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Clinically focused interventions for people living with pain, such as health professional education, clinical decision support systems, prescription drug monitoring programs, and multidisciplinary care to support opioid tapering, have all been promoted as important solutions to the North American opioid crisis. Yet none have so far delivered substantive beneficial opioid-related population health outcomes. In fact, while total opioid prescribing has leveled off or reduced in many jurisdictions, population-level harms from opioids have continued to increase dramatically.We attribute this failure partly to a poor recognition of the epistemic and ethical complexities at the interface of clinical and population health. We draw on a framework of knowledge networks in wicked problems to identify 3 strategies to help navigate these complexities: (1) designing and evaluating clinically focused interventions as complex interventions, (2) reformulating evidence to make population health dynamics apparent, and (3) appealing to the inseparability of facts and values to support decision-making in uncertainty.We advocate that applying these strategies will better equip clinically focused interventions as complements to structural and public health interventions to achieve the desired beneficial population health effects. (Am J Public Health. 2022;112(S1):S56–S65. https://doi.org/10.2105/AJPH.2021.306500 )

We implemented the HIV preexposure prophylaxis (PrEP) care continuum among individuals receiving medication for opioid use disorder (MOUD). We screened HIV-negative MOUD participants for PrEP eligibility by assessing injection drug use risk factors and sexual behaviors. Implementation of the PrEP care continuum was challenging; less than a third of MOUD participants were aware of PrEP, and very few initiated PrEP. Findings should promote the development of effective interventions to increase engagement in PrEP during MOUD treatment. (Am J Public Health. 2022;112(1):34–37. https://doi.org/10.2105/AJPH.2021.306566 )

Opioid agonist medication, including methadone, is considered the first-line treatment for opioid use disorder. Methadone, when taken daily, reduces the risk of fatal overdose; however, overdose risk increases following medication cessation. Amid an overdose epidemic accelerated by the proliferation of fentanyl, ensuring continuity of methadone treatment during the COVID-19 pandemic is a vital public health priority. (Am J Public Health. 2021;111(12):2115–2117. https://doi.org/10.2105/AJPH.2021.306523 )

IntroductionThe Coronavirus Disease 2019 (COVID-19) pandemic has had devastating consequences for persons with opioid use disorder (OUD). Yet, little is known about how people seeking treatment for OUD perceive the risks of COVID-19 and how their perception interplays with their health behaviours.MethodsIn-depth interviews were conducted from September 2021 to March 2022 with 32 patients seeking medication treatment for OUD (MOUD) in Southern California. All interviews were conducted virtually and lasted between one and two hours. Interviews were recorded and transcribed verbatim. Two qualitative researchers independently conducted a content analysis of the transcripts to identify themes.ResultsThree primary themes were identified: (1) perceptions and beliefs about COVID-19 susceptibility and severity; (2) perceptions of COVID-19 risk compared to substance use behaviours; and (3) vaccine hesitancy. Participants were mixed in their beliefs of susceptibility to contracting COVID-19 and the severity of the disease if contracted. Some participants reported taking precautions to mitigate their chances of acquiring COVID-19, and other participants reported that COVID was not a big concern as substance use took priority. For many of the participants, COVID-19 concerns were overshadowed by the risk of overdosing on substances and other risky substance use behaviour. Most of the participants (n = 23; 72%) had received at least one COVID-19 vaccine by the time of the interview, but over half (n = 19; 59%) expressed vaccine hesitancy. Vaccine hesitancy was driven by concerns about the unknown long-term side effects and potential interactions of the vaccine with MOUD.ConclusionsOur study provides insight into COVID-19 prevention measures as well as vaccination perceptions and hesitancy among people who received treatment for OUD.Key messagesParticipants expressed diverse perceptions of the seriousness of COVID-19, with some taking precautions to mitigate their chances of acquiring COVID-19 and others perceiving that the risk of contracting COVID-19 was less than the risk of overdosing.Substance use, social isolation, vaccine hesitancy and COVID-19 risk behaviours should be studied as co-occurring phenomena that have potentially overlapping relationships that can influence behaviours that impact health and well-being.

Substance use disorder is a chronic disease carrying a high risk of morbidity and mortality. We report a case of a patient on long-term opioid agonist treatment who was diagnosed with metastatic cholangiocarcinoma and was referred to palliative care services almost contemporaneously with this diagnosis. In this report, we explore the challenges posed in offering holistic care during the end of life of a patient with a history of opioid dependence. A coordinated approach by addiction medicine and palliative care teams can allow patients from this complex cohort to ultimately die with dignity.

The prevalence of pregnant people with opioid use disorder (OUD), including those receiving medications for opioid use disorder (MOUD), is increasing. Challenges associated with pain management in people with OUD include tolerance, opioid-induced hyperalgesia, and risk for return to use. Yet, there are few evidence-based recommendations for pain management in the setting of pregnancy and the postpartum period, and many peripartum pain management studies exclude people with OUD. This scoping review summarized the available literature on peridelivery pain management in people with OUD, methodologies used, and identified specific areas of knowledge gaps. PubMed and Embase were comprehensively searched for publications in all languages on peripartum pain management among people with OUD, both treated with MOUD and untreated. Potential articles were screened by title, abstract, and full text. Data abstracted were descriptively analyzed to map available evidence and identify areas of limited or no evidence. A total of 994 publications were imported for screening on title, abstracts, and full text, yielding 84 publications identified for full review: 32 (38.1%) review articles, 14 (16.7%) retrospective studies, and 8 (9.5%) case reports. There were 5 randomized controlled trials. Most studies (64%) were published in perinatology (32; 38.1%) journals or anesthesiology (22; 26.2%) journals. Specific areas lacking trial or systematic review evidence include: (1) methods to optimize psychological and psychosocial comorbidities relevant to acute pain management around delivery; (2) alternative nonopioid and nonpharmacologic analgesia methods; (3) whether or not to use opioids for severe breakthrough pain and how best to prescribe and monitor its use after discharge; (4) monitoring for respiratory depression and sedation with coadministration of other analgesics; (5) optimal neuraxial analgesia dosing and adjuncts; and (6) benefits of abdominal wall blocks after cesarean delivery. No publications discussed naloxone coprescribing in the labor and delivery setting. We observed an increasing number of publications on peripartum pain management in pregnant people with OUD. However, existing published works are low on the pyramid of evidence (reviews, opinions, and retrospective studies), with a paucity of original research articles (6%). Opinions are conflicting on the utility and disutility of various analgesic interventions. Studies generating high-quality evidence on this topic are needed to inform care for pregnant people with OUD. Specific research areas are identified, including utility and disutility of short-term opioid use for postpartum pain management, role of continuous wound infiltration and truncal nerve blocks, nonpharmacologic analgesia options, and the best methods to support psychosocial aspects of pain management.

