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Objective: Youth in the legal system are vulnerable to initiation and escalation of opioid use. The transition period during which a young person is released from the institutional setting to the community is a critical window of opportunity for preventive intervention targeting the uptake and intensification of opioid and other drug use. Adaptive preventive interventions are a promising approach to systematically varying the timing and intensity of substance use preventive interventions for these youth. Method: This pilot study of 30 youth (97% young men; 37% White; Mage = 18.34, SD = 1.84) examined the feasibility and acceptability of adaptive and nonadaptive preventive interventions that incorporate components of the Adolescent Community Reinforcement Approach with Assertive Continuing Care, Trauma Affect Regulation: Guide for Education and Treatment, and Motivational Interviewing using the Sequential Multiple Assignment Randomized Trial study design. Participants completed assessments at baseline, 1-month postrelease, and 2-months postrelease. Results: Enrollment rate was 65%. Nearly three-quarters (73%) of enrolled youth had substance use disorder at intake. Moreover, 60% of enrolled participants completed the 2-month postrelease follow-up assessment. Participants reported high satisfaction with the interventionist interactions, and 95% indicated they would recommend the program to other youth. The pilot study revealed the need for several adaptations to study and intervention protocols. Conclusions: This pilot study provides evidence of the feasibility of a research–practice partnership with state juvenile rehabilitation facilities, successful recruitment of youth involved in the legal system, and feasibility and acceptability of adaptive preventive interventions spanning pre- and post-release for legal system-involved youth. Public Health Significance Statement: Adaptive preventive interventions that transition with youth as they leave the legal system are feasible and acceptable approaches to preventive interventions for this high-risk population. [ABSTRACT FROM AUTHOR]

Objective: Both opioid misuse and overdose mortality have disproportionately impacted the American Indian population. Although medications for opioid use disorder, such as buprenorphine (BUP-NX), are highly effective in reducing overdose mortality, questions have been raised about the cultural acceptability of Western medical approaches in this population. Understanding patients' desired recovery pathways can lead to more culturally appropriate, patient-centered, and effective approaches to opioid use disorder (OUD) treatment. In this qualitative study, we document experiences with combined pharmacobehavioral treatment for OUD and suggestions for enhancing it. Method: Participants (N = 45) were American Indian patients and community members impacted by OUD. They participated in one-time, 45- to 60-min, semistructured interviews. Results: Findings from conventional content analysis indicated participants were grateful for a Tribally run combined pharmacobehavioral OUD treatment program, which made treatment more financially and geographically accessible over a large, rural area. Participants expressed satisfaction with BUP-NX and the accompanying behavioral health programming but were interested in making it more accessible through telemedicine appointments and mailed prescriptions. Participants noted the importance of clear communication about this kind of programming, which tends to be less structured than other substance-use treatment programs, but also appreciated its tailored, compassionate, and holistic approach. Participants were interested in robust counseling options; a low-barrier, acceptance-based, and harm-reduction orientation; as well as more culturally aligned programming that honored their Native heritage and traditional medicine. Conclusions: Treatment providers, researchers, and policymakers should consider integration of more patient-driven, compassionate, and culturally aligned means of intervention for American Indian patients with OUD. Public Health Significance Statement: This study summarizes important insights from American Indian patients and community members impacted by opioid use disorder that may make treatment more patient-centered, accessible, and culturally relevant. [ABSTRACT FROM AUTHOR]

Fentanyl use has been linked with an increasing number of opioid-related deaths. The emergency department (ED) is a critical contact point for patients with opioid use disorder (OUD) to access basic healthcare. Little information is known about buprenorphine precipitated opioid withdrawal (BPOW). This study sought to examine the rates of BPOW in patients who used fentanyl and received buprenorphine in the ED. A retrospective cohort study was conducted in a single emergency department in an urban city and included patients who reported use of fentanyl and who received buprenorphine for opioid withdrawal. The primary outcome was occurrence of BPOW, in which we assessed for interrater reliability between data abstractors. Data extraction included patients' demographic characteristics, date of service, length of stay, Clinical Opiate Withdrawal Scale (COWS) score assessments, dosages of administered buprenorphine, occurrence of BPOW, and ED disposition. Over the course of 28 months, buprenorphine was administered 113 patients (12.5 %) who reported using fentanyl prior to their ED presentation. The majority of patients identified as White (49 %), and most patients presented with a chief complaint other than specific opioid related concerns. Fifty-one patients (45 %) had an initial COWS score documented, with a median score of 11. Three patients (2.6 %) had BPOW, two of whom required intensive care unit (ICU) admission. We demonstrate that the prevalence of BPOW is low in a cohort of patients who use fentanyl. When precipitated withdrawal does occur, however, it can be severe and require intensive treatment, ICU admission, and prolonged hospital stay. • Buprenorphine initiation in the emergency department is beneficial for people with opioid use disorder (OUD). • Fentanyl use is becoming a more common opioid choice for people with OUD. • Buprenorphine initiation in the emergency department for OUD leads to low rates of precipitated withdrawal. [ABSTRACT FROM AUTHOR]

Objective: Opioid agonist therapy (OAT) remains the first-line therapy for people with opioid use disorder. Whereas overdose rates among adolescents and young adults (AYAs) remain high, little is known about their access to OAT. Therefore, we sought to evaluate factors that shape access to OAT among AYAs aged 14 to 26 years. Methods: Data were derived from the At-Risk Youth Study, a prospective cohort study that involves street-involved AYAs who use illicit substances in Vancouver, Canada. Generalized estimating equations were used to identify factors associated with OAT enrollment from September 2005 to October 2021. Results: A total of 759 AYAs reported at least weekly opioid or OAT use, with a median age of 23 years and 65.7% self-identifying as male. At baseline, 147 participants (19.4%) were on OAT, and another 199 (26.2%) initiated OAT during study follow-up (median number of follow-up visits, 5 [Q1–Q3, 2.5–8]). In a multivariable analysis, being <19 years old (adjusted odds ratio [AOR], 0.40; 95% confidence interval [CI], 0.23–0.71), Indigenous ancestry (OR, 0.72; 95% CI, 0.52–1.00), homelessness (AOR, 0.65; 95% CI, 0.54–0.77), drug dealing (AOR, 0.73; 95% CI, 0.61–0.87), daily opioid use (AOR, 0.47; 95% CI, 0.40–0.55), and nonfatal overdose (AOR, 0.73; 95% CI, 0.60–0.89) were negatively associated with OAT use. Conclusions: This study identified a low rate of OAT access among AYAs. Adolescents and young adults were less likely to be on OAT if they were <19 years old, Indigenous, and possessed certain risk markers. These findings highlight the need for mitigation strategies to facilitate OAT access for this population and for additional harm reduction measures to support AYAs who do not want to use OAT. [ABSTRACT FROM AUTHOR]

Study Objective: Although buprenorphine is an effective treatment for opioid use disorder (OUD), this treatment is often not universally provided in the emergency department (ED). We aimed to determine whether patient characteristics, particularly race and ethnicity, were associated with buprenorphine administration. Methods: This was a retrospective cross-sectional study of adult patients who had a positive screening result for opioid misuse in the ED at a single urban hospital. Univariate and multivariable logistic regressions were used to assess the association of patient characteristics (race, ethnicity, age, sex, insurance type, and Area Deprivation Index) with buprenorphine administration. Results: Of 1082 patients who screened positive for opioid misuse, 133 (12%) were treated with buprenorphine and 949 (88%) were not. Despite representing over half the patient sample, Black patients (n = 682) were less likely than White patients (n = 310) to be treated with buprenorphine (multivariable: OR, 0.56; 95% CI, 0.35–0.88; P = 0.023). Age, sex, insurance type, ethnicity, and Area Deprivation Index were not associated with buprenorphine administration. Conclusions: Patient race was associated with buprenorphine administration, even after controlling for multiple other social determinants of health. These data suggest racial disparities in care that should be investigated through further research to optimize equitable administration of buprenorphine. [ABSTRACT FROM AUTHOR]

Objectives: Trauma screening is recommended for pregnant persons with opioid use disorder (OUD), but there is limited literature on screening results from buprenorphine treatment. This study's objectives were to 1) describe the types, and severity, of traumatic events reported and 2) evaluate the associations between trauma and health-related quality of life (HRQoL). Methods: Baseline data from an ongoing trial were analyzed. Participants were 155 pregnant persons with OUD receiving, or enrolling in, buprenorphine treatment at one of 13 sites. The experience, and relative severity, of 14 high magnitude stressors were assessed with the trauma history screen. The Patient-Reported Outcomes Measurement Information System-29+2 was used to assess 8 HRQoL domains. Results: Traumatic stressors were reported by 91% of the sample (n = 155), with 54.8% reporting a lifetime persisting posttraumatic distress (PPD) event and 29.7% reporting a childhood PPD event. The most prevalent lifetime PPD event was sudden death of a close family/friend (25.8%); physical abuse was the most prevalent childhood PPD event (10.3%). Participants with lifetime PPD, relative to no PPD, reported significantly greater pain interference (P = 0.02). Participants with childhood PPD, relative to no PPD, had significantly worse HRQoL overall (P = 0.01), and worse pain intensity (P = 0.002), anxiety (P = 0.003), depression (P = 0.007), fatigue (P = 0.002), and pain interference (P < 0.001). Conclusions: A majority of pregnant persons enrolled/enrolling in buprenorphine treatment reported persisting posttraumatic distress with sudden death of close family/friend being the most prevalent originating event; clinicians should consider the impact that the opioid-overdose epidemic may be having in increasing trauma exposure in patients with OUD. [ABSTRACT FROM AUTHOR]

