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Background: Office-based opioid treatment (OBOT) is an evidence-based treatment model for opioid use disorder (OUD) offered by both addiction and general primary care providers (PCPs). Calls exist for more PCPs to offer OBOT. Few studies have been conducted on the primary care characteristics of OBOT patients.Objective: To characterize medical conditions, medications, and treatment outcomes among patients receiving OBOT with buprenorphine for OUD, and to describe differences among patients by age and by time in care.Methods: This study is a retrospective review of medical records on or before 4/29/2019 at an outpatient primary care clinic within a nonprofit addiction treatment setting. Inclusion criterion was all clinic patients actively enrolled in the OBOT program. Patients not prescribed buprenorphine or with no OBOT visits were excluded.Results: Of 355 patients, 42.0% had another PCP. Common comorbid conditions included chronic pain and psychiatric diagnosis. Few patients had chronic viral hepatitis or HIV. Patients reported a median of 4 medications. Common medications were cardiovascular, antidepressant, and nonopioid pain agents. Older patients had a higher median number of medications. There was no significant difference in positive opioid urine toxicology (UT) based on age, chronic pain status, or psychoactive medications. Patients retained >1 year were less likely to have positive opioid UT.Conclusion: Clinical needs of many patients receiving OBOT are similar to those of the general population, supporting calls for PCPs to provide OBOT. [ABSTRACT FROM AUTHOR]

The article examines the issues associated with the care for patients with opioid use disorders during the acute hospital admissions. Topics discussed include the use of guidelines, existing related studies and systematic reviews to get familiar with opioid agonist therapy use, and the management of opioid overdose and withdrawal.

Background: Open-access opioid treatment programs (OTP) offer same-day access to methadone without an appointment and aim to minimize treatment barriers that often reduce admission and/or retention. We explored whether patients with benzodiazepine exposure at treatment entry would have similar 12-month retention compared to those without benzodiazepine exposure.Methods: We conducted a retrospective cohort study of 2968 patients consecutively initiated on methadone between January 2015 and February 2017 at an open-access OTP. The sample was stratified into benzodiazepine-exposed and nonexposed groups based on intake urine toxicology. Group comparison of 12-month retention was conducted. Kaplan Meier analysis compared time to methadone treatment discontinuation between groups with a log-rank test. Multivariable Cox regression was performed to compare retention by baseline benzodiazepine exposure with adjustment for confounders.Results: Overall, 31% of patients with benzodiazepine exposure (n = 171) and 31% without exposure (n = 2423) were retained at 12 months (p = 0.95). Median treatment duration was 182 days (95% CI, 152-239) and 175 days (95% CI, 156-196) for patients with and without benzodiazepine exposure, respectively. Kaplan-Meier analysis showed no significant difference in treatment duration between groups (log-rank test p = 0.73). Cox regression found no difference in treatment retention between groups (adjusted Hazard Ratio= 1.03, 95% CI, 0.91-1.16).Conclusions: In this cohort of patients receiving methadone at an open-access OTP, benzodiazepine exposure at intake was not observed to impact 12-month treatment retention or duration. These findings support U.S. Food and Drug Administration (FDA) recommendations to not withhold medications for opioid use disorder from patients taking benzodiazepines. [ABSTRACT FROM AUTHOR]

