Faculty Bibliography

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:Despite proliferation of acute-care interventions to initiate medications for opioid use disorder (MOUD), significant challenges remain to supporting care continuity following discharge. Research is needed to inform effective hospital strategies to support patient transitions to ongoing MOUD in the community. OBJECTIVE:To inform a taxonomy of care transition strategies to support MOUD continuity from hospital to community-based settings and assess their perceived impact and feasibility among experts in the field. DESIGN/METHODS:A modified Delphi consensus process through three rounds of electronic surveys. PARTICIPANTS/METHODS:Experts in hospital-based opioid use disorder (OUD) treatment, care transitions, and hospital-based addiction treatment. MAIN MEASURES/METHODS:Delphi participants rated the impact and feasibility of 14 OUD care transition strategies derived from a review of the scientific literature on a scale from 1 to 9 over three survey rounds. Panelists were invited to suggest additional care transition strategies. Agreement level was calculated based on proportion of ratings within three points of the median. KEY RESULTS/RESULTS:Forty-five of 71 invited panelists participated in the survey. Agreement on impact was strong for 12 items and moderate for 10. Agreement on feasibility was strong for 11 items, moderate for 7, and poor for 4. Strategies with highest ratings on impact and feasibility included initiation of MOUD in-hospital and provision of buprenorphine prescriptions or medications before discharge. All original 14 strategies and 8 additional strategies proposed by panelists were considered medium- or high-impact and were incorporated into a final taxonomy of 22 OUD care transition strategies. CONCLUSIONS:Our study established expert consensus on impactful and feasible hospital strategies to support OUD care transitions from the hospital to community-based MOUD treatment, an area with little empirical research thus far. It is the hope that this taxonomy serves as a stepping-stone for future evaluations and clinical practice implementation toward improved MOUD continuity and health outcomes.

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.

BACKGROUND:U.S. state electronic prescription drug monitoring programs (PDMPs) are associated with reduced opioid dispensing among people with chronic pain and may impact use of other chronic pain treatments. In states with medical cannabis laws (MCLs), patients can use cannabis for chronic pain management, reducing their need for chronic-pain related treatment visits and moderating effects of PDMP laws. OBJECTIVE:Given high rates of chronic pain among Medicaid enrollees, we examined associations between PDMP enactment in the presence or absence of MCL on chronic pain-related outpatient and emergency department (ED) visits. DESIGN/METHODS:We created annual cohorts of Medicaid enrollees with chronic pain diagnoses using national Medicaid claims data from 2002-2013 and 2016. Negative binomial hurdle models produced adjusted odds ratios (aOR) for the likelihood of any chronic pain-related outpatient or ED visit and incident rate ratios (IRR) for the rate of visits among patients with ≥ 1 visit. PARTICIPANTS/METHODS:Medicaid enrollees aged 18-64 years with chronic pain (N = 4,878,462). MAIN MEASURES/METHODS:A 3-level state-year variable with the following categories: 1) no PDMP, 2) PDMP enactment in the absence of MCL, or 3) PDMP enactment in the presence of MCL. Healthcare codes for chronic pain-related outpatient and ED visits each year. KEY RESULTS/RESULTS:The sample was primarily female (67.2%), non-Hispanic White (51.2%), and ages 40-55 years (37.2%). Compared to no-PDMP states, PDMP enactment in the absence of MCL was not associated with chronic pain-related outpatient visits but PDMP enactment in the presence of MCL was associated with lower odds of chronic pain-related outpatient visits (aOR = 0.81, 95% CI:0.71-0.92). PDMP enactment was not associated with ED visits, irrespective of MCL. CONCLUSIONS:During a period of PDMP and MCL expansion, our findings suggest treatment shifts for persons with chronic pain away from outpatient settings, potentially related to increased use of cannabis for chronic pain management.

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.

Mandatory prescription drug monitoring programs and cannabis legalization have been hypothesized to reduce overdose deaths. We examined associations between prescription monitoring programs with access mandates ("must-query PDMPs"), legalization of medical and recreational cannabis supply, and opioid overdose deaths in United States counties in 2013-2020. Using data on overdose deaths from the National Vital Statistics System, we fit Bayesian spatiotemporal models to estimate risk differences and 95% credible intervals (CrI) in county-level opioid overdose deaths associated with enactment of these state policies. Must-query PDMPs were independently associated with on average 0.8 (95% CrI: 0.5, 1.0) additional opioid-involved overdose deaths per 100,000 person-years. Legal cannabis supply was not independently associated with opioid overdose deaths in this time period. Must-query PDMPs enacted in the presence of legal (medical or recreational) cannabis supply were associated with 0.7 (95% CrI: 0.4, 0.9) more opioid-involved deaths, relative to must-query PDMPs without any legal cannabis supply. In a time when overdoses are driven mostly by non-prescribed opioids, stricter opioid prescribing policies and more expansive cannabis legalization were not associated with reduced overdose death rates.