The worsening opioid epidemic in the United States, exacerbated by the COVID-19 pandemic, necessitates innovative approaches to pain management. Buprenorphine, a long-acting opioid, has gained popularity due to its safety profile and accessibility. Orthopaedic surgeons, encountering an increasing number of patients on buprenorphine, face challenges in perioperative management. This article will update orthopaedic surgeons on new developments in the understanding of buprenorphine as a pain reliever and share evidence-based practice guidelines for buprenorphine management. For patients on buprenorphine for opioid use disorder or chronic pain, the updated recommendation is to continue their home dose of buprenorphine through the perioperative period. The patient's buprenorphine prescriber should be contacted and notified of any impending surgery. The continuation of buprenorphine should be accompanied by a multimodal approach to analgesia, including a preoperative discussion about expectations of pain and pain control, regional anesthesia, standing acetaminophen, Nonsteroidal anti-inflammatory drugs when possible, gabapentinoids at night for patients under 65 years, cryotherapy, elevation, and early mobilization. Patients can also be prescribed short-acting, immediate-release opioids for breakthrough pain. Transdermal buprenorphine is emerging as an excellent option for the management of acute perioperative pain in both elective and nonelective orthopaedic patients. A single patch can provide a steady dose of pain medication for up to 1 week during the postoperative period. A patch delivery method can help combat patient nonadherence and ultimately provide better overall pain control. In the future, transdermal buprenorphine patches could be applied in virtually all fracture surgery, spinal surgery, total joint arthroplasty, ligament reconstructions with bony drilling, etc. As the stigma surrounding buprenorphine decreases, further opportunities for perioperative use may develop. [ABSTRACT FROM AUTHOR]

Objective: The current qualitative study examines the perspectives of women with opioid use disorder (OUD) and professionals that serve them on barriers to engaging in overdose prevention and harm reduction practices and recommendations for improving engagement. Method: Semistructured interviews (N = 42) were conducted with women with a history of OUD (n = 20), substance use disorder treatment professionals (n = 12), and criminal legal professionals (n = 10). The interviews were inductively coded to identify themes and subthemes regarding experiences with overdose and harm reduction practices. Results: Themes included heightened vulnerability to overdose, harm reduction challenges faced by women with OUD, and recommendations for overdose prevention and harm reduction practices. Heightened vulnerability to overdose included concerns about toxic supply and concerns about women's drug use behaviors. Challenges to women's harm reduction engagement included lack of knowledge and education about harm reduction tools and strategies and continued stigma toward harm reduction practices. Finally, recommendations for improving harm reduction engagement included increasing accessibility of harm reduction tools, expanding harm reduction education, and shifting away from "abstinence-only" paradigms. Conclusions: Finding ways to teach women with OUD about harm reduction, more effectively distribute harm reduction tools to them, and reduce stigma among providers and professionals is essential to reduce overdose risk for women with OUD. Public Health Significance Statement: Improving engagement in overdose prevention and harm reduction practices is one challenge that must be addressed to mitigate the impacts of the U.S. overdose crisis. [ABSTRACT FROM AUTHOR]

This scoping review synthesizes the characteristics and outcomes of recent evidence-based treatments and services for youth with nonmedical opioid use/opioid use disorder in the context of the ongoing opioid crisis in Canada and the United States. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - Extension for Scoping Reviews guidelines, empirical health databases were searched for literature describing treatments or health-related services for nonmedical opioid use/opioid use disorder among youth (ages 12–25). Two independent reviewers conducted study screening, selection, and data extraction. A deductive content analysis further synthesized the interventions' characteristics following the Consolidated Framework for Implementation Research and an inductive content analysis synthesized the interventions' efficacy/effectiveness outcomes. Twenty-five articles met inclusion from 2,761 screened; 88% described opioid agonist treatment (alone or in combination with nonpharmacological treatment). Following the Consolidated Framework for Implementation Research, commonly identified adaptable characteristics included treatment decision-making processes, integrated health and social services, and treatment settings. Efficacy/effectiveness outcomes most frequently included substance use and treatment engagement. This study informs future development, implementation, and evaluation of practices and policies that could be tailored to improve the quality of opioid agonist treatment for youth at risk of significant harms from nonmedical opioid use. [ABSTRACT FROM AUTHOR]

Background: Medications for opioid use disorder are associated with a lower risk of drug overdoses at the individual level. However, little is known about whether these effects translate to population-level reductions. We investigated whether county-level efforts to increase access to medication for opioid use disorder in 2012–2014 were associated with opioid overdose deaths in New York State during the first years of the synthetic opioid crisis. Methods: We performed an ecologic county-level study including data from 60 counties (2010–2018). We calculated rates of people receiving medication for opioid use disorder among the population misusing opioids in 2012–2014 and categorized counties into quartiles of this exposure. We modeled synthetic and nonsynthetic opioid overdose death rates using Bayesian hierarchical models. Results: Counties with higher rates of receiving medications for opioid use disorder in 2012-2014 had lower synthetic opioid overdose deaths in 2016 (highest vs. lowest quartile: rate ratio [RR] = 0.33, 95% credible interval [CrI] = 0.12, 0.98; and second-highest vs. lowest: RR = 0.20, 95% CrI = 0.07, 0.59) and 2017 (quartile second-highest vs. lowest: RR = 0.22, 95% CrI = 0.06, 0.83), but not 2018. There were no differences in nonsynthetic opioid overdose death rates comparing higher quartiles versus lowest quartile of exposure. Conclusions: A spatio-temporal modeling approach incorporating counts of the population misusing opioids provided information about trends and interventions in the target population. Higher rates of receiving medications for opioid use disorder in 2012–2014 were associated with lower rates of synthetic opioid overdose deaths early in the crisis. [ABSTRACT FROM AUTHOR]

Objectives: For people with opioid use disorder (OUD), transitioning from pregnancy to postpartum and from incarceration to the community is a time of increased risk for opioid overdose. This prospective project evaluated the extent of Jenna's Project's success in preventing overdoses and improving recovery outcomes by coordinating postrelease care in incarcerated OUD perinatal patients. Methods: Participants (N = 132) were pregnant or postpartum (1 year postdelivery) with OUD during incarceration and self-referred for post-release services. FromMarch 2020 to October 2021, participants could receive up to 6 months of postincarceration care coordination services (eg, regular communication, transportation, emergency housing, SUD treatment), medication to treat OUD (MOUD) and other treatment services. Outcomes included verified overdose (fatal), self-reported nonfatal overdose, reincarceration, active Medicaid, receipt of MOUD, presence of children living with participants, open Child Protective Services cases, and number of referrals for services. Results: There were 0 nonfatal and 0 fatal overdoses at both 1 and 6 months postrelease, and 3 of 132 (2%) returned to incarceration. Significantly fewer participants had Medicaid at release (36%) and at 6 months postrelease (60%) than before incarceration (87%) (P < 0.001 for all 3 pairwise comparisons). At 6 months postrelease, significantly more participants reportedMOUDreceipt (51%) comparedwith before incarceration (39%) (P < 0.001). Therewas no significant change in the number of open Child Protective Services cases. Referrals for childcare or parenting services were the most common referrals provided. Conclusion: Immediate postrelease care coordination for pregnant and postpartum women with OUD was feasible and effective in preventing overdose, reincarceration, and promoting recovery outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The United States faces an ongoing drug overdose crisis, but accurate information on the prevalence of opioid use disorder (OUD) remains limited. A recent analysis by Keyes et al used a multiplier approach with drug poisoning mortality data to estimate OUD prevalence. Although insightful, this approach made stringent and partly inconsistent assumptions in interpreting mortality data, particularly synthetic opioid (SO)--involved and non--opioid-involved mortality. We revise that approach and resulting estimates to resolve inconsistencies and examine several alternative assumptions. Methods:We examine 4 adjustments to Keyes and colleagues' estimation approach: (A) revising how the equations account for SOeffects on mortality, (B) incorporating fentanyl prevalence data to inform estimates of SO lethality, (C) using opioid-involved drug poisoning data to estimate a plausible range for OUD prevalence, and (D) adjusting mortality data to account for underreporting of opioid involvement. Results: Revising the estimation equation and SO lethality effect (adj. A and B) while using Keyes and colleagues' original assumption that people with OUD account for all fatal drug poisonings yields slightly higher estimates, with OUD population reaching 9.3 million in 2016 before declining to 7.6 million by 2019. Using only opioid-involved drug poisoning data (adj. C and D) provides a lower range, peaking at 6.4 million in 2014--2015 and declining to 3.8 million in 2019. Conclusions: The revised estimation equation presented is feasible and addresses limitations of the earlier method and hence should be used in future estimations. Alternative assumptions around drug poisoning data can also provide a plausible range of estimates for OUD population. [ABSTRACT FROM AUTHOR]

