Faculty Bibliography

OBJECTIVE:The CDC recommends initiating opioids for pain treatment at the lowest effective dose and duration. We examine how interactions between dose, duration, and other medication factors (e.g., drug type) influence opioid use disorder (OUD) risk-a gap not considered by CDC guidelines. SUBJECTS/METHODS:Using Medicaid claims data (2016-2019) from 25 states, we analyzed opioid-naïve adults, newly diagnosed with musculoskeletal pain who initiated opioids within three months of diagnosis. A 6-month washout confirmed no prior opioid exposure or musculoskeletal diagnosis. METHODS:Initial opioids were categorized by "dose-days supplied" (low [>0-20 mg MME] to very high [>90 mg MME] dose, and short [1-7 days] to moderate [>7-30 days] supply), and by opioid type; physical therapy (PT) sessions were also recorded. Using Poisson regression models, we estimated the OUD risk associated with dose-days categories, adjusting for baseline demographics, clinical characteristics, and medications. We separately examined opioid dose-days and PT, and assessed PT's moderating effect on dose-days' impact. RESULTS:Among 30,536 patients, half initiated opioids at 20-50 MME for 1-7 days, and 20% received PT. OUD risk was 2-3 times higher for opioids initiated for >7-30 days compared to 1-7 days across doses, and 5.5 times higher for opioids initiated for >7-30 days at > 90 MME versus 1-7 days at < 20 MME. PT alone, neither affected OUD risk nor mitigated the increased risk from longer or higher-dose opioids. CONCLUSIONS:Our findings support the need for careful opioid prescribing and alternative pain management strategies, as the observed associations between initial prescription characteristics and OUD were not mitigated by adjunctive PT. PERSPECTIVE/CONCLUSIONS:This study demonstrated that initial opioid prescriptions of 7-30 days, especially above 90 MME/day, increased OUD risk in opioid-naïve patients with musculoskeletal pain; physical therapy did not mitigate the risk. Different opioids posed varied risks, even at the same dose and duration. Careful prescribing and alternative pain management are essential.

Policy Points There have been significant advancements in expanding care for opioid use disorder and suicide in general medical settings in the first quarter of the 21st century. Incessant barriers in the US health system continue to hinder progress in sufficiently scaling up evidence-based behavioral health interventions and getting them to those at highest risk. State policymakers have multiple levers available to make significant improvements to address ongoing challenges and improve access to evidence-based behavioral health services in emergency and primary care settings.

IMPORTANCE/UNASSIGNED:As the primary facilities authorized to dispense methadone, opioid treatment programs (OTPs) are a critical access point for medications for opioid use disorder (MOUD). However, research is limited on the extent to which OTPs offer a broad range of MOUD and on the characteristics of programs that provide more comprehensive medication offerings. OBJECTIVE/UNASSIGNED:To assess the percentage of US OTPs offering all 3 forms of MOUD (methadone, buprenorphine, and naltrexone) and compare organizational and county characteristics of OTPs with different MOUD service offerings. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This longitudinal cross-sectional study used data on a panel of OTPs listed in the annual National Directory of Drug and Alcohol Use Treatment Facilities from 2017 to 2023. MAIN OUTCOMES AND MEASURES/UNASSIGNED:Measures included the percentage of OTPs offering buprenorphine, extended-release naltrexone, or all 3 MOUD from 2017 to 2023 (assuming all OTPs offered methadone). Descriptive statistics on organizational and county characteristics of OTPs by MOUD offerings were collected. Three longitudinal logistic regression models were used to estimate the odds of different MOUD offerings within OTPs, adjusting for organizational and county-level characteristics. RESULTS/UNASSIGNED:This analysis included 10 298 facility-year observations, ranging from 1211 in 2017 to 1421 in 2023. From 2017 to 2023, the percentage of OTPs offering MOUD beyond methadone increased (buprenorphine: 811 [67.0%] in 2017 to 1209 [85.1%] in 2023; naltrexone: 463 [38.2%] in 2017 to 749 [52.7%] in 2023; all 3 MOUD: 402 [33.2%] in 2017 to 639 [45.0%] in 2023). OTPs offering all 3 MOUD (3985 [38.7%]) had significantly higher odds of accepting Medicare (adjusted odds ratio [AOR], 2.14; 95% CI, 1.67-2.74); offering peer services (AOR, 1.63; 95% CI, 1.25-2.12), mental health services (AOR, 2.07; 95% CI, 1.53-2.80), and telemedicine services (AOR, 1.53; 95% CI, 1.22-1.92); and being private nonprofit (AOR, 7.45; 95% CI, 4.67-11.87) or government operated (AOR, 41.83; 95% CI, 19.71-88.75) compared with private for profit. CONCLUSIONS/UNASSIGNED:In this cross-sectional study of OTPs, although the availability of MOUD beyond methadone increased over time, most OTPs still did not offer all 3 forms of MOUD as of 2023. Specific organizational characteristics, such as being government operated and accepting Medicare, were associated with more comprehensive MOUD offerings. Future research should evaluate why OTPs vary in their MOUD offerings.

