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BackgroundEfforts to address opioid-involved overdose fatalities have led to widespread implementation of various initiatives to taper (i.e., reduce or discontinue) opioid prescriptions despite a limited understanding of patients' experience.MethodsFrom 2019-2020, we recruited patients with chronic, non-cancer pain who had undergone a reduction in opioid daily dosage of ≥50 % in the past two years at Boston Medical Center or Michigan Medicine. Participants completed semi-structured interviews exploring health history, opioid use, and taper experiences. Inductive analysis, guided by theoretical conceptualizations of structural stigma, identified emergent themes.ResultsAmong 41 participants, three elements of structural stigma were identified across participants' lives. First, participants identified themselves as overlooked subjects of the U.S. opioid crisis, who experienced overprescribing, subsequent stigmatization and surveillance of opioid use (e.g., toxicology screening, "pill counts"), and various tapering initiatives. Second, during the course of pain treatment, participants felt stigmatized and invalidated by cultural norms linking chronic pain to stereotypes of acting disingenuously (e.g., "drug-seeking"). Finally, during and after tapers, institutional policies and programs further increased participants' feelings of marginalization, producing multiple unintended consequences, including reduced access to medical care and feeling "orphaned by the system."ConclusionsOpioid tapers may exacerbate the social production and burden of stigma among patients with chronic pain, especially when processes are perceived to invalidate pain, endorse stereotypes, and label previously effective, acceptable treatment as inappropriate. Findings highlight how various tapering initiatives reinforce the devalued status of people living with chronic pain while also reducing patients' wellbeing and confidence in medical systems.

Background: Patterns of opioid use vary, including prescribed use without aberrancy, limited aberrant use, and potential opioid use disorder (OUD). In clinical practice, similar opioid-related International Classification of Disease (ICD) codes are applied across this spectrum, limiting understanding of how groups vary by sociodemographic factors, comorbidities, and long-term risks. Objective: (1) Examine how Veterans assigned opioid abuse/dependence ICD codes vary at diagnosis and with respect to long-term risks. (2) Determine whether those with limited aberrant use share more similarities to likely OUD vs those using opioids as prescribed. Design: Longitudinal observational cohort study. Participants: National sample of Veterans categorized as having (1) likely OUD, (2) limited aberrant opioid use, or (3) prescribed, non-aberrant use based upon enhanced medical chart review. Main Measures: Comparison of sociodemographic and clinical factors at diagnosis and rates of age-adjusted mortality, non-fatal opioid overdose, and hospitalization after diagnosis. An exploratory machine learning analysis investigated how closely those with limited aberrant use resembled those with likely OUD. Key Results: Veterans (n = 483) were categorized as likely OUD (62.1%), limited aberrant use (17.8%), and prescribed, non-aberrant use (20.1%). Age, proportion experiencing homelessness, chronic pain, anxiety disorders, and non-opioid substance use disorders differed by group. All-cause mortality was high (44.2 per 1000 person-years (95% CI 33.9, 56.7)). Hospitalization rates per 1000 person-years were highest in the likely OUD group (831.5 (95% CI 771.0, 895.5)), compared to limited aberrant use (739.8 (95% CI 637.1, 854.4)) and prescribed, non-aberrant use (411.9 (95% CI 342.6, 490.4). The exploratory analysis reclassified 29.1% of those with limited aberrant use as having likely OUD with high confidence. Conclusions: Veterans assigned opioid abuse/dependence ICD codes are heterogeneous and face variable long-term risks. Limited aberrant use confers increased risk compared to no aberrant use, and some may already have OUD. Findings warrant future investigation of this understudied population. [ABSTRACT FROM AUTHOR]

Abstract: Many primary care clinics are resistant to accept new patients taking prescription opioids for chronic pain. It is unclear how much of this practice is specific to individuals who may be perceived to have aberrant opioid use. This study sought to determine whether clinics are more or less willing to accept and prescribe opioids to patients depending on whether their history is more or less suggestive of aberrant opioid use by conducting an audit survey of primary care clinics in 9 states from May to July 2019. Simulated patients taking opioids for chronic pain called each clinic twice, giving one of 2 scenarios for needing a new provider: their previous physician had either (1) retired or (2) stopped prescribing opioids for unspecified reasons. Clinic willingness to continue prescribing opioids and accept the patient for general primary care were assessed. Of 452 clinics responding to both scenarios (904 calls), 193 (43%) said their providers would not prescribe opioids in either scenario, 146 (32%) said their providers might prescribe in both, and 113 (25%) responded differently to each scenario. Clinics responding differently had greater odds (odds ratio = 1.83 confidence interval [1.23-2.76]) of willingness to prescribe when the previous doctor retired than when the doctor had stopped prescribing. These findings suggest that primary care access is limited for patients taking opioids for chronic pain, and differentially further reduced for patients whose histories are suggestive of aberrant use. This denial of care could lead to unintended harms such as worsened pain or conversion to illicit substances. [ABSTRACT FROM AUTHOR]

Beetham and colleagues reported a "secret shopper" study that describes barriers patients face when seeking clinicians who provide buprenorphine treatment for opioid use disorders. The editorialists believe that the most pressing challenge is connecting patients to willing prescribers. [ABSTRACT FROM AUTHOR]

The authors reflect on a proposal for re-purposing anticoagulation clinics, and it mentions the potential expansion of such clinics and primary medical care settings to increase access to programs such as opioid agonist therapy (OAT). According to the article, anticoagulation clinics provide interdisciplinary medication management and monitoring for patients on drugs such as warfarin. Buprenorphine and methadone are examined, along with medication for patients with substance use disorders.

