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Crisis stabilization units (CSUs), which offer a range of short-term psychiatric and psychological services, are one of several treatment programs that may create "alternative to arrest" options for law enforcement. Here, we examined the characteristics of the population who was referred to a newly established CSU in its first year of operation and examined the impact of the CSU on regional jail bookings. Administrative medical records and regional jail booking data were merged to form our study sample. Adults who had at least one jail booking and/or one CSU admission during our study period were included. We found that from September 1, 2018 to August 30, 2019, 458 people were admitted into the CSU. Approximately one-third (33.8%) had a jail booking during the study period. In the 3 months following CSU admission, 4.1% had an increase in jail bookings, 11.1% had a decrease, and 66.2% had no change. CSU patients self-reported high depressive and posttraumatic stress disorder symptoms, while also reporting low quality of life scores overall. We conclude that CSUs may be promising components of jail diversion efforts, providing critical services to populations experiencing significant mental health symptoms and who are at risk for incarceration. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Adolescents and young adults ("youth") account for one-fifth of new HIV diagnoses in the U.S. HIV pre-exposure prophylaxis (PrEP), which became FDA approved in adolescents in May 2018, is highly effective at preventing HIV infection though there are limited data for PrEP initiation in youth. We aimed to quantify PrEP initiation and identify factors associated with PrEP initiation among youth at risk for HIV. We conducted a retrospective cohort study of youth aged 13-26 years who had an indication for PrEP between 1 January 2015, and 31 December 2018. We used data on commercially insured US individuals from the IBM MarketScan Commercial Database. We compared factors among youth who did and did not receive PrEP. We developed a multivariable logistic regression model to identify the association of all study covariates with receipt of PrEP. Among potentially PrEP eligible youth, only 2171 (1.6%) received a PrEP prescription in the year following their PrEP eligible claim. In multivariable models, youth who received PrEP were more likely to be older (adjusted odd ratio [aOR] for 18-20 year olds = 5.11; 95% CI = 3.35-7.77; aOR for 21-26 year olds = 16.90; 95% CI = 11.0-24.7), male (aOR = 92.42; 95% CI = 68.24-125), have sexual activity with elevated risk (aOR = 7.47; 95% CI = 6.50-8.60), or be diagnosed with gonorrhea or syphilis than youth who did not receive PrEP. Our findings highlight an opportunity to improve HIV prevention early in the life course.

Medications for opioid use disorder (MOUD) are shown to reduce opioid use and the risk of overdose. People with opioid use disorder (OUD) who exit inpatient medically managed withdrawal programs (detox) without initiating MOUD and linking to outpatient care have high rates of overdose. While detox encounters provide a theoretical opportunity for MOUD initiation, this is not ubiquitous in the United States. We used simulation modeling to estimate the population-level health effects and cost-effectiveness of a policy encouraging MOUD initiation during inpatient detox encounters.We employed a dynamic population state-transition model to evaluate the effectiveness and cost-effectiveness of using detox programs as venues for initiating MOUD in Massachusetts, United States. We compared standard of care, where no detox patients initiate MOUD or link to outpatient MOUD providers, to strategies of offering MOUD to detox patients and linking those patients to outpatient MOUD.Budgetary impact to the Massachusetts health-care sector, incremental cost-effectiveness ratios (ICER) and total counts and percentage differences of fatal overdoses prevented.Initiating MOUD in detox with perfect linkage to outpatient MOUD would reduce fatal overdoses by 4.5% [95% confidence interval (CI) = 2.3-5.9], at an ICER of $56 000 per quality-adjusted life-year (QALY) gained, compared with the standard of care. With moderate linkage, fatal overdoses would be reduced by 2.3% (95% CI= 1.2-3.1) with an ICER of $78 500 per QALY gained, compared with standard of care. Budgetary increase to Massachusetts health-care spending ranged from 0.5-1%.A simulation model indicates that initiation of medications for opioid use disorder and linkage policies among detox patients in Massachusetts, USA could prevent fatal opioid overdoses in the opioid use disorder population and would be cost-effective from a health-care sector perspective.

To estimate the number of treatment initiations, averted fatal opioid overdoses and the cost-effectiveness associated with offering buprenorphine-naloxone (buprenorphine) treatment on-site within existing syringe service programs (SSPs) in Massachusetts, USA.This was a cohort-based mathematical model and cost-effectiveness analysis. We derived model inputs from state and national surveillance data, clinical trials and observational cohort studies. We compared an intervention scenario where 30% of SSP clients initiated buprenorphine treatment on-site at least once annually to a status quo scenario where no buprenorphine was available on-site among community treatment providers in Massachusetts, 2020-30. In individuals with opioid use disorder (OUD) we assumed that 80% of SSP clients had recently injected drugs and that treatment within SSPs would have similar or improved retention compared with standard-of-care buprenorphine programs, but higher rates of active opioid use while in treatment.Number of treatment initiations (i.e. individuals began treatment on a medication for opioid use disorder or entered medically managed withdrawal), averted fatal opioid overdoses, quality-adjusted life-years (QALYs) and life-time discounted costs from a health sector and a limited societal perspective.The status quo scenario resulted in 23 051 fatal overdoses and 1 511 613 treatment initiations over a 10-year simulation period. An intervention scenario with on-site SSP buprenorphine treatment averted 4797 (-20.8%) fatal opioid overdoses and resulted in 129 359 (+8.6%) additional treatment initiations compared with the status quo. The intervention scenario was the dominating scenario: providing OUD treatment through Massachusetts SSPs cost less (-$3612 per person) with patients accumulating more QALYs (0.2 per person) compared with the status quo scenario.Offering buprenorphine treatment on-site within syringe service programs has the potential to decrease fatal overdoses substantially, improve treatment engagement and save on costs.