Objective: To examine the quarterly incidence and prevalence of medications for opioid use disorder (OUD) and alcohol use disorder (AUD) from 2015 to 2021. Methods: A retrospective population-wide observational study in Manitoba, Canada, was conducted using administrative claims data from the Manitoba Centre for Health Policy to examine the incidence and prevalence of OUD (methadone, buprenorphine-naloxone, buprenorphine) or AUD medications (naltrexone, acamprosate, disulfiram) per 10,000 individuals in each quarter between January 1, 2015, and December 31, 2021. Results: There were 1179 and 451 individuals who received at least one prescription for OUD and AUD, respectively, in the first quarter of 2020. The prevalence of OUD medications more than doubled from 6.3 to 14.3 per 10,000 from January 1, 2015, to December 31, 2021. Likewise, AUD medication prevalence increased almost 10-fold from 0.68 to 6.5 per 10,000 from January 1, 2015, to December 31, 2021, primarily due to naltrexone. The incidence of AUD prescription use increased 8.6-fold from 0.29 to 2.51 per 10,000 during the study period. In contrast, the incidence of opioid agonist therapy declined from 2.1 per 10,000 in the first quarter of 2015 to 0.53 per 10,000 the first quarter of 2016, primarily due tomethadone.Whereasmethadone incidence declined, buprenorphine-naloxone incidence increased almost 15-fold during the study period. Conclusion: An increase in both AUDmedication prevalence and incidence in addition to an increase in buprenorphine-naloxone incidence was observed. These findings reflect an increase in the uptake of medications for treating AUD and OUD following changes to improve coverage and access to these medications. [ABSTRACT FROM AUTHOR]

Objectives:Age-related psychometric differences inDiagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) opioid use disorder (OUD) diagnostic criteria have been hypothesized, but not been tested. This study investigated DSM-5 OUD diagnostic criteria for age-related measurement noninvariance among younger adults (YAs) and middle/older adults (MOAs) with past 12-month nonmedical use of prescription opioids. Methods: People who participated in the 2012--2013 National Epidemiologic Survey on Alcohol and Related Conditions III and reported past 12-month nonmedical use of prescription opioids were included. YAs we r e 18--49 years old, andMOAs were 50+ years old. Item response theory, differential item functioning (DIF), and differential test functioning were used to assess for age-related measurement noninvariance. Results: One in 5 people met the DSM-5 OUD diagnostic criteria for OUD within the past 12 months, with the most endorsed criteria being tolerance (17.96%). DIF was identified for 3 criteria, including (1) taking opioids for longer or in larger doses than intended, (2) long periods spent obtaining/using/recovering from use, and (3) withdrawal. DIF was associated with the latent OUD severity needed to correctly endorse the criteria, with criteria being correctly endorsed at less severe levels of latent OUD for MOAs when compared with YAs. Differential test functioning analyses showed collectively the criteria had improved detection in MOAs when compared with YAs (P <0.01). Conclusions: These findings suggest that there may be age-related variations in the DSM-5 OUD diagnostic criteria's ability to detect latent OUD. Future research should identify contributing factors and the influence it has on the accuracy of age-specific surveillance estimations. [ABSTRACT FROM AUTHOR]

Objectives: Our study evaluated if rapid inpatient titration of methadone for pregnant patients with opioid use disorder (OUD) improved outcomes without increasing the risk for overdose. Methods: This is a retrospective cohort study of pregnant patients admitted for inpatient methadone titration from January 2020 to June 2022.Outcomeswere compared between standard versus rapid titration protocols. Standard titration involved an initial methadone dose with additional doses every 6 hours if clinical opiate withdrawal score (COWS) is >9. Rapid titration involved an initial methadone dose with additional doses every 4 hours if COWS is >9. The primary outcome was time required to achieve stable dose. Secondary outcomes included elopement prior to achieving stable dose, methadone-related readmission, opioid overdose, and final dose. Results: There were 97 patients in the standard titration (STP) and 97 patients in the rapid titration (RTP) groups. Demographic characteristics and substance use history did not differ between the 2 groups. Time to stable dose did not differ between the 2 groups (RTP, 5.0 days ±4.0; STP, 4.0 days ±3.0; P = 0.08). Patients in the rapid titration group were less likely to elope from the hospital prior to stabilization (RTP 23.0% vs STP 37.9%, P = 0.03) and had fewer methadone-related readmissions (P < 0.001). One patient (1.0%) in the RTP group required naloxone treatment while inpatient for concern for overdose, while none did in the STP group (P = 0.32). There was no difference in median final stable dose between the 2 groups (P = 0.07). Conclusions: Rapid titration of methadone for pregnant patients with OUD was associated with decreased medical elopement and methadone-related readmission, without increasing the risk for overdose. [ABSTRACT FROM AUTHOR]

Objective: The opioid intervention court (OIC) is an innovative, preplea treatment court to facilitate rapid linkage to medications for opioid use disorder (MOUD) for people at risk of overdose. This study compares participants in OIC and participants with opioid use problems in a traditional drug treatment court model on (i) initiation for any substance use (SU) treatment, (ii) initiation ofMOUD, (iii) number of days toMOUD initiation, and (iv) retention in the OIC program/retention on MOUD. Methods:We used administrative court records from n = 389 OIC and n = 229 drug court participants in 2 counties in New York State. Differences in outcomes by court were assessed using logistic, multinomial, or linear regressions. Results: After adjusting for current charge severity, gender, race/ethnicity, age, and county, OIC participants were nomore likely to initiate any SU treatment but were significantly more likely to initiate MOUD (81.2% OIC vs 45.9% drug court, P < 0.001) and were more quickly linked to any SU treatment (hazard ratio = 1.68, 95% confidence interval = 1.35--2.08) and MOUD (hazard ratio = 4.25, 95% confidence interval = 3.23--5.58) after starting the court. Retention in court/MOUD was higher among drug court participants and may speak to the immediate sanctions (eg, jail) for noncompliance with drug court directives as compared with opioid court, which does not carry such immediate sanctions for noncompliance. Conclusions: These analyses suggest that the new OIC model can more rapidly link participants to treatment, including MOUD, as compared with traditional drug court model, and may demonstrate improved ability to immediately stabilize and reduce overdose risk in court participants. [ABSTRACT FROM AUTHOR]

• This case series describes PRS-delivered behavioral activation to support MT. • Three cases were chosen to depict intervention adaption for varying presentations. • The PRS worked with each participant to implement value-driven, rewarding activities. • PRS shared experiences and intervention flexibility played key roles in pilot success. While methadone treatment (MT) is effective in treating opioid use disorder (OUD), retention remains an issue nationwide, especially among low-income, minoritized populations. Peer recovery specialists (PRSs), individuals with lived substance use experience, are particularly well suited to support vulnerable populations, though often are not trained in delivering evidence-based interventions. Thus, our team developed a Type 1 hybrid effectiveness-implementation open-label pilot trial to evaluate the effectiveness of PRS-delivered BA (Peer Activate) in improving MT retention and establish feasibility, acceptability and PRS fidelity of the intervention. In this case series, we provide a more in-depth depiction of the adaption of Peer Activate and present three cases to illustrate how Peer Activate can be implemented among patients in routine MT care and adapted to meet the needs of varying clinical presentations. We include descriptive data on participant substance use and MT outcomes to supplement the narrative discussion. While varying participant presentations and needs presented challenges to the PRS interventionist, the PRS utilized his shared, lived substance use and recovery experiences and met participants where they were at, as well as successfully used BA techniques, ultimately leading to intervention success. [ABSTRACT FROM AUTHOR]

Background: Methadone is commonly utilized to treat opioid use disorder (OUD). Requirements to visit an opioid treatment provider (OTP) clinic for methadone treatment limits access to treatment, impacts quality of life, and reduces OUD treatment program retention. The Computerized Oral Prescription Administration (COPA) system is a dual-biometric dispensing device for take-home dosing that could reduce the impacts of methadone administration on patients and clinic staff. Objective: To identify challenges for patients treated with methadone for OUD and gain their perspectives on COPA. Methods: Adult patients treated with methadone at a single-site OTP clinic were recruited to complete a qualitative interview regarding their experience with methadone and the impact that expansion of take-home doses would have on their life. Participants were provided printed resources describing COPA and handled a COPA device before being asked for their perspectives. Results: Participants (n=12) were 58.33 percent male and 41.67 percent female, and had no take-home doses (n=5), 2 to 5 days of take-home doses (n=4), or six or more days of take-home doses (n=3). Most (91.67%) participants desired more take-home doses, and 66.7 percent stated more take-home doses would reduce the negative impact of OUD treatment on their ability to work. Average time and cost per trip to obtain their methadone dose at the clinic was 75 minutes and $36.58, respectively. Participants responded positively toward COPA. Participants with no take-home privileges would pay $126.88 per month to obtain take-home privileges by using COPA, and those with take-home privileges would pay $30.31 per month to keep the same level of take-home doses and $117.50 per month to expand their take-home doses using COPA. Conclusion: Participants endured a monetary and time burden to access their methadone treatment, and wished to have more take-home doses to reduce the frequency of their visits to the OTP clinic. Participants viewed take-home doses as having a positive impact on their ability to care for family members, hold a job, and travel, and they appreciated the key attributes of COPA and were willing to invest their own funds to gain access to the device. COPA is a potential solution to expand take-home methadone access to patients while ensuring safety, adherence, retention, and appropriate use. [ABSTRACT FROM AUTHOR]