Background: The Rhode Island State Legislature passed the Uniform Controlled Substances Act in 2016 to limit opioid prescriptions. We aimed to objectively evaluate its effect on opioid prescribing for hand surgery patients and also identify risk factors for prolonged opioid use. Methods: A 6-month period (January-June 2016) prior to passage of the law was compared with a period following its implementation (July-December 2017). Thumb carpometacarpal arthroplasty and distal radius fracture fixation were classified as “major surgery” and carpal tunnel and trigger finger release as “minor surgery.” Prescription Drug Monitoring Database was used to review controlled substances filled during the study periods. Results: A total of 1380 patients met our inclusion criteria, with 644 prelaw and 736 postlaw patients. Patients undergoing “major surgery” saw a significant decrease in the number of pills issued in the first postoperative prescription (41.1 vs 21.0) and a corresponding decrease in morphine milligram equivalents (MMEs) (318.6 vs 159.2 MMEs) after implementation. A 30% decrease in MMEs was also seen in those undergoing “major surgery” in the first 30 days postoperatively (544.7 vs 381.7 MMEs). Risk factors for prolonged opioid use included male sex and preoperative opioid use. Conclusions: In Rhode Island, opioid-limiting legislation resulted in a significant decrease in the number of pills and MMEs of the initial prescription and a 30% decrease in total MMEs in the 30-day postoperative period after “major hand surgery.” Additional research is needed to explore the association between legislation and clinical outcomes.

OBJECTIVE Describe the incidence of new persistent opioid use after inguinal hernia repair as well as its associated risk factors. SUMMARY BACKGROUND DATA The development of new persistent opioid use after surgery is a common complication, however its incidence following inguinal hernia repair has not been described. Given that roughly 800,000 inguinal hernia repairs are performed annually in the United States, any incidence could have profound implications for patients. METHODS Retrospective cross-sectional study of the incidence of new persistent opioid use after inguinal hernia repair using a national database of de-identified administrative health claims of opioid-naive patients undergoing surgery from 2008-2016. RESULTS During the study period, 59,795 opioid-naive patients underwent inguinal hernia repair and met inclusion criteria. Mean (SD) age was 57.8 (16.1) years old and 55,014 (92%) patients were male. 922 (1.5%) patients continued filling opioids prescriptions for at least 3 months after surgery. The most significant risk factor for developing new persistent opioid use after surgery was filling an opioid prescription in the 30 days prior to surgery (OR 4.34, 95% CI 3.75-5.01). These prescriptions were provided by surgeons in 52% of cases and primary care physicians in 16% of cases. Other risk factors for new persistent opioid use included receiving a larger opioid prescription, having more comorbidities, having a major postoperative complication, and certain mental health disorders and pain disorders. CONCLUSION After undergoing inguinal hernia repair, 1.5% of patients developed new persistent opioid use. Filling an opioid prescription in the 30 days prior to surgery had the strongest association with this complication.

The authors examined the impact of COVID-19-related policies reducing barriers to telehealth delivery of buprenorphine treatment for opioid use disorder (OUD) on buprenorphine treatment across different modalities (telephone, video, and in-person visits).This was a national retrospective cohort study with interrupted time-series analyses to examine the impact of policy changes in March 2020 on buprenorphine treatment for OUD in the Veterans Health Administration, during the year before the start of the COVID-19 pandemic (March 2019 to February 2020) and during the first year of the pandemic (March 2020 to February 2021). The authors also examined trends in the use of telephone, video, and in-person visits for buprenorphine treatment and compared patient demographic characteristics and retention in buprenorphine treatment across the two periods.The number of patients receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021. By February 2021, telephone visits were used by the most patients (50.2%; 4,456 visits), followed by video visits (32.4%; 2,870 visits) and in-person visits (17.4%; 1,544 visits). During the pre-pandemic period, the number of patients receiving buprenorphine increased significantly by 103 patients per month. After the COVID-19 policy changes, there was an immediate increase of 265 patients in the first month, and the number continued to increase significantly, at a rate of 47 patients per month. The demographic characteristics of patients receiving buprenorphine during the pandemic period were similar to those during the pre-pandemic period, but the proportion of patients reaching 90-day retention on buprenorphine treatment decreased significantly from 49.6% to 47.7%, while days on buprenorphine increased significantly from 203.8 to 208.7.The number of patients receiving buprenorphine continued to increase after the COVID-19 policy changes, but the delivery of care shifted to telehealth visits, suggesting that any reversal of COVID-19 policies must be carefully considered.

Impulsivity is a key feature of opioid use disorder (OUD) and other psychiatric conditions, including posttraumatic stress disorder (PTSD). The relationship between disorders and impulsivity may be additive, such that individuals with multiple disorders exhibit greater impulsivity than those with a single disorder. However, the association between impulsivity, OUD, and PTSD is unclear. Accordingly, this study compared individuals with concurrent OUD and PTSD (OUD + PTSD; n = 55), OUD without PTSD (OUD-PTSD; n = 34), PTSD without OUD (n = 32), and healthy controls (HCs; n = 55) on the Short Urgency, Premeditation, Perseverance, Sensation Seeking, Positive Urgency Impulsive Behavior Scale (SUPPS-P), and the 27-item Monetary Choice Questionnaire (MCQ). With respect to the SUPPS-P, the OUD + PTSD, OUD-PTSD, and PTSD without OUD groups reported more impulsivity on the negative urgency, positive urgency, and lack of premeditation subscales compared to HCs (ps < .001). The OUD + PTSD group also reported greater negative urgency compared to the OUD-PTSD group (p = .001) and HCs (p < .001), but not the PTSD without OUD group (p = .07). Furthermore, participants with OUD + PTSD exhibited greater discounting of delayed rewards on the MCQ than those in the PTSD without OUD group and HCs (p's < .001). However, no significant differences were observed between the two OUD groups (p = .86). These results support impulsivity as a mechanism underlying both OUD and PTSD. Future research should examine whether interventions targeting impulsivity, emotion regulation, and delay discounting are associated with meaningful improvements in functioning among individuals with OUD and PTSD. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

