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IntroductionDuring the 2018–2020 Ebola virus disease (EVD) outbreak in the eastern part of the Democratic Republic of the Congo (DRC), prevention and control measures, such as Ebola vaccination were challenging by community mistrust. We aimed to understand perceptions regarding Ebola vaccination and identify determinants of Ebola vaccine uptake among HCWs.MethodsIn March 2021, we conducted a cross-sectional survey among 438 HCWs from 100 randomly selected health facilities in three health zones (Butembo, Beni, Mabalako) affected by the 10th EVD outbreak in North Kivu, DRC. HCWs were eligible if they were ≥ 18 years and were working in a health facility during the outbreak. We used survey logistic regression to assess correlates of first-offer uptake (i.e., having received the vaccine the first time it was offered vs. after subsequent offers).ResultsOf the 438 HCWs enrolled in the study, 420 (95.8%) reported that they were eligible and offered an Ebola vaccine. Among those offered vaccination, self-reported uptake of the Ebola vaccine was 99.0% (95% confidence interval (CI) [98.5–99.4]), but first-offer uptake was 70.2% (95% CI [67.1, 73.5]). Nearly all HCWs (94.3%; 95% CI [92.7–95.5]) perceived themselves to be at risk of contracting EVD. The most common concern was that the vaccine would cause side effects (65.7%; 95% CI [61.4–69.7]). In the multivariable analysis, mistrust of the vaccine source or how the vaccine was produced decreased the odds of first-time uptake.DiscussionOverall uptake of the Ebola vaccine was high among HCWs, but uptake at the first offer was substantially lower, which was associated with mistrust of the vaccine source. Future Ebola vaccination efforts should plan to make repeated vaccination offers to HCWs and address their underlying mistrust in the vaccines, which can, in turn, improve community uptake.

Populations affected by humanitarian crises and emerging infectious disease outbreaks may have unique concerns and experiences that influence their perceptions toward vaccines. In March 2021, we conducted a survey to examine the perceptions toward COVID-19 vaccines and identify the factors associated with vaccine intention among 631 community members (CMs) and 438 healthcare workers (HCWs) affected by the 2018–2020 Ebola Virus Disease outbreak in North Kivu, Democratic Republic of the Congo. A multivariable logistic regression was used to identify correlates of vaccine intention. Most HCWs (81.7%) and 53.6% of CMs felt at risk of contracting COVID-19; however, vaccine intention was low (27.6% CMs; 39.7% HCWs). In both groups, the perceived risk of contracting COVID-19, general vaccine confidence, and male sex were associated with the intention to get vaccinated, with security concerns preventing vaccine access being negatively associated. Among CMs, getting the Ebola vaccine was associated with the intention to get vaccinated (RR 1.43, 95% CI 1.05–1.94). Among HCWs, concerns about new vaccines’ safety and side effects (OR 0.72, 95% CI 0.57–0.91), religion’s influence on health decisions (OR 0.45, 95% CI 0.34–0.61), security concerns (OR 0.52, 95% CI 0.37–0.74), and governmental distrust (OR 0.50, 95% CI 0.35–0.70) were negatively associated with vaccine perceptions. Enhanced community engagement and communication that address this population’s concerns could help improve vaccine perceptions and vaccination decisions. These findings could facilitate the success of vaccine campaigns in North Kivu and similar settings.

Leptomeningeal carcinomatosis accounts for only 4% of cases of multiple cranial neuropathies. Here, we report the case of a patient who presented with multiple synchronous cranial neuropathies. After treatment for neuroborreliosis and broad infectious workup, endobronchial ultrasound-guided mediastinal lymph node biopsy confirmed a diagnosis of metastatic BRAF-mutated lung adenocarcinoma with leptomeningeal involvement. To our knowledge, this is the first reported case of metastatic BRAF-driven lung adenocarcinoma with leptomeningeal disease at diagnosis. In this case, the presence of leptomeningeal carcinomatosis at diagnosis, not as a late manifestation of heavily pretreated disease, alludes to a possible association between leptomeningeal involvement and BRAF-mutated non-small cell lung cancer.

Background: Alcohol use disorder is among the most pervasive substance use disorders in the United States, with a lifetime prevalence of 30%. Recommended treatment options include evidence-based behavioral interventions; smartphone-based interventions confer a number of benefits such as portability, continuous access, and stigma avoidance; and research suggests that interventions involving couples may outperform those for patients only. In this context, a behavioral intervention delivered to couples through smartphones may serve as an effective adjunct to alcohol use disorder treatment., Objective: This pilot study aimed to (1) evaluate the feasibility of comparing a patient-only (Addiction version of the Comprehensive Health Enhancement Support System; A-CHESS) versus a couple-focused (Partner version of the Comprehensive Health Enhancement Support System; Partner-CHESS) eHealth app for alcohol misuse delivered by smartphone, (2) assess perceptions about and use of the 2 apps, and (3) examine initial indications of differences in primary clinical outcomes between patient groups using the 2 apps. Broadly, these aims serve to assess the feasibility of the study protocol for a larger randomized controlled trial., Methods: A total of 33 romantic couples were randomized to 6 months of A-CHESS app use (active treatment control) or Partner-CHESS app use (experimental). Couples comprised a patient with current alcohol use disorder (25/33, 76% male) and a romantic partner (26/33, 79% female). Patients and partners in both arms completed outcome measure surveys at 0, 2, 4, and 6 months. Primary outcomes were patients' percentage of days with heavy drinking and percentage of days with any drinking, measured by timeline follow back. Secondary outcomes included app use and perceptions, and multiple psychosocial variables., Results: At 6 months, 78% (14/18) of Partner-CHESS patients and 73% (11/15) of A-CHESS patients were still using the intervention. The apps were rated helpful on a 5-point scale (1=not at all helpful, 5=extremely helpful) by 89% (29/33) of both Partner-CHESS patients (mean 3.7, SD 1) and partners (mean 3.6, SD 0.9) and by 87% (13/15) of A-CHESS patients (mean 3.1, SD 0.9). At 6 months, Partner-CHESS patients had a nonsignificantly lower percentage of days with heavy drinking compared with A-CHESS patients (β=-17.4, 95% CI -36.1 to 1.4; P=.07; Hedges g=-0.53), while the percentage of drinking days was relatively equal between patient groups (β=-2.1, 95% CI -24.8 to 20.7; P=.85; Hedges g=-0.12)., Conclusions: Initial results support the feasibility of evaluating patient-only and couple-focused, smartphone-based interventions for alcohol misuse. Results suggest that both interventions are perceived as helpful and indicate maintained engagement of most participants for 6 months. A future, fully powered trial is warranted to evaluate the relative effectiveness of both interventions., Trial Registration: ClinicalTrials.gov NCT04059549; https://clinicaltrials.gov/ct2/show/NCT04059549., (©David H Gustafson Sr, David H Gustafson Jr, Marie-Louise Mares, Darcie C Johnston, Olivia J Vjorn, John J Curtin, Elizabeth E Epstein, Genie L Bailey. Originally published in JMIR Formative Research (https://formative.jmir.org), 01.11.2024.)

Introduction and Background: Buprenorphine, and extended-release naltrexone, are effective in decreasing opioid use, morbidity and mortality. The available evidence suggests that these medications should be used for long term treatment; however, patients often ask how long they need to be on medication, and whether it would be safe to discontinue. There are sparse data to guide us. The CTN-0100 trial will address this gap in our knowledge by studying participants who have decided to discontinue buprenorphine and extended-release naltrexone for OUD., Research Design and Methods: The trial is a multicenter, randomized, non-blinded study. Participants are stable adult volunteers, on sublingual buprenorphine, extended-release buprenorphine, or extended-release naltrexone, expressing an interest in discontinuing medication. Participants on buprenorphine must be stable for at least 1 year and participants on extended-release naltrexone must be stable for at least 6 months. Participants are engaged in the study for up to 96 weeks, including a flexible taper period, and are then transitioned to follow-up within the trial. All participants are randomly assigned to the study Medical Management (MM) or to MM plus Connections (CHESS health) digital smartphone application aimed at recovery and abstinence (MMD). Sublingual Buprenorphine participants are also randomized (2 × 2 design) to a taper using either sublingual or extended-release buprenorphine., Discussion/conclusion: It is hoped that this trial will provide a rich source of data on management of patients discontinuing medication for opioid use disorder (MOUD) to inform future research and practice. The trial will shed light on which strategies are most likely to lead to long-term success (absence of relapse), and what participant characteristics distinguish those who can safely discontinue MOUD from those who remain at risk of relapse should they discontinue., Clinicaltrials: gov Identifier: NCT04464980., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:, (Copyright © 2023. Published by Elsevier Inc.)