Objectives: Current guidelines for methadone titration may unnecessarily delay reaching effective doses for patients using fentanyl, resulting in an increased risk of ongoing fentanyl use, dissatisfaction with treatment, and early dropout. Development and evaluation of rapid methadone induction protocols may improve treatment for patients using fentanyl. Methods: Retrospective chart review was conducted for patients admitted in 2022 to a single licensed opioid treatment program (OTP) where a rapid induction protocol provides methadone 40 mg on day 1, 60 mg on day 2, and 80 mg on day 3 to patients using fentanyl <65 years old without significant medical comorbidities. The primary feasibility outcome was completion of the protocol, defined by receipt of methadone dose 80 mg or more on treatment day 7. The primary safety outcomes were oversedation, nonfatal overdose, and death. A secondary outcome was retention in treatment at 30 days. Results: Rapid induction was ordered for 93 patients and completed by 65 (70%). Average dose on day 7 for patients who completed was 89 mg (SD 9.5 mg) versus 49 mg (SD 14.0 mg) for those who did not. No episodes of oversedation, nonfatal overdose, or death were observed. At 30 days, 85% of the patients who had the rapid protocol ordered (79/93) were retained, with 88% (57/65) who completed the protocol retained versus 79% (22/28) who did not complete (OR 1.9, 95% CI 0.6--6.2). Conclusions: Rapid induction to methadone 80 mg by day 7 was feasible for outpatients using fentanyl in this study at a single OTP. No significant safety events were identified. [ABSTRACT FROM AUTHOR]

Objectives: Stimulant use is a growing problem, but little is known about service utilization among patients with stimulant use disorder (StUD). In the context of the overdose crisis, much research has focused on patients with opioid use disorder (OUD). It is unclear how the characteristics, treatment receipt, and hospitalization of patients with StUD differ from patients with OUD. Methods: Electronic health record datawere extracted for national Veterans Health Administration patients with a visit from March 1, 2020, to February 28, 2021 with StUD and/or OUD (N = 132,273).We compared patients with StUD without OUD to those with (1) co-occurring StUD + OUD and (2) OUD without StUD. Patient characteristics, substance use disorder treatment, and hospitalizations in the year following patients' first study period visit were descriptively compared. Treatment and hospitalization were also compared in adjusted regression models. Results: Compared with patients with OUD + StUD, those with StUD without OUD were less likely to receive outpatient (adjusted odds ratio [aOR] 0.49, 95% confidence interval [CI] 0.47--0.50) or any treatment (aOR 0.47, 95% CI 0.46--0.49). Compared with patients with OUD without StUD, those with StUD without OUD were less likely to receive outpatient (aOR 0.51, 95% CI 0.49--0.52) or any treatment (aOR 0.56, 95% CI 0.54--0.58) and more likely to receive residential treatment (aOR 2.18, 95% 2.05--2.30) and to be hospitalized (aOR 1.62, 95% 1.56--1.69). Conclusions: Patients with StUD may be less likely to receive treatment andmore likely to be hospitalized than patientswithOUD. Efforts focused on mitigating hospitalization and increasing treatment receipt for patients with StUD are needed. [ABSTRACT FROM AUTHOR]

A trial comparing extended-release naltrexone and sublingual buprenorphine-naloxone demonstrated higher relapse rates in individuals randomized to extended-release naltrexone. The effectiveness of treatment might vary based on patient characteristics. We hypothesized that causal machine learning would identify individualized treatment effects for each medication. Methods: This is a secondary analysis of a multicenter randomized trial that compared the effectiveness of extended-release naltrexone versus buprenorphine-naloxone for preventing relapse of opioid misuse. Three machine learning models were derived using all trial participants with 50% randomly selected for training (n = 285) and the remaining 50% for validation. Individualized treatment effect was measured by the Qini value and c-for-benefit, with the absence of relapse denoting treatment success. Patients were grouped into quartiles by predicted individualized treatment effect to examine differences in characteristics and the observed treatment effects. Results: The best-performing model had a Qini value of 4.45 (95% confidence interval, 1.02--7.83) and a c-for-benefit of 0.63 (95% confidence interval, 0.53--0.68). The quartile most likely to benefit from buprenorphine-naloxone had a 35% absolute benefit from this treatment, and at study entry, they had a high median opioid withdrawal score (P < 0.001), used cocaine on more days over the prior 30 days than other quartiles (P < 0.001), and had highest proportions with alcohol and cocaine use disorder (P ≤ 0.02). Quartile 4 individuals were predicted to be most likely to benefit from extended-release naltrexone, with the greatest proportion having heroin drug preference (P = 0.02) and all experiencing homelessness (P < 0.001). Conclusions: Causal machine learning identified differing individualized treatment effects between medications based on characteristics associated with preventing relapse. [ABSTRACT FROM AUTHOR]

Opioid use disorder (OUD) is a significant health issue impacting millions in the United States (US). Medications used for OUD (MOUD) (e.g., buprenorphine, methadone, naltrexone) and medications for overdose and symptom management (e.g., naloxone, clonidine) have been shown to be safe and effective tools in clinical management. MOUD therapy in Emergency Departments (EDs) improves patient outcomes and enhances engagement with formal addiction treatment; however, provider factors and institutional barriers have created hurdles to ED-based MOUD treatment and heterogeneity in ED based OUD care. We used a nationally representative dataset, the National Hospital Ambulatory Medical Care Survey (NHAMCS) to characterize MOUD prescribing practices across patient demographics, geographic regions, payers, providers, and comorbidities in EDs. NHAMCS is a survey conducted by the US Census Bureau assessing utilization of ambulatory healthcare services nationally. Survey staff compile encounter records from a nationally representative sample of EDs. We conducted a cross-sectional study using this data to assess visits in 2020 among patients aged 18–64 presenting with an opioid overdose or OUD. We estimated the proportion of patients who had any MOUD, clonidine, or naloxone treatment and 95% confidence intervals (CI). We modeled the association between patient demographic, location, comorbidities, and provider characteristics with receipt of MOUD treatment as unadjusted odds ratios (OR) and 95% CI. There was a weighted frequency of 469,434 patients who were discharged from EDs after being seen for OUD or overdose. Naloxone, clonidine, and buprenorphine were the most frequent treatments administered and/or prescribed for OUDs or overdose. Overall, 54,123 (11.5%, 95%CI 0–128,977) patients who were discharged from the ED for OUDs or overdose received at least one type of MOUD. Hispanic race, (OR 17.9, 95%CI 1.33–241.90) and Western region (OR43.77, 95%CI 2.97–645.27) were associated with increased odds of receiving MOUDs, while arrival by ambulance was associated with decreased odds of receiving MOUDs (OR0.01, 95%CI 0.001–0.19). Being seen by an APP or physician assistant was associated with MOUD treatment (OR 16.68, 95%CI: 1.41–152.33; OR: 13.84, 95%CI: 3.58–53.51, respectively). Our study findings suggest that MOUD and other medications for opioid overdose are infrequently used in the ED setting. This finding was especially notable in race, geographic region, mode of arrival, and those seen by APP, underscoring the need for further study into the root causes of these disparities. Our study provides a foundational understanding of MOUD patterns, guiding future research as the landscape of OUD treatment continues to shift. [ABSTRACT FROM AUTHOR]

This study aims to examine the complex nature of opioid use disorder (OUD) in chronic noncancer pain (CNCP) by exploring its antecedents, attributes, consequences, and interrelated concepts. A systematic literature review was conducted to gather relevant studies published between 2015 and 2022, utilizing the CINAHL, MEDLINE, PsycINFO, and PubMed databases. The selected databases provided a comprehensive range of articles related to OUD in CNCP, ensuring a comprehensive topic analysis. Twenty-two articles meeting the inclusion criteria were included in the analysis. These articles were critically reviewed and analyzed to identify key themes and concepts related to OUD in CNCP. The findings of this study shed light on the multifaceted aspects of OUD in CNCP, including its antecedents, such as goals of physical function improvement, prescription of opioids for CNCP, social influences, and mental health dynamics. The attributes of OUD in CNCP were identified as chronic pain, noncancer pain, opioid use, misuse, and abuse. OUD's consequences in CNCP include impaired functioning, increased health risks, psychological distress, social challenges, and economic burden. Understanding the complexity of OUD in CNCP is crucial for improving patient outcomes. Collaborative efforts among healthcare systems, regulatory bodies, and professional organizations are needed to develop policies promoting safe and effective pain management while mitigating risks associated with opioid use in CNCP. Implementing policy recommendations derived from this study enhances care and outcomes for individuals with CNCP. By addressing complex issues of OUD in CNCP and adopting evidence-based practices, healthcare providers can optimize pain management and promote well-being in CNCP patients. [ABSTRACT FROM AUTHOR]