Crisis stabilization units (CSUs) are one type of “alternative to arrest” program used for jail diversion. We aimed to estimate the economic costs of starting and operating a CSU in Arkansas. We estimated the economic costs of the Pulaski County Regional CSU (PCRCSU) located in Little Rock, Arkansas, from September 1, 2018, to August 31, 2019. We collected data through interviews about start-up and ongoing management costs. We calculated total annual economic cost, average admission cost, and average 24 hr admission cost. There were 536 admissions to the CSU during the study period. The average length of stay was 60.27 hr. The total annual cost of the PCRCSU was $1,636,831 and average per admission cost was $3,054. Our results provide valuable economic data to government stakeholders who are considering establishing a CSU.

The human version of the monkeypox virus (MPXV) is establishing itself to various degrees across the globe. While substantial attention has been focused on sexual risk, particularly among men who have sex with men, other populations are vulnerable to this virus. In particular, people experiencing homelessness and those with substance use disorders are vulnerable to MPXV. Overcrowded and unsanitary shelter conditions and city policies that force the relocation of people experiencing homelessness provide ample opportunity for the virus to flourish in this population. Furthermore, people with substance use disorders, specifically those who inject drugs, are at increased risk due to lack of access to sterile injection equipment. Herein, we present a spectrum of structural determinants underpinning increased risks in these populations and recommendations that could help mitigate the spread.

Background The coronavirus disease 2019 (COVID-19) pandemic disrupted access to and uptake of hepatitis C virus (HCV) care services in the United States. It is unknown how substantially the pandemic will impact long-term HCV-related outcomes. Methods We used a microsimulation to estimate the 10-year impact of COVID-19 disruptions in healthcare delivery on HCV outcomes including identified infections, linkage to care, treatment initiation and completion, cirrhosis, and liver-related death. We modeled hypothetical scenarios consisting of an 18-month pandemic-related disruption in HCV care starting in March 2020 followed by varying returns to pre-pandemic rates of screening, linkage, and treatment through March 2030 and compared them to a counterfactual scenario in which there was no COVID-19 pandemic or disruptions in care. We also performed alternate scenario analyses in which the pandemic disruption lasted for 12 and 24 months. Results Compared to the “no pandemic” scenario, in the scenario in which there is no return to pre-pandemic levels of HCV care delivery, we estimate 1060 fewer identified cases, 21 additional cases of cirrhosis, and 16 additional liver-related deaths per 100 000 people. Only 3% of identified cases initiate treatment and Conclusions A recommitment to the HCV epidemic in the United States that involves additional resources coupled with aggressive efforts to screen, link, and treat people with HCV is needed to overcome the COVID-19-related disruptions.

We investigated the association of 90-day opioid and stimulant co-use and HIV risk behaviors in a cross-sectional analysis of hospitalized HIV-negative people who inject drugs (PWID). We compared those injecting opioids alone to two sub-groups who co-used opioids with (1) cocaine, (2) amphetamine-type stimulants (ATS), on sex and injection drug risk behaviors assessed via the Risk Assessment Battery (RAB), where a higher score indicates a higher risk. Of 197 participants who injected opioids, 53% co-used cocaine only, 5% co-used ATS only, 18% co-used both cocaine and ATS, 24% co-used neither stimulant. PWID who injected opioids alone had a mean RAB drug risk score of 5.98 points and sex risk score of 2.16 points. Compared to PWID who injected opioids alone, PWID who co-used stimulants had higher mean drug risk RAB scores: cocaine, b = 2.84 points [95% confidence interval (CI) 1.01; 4.67]; ATS, b = 3.43 points (95% CI 1.29; 5.57). Compared to PWID who injected opioids alone, cocaine co-use was associated with higher sex RAB scores b = 1.06 points (95% CI 0.32; 1.79). Overall, we found a significant association between stimulant co-use and higher HIV sex and drug risk scores.Investigamos la asociación entre el uso conjunto de opioides y estimulantes durante 90 días y las conductas de riesgo frente al VIH en un análisis transversal de personas hospitalizadas que se inyectan drogas y que son VIH negativas (“PWID” en lo sucesivo). Se comparó a los que consumían únicamente opioides con dos subgrupos que consumían opioides junto con (1) cocaína, (2) estimulantes de tipo anfetamínico (“ATS” en lo sucesivo), en relación con las conductas de riesgo evaluadas mediante la Serie de Pruebas de Evaluación de Riesgos (“RAB” en lo sucesivo). De los 197 participantes, el 53% sólo consumía cocaína, el 5% sólo ATS y el 18% cocaína y ATS; el 24% restante únicamente se inyectaba opiáceos. En comparación con las PWID que únicamente se inyectaban opioides, las PWID que consumían paralelamente estimulantes tenían puntuaciones medias más altas en el RAB de riesgo de drogas: cocaína, b = 2.84 puntos (intervalo de confianza [IC] del 95% 1.01; 4.67); ATS, b = 3.43 puntos (IC del 95% 1.29; 5.57). En comparación con las PWID que únicamente se inyectaban opioides, el co-consumo de cocaína se relacionó con puntuaciones más altas en la RAB en el sexo (1.06 puntos, IC del 95% 0.32; 1.79). En general, se encontró una asociación significativa entre el co-consumo de estimulantes y las puntuaciones más altas de riesgo sexual y de drogas frente al VIH.

