Faculty Bibliography

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.

Methadone treatment (MT) for opioid use disorder saves lives, but the US MT system has long been dominated by punitive policies and practices that make MT inaccessible, burdensome, and traumatic for patients. After generations without changes to methadone regulations, a confluence of circumstance-including the COVID-19 pandemic and an overdose crisis that has taken over a million lives-has begun to shift the MT advocacy and political landscape. This commentary describes the building of the "Liberate Methadone" movement; a grassroots effort led by people with lived and living experience with methadone, addiction clinicians, researchers, community leaders, and people with many of these identities. The Liberate Methadone movement is dedicated to building a more accessible, equitable MT system that prioritizes patient health, promotes dignity, and is grounded in evidence. We describe the experience of planning and hosting a national conference and generating proceedings with recommendations for needed incremental and structural reforms within the US MT system. The lessons learned from this movement can motivate others across clinical, research, and policy roles to partner with and learn from patient and community-led groups, guiding needed reforms within systems of care. It is through these joint efforts and listening to those directly impacted groups who have been left out of the conversation for far too long, that we can successfully reduce overdose and suffering, toward better health, dignity, and thriving in our communities.

BACKGROUND:Take-home methadone (THM) flexibility has increased since 2020, representing innovation in opioid use disorder treatment. There are no established approaches to measuring THM using insurance claims data. We proposed and validated candidate measures of THM. METHODS:Using 2020 Medicaid data from 4 states, we constructed treatment episodes for enrollees aged 18-64. Episodes started after July 1, 2020 and lasted at least 60 days. We labelled individuals as receiving THM if they received ≥6 consecutive days of THM in their 2nd month of treatment, as defined by presence of claims with a modifier code indicating THM (the "gold-standard" indicator). We defined 4 candidate indicators of THM based on intervals between in-clinic methadone administrations. We assessed performance of each candidate indicator against the gold-standard. We assessed the extent to which between-program variation explained total variation in measured THM. RESULTS:The study sample included 4836 episodes for 4801 individuals. THM was present in 14 % of episodes. Sensitivity of candidate indicators ranged from 65 to 100 %, with the most sensitive being an indicator that was true if any two adjacent in-clinic service dates had a gap of ≥7 days. Specificity ranged from 80 to 96 %, with the most specific measure being one requiring 2 consecutive intervals of ≥7 days that were of the same length. Between-program variation explained 38.6-48.3 % of variation in THM receipt. CONCLUSIONS:Two indicators of THM using Medicaid data presented excellent performance when evaluated against a gold-standard indicator. Our approach can be used to assess uptake and outcomes of THM.

BACKGROUND:Practical and motivational barriers can deter people from engaging in substance use disorder (SUD) treatment, even those who seek treatment. Care navigation is a psychosocial intervention that seeks to facilitate patients' timely access to care by identifying and intervening upon barriers. Few trials have tested the effectiveness of care navigation when embedding in real-world healthcare, and no trials have studied the process of implementing care navigation into clinical practice. This protocol describes a study that will evaluate whether care navigation can increase treatment engagement among patients seeking SUD treatment. METHODS:The Addressing Barriers to Care for Substance Use Disorder (ABC-SUD) study is a hybrid type I cluster-randomized effectiveness-implementation trial. It is conducted in a mental health access center of an integrated healthcare system in Washington state. Within this center, licensed mental health clinicians assess patient needs and use shared decision-making to establish SUD treatment plans for patients (usual care). This study tests whether an added care navigation intervention can improve patient engagement in SUD treatment. Care navigation begins after a treatment plan is made and provides up to 7 weeks of support focused on enhancing patient motivation to initiate and engage in treatment, problem-solving barriers (e.g., transportation logistics), and accommodating patient preferences (e.g., preferred language of care, cultural preferences). This trial uses a two period, two sequence crossover design. Clinicians are randomized to offer care navigation to patients during the first or second study period (i.e., clinicians are assigned to an initial study condition and switch conditions halfway through the trial). Care navigation is implemented with several strategies: leadership engagement, clinical workflow specifications, electronic health record (EHR) tools, training, performance improvement, and electronic learning collaborative. The primary outcome-obtained from EHRs and insurance claims-is engagement in SUD treatment, defined as ≥3 SUD treatment visits within 48 days of a treatment plan. This study uses standardized measures of implementation climate and outcomes to examine mechanisms with which the intervention strategies exert their impact on implementation and effectiveness outcomes. DISCUSSION/CONCLUSIONS:The ABC-SUD study will test whether care navigation improves SUD treatment engagement while concurrently generating information about its implementation in healthcare. TRIAL REGISTRATION/BACKGROUND:This study was prospectively registered at www. CLINICALTRIALS/RESULTS:gov (NCT06729957) on December 9, 2024.

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.

BACKGROUND:Individuals with opioid use disorder have high rates of hospital admissions, which represent a critical opportunity to engage patients and initiate medications for opioid use disorder (MOUD). However, few patients receive MOUD and, even if MOUD is initiated in the hospital, patients may encounter barriers to continuing MOUD in the community. OBJECTIVE:Describe hospital providers' experiences and perspectives to inform initiatives and policies that support hospital-based MOUD initiation and continuation in community treatment programs. DESIGN/METHODS:As part of a broader implementation study focused on inpatient MOUD (NCT#04921787), we conducted semi-structured interviews with hospital providers. PARTICIPANTS/METHODS:Fifty-seven hospital providers from 12 community hospitals. APPROACH/METHODS:Thematic analysis examined an emergent topic on challenges transitioning patients to outpatient MOUD treatment and related impacts on MOUD initiation by inpatient providers. KEY RESULTS/RESULTS:Participants described structural barriers to transitioning hospitalized patients to continuing outpatient MOUD including (a) limited outpatient buprenorphine prescriber availability, (b) the siloed nature of addiction treatment, and (c) long wait times. As a result of observing these structural barriers, participants experienced a sense of futility that deterred them from initiating MOUD. Participants proposed strategies that could better support these patient transitions, including developing partnerships between hospitals and outpatient addiction treatment and supporting in-reach services from community providers. CONCLUSIONS:We identified concerns about inadequate and inaccessible community-based care and transition pathways that discouraged hospital providers from prescribing MOUD. As hospital-based opioid treatment models continue to expand, programmatic and policy strategies to support inpatient transitions to outpatient addiction treatment are needed. NCT TRIAL NUMBER/UNASSIGNED:04921787.

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.

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.