Introduction: Individuals with HIV and hepatitis C (HCV) infection, alcohol use disorder, or who are prescribed potentially hepatotoxic medications may be at increased risk for buprenorphine (BUP) associated hepatotoxicity.Materials and Methods: We examined a cohort of HIV-infected and uninfected patients receiving an initial BUP prescription between 2003 and 2012. We compared changes in alanine and aspartate aminotransferases (ALT and AST) and total bilirubin (TB) stratified by HIV status. We identified cases of liver enzyme elevation (LEE), TB elevation (TBE), and conducted chart review to assess for cases of drug induced liver injury (DILI) and death. We examined associations between age, sex, race, HIV-infection, HCV-infection, alcohol use disorder, and prescription of other potentially heptatotoxic medications with the composite endpoint of LEE, TBE, and DILI.Results: Of 666 patients prescribed BUP, 36% were HIV-infected, 98% were male, 60% had RNA-confirmed HCV infection, 50% had a recent diagnosis of alcohol use disorder, and 64% were prescribed other potentially hepatotoxic medications. No clinically significant changes were observed in median ALT, AST and TB and these changes did not differ between HIV-infected and uninfected patients. Compared with uninfected patients, HIV-infected (OR 7.3, 95% CI 2.1-26.1, p=0.002), HCV-infected (OR 4.9 95% CI 1.6-15.2, p=0.007) or HIV/HCV co-infected patients (OR 6.9, 95%CI 2.1-22.2, p=0.001) were more likely to have the composite endpoint of LEE, TB elevation or DILI, in analyses that excluded 60 patients with evidence of pre-existing liver injury. 31 patients had LEE, 14/187 HIV-infected and 17/340 uninfected (p=0.25); 11 had TBE, including 9/186 HIV-infected and 2/329 uninfected (p=0.002); 8 experienced DILI, 4/202 HIV-infected and 4/204 uninfected (p=0.45). There were no significant associations with alcohol use disorder or prescription of other potentially hepatotoxic medications after adjustment for HIV/HCV status.Conclusions: Liver enzymes and TB are rarely elevated in HIV-infected and uninfected patients receiving BUP. Risk of hepatotoxicity was greater in individuals infected with HIV, HCV, or HIV/HCV co-infection, who may benefit from increased monitoring. [ABSTRACT FROM AUTHOR]

Krebs and colleagues showed that immediate access to opioid agonist treatment (OAT) for all patients with opioid use disorder seeking treatment in California's publicly funded treatment programs is cost-effective compared with the state-level standard of time-limited medically supervised withdrawal. The editorialists discuss the findings and conclude that we must use fewer health care resources on medically supervised withdrawal “beds” and more on outpatient “chairs” for OAT. [ABSTRACT FROM AUTHOR]

Background: Despite the availability and demonstrated effectiveness of office-based buprenorphine maintenance treatment (BMT), the systematic examination of physicians' attitudes towards this new medical practice has been largely neglected.Objective: To identify facilitators and barriers to the potential or actual implementation of BMT by office-based medical providers.Design: Qualitative study using individual and group semi-structured interviews.Participants: Twenty-three practicing office-based physicians in New England.Approach: Interviews were audiotaped, transcribed, and entered into a qualitative software program. The transcripts were thematically coded using the constant comparative method by a multidisciplinary team.Results: Eighty percent of the physicians were white; 55% were women. The mean number of years since graduating medical school was 14 (SD = 10). The primary areas of clinical specialization were internal medicine (50%), infectious disease (20%), and addiction medicine (15%). Physicians identified physician, patient, and logistical factors that would either facilitate or serve as a barrier to their integration of BMT into clinical practice. Physician facilitators included promoting continuity of patient care, positive perceptions of BMT, and viewing BMT as a positive alternative to methadone maintenance. Physician barriers included competing activities, lack of interest, and lack of expertise in addiction treatment. Physicians' perceptions of patient-related barriers included concerns about confidentiality and cost, and low motivation for treatment. Perceived logistical barriers included lack of remuneration for BMT, limited ancillary support for physicians, not enough time, and a perceived low prevalence of opioid dependence in physicians' practices.Conclusions: Addressing physicians' perceptions of facilitators and barriers to BMT is crucial to supporting the further expansion of BMT into primary care and office-based practices. [ABSTRACT FROM AUTHOR]

This legislation proposes removing the X waiver provided that Congress passes a bill that requires addiction training for all health care professionals, such as the Medication Access and Training Expansion Act ([1]). Such efforts should include an immediate addiction medicine training plan, not future uncoordinated health care professional training in this field that may or may not address the need. Training is an opportunity to address the misinformation and stigma about addiction to which the health care workforce is not immune. [Extracted from the article]