There are ongoing concerns regarding pharmaceutical opioid-related harms, including overdose and dependence, with an associated increase in treatment demand. People dependent on pharmaceutical opioids appear to differ in important ways from people who use heroin, yet most opioid agonist treatment research has been conducted in people who use heroin. OBJECTIVES: To assess the effects of maintenance opioid agonist pharmacotherapy for the treatment of pharmaceutical opioid dependence.We updated our searches of the following databases to January 2022: the Cochrane Drugs and Alcohol Group Specialised Register, CENTRAL, MEDLINE, four other databases, and two trial registers. We checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).We included RCTs with adults and adolescents examining maintenance opioid agonist treatments that made the following two comparisons. 1. Full opioid agonists (methadone, morphine, oxycodone, levo-alpha-acetylmethadol (LAAM), or codeine) versus different full opioid agonists or partial opioid agonists (buprenorphine) for maintenance treatment. 2. Full or partial opioid agonist maintenance versus non-opioid agonist treatments (detoxification, opioid antagonist, or psychological treatment without opioid agonist treatment).We used standard Cochrane methods.We identified eight RCTs that met inclusion criteria (709 participants). We found four studies that compared methadone and buprenorphine maintenance treatment, and four studies that compared buprenorphine maintenance to either buprenorphine taper (in addition to psychological treatment) or a non-opioid maintenance treatment comparison. We found low-certainty evidence from three studies of a difference between methadone and buprenorphine in favour of methadone on self-reported opioid use at end of treatment (risk ratio (RR) 0.49, 95% confidence interval (CI) 0.28 to 0.86; 165 participants), and low-certainty evidence from four studies finding a difference in favour of methadone for retention in treatment (RR 1.21, 95% CI 1.02 to 1.43; 379 participants). We found low-certainty evidence from three studies showing no difference between methadone and buprenorphine on substance use measured with urine drug screens at end of treatment (RR 0.81, 95% CI 0.57 to 1.17; 206 participants), and moderate-certainty evidence from one study of no difference in days of self-reported opioid use (mean difference 1.41 days, 95% CI 3.37 lower to 0.55 days higher; 129 participants). There was low-certainty evidence from three studies of no difference between methadone and buprenorphine on adverse events (RR 1.13, 95% CI 0.66 to 1.93; 206 participants). We found low-certainty evidence from four studies favouring maintenance buprenorphine treatment over non-opioid treatments in terms of fewer opioid positive urine drug tests at end of treatment (RR 0.66, 95% CI 0.52 to 0.84; 270 participants), and very low-certainty evidence from four studies finding no difference on self-reported opioid use in the past 30 days at end of treatment (RR 0.63, 95% CI 0.39 to 1.01; 276 participants). There was low-certainty evidence from three studies of no difference in the number of days of unsanctioned opioid use (standardised mean difference (SMD) -0.19, 95% CI -0.47 to 0.09; 205 participants). There was moderate-certainty evidence from four studies favouring buprenorphine maintenance over non-opioid treatments on retention in treatment (RR 3.02, 95% CI 1.73 to 5.27; 333 participants). There was moderate-certainty evidence from three studies of no difference in adverse effects between buprenorphine maintenance and non-opioid treatments (RR 0.50, 95% CI 0.07 to 3.48; 252 participants). The main weaknesses in the quality of the data was the use of open-label study designs, and difference in follow-up rates between treatment arms.There is very low- to moderate-certainty evidence supporting the use of maintenance agonist pharmacotherapy for pharmaceutical opioid dependence. Methadone or buprenorphine did not differ on some outcomes, although on the outcomes of retention and self-reported substance use some results favoured methadone. Maintenance treatment with buprenorphine appears more effective than non-opioid treatments. Due to the overall very low- to moderate-certainty evidence and small sample sizes, there is the possibility that the further research may change these findings.

Objectives Disparities in substance use disorder (SUD) treatment use persist across groups, including gender. Using a gender-informed approach to expand treatment capacity and reduce barriers to treatment engagement is vital. We examined SUD treatment need and receipt among people with SUD in the United States, by gender, and assessed gender-specific sociodemographic factors associated with unmet need for SUD treatment and reported treatment barriers. Methods We conducted an analysis of data among adults aged ≥18 with a past-year SUD from the National Survey on Drug Use and Health (2015-2018). We computed population-adjusted frequencies and proportions for SUD treatment need and receipt and assessed gender differences. Multivariate logistic regression assessed gender-specific sociodemographic variables associated with SUD treatment receipt. Results Among adults with a past-year SUD, 63.4% were men and 36.6% were women ( P < .001), only 10.6% received SUD treatment, and a greater percentage of women than men needed treatment for opioid use disorder (11.9% vs 9.9%; P = .002). Receipt of SUD treatment was lowest among women with alcohol use disorder followed by men with alcohol use disorder (7.5% vs 8.9%; P = .052). Non-Latinx Black men had fewer than half the adjusted odds of receiving SUD treatment than non-Latinx White men (adjusted odds ratio [aOR] = 0.44; 95% CI, 0.27-0.71). Latinx women (aOR = 0.37; 95% CI, 0.18-0.73) and non-Latinx Black women (aOR = 0.51; 95% CI, 0.27-0.94) had significantly lower odds of receiving SUD treatment than non-Latinx White women. Conclusions As public health efforts target expanding SUD treatment capacity and addressing disparities in use of SUD treatment, interventions informed by gender and culture should be prioritized.

Objectives. To estimate use of medication for opioid use disorder (MOUD) and prescription opioids in pregnancy among mothers of infants with neonatal opioid withdrawal syndrome (NOWS). Methods. We used linked 2016–2018 North Carolina birth certificate and newborn and maternal Medicaid claims data to identify infants with an NOWS diagnosis and maternal claims for MOUD and prescription opioids in pregnancy (n = 3395). Results. Among mothers of infants with NOWS, 38.6% had a claim for MOUD only, 14.3% had a claim for prescription opioids only, 8.1% had a claim for both MOUD and prescription opioids, and 39.1% did not have a claim for MOUD or prescription opioids in pregnancy. Non-Hispanic Black women were less likely to have a claim for MOUD than non-Hispanic White women. The percentage of infants born full term and normal birth weight was highest among women with MOUD or both MOUD and prescription opioid claims. Conclusions. In the 2016–2018 NC Medicaid population, 60% of mothers of infants with NOWS had MOUD or prescription opioid claims in pregnancy, underscoring the extent to which cases of NOWS may be a result of medically appropriate opioid use in pregnancy.

Social inequities made some sociodemographic groups - including those of older age, minoritized race/ethnicity, and low socioeconomic status - disproportionately vulnerable to morbidity and mortality associated with the opioid epidemic and COVID-19 pandemic. Given shared vulnerability to these public health crises, it is critical to understand how COVID-19 impacts substance use disorder (SUD) treatment and recovery among people with these characteristics. The current study examined COVID-19's perceived impact on treatment factors and psychosocial outcomes by sociodemographic vulnerability. Patients receiving SUD treatment with a history of opioid misuse were recruited. Participants completed self-report questionnaires regarding the impact of COVID-19 on treatment indicators and mood and substance use symptoms. Most participants reported that COVID-19 decreased their treatment access and quality. There were no sociodemographic differences in treatment factors. Those with high sociodemographic vulnerability reported greater pandemic-related increases in depression and demonstrated greater mood symptoms. Post-hoc analyses demonstrated that unmet basic needs were significantly associated with lower treatment access and quality, greater mood symptoms, and higher substance use. Findings suggest pandemic-related stressors and barriers affected those across the sociodemographic spectrum. Treatment systems must address socioeconomic barriers to care exacerbated by the pandemic and bolster integrated treatment options for opioid use and mood disorders.

Despite evidence that social support is beneficial for people living with opioid use disorders (OUDs), research has yet to investigate whether social support within certain relationships is more or less effective. The current study examined whether social support, relationship closeness with a disclosure partner, and/or the history of joint substance use between participants and disclosure partners affect commitment to sobriety among people receiving medications for OUD.Over a period of 3 months (two time points), participants taking OUD medications took part in a mixed-methods egocentric social network study exploring their relationships with disclosure partners before and following OUD disclosure (i.e., first telling a disclosure partner about one's OUD history or treatment). Data included 131 disclosure events/relationships clustered within 106 participants.Greater relationship closeness was associated with increased commitment to sobriety over time. Further, significant interactions were found between social support and disclosure partner closeness, partner closeness and history of joint substance use, and social support and history of joint substance use. Higher social support was associated with greater commitment to sobriety among those disclosing to close partners. In contrast, receiving social support or disclosing to a close partner with whom there was a history of joint substance use was associated with decreased commitment to sobriety.Findings highlight the complexities of social support among people in treatment for OUD and demonstrate that relationship closeness and a history of joint substance use with a disclosure partner may be important factors to consider before disclosure.