Objective: Medication for opioid use disorder (MOUD) improves treatment retention and reduces illicit opioid use. A-CHESS is an evidence-based smartphone intervention shown to improve addiction-related behaviors. The authors tested the efficacy of MOUD alone versus MOUD plus A-CHESS to determine whether the combination further improved outcomes., Methods: In an unblinded parallel-group randomized controlled trial, 414 participants recruited from outpatient programs were assigned in a 1:1 ratio to receive either MOUD alone or MOUD+A-CHESS for 16 months and were followed for an additional 8 months. All participants were on methadone, buprenorphine, or injectable naltrexone. The primary outcome was abstinence from illicit opioid use; secondary outcomes were treatment retention, health services use, other substance use, and quality of life; moderators were MOUD type, gender, withdrawal symptom severity, pain severity, and loneliness. Data sources were surveys comprising multiple validated scales, as well as urine screens, every 4 months., Results: There was no difference in abstinence between participants in the MOUD+A-CHESS and MOUD-alone arms across time (odds ratio=1.10, 95% CI=0.90-1.33). However, abstinence was moderated by withdrawal symptom severity (odds ratio=0.95, 95% CI=0.91-1.00) and MOUD type (odds ratio=0.57, 95% CI=0.34-0.97). Among participants without withdrawal symptoms, abstinence rates were higher over time for those in the MOUD+A-CHESS arm than for those in the MOUD-alone arm (odds ratio=1.30, 95% CI=1.01-1.67). Among participants taking methadone, those in the MOUD+A-CHESS arm were more likely to be abstinent over time (b=0.28, SE=0.09) than those in the MOUD-alone arm (b=0.06, SE=0.08), although the two groups did not differ significantly from each other (∆b=0.22, SE=0.11). MOUD+A-CHESS was also associated with greater meeting attendance (odds ratio=1.25, 95% CI=1.05-1.49) and decreased emergency department and urgent care use (odds ratio=0.88, 95% CI=0.78-0.99)., Conclusions: Overall, MOUD+A-CHESS did not improve abstinence relative to MOUD alone. However, MOUD+A-CHESS may provide benefits for subsets of patients and may impact treatment utilization., Competing Interests: Dr. Gustafson has served as a consultant for Dartmouth-Hitchcock Medical Center (on matters of quality improvement), and he is a shareholder in CHESS Health. The other authors report no financial relationships with commercial interests.

Sarcoidosis is the classic multisystem granulomatous disease. First reported as a disorder of the skin, it is now clear that, in the overwhelming majority of patients with sarcoidosis, the lungs will bear the brunt of the disease. This review explores some of the key concepts in the imaging of pulmonary sarcoidosis: the wide array of typical (and some of the less common) findings on high-resolution computed tomography (HRCT) are reviewed and, with this, the concept of morphologic/HRCT phenotypes is discussed. The pathophysiologic insights provided by HRCT through studies where morphologic abnormalities and pulmonary function tests are compared are evaluated. Finally, this review outlines the important contribution of HRCT to disease monitoring and prognostication.

Since the first few cases of pneumonia attributed to infection with the highly contagious novel coronavirus 2 (SARs-CoV-2) were detected in Wuhan, China, in December 2019, imaging has proven an invaluable diagnostic tool throughout the resulting global pandemic. This review describes the imaging features of severe pulmonary disease caused by SARs-CoV-2, named COVID-19 by the World Health Organization (WHO), particularly focussing on computed tomography (CT). CT plays an important role in understanding the pathology behind the progression of disease, as well as helping to identify the potential complications of COVID-19 pneumonia and recognising possible alternative or concurrent diagnoses. This review also focusses on follow-up imaging of survivors of COVID-19, which continues to contribute substantially to our understanding of the longer-term pulmonary changes in patients who have survived severe COVID-19 pneumonia., (Copyright © 2023. Published by Elsevier Ltd.)

Background: HIV disproportionally affects persons who inject drugs (PWID), but engagement with HIV pre-exposure prophylaxis (PrEP) is low. We describe the rationale and study design for a new study, "Contingency Management and Pre-Exposure Prophylaxis (PrEP) Adherence Support Services (CoMPASS)," a hybrid type 1 effectiveness-implementation trial to promote HIV risk reduction among PWID., Methods: In four community-based programs in the northeastern United States, PrEP-eligible PWID (target n = 526) are randomized to treatment as usual or Contingency Management (CM) and, as indicated, stepped up to PrEP Adherence Support Services (CoMPASS) over 24 weeks. During CM sessions, participants receive timely tangible rewards for verifiable activities demonstrating 1) PrEP initiation and adherence, and 2) engagement with medications for opioid use disorder (MOUD) and other OUD-related care. Participants who do not have high levels of biomarker-confirmed PrEP adherence at week 12 will be stepped up to receive PrEP Adherence Support Services (PASS) consisting of strengths-based case management over 12 weeks. Interventions are delivered by trained PrEP navigators, staff embedded within the respective sites. The primary outcome is sustained PrEP adherence by dried blood spot testing at 24 weeks. To inform future implementation, we are conducting implementation-focused process evaluations throughout the clinical trial., Conclusions: Results from this protocol are anticipated to yield novel findings regarding the impact and scalability of CoMPASS to promote HIV prevention among PWID in partnership with community-based organizations. http://ClinicalTrials.gov identifier: NCT04738825., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose. POC: Point of Care., (Published by Elsevier Inc.)

Introduction: In the current overdose epidemic, effective treatments for opioid use disorders (OUD), including innovations in medication delivery such as extended-release formulations, have the potential to improve treatment access and reduce treatment discontinuation. This study assessed treatment retention in a primary care-based, extended-release buprenorphine program., Methods: The study recruited individuals (n = 92) who transitioned from sublingual buprenorphine to extended-release buprenorphine (BUP-XR) in 2018-2019. The study defined the primary outcome, treatment retention, as three or more consecutive, monthly BUP-XR injections following the transition to BUP-XR in this retrospective chart review., Results: Participants' mean age was 38 years old and 67% were male. The average duration of sublingual buprenorphine prior to transition was 17.1 (±28.1) months. Three months after transition, 48% of extended-release buprenorphine patients had discontinued BUP-XR treatment. Persons with chronic pain were more likely, and those who had used heroin in the past month less likely to continue BUP-XR. Mean months on sublingual buprenorphine prior to BUP-XR initiation was 24.3 (±32.5) months for people who received 3+ post-induction injections compared to only 8.9 (±19.5) months for those who did not (p = .009)., Conclusions: Extended-release buprenorphine discontinuation was high in a real-world setting. Retention continues to represent a major obstacle to treatment effectiveness, and programs need interventions with even newer MOUD formulations., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Persons with opioid use disorder (OUD) are prone to frequent relapse following brief inpatient medically managed withdrawal. This longitudinal, naturalistic study examines associations among illicit opioid use, use of medication for opioid use disorder (MOUD), and one's confidence in the ability to resist drug use in the face of negative emotions (i.e., negative affect-associated drug refusal self-efficacy)., Method: Participants were 220 adults with OUD who recently completed a short-term inpatient program and the study followed for 6 months. At baseline, participants reported demographics, illicit opioid use, recent engagement with MOUD, and negative affect-associated drug refusal self-efficacy. At follow-up (1 week and 1-, 3-, and 6-months following discharge), participants reported illicit opioid use and MOUD., Results: Participants averaged 30.7 years of age, 63.2% were male, and 84.1% were white. Both illicit opioid use and rates of MOUD increased during the 6-month follow-up period, although only 34.1% received MOUD. At baseline, participants reported less than 50% self-confidence to resist using opioids during negative emotional states. Baseline negative affect-associated drug refusal self-efficacy inversely predicted illicit opioid use (p = .01) at follow-up but was not associated with follow-up MOUD., Conclusion: Among persons with OUD, lower confidence to resist using opioids in negative emotional states predicts greater use of illicit opioids in the months following medically managed withdrawal, even with receipt of MOUD., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and Objectives: Internationally, supervised injection facilities (SIFs) have demonstrated efficacy in reducing rates of overdose and promoting entry into treatment among persons who inject drugs (PWID); however, they remain unavailable in the United States. Early findings examining American PWID illustrate high overall willingness to use SIFs. The current study expands upon this research by examining PWID's likelihood to use SIFs based on services offered (eg, provides clean needles, linkage to treatment programs) and whether known risk factors (prior overdose, homelessness) influence PWID's willingness to use a SIF., Methods: Participants (n = 184) were patients entering short-term inpatient opioid withdrawal management in Massachusetts between May 2018 and February 2019 who reported injection drug use in the prior 30 days. We examined PWID's likelihood to use a SIF if eight unique services were available, and compared if this differed by overdose history and homelessness status using ordered logistic regression and Pearson's χ 2 -tests of independence., Results: Participants (34.2 [±8.3 SD] years of age, 68.5% male, 85.9% white, 8.2% Hispanic) reported being most likely to use SIFs that provided safety from police intervention (86.7%), entry into withdrawal management (85.9%), or clean needles (83.2%). Drug works disposal and safety from police were particularly important for PWID with a history of overdose., Conclusion and Scientific Significance: Overall, treatment-seeking PWIDs reported greater willingness to utilize SIFs if particular services were provided. These findings point to features of SIFs that may enhance treatment-seeking PWID's amenability to utilizing these services if such sites open in the United States. (Am J Addict 2021;30:21-25)., (© 2020 American Academy of Addiction Psychiatry.)