To characterize opioid toxicity deaths among adolescents and young adults in Ontario, Canada, prior to and during the first year of the COVID-19 pandemic. We conducted a descriptive, cross-sectional study of opioid toxicity deaths among individuals aged 15-24 in Ontario in the year prior to (March 17, 2019, to March 16, 2020) and the first year of the pandemic (March 17, 2020, to March 16, 2021) using administrative health databases. We analyzed circumstances surrounding death, substances contributing to death, and health-care encounters prior to death. We identified 284 deaths among Ontarians aged 15-24, including 115 in the year preceding and 169 in the first year of the pandemic. Fentanyl contributed to 84.3% of deaths in the prepandemic year, rising to 93.5% (p =.012) the following year. Stimulants contributed to approximately half of deaths in both periods (41.7% prepandemic and 49.1% during pandemic). In both periods, roughly one in 4 decedents had a health-care encounter in the week prior to death and less than 20% of those with an opioid use disorder received opioid agonist treatment in the 30 days prior to death. Among young Ontarians, the number of opioid-related deaths increased by 47% in the first year of the COVID-19 pandemic. Fentanyl contributed to the vast majority of deaths, with non-opioid substances (primarily stimulants) also contributing to approximately half of deaths. Patterns of health-care utilization prior to death suggest opportunities to better connect this population to services that address opioid use disorder needs and promote harm reduction. [ABSTRACT FROM AUTHOR]

Purpose: To understand how barriers and facilitators interact over time to support or disrupt breastfeeding among women on opioid maintenance therapy for opioid use disorder. Background: Breastfeeding has additional benefits for newborns with prenatal opioid exposure. Up to 80% of women on opioid maintenance therapy plan to breastfeed, but many do not beyond the first 7 to 10 days. Methods: A qualitative, longitudinal design was used. Semi-structured interviews occurred during the third trimester of pregnancy and again between 1 and 6 weeks postpartum. Thematic analysis was conducted using the Breastfeeding in a Life Course Context model as a framework. The design and methods were informed by a post-positivist, critical realist perspective. Results: Thirteen participants were enrolled, and 19 interviews were completed. Five themes were identified. It Will Work Out was the primary theme that describes participants' sense of self-efficacy, stemming from their experiences of managing addiction recovery. Women considered breastfeeding to support their own health and that of their newborn while in recovery, summarized by Being Healthy. Making the choice to breastfeed, represented by Weighing the Options, was influenced by their perinatal health care providers. During the Sensitive Period, challenges could overwhelm their self-efficacy. Of 9 women, 4 were still breastfeeding when interviewed postpartum, exemplified by Moving On. Conclusions and Implications for Practice: Participants' self-efficacy and motivation to be healthy played a significant role in managing breastfeeding challenges over time. Nursing interventions must empower women's self-efficacy to help them achieve their breastfeeding goals. [ABSTRACT FROM AUTHOR]

The Opioid and Naloxone Education (ONE) Program focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The purpose of this paper is to reevaluate the ONE Program performance using the RE-AIM model, in comparison to the review performed in 2019. The program performance of the ONE Program was evaluated from January 1, 2021 to December 31, 2022 was evaluated using the five domains of the RE-AIM model. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk who received a pharmacist intervention. Adoption was defined as the proportion of community pharmacies who enrolled in the ONE Program. Implementation was defined as the proportion of pharmacies that enrolled that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that completed at least one screening three months. These results were compared against evaluation of the program from October 12, 2018 to June 1, 2019. Approximately 7.28 % of patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose (Reach). Of the patients screened, 97.4 % of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention (Efficacy). Additionally, 49.6 % of the pharmacist that enrolled in the ONE Program completed at least five screenings (79 %) and of those, 86.4 % maintained the program three months later. In years four and five of implementation, the ONE Program demonstrated improvement in four of the five domains of the RE-AIM model compared to years one and two. However, Reach declined over time. This reevaluation has demonstrated the importance of longitudinal program assessment, and the possibility of improved program performance over time. [ABSTRACT FROM AUTHOR]

The concept of treatment-refractory addiction, proposed by Eric Strain in this edition of the Journal, has the potential to invigorate the field of addiction treatment and research by focusing on a phenomenon that is familiar to any clinician treating patientswith substance use disorders, namely, the patient who does not experience sufficient improvement from standard treatments. An analogy is drawn to the concept of treatment-resistant depression and the STAR*D study, which demonstrated an algorithmic approach to treatment, where if the first antidepressant medication tried did not result in remission from depression, subsequent trials of medications or cognitive behavioral therapy doubled the proportion of patients achieving remission. Recognizing treatment-refractory addiction challenges our field to develop analogous, stepwise, algorithmic approaches to treatment of substance use disorders, moving away from siloed treatment programs toward integrated treatment systems where alternative treatments are available, offering the kind of personalized, tailored forms of care used in the treatment of most other chronic illnesses. Like in STAR*D, research could focus on samples of patients who have not benefitted from initial trials of standard addiction treatments, addressing the key clinical question of what to do next when previous treatments fail. [ABSTRACT FROM AUTHOR]

• The rate of opioid use disorder (OUD) among women in the U.S. is increasing and medications for OUD (MOUD) do not prevent drug seeking and relapse. • There is a critical need for adjunctive therapies capable of improving long-term clinical outcomes in women with OUD. • Eight-week Mindfulness-Oriented Recovery Enhancement (MORE) intervention as an adjunct to MOUD may improve emotional regulation and brain function to assist in recovery for women with OUD. • A 10-minute guided MORE meditation may improve immediate mood in women with OUD. Mindfulness-Oriented Recovery Enhancement (MORE) is an efficacious intervention to aid recovery from substance use disorder. This study in a pilot sample of individuals in treatment for opioid use disorder (OUD) characterizes longer-term changes after the MORE intervention and immediate effects of a brief MORE guided meditation session. Twelve female participants in residential treatment for OUD completed an 8-week MORE intervention. Participants completed two sessions: one before and one after the 8-week MORE intervention. Each session included an emotional regulation questionnaire outside an MRI scanner first and then a 10-minute guided MORE meditation inside the scanner during which functional magnetic resonance imaging (fMRI) data were collected. Emotional regulation was measured after 8-weeks of MORE intervention. In addition, functional connectivity (i.e. correlated fMRI signal) between regions in a hypothesized affect regulation network was measured during the meditation state to assess change in brain network function due to 8-weeks of MORE. For each 10-min guided meditation, we also assessed their mood and opioid craving. Nine participants completed all measurements. Participants' emotional regulation difficulty significantly decreased after 8-weeks of MORE intervention. Furthermore, after 8-weeks of MORE, there was significantly increased connectivity between left ventromedial prefrontal cortex and left amygdala and between left ventrolateral prefrontal cortex and left nucleus accumbens captured during a meditation state. In both sessions, positive mood significantly increased after 10-min of guided mediation, however opioid craving was not significantly influenced. This pilot study characterizes potential benefits of 8-week MORE intervention in improving emotional regulation difficulty and brain function. A 10-min guided MORE meditation may immediately improve mood, with potential to reduce acute stress- or cue-provoked craving. These results warrant future studies with larger sample size. [ABSTRACT FROM AUTHOR]

Objective: Buprenorphine is a medication for opioid use disorder that reduces mortality. This study aims to investigate the less well-understood relationship between the dose in the early stages of treatment and the subsequent risk of death. Methods: We used Kentucky prescription monitoring data to identify adult Kentucky residents initiating transmucosal buprenorphine medication for opioid use disorder (January 2017 to November 2019). Average daily buprenorphine dose for days covered in the first 30 days of treatment was categorized as ≤8 mg, >8 to ≤16 mg, and >16 mg. Patients were followed for 365 days after the first 30 days of buprenorphine treatment. Endpoints were opioid-involved overdose death and death from other causes. Causes and dates of death were obtained using Kentucky death certificate records. Associations were evaluated using multivariable Fine and Gray models adjusting for patient baseline characteristics. Results: In the cohort of 49,857 patients, there were 227 opioid-involved overdose deaths and 459 deaths from other causes. Compared with ≤8 mg, the adjusted subdistribution hazard ratio (aSHR) of opioid-involved overdose death decreased by 55% (aSHR, 0.45; 95% confidence interval [CI], 0.34–0.60) and 64% (aSHR, 0.36; 95% CI, 0.25–0.52) for patients receiving doses of >8 to ≤16 mg and >16 mg, respectively. The incidence of death from other causes was lower in patients receiving >8 to ≤16 mg (aSHR, 0.78; 95% CI, 0.62–0.98) and >16 mg (aSHR, 0.62; 95% CI, 0.47–0.80) versus ≤8 mg dose. Conclusions: Higher first 30-day buprenorphine doses were associated with reduced opioid-involved overdose death and death from other causes, supporting benefit of higher dosing in reducing mortality. [ABSTRACT FROM AUTHOR]