Introduction: The introduction of depot buprenorphine for the treatment of opioid dependence allows for reduced dosing frequency compared with conventional treatments, such as oral methadone and sublingual buprenorphine-naloxone. Reduced dosing frequency is perceived to reduce issues such as high out-of-pocket costs, frequent attendance to pharmacies, stigmatisation and the risk of diversion for unsanctioned opioid use. This study aims to explore the experiences of patients receiving depot buprenorphine from an Australian publicly operated drug and alcohol service. Methods: Participants were recruited from the service over a 5-week period in 2021. Twenty-eight participants consented to be involved in a mixed methods quantitative verbal survey and qualitative interview process Results: The majority of participants reported satisfaction with depot buprenorphine across the domains of efficacy, convenience and global satisfaction. Participants perceived benefits as increased convenience, reduced stigmatisation and the inability to ‘skip’ daily Medication Assisted Treatment for Opioid Dependence (MATOD) doses. There were mixed experiences with the ability for depot buprenorphine to ‘hold’ participants throughout the dosing interval. Reduced contact and disconnection from healthcare services were reported as an issue for some participants when initiating depot buprenorphine. Discussion and Conclusions: Patient perceptions of depot buprenorphine appear to be deeply rooted in prior experience with ‘conventional’ MATOD treatments. Depot buprenorphine is seen to be beneficial socially, personally, and financially by the majority of patients interviewed. The potential for disconnection from services and mixed experiences of efficacy throughout the dosing period may negatively influence patient experience. Refereed/Peer-reviewed

To assess the variation in migraine management over time across US children's hospitals and to identify factors associated with disparities in management.We conducted a retrospective study of 32 hospitals in the Pediatric Health Information System from 2009 to 2019. We included children 7 to 21 years old with primary ICD-9 or ICD-10 diagnosis codes for migraine headache. We surveyed hospitals to assess for clinical guideline presence. We assessed medication use trends over time. To examine differences in medication and advanced head imaging use by patient characteristics and presence of clinical guideline, we performed multivariable logistic regression analyses reporting adjusted odds ratios (aOR) with 95% confidence intervals (CI).We identified 112,077 eligible visits. Opioid use decreased over time, while nonopioid analgesic, dopamine antagonist, and diphenhydramine use increased. Multivariable analysis for opioids revealed increased odds of use for those 14 to 17 (aOR 1.19; 95% CI, 1.06, 1.34) and 18 to 21 years old (aOR 1.69; CI, 1.37, 2.08), and clinical guideline presence had decreased odds (aOR 0.64; CI, 0.48, 0.84). For head computed tomography, increased odds of use were reported for Hispanic ethnicity (aOR 1.15; CI, 1.06, 1.24) and decreased odds for 14 to 17 years (aOR 0.85; CI, 0.80, 0.90), 18 to 21 years (aOR 0.87; CI, 0.77, 0.98), and female sex (aOR 0.74; CI, 0.70, 0.79).Opioid use decreased while other medications increased over time. Medication and imaging differed by demographic characteristics. Opioid use was less likely in hospitals with clinical guidelines. Standardization in management may decrease care disparities and variability.

OBJECTIVE(S): To understand how contraception method use differed between women prescribed and not prescribed medications for opioid use disorder (MOUD) among commercially-insured and Medicaid insured women. STUDY DESIGN: IBM Watson Health MarketScan Commercial Claims and Encounters database and the Multi-State Medicaid database were used to calculate the (1) crude prevalence, and (2) adjusted odds ratios (adjusted for demographic characteristics) of using long-acting reversible or short-acting hormonal contraception methods or female sterilization compared with none of these methods (no method) in 2018 by MOUD status among women with OUD, aged 20 to 49 years, with continuous health insurance coverage through commercial insurance or Medicaid for ≥6 years. Claims data was used to define contraception use. Fisher exact test or χ(2) test with a P-value ≤ 0.0001, based on the Holm-Bonferroni method, and 95% confidence intervals were used to determine statistically significant differences for prevalence estimates and adjusted odds ratios, respectively. RESULTS: Only 41% of commercially-insured and Medicaid-insured women with OUD were prescribed MOUD. Medicaid-insured women with OUD prescribed MOUD had a significantly lower crude prevalence of using no method (71.1% vs 79.0%) and higher odds of using female sterilization (aOR, 1.33; 95% CI: 1.06–1.67 vs no method) than those not prescribed MOUD. Among commercially-insured women there were no differences in contraceptive use by MOUD status and 66% used no method. CONCLUSIONS: Among women with ≥ 6 years of continuous insurance coverage, contraceptive use differed by MOUD status and insurance. Prescribing MOUD for women with OUD can be improved to ensure quality care. IMPLICATIONS: : Only two in five women with OUD had evidence of being prescribed MOUD, and majority did not use prescription contraception or female sterilization. Our findings support opportunities to improve prescribing for MOUD and integrate contraception and MOUD services to improve clinical care among women with OUD.

Postoperative opioid use following gynecologic surgery may be necessary for effective treatment of pain; however, it can result in significant side effects, adverse reactions, and negative health consequences, including prolonged problematic use. Surgeons and healthcare providers of patients recovering from gynecologic procedures should be aware of effective strategies that can decrease the need for opioid use, while providing high-quality pain management. These include adherence to Enhanced Recovery After Surgery Protocols, particularly the use of multimodal analgesia management. When prescribing opioids, providers should adhere to responsible prescribing practices to minimize the risk of inappropriate and/or long-term opioid use.

Interventions to reduce the stigma of substance use disorders by health professionals often include didactic instruction combined with an interactive component that includes a guest speaker in recovery. Few interactive studies have focused on pharmacy students. Community pharmacists are moving to the front lines to battle the opioid epidemic; therefore, pharmacy students should be included in interventions aimed at reducing stigma by health professionals.This study examined the effects of a contact-based interactive intervention delivered by a peer recovery support specialist on perceived stigma of opioid use disorder among third-year pharmacy students (N = 115) enrolled in an integrative psychiatry course. Stigma was measured using the Brief Opioid Stigma Scale.Our study found significant differences in students' perceived stigma, both with their personal beliefs and their beliefs regarding the public, supporting the use of interactive presentations by peer recovery support specialists to decrease perceived stigma of opioid use disorder by health professionals.This type of intervention for pharmacy students shows promise in reducing substance use disorder stigma and should be further explored.

The purpose of this illustrative, thematic review was to demonstrate the utility of data from the National Longitudinal Study of Adolescent to Adult Health (Add Health) for substance use research and to describe substance use-specific insights gained from Add Health research over the past 2 decades.We searched multiple electronic databases (PubMed, PsycInfo, and Web of Science) and selected an illustrative sample of 40 articles that used Add Health data and longitudinally examined a measure of alcohol, marijuana, or illicit drug use or prescription drug misuse as the exposure or outcome in association with diverse domains of additional factors assessed (social, emotional, behavioral, contextual, biological, and genetic).Included articles identified several key associations between substance use behaviors and additional factors from a wide range of domains. For example, results from several studies indicated that experiences of sexual violence, adolescent dating violence, and intimate partner violence are associated with an increased likelihood of later prescription opioid misuse, heavy drinking, and marijuana use, with some differences by biological gender and race/ethnicity. Results from other studies showed that bidirectional associations between substance use and mental health differ by specific type of substance and mental health condition.Existing research using Add Health data has provided valuable insights regarding substance use by leveraging the study's longitudinal design, the prospective nature of data collection, the breadth and depth of substance use questions assessed from adolescence to adulthood, the size and diversity of the cohort, and the wide range of additional factors measured over time.

