Retention in care for persons with opioid use disorder transitioning from sublingual to injectable buprenorphine.

INTRODUCTION: In the current overdose epidemic, effective treatments for opioid use disorders (OUD), including innovations in medication delivery such as extended-release formulations, have the potential to improve treatment access and reduce treatment discontinuation. This study assessed treatment retention in a primary care-based, extended-release buprenorphine program. METHODS: The study recruited individuals (n = 92) who transitioned from sublingual buprenorphine to extended-release buprenorphine (BUP-XR) in 2018-2019. The study defined the primary outcome, treatment retention, as three or more consecutive, monthly BUP-XR injections following the transition to BUP-XR in this retrospective chart review. RESULTS: Participants' mean age was 38 years old and 67% were male. The average duration of sublingual buprenorphine prior to transition was 17.1 (±28.1) months. Three months after transition, 48% of extended-release buprenorphine patients had discontinued BUP-XR treatment. Persons with chronic pain were more likely, and those who had used heroin in the past month less likely to continue BUP-XR. Mean months on sublingual buprenorphine prior to BUP-XR initiation was 24.3 (±32.5) months for people who received 3+ post-induction injections compared to only 8.9 (±19.5) months for those who did not (p = .009). CONCLUSIONS: Extended-release buprenorphine discontinuation was high in a real-world setting. Retention continues to represent a major obstacle to treatment effectiveness, and programs need interventions with even newer MOUD formulations.

Negative affect-associated drug refusal self-efficacy, illicit opioid use, and medication use following short-term inpatient opioid withdrawal management.

INTRODUCTION: Persons with opioid use disorder (OUD) are prone to frequent relapse following brief inpatient medically managed withdrawal. This longitudinal, naturalistic study examines associations among illicit opioid use, use of medication for opioid use disorder (MOUD), and one's confidence in the ability to resist drug use in the face of negative emotions (i.e., negative affect-associated drug refusal self-efficacy). METHOD: Participants were 220 adults with OUD who recently completed a short-term inpatient program and the study followed for 6 months. At baseline, participants reported demographics, illicit opioid use, recent engagement with MOUD, and negative affect-associated drug refusal self-efficacy. At follow-up (1 week and 1-, 3-, and 6-months following discharge), participants reported illicit opioid use and MOUD. RESULTS: Participants averaged 30.7 years of age, 63.2% were male, and 84.1% were white. Both illicit opioid use and rates of MOUD increased during the 6-month follow-up period, although only 34.1% received MOUD. At baseline, participants reported less than 50% self-confidence to resist using opioids during negative emotional states. Baseline negative affect-associated drug refusal self-efficacy inversely predicted illicit opioid use (p = .01) at follow-up but was not associated with follow-up MOUD. CONCLUSION: Among persons with OUD, lower confidence to resist using opioids in negative emotional states predicts greater use of illicit opioids in the months following medically managed withdrawal, even with receipt of MOUD.

Examining Overdose and Homelessness as Predictors of Willingness to Use Supervised Injection Facilities by Services Provided Among Persons Who Inject Drugs.

BACKGROUND AND OBJECTIVES: Internationally, supervised injection facilities (SIFs) have demonstrated efficacy in reducing rates of overdose and promoting entry into treatment among persons who inject drugs (PWID); however, they remain unavailable in the United States. Early findings examining American PWID illustrate high overall willingness to use SIFs. The current study expands upon this research by examining PWID's likelihood to use SIFs based on services offered (eg, provides clean needles, linkage to treatment programs) and whether known risk factors (prior overdose, homelessness) influence PWID's willingness to use a SIF. METHODS: Participants (n = 184) were patients entering short-term inpatient opioid withdrawal management in Massachusetts between May 2018 and February 2019 who reported injection drug use in the prior 30 days. We examined PWID's likelihood to use a SIF if eight unique services were available, and compared if this differed by overdose history and homelessness status using ordered logistic regression and Pearson's χ2 -tests of independence. RESULTS: Participants (34.2 [±8.3 SD] years of age, 68.5% male, 85.9% white, 8.2% Hispanic) reported being most likely to use SIFs that provided safety from police intervention (86.7%), entry into withdrawal management (85.9%), or clean needles (83.2%). Drug works disposal and safety from police were particularly important for PWID with a history of overdose. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: Overall, treatment-seeking PWIDs reported greater willingness to utilize SIFs if particular services were provided. These findings point to features of SIFs that may enhance treatment-seeking PWID's amenability to utilizing these services if such sites open in the United States. (Am J Addict 2021;30:21-25).