Background: Persons with opioid use disorder (OUD) are at increased risk for gabapentin misuse. Rising rates of concomitant gabapentin-opioid use in the U.S. are concerning given heightened risk of fatal overdose., Objective: To examine predictors of ever using gabapentin among persons seeking treatment for opioid use and to assess if reasons for gabapentin use differed by gender and how gabapentin was procured (prescribed, non-prescribed, or both)., Method: Persons with OUD were recruited from a managed withdrawal program. t-Tests and Pearson χ2 tests of independence were used to compare reasons for gabapentin use by gender and source of acquisition., Results: Among participants (n = 401; 69.1% male, 84.5% White, 86.8% sought treatment for heroin use, 90.0% insured), female gender, higher educational attainment, injection drug use (IDU), history of overdose, and chronic pain were associated with gabapentin use. Overall, reasons for use were similar across genders among those reporting a history of gabapentin use (65.8%), although males were more likely to use to get high than females. About half (47.0%) reported only using gabapentin that was not prescribed, 20.5% had only used prescribed gabapentin, and 32.5% reported prescribed and non-prescribed use. Persons prescribed gabapentin were most likely to use it to control pain (81.5%); for those using diverted gabapentin only and those reporting both prescribed and non-prescribed gabapentin use, the most common reasons for intake were to: get high, increase effects of heroin, substitute for opioids, and help with opioid withdrawal., Conclusions: In this sample of people with OUD entering inpatient detoxification program, a majority reported a history of gabapentin use, with most using diverted gabapentin. The range of reasons for gabapentin use point to the need to better understand why co-use is common., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Fentanyl-adulterated heroin supply chains are increasing risks for fatal overdose in the U.S., Objective: The current study examined the use of overdose risk reduction behaviors among persons seeking treatment for heroin use and whether perceptions about the presence of fentanyl in one's heroin are associated with overdose risk reduction behaviors., Method: We recruited persons with opioid use disorder entering a managed withdrawal program. We used multiple linear regression to estimate the adjusted associations of participant characteristics and perception of fentanyl exposure with the frequency of engaging in each of five overdose reduction behaviors., Results: Participants (n = 239; 75.3% male, 81.2% White, 67% injectors) estimated that 69.2% of the heroin they use contains fentanyl, and 94.6% knew that fentanyl increases overdose risk. Approximately 30% of respondents reported usually or always making sure others are around when they use heroin, carrying naloxone, taking "tester" doses of heroin or intentionally using in reduced amounts. While a majority of the sample reported never carrying naloxone or taking tester doses, and 70.2% reported never making sure that others around them carry naloxone, 84.5% had implemented one or more behavior at least rarely. Past month injection drug use was associated with making sure others are around, but perceptions about fentanyl in one's heroin were not associated with use of harm reduction behaviors., Conclusions: In this sample of people who use heroin, although overdose risk reduction behaviors were not usually used, a majority had tried at least one behavior. That perceived exposure to fentanyl-adulterated heroin was not associated with the use of such behaviors provides important implications for public health education and intervention programming., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims: To assess the long-term safety of subcutaneous buprenorphine (CAM2038) weekly and monthly depots., Design: Phase 3, open-label, observational, multi-centre 48-week trial (ClinicalTrials.gov NCT02672111)., Setting: Twenty-six out-patient sites (United States, United Kingdom, Hungary, Denmark, Sweden, Germany, Australia) between 14 December 2015 and 12 April 2017., Participants: Two hundred and twenty-eight adults with opioid use disorder; 227 received CAM2038 (37 initiated onto CAM2038 and 190 converted from sublingual buprenorphine)., Interventions: CAM2038 weekly (8, 16, 24 or 32 mg) or monthly (64, 96, 128 or 160 mg) with flexible dosing and individualized titration utilizing multiple CAM2038 weekly and monthly doses., Measurements: Safety variables, urine toxicology samples and self-reported illicit opioid use were collected at each visit. Participants were administered a patient satisfaction survey at months 6 and 12, completed by 162 of 227 (71.4%) participants., Findings: The study treatment period was completed by 167 of 227 (73.6%) participants. At least one treatment-emergent adverse event (TEAE) was reported by 143 of 227 (63.0%) participants, of whom 60 of 227 (26.4%) reported as being drug-related. Most of the TEAEs, reported by 128 of 227 (56.4%) of participants, were mild or moderate in intensity. Injection-site reactions were reported by 46 of 227 (20.3%) participants, with most [45 of 46 (97.8%)] reported as mild to moderate. Five participants (2.2%) discontinued the study drug due to a TEAE, two cases (0.9%) of which were injection-site-related. No serious adverse events were attributed to the study drug. Among those remaining in the study, the percentage of opioid-negative urine tests combined with self-reports was 63.0% (17 of 27) in new-to-treatment participants and 82.8% (111 of 134) for those converted from sublingual buprenorphine. Participants reported high levels of satisfaction with CAM2038., Conclusions: Subcutaneous buprenorphine delivered weekly or monthly (CAM2038) was well tolerated, with a systemic safety profile consistent with the known profile of sublingual buprenorphine. CAM2038 weekly and monthly was associated with high retention rates and low levels of illicit opioid use throughout this study., (© 2019 Braeburn Inc. Addiction published by John Wiley & Sons Ltd on behalf of Society for the Study of Addiction.)

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

Objective: Normative perceptions about substance use are well-established predictors of substance use risk behaviors, yet no research to date has examined how people who use heroin perceive the drug use behaviors and their association with personal behaviors. In a sample of persons seeking heroin withdrawal, we compared normative beliefs (descriptive norms) about others' drug use behaviors, and examined the association between normative beliefs and behaviors., Method: Participants (n = 241) were patients undergoing short-term inpatient heroin withdrawal management in Massachusetts. t-Tests were used to compare participants' perceptions about various substance use behaviors among both US adults and persons seeking heroin withdrawal at the same site. We also examined associations between participants' normative beliefs and personal substance use behaviors., Results: Participants significantly overestimated drug-related risk behaviors of adults nationally; overall, participants estimated that 44.7% had tried heroin, 37.6% had injected drugs in the past year, and 63.2% had smoked marijuana in the past month when actual national rates are 2.0%, 0.3%, and 5.5%, respectively. Participants also held significant misperceptions about contemporaneous patients in the heroin withdrawal program; behaviors about sharing works, diverting buprenorphine or methadone, and exchanging sex for drugs or money were most substantially overestimated. Normative perceptions were associated with a range of personal drug-using behaviors (eg, injection drug use, exchanging sex for drugs or money)., Conclusions: Consistent with existing substance use norms research, participants in the current sample tended to overestimate others' engagement in risky substance use, and these normative perceptions were associated with increased personal risk. Leveraging norms in heroin harm reduction interventions may hold substantial promise.