Explore sleep disturbance in postoperative orthopedic trauma patients and determine the impact of melatonin supplementation on postoperative sleep, pain, and quality of life.In this prospective, randomized controlled trial at a Level I trauma center, 84 adult orthopedic trauma patients with operative fracture management were randomized 2-weeks postoperatively to either the melatonin or placebo group. Patients randomized to the melatonin group (42 subjects, mean age 41.8 ± 15.5 years) received 5 mg melatonin supplements. Patients in the placebo group (42 subjects, mean age 41.3 ± 14.0 years) received identical glucose tablets. Both groups were instructed to take the tablets 30 minutes before bed for 4 weeks and received sleep hygiene education and access to the Cognitive Behavioral Therapy for Insomnia (CBT-I) Coach app.Our primary outcome was sleep quality as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary outcomes were pain measured by the Visual Analog Scale (VAS), quality of life measured by the 36-Item Short Form Survey (SF-36), and opioid use.Patients in both groups had significant sleep disturbance (PSQI ≥ 5) at 2-weeks (83%) and 6-weeks (67%) postoperatively. PSQI improved by 3.3 points (p0.001) at follow-up, but there was no significant difference between groups (melatonin PSQI = 5.6, placebo PSQI = 6.1, P = 0.615). Compared to placebo, melatonin did not affect VAS, SF-36, or opioid use significantly.Sleep disturbance is prevalent in orthopedic trauma patients. Melatonin treatment did not significantly improve subjective sleep quality, pain, quality of life or opioid use.Therapeutic Level I.

Buprenorphine induction for treating opioid use disorder is being implemented in emergency care. During this era of high-potency synthetic opioid use, novel and divergent algorithms for buprenorphine induction are emerging to optimize induction experience, facilitating continued treatment. Specifically, in patients with chronic fentanyl or other drug exposures, some clinicians are using alternative buprenorphine induction strategies, such as quickly maximizing buprenorphine agonist effects (eg, macrodosing) or, conversely, giving smaller initial doses and slowing the rate of buprenorphine dosing to avoid antagonist/withdrawal effects (eg, microdosing). However, there is a lack of foundational theory and empirical data to guide clinicians in evaluating such novel induction strategies. We present data from clinical studies of buprenorphine induction and propose a neuropharmacologic working model, which posits that acute clinical success of buprenorphine induction (achieving a positive agonist-to-withdrawal balance) is a nonlinear outcome of the opioid balance at the time of initial buprenorphine dose and mu-opioid-receptor affinity, lipophilicity, and mu-opioid-receptor intrinsic efficacy (the "ALE value") of the prior opioid. We discuss the rationale for administering smaller or larger doses of buprenorphine to optimize the patient induction experience during common clinical situations.

Rates of opioid misuse and opioid use disorder have been increasing in recent years. Buprenorphine has emerged as an appealing medication for its use not only as treatment for opioid use disorder, but also as an opioid for chronic pain that has a ceiling effect on risks associated with opioid therapy. As other opioid prescribing decreases, buprenorphine prescribing continues to increase. As a result, it is imperative to understand the safety and efficacy of its use in special populations. This review article will explore the safety and efficacy of buprenorphine when used in subjects with hepatic and renal impairment, the elderly, and pregnant women. While manufacturer labeling for buprenorphine products may caution against their use in these populations, further examination of available data indicates that buprenorphine can be used safely and effectively for both chronic pain and/or opioid use disorder in all four of these populations.

The primary objective was to quantify postoperative opioid use after laparoscopic surgery for endometriosis or pelvic pain. The secondary objective was to identify patient characteristics associated with greater postoperative opioid requirements.Prospective, survey-based study in which subjects completed 1 preoperative and 7 postoperative surveys within 28 days of surgery regarding medication usage and pain control.Tertiary care, academic center.A total of 100 women with endometriosis or pelvic pain.Laparoscopic same-day discharge surgery by fellowship-trained minimally invasive gynecologists.A total of 100 patients were recruited and 8 excluded, for a final sample size of 92 patients. All patients completed the preoperative survey. Postoperative response rates ranged from 70.7% to 80%. The mean number of pills (5 mg oxycodone tablets) taken by day 28 was 6.8. The average number of pills prescribed was 10.2, with a minimum of 4 (n = 1) and maximum of 20 (n = 3). Previous laparoscopy for pelvic pain was associated with a significant increase in postoperative narcotic use (8.2 vs 5.6; p = .044). Hysterectomy was the only surgical procedure associated with a significant increase in postoperative narcotic use (9.7 vs 5.4; p = .013). There were no difference in number of pills taken by presence of deep endometriosis or pathology-confirmed endometriosis (all p.36). There was a trend of greater opioid use in patients with diagnoses of self-reported chronic pelvic pain, anxiety, and depression (7.9 vs 5.7, p = .051; 7.7 vs 5.2, p = .155; 8.1 vs 5.6, p = .118).Most patients undergoing laparoscopic surgery for endometriosis and pelvic pain had a lower postoperative opioid requirement than prescribed, suggesting surgeons can prescribe fewer postoperative narcotics in this population. Patients with a previous surgery for pelvic pain, self-reported chronic pelvic pain syndrome, anxiety, and depression may represent a subset of patients with increased postoperative opioid requirements.

The world has been experiencing an opioid epidemic for over 20 years, and rates of use and overdose among women, including during pregnancy, have risen markedly. Women receive more prescriptions for opioids compared to men. Data suggest that 20% of women filled at least one prescription for an opioid during their pregnancy, and the prevalence of prenatal exposure averaged 14%. Opioid use by women, especially during pregnancy and while breastfeeding, and management and treatment is complex for healthcare providers, especially related to methadone treatment, pain management during labour, neonatal opioid withdrawal syndrome, nutritional issues and maternal withdrawal. Opioid use during pregnancy has been associated with maternal, foetal and infant complications, and overdose has become a leading cause of death in post-partum women in some countries. Universal screening for opioid use disorder (OUD) is recommended in pregnancy, and prevention and treatment programs that meet the specific needs of women are important to understand and consider as the world continues to try to anticipate and respond to the realities of the opioid epidemic.

