Faculty Bibliography

We estimated the extent to which different pain management practices, considered together as well as individually, mediated the relationship between chronic pain or physical disability and new-onset opioid use disorder (OUD) in a large cohort of adult Medicaid patients. Considering the plausibility of the assumptions required to identify different mediational estimands, we estimated natural indirect effects when considering mediation through the group of mediators together and estimated interventional indirect effects when considering mediation through each pain management practice individually. We estimated each effect using a nonparametric one-step estimator. The pain management variables we examined mediated all of the total effect of chronic pain on OUD risk and nearly half of the total effect of physical disability on OUD risk. High-dose, long-duration opioid prescribing and co-prescription of opioids with benzodiazepines, gabapentinoids, and muscle relaxants each contributed substantially to the increased risk of OUD due to chronic pain (contributing to 10-37% of the overall effect) and more moderately to the increased risk of OUD due to physical disability (contributing to 3-19% of the overall effect). Antidepressant or anti-inflammatory prescribing and physical therapy generally did not contribute to increased OUD risk, and, in some cases, even contributed to small reductions in risk.

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.

IMPORTANCE/UNASSIGNED:Treatment retention for pregnant individuals with opioid use disorder (OUD) is critical, especially during the high-potency synthetic opioid (HPSO) era. Current data on the relationship between medication for opioid use disorder (MOUD) receipt in specialty substance use treatment facilities and retention are needed for this population. OBJECTIVE/UNASSIGNED:To examine the association between MOUD inclusion in treatment and 6-month treatment retention among pregnant individuals with OUD in publicly funded specialty treatment facilities during the HPSO era. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This cross-sectional study pooled data from January 1, 2015, to December 31, 2021, from the Treatment Episode Data Set-Discharges, a national dataset managed by the Substance Abuse and Mental Health Services Administration that tracks annual discharges from state-licensed, publicly funded substance use treatment facilities. Individuals who were pregnant at the time of admission, reported an opioid (heroin, nonprescription methadone, or other opiates and synthetics) as their primary substance, and were discharged from ambulatory, nonintensive outpatient facilities were included. Data were analyzed November 2023 to April 2024. EXPOSURE/UNASSIGNED:MOUD inclusion in a treatment episode. MAIN OUTCOMES AND MEASURES/UNASSIGNED:The main outcome was treatment retention (length of stay >6 months vs ≤6 months). To account for the nonrandom assignment to MOUD, inverse probability of treatment-weighted logistic regression models were estimated adjusting for sociodemographics; substance use, mental health, and treatment history; treatment admission-related variables; census division; state policy characteristics; and year fixed effects. RESULTS/UNASSIGNED:Of 29 981 treatment episodes, most involved individuals aged 25 to 34 years (19 106 [63.7%]). Approximately two-thirds of 29 071 episodes in the final analysis (19 884 [68.4%]) included MOUD across all study years. From 2015 to 2021, MOUD inclusion in treatment episodes increased by 9.1 percentage points, from 65.0% to 74.1%. Treatment episodes with MOUD were associated with greater odds of 6-month treatment retention compared with those without MOUD (adjusted odds ratio, 1.86 [95% CI, 1.72-2.01]). This finding translated to an estimated 14.2 percentage point greater adjusted probability of 6-month retention among treatment episodes with MOUD (43.1%) vs those without it (28.9%). CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this cross-sectional study of treatment episodes from ambulatory, nonintensive facilities, MOUD inclusion among pregnant individuals was associated with significant improvements in treatment retention. However, retention remained low during the HPSO era. These findings underscore the importance of MOUD in improving OUD-related outcomes in this high-risk population.

BACKGROUND AND AIMS/OBJECTIVE:Evidence from high-income countries has linked duration and compliance with treatment for substance use disorders (SUDs) with reductions in substance use and improvements in mental health. Generalizing these findings to other regions like South America, where opioid and injection drug use is uncommon, is not straightforward. We examined if length of time in treatment and compliance with treatment reduced subsequent substance use and presence of psychiatric comorbidities. DESIGN/METHODS:Prospective cohort analysis (3 assessments, 18 months) using inverse probability weighting to account for confounding and loss to follow-up. SETTINGS/METHODS:Outpatient/inpatient programs in Región Metropolitana, Chile. PARTICIPANTS/METHODS:Individuals initiating publicly funded treatment (n = 399). MEASUREMENTS/METHODS:Exposures included length of time in (0-3, 4-7, 8 + months, currently in) and compliance with treatment (not completed, completed, currently in) measured in the intermediate assessment (12 months). Primary outcomes were past-month use of primary substance (most problematic) and current psychiatric comorbidities (major depressive episode, panic, anxiety or post-traumatic stress disorders) measured 6 months later (18 months). Secondary outcomes included past month use of alcohol, cannabis, cocaine powder and cocaine paste. FINDINGS/RESULTS:18.3% [95% confidence interval (CI) = 14.7%-22.6%] of individuals participated for 3 or fewer months in treatment and 50.1% (95% CI = 45.2%-55.1%) did not complete their treatment plan at 12 months. Participating for 8 + months in treatment was associated with lower risk of past month use of primary substance at 18 months [vs. 0-3 months, risk ratio (RR) = 0.62, 95% CI = 0.38-1.00] and completion of treatment (vs. not completed, RR = 0.49, 95% CI = 0.30-0.80). Neither participating 8 + months (vs. 0-3 months, RR = 0.83, 95% CI = 0.57-1.22) nor treatment completion (vs. not completed, RR = 1.02, 95% CI = 0.72-1.46) were associated with lower risk of psychiatric comorbidity at 18 months. CONCLUSIONS:Longer time in treatment and compliance with treatment for substance use disorders in Chile appears to be associated with lower risk of substance use but not current comorbid psychiatric conditions 18 months after treatment initiation.