BACKGROUND AND OBJECTIVE/OBJECTIVE:Youth overdose deaths have remained elevated in recent years as the illicit drug supply has become increasingly contaminated with fentanyl and other synthetics. There is a need to better understand fatal drug combinations and how trends have changed over time and across sociodemographic groups in this age group. METHODS:We used the National Vital Statistics System's multiple cause of death datasets to examine trends in overdose deaths involving combinations of synthetic opioids with benzodiazepine, cocaine, heroin, prescription opioids, and other stimulants among US youth aged 15 to 24 years from 2018 to 2022 across age, sex, race and ethnicity, and region. RESULTS:Overdose death counts rose from 4652 to 6723 (10.85 to 15.16 per 100 000) between 2018 and 2022, with a slight decrease between 2021 and 2022. The largest increases were deaths involving synthetic opioids only (1.8 to 4.8 deaths per 100 000). Since 2020, fatal synthetic opioid-only overdose rates were higher than polydrug overdose rates involving synthetic opioids, regardless of race, ethnicity, or sex. In 2022, rates of synthetic-only overdose deaths were 2.49-times higher among male youths compared with female youths and 2.15-times higher among those aged 20 to 24 years compared with those aged 15 to 19 years. CONCLUSIONS:Polydrug combinations involving synthetic opioids continue to contribute to fatal youth overdoses, yet deaths attributed to synthetic opioids alone are increasingly predominant. These findings highlight the changing risks of the drug supply and the need for better access to harm-reduction services to prevent deaths among youth.

BACKGROUND AND AIMS/OBJECTIVE:US regulatory changes allowed for additional methadone take-home doses following COVID-19 onset. How dispensing practices changed and which factors drove variation remains unexplored. We determined daily methadone dispensing trajectories over six months before and after regulatory changes due to COVID-19 using state sequence analysis and explored correlates. DESIGN/METHODS:Retrospective chart review of electronic health records. SETTINGS/METHODS:Nine opioid treatment programs (OTPs) across nine US states. PARTICIPANTS/METHODS:Adults initiating treatment in 2019 (n = 328) vs. initiating 1 month after the COVID-19 regulatory changes of March 2020 (n = 376). MEASUREMENTS/METHODS:Type of daily methadone medication encounter (in-clinic, weekend/holiday take-home, take-home, missed dose, discontinued) based on OTP clinic; cohort (pre vs. post-COVID-19); and patient substance use, clinical and sociodemographic characteristics. FINDINGS/RESULTS:Following COVID-19 regulatory changes, allotted methadone take-home doses increased from 3.5% to 13.8% of total person-days in treatment within the first 6 months in care. Clinic site accounted for the greatest variation in methadone dispensing (6.2% and 9.5% of the variation of discrepancy between sequences pre- and post-COVID-19, respectively). People who co-use methamphetamine had a greater increase in take-homes than people who did not use methamphetamine (from 3.7% pre-pandemic to 21.2% post-pandemic vs. 3.5% to 12.5%) and higher discontinuation (average 3.6 vs. 4.7 months among people who did not use methamphetamine pre-COVID-19; average 3.3 vs. 4.6 months post-COVID-19). In the post-COVID-19 cohort, females had a higher proportion of missed doses (17.2% vs. 11.9%) than males. People experiencing houselessness had a higher proportion of missed doses (19% vs. 12.3%) and shorter stays (average 3.5 vs. 4.5 months) when compared with those with stable housing. CONCLUSION/CONCLUSIONS:Daily methadone dispensing trajectories in the US both before and following COVID-19 regulatory changes appeared to depend more on the opioid treatment programs' practices than individual patient characteristics or response to treatment.

An increasing number of U.S. states have legalized cannabis, but the effect on adolescent and young adult psychosis-related hospitalizations remains under-studied. Using data from Denver Health between 2005 and 2020, we examined associations between implementation of the Ogden Memo (expanding use of medical cannabis in Colorado, October 2009) and Amendment 64 (legalizing adult-use cannabis in Colorado, November 2012) and trends in psychosis-related emergency department and hospital visits with and without cannabis use disorder (CUD) among youth aged 10-29. Patients with psychosis hospitalizations were predominately male (68 %), white (53 %), and Medicaid recipients (59 %). Significant increases (p < 0.05) were observed in the monthly average rate of psychosis hospitalizations between pre-Ogden memo (21.9 per 100,000) and post-Ogden memo pre-legalization (28.0 per 100,000) and post-legalization (32.3 per 100,000). Similarly, significant increases (p < 0.05) were observed in the monthly average rate of psychosis hospitalizations involving CUD between pre-Ogden memo (2.0 per 100,000), post-Ogden memo and pre-legalization (3.4 per 100,000), and post-legalization (8.5 per 100,000). Interrupted time series modeling found a significant difference in the trends for psychosis hospitalizations involving CUD following recreational legalization (change in average monthly rate went from 0.02/100,000 (95 % CI -0.02, 0.06) to 0.11/100,000 (95 % CI 0.09, 0.13), (difference (0.09 (95 %CI 0.05, 0.14)). Findings suggest an increase in overall hospital encounters for psychosis among youth after the legalization of recreational cannabis. Given the adoption of increasingly permissive cannabis laws, there is a need to plan effective public health responses that could mitigate unintended consequences related to cannabis use.