Sleep impairment is a common comorbid and debilitating symptom for persons with opioid use disorder (OUD). Research into underlying mechanisms and efficacious treatment interventions for OUD-related sleep problems requires both precise and physiologic measurements of sleep-related outcomes and impairment. This pilot examined the feasibility of a wireless sleep electroencephalography (EEG) monitor (Sleep Profiler™) to measure sleep outcomes and architecture among participants undergoing supervised opioid withdrawal. Sleep outcomes were compared to a self-reported sleep diary and opioid withdrawal ratings. Participants (n = 8, 100% male) wore the wireless EEG 85.6% of scheduled nights. Wireless EEG detected measures of sleep architecture including changes in total, NREM and REM sleep time during study phases, whereas the diary detected changes in wakefulness only. Direct comparisons of five overlapping outcomes revealed lower sleep efficiency and sleep onset latency and higher awakenings and time spent awake from the wireless EEG versus sleep diary. Associations were evident between wireless EEG and increased withdrawal severity, lower sleep efficiency, less time in REM and non-REM stages 1 and 2, and more hydroxyzine treatment; sleep diary was associated with total sleep time and withdrawal only. Data provide initial evidence that a wireless EEG is a feasible and useful tool for objective monitoring of sleep in persons experiencing acute opioid withdrawal. Data are limited by the small and exclusively male sample, but provide a foundation for using wireless EEG sleep monitors for objective evaluation of sleep-related impairment in persons with OUD in support of mechanistic and treatment intervention research. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

AIM: Deprescribing is the systematic process of discontinuing medications when the harms outweigh the benefits. This study aimed to identify barriers and facilitators in people with chronic non-cancer pain when deprescribing opioid analgesics, and their views on resources that assist with deprescribing.METHODS: A purposive sampling strategy was used to recruit 19 adults with chronic non-cancer pain from the community who were, or had been, on long-term opioid therapy. Recruitment continued until thematic saturation was achieved. Semi-structured telephone interviews were conducted. A five-step framework and thematic analysis method identified themes for each study aim.RESULTS: Themes identifying barriers to opioid deprescribing raised challenges of a lack of available alternatives, managing opioid dependency and withdrawal symptoms or inability to function without opioids when in extreme pain. Facilitating themes described the value of support networks, including a trusting doctor-patient relationship and finding individual coping strategies to address deprescribing barriers. We explored a variety of resources from electronic forms such as websites and apps to paper-based or face to face. Participants expressed that whatever the form, resources need to be educational but also simple and engaging.CONCLUSIONS: Most people suffering from chronic non-cancer pain expressed dissatisfaction with being on opioids but most were still unwilling to deprescribe due to insufficient alternatives, a lack of support from their doctors and lack of information about the deprescribing process. Deprescribing can be facilitated by improving supportive networks and strategies and providing simple and positive educational resources.

Opioid addiction continues to be a devastating problem in our communities, and up to 40% of patients begin their addiction with legally prescribed opioids after injury or surgical procedure. An opioid-free multimodal pain regimen was developed with the goal of decreasing opioid exposure while maintaining adequate pain control.A retrospective single-institution study was conducted of 313 consecutive patients undergoing minimally invasive lobectomy before (n = 211) and after (n = 102) implementation of an opioid-free protocol from 2016 to 2020. Data analysis was conducted on preoperative characteristics, postoperative opioid use at set time points (postoperative day 0, postoperative days 1 to 7, and total stay), pain scores, discharge with opioid prescription, and postoperative outcomes.Patients on the opioid-free protocol had significantly lower average total morphine milligram equivalents at all time points. In addition, 56% of patients in the opioid-free group received no oral opioids at all, and 91% did not receive a patient-controlled analgesia pump. Average pain scores were significantly lower in the opioid-free protocol patients along with percentage of time spent with pain scores3 and6. With implementation of the protocol, 62% of patients are discharged without an opioid prescription compared with only 7% previously.Implementation of an opioid-free protocol led to a significant decrease in the use of postoperative opioids at all time points while improving overall management of pain. In addition, most patients are discharged with no home opioid prescription, decreasing a potential source of community opioid spread.

Owing to the opioid epidemic, more cardiac surgery patients present with opioid use disorder (OUD). A better understanding of national readmissions among these patients is necessary to improve outcomes and optimize resource utilization. We sought to examine the effect of OUD on readmission after cardiac surgery.Of 555 394 cardiac surgery patients from 2016 to 2017 in the Nationwide Readmissions Database, 6082 (1.1%) presented with OUD. These patients were assessed at 30, 90, and 180 days after discharge. The OUD patients and non-OUD patients were propensity score matched for patient- and procedure-level characteristics. Kaplan-Meier curves were compared using the log rank test.First-time readmissions were significantly higher among patients with OUD (30 days 19.7% vs 15.7%, P = .04; 90 days 31.8% vs 24.2%, P.0001; and 180 days 42.3% vs 30.6%, P.0001). There was a trend toward higher reoperation by 180 days, with 90% of those being isolated valve surgery. By 180 days, significantly more OUD patients had three or more readmissions (7.8% vs 4.5%) compared with non-OUD patients. Yet, only 2.4% of OUD patients received any counseling or treatment for substance abuse during the index admission. The most common readmitting diagnosis was infection (55% vs 41%, P.0001) including endocarditis, prosthetic infections, and skin or subcutaneous infections. Respiratory failure, opioid overdose, and acute pain were also more common among patients with OUD.Cardiac surgery patients with OUD have multiple readmissions but are rarely provided adequate addiction management during their index admission. Greater emphasis on multidisciplinary management is necessary to limit costs and morbidity associated with readmission or reoperation.

Expanding access to medications for opioid use disorder is a cornerstone to addressing the opioid overdose epidemic. However, recent research suggests that the distribution of medications for opioid use disorder has been inequitable. This study analyzes the racial‒ethnic disparities in the receipt of medications for opioid use disorder among Medicaid patients diagnosed with opioid use disorder.Medicaid claims data from the Transformed Medicaid Statistical Information System for the years 2017-2019 were used for the analysis. Logistic regression models estimated the odds of receiving buprenorphine and Vivitrol within 180 days after initial opioid use disorder diagnosis on the basis of race‒ethnicity. Analysis was conducted in 2022.Non-Hispanic Black people, non-Hispanic American Indian or Alaskan Native/Asian/Hawaiian/Pacific Islander people, and Hispanic people had 42%, 12%, and 22% lower odds of buprenorphine receipt and 47%, 12%, and 20% lower odds of Vivitrol receipt, respectively, than non-Hispanic White people, controlling for clinical and demographic patient variables.This study suggests that there are racial‒ethnic disparities in the receipt of buprenorphine and Vivitrol among Medicaid patients diagnosed with opioid use disorder after adjusting for demographic, geographic, and clinical characteristics. The potential strategies to address these disparities include expanding the workforce of providers who can prescribe medications for opioid use disorder in low-income communities and communities of color and allocating resources to address the stigma in medications for opioid use disorder treatment.

Opioids play an important role in pain management after surgery but also increase the risk of prolonged opioid use in patients. The identification of patients who are more likely to use opioids after intended short-term treatment is critical for employing alternative management approaches or targeted interventions for the prevention of opioid-related problems. We used patient-reported data (PRD) and electronic health record information to identify factors predictive of prolonged opioid use after surgery.We used our institutional registry containing data on all patients who underwent elective upper extremity surgeries. We evaluated factors associated with prolonged opioid use in the cohort from the year 2018 to 2019. We then validated our results using the 2020 cohort. The predictive variables included preoperative PRD and electronic health record data. Opioid use was determined based on patient reports and/or filled opioid prescriptions 3 months after surgery. We conducted bivariate regression, followed by multivariable regression analyses, and model validation using area under the receiver operating curve.We included 2,114 patients. In our final model on the 2018-2019 electronic health records and PRD data (n = 1,589), including numerous patient-reported outcome questionnaire scores, patients who were underweight and had undergone trauma-related surgery had higher odds of being on opioids at 3 months. Additionally, each 5-unit decrease in the preoperative Patient-Reported Outcomes Measurement Information System Global Physical Health score was associated with a 30% increased odds of being on opioids at 3 months. The area under the receiver operating curve of our model was 70.4%. On validation using data from the 2020 cohort, the area under the receiver operating curve was 60.3%. The Hosmer-Lemeshow test indicated a good fit.We found that preoperative questionnaire scores were associated with prolonged postoperative opioid use, independent of other variables. Furthermore, PRD may provide unique patient-level insights, alongside other factors, to improve our understanding of postsurgical pain management.Prognostic II.