Prescribed and non-prescribed gabapentin use among persons seeking inpatient opioid detoxification.

BACKGROUND: Persons with opioid use disorder (OUD) are at increased risk for gabapentin misuse. Rising rates of concomitant gabapentin-opioid use in the U.S. are concerning given heightened risk of fatal overdose. OBJECTIVE: To examine predictors of ever using gabapentin among persons seeking treatment for opioid use and to assess if reasons for gabapentin use differed by gender and how gabapentin was procured (prescribed, non-prescribed, or both). METHOD: Persons with OUD were recruited from a managed withdrawal program. t-Tests and Pearson χ2 tests of independence were used to compare reasons for gabapentin use by gender and source of acquisition. RESULTS: Among participants (n = 401; 69.1% male, 84.5% White, 86.8% sought treatment for heroin use, 90.0% insured), female gender, higher educational attainment, injection drug use (IDU), history of overdose, and chronic pain were associated with gabapentin use. Overall, reasons for use were similar across genders among those reporting a history of gabapentin use (65.8%), although males were more likely to use to get high than females. About half (47.0%) reported only using gabapentin that was not prescribed, 20.5% had only used prescribed gabapentin, and 32.5% reported prescribed and non-prescribed use. Persons prescribed gabapentin were most likely to use it to control pain (81.5%); for those using diverted gabapentin only and those reporting both prescribed and non-prescribed gabapentin use, the most common reasons for intake were to: get high, increase effects of heroin, substitute for opioids, and help with opioid withdrawal. CONCLUSIONS: In this sample of people with OUD entering inpatient detoxification program, a majority reported a history of gabapentin use, with most using diverted gabapentin. The range of reasons for gabapentin use point to the need to better understand why co-use is common.

Initiating buprenorphine treatment for opioid use disorder during short-term in-patient 'detoxification': a randomized clinical trial.

BACKGROUND AND AIMS: The effectiveness of linking people from short-term in-patient managed withdrawal programs ('detoxification') to long-term, primary care-based buprenorphine is unknown. We tested whether buprenorphine initiation during an opioid withdrawal program and linkage to office-based buprenorphine (LINK) after discharge would increase engagement with office-based buprenorphine and decrease illicit opioid use during the ensuing 6 months compared with standard withdrawal management (WM). DESIGN: Single-site randomized controlled trial. SETTING: Short-term in-patient detoxification program in Massachusetts, USA. PARTICIPANTS: People with opioid use disorder (n = 115) who averaged 32.4 years of age, 68.2% male, 79.1% white, using illicit opioids on 27.3 of the last 30 days, were randomly assigned to WM (n = 59) versus LINK (n = 56). INTERVENTION AND COMPARATOR: Intervention was buprenorphine induction, in-patient dose stabilization and post-discharge transition to maintenance buprenorphine at an affiliated primary care clinic (LINK). Comparator was 5-day buprenorphine managed withdrawal protocol (WM). MEASUREMENTS: Mean 30-day rate of use of illicit opioids (primary aim) and prescribed buprenorphine (secondary aim) at 1, 3 and 6 months. FINDINGS: Compared with WM, participants in the LINK condition had lower illicit opioid use rates at days 12 [b = -6.81, 95% confidence interval (CI) = -9.69; -3.92, P < 0.001], 35 (b = -8.55, 95% CI - 11.63; -5.47, P < 0.001), 95 (b = -7.34, 95% CI = -10.59; -4.11, P < 0.001) and 185 (b = -3.52, 95% CI = -7.07; 0.27, P = 0.052). The LINK arm had higher prescription buprenorphine use rates (P < 0.001) at all assessments. CONCLUSIONS: Among people with opioid use disorder, initiation of, and linkage to, office-based buprenorphine treatment post-discharge reduced illicit opioid use and increased days of buprenorphine treatment for up to 6 months post-discharge compared with an in-patient detoxification protocol.