One key strategy to improve treatment access for persons with opioid use disorder (OUD) is overcoming stigma that is internalized by such individuals. Because few theoretically-derived, multidimensional measures of substance abuse stigma exist, we contribute a brief, theoretically-based measure of opioid-related stigma (adapted from Corrigan's Self-Stigma of Mental Illness Scale) to assess perceived stigma and internalized stigma among individuals with OUD. This study presents initial validation of the newly-developed Brief Opioid Stigma Scale among 387 adults who entered an inpatient opioid managed-withdrawal program. The scale assesses: (1) Stereotype awareness ("Aware"), or the extent to which individuals who use opioids perceive community members to believe OUD-related stereotypes; (2) Stereotype agreement ("Agree"), or the endorsement of stigmatizing beliefs by individuals who use opioids; (3) Self-esteem decrement ("Harm"), or the diminution of self-esteem due to these negative stereotypes' impacts on self-worth. Psychosocial measures including self-esteem, depressive symptoms, mental and physical functioning, and desire for aftercare OUD medication treatment, were administered to assess construct validity. Results showed that greater endorsement of the "harm" stigma subscale was associated with greater depressive symptoms, lower self-esteem, and poorer mental and physical functioning. The "aware" stigma subscale displayed similar overall patterns of associations with self-esteem and depression but to a lesser magnitude. The "aware" stigma subscale was positively associated with desire for aftercare methadone and naltrexone treatment, and the "harm" subscale was positively associated with desire for aftercare buprenorphine treatment. Results indicated good initial construct validity. Tailored stigma interventions are recommended for specific aftercare OUD medication treatments., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background and Objectives: Polysubstance use is associated with relapse and poor treatment outcomes among people dependent on heroin. Despite the high prevalence of polysubstance use among patients detoxifying from heroin, little is known about patients' expectations to abstain or use non-opiate substances. The current study examined factors associated with expectations about abstaining from alcohol, cocaine, and benzodiazepines (BZDs) following heroin withdrawal management., Methods: Between May and December of 2015, we surveyed 417 patients (71.9% male, 31.7 [±8.39] mean years old) initiating short-term inpatient heroin withdrawal management who reported alcohol, cocaine, or BZD use in the past 30 days. We used logistic regression to evaluate the adjusted associations of background characteristics with expectations about using each substance following discharge., Results: Approximately half of respondents reported past month alcohol (52%), cocaine (47.0%), or BZD (47.0%) use, and 25.9% reported using all three substances. Approximately half of those reporting drinking, 6.6% reporting cocaine use, and 27% of reporting BZD use expected to abstain from using that substance following heroin withdrawal. Prior opioid withdrawal was associated with a lower likelihood of expecting to stop using alcohol and BZDs, and more days of BZD use was associated with a greater likelihood of expecting to abstain from BZDs following discharge., Conclusion: Persons with opioid use disorder often do not expect to stop using other substances following withdrawal management, with very few planning cocaine cessation., Scientific Significance: Inpatient heroin withdrawal programs need to address and educate patients about how polysubstance use complicates recovery from heroin use. (Am J Addict 2019;28:36-42)., (© 2018 American Academy of Addiction Psychiatry.)

Background: In the current study, we examined factors predicting willingness to receive buprenorphine treatment and preferences for various buprenorphine formulations (oral, injection, implant) among persons in opioid withdrawal management., Methods: Participants were three hundred thirty-eight persons entering brief inpatient opioid withdrawal management programs at two sites. We used t-tests and Pearson χ2 - tests of independence to compare participants willing and unwilling to be prescribed buprenorphine in the future. Among persons willing to receive buprenorphine, we used multinomial logistic regression to estimate the adjusted effects of potential correlates of type of buprenorphine formulation preferred., Results: Participants averaged 33.9 (±9.5) years of age, 70.4% were male, 82.8% were White, and 11.0% were Latino/a. In all, 55.6% of participants had been prescribed buprenorphine in the past, and 54.7% were willing to use prescribed buprenorphine in the future. Those reporting past month illicit buprenorphine use and prior overdose were more willing to use prescribed buprenorphine. Of these (n = 180), most preferred daily buprenorphine formulations (tablet or film) (48.6%) over a weekly or monthly injection (23.1%) or bi-annual implant (28.3%)., Conclusions: Past buprenorphine prescription does not predict future willingness to restart. Among those willing to use buprenorphine, newer formulations of buprenorphine appealed to more than half of the participants., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Importance: Buprenorphine treatment for opioid use disorder may be improved by sustained-release formulations., Objective: To determine whether treatment involving novel weekly and monthly subcutaneous (SC) buprenorphine depot formulations is noninferior to a daily sublingual (SL) combination of buprenorphine hydrochloride and naloxone hydrochloride in the treatment of opioid use disorder., Design, Setting, and Participants: This outpatient, double-blind, double-dummy randomized clinical trial was conducted at 35 sites in the United States from December 29, 2015, through October 19, 2016. Participants were treatment-seeking adults with moderate-to-severe opioid use disorder., Interventions: Randomization to daily SL placebo and weekly (first 12 weeks; phase 1) and monthly (last 12 weeks; phase 2) SC buprenorphine (SC-BPN group) or to daily SL buprenorphine with naloxone (24 weeks) with matched weekly and monthly SC placebo injections (SL-BPN/NX group)., Main Outcomes and Measures: Primary end points tested for noninferiority were response rate (10% margin) and the mean proportion of opioid-negative urine samples for 24 weeks (11% margin). Responder status was defined as having no evidence of illicit opioid use for at least 8 of 10 prespecified points during weeks 9 to 24, with 2 of these at week 12 and during month 6 (weeks 21-24). The mean proportion of samples with no evidence of illicit opioid use (weeks 4-24) evaluated by a cumulative distribution function (CDF) was an a priori secondary outcome with planned superiority testing if the response rate demonstrated noninferiority., Results: A total of 428 participants (263 men [61.4%] and 165 women [38.6%]; mean [SD] age, 38.4 [11.0] years) were randomized to the SL-BPN/NX group (n = 215) or the SC-BPN group (n = 213). The response rates were 31 of 215 (14.4%) for the SL-BPN/NX group and 37 of 213 (17.4%) for the SC-BPN group, a 3.0% difference (95% CI, -4.0% to 9.9%; P < .001). The proportion of opioid-negative urine samples was 1099 of 3870 (28.4%) for the SL-BPN/NX group and 1347 of 3834 (35.1%) for the SC-BPN group, a 6.7% difference (95% CI, -0.1% to 13.6%; P < .001). The CDF for the SC-BPN group (26.7%) was statistically superior to the CDF for the SL-BPN/NX group (0; P = .004). Injection site adverse events (none severe) occurred in 48 participants (22.3%) in the SL-BPN/NX group and 40 (18.8%) in the SC-BPN group., Conclusions and Relevance: Compared with SL buprenorphine, depot buprenorphine did not result in an inferior likelihood of being a responder or having urine test results negative for opioids and produced superior results on the CDF of no illicit opioid use. These data suggest that depot buprenorphine is efficacious and may have advantages., Trial Registration: ClinicalTrials.gov Identifier: NCT02651584.