Objective: Problem opioid use (POU) is a serious public health crisis in the United States. However, little research has examined the prevalence, correlates, and psychiatric characteristics of POU in vulnerable segments of the population, such as US military veterans. Methods: Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of 2441 US veterans. Multivariable logistic regression models were conducted to identify correlates and psychiatric correlates of POU (defined as a positive screen on the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool). Results: A total 3.0% (95% confidence interval, 2.0%–4.5%) of US veterans screened positive for POU. Black, non-Hispanic race/ethnicity (odds ratio [OR], 3.83), lifetime alcohol use disorder (OR, 3.38), major depressive disorder (MDD; OR, 2.52), greater number of medical conditions (OR, 1.15), and disability in instrumental activities of daily living (IADL); OR, 1.86) were independently associated with POU. A significant interaction between IADL disability and MDD was observed (OR, 10.73)—among veterans with IADL disability, those with MDD had more than 6-fold greater POU than those without MDD (20.6% vs 3.2%). Furthermore, POU was associated with 2- to 3-folds greater odds of current generalized anxiety disorder and current posttraumatic stress disorder, and lifetime suicide attempt. Conclusions: POU affects 3.0% of US veterans and is associated with Black race/ethnicity, lifetime physical and mental health morbidities, as well as current psychiatric disorders and lifetime suicide attempts. Results underscore the importance of assessing physical and mental health disorders in veterans at-risk for POU and addressing co-occurring psychiatric disorders associated with POU in this population. [ABSTRACT FROM AUTHOR]

Objective: There is a lack of knowledge about the relative safety and efficacy of naltrexone for the treatment of pregnant individuals with opioid and/or alcohol use disorder, including the range of outcomes, in both the pregnant individual and the infant, over the course of peripartum period. Our objective was to describe these outcomes in a cohort of pregnant individuals on naltrexone. Methods: In this prospective case series, 7 pregnant individuals with opioid use disorder (OUD) or alcohol use disorder (AUD) treated with naltrexone were followed from pregnancy through 12 months after delivery. Clinical treatment protocols and outcomes related to safety and efficacy during pregnancy, delivery, and the postpartum period are described. Results: There were 4 pregnant individuals with OUD and 3 with AUD, of which 3 were managed with oral and 4 with extended-release naltrexone. The mean gestational age at study enrollment was 21.7 (SD, 12) weeks. Of the 7 participants, there was no return to nonprescribed opioid use and 2 who experienced a return to alcohol use over the course of the study. All individuals delivered vaginally at a mean of 37 weeks gestation without any peripartum pain difficulties. Five of the individuals (71.4%) remained on naltrexone 12 months after delivery. There were no reported fetal anomalies and one preterm delivery. None of the infants developed neonatal opioid withdrawal syndrome. Conclusions: For pregnant individuals with OUD or AUD treated with naltrexone, there were low rates of return to nonprescribed use and reassuring pregnant person and infant outcomes to 12 months postpartum. [ABSTRACT FROM AUTHOR]

Objectives: Buprenorphine is not reliably stocked in many pharmacies, and pharmacy-level barriers may deter patients from opioid use disorder care. We surveyed all outpatient pharmacies in Philadelphia to describe variation in buprenorphine access and developed a map application to aid in identifying pharmacies that stock the medication. Methods: Using a dataset from the Bureau of Professional and Occupational Affairs, we conducted a telephone survey of operating outpatient pharmacies (N = 422) about their buprenorphine stocking and dispensing practices. We used ArcGIS Pro 3.0.3 to join US Census Bureau ZIP code-level race and ethnicity data, conduct descriptive analyses, and create a map application. Results: We collected data from 351 pharmacies (83% response rate). Two hundred thirty-eight pharmacies (68%) indicated that they regularly stock buprenorphine; 6 (2%) would order it when a prescription is sent. Ninety-one (26%) said that they do not stock or order buprenorphine, and 16 (5%) were unsure. We identified 137 "easier access" pharmacies (39%), meaning they regularly stock buprenorphine, dispense to new patients, and have no dosage maximums. Zip codes with predominantly White residents had a median (interquartile range) of 3 (2–4) "easier access" pharmacies, and those with predominantly Black residents a median (interquartile range) of 2 (1–4.5). Nine zip codes had no "easier access" pharmacies, and 3 had only one; these 3 zip codes are areas with predominantly Black residents. Conclusions: Buprenorphine access is not equitable across Philadelphia and a quarter of pharmacies choose not to carry the medication. Our map application may be used to identify pharmacies in Philadelphia that stock buprenorphine. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined illness models among people with addiction. We investigated illness models and their associations with demographics and treatment beliefs among patients receiving methadone treatment for opioid use disorder. Methods: From January 2019 to February 2020, patients receiving methadone treatment at outpatient opioid treatment programs provided demographics and rated using 1 to 7 Likert-type scales agreement with addiction illness models (brain disease model, chronic medical condition model [CMCM], and no explanation [NEM]) and treatment beliefs. Pairwise comparisons and multivariate regressions were used to examine associations between illness models, demographics, and treatment beliefs. Statistical significance was set at P < 0.05. Results: A total of 450 patients participated in the study. Forty percent self-identified as female, 13% as Hispanic, and 78% as White; mean age was 38.5 years. Brain disease model was the most frequently endorsed illness model (46.2%), followed by CMCM (41.7%) and NEM (21.9%). In multivariate analyses, agreement with brain disease model was significantly positively associated with beliefs that methadone treatment would be effective, counseling is important, and methadone is lifesaving, whereas agreement with CMCM was significantly positively associated with beliefs that methadone treatment would be effective, counseling is important, 12-step is the best treatment, taking methadone daily is important, and methadone is lifesaving. In multivariate analyses, agreement with NEM was negatively significantly associated with beliefs that methadone would be effective, counseling is important, taking methadone daily is important, and methadone is lifesaving. Discussion: Many patients in methadone treatment endorsed medicalized addiction models. Agreement with addiction illness models appear to be related to treatment beliefs. [ABSTRACT FROM AUTHOR]

Objectives: Persons with chronic pain and women tend to enter treatment for opioid use disorder with greater opioid withdrawal severity than persons without chronic pain and men, respectively. This study examined characteristics of facilities with opioid withdrawal treatment, including gender-based services, as a function of whether they reported having a tailored pain management program. Methods: The National Survey of Substance Abuse Treatment Services 2020 was used to examine 3942 facilities with opioid withdrawal treatment in the United States. Using a multivariable binary logistic regression model, facilities were examined for the presence of a tailored program for individuals with co-occurring pain. Regional location of the facility, ownership status, and availability of tailored gender programs, nonhospital residential services, and outpatient services served as independent variables in the analysis. Results: A slight majority of the sample had a program for both adult men and adult women (n = 2010, 51.0%). Most facilities had outpatient services (n = 3289, 83.4%) and did not have a tailored program for addressing co-occurring pain (n = 2756, 69.9%). Binary logistic regression analysis showed that among opioid withdrawal facilities, programs with nonhospital residential services, government or private nonprofit funding, or tailored gender programming had higher odds of reporting having a tailored program for pain and substance use disorder. Facilities in the Western United States were most likely to have tailored programs for pain and substance use disorder. Conclusions: Future research should investigate what support patients may receive and how to better scale access to pain management during opioid withdrawal treatment. [ABSTRACT FROM AUTHOR]

Objectives: Medication treatment for opioid use disorder (MOUD) is effective and recommended for outpatient settings. We implemented and evaluated the SUpporting Primary care Providers in Opioid Risk reduction and Treatment (SUPPORT) Center—a quality improvement partnership to implement stepped care for MOUD in 2 Veterans Health Administration (VA) primary care (PC) clinics. Methods: SUPPORT provided a dedicated clinical team (nurse practitioner prescriber and social worker) and stepped care ([1] identification, assessment, referral; [2] MOUD induction; [3] stabilization; and [4] maintenance supporting PC providers [PCPs] to initiate and/or sustain treatment) coupled with ongoing internal facilitation (consultation, trainings, informatics support). Qualitative interviews with stakeholders (PCPs and patients) and meeting notes identified barriers and facilitators to implementation. Electronic health record and patient tracking data measured reach, adoption, and implementation outcomes descriptively. Results: SUPPORT's implementation barriers included the need for an X-waiver, VA's opioid tapering policies, patient and PCP knowledge gaps and PCP discomfort, and logistical compatibility and sustainability challenges for clinics. SUPPORT's dedicated clinical staff, ongoing internal facilitation, and high patient and PCP satisfaction were key facilitators. SUPPORT (January 2019 to September 2021) trained 218 providers; 63 received X-waivers, and 23 provided MOUD (10.5% of those trained). SUPPORT provided care to 167 patients, initiated MOUD for 33, and provided education and naloxone to 72 (all = 0 in year before launch). Conclusions: SUPPORT reached many PCPs and patients and resulted in small increases in MOUD prescribing and high levels of stakeholder satisfaction. Dedicated clinical staff was key to observed successes. Although resource-intensive, SUPPORT offers a potential model for outpatient MOUD provision. [ABSTRACT FROM AUTHOR]

Objectives: Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative. Methods: Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post–index year and retention the proportion who received buprenorphine for 180 days or longer. Results: Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%–12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%–63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27–0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45–0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37–0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04–1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35–0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19–0.84) were less likely among non-Hispanic Black patients. Conclusions: Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients. [ABSTRACT FROM AUTHOR]