ImportanceUS primary care practitioners (PCPs) are the largest clinical workforce, but few provide addiction care. Primary care is a practical place to expand addiction services, including buprenorphine and harm reduction kits, yet the clinical outcomes and health care sector costs are unknown.ObjectiveTo estimate the long-term clinical outcomes, costs, and cost-effectiveness of integrated buprenorphine and harm reduction kits in primary care for people who inject opioids.Design, Setting, and ParticipantsIn this modeling study, the Reducing Infections Related to Drug Use Cost-Effectiveness (REDUCE) microsimulation model, which tracks serious injection-related infections, overdose, hospitalization, and death, was used to examine the following treatment strategies: (1) PCP services with external referral to addiction care (status quo), (2) PCP services plus onsite buprenorphine prescribing with referral to offsite harm reduction kits (BUP), and (3) PCP services plus onsite buprenorphine prescribing and harm reduction kits (BUP plus HR). Model inputs were derived from clinical trials and observational cohorts, and costs were discounted annually at 3%. The cost-effectiveness was evaluated over a lifetime from the modified health care sector perspective, and sensitivity analyses were performed to address uncertainty. Model simulation began January 1, 2021, and ran for the entire lifetime of the cohort.Main Outcomes and MeasuresLife-years (LYs), hospitalizations, mortality from sequelae (overdose, severe skin and soft tissue infections, and endocarditis), costs, and incremental cost-effectiveness ratios (ICERs).ResultsThe simulated cohort included 2.25 million people and reflected the age and gender of US persons who inject opioids. Status quo resulted in 6.56 discounted LYs at a discounted cost of $203 500 per person (95% credible interval, $203 000-$222 000). Each strategy extended discounted life expectancy: BUP by 0.16 years and BUP plus HR by 0.17 years. Compared with status quo, BUP plus HR reduced sequelae-related mortality by 33%. The mean discounted lifetime cost per person of BUP and BUP plus HR were more than that of the status quo strategy. The dominating strategy was BUP plus HR. Compared with status quo, BUP plus HR was cost-effective (ICER, $34 400 per LY). During a 5-year time horizon, BUP plus HR cost an individual PCP practice approximately $13 000.Conclusions and RelevanceThis modeling study of integrated addiction service in primary care found improved clinical outcomes and modestly increased costs. The integration of addiction service into primary care practices should be a health care system priority.

Infective endocarditis associated with injection drug use (IDU-IE) is markedly increasing in the United States and Canada. Long-term outcomes are dismal and stem from insufficient substance use disorder treatment. In this review, we summarize the principles of antimicrobial and surgical management for infective endocarditis associated with injection drug use. We discuss approaches to opioid use disorder care and harm reduction in the inpatient setting and review opportunities to address preventable infections among persons injecting drugs. We highlight barriers to implementing optimal treatment and consider novel approaches that may reshape infective endocarditis associated with injection drug use treatment in coming years.

BACKGROUND: As stimulant use increases across the United States, emergency medical services (EMS) are crucial touchpoints in the health care system. To better measure the prevalence of stimulant use, misuse, and EMS incidents related to stimulant intoxication, definitions for stimulant-related incidents (SRIs) are needed. METHODS: We used the Massachusetts Ambulance Trip Record Information System (MATRIS) from 2013 to 2020 to develop definitions of stimulant-related incidents. EMS runs reported to MATRIS were categorized based on stimulant-related words and symptoms. The three tiers were “any stimulant use” (class 1), “problematic stimulant use” (class 2), and “acute stimulant-related incidents” (class 3). A group of four reviewers studied over 650 cases in eight rounds to refine the search terms, achieving definitions with a correct characterization of over 80% of cases that the code selected. RESULTS: SRI definitions were applied against all EMS runs within Massachusetts between 2013 and 2020 (n = 6,584,836 runs). Of these, 43,538 (0.7%) met the class 1 definition, 38,669 (0.6%) met the class 2 definition, and 19,157 (0.3%) met the class 3 definition. Incidents at all tiers of severity increased over time and were more likely to occur among younger adults and males. Race and ethnicity data indicated that Hispanic/Latinx and Black non-Hispanic/non-Latinx residents formed a disproportionately large percentage of SRIs relative to their total percentage of EMS runs. CONCLUSIONS: The prevalence of all three tiers of SRIs are increasing in Massachusetts, and this protocol provides a source of administrative data on stimulant use that complements sources such as hospital, treatment-based, and/or prescribing records.

Hospitalizations for drug-use associated infective endocarditis (DUA-IE) have led to increasing surgical consultation for valve replacement. Cardiothoracic surgeons' perspectives about the process of decision making around operation for people with DUA-IE are largely unknown.This multisite semiqualitative study sought to gather the perspectives of cardiothoracic surgeons on initial and repeat valve surgery for people with DUA-IE through purposeful sampling of surgeons at 7 hospitals: University of Alabama, Tufts Medical Center, Boston Medical Center, Massachusetts General Hospital, University of North Carolina-Chapel Hill, Vanderbilt University Medical Center, and Rhode Island Hospital-Brown University.Nineteen cardiothoracic surgeons (53% acceptance) were interviewed. Perceptions of the drivers of addiction varied as well as approaches to repeat valve operations. There were mixed views on multidisciplinary meetings, although many surgeons expressed an interest in more efficient meetings and more intensive postoperative and posthospitalization multidisciplinary care.Cardiothoracic surgeons are emotionally and professionally impacted by making decisions about whether to perform valve operation for people with DUA-IE. The use of efficient, agenda-based multidisciplinary care teams is an actionable solution to improve cross-disciplinary partnerships and outcomes for people with DUA-IE.

This Viewpoint presents an evidence-based argument against criminalization policies and for more treatment-focused policies.