Introduction: Despite ample research examining how alcohol use relates to gun involvement, little is known about the relationship between opioids and gun involvement. In the current study, we examined correlates of gun possession, accessibility, and related behaviors in an opioid dependent sample., Methods: Between October 2016 and April 2017, we surveyed persons entering a brief, inpatient opioid detoxification (n = 386) and 51 contemporaneous persons seeking alcohol detoxification at the same facility in Massachusetts and recorded their lifetime experiences with gun involvement., Results: Participants averaged 33 years of age, 74% were male, 83% were White, and 64% had a history of incarceration. Opioid users had significantly higher rates of gun involvement than persons in alcohol detoxification; for example, 31.3% (vs. 3.9%) had carried a gun for protection, 45.1% (vs. 25.5%) had been threatened with a gun, and 13.8% (vs. 2.0%) had shot at another person. Among persons misusing opioids, male and non-White respondents, and those with a history of incarceration or poorer self-control reported greater gun involvement., Conclusions: Opioid users, both men and women, lead gun-involved lives., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: Fentanyl-contaminated opioid supplies have led to rising overdose fatalities in recent years. We compared beliefs, behaviors, and risk perceptions related to fentanyl with actual toxicology reports among people who used opioids., Method: Participants (n=231) were patients undergoing short-term inpatient opioid withdrawal management in Fall River, Massachusetts. We compared persons testing positive and negative for fentanyl on urine toxicological testing at program entry., Results: Nearly all (95.7%) participants believed that fentanyl increases risk for overdose/death, and 86.6% of participants tested positive for fentanyl. Positive fentanyl toxicology test results were associated with lower educational attainment, history of injection drug use, and self-reported lifetime use of fentanyl. Of those reporting they had never been exposed to fentanyl (intentionally or unintentionally) (n=33), two-thirds tested positive for fentanyl; among those believing their tests would be negative (n=49), 71.4% tested positive for fentanyl. Heroin use was associated with fentanyl exposure; persons who reported past month heroin use (n=213) were more likely to test positive for fentanyl (91.1%) than persons using non-heroin opioids (n=18; 33.3%)., Conclusions: Nearly nine in ten participants tested positive for fentanyl, including participants who anticipated their tests would be negative. Leveraging toxicology results in opioid withdrawal settings may be helpful in educating patients about fentanyl exposure and risks., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Extended-release naltrexone (XR-NTX), an opioid antagonist, and sublingual buprenorphine-naloxone (BUP-NX), a partial opioid agonist, are pharmacologically and conceptually distinct interventions to prevent opioid relapse. We aimed to estimate the difference in opioid relapse-free survival between XR-NTX and BUP-NX., Methods: We initiated this 24 week, open-label, randomised controlled, comparative effectiveness trial at eight US community-based inpatient services and followed up participants as outpatients. Participants were 18 years or older, had Diagnostic and Statistical Manual of Mental Disorders-5 opioid use disorder, and had used non-prescribed opioids in the past 30 days. We stratified participants by treatment site and opioid use severity and used a web-based permuted block design with random equally weighted block sizes of four and six for randomisation (1:1) to receive XR-NTX or BUP-NX. XR-NTX was monthly intramuscular injections (Vivitrol; Alkermes) and BUP-NX was daily self-administered buprenorphine-naloxone sublingual film (Suboxone; Indivior). The primary outcome was opioid relapse-free survival during 24 weeks of outpatient treatment. Relapse was 4 consecutive weeks of any non-study opioid use by urine toxicology or self-report, or 7 consecutive days of self-reported use. This trial is registered with ClinicalTrials.gov, NCT02032433., Findings: Between Jan 30, 2014, and May 25, 2016, we randomly assigned 570 participants to receive XR-NTX (n=283) or BUP-NX (n=287). The last follow-up visit was Jan 31, 2017. As expected, XR-NTX had a substantial induction hurdle: fewer participants successfully initiated XR-NTX (204 [72%] of 283) than BUP-NX (270 [94%] of 287; p<0·0001). Among all participants who were randomly assigned (intention-to-treat population, n=570) 24 week relapse events were greater for XR-NTX (185 [65%] of 283) than for BUP-NX (163 [57%] of 287; hazard ratio [HR] 1·36, 95% CI 1·10-1·68), most or all of this difference accounted for by early relapse in nearly all (70 [89%] of 79) XR-NTX induction failures. Among participants successfully inducted (per-protocol population, n=474), 24 week relapse events were similar across study groups (p=0·44). Opioid-negative urine samples (p<0·0001) and opioid-abstinent days (p<0·0001) favoured BUP-NX compared with XR-NTX among the intention-to-treat population, but were similar across study groups among the per-protocol population. Self-reported opioid craving was initially less with XR-NTX than with BUP-NX (p=0·0012), then converged by week 24 (p=0·20). With the exception of mild-to-moderate XR-NTX injection site reactions, treatment-emergent adverse events including overdose did not differ between treatment groups. Five fatal overdoses occurred (two in the XR-NTX group and three in the BUP-NX group)., Interpretation: In this population it is more difficult to initiate patients to XR-NTX than BUP-NX, and this negatively affected overall relapse. However, once initiated, both medications were equally safe and effective. Future work should focus on facilitating induction to XR-NTX and on improving treatment retention for both medications., Funding: NIDA Clinical Trials Network., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Introduction: Among people with opioid use disorder (OUD), stigma is a known barrier to accessing treatment and has negative impacts on physical and mental health. The purpose of this study was to understand the factors associated with self-stigma and perceived stigma severity among people with OUD entering an inpatient detoxification program., Methods: Between December 2015 and August 2016, consecutive persons seeking inpatient opioid detoxification were asked to complete a survey that included sociodemographic, drug use, treatment variables, an 8-item General Self-Stigma scale, and a 3-item Treatment Stigma scale. Correlates of stigma severity were estimated using ordinary least squares regression., Results: The 407 participants had an average age of 32.4 (±8.79) years, with 72.2% male and 84.5% non-Hispanic White. Two-thirds had ever received medication-assisted treatment for OUD and 323 (79.4%) had ever been admitted to a detoxification program. Adjusted mean General Self-Stigma scores were positively and significantly associated with recent injection drug use (b = 0.262, P = 0.032), and having previously entered detoxification programs (b = 0.330, P = 0.016). Adjusted mean Treatment Stigma scores were positively and significantly associated with years of education (b = 0.142, P = 0.002), having ever been prescribed naltrexone (b = 0.277, P = 0.025) and having previously entered detoxification programs (b = 0.389, P = 0.007)., Conclusion: People with OUD presenting for inpatient detoxification struggle with experiences of self and perceived stigma. Strikingly, people with previous detoxification program admission had higher levels of stigma on both scales. Our findings suggest an opportunity for targeted intervention in this group.

Introduction: Naloxone is a safe and effective antidote for reversing opioid overdose. Layperson administration of naloxone is increasingly common, yet little is known about demographic and clinical factors associated with opioid users' likelihood of having administered naloxone to another opioid user who had overdosed. We examined predictors of reported naloxone administration in the past year., Methods: Four hundred and sixty-eight patients were interviewed upon admission to brief, inpatient opioid detoxification between May and December of 2015. Between group differences were tested using t-tests for differences in means and χ 2 -tests for differences in counts., Results: Participants averaged 32years of age, 28.9% were female, and 86.8% were White. Most (86.8%) reported detoxifying from heroin, 69.0% had injected drugs in the last 30days. One sixth (n=68) of those detoxifying from heroin, but none of those detoxifying from other opioids (n=62) had administered naloxone in the past year. Among the small number of Black/African American participants (n=20), none had administered naloxone, although 90% were heroin users. Respondents were more likely to have administered naloxone if they reported recent injection drug use (IDU), had a history of overdose, or witnessed an overdose in the past year (ps<0.05), even though less than one-third of bystanders of overdose reported administering naloxone., Conclusions: Higher opioid-related mortality risk (heroin use, IDU, past overdose) was associated with greater likelihood of reported naloxone administration in the past year. The non-use of naloxone among certain groups-prescription pill users and Blacks-was unexpected., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Sleep disturbance is common among patients receiving long-term opioid therapies, such as methadone maintenance. However, little is known about sleep disturbances in patients receiving medication treatment with buprenorphine. We sought to determine the frequency of subjective sleep disturbance in a sample of patients receiving medication treatment and to examine clinical factors related to sleep disturbance., Methods: Participants were 328 persons receiving buprenorphine at 3 primary care sites. Sleep difficulty was assessed 2 questions adapted from the Patient Health Questionnaire-9 (PHQ-9) item assessing sleep. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CESD)-10 and PHQ-2. In addition, information was gathered on participant demographics and treatment characteristics. Demographics, buprenorphine treatment history, and depressive symptoms were compared for those with and without self-reported sleep difficulty. Logistic regression was used to estimate the adjusted association of sleep disturbance with these correlates., Results: Seventy-one percent of persons receiving medication treatment with buprenorphine in the present study reported sleep difficulty. Persons reporting sleep disturbance reported shorter time in buprenorphine treatment and more depressed mood compared with those without sleep difficulty (p < .01). Men were significantly less likely to report disturbed sleep than women (odds ratio [OR] = 0.57, 95% confidence interval [CI]: 0.33, 0.98). Sleep disturbance was not associated significantly with age, ethnicity, educational attainment, or buprenorphine dose., Conclusions: Sleep disturbance is common in patients receiving medication treatment with buprenorphine and is associated with more depressive symptoms as well as a shorter duration of medication treatment. Future research, using subjective and objective sleep measures, is warranted to understand whether sleep disturbance is mitigated by longer buprenorphine treatment and whether difficulty sleeping predicts buprenorphine discontinuation among patients seeking treatment for opioid dependence.