OBJECTIVES/OBJECTIVE:To evaluate the predictive performance of different data sources to forecast fatal overdose in Rhode Island neighborhoods, with the goal of providing a template for other jurisdictions interested in predictive analytics to direct overdose prevention resources. METHODS:We evaluated seven combinations of data from six administrative data sources (American Community Survey (ACS) five-year estimates, built environment, emergency medical services non-fatal overdose response, prescription drug monitoring program, carceral release, and historical fatal overdose data). Fatal overdoses in Rhode Island census block groups (CBGs) were predicted using two machine learning approaches: linear regressions and random forests embedded in a nested cross-validation design. We evaluated performance using mean squared error and the percentage of statewide overdoses captured by CBGs forecast to be in top percentiles from 2019 to 2021. RESULTS:Linear models trained on ACS data combined with one other data source performed well, and comparably to models trained on all available data. Those including emergency medical service, prescription drug monitoring program, or carceral release data with ACS data achieved a priori goals for percentage of statewide overdoses captured by CBGs prioritized by models on average. CONCLUSIONS:Prioritizing neighborhoods for overdose prevention with forecasting is feasible using a simple-to-implement model trained on publicly available ACS data combined with only one other administrative data source in Rhode Island, offering a starting point for other jurisdictions.

OBJECTIVES/OBJECTIVE:The escalating overdose crisis in the United States points to the urgent need for new and novel data tools. Overdose data tools are growing in popularity but still face timely delays in surveillance data availability, lack of completeness, and wide variability in quality by region. As such, we need innovative tools to identify and prioritize emerging and high-need areas. Forecasting offers one such solution. Machine learning methods leverage numerous datasets that could be used to predict future vulnerability to overdose at the regional, town, and even neighborhood levels. This study aimed to understand the multi-level factors affecting the early stages of implementation for an overdose forecasting dashboard. This dashboard was developed with and for statewide harm reduction providers to increase data-driven response and resource distribution at the neighborhood level. METHODS:As part of PROVIDENT (Preventing OVerdose using Information and Data from the EnvironmeNT), a randomized, statewide community trial, we conducted an implementation study where we facilitated three focus groups with harm reduction organizations enrolled in the larger trial. Focus group participants held titles such as peer outreach workers, case managers, and program coordinators/managers. We employed the Exploration, Preparation, Implementation, Sustainment (EPIS) Framework to guide our analysis. This framework offers a multi-level, four-phase analysis unique to implementation within a human services environment to assess the exploration and preparation phases that influenced the early launch of the intervention. RESULTS:Multiple themes centering on organizational culture and resources emerged, including limited staff capacity for new interventions and repeated exposure to stress and trauma, which could limit intervention uptake. Community-level themes included the burden of data collection for program funding and statewide efforts to build stronger networks for data collection and dashboarding and data-driven resource allocation. DISCUSSION/CONCLUSIONS:Using an implementation framework within the larger study allowed us to identify multi-level and contextual factors affecting the early implementation of a forecasting dashboard within the PROVIDENT community trial. Additional investments to build organizational and community capacity may be required to create the optimal implementation setting and integration of forecasting tools.

PURPOSE/OBJECTIVE:In this article, we studied whether pathways in substance use disorder (SUD) treatment differ among people admitted to residential versus ambulatory settings. METHODS:We analyzed a retrospective cohort of 84,755 adults (ages ≥ 18) in Chilean SUD treatment during 2010-2019, creating a comparable sample of 11,226 pairs in ambulatory and residential treatment through cardinality matching. We used a nine-state multistate model, stratifying readmissions by baseline treatment outcome (i.e., completion vs. noncompletion) from admission to the third readmission. We estimated transition probabilities and lengths of stay in states at three-month, one-year, three-year, and five-year follow-ups. Sensitivity analyses tested different model specifications and estimated E-values. RESULTS:Patients in residential settings (vs. ambulatory) had greater treatment completion probabilities (difference at three months; 3.4% [95% CI: 2.9%, 3.9%]), and longer treatment retention (e.g., 1.6 days longer at three months, 95% CI: 0.8, 2.3). Patients in residential vs. ambulatory settings had higher first readmission probabilities regardless of baseline treatment outcome (e.g., three-month difference: 5.7% if completed baseline [95% CI: 4.4%, 7.0%] and 8.0% if did not complete baseline [95% CI: 6.7, 9.3%]). Third readmission probabilities were higher only among patients in residential settings with an incomplete baseline treatment (at least 3.7%; 95% CI: 0.2%, 7.3% at 1-year). CONCLUSION/CONCLUSIONS:Patients in residential settings at baseline were more likely to experience a second treatment and a third readmission among patients with incomplete treatments. Findings underscore the importance of completing initial SUD treatments to reduce readmissions. Residential treatments might require additional strategies to prevent readmissions.