There has been a substantial rise in the number of publications and training opportunities on the care and treatment of emergency department (ED) patients with opioid use disorder over the past several years. The American College of Emergency Physicians recently published recommendations for providing buprenorphine to patients with opioid use disorder, but barriers to implementing this clinical practice remain. We describe the models for implementing ED-initiated buprenorphine at 4 diverse urban, academic medical centers across the country as part of a federally funded effort termed "Project ED Health." These 4 sites successfully implemented unique ED-initiated buprenorphine programs as part of a comparison of implementation facilitation to traditional educational dissemination on the uptake of ED-initiated buprenorphine. Each site describes the elements central to the ED process, including screening, treatment initiation, referral, and follow-up, while harnessing organizational characteristics, including ED culture. Finally, we discuss common facilitators to program success, including information technology and electronic medical record integration, hospital-level support, strong connections with outpatient partners, and quality improvement processes.

Excess postoperative opioid prescribing increases the risk of opioid abuse, diversion, and addiction. Clinicians receive variable training for opioid prescribing, and despite the availability of guidelines, wide variations in prescribing practices persist. This quality improvement initiative aimed to assess and improve institutional adherence to published guidelines.This study represented a quality improvement initiative at an academic medical center implemented over a 6-month period with data captured 1 year before and after implementation. The quality improvement initiative focused on prescribing education and monthly feedback reports for clinicians. All opioid-naïve, adult patients undergoing a reviewed procedure were included. Demographics, surgical details, hospital course, and opioid prescriptions were reviewed. Opioids prescribed on discharge were evaluated for concordance with recommendations based on published guidelines. Pre- and postimplementation cohorts were compared.There were 4,905 patients included: 2,343 preimplementation and 2,562 postimplementation. There were similar distributions in patient demographics between the 2 cohorts. Guideline-concordant discharge prescriptions improved from 50.3% to 72.2% after the quality improvement initiative was implemented (Plt; .001). Adjusted analysis controlling for sex, age, discharge clinician, length of stay, outpatient surgery, and procedure demonstrated a 190% increase in odds of receiving a guideline-concordant opioid prescription on discharge in the postimplementation cohort (adjusted odds ratio 2.90; 95% confidence interval = 2.55-3.30).This study represented a successful quality improvement initiative improving guideline-concordant opioid discharges and decreasing overprescribing. This study suggested published guidelines are insufficient without close attention to elements of effective change management including the critical importance of locally targeting educational efforts and suggested that real-time, data-driven feedback amplifies impact on prescribing behavior.

BACKGROUND: While factors associated with completion of medical detoxification treatment for substance use disorders (SUD) are well described, there is limited information on barriers and facilitators to subsequent linkage to SUD treatment in the community. This study aimed to evaluate correlates of successful linkage to community SUD treatment on discharge. METHODS: Data were drawn from two prospective cohorts of people who use unregulated drugs (PWUD) in Vancouver, Canada between December 2012 and May 2018. Multivariable generalized estimating equations were used to investigate factors associated with linkage to community SUD treatment in the six-month period after attending detoxification treatment. RESULTS: Of the 264 detoxification treatment encounters contributed by 178 PWUD, these were most often (n=104, 39%) related to polysubstance use, and the majority (n=174, 66%) resulted in subsequent linkage to community treatment. In the multivariable analysis, compared to attending detoxification treatment for opioid use, attending detoxification treatment for stimulants (Adjusted Odds Ratio [AOR] = 0.23, 95% confidence interval [CI]: 0.10–0.51) and alcohol (AOR = 0.17, 95% CI: 0.06–0.54) were associated with lower odds of subsequent linkage to community treatment. Conversely, later calendar year of detoxification treatment remained associated with higher odds (AOR = 1.23, 95% CI: 1.06–1.42). CONCLUSION: Only two-thirds of detoxification treatment encounters in Vancouver were subsequently linked to community SUD treatment, with those related to non-opioid substances being less likely. Findings suggest the need for tailored interventions for specific substances to improve linkage to SUD treatment in the community on discharge.

Although video visits may offer some benefits over the telephone, not all patients may be equipped to access video telemedicine, raising questions surrounding access disparities. The aim of this study is to examine patient characteristics associated with the use of phone versus video-enabled tele-medication for opioid use disorders (MOUD) during COVID-19.This study uses data from a nonurban integrated substance use disorder treatment site in New York to examine patient characteristics associated with the modality of tele-MOUD care. The provider did not offer in-person care. Multivariable regression models were used to assess the association between patient's primary mode of tele-MOUD and patient demographic characteristics. Additional analysis of new patient inductions examined associations between mode of tele-MOUD induction and 30-day follow-up receipt.Of the 4557 tele-MOUD encounters, 76.92% were video and 23.08% were telephone visits. Older patients had significantly higher odds of primarily using telephone (odds ratio [OR]: 0.580; 95% confidence interval [CI]: 0.045, 1.115). Patients with higher education (OR: -0.791; 95% CI: -1.418, -0.168), recent overdose (OR: -0.40; 95% CI: -0.793, -0.010), and new patients (OR: 0.484; 95% CI: -0.945, 0.023) were significantly less likely to rely on telephone. Of 336 new patient initiations, 31 were conducted by telephone while 305 were conducted through video. The mode of new patient initiation was not associated with a follow-up visit within 30 days of initiation.Telemedicine may increase access to MOUD, though certain patients may rely on different forms of telemedicine. Attention must be paid to policies that promote equitable access to both video and telephone tele-MOUD visits.

In response to the drug overdose crisis, first responders, in partnership with public health, provide new pathways to substance use disorder (SUD) treatment and other services for individuals they encounter in their day-to-day work. OBJECTIVE: This scoping review synthesizes available evidence on first responder programs that take an assertive approach to making linkages to care. RESULTS: Seven databases were searched for studies published in English in peer-reviewed journals between January 2000 and December 2019. Additional articles were identified through reference-checking and subject matter experts. Studies were selected for inclusion if they sufficiently described interventions that (1) focus on adults who use drugs; (2) are in the United States; (3) involve police, fire, or emergency medical services; and (4) assertively link individuals to SUD treatment. Twenty-two studies met inclusion criteria and described 34 unique programs, implementation barriers and facilitators, assertive linkage strategies, and linkage outcomes, including unintended consequences. CONCLUSIONS: Findings highlight the range of linkage strategies concurrently implemented and areas for improving practice and research, such as the need for more linkages to evidence-based strategies, namely, medications for opioid use disorder, harm reduction, and wraparound services.