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

Introduction: Adverse childhood experiences are associated with the development of substance use disorders. With opioid use disorder, a growing concern in the United States, we were interested in examining the relationship between adverse experiences and three landmarks of opioid use: age of opioid initiation, injection drug use, and lifetime overdose., Methods: Between May and December 2015, we interviewed consecutive persons seeking inpatient opioid detoxification. Participants were asked about age of opioid initiation, last month injection drug use, and lifetime history of overdose, and completed the ten-item Adverse Childhood Experience (ACE) questionnaire., Results: Participants (n=457) averaged 32.2 (±8.64) years of age, 71.3% were male, and 82.5% were non-Hispanic White. The mean score on the ACE scale was 3.64 (±2.75). Mean age at time of initiating opioid use was 21.7 (±7.1) years, 68.7% had injected drugs within the past month, and 39.0% had overdosed. After adjusting for age, gender, and ethnicity, the ACE score was inversely associated with age of initiating opioid use (b=-0.50, 95% CI -0.70; -0.29, p<.001), and positively associated with recent injection drug use (OR=1.11, 95% CI 1.02; 1.20, p=0.014) and the likelihood of experiencing an overdose (OR=1.10, 95% CI 1.02; 1.20, p=0.015) in a graded dose response manner., Conclusion: Greater adverse childhood experiences are associated with three landmarks of opioid use risk. ACE screening may be useful in identifying high-risk subsets of opioid-using populations., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: An individual's self-efficacy to refuse using heroin in high-risk situations is believed to minimize the likelihood for relapse. However, among individuals completing inpatient heroin detoxification, perceived refusal self-efficacy may also reduce one's perceived need for medication-assisted treatment (MAT), an effective and recommended treatment for opioid use disorder. In the current study, we examined the relationship between heroin refusal self-efficacy and preference for MAT following inpatient detoxification., Method: Participants (N=397) were interviewed at the start of brief inpatient opioid detoxification. Multiple logistic regression was used to estimate the adjusted association of background characteristics, depressed mood, and perceived heroin refusal self-efficacy with preference for MAT., Results: Controlling for other covariates, depressed mood and lower perceived refusal self-efficacy were associated with a significantly greater likelihood of expressing preference for MAT (versus no MAT)., Conclusions: Perceived ability to refuse heroin after leaving detox is inversely associated with a heroin user's desire for MAT. An effective continuum of care model may benefit from greater attention to patient's perceived refusal self-efficacy during detoxification which may impact preference for MAT and long-term recovery., (Copyright © 2017. Published by Elsevier Ltd.)

Background: The lives of persons who use illicit substances are filled with physical adversities and negative outcomes., Objectives: The purpose of this study was to determine: 1) the frequency of substance-related fights, fractures, and driving accidents in the past year among heroin users entering an inpatient detoxification program, and 2) to determine demographic and recent substance use factors associated with the most common of these physical traumas., Methods: Between May 2015 and December 2015, we surveyed 433 persons entering a short-term inpatient detoxification program that reported heroin use in the last month and recorded their experiences of physical traumas in the last year., Results: Among participants (72% male; 74% heroin injectors), more than a quarter (28.6%) reported a substance-related fight in the past year. Multivariate modeling revealed cocaine use, hazardous alcohol use, and younger age were significantly associated with fighting, but gender was not. Forty-five (10.4%) persons reported a fracture in the past year, with 64% of fractures related to a substance-related fall or fight. Additionally, 9.0% reported being a driver in a car accident after drinking or using drugs in the past year. Trauma rates were not significantly different from a contemporaneous cohort seeking alcohol detoxification at the same facility., Conclusion: Heroin users, both men and women, lead physically traumatic lives, interrupted by interpersonal violence, falls, fractures, and motor vehicle accidents., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objective: Buprenorphine medication-assisted treatment (B-MAT) is an efficacious and popular outpatient treatment for opioid use disorder. However, the likelihood of buprenorphine diversion is a public health concern. We examined the relationship between attitudes toward diversion as predictors of both sharing and selling buprenorphine., Method: Participants (n=476) were patients undergoing short-term inpatient opioid detoxification. Multinomial logistic regression was used to estimate the adjusted association of sharing and selling buprenorphine with demographics, substance use behaviors, and attitudes toward sharing and selling buprenorphine., Results: Among the two hundred persons who had ever been prescribed buprenorphine (73.4% male, 89% heroin users), 50.5% reported they had shared buprenorphine and 28.0% reported they had sold buprenorphine. Controlling for other covariates, the odds of sharing buprenorphine were 3.17 (95% CI 1.21; 8.32) times higher for persons who agreed that it was "right to share buprenorphine with dope sick friends" than for those who did not agree with this attitude. Attitudes toward selling (OR 2.92; 95% CI 1.35; 6.21) and sharing (OR 4.12; 95% CI 1.64; 10.32) buprenorphine were the only significant correlates of selling, with the odds of selling exponentially greater among persons with favorable attitudes toward sharing or selling buprenorphine., Conclusions: Although considered diversion, sharing B-MAT is normative among B-MAT patients. Assessing B-MAT patients' attitudes about diversion may help identify patients requiring enhanced oversight, education, or intervention aimed at modifying attitudes to reduce their likelihood to share or sell buprenorphine., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: Depression is common among persons with opioid use disorder. We examined the perceived need for depression treatment (PNDT) among opioid-dependent patients and the relationship of PNDT to depression screening result., Methods: Between May and December 2015, we surveyed consecutive persons (n = 440) seeking inpatient opioid detoxification. We used the Patient Health Questionnaire-2 (PHQ-2) to screen for depression. To assess perceived need for depression services, participants were asked, "Do you believe you should be treated for depression?" Response options were recorded into four categories: "Not Depressed (ND)," "Perceive Need for Depression Treatment (PNDT)," "Depressed/Don't Want Treatment," and "Currently Treated.", Results: Participants' mean age was 32.3 (±8.7) years; 70.7% were male. Nearly two out of three persons screened positive for depression yet only 8.2% were being treated for depression prior to admission. Screening positive for depression was associated with a 2.95 (95%CI 1.82-4.81, p < .005) fold increase in the expected odds of PNDT. But nearly half of those depressed (48%) did not perceive the need for treatment. Approximately 40% of the participants (n = 177) perceived that they were not depressed; of these persons, 52% screened positive for depression., Discussion and Conclusions: Detoxification program staff should screen patients for depression, and if a clinical diagnosis is confirmed, discuss treatment options, exploring the level of interest in mental health treatment for depression., Scientific Significance: Screening for and addressing depression, including patients' interest in treatment, should be central to post-detoxification aftercare planning. (Am J Addict 2017;26:395-399)., (© 2017 American Academy of Addiction Psychiatry.)