Medications for opioid use disorder (MOUD) including methadone (MMT), buprenorphine (BUP), and naltrexone (NTX) are safe and effective. However, there are significant negative perceptions surrounding MOUD, creating barriers to uptake. While research on MOUD stigma has largely focused on provider and patient experiences, fewer studies have explored MOUD perceptions among the general public. Given that MOUD stigma expressed by social ties surrounding individuals with OUD can influence treatment choices, we assessed MOUD perceptions among U.S. adults to determine how beliefs impacted treatment preference. We further explored how MOUD perceptions may be amplified among racialized groups with histories of experiencing drug-related discrimination. The study collected survey data from a diverse sample of U.S. adults (n = 1508) between October 2020 and January 2021. The survey measured knowledge of MOUD and non-medication treatments, relative agreement with common MOUD perceptions, and treatment preferences. Multinomial logistic regression analysis tested associations with treatment preference, stratified by race/ethnicity. Descriptive results indicated that across groups, many respondents (66.8 %) had knowledge of MOUD, but believed MOUD was a "substitute" for opioids and had some degree of concern about misuse. Multivariable results showed knowledge of non-medication treatments was positively associated with MOUD preference among White (MMT OR = 3.16, 95 % CI = 1.35–7.39; BUP OR = 2.69, CI = 1.11–6.47), Black (MMT OR = 3.91, CI = 1.58–9.69), and Latino/a (MMT OR = 5.12, CI = 1.99–13.2; BUP OR = 3.85, CI = 1.5–9.87; NTX OR = 4.51, CI = 1.44–14.06) respondents. Among White respondents, we identified positive associations between MOUD experience and buprenorphine preference (OR = 4.33, CI = 1.17–16.06); non-medication treatment experience and preference for buprenorphine (OR = 2.86, CI = 1.03–7.94) and naltrexone (OR = 3.17, CI = 1.08–9.28). Concerns around misuse of methadone were negatively associated with methadone preference among White (OR = 0.65, CI = 0.43–0.98) and Latino/a (OR = 0.49, CI = 0.34–0.7), and concerns around misuse of buprenorphine was negatively associated with preference for MOUD among White (MMT OR = 0.62, CI = 0.39–0.99; BUP OR = 0.48, CI = 0.3–0.77; NTX OR = 0.6, CI = 0.36–0.99) and Latino/a (BUP OR = 0.59, CI = 0.39–0.89) respondents. This analysis offers critical insights into treatment perceptions beyond the patient population, finding that negative beliefs around MOUD are common and negatively associated with preferences for medication-based treatment. These findings highlight implications for public support of evidence-based treatment and lay the groundwork for future interventions addressing public stigma toward MOUD. • In a sample of US adults, many held negative views of medication-based treatment. • Perceptions of medications for opioid use disorder can vary by race/ethnicity. • The public's medication perceptions can shape support for people seeking treatment. [ABSTRACT FROM AUTHOR]

Background: The loosening of U.S. methadone regulations during the COVID-19 pandemic expanded calls for methadone reform. This study examines professional perceptions of methadone take-home dose regulation before and during the COVID-19 pandemic to understand responses to varied methadone distribution policies.Methods: Fifty-nine substance use disorder treatment professionals were interviewed between 2017 and 2020 in-person or over video call. An inductive iterative coding process was used to analyze the data. Constructivist grounded theory guided the collection and analysis of in-depth interviews.Results: Treatment professionals expressed mixed views toward methadone take-home regulations. Participants justified regulation using several arguments: 1) patient care benefitting from supervision, 2) attributing improved patient safety to take-home regulation, 3) fearing liability for methadone-related harms, and 4) relying on buprenorphine as an "escape hatch" for patients who cannot manage MMT policies. Other professionals suggested partial deregulation, while others strongly opposed pre-pandemic take-home regulation, explaining such regulations impede medication access and hinder patient-centered care. Some professionals supported the COVID-19 policy changes and saw these as a test run for broader deregulation, while others framed the changes as temporary and cautiously applied deregulation to their services, at times revoking looser rules for patients they perceived as nonadherent.Conclusion: Treatment professionals working in a range of modalities, including opioid treatment programs, expressed hesitation toward expanded take-home methadone access. While some participants also supported forms of deregulation, post-pandemic efforts to extend looser methadone distribution policies will have to address apprehensive professionals if such policy changes are to be meaningfully adopted in community services. [ABSTRACT FROM AUTHOR]