We sought to understand how opioid treatment programs (OTPs) adapted OTP operations to the COVID-19 pandemic and new federal regulations around methadone and buprenorphine.In fall 2020, we conducted an online survey of all 103 OTPs licensed by the Pennsylvania Department of Drug and Alcohol Programs, including clinical directors. Survey domains included changes to methadone take-home and telehealth practices; overdose and diversion prevention tactics; perceptions regarding how such changes influence patient well-being; and financial/operational concerns related to the new policies and practices. We calculated descriptive statistics and conducted Chi-square test to test for differences between not-for-profit versus for-profit and large versus small OTPs.Forty-seven percent (46%) OTPs responded to the survey. 10% and 25%, respectively, endorsed offering telephone and video-based telemedicine buprenorphine induction. Sixty-six percent endorsed extending take-home supplies of methadone, but most indicated that these extensions applied to a minority of their patients. Most respondents agreed that provision of buprenorphine via telehealth and extended take-home methadone reduced patient burden in accessing medications and prevented exposure to COVID-19, while not significantly increasing risk of overdose. We did not find major differences in COVID-19 practice modifications by nonprofit status or size of OTP.In Pennsylvania, the COVID-19 pandemic led to rapid changes in provision of opioid treatment services. Findings on relatively low uptake of longer methadone take-home regimens and virtual buprenorphine initiation despite general support for these practices imply a need to further develop guidelines for best clinical practices and understand/address barriers to their implementation.

We aimed to better understand emergency department (ED) use, admission patterns, and demographics for substance use disorder in pregnancy and postpartum (SUDPP).In this longitudinal study, the United States Nationwide Emergency Department Sample was queried for all ED visits by 15- to 50-year-old women with a primary diagnosis defined by International Classification of Diseases, 9th or 10th edition Clinical Modification, codes of SUDPP between 2006 and 2016. Patterns of ED visit counts, rates, admissions, and ED charges were analyzed.Annual national estimated ED visits for SUDPP increased from 2,919 to 9,497 between 2006 and 2016 (a 12.4% annual average percentage change), whereas admission rates decreased (from 41.9% to 32.0%). ED visits were more frequent among women who were 20-29 years old, using Medicaid insurance, in the lowest income quartile, living in the South, and in metropolitan areas. Compared with the proportion of ED visits, 15- to 19-year-olds had significantly lower admission rates, whereas women with Medicaid and in the lowest income quartile had higher admission rates (p .001). Opioid use, tobacco use, and mental health disorders were most commonly associated with SUDPP. The ED average inflation-adjusted charges for SUDPP increased from $1,486 to $3,085 between 2006 and 2016 (7.1% annual average percentage change; p .001), yielding total annual charges of $4.02 million and $28.53 million.Despite the decrease in admissions, the number and charges for ED visits for SUDPP increased substantially between 2006 and 2016. These increasing numbers suggest a continuous need to implement preventive public health measures and provide adequate outpatient care for this condition in this population specifically.

OBJECTIVES: The number of women with opioid-related diagnoses in the United States has significantly increased in recent decades, resulting in concomitantly higher rates of infants born with neonatal opioid withdrawal syndrome (NOWS). Addressing prenatal opioid exposure is a priority for Alaska health systems. The objectives of this study were to: 1) identify maternal and neonatal factors associated with receipt of Medication for opioid use disorder (MOUD) and 2) determine the impact of prenatal MOUD on discharge to parents among infants with NOWS in three Alaska hospitals. METHODS: A retrospective chart review using a standard abstraction form was conducted to collect data on neonatal and maternal characteristics, neonatal treatment, and infant discharge disposition for infants with NOWS born at the three hospitals between July 2016 and December 2019. A multivariable logistic regression model was used to determine factors associated with discharge to parents. RESULTS: There were 10,719 births at the three hospitals during the study period, including 193 infants (1.8%) with NOWS. Among the 193 mothers, 91 (47.2%) received MOUD during pregnancy. Among infants with NOWS, 136 (70.5%) were discharged to parents, 51 (26.4%) were discharged to a relative or foster care. Infants were significantly (OR 3.9) more likely to be discharged to parents if the mother had received prenatal MOUD. CONCLUSIONS: MOUD among pregnant women with opioid use disorder furthers the goal of keeping families together and is a critical step towards reducing the impact of the ongoing opioid epidemic on Alaska families, communities, and the child welfare system.

OBJECTIVE: Factors contributing to racial and ethnic disparities in medication for opioid use disorder (MOUD) receipt during pregnancy are largely unknown. We quantified the contribution of individual, healthcare access and quality, and community factors to racial-ethnic disparities in MOUD during pregnancy and postpartum among Medicaid-enrolled pregnant women with OUD. METHODS: This retrospective cohort study used regression and nonlinear decomposition to examine how individual, healthcare access and quality, and community factors explain racial-ethnic disparities in MOUD receipt among Medicaid-enrolled women with OUD who had a live birth from 2011-2017. The exposure was self-reported race and ethnicity. The outcomes were any MOUD receipt during pregnancy or postpartum. All factors included were identified from the literature. RESULTS: Racial-ethnic disparities in individual, healthcare access and quality, and community factors explained 15.8% of the racial-ethnic disparity in MOUD receipt during pregnancy and 68.9% of the disparity in the postpartum period. Despite comparable healthcare utilization, nonwhite/Hispanic women were diagnosed with OUD 37 days later in pregnancy, on average, than non-Hispanic White women, which was the largest contributor to the racial-ethnic disparity in MOUD receipt during pregnancy (111.0%). The racial-ethnic disparity in MOUD receipt during pregnancy was the largest contributor (112.2%) to the racial-ethnic disparity in MOUD in the postpartum period. CONCLUSIONS: Later diagnosis of OUD in pregnancy among nonwhite/Hispanic women partially explains the disparities in MOUD receipt in this population. Universal substance use screening earlier in pregnancy, combined with connecting patients to evidence-based and culturally competent care, is one approach that could close the observed racial-ethnic disparity in MOUD receipt.

Opioid use continues to rise globally. So too do the associated adverse consequences. Opioid use disorder (OUD) is a chronic and relapsing brain disease characterized by loss of control over opioid use and impairments in cognitive function, mood, pain perception, and autonomic activity. Sleep deficiency, a term that encompasses insufficient or disrupted sleep due to multiple potential causes, including sleep disorders, circadian disruption, and poor sleep quality or structure due to other medical conditions and pain, is present in 75% of patients with OUD. Sleep deficiency accompanies OUD across the spectrum of this addiction. The focus of this concise clinical review is to highlight the bidirectional mechanisms between OUD and sleep deficiency and the potential to target sleep deficiency with therapeutic interventions to promote long-term, healthy recovery among patients in OUD treatment. In addition, current knowledge on the effects of opioids on sleep quality, sleep architecture, sleep-disordered breathing, sleep apnea endotypes, ventilatory control, and implications for therapy and clinical practice are highlighted. Finally, an actionable research agenda is provided to evaluate the basic mechanisms of the relationship between sleep deficiency and OUD and the potential for behavioral, pharmacologic, and positive airway pressure treatments targeting sleep deficiency to improve OUD treatment outcomes.