Background: Patients admitted to addiction treatment programs report high rates of concurrent opioid and benzodiazepine (BZD) use. This combination places individuals at high risk for accidental overdose and other serious consequences. However, little is known about the beliefs opioid users have about the consequences of BZD use., Methods: We surveyed consecutive persons initiating inpatient opioid detoxification (N=476; 95.0% enrollment) and identified 245 who reported BZD use in the past 30days and/or had a positive toxicology. We compared those who did and did not report BZD use on demographic and substance use variables, and specific beliefs about the potential effects of BZDs., Results: Participants averaged 32.2years of age, 71.2% were male, 86.6% used heroin, and 68.7% reported injection drug use in the past 30days. Over half (51.5%) used a BZD in the month prior to admission; of these, 26.2% (n=64) reported being prescribed a BZD. Alprazolam (Xanax) was the most commonly used BZD (54%). Benzodiazepine users (versus non-users) were significantly more likely to be female and non-Hispanic White, use concurrent substances, and report past year overdose. Overall, nearly all BZD users endorsed accurate beliefs that BZDs can increase the risk of overdose and can be addictive. However, BZD users, relative to non-users, were significantly less likely to endorse some known adverse consequences of BZDs, such as risk of worsening depression and poor medication-assisted opioid treatment retention., Conclusions: Delineating the full array of risks from combining BZDs and opioids should be a high priority in detoxification settings, given the increased risks associated with BZD misuse in this population., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background/objectives: The current study examined knowledge of previous use, and willingness to take alcohol-related medication among individuals in medically supervised detoxification., Methods: Participants (n = 302) provided health and demographic information, substance use and detoxification history, PCP visits, and AA attendance., Results: Most patients had knowledge of alcohol medications, one-third had past prescription, and over 80% reported willingness to take medication. Previous detoxification predicted medication knowledge, while previous treatment predicted past prescription., Discussion/conclusions: More patients are willing to take medication than are prescribed medication., Scientific Significance: Findings suggest the opportunity to increase medication use following detoxification which could reduce subsequent relapse. (Am J Addict 2017;26:118-121)., (© 2017 American Academy of Addiction Psychiatry.)

Introduction: For opioid-dependent patients in the US and elsewhere, detoxification and counseling-only aftercare are treatment mainstays. Long-term abstinence is rarely achieved; many patients relapse and overdose after detoxification. Methadone, buprenorphine-naloxone (BUP-NX) and extended-release naltrexone (XR-NTX) can prevent opioid relapse but are underutilized. This study is intended to develop an evidence-base to help patients and providers make informed choices and to foster wider adoption of relapse-prevention pharmacotherapies., Methods: The National Institute on Drug Abuse's Clinical Trials Network (CTN) study CTN-0051, X:BOT, is a comparative effectiveness study of treatment for 24weeks with XR-NTX, an opioid antagonist, versus BUP-NX, a high affinity partial opioid agonist, for opioid dependent patients initiating treatment at 8 short-term residential (detoxification) units and continuing care as outpatients. Up to 600 participants are randomized (1:1) to XR-NTX or BUP-NX., Results: The primary outcome is time to opioid relapse (i.e., loss of persistent abstinence) across the 24-week treatment phase. Differences between arms in the distribution of time-to-relapse will be compared (construction of the asymptotic 95% CI for the hazard ratio of the difference between arms). Secondary outcomes include proportions retained in treatment, rates of opioid abstinence, adverse events, cigarette, alcohol, and other drug use, and HIV risk behaviors; opioid cravings, quality of life, cognitive function, genetic moderators, and cost effectiveness., Conclusions: XR-NTX and BUP-NX differ considerably in their characteristics and clinical management; no studies to date have compared XR-NTX with buprenorphine maintenance. Study design choices and compromises inherent to a comparative effectiveness trial of distinct treatment regimens are reviewed., Clinical Trial Registration: NCT02032433., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Over the past decade, patients admitted to addiction treatment programs have reported increasing rates of concurrent opioid and benzodiazepine (BZD) use. This drug combination places individuals at high risk for accidental overdose. Little is known about reasons for BZD use among individuals seeking treatment for opioid use disorders., Methods: We surveyed consecutive persons initiating inpatient opioid detoxification and identified 176 out of 438 who reported BZD use in the past 30 days and/or had a positive toxicology., Results: Forty percent of persons surveyed used a BZD in the month prior to admission, and 25% of these met criteria for BZD dependence (DSM IV). BZD users averaged 32.0 years of age, 63.6% were male, 85.2% used heroin, and reported, on average, 13.3 (±11.2) days of BZD use during the past month. Alprazolam (Xanax) was the most commonly used BZD (52%), and buying it on the street the most common source (48%). The most commonly reported reason for BZD use was 'to manage anxiety' (42.6%), followed by 'to get or enhance a high' (27.7%), 'to help with sleep' (11.4%), and 'to decrease opioid withdrawal' (10.2%). The most common reason for BZD use was significantly associated (p<.001) with most likely source of BZDs, with persons who got their BZDs from a prescriber (23%) more likely to report BZD anxiety as their primary reason for use, while persons who bought BZDs on "the street" (48%) had the highest likelihood of reporting using BZD to get or enhance a high. Participants using BZDs most commonly for anxiety did not endorse lower anxiety than those using BZDs for other reasons., Conclusions: Two in five persons seeking detoxification for an opioid use disorder used a BZD in the prior month. Anxiety was the most common reason patients reported using a benzodiazepine, but they also reported using BZDs to enhance a 'high' and manage opioid withdrawal. Evidence-based discussions about the risks of combining BZDs and opioids, and alternatives to BZDs should be a high priority in detoxification settings., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In this pilot study, we assessed feasibility and acceptability of a behavior therapy intervention for pain and depressive symptoms in persons living with HIV/AIDS (PLWH). We randomly assigned 23 participants to HIV-PASS (HIV-Pain and Sadness Study) or a health education control arm for 3 months. On average, participants attended more than 5 sessions (of 7 possible) in both arms. Qualitative data suggest HIV-PASS participants understood key messages and made concrete behavioral changes. HIV-PASS was associated with effects in the expected direction for three of four outcomes, including the primary outcome (pain-related interference with functioning). Findings suggest that HIV-PASS is promising.