There are ongoing efforts to lift training requirements for providers to prescribe buprenorphine for the treatment of opioid use disorder. These authors argue that such efforts, while well-meaning, are short-sighted, and that more rather than less training is needed. [ABSTRACT FROM AUTHOR]

Background: Co-located treatment for hepatitis C virus (HCV) infection for patients with opioid use disorder (OUD) within an opioid treatment program (OTP) addresses gaps in the HCV care continuum. Few reports have analyzed outcomes related to OUD treatment, such as retention, associated with co-located HCV treatment.Methods: Patients (n = 89) treated for OUD and chronic HCV infection in a Northeast US OTP from January 2014 through July 2017 were compared to control patients (n = 199) being treated for OUD and diagnosed with but not treated for HCV during the same period. All patients received opioid agonist treatment (OAT). The outcome of interest is patient retention in the OTP from January 2014 through September 2018, analyzed using logistic regression and survival analysis based on OTP loss to follow-up dates.Results: After adjusting for baseline covariates, patients who completed HCV treatment had 2.22 (95 % CI: 1.11, 4.45) increased likelihood of remaining in the OTP compared to patients in the control group. Survival analysis indicated the HCV treatment group had a significantly greater probability of being retained over the duration of the study compared with the control group.Conclusion: Results indicate that a co-located model of care is associated with improved OTP treatment retention following HCV treatment, and suggest that co-locating HCV and OUD treatment has a secondary impact on keeping patients engaged in OAT. [ABSTRACT FROM AUTHOR]

The article reports on the public health crisis related to opioid use disorder and overdose in the U.S. Topics discussed include influx in highly potent illicit synthetic opioids, such as fentanyl and carfentanil; an evidence based guideline on the management of opioid use disorder; and evaluation and treatment of patients with the disorder.

Introduction: Urine adulteration is a concern among patients treated for opioid use disorder. Quantitative urine testing for buprenorphine (B) and norbuprenorphine (NB), and the appropriate interpretation of B and NB levels, can facilitate constructive conversations with patients that may lead to modifications in the treatment plan, and strengthening of the patient-provider relationship.Case Summary: Three cases are presented in which discordant urine B and NB levels were recognized. Each patient was submerging buprenorphine/naloxone strips in their urine to mask ongoing illicit drug use. The authors used an approach to addressing intentional adulteration of urine samples that adheres to the principles of harm-reduction, the centrality of the patient-provider relationship, and the acknowledgment that ongoing illicit drug use and subsequent dishonesty about disclosure may be common among persons with substance use disorders. Each of the three patients ultimately endorsed diluting their urine, which allowed for strengthening of the patient-provider relationship and modifications to their treatment plans. Two of the three patients stabilized and achieved abstinence, while the third was eventually referred to a methadone treatment program.Conclusion: Providers should routinely monitor B and NB levels, rather than qualitative screening alone, and discordant levels should elicit a timely conversation with the patient. The authors use of a nonjudgmental approach to address urine adulteration, including giving patients an opportunity to reflect on potential solutions, has been effective at helping patients and providers to reestablish a therapeutic alliance and maintain retention in treatment. [ABSTRACT FROM AUTHOR]

With the advent of the direct acting antivirals (DAA), or all oral HCV treatment regimens, there exists a great opportunity to provide HCV treatment to people who inject drugs (PWID) enrolled in an opioid treatment program (OTP). This retrospective study conducted in the context of routine clinical care explores the outcomes of HCV treatment with DAAs in PWID enrolled in an OTP. Our study showed treatment outcomes among our first 75 patients treated with DAAs were nearly equivalent to patients in the general population. Ninety-eight percent of patients completing treatment obtained a sustained virologic response, with 10 patients lost to follow-up. Ninety-nine percent of patients adhered to HCV treatment. Ongoing drug use occurred in 23% of patients, however this did not alter HCV treatment outcomes. Treating HCV infection with DAAs in PWID onsite in an OTP is feasible. [ABSTRACT FROM AUTHOR]