and behavioral health for a highly vulnerable urban population during an unprecedented natural disaster.

Stigma is a fundamental driver of adverse health outcomes. Although stigma is often studied at the individual level to focus on how stigma influences the mental and physical health of the stigmatized, considerable research has shown that stigma is multilevel and structural. This paper proposes a theoretical approach that synthesizes the literature on stigma with the literature on scapegoating and divide-and-rule as strategies that the wealthy and powerful use to maintain their power and wealth; the literatures on racial, gender, and other subordination; the literature on ideology and organization in sociopolitical systems; and the literature on resistance and rebellion against stigma, oppression and other forms of subordination. we develop a model of the "stigma system" as a dialectic of interacting and conflicting structures and processes. Understanding this system can help public health reorient stigma interventions to address the sources of stigma as well as the individual problems that stigma creates. On a broader level, this model can help those opposing stigma and its effects to develop alliances and strategies with which to oppose stigma and the processes that create it.

OBJECTIVE:Availability of medications for opioid use disorder (MOUD) remains sparse. To date, there has been no national, state-by-state comparison of patient MOUD utilization relative to treatment availability and burden of overdose deaths. We aimed to quantify, for each state, the number of MOUD patients relative to (1) office-based buprenorphine providers and opioid treatment programs (OTPs) and (2) overdose deaths. METHODS:We conducted a spatial analysis of patients receiving MOUD from OTPs or buprenorphine providers in March 2017 across all 50 states and Washington, DC. For each state, we calculated the number of patients receiving MOUD from OTPs and buprenorphine prescriptions, relative to available OTPs and buprenorphine providers; as well as ratios of number of patients receiving MOUD relative to overdose deaths. RESULTS:In March 2017, 942,368 patients attended an OTP (410,288) or received a buprenorphine prescription (486,318). Patient to OTP ratio was highest in West Virginia, Delaware, Washington, DC, New Jersey, New Hampshire, Connecticut and Ohio, ranging from 91 to 193 patients per OTP in the first quintile to 430 to 648 in the fifth. Patient to buprenorphine provider ratio was highest in Kentucky and West Virginia, ranging from 3 to 7 patients per provider in the first quintile to 19 to 28 in the fifth. Median MOUD patients per overdose death was 21 (IQR:14.9-28.2). Of high overdose states, Washington, DC, New Jersey, and Ohio had the smallest number of patients on MOUD relative to deaths. CONCLUSIONS:High patient volume relative to treatment availability in overdose-burdened areas may indicate strain on MOUD providers and OTPs. Promoting greater utilization while expanding MOUD providers and programs is critical.

Criminal justice involved individuals have a high rate of opioid overdose death following release. In March 2020, New York City jails released over 1000 inmates due to concern of COVID-19 outbreaks in county jails. The closure of addiction treatment clinics further complicated efforts to expand access to medications for opioid use disorder among criminal justice involved adults. The New York City Health + Hospitals Virtual Buprenorphine Clinic established in March 2020 offered low-threshold telemedicine-based opioid treatment with buprenorphine-naloxone, specifically for criminal justice involved adults post-release. We describe a case report of the novel role of tele-conferencing for the provision of buprenorphine-naloxone for jail-released adults with opioid use disorder experiencing homelessness during the COVID-19 pandemic. The patient is a 49-year-old male with severe opioid use disorder released from New York City jail as part of its early release program. He then started using diverted buprenorphine-naloxone, and 1 month later a harm-reduction specialist at his temporary housing at a hotel referred him to an affiliated buprenorphine provider and then eventually to the New York City Health + Hospitals Virtual Buprenorphine Clinic, where he was continued on buprenorphine-naloxone, and was followed biweekly thereafter until being referred to an office-based opioid treatment program. For this patient, telemedicine-based opioid treatment offered a safe and feasible approach to accessing medication for opioid use disorder during the COVID-19 pandemic and following incarceration.

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:Drug overdoses surged during the COVID-19 pandemic, underscoring the need for expanded and accessible substance use disorder (SUD) treatment. Relatively little is known about the experiences of patients receiving treatment during the pandemic. METHODS:We worked with 21 harm reduction and drug treatment programs in nine states and the District of Columbia from August 2020 to January 2021. Programs distributed study recruitment cards to clients. Clients responded to the survey by calling a study hotline and providing a unique study identification number. Our survey included detailed questions about use of SUD treatment prior to and since the COVID-19 pandemic. We identified settings where individuals received treatment and, for those treated for opioid use disorder, we examined use of medications for opioid use disorder. Individuals also reported whether they had received telehealth treatment and pandemic related treatment changes (e.g., more take-home methadone). We calculated p-values for differences pre and since COVID-19. RESULTS:We interviewed 587 individuals of whom 316 (53.8%) were in drug treatment both before and during the COVID-19 pandemic. Individuals in treatment reported substantial reductions in in-person service use since the start of the pandemic, including a 27 percentage point reduction (p<.001) in group counseling sessions and 28 percentage point reduction in mutual aid group participation (p<.001). By contrast, individuals reported a 21 percentage point increase in receipt of overdose education (p<.001). Most people receiving medications for opioid use disorder reported taking methadone and had high continuity of treatment (86.1% received methadone pre-COVID and 87.1% since-COVID, p=.71). Almost all reported taking advantage of new policy changes such as counseling by video/phone, increased take-home medication, or fewer urine drug screens. Overall, respondents reported relatively high satisfaction with their treatment and with telehealth adaptations (e.g., 80.2% reported "I'm able to get all the treatment that I need"). CONCLUSIONS:Accommodations to treatment made under the federal public health emergency appear to have sustained access to treatment in the early months of the pandemic. Since these changes are set to expire after the official public health emergency declaration, further action is needed to meet the ongoing need.