Introduction: Opioid use disorders commonly require ongoing medication-assisted treatment to reduce relapse following discharge from inpatient detoxification programs. Naltrexone, an opioid antagonist, is an increasingly popular treatment option in its once-monthly injectable form (XR-NTX). The aim of this study was to examine the follow-up rates of persons who received an initial injection during inpatient detoxification and scheduled for receipt of a first outpatient injection in the primary care setting., Methods: We reviewed the electronic health records of 62 consecutive opioid dependent adults who received an initial injection of XR-NTX during extended inpatient detoxification at Stanley Street Treatment and Resources (SSTAR) in Fall River, Massachusetts, from March 2013 to August 2015, and were referred to the adjacent SSTAR primary care health center for their second injection 1 month later. Demographic information, drug use and opioid treatment history, and aftercare planning were assessed., Results: Participants averaged 32.4 (±7.8) years of age, 90.3% were non-Latino Caucasian, 35.5% were homeless, 21.3% reported a drug overdose in the last year, and 53.2% had been in detoxification within the last year. Of the 62 participants referred to primary care, 34 (54.8%) followed up to receive their second XR-NTX injection. Twenty of these persons received at least a third XR-NTX injection. No demographic, treatment history, substance use behaviors, or aftercare plan variables were associated with receipt of a second injection (p<.20)., Conclusion: Predicting, and therefore improving, XR-NTX continuation during the transition from inpatient detoxification to primary care may be difficult in this population., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: Smoking cessation pharmacotherapies tested in persons with opioid use disorder have produced low quit rates. Electronic cigarettes (e-cigarettes) have been used by many methadone-maintained (MMT) smokers, but controlled trials evaluating cessation and reduction outcomes have not been performed in this population with deleterious tobacco-related health consequences., Methods: In this open trial of NJOY e-cigarettes, MMT smokers received 6 weeks of treatment and were instructed to use only e-cigarettes. Outcomes included carbon monoxide confirmed 7-day point smoking cessation prevalence at week 7 (end of treatment) and self-reported change in mean cigarettes per day (CPD) at each 2-week assessment. The final assessment was 2 weeks after treatment ended (week 9)., Results: The 12 participants averaged 46 years old and 50% were male. On average, participants reported smoking 17.8 (±5.3) CPD. One person had a biochemically confirmed quit at week 7. Participants tended to report marked reductions in mean CPD between quit day (week 1) and the week 3 assessment. Relative to baseline, statistically significant reductions in mean CPD were observed at all follow-up assessments. Mean reductions in CPD were -12.4 (95% confidence interval [CI]: -15.0, -9.9; P < .001), -14.8 (95% CI: -17.4, -12.2; P < .001), -13.9 (95% CI: -16.6, -11.2), and -10.8 (95% CI: -13.4, -8.2; P < .01) at the 3-, 5-, 7-, and 9-week assessments, respectively. Adherence to e-cigarettes was 89.1% during the 6 treatment weeks., Conclusions: E-cigarettes were associated with reductions in cigarette use. Smoking cessation rates in MMT smokers are low and whether long-term smoking reductions can persist and produce health benefits should be studied., Implications: E-cigarettes were associated with reduced tobacco use in MMT smokers. Adherence to e-cigarettes is high among methadone smokers. Week-7 smoking quit rates are similar to pharmacotherapies tested in this population., (© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: This study explored the life concerns of persons seeking alcohol detoxification, a group with multiple life and psychosocial challenges. Gender may be an important contributor to the particular life concerns of persons with alcohol use disorders., Methods: Using a 32-item, previously-validated life concerns survey that captures ten conceptual domains, we interviewed persons entering inpatient alcohol detoxification asking them to rate their level of concern about health and welfare items., Results: Participants (n=189) were 27% female, with a mean age of 43.5 years. Overall, concern about alcohol problems was perceived as the most serious, followed by mental health, cigarette smoking, financial, and relationship problems. Men were significantly more concerned than women about six of the ten domains including money, drug use, transmissible diseases, and physical illness., Conclusions: Recognition of the daily worries of persons seeking inpatient alcohol detoxification persons could allow providers to better tailor their services to the context of their patients' lives. Focusing on pressing life concerns such as mental health, financial, relationship problems, and other drug use may influence detoxification services and aftercare treatment choices., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Substance misuse and excessive alcohol consumption are major public health issues. Internet-based interventions for substance use disorders (SUDs) are a relatively new method for addressing barriers to access and supplementing existing care. This study examines cost-effectiveness in a multisite, randomized trial of an internet-based version of the community reinforcement approach (CRA) with contingency management (CM) known as the Therapeutic Education System (TES)., Methods: Economic evaluation of the 12-week trial with follow-up at 24 and 36 weeks. 507 individuals who were seeking therapy for alcohol or other substance use disorders at 10 outpatient community-based treatment programs were recruited and randomized to either treatment as usual (TAU) or TES+TAU. Sub-analyses were completed on participants with a poorer prognosis (i.e., those not abstinent at study entry)., Results: From the provider's perspective, TES+TAU as it was implemented in this study costs $278 (SE=87) more than TAU alone after 12 weeks. The quality-adjusted life years gained by TES+TAU and TAU were similar; however, TES+TAU has at least a 95% chance of being considered cost-effective for providers and payers with willingness-to-pay thresholds as low as $20,000 per abstinent year. Findings for the subgroup not abstinent at study entry are slightly more favorable., Conclusions: With regard to the clinical outcome of abstinence, our cost-effectiveness findings of TES+TAU compare favorably to those found elsewhere in the CM literature. The analyses performed here serve as an initial economic framework for future studies integrating technology into SUD therapy., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Without aftercare treatment, the period following discharge from short-term inpatient detoxification for opioid dependence presents a high risk of relapse. Yet the role of patient preference in treatment selection is rarely discussed in the substance-abuse literature. We surveyed 485 persons initiating inpatient opioid detoxification who were predominantly male (71.3%) and had detoxed in the past (73.2%). When asked to choose the one treatment that would work best for them after discharge, 43% of participants selected medication-assisted treatment (MAT), 29% preferred residential, 12% selected drug-free counseling, 12% NA/AA meetings only, and 4% preferred no additional treatment. Residential treatment preference was significantly associated with homelessness, having been in a detox program within the past year, and having pending legal problems, indicating that there is a distinct profile of detox patients who prefer residential treatment despite its limited availability. Detox program staff should work with patients to understand reasons for treatment preferences to optimize aftercare services., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: As the advent of highly active antiretroviral therapy, HIV has become a chronic disease for most individuals in developed countries. Chronic pain is a common occurrence for HIV-infected patients and has an impact on quality of life and antiretroviral adherence. The objective of this study was to examine relationships between chronic pain and depression, substance use, mental health treatment, and pain treatment in HIV-infected patients., Design: Cross-sectional study., Setting: Three primary care sites where HIV+ patients receive treatment., Subjects: Two hundred and thirty eight HIV-infected primary care patients., Methods: We collected self-report and chart-review information on demographics, HIV clinical status, chronic pain, depression, substance use, mental health treatment, and pain treatment. We collected data between October 2012 and November 2013., Results: Of the patients enrolled in this study, 107 reported no chronic pain, 24 reported mild chronic pain, and 107 reported moderate-severe chronic pain. Participants in the moderate-severe pain group were more likely to have high levels of depressive symptoms than those in the no chronic pain group. Similarly, there was a significant relationship between chronic pain status and interference with life activities due to pain. Participants with moderate-severe chronic pain were more likely to be taking an antidepressant medication than those with mild chronic pain, and more likely to be taking a prescription opioid than the other two groups. We did not find a significant relationship between problematic substance use and chronic pain status., Conclusions: Despite pharmacologic treatment, moderate-severe chronic pain and elevated depression symptoms are common among HIV-infected patients and frequently co-occur., (Wiley Periodicals, Inc.)

Background: Pain and depression are each prevalent among opioid dependent patients receiving maintenance buprenorphine, but their interaction has not been studied in primary care patients., Objective: We set out to examine the relationship between chronic pain, depression, and ongoing substance use, among persons maintained on buprenorphine in primary care settings., Design: Between September 2012 and December 2013, we interviewed buprenorphine patients at three practice sites., Participants: Opioid dependent persons at two private internal medicine offices and a federally qualified health center participated in the study., Main Measures: Pain was measured in terms of chronicity, with chronic pain being defined as pain lasting at least 6 months; and in terms of severity, as measured by self-reported pain in the past week, measured on a 0-100 scale. We defined mild chronic pain as pain severity between 0 and 39 and lasting at least 6 months, and moderate/severe chronic pain as severity ≥ 40 and lasting at least 6 months. To assess depression, we used the Center for Epidemiologic Studies Depression (CESD) ten-item symptom scale and the two-item Patient Health Questionnaire (PHQ-2)., Key Results: Among 328 participants, 169 reported no chronic pain, 56 reported mild chronic pain, and 103 reported moderate/severe chronic pain. Participants with moderate/severe chronic pain commonly used non-opioid pain medications (56.3%) and antidepressants (44.7%), yet also used marijuana, alcohol, or cocaine (40.8%) to help relieve pain. Mean CESD scores were 7.1 (±6.8), 8.3 (±6.0), and 13.6 (±7.6) in the no chronic, mild, and moderate/severe pain groups, respectively. Controlling for covariates, higher CESD scores were associated with a higher likelihood of moderate/severe chronic pain relative to both no chronic pain (OR = 1.09, p < 0.001) and mild chronic pain (OR = 1.06, p = 0.04)., Conclusion: Many buprenorphine patients are receiving over-the-counter or prescribed pain medications, as well as antidepressants, and yet continue to have significant and disabling pain and depressive symptoms. There is a clear need to address the pain-depression nexus in novel ways.