Worries About Discontinuing Buprenorphine Treatment: Scale Development and Clinical Correlates.

BACKGROUND AND OBJECTIVES: Despite the benefits of maintenance buprenorphine treatment for opioid use disorder (OUD), many individuals report an interest in discontinuing the medication, while also expressing worries about tapering. The purpose of this study was to develop a measure of worries about buprenorphine discontinuation ("Off Bupe") and determine the demographic and clinical characteristics associated with these worries. METHODS: Between May 2017 and May 2018, we surveyed adults in an outpatient primary care buprenorphine program (n = 138). Reliability and validity of the Off Bupe measure were examined. RESULTS: Participants averaged 39 years of age, 54% were male, average duration of buprenorphine was 189 weeks and 85.5% reported eventually wanting to discontinue buprenorphine, although fewer than 10% were actively tapering. We derived two scales, withdrawal symptom worry (10 items, ɑ = 0.94) and relapse worry (7 items, ɑ = 0.88). Worry about symptoms was positively associated with current buprenorphine dose (P = 0.016), physical discomfort avoidance (P < 0.001), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001) and distress tolerance (P < 0.001). Worry about opioid relapse was associated positively with age (P = 0.019), current buprenorphine dose (P = 0.004), physical discomfort avoidance (P < 0.001), and impulsivity (P = 0.002), and inversely associated with self-efficacy to quit buprenorphine (P < 0.001). DISCUSSION AND CONCLUSIONS: Psychometric evaluation of the "Off Bupe" scale demonstrated its content and construct validity and internal reliability. SCIENTIFIC SIGNIFICANCE: The scale might help individuals with OUD and their providers identify concerns about discontinuing buprenorphine. (Am J Addict 2019;28:270-276).

Expected and actual fentanyl exposure among persons seeking opioid withdrawal management.

OBJECTIVE: Fentanyl-contaminated opioid supplies have led to rising overdose fatalities in recent years. We compared beliefs, behaviors, and risk perceptions related to fentanyl with actual toxicology reports among people who used opioids. METHOD: Participants (n=231) were patients undergoing short-term inpatient opioid withdrawal management in Fall River, Massachusetts. We compared persons testing positive and negative for fentanyl on urine toxicological testing at program entry. RESULTS: Nearly all (95.7%) participants believed that fentanyl increases risk for overdose/death, and 86.6% of participants tested positive for fentanyl. Positive fentanyl toxicology test results were associated with lower educational attainment, history of injection drug use, and self-reported lifetime use of fentanyl. Of those reporting they had never been exposed to fentanyl (intentionally or unintentionally) (n=33), two-thirds tested positive for fentanyl; among those believing their tests would be negative (n=49), 71.4% tested positive for fentanyl. Heroin use was associated with fentanyl exposure; persons who reported past month heroin use (n=213) were more likely to test positive for fentanyl (91.1%) than persons using non-heroin opioids (n=18; 33.3%). CONCLUSIONS: Nearly nine in ten participants tested positive for fentanyl, including participants who anticipated their tests would be negative. Leveraging toxicology results in opioid withdrawal settings may be helpful in educating patients about fentanyl exposure and risks.

Adverse childhood experience effects on opioid use initiation, injection drug use, and overdose among persons with opioid use disorder.

INTRODUCTION: Adverse childhood experiences are associated with the development of substance use disorders. With opioid use disorder, a growing concern in the United States, we were interested in examining the relationship between adverse experiences and three landmarks of opioid use: age of opioid initiation, injection drug use, and lifetime overdose. METHODS: Between May and December 2015, we interviewed consecutive persons seeking inpatient opioid detoxification. Participants were asked about age of opioid initiation, last month injection drug use, and lifetime history of overdose, and completed the ten-item Adverse Childhood Experience (ACE) questionnaire. RESULTS: Participants (n=457) averaged 32.2 (±8.64) years of age, 71.3% were male, and 82.5% were non-Hispanic White. The mean score on the ACE scale was 3.64 (±2.75). Mean age at time of initiating opioid use was 21.7 (±7.1) years, 68.7% had injected drugs within the past month, and 39.0% had overdosed. After adjusting for age, gender, and ethnicity, the ACE score was inversely associated with age of initiating opioid use (b=-0.50, 95% CI -0.70; -0.29, p<.001), and positively associated with recent injection drug use (OR=1.11, 95% CI 1.02; 1.20, p=0.014) and the likelihood of experiencing an overdose (OR=1.10, 95% CI 1.02; 1.20, p=0.015) in a graded dose response manner. CONCLUSION: Greater adverse childhood experiences are associated with three landmarks of opioid use risk. ACE screening may be useful in identifying high-risk subsets of opioid-using populations.