Kentucky has one of the highest opioid overdose mortality rates in the United States. Accurate estimates of people with opioid use disorder (OUD) are critical to plan for the scope of interventions required to reduce overdose and opioid misuse. Commonly used household surveys are known to underestimate OUD at the state-level and do not provide county-level estimates.We performed a multi-sample capture-recapture analysis to estimate OUD prevalence in Kentucky in 2018 and 2019. We utilized four statewide datasets that were linked at the individual level: 1) Registry of Vital Statistics, 2) Emergency Medical Services (EMS), 3) Kentucky's Prescription Drug Monitoring Program (PDMP), and 4) Kentucky Medicaid. We included persons aged 18-64 years who resided in Kentucky between 2018 and 2019. We identified individuals with administrative data consistent with OUD in each of the datasets, including a fatal opioid-involved overdose (Vital Statistics), EMS runs for suspected opioid overdose, receipt of buprenorphine for OUD treatment (PDMP), or Medicaid claims for OUD. Observed and estimated counts of OUD cases and prevalence of OUD among the adult population in Kentucky.The estimated statewide OUD prevalence was 5.5 % and 5.9 % for 2018 and 2019, respectively, ranging from 1.3 % to 17.7 % across Kentucky counties. As expected, counties with the highest OUD rates were Appalachian counties (eastern area) of the state.Our analysis reveals a substantially larger proportion of KY residents have OUD than previously estimated. Our approach offers a model for states needing county-level estimates of OUD.

Summary Background The syndemic of injection drug use and serious injection-related infections is leading to increasing mortality in the USA. Although outpatient treatment with medications for opioid use disorder reduces overdose risk and recurrent infections, hospitalisation remains common. We evaluated the clinical impact, costs, and cost-effectiveness of hospital-based strategies to address the US opioid epidemic. Methods We developed a microsimulation model to compare the cost-effectiveness of: standard hospital care—detoxification for opioids, no addiction consult service (status quo); expanded inpatient prescribing of medications for opioid use disorder, including bridge prescriptions (ie, medication until they can see an outpatient provider) when possible (medications for opioid use disorder with bridge); implementation of addiction consult services within the hospital (addiction consult services alone); and a combined medication for opioid use disorder with addiction consult services strategy (combined). We used clinical trials and observational cohorts to inform model inputs. Outcomes were life-years, discounted costs, incremental cost-effectiveness ratios, hospitalisations, and deaths. We did deterministic sensitivity analyses on key model inputs related to costs and sequelae of drug use and probabilistic sensitivity analysis to further address uncertainty. Findings Among people who inject opioids in the USA, we estimated that expanding medications for opioid use disorder with bridge prescriptions would reduce hospitalisations and overdose deaths by 3·2% and 3·6%, respectively, and the combination of expanded medications with opioid use disorder along with addiction consult sevices would reduce hospitalisations and overdoses by 5·2% and 6·6%, respectively, compared with the status quo. Mean lifetime costs ranged from US$731 400 (95% credible interval 447 911–859 189 for the medications for opioid use disorder strategy) to $741 200 (470 930–868 551 for the combined strategy) per person. Assuming a willingness-to-pay threshold of $100 000 per life-year gained, medications for opioid use disorder with bridge and combined strategies were cost-effective ($7600 and $14 300, respectively). A scenario that assumed ideal access to harm reduction services came to the same conclusions as the base case and our results were robust in deterministic and probabilistic sensitivity analyses. Interpretation The combined interventions of expanding hospital-based prescribing of medications for opioid use disorder and implementing addiction consult services could improve life expectancy, be cost-effective, and could be the basis for a comprehensive hospital-based strategy for addressing the opioid epidemic in the USA and countries with similar opioid epidemics. Funding National Institute on Drug Abuse and National Institute of Allergy and Infectious Diseases.

Background Untreated opioid use disorder (OUD) affects the care of HIV/HCV co-infected people who inject opioids. Despite active injection opioid use, there is evidence of increasing engagement in HIV care and adherence to HIV medications among HIV/HCV co-infected persons. However, less than one-half of this population is offered HCV treatment onsite. Treatment for OUD is also rare and largely occurs offsite. Integrating buprenorphine-naloxone (BUP-NX) into onsite care for HIV/HCV co-infected persons may improve outcomes, but the clinical impact and costs are unknown. We evaluated the clinical impact, costs, and cost-effectiveness of integrating (BUP-NX) into onsite HIV/HCV treatment compared with the status quo of offsite referral for medications for OUD. Methods We used a Monte Carlo microsimulation of HCV to compare two strategies for people who inject opioids: 1) standard HIV care with onsite HCV treatment and referral to offsite OUD care (status quo) and 2) standard HIV care with onsite HCV and BUP-NX treatment (integrated care). Both strategies assume that all individuals are already in HIV care. Data from national databases, clinical trials, and cohorts informed model inputs. Outcomes included mortality, HCV reinfection, quality-adjusted life years (QALYs), costs (2017 US dollars), and incremental cost-effectiveness ratios. Results Integrated care reduced HCV reinfections by 7%, cases of cirrhosis by 1%, and liver-related deaths by 3%. Compared to the status quo, this strategy also resulted in an estimated 11/1,000 fewer non-liver attributable deaths at one year and 28/1,000 fewer of these deaths at five years, at a cost-effectiveness ratio of $57,100/QALY. Integrated care remained cost-effective in sensitivity analyses that varied the proportion of the population actively injecting opioids, availability of BUP-NX, and quality of life weights. Conclusions Integrating BUP-NX for OUD into treatment for HIV/HCV co-infected adults who inject opioids increases life expectancy and is cost-effective at a $100,000/QALY threshold.