BACKGROUND:The COVID-19 pandemic has exerted a significant toll on the lives of people who use opioids (PWUOs). At the same time, more flexible regulations around provision of opioid use disorder (OUD) services have led to new opportunities for facilitating access to services for PWUOs. In the current scoping review, we describe new services and service modifications implemented by treatment and harm reduction programs serving PWUO, and discuss implications for policy and practice. METHODS:Literature searches were conducted within PubMed, LitCovid, Embase, and PsycInfo for English-language studies published in 2020 that describe a particular program, service, or intervention aimed at facilitating access to OUD treatment and/or harm reduction services during the COVID-19 pandemic. Abstracts were independently screened by two reviewers. Relevant studies were reviewed in full and those that met inclusion criteria underwent final data extraction and synthesis (n = 25). We used a narrative synthesis approach to identify major themes around key service modifications and innovations implemented across programs serving PWUO. RESULTS:Reviewed OUD treatment and harm reduction services spanned five continents and a range of settings from substance use treatment to street outreach programs. Innovative service modifications to adapt to COVID-19 circumstances primarily involved expanded use of telehealth services (e.g., telemedicine visits for buprenorphine, virtual individual or group therapy sessions, provision of donated or publicly available phones), increased take-home medication allowances for methadone and buprenorphine, expanded uptake of long-acting opioid medications (e.g. extended-release buprenorphine and naltrexone), home delivery of services (e.g. MOUD, naloxone and urine drug screening), outreach and makeshift services for delivering MOUD and naloxone, and provision of a safe supply of opioids. CONCLUSIONS:The COVID-19 pandemic has posed multiple challenges for PWUOs, while simultaneously accelerating innovations in policies, care models, and technologies to lower thresholds for life-saving treatment and harm reduction services. Such innovations highlight novel patient-centered and feasible approaches to mitigating OUD related harms. Further studies are needed to assess the long-term impact of these approaches and inform policies that improve access to care for PWUOs.

BACKGROUND:Evidence suggests that individuals with history of substance use disorder (SUD) are at increased risk of COVID-19, but little is known about relationships between SUDs, overdose and COVID-19 severity and mortality. This study investigated risks of severe COVID-19 among patients with SUDs. METHODS:We conducted a retrospective review of data from a hospital system in New York City. Patient records from 1 January to 26 October 2020 were included. We assessed positive COVID-19 tests, hospitalizations, intensive care unit (ICU) admissions and death. Descriptive statistics and bivariable analyses compared the prevalence of COVID-19 by baseline characteristics. Logistic regression estimated unadjusted and sex-, age-, race- and comorbidity-adjusted odds ratios (AORs) for associations between SUD history, overdose history and outcomes. RESULTS:Of patients tested for COVID-19 (n = 188 653), 2.7% (n = 5107) had any history of SUD. Associations with hospitalization [AORs (95% confidence interval)] ranged from 1.78 (0.85-3.74) for cocaine use disorder (COUD) to 6.68 (4.33-10.33) for alcohol use disorder. Associations with ICU admission ranged from 0.57 (0.17-1.93) for COUD to 5.00 (3.02-8.30) for overdose. Associations with death ranged from 0.64 (0.14-2.84) for COUD to 3.03 (1.70-5.43) for overdose. DISCUSSION/CONCLUSIONS:Patients with histories of SUD and drug overdose may be at elevated risk of adverse COVID-19 outcomes.

OBJECTIVES/OBJECTIVE:To examine patient characteristics and outcomes among opioid use disorder patients enrolled in low-threshold buprenorphine treatment during the COVID-19 pandemic. METHODS:This paper describes the adaptation of the Project Connections (PC) program, a low-threshold buprenorphine program in Baltimore, in response to the COVID-19 pandemic. This paper examines patient characteristics and initial outcomes of patients served during a rapid protocol shift to telehealth that allowed buprenorphine initiation without an in-person encounter following a state-mandated stay-at-home order. Patient characteristics were compared to a subsample of patients enrolled in the program before the COVID-19 pandemic. RESULTS:In March 2020, there was a sharp increase in new enrollments to the PC program. A total of 143 patients completed an intake assessment between March and May 2020 and 140 began treatment with buprenorphine/naloxone. Those who completed an intake assessment were primarily male (68.5%), Black (83.2%), had a mean age of 43.2 years (SD = 11.7), and reported a mean of 17.0 years of opioid use (SD = 12.9). The majority of patients were unemployed (72.7%) and reported previous criminal justice involvement (69.2%). Of those who completed an intake assessment, 96.5% returned for a second visit. Among those for whom 30-day retention data was available (n = 113), 63.7% were engaged for 30 days or longer. CONCLUSIONS:The PC program illustrates that offering on-demand, flexible treatment is an opportunity to increase opioid use disorder treatment access, even during a public health emergency that disrupted access to services. Relaxation of buprenorphine telehealth regulations allowed for flexibility in treatment and benefits vulnerable populations.