Overdose history is associated with postdetoxification treatment preference for persons with opioid use disorder.

BACKGROUND: Without aftercare treatment, persons discharged from short-term inpatient detoxification for opioid use disorder are at high risk of relapse. In previous work, those who were recently homeless or had pending legal problems were more likely to prefer residential treatment for aftercare. Here, based on clinical experience, the authors hypothesize that a particular clinical factor, surviving an opioid overdose, will be associated with aftercare preference. METHODS: Between May and December 2015, the authors surveyed consecutive persons seeking inpatient opioid detoxification. To assess aftercare treatment preference, participants were asked, "If you had unlimited treatment options and all were free, which one would work best for you when you leave here?" To assess overdose history, participants were asked about overdose "since your first drug use," and "in the last year." RESULTS: Participants' (N = 440) mean age was 32.3 (± 8.7) years; 70.7% were male. More than half (51.1%) of participants expressed an aftercare preference for medication-assisted treatment (MAT), 12.7% for outpatient counseling only, 10.7% for residential treatment,18.6% for no formal treatment (Narcotics Anonymous/Alcoholics Anonymous only or a halfway house), and 6.8% did not want any postdetoxification treatment. About 40% reported a history of overdose, and 24.8% reported past year overdose. In the multivariate model, treatment preference was associated with sex (P < .001), homelessness (P = .01), and history of drug overdose (P = .02). CONCLUSIONS: Although MAT was preferred by the majority of participants, the experience of a nonfatal overdose was associated with the choice of residential treatment as postdetoxification treatment.

Knowledge, past use, and willingness to start medication-assisted treatment among persons undergoing alcohol detoxification.

BACKGROUND/OBJECTIVES: The current study examined knowledge of previous use, and willingness to take alcohol-related medication among individuals in medically supervised detoxification. METHODS: Participants (n = 302) provided health and demographic information, substance use and detoxification history, PCP visits, and AA attendance. RESULTS: Most patients had knowledge of alcohol medications, one-third had past prescription, and over 80% reported willingness to take medication. Previous detoxification predicted medication knowledge, while previous treatment predicted past prescription. DISCUSSION/CONCLUSIONS: More patients are willing to take medication than are prescribed medication. SCIENTIFIC SIGNIFICANCE: Findings suggest the opportunity to increase medication use following detoxification which could reduce subsequent relapse. (Am J Addict 2017;26:118-121).

Gender Differences in the Life Concerns of Persons Seeking Alcohol Detoxification.

BACKGROUND: This study explored the life concerns of persons seeking alcohol detoxification, a group with multiple life and psychosocial challenges. Gender may be an important contributor to the particular life concerns of persons with alcohol use disorders. METHODS: Using a 32-item, previously-validated life concerns survey that captures ten conceptual domains, we interviewed persons entering inpatient alcohol detoxification asking them to rate their level of concern about health and welfare items. RESULTS: Participants (n=189) were 27% female, with a mean age of 43.5 years. Overall, concern about alcohol problems was perceived as the most serious, followed by mental health, cigarette smoking, financial, and relationship problems. Men were significantly more concerned than women about six of the ten domains including money, drug use, transmissible diseases, and physical illness. CONCLUSIONS: Recognition of the daily worries of persons seeking inpatient alcohol detoxification persons could allow providers to better tailor their services to the context of their patients' lives. Focusing on pressing life concerns such as mental health, financial, relationship problems, and other drug use may influence detoxification services and aftercare treatment choices.