Background and aims While prescribed and illicit opioid use are primary drivers of the national surges in overdose deaths, opioid overdose deaths in which stimulants are also present are increasing in the U.S. We determined the social determinants and sociodemographic factors associated with opioid-only versus polysubstance opioid overdose deaths in Massachusetts. Particular attention was focused on the role of stimulants in opioid overdose deaths. Methods We analyzed all opioid-related overdose deaths from 2014 to 2015 in an individually-linked population database in Massachusetts. We used linked postmortem toxicology data to identify drugs present at the time of death. We constructed a multinomial logistic regression model to identify factors associated with three mutually exclusive overdose death groups based on toxicological results: opioid-related deaths with (1) opioids only present, (2) opioids and other substances not including stimulants, and (3) opioids and stimulants with or without other substances. Results Between 2014 and 2015, there were 2,244 opioid-related overdose deaths in Massachusetts that had accompanying toxicology results. Toxicology reports indicated that 17% had opioids only, 36% had opioids plus stimulants, and 46% had opioids plus another non-stimulant substance. Persons older than 24 years, non-rural residents, those with comorbid mental illness, non-Hispanic black residents, and persons with recent homelessness were more likely than their counterparts to die with opioids and stimulants than opioids alone. Conclusions Polysubstance opioid overdose is increasingly common in the US. Addressing modifiable social determinants of health, including barriers to mental health services and homelessness, is important to reduce polysubstance use and overdose deaths.

Injecting-related skin and soft tissue infections (SSTIs) are a preventable cause of inpatient hospitalisation among people who inject drugs (PWID). This study aimed to determine the prevalence of hospitalisation for SSTIs among PWID, and identify similarities and differences in factors associated with hospitalisation for SSTIs versus non-bacterial harms related to injecting drug use.We performed cross-sectional analyses of baseline data from an observational cohort study of PWID attending drug treatment clinics and needle and syringe programs in Australia. Logistic regression models were used to identify factors associated with self-reported hospitalisation for (1) SSTIs (abscess and/or cellulitis), and (2) non-bacterial harms related to injecting drug use (e.g., non-fatal overdose; hereafter referred to as non-bacterial harms), both together and separately.1851 participants who injected drugs in the previous six months were enrolled (67% male; 85% injected in the past month; 42% receiving opioid agonist treatment [OAT]). In the previous year, 40% (n = 737) had been hospitalised for drug-related causes: 20% (n = 377) and 29% (n = 528) of participants were admitted to hospital for an SSTI and non-bacterial harm, respectively. Participants who were female (adjusted odds ratio [aOR]: 1.53, 95% CI: 1.19-1.97) or homeless (aOR: 1.59, 95% CI: 1.16-2.19) were more likely to be hospitalised for an SSTI, but not a non-bacterial harm. Both types of hospitalisation were more likely among people recently released from prison.Hospitalisation for SSTIs is common among PWID. Community-based interventions to prevent SSTIs and subsequent hospitalisation among PWID will require targeting of at-risk groups, including women, people experiencing homelessness, and incarcerated people upon prison release.

Background and Aims While the United States is in the midst of an overdose epidemic, effective treatments are underutilized and commonly discontinued. Innovations in medication delivery, including an extended-release formulations, have the potential to improve treatment access and reduce discontinuation. We sought to assess extended-release buprenorphine discontinuation among individuals with opioid use disorder (OUD) in a real-world, nationally representative cohort. Setting United States Participants Commercially insured individuals initiating one of four FDA-approved medications for opioid use disorder (MOUD) in 2018: extended-release buprenorphine, extended-release naltrexone, mucosal buprenorphine (mono- or co-formulated with naloxone), or methadone. Measurements Our primary outcome was medication discontinuation, defined as a gap of more than 14 days between the end of one prescription or administration and the subsequent dose. Findings We identified 14,358 individuals initiating MOUD in 2018, including 204 (1%) extended-release buprenorphine, 1,173 (8%) extended-release naltrexone, 12,171 (85%) mucosal buprenorphine, and 810 (6%) methadone initiations. Three months after initiation, 50% (95% confidence interval [CI] 40%-60%) of extended-release buprenorphine, 64% (95% CI 61%-69%) of extended-release naltrexone, 34% (95% CI 33%-35%) of mucosal buprenorphine, and 58% (95% CI 54%-62%) of methadone initiators had discontinued treatment. Conclusions Across all treatment groups, medication discontinuation was high, and in this sample of early adopters with limited follow-up time, we found no evidence that extended-release buprenorphine offered a retention advantage compared to other MOUD in real-world settings. Retention continues to represent a major obstacle to treatment effectiveness, and interventions are needed to address this challenge even as new MOUD formulations become available.

To determine the association between immunosuppression and time to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) polymerase chain reaction (PCR) clearance, we studied 3758 adults retested following initial SARS-CoV-2 infection. Cox proportional hazards models demonstrated delayed PCR clearance with older age, multiple comorbidities, and solid organ transplant but not by degree of immunocompromise. These findings challenge current retesting practices., Few studies support SARS-CoV-2 retesting practices to end isolation. Among 3758 adults retested after SARS-CoV-2 infection, we observed delayed PCR clearance with older age, multiple comorbidities and solid organ transplant, but not other immunocompromising conditions. This challenges current retesting guidance., Graphical Abstract Graphical Abstract

BACKGROUND: Current hepatitis C virus (HCV) counseling guidelines do not recommend that HCV-infected patients notify their partners or encourage them to get tested. We aimed to assess healthcare professionals’ knowledge of and attitudes toward counseling and testing recommendations for HCV-infected patients. METHODS: A 15-question, anonymous survey was designed and distributed via email to a convenience sample of healthcare professionals who work with Brown University or Boston University affiliated hospitals to assess their knowledge of and attitudes toward counseling recommendations for HCV-infected patients. The data was collected electronically and analyzed using descriptive statistical methods. RESULTS: Of the 55 respondents (a 20% response rate), 73% incorrectly believed that, at the time the survey was completed, CDC HCV testing guidelines already recommended partners of HCV-infected patients be tested for HCV infection. Furthermore, 80% of respondents believed recommendations should be revisited to explicitly include that HCV-infected patients encourage their partners to get tested. When counseling patients with HCV, 44% of respondents reported they always ask whether the patient’s partners have been tested for HCV and 42% reported they sometimes do. Similarly, 42% reported they always suggest that the HCV-infected patient’s partners be tested for HCV. CONCLUSIONS: Our survey shows that healthcare providers believe that HCV-counseling and testing recommendations could be revisited, with specific attention given to the promotion of HCV testing for partners of HCV-infected patients.