Following federal regulatory changes during the COVID-19 pandemic, Rhode Island expanded methadone access for opioid treatment programs (OTPs) in March 2020. The policy, which permitted take-home dosing for patients, contrasted with longstanding restrictions on methadone. This study used patient-level OTP admission and discharge records to compare six-month retention before and after the policy change. We conducted a retrospective cohort study of 1,248 patients newly admitted to OTPs between March 18 and June 30 of 2019 (pre-policy) and 2020 (post-policy). We used logistic regression to estimate associations with retention before and after the policy and used a machine learning approach, the Heterogeneous Treatment Effect (HTE)-Scan, to explore heterogeneity in retention across subgroups. Overall, we found no change in retention following the policy, with an adjusted OR of 1.08 (95% CI: 0.80-1.45) and adjusted RR of 1.03 (0.90-1.18). Using HTE-Scan, we identified two subgroups with significantly increased retention above the overall cohort: (1) patients with below high school education and past-month arrest and (2) male, non-Hispanic white or Hispanic/Latino patients reporting heroin or fentanyl use with past-month arrest. We identified no subgroups with significantly decreased retention. Collectively, findings suggest that expanded methadone access may benefit vulnerable populations without harming overall retention.

INTRODUCTION/BACKGROUND:Specialty substance use treatment programs may adopt harm reduction practices to protect the health of their patients with opioid use disorder (OUD). Two such harm reduction strategies are distributing naloxone to clients and refraining from discharging clients if they have positive urine drug screens for drugs. The purpose of this study was to understand the prevalence of programs that adopt each of these harm reduction practices and the characteristics of clients attending programs that adopt both practices in a sample of state-licensed substance use treatment programs in New Jersey. METHODS:We conducted a cross-sectional survey of specialty treatment programs in New Jersey about a) naloxone dispensing and b) use of urine toxicology screens in client discharge decisions. We linked this survey to the treatment programs' administrative records of client admissions for OUD treatment between July 2021 to June 2022 (n = 14,838). We estimated the proportion of programs that reported that they adopted each practice. We then examined program and client characteristics associated with applying these harm reduction practices using regression methods. RESULTS:Of 108 programs included in this analysis, 55.6 % dispensed naloxone and 50.9 % did not consider toxicology screens in discharge decisions. Opioid treatment programs (OTP) were significantly more likely to adopt both harm reduction practices than non-OTPs. Clients referred by correctional programs, as opposed to self-referred to treatment, were significantly less likely to attend a program that used either harm reduction practice. CONCLUSIONS:Our findings suggest efforts are needed to increase adoption of harm reduction practices in SUD treatment settings, especially that are not OTPs, and programs serving clients referred by the criminal justice system.

INTRODUCTION/BACKGROUND:Harm reduction is a philosophical approach to improve the health of people who use drugs (PWUD) that integrates risk reduction, evidence-based treatment, and person-centered care. Specialty substance use treatment programs have historically been siloed from, and often misaligned with, harm reduction principles, but this trend has begun to shift in recent years. This study explored the ways in which some specialty treatment settings are adopting harm reduction principles and practices. METHODS:We conducted qualitative interviews with leaders of 14 New Jersey specialty treatment programs around their opioid use disorder treatment practices. Using thematic analysis, we assessed how aligned treatment practices were with the core pillars, principles, and practice areas outlined in the 2023 Harm Reduction Framework developed by the Substance Abuse and Mental Health Services Administration. RESULTS:Programs described integrating a range of harm reduction principles, including respect for autonomy, low-barrier treatment, and nonpunitive care, into their approach to care. However, several ongoing practices conflicted with these principles, including imposing attendance requirements, lacking an on-site provider to facilitate same-day medication initiation, and use of urine toxicology testing as a major marker of treatment success. Additionally, while many programs were engaging in some overdose prevention practices (e.g., naloxone distribution), few programs offered other risk reduction services. CONCLUSIONS:Findings highlight that significant opportunities remain to better integrate harm reduction principles and practices into specialty substance use treatment facilities to improve the quality of care provided to PWUD.