Background: This systematic review summarizes the development, accuracy, quality, and clinical utility of predictive models to assess the risk of opioid use disorder (OUD), persistent opioid use, and opioid overdose. Methods: In accordance with Preferred Reporting Items for a Systematic Review and Meta-analysis guidelines, 8 electronic databases were searched for studies on predictive models and OUD, overdose, or persistent use in adults until June 25, 2023. Study selection and data extraction were completed independently by 2 reviewers. Risk of bias of included studies was assessed independently by 2 reviewers using the Prediction model Risk of Bias ASsessment Tool (PROBAST). Results: The literature search yielded 3130 reports; after removing 199 duplicates, excluding 2685 studies after abstract review, and excluding 204 studies after full-text review, the final sample consisted of 41 studies that developed more than 160 predictive models. Primary outcomes included opioid overdose (31.6% of studies), OUD (41.4%), and persistent opioid use (17%). The most common modeling approach was regression modeling, and the most common predictors included age, sex, mental health diagnosis history, and substance use disorder history. Most studies reported model performance via the c statistic, ranging from 0.507 to 0.959; gradient boosting tree models and neural network models performed well in the context of their own study. One study deployed a model in real time. Risk of bias was predominantly high; concerns regarding applicability were predominantly low. Conclusions: Models to predict opioid-related risks are developed using diverse data sources and predictors, with a wide and heterogenous range of accuracy metrics. There is a need for further research to improve their accuracy and implementation. [ABSTRACT FROM AUTHOR]

Buprenorphine is an effective treatment for opioid use disorder (OUD). Patients in the emergency department (ED) can be initiated or continued on buprenorphine as a bridge to follow-up in the outpatient setting, but gaps in care may arise. The objective was to evaluate the impact of buprenorphine to-go packs as a continuing treatment option for patients presenting to the ED with OUD across a health system. Adult patients discharged with a buprenorphine to-go pack from one of ten EDs within a major health system were included. The primary outcomes assessed within 30 days of ED discharge were: (1) return to a health system ED, and (2) fill history of buprenorphine in the state prescription drug monitoring program database. Data was analyzed using descriptive statistics in Microsoft Excel (Redmond, WA). A total of 124 patients received buprenorphine to-go packs. The sample was primarily male (79; 63.7%), white (89; 71.8%), on Medicaid (79; 63.7%), and had a mean age of 40.9 years. A total of 43 patients (34.7%) were initiated on buprenorphine for the first time, while 81 (65.3%) had received buprenorphine (prescription or to-go) previously. At 30 days post-visit, 76 (61.3%) had filled buprenorphine prescriptions, and 40 (32.3%) returned to an ED within the health system for opioid withdrawal (17; 42.5%), non-OUD-related reasons (22; 55%), or overdose (1; 2.5%). The implementation of a system-wide buprenorphine to-go supply at ED discharge is a feasible option to provide continuity of care to patients with OUD. [ABSTRACT FROM AUTHOR]

Background: Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). Methods: Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber's preference IV in analyzing the treatment assignment-treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. Results: The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in providerlevel prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. Conclusions: Our results suggest that prescriber's preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD. [ABSTRACT FROM AUTHOR]

Objective: Medications for opioid use disorder (OUD or MOUD) treatment combining pharmacotherapy with psychosocial support are effective for managing OUD. However, treatment engagement remains a challenge, with retention rates ~30%-50%. Although social connection has been identified as important to recovery, it remains unclear whether and how social factors can bolster participation in treatment. Method: Individuals receiving MOUD at three outpatient treatment programs (N = 82) and healthy community controls (N = 62) completed validated measures assessing social connection including (a) size, diversity, and embeddedness of social networks; (b) perceived social support and criticism within familial relationships; and (c) subjective social status. For those receiving MOUD, we also examined how aspects of social connection related to opioid (re)use and treatment engagement (medication adherence, group, and individual meeting attendance) assessed over ~8 weeks/person. Results: Compared to controls, individuals receiving MOUD had smaller and less diverse and embedded social networks (Cohen's d > 0.4), and despite similar levels of perceived social support (d = 0.02), reported higher levels of social criticism (d = 0.6) and lower subjective social status (d = 0.5). Within the MOUD group, higher social network indices correlated specifically with higher therapeutic group attendance (Rs > 0.30), but not medication adherence, while higher levels of perceived criticism correlated with more frequent opioid use (R = 0.23). Results were mostly robust to control for sociodemographic variables, psychological distress/COVID-19, and treatment duration, but differed by MOUD type/program. Conclusions: These findings highlight the potential importance of assessing an individual's social capital, promoting positive social connection, and continuing to assess the implementation and value of psychosocial support in MOUD treatment. [ABSTRACT FROM AUTHOR]

Objective: The main reasons women in the general population seek abortion are financial, timing, and partnerrelated reasons. While women with opioid use disorder (OUD) appear to use abortion services more than women in the general population, reasons for abortion in this group have not been examined to our knowledge. Method: Female patients aged 18-50 years in OUD treatment at 22 randomly selected facilities in Michigan were surveyed. The survey included items assessing reproductive health history. Women who reported having one or more abortions were asked to think back to that time and their reasons for choosing abortion. Twenty potential reasons and a write-in option were offered; women could endorse as many as applied. Results: Of 260 women surveyed, 84 reported having an abortion. Of these, most (77.4%) reported multiple reasons for having an abortion. The most common reasons for having an abortion were not having money to take care of a baby (54.8%), feeling too young to have a child and not feeling ready to be a mother (both 42.9%), not loving the father and other partner-related concerns (25.0%-32.1%), and having concerns about the effects of their drug use (28.6%). No combination of reasons for abortion emerged as more prevalent than any other. Conclusions: Like women in the general population, women in treatment for OUD had not only abortions because of financial, timing, and partner-related reasons but also concerns about the effects of their drug use. These results underscore the multiple and often interrelated reasons that lead women to seek abortion. [ABSTRACT FROM AUTHOR]

Objective: Early adversity, such as adverse childhood experiences (ACEs), is a risk factor for the development of substance use disorder (SUD). ACEs are associated with earlier initiation of substance use. This study examined the relationship between ACEs and age of initiation of substance use using survival analysis. It is hypothesized that individuals with higher ACEs will have an earlier age of initiation. Method: Participants were recruited from the University of Kentucky's Laboratory for Human Behavioral Pharmacology. Participants were 18 years or older, English speaking, and actively engaged in substance use. Participants were not in substance abuse treatment nor were they seeking treatment. ACE scores were calculated, and age of substance use initiation was recorded. A Cox proportional hazard model was used to examine the effect of ACE score on age of substance use initiation. Results: A total of 107 participants completed the study. An average number of 2.3 ACEs (SD = 2.2) were endorsed with 24% of participants reporting 4 or more ACEs. Higher ACE scores were associated with cigarette smoking and non-medical prescription opioid use onset (hazard ratio (HR) = 1.14, 95% CI=1.02–1.28, p = 0.02, and HR=1.19, 95% CI = 1.04–1.37, p = 0.01, respectively. Conclusions: A significant association was found between higher ACE scores and earlier initiation of cigarette and non-medical prescription opioid use, consistent with prior research. Primary prevention of ACEs, screening for ACEs during childhood, and interventions for ACEs if detected, may help to reduce the risk of substance use/SUD in adulthood. [ABSTRACT FROM AUTHOR]

Background: There is a pressing need to understand the implications of the rapid adoption of virtual primary care for people with opioid use disorder. Potential impacts, including disruptions to opiate agonist therapies, and the prospect of improved service accessibility remain underexplored. Objective: This scoping review synthesized current literature on virtual primary care for people with opioid use disorder with a specific focus on benefits, challenges, and strategies. Methods: We followed the Joanna Briggs Institute methodological approach for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist for reporting our findings. We conducted searches in MEDLINE, Web of Science, CINAHL Complete, and Embase using our developed search strategy with no date restrictions. We incorporated all study types that included the 3 concepts (ie, virtual care, primary care, and people with opioid use disorder). We excluded research on minors, asynchronous virtual modalities, and care not provided in a primary care setting. We used Covidence to screen and extract data, pulling information on study characteristics, health system features, patient outcomes, and challenges and benefits of virtual primary care. We conducted inductive content analysis and calculated descriptive statistics. We appraised the quality of the studies using the Quality Assessment With Diverse Studies tool and categorized the findings using the Consolidated Framework for Implementation Research. Results: Our search identified 1474 studies. We removed 36.36% (536/1474) of these as duplicates, leaving 938 studies for title and abstract screening. After a double review process, we retained 3% (28/938) of the studies for extraction. Only 14% (4/28) of the studies were conducted before the COVID-19 pandemic, and most (15/28, 54%) used quantitative methodologies. We summarized objectives and results, finding that most studies (18/28, 64%) described virtual primary care delivered via phone rather than video and that many studies (16/28, 57%) reported changes in appointment modality. Through content analysis, we identified that policies and regulations could either facilitate (11/28, 39%) or impede (7/28, 25%) the provision of care virtually. In addition, clinicians' perceptions of patient stability (5/28, 18%) and the heightened risks associated with virtual care (10/28, 36%) can serve as a barrier to offering virtual services. For people with opioid use disorder, increased health care accessibility was a noteworthy benefit (13/28, 46%) to the adoption of virtual visits, whereas issues regarding access to technology and digital literacy stood out as the most prominent challenge (12/28, 43%). Conclusions: The available studies highlight the potential for enhancing accessibility and continuous access to care for people with opioid use disorder using virtual modalities. Future research and policies must focus on bridging gaps to ensure that virtual primary care does not exacerbate or entrench health inequities. [ABSTRACT FROM AUTHOR]