BACKGROUND AND AIMS: Some adolescents and young adults (termed ‘youth’) prescribed an opioid will develop opioid use disorder or experience overdose. This study aimed to identify patient and prescription characteristics associated with subsequent risk of opioid use disorder or overdose during the year after an opioid is first dispensed. DESIGN: Retrospective cohort study. SETTING: Commercial health insurance claims in a large US database from 2006 to 2016. PARTICIPANTS: Youth aged 11–25 years filling an initial opioid prescription. EXPOSURES: Patient (sociodemographic information, and physical and mental health diagnoses) and prescription characteristics (opioid formulation, dose, and duration). MEASUREMENT: The primary outcome was development of an ‘opioid-related complication’ (a diagnosis of opioid use disorder or opioid-related overdose) during the subsequent 12 months. Exposures of interest were patient (sociodemographic information, and physical and mental health diagnoses) and prescription characteristics (opioid formulation, dose, and duration). FINDINGS: Among 3,278,990 youth filling an initial opioid prescription, median age was 18 years (IQR, 16–21) and 56.1% were female. During the subsequent 12 months, 10,405 (0.3%) youth experienced an opioid-related complication. Conditions associated with increased risk included mood/anxiety disorders (aRR, 4.45 [95% CI, 4.25–4.66]) and substance use (aRR, 20.77 [95% CI, 19.74–21.84]). Comorbid substance use disorders were present among 72.8% of youth experiencing an opioid-related complication and included alcohol (33.4%), cannabis (33.0%), nicotine (43.2%), and other substance use disorders (75.5%). Long-acting opioids (aRR, 2.59 [95% CI, 2.18–3.09]) and longer durations were associated with increased risk (7–14 days: aRR, 1.15 [95% CI, 1.08–1.22]; ≥15 days: aRR, 1.96 [95% CI, 1.80–2.12]) compared to short-acting formulations and durations ≤3 days, respectively. CONCLUSIONS: Complications after an initial opioid prescription are relatively rare. Screening for mental health conditions and substance use before prescribing might identify youth at risk for OUD and overdose. Clinicians might mitigate the risk by prescribing short-acting opioids for short durations.

BACKGROUND: Sharing needles and injection drug preparation equipment (IDPE) among people who inject drugs (PWID) are well-established risk factors for viral transmission. Shared needles and IDPE may serve as bacterial niduses for skin and soft tissue infections (SSTI). Given the rising rates of SSTI in PWID, we investigated the association of needle and IDPE sharing on incidence of SSTI in a cohort of PWID. METHODS: Inpatient PWID (N=252) were recruited to a randomized controlled trial of an intervention aimed at reducing infections. The primary outcome was self-reported incidence of SSTI one-year post-hospitalization. In this secondary analysis, we assessed two variables: 1) sharing of IDPE alone, 2) sharing needles with or without IDPE, and compared these groups separately to persons who reported no sharing of needles or IDPE via a mixed-effects negative binomial regression model to estimate the effect of baseline sharing behavior on SSTI during follow-up via incidence rate ratios (IRR). RESULTS: Participant characteristics: 38 years [mean], 58% male, 60% White, 90% primarily injected opioids, 1.58 (± 2.35) mean SSTI in the year prior to baseline. In terms of sharing behavior, 29% didn’t share needles or IDPE, 13% shared IDPE only, and 58% shared needles with or without IDPE three months prior to baseline. After adjusting for co-variables, PWID who shared IDPE alone had a 2.2 fold higher IRR of SSTI (95%CI 1.27; 3.85, p = 0.005) and PWID who shared needles with or without IDPE had a 3.31 fold higher IRR of SSTI (95%CI 2.04; 5.37, p < 0.001), compared to those who did not share any equipment. The number of SSTI at baseline was associated with an IRR of 1.20 of SSTI during follow-up (95%CI 1.09; 1.32, p < 0.001). CONCLUSIONS: In this cohort of hospitalized PWID, we found a significant association between baseline sharing of IDPE alone and of sharing of needles with or without IDPE with one-year incidence of SSTI.

Business Not as Usual Persons with substance use disorders — particularly those in living conditions that increase Covid risk — should be prioritized to receive SARS-CoV-2 vaccines, and vaccine-rol...

Introduction Addiction consult services (ACS) engage hospitalized patients with opioid use disorder (OUD) in care and help meet their goals for substance use treatment. Little is known about how ACS affect mortality for patients with OUD. The objective of this study was to design and validate a model that estimates the impact of ACS care on 12-month mortality among hospitalized patients with OUD. Methods We developed a Markov model of referral to an ACS, post-discharge engagement in SUD care, and 12-month drug-related and non-drug related mortality among hospitalized patients with OUD. We populated our model using Oregon Medicaid data and validated it using international modeling standards. Results There were 6,654 patients with OUD hospitalized from April 2015 through December 2017. There were 114 (1.7%) drug-related deaths and 408 (6.1%) non-drug related deaths at 12 months. Bayesian logistic regression models estimated four percent (4%, 95% CI = 2%, 6%) of patients were referred to an ACS. Of those, 47% (95% CI = 37%, 57%) engaged in post-discharge OUD care, versus 20% not referred to an ACS (95% CI = 16%, 24%). The risk of drug-related death at 12 months among patients in post-discharge OUD care was 3% (95% CI = 0%, 7%) versus 6% not in care (95% CI = 2%, 10%). The risk of non-drug related death was 7% (95% CI = 1%, 13%) among patients in post-discharge OUD treatment, versus 9% not in care (95% CI = 5%, 13%). We validated our model by evaluating its predictive, external, internal, face and cross validity. Discussion Our novel Markov model reflects trajectories of care and survival for patients hospitalized with OUD. This model can be used to evaluate the impact of other clinical and policy changes to improve patient survival.

SARS-CoV-2 Vaccination and Vulnerable Populations In this audio interview conducted on December 9, 2020, the editors are joined by Dr. Joshua Barocas, an infectious disease specialist at Boston Med...

In response to the novel coronavirus 2019 (Covid-19) pandemic, many people experiencing homelessness and substance use disorders entered respite and recuperation facilities for care and to isolate and prevent subsequent SARS-CoV-2 transmission. However, because drug use was officially prohibited in these facilities, we observed people who use substances leaving isolation temporarily or prematurely. The initial Covid-19 surge magnified the need for harm reduction access for those who use substances to ensure their safety and well-being and that of their local communities. In this commentary, we argue that expanding harm reduction access is crucial for subsequent waves of SARS-CoV-2 infection and also for patients who use substances and are hospitalized for other reasons., Highlights • The Covid-19 pandemic disproportionately affects people experiencing homelessness. • Respite facilities allow people experiencing homelessness and Covid-19 to isolate. • Prohibiting substance use in respite facilities is a barrier to isolation. • Harm reduction interventions could facilitate successful and safe isolation. • Harm reduction interventions should be broadly integrated into clinical care.

Background: As COVID-19 surged in people experiencing homelessness, leaders at Boston Medical Center (BMC), New England’s largest safety-net hospital, developed a program to care for them.Aim: Provide an opportunity for COVID-infected people experiencing homelessness to isolate and receive care until no longer contagiousSetting: A decommissioned hospital building.Participants: COVID-infected people experiencing homelessnessProgram Description: Care was provided by physician volunteers and furloughed staff. Care focused on allowing isolation, managing COVID-19 symptoms, harm-reduction interventions, and addressing problems related to substance use and mental illness.Program evaluation: Among 226 patients who received care, 65% were referred from BMC. Five percent were transferred to the hospital for a complication that appeared COVID-related. There were no deaths, but 7 patients had non-fatal overdoses. Seventy-nine % had at least one diagnosis of mental illness, and 42% reported actively using at least one substance at the time of admission. Thirty % had at least one mental health diagnosis plus active substance use.Discussion: This hospital-based COVID Recuperation Unit was rapidly deployed, provided safe isolation for 226 patients over 8 weeks, treated frequent SUD and mental illness, and helped prevent the hospital’s acute-care bed capacity from being overwhelmed during the peak of the COVID-19 epidemic.

In response to the opioid crisis, IDSA and HIVMA established a working group to drive an evidence- and human rights-based response to illicit drug use and associated infectious diseases. Infectious diseases and HIV physicians have an opportunity to intervene, addressing both conditions. IDSA and HIVMA have developed a policy agenda highlighting evidence-based practices that need further dissemination. This paper reviews (1) programs most relevant to infectious diseases in the 2018 SUPPORT Act; (2) opportunities offered by the “End the HIV Epidemic” initiative; and (3) policy changes necessary to affect the trajectory of the opioid epidemic and associated infections. Issues addressed include leveraging harm reduction tools and improving integrated prevention and treatment services for the infectious diseases and substance use disorder care continuum. By strengthening collaborations between infectious diseases and addiction specialists, including increasing training in substance use disorder treatment among infectious diseases and addiction specialists, we can decrease morbidity and mortality associated with these overlapping epidemics.

We compared oropharyngeal swab test performance with nasopharyngeal testing for discontinuation of transmission-based COVID-19 precautions. We performed a retrospective review of confirmed COVID-19-positive patients who received paired nasopharyngeal and oropharyngeal SARS-CoV-2 tests for clearance from isolation from May 4, 2020, to May 26, 2020. Using nasopharyngeal swabs as the reference standard, we calculated the sensitivity, specificity, and negative predictive value of oropharyngeal swabs. We also calculated the kappa between the 2 tests. A total of 189 paired samples were collected from 74 patients. Oropharyngeal swab sensitivity was 38%, specificity was 87%, and negative predictive value was 70%. The kappa was 0.25. Our study suggests that oropharyngeal swabs are inferior to nasopharyngeal swabs for test-based clearance from COVID-19 isolation.

Highlights • The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention to reduce opioid overdose deaths. • The HCS includes a health economics study. • Costs of CTH will be estimated for multiple perspectives. • The health economics study includes cost-effectiveness analyses and simulation modeling., Background The HEALing Communities Study (HCS) is designed to implement and evaluate the Communities That HEAL (CTH) intervention, a conceptually driven framework to assist communities in selecting and adopting evidence-based practices to reduce opioid overdose deaths. The goal of the HCS is to produce generalizable information for policy makers and community stakeholders seeking to implement CTH or a similar community intervention. To support this objective, one aim of the HCS is a health economics study (HES), the results of which will inform decisions around fiscal feasibility and sustainability relevant to other community settings. Methods The HES is integrated into the HCS design: an unblinded, multisite, parallel arm, cluster randomized, wait list–controlled trial of the CTH intervention implemented in 67 communities in four U.S. states: Kentucky, Massachusetts, New York, and Ohio. The objectives of the HES are to estimate the economic costs to communities of implementing and sustaining CTH; estimate broader societal costs associated with CTH; estimate the cost-effectiveness of CTH for overdose deaths avoided; and use simulation modeling to evaluate the short- and long-term health and economic impact of CTH, including future overdose deaths avoided and quality-adjusted life years saved, and to develop a simulation policy tool for communities that seek to implement CTH or a similar community intervention. Discussion The HCS offers an unprecedented opportunity to conduct health economics research on solutions to the opioid crisis and to increase understanding of the impact and value of complex, community-level interventions.