Background: Severe skin and soft tissue infections related to injection drug use have increased in concordance with a shift to heroin and illicitly manufactured fentanyl. Opioid agonist therapy medications (methadone and buprenorphine) may improve long-term outcomes by reducing injection drug use. We aimed to examine the association of medication use with mortality among people with opioid use-related skin or soft tissue infections. Methods: An observational cohort study of Medicaid enrollees aged 18 years or older following their first documented medical encounters for opioid use-related skin or soft tissue infections during 2007–2018 in North Carolina. The exposure was documented medication use (methadone or buprenorphine claim) in the first 30 days following initial infection compared with no medication claim. Using Kaplan–Meier estimators, we examined the difference in 3-year incidence of mortality by medication use, weighted for year, age, comorbidities, and length of hospital stay. Results: In this sample, there were 13,286 people with opioid use-related skin or soft tissue infections. The median age was 37 years, 68% were women, and 78% were white. In Kaplan–Meier curves for the total study population, 12 of every 100 patients died during the first 3 years. In weighted models, for every 100 people who used medications, there were four fewer deaths over 3 years (95% confidence interval = 2, 6). Conclusion: In this study, people with opioid use-related skin and soft tissue infections had a high risk of mortality following their initial healthcare visit for infections. Methadone or buprenorphine use was associated with reductions in mortality. [ABSTRACT FROM AUTHOR]

Objectives: We examined substance use hotline operator certainty of each US state and Washington, DC's endorsement of buprenorphine (initiation and continuation) prescribing via telemedicine. Methods: Between March andMay 2021, we called hotlines in 50 US states and Washington, DC, requesting information on whether practitioners in that state could initiate or continue buprenorphine treatment for opioid use disorder (OUD) via telephone or video conference. We compared operator responses to state implementation of buprenorphine telemedicine initiation. This study was designated as not human subjects research by the Boston University Institutional Review Board. Results: We spoke with operators in 47 states and Washington, DC. Operators could not be reached in Alaska, California, and Montana. Most operators were uncertain (don't know, probably yes, probably no) whether the state permitted buprenorphine initiation (81%, n = 39) or continuation (83%, n = 40) via telemedicine. Practitioners could initiate buprenorphine prescribing via telemedicine in 7 states (100%) where operators were certain practitioners could initiate buprenorphine, 1 state (100%) where the operator was certain practitioners could not, and 6 states (86%) where operators indicated practitioners probably could not. Conclusions: Most US states and Washington, DC, expanded the role of telemedicine in OUD treatment. However, most operators expressed uncertainty and sometimes communicated inaccurate information regarding whether practitioners could initiate buprenorphine treatment via telemedicine. There is an urgent need for policy mandates institutionalizing the role of telemedicine, and of buprenorphine specifically, in OUD treatment and for resources to train and support substance use hotline operators in this evolving policy environment. [ABSTRACT FROM AUTHOR]

Objectives: Methadone for opioid use disorder treatment in ambulatory settings is restricted to federally licensed opioid treatment programs (OTPs) in the United States. However, these restrictions do not apply during hospitalization. A recent change to the rule governing methadone in non-OTP settings created an opportunity to dispense methadone at hospital discharge for up to 72 hours. Methods: Here, we describe one hospital's approach to dispensing methadone at discharge in alignment with the "72-hour rule," including implementation challenges and considerations for other hospitals planning on adopting this practice. Implementation included creating a workflow and detailed documents outlining dispensing procedure, educating interprofessional staff, and coordinating with local OTPs. Results: Our experiences highlight the importance of pharmacy champions to support implementation and interdisciplinary staff education, the need to consider electronic health record capabilities, and the importance of having policies and practices that support appropriate interpretation of the "72-hour rule" renewal timeline. Conclusions: Exceptions to federal regulations allow greater flexibility in discharge planning for patients with opioid use disorder; however, dispensation workflow falls outside standard hospital care and may be challenging to implement. [ABSTRACT FROM AUTHOR]

Background and Objectives: Parenting women in treatment for opioid use disorder (OUD) report a lack of family centeredness and anticipatory guidancewithin well child care (WCC), andWCC utilization is low among affected children. We explore priorities for WCC visit content to inform primary care recommendations for this population. Methods: This study is a qualitative study of parenting women from one urban, academic OUD treatment program and pediatric primary care clinicians from a nearby affiliated pediatric practice. Eligible parent participants had a child =2 years old and were English speaking. Semistructured interviews elicited perspectives on WCC, with questions and prompts related to visit content. Inductive thematic analysis was led by 2 investigators using open coding procedures. Results:Among 30 parent participants, the majority were White (83%) and unmarried (90%). Approximately 60% reported their child received pharmacotherapy for neonatal opioid withdrawal syndrome. Of 13 participating clinicians, 9 were attending pediatricians. Five themes emerged from parental and clinician interviews: (1) improving knowledge and confidence related to child development, behavior, and nutrition; (2) mitigating safety concerns; (3) addressing complex health and subspecialty needs through care coordination; (4) acknowledging parental health and wellbeing in the pediatric encounter; and (5) supporting health education and care related to neonatal opioid withdrawal syndrome. Parents and clinicians expressed difficulty comprehensively addressing such issues due to time constraints, social determinants of health, and significant informational needs. Conclusions: Parenting women in treatment for OUD and pediatric clinicians share multiple priorities for anticipatory guidance withinWCC visits and barriers to addressing them comprehensively. [ABSTRACT FROM AUTHOR]

Objective: Low-dose buprenorphine initiation (LDBI) strategies to transition patients from full opioid agonists to buprenorphine have previously been described using sublingual films, intravenous solution, transdermal patches, and, more recently, buccal films. The objective of this study was to describe the effectiveness of LDBI using novel titration schedules with buccal films. Methods: This is a retrospective cohort study of hospitalized patients with opioid use disorder (OUD) or physiologic dependence to opioids who underwent LDBI with buprenorphine buccal films at NYU Langone Health. Two LDBI protocolswere evaluated, including a short titration schedule over 4 days and a long schedule over 7 days. The primary outcomes of interest included LDBI completion rates and incidence of opioid withdrawal. Results: Forty-two patients underwent 46 LDBIs at NYU Langone Health between October 2020 and April 2022. The cohort comprised patients with OUD (57%), chronic pain with OUD (33%), and chronic pain without OUD (10%). Indications for LDBI most commonly included co-occurring pain precluding discontinuation of full opioid agonists (72%), prior history of precipitated withdrawal (30%), and methadone use (23%). The overall completion rate of LDBI was 78%. Withdrawal was encountered in 33% of patients; however, only 2 patients required LDBI discontinuation as a result. On multivariate analysis, a diagnosis of OUD was independently associated with withdrawal during LDBI. Conclusions: Buprenorphine buccal films can successfully be used off-label to facilitate LDBI in the hospital setting. We present 4- and 7-day titration protocols, which were well-tolerated, and provide practical considerations for use. [ABSTRACT FROM AUTHOR]

Reducing nurse bias about patients with opioid use disorder in the emergency department is critical for providing nonjudgmental care, enhancing patient outcomes, supporting effective communication, and promoting a holistic approach to care. Emergency nurses can make a positive impact on the lives of individuals diagnosed as having opioid use disorder by providing care that is free from stigma and discrimination. The study used an observational, pretest-posttest design to compare educational sessions addressing bias and stigma toward patients with opioid use disorder. The study population consisted of emergency nurses who self-selected into a virtual learning experience consisting of e-modules or simulation-based experience consisting of simulation-based experience consisting of simulation, discussion, and a speaker. After the intervention, the simulation-based experience group showed an increase in total score postintervention from a mean of 118.6 to a mean of 127.1 (P <.001). The virtual learning experience group also showed an increase in total score postintervention from a mean of 116.3 to 120.7 (P <.001). Although both groups showed an increase in scores over time, the simulation-based experience group had a greater increase (P =.0037). Within the simulation-based experience, there was an increase in scores across all age groups (P <.05) but a significantly greater increase in scores among younger nurses (18-29 years) than the older age groups (P =.006). Opioid use disorder is a complex condition that requires a comprehensive and holistic approach to care. Study results indicate that providing an educational experience to address stigma about patients diagnosed as having opioid use disorder can significantly affect nurse perceptions about these patients and their self-efficacy when working with them. However, investing in a simulation-based educational experience provides a stronger experience and results in greater change, particularly for younger, less experienced emergency nurses. [ABSTRACT FROM AUTHOR]