Infective endocarditis associated with injection drug use (IDU-IE) is markedly increasing in the United States and Canada. Long-term outcomes are dismal and stem from insufficient substance use disorder treatment. In this review, we summarize the principles of antimicrobial and surgical management for infective endocarditis associated with injection drug use. We discuss approaches to opioid use disorder care and harm reduction in the inpatient setting and review opportunities to address preventable infections among persons injecting drugs. We highlight barriers to implementing optimal treatment and consider novel approaches that may reshape infective endocarditis associated with injection drug use treatment in coming years.

Highlights • HEALing Communities Study is a parallel-group cluster randomized controlled trial. • Communities That HEAL intervention’s goal is to reduce opioid overdose deaths. • Structured consensus decision-making strategy guided study measure development. • More than 80 study measure specifications and a common data model were developed. • The study will provide methodology and longitudinal community data for research., Background Opioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths. Methods The HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) A community engagement strategy with local coalitions to guide and implement the intervention; 2) A compendium of EBPs coupled with technical assistance; and 3) A series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined. Discussion The HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Background An epidemic of opioid overdose has spread across North America, with illicit drug-related overdose emerging as a leading cause of death in recent years. Estimates of opioid use disorder (OUD) prevalence at the level of the public health service delivery area are needed to project resource needs and identify priority areas for targeted intervention. Our objective is to estimate the annual prevalence of OUD in British Columbia (BC), Canada, from 2000 to 2017. Methods We performed a multi-sample stratified capture-recapture analysis to estimate OUD prevalence in BC. The analysis included individuals identified from 3 administrative databases for 2000–2011 and 4 databases for 2012–2017, linked at the individual level. Negative binomial regression models on the counts of individuals within these strata were used to estimate prevalence, adjusting for dependency between databases. Results OUD prevalence in BC among people aged 12 years or older was 1.00 % (N = 34,663 individuals) in 2000 and increased to 1.54 % (N = 61,080) in 2011. Between 2013 and 2017 prevalence increased from 1.57 % (95 % confidence interval: 1.56–1.58) to 1.92 % (1.89–1.95; N = 83,760; 82,492-84,855). The greatest increases in prevalence were observed among males 12–30 years old and 31–44 years old, with 43.2 % and 40.2 % increases from 2013 to 2017. Conclusions In BC, the OUD prevalence was 1.92 % among people 12 years or older in 2017. We estimated that prevalence has nearly doubled since 2000, with the highest increases in prevalence observed among males under 45.

A Homeless Man with Covid-19 A 66-year-old homeless man was evaluated for cough and rhinorrhea during the Covid-19 pandemic. He had tested positive for SARS-CoV-2 through a universal testing progra...

Background The expansion of the US opioid epidemic has led to significant increases in infections, such as infective endocarditis (IE), which is tied to injection behaviors. We aimed to estimate the population-level IE mortality rate among people who inject opioids and compare the risk of IE death against the risks of death from other causes. Methods We developed a microsimulation model of the natural history of injection opioid use. We defined injection behavior profiles by both injection frequency and injection techniques. We accounted for competing risks of death and populated the model with primary and published data. We modeled cohorts of 1 million individuals with different injection behavior profiles until age 60 years. We combined model-generated estimates with published data to project the total expected number of IE deaths in the United States by 2030. Results The probabilities of death from IE by age 60 years for 20-, 30-, and 40-year-old men with high-frequency use with higher infection risk techniques compared to lower risk techniques for IE were 53.8% versus 3.7%, 51.4% versus 3.1%, and 44.5% versus 2.2%, respectively. The predicted population-level attributable fraction of 10-year mortality from IE among all risk groups was 20%. We estimated that approximately 257 800 people are expected to die from IE by 2030. Conclusions The expected burden of IE among people who inject opioids in the United States is large. Adopting a harm reduction approach, including through expansion of syringe service programs, to address injection behaviors could have a major impact on decreasing the mortality rate associated with the opioid epidemic.

Background Inpatient treatment for substance use disorders is a collection of strategies ranging from short term detoxification to longer term residential treatment. How those with opioid use disorder (OUD) navigate this inpatient treatment system after an encounter for detoxification and subsequent risk of opioid-related overdose is not well understood. Methods We used a comprehensive Massachusetts database to characterize the movement of people with OUD through inpatient care from 2013 to 2015, identifying admissions to inpatient detoxification, subsequent inpatient care, and opioid overdose while navigating treatment. We measured the person-years accumulated during each transition period to calculate rates of opioid-related overdose, and investigated how overdose differed in select populations. Results Sixty-one percent of inpatient detoxification admissions resulted in a subsequent inpatient detoxification admission without progressing to further inpatient care. Overall, there were 287 fatal and 7337 non-fatal overdoses. Persons exiting treatment after detoxification had the greatest risk of overdose (17.3 per 100 person-years) compared to those who exited after subsequent inpatient care (ranging from 5.9 to 6.6 overdoses per 100 person-years). Non-Hispanic whites were most at risk for opioid related overdose with 16 overdoses per 100 person-years and non-Hispanic blacks had the lowest risk with 5 overdoses per 100 person-years. Conclusions The majority of inpatient detoxification admissions do not progress to further inpatient care. Recurrent inpatient detoxification admission is common, likely signifying relapse. Rather than functioning as the first step to inpatient care, inpatient detoxification might be more effective as a venue for implementing strategies to expand addiction services or treatment such as medications for opioid use disorder.