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Objective: This paper will discuss the process of mapping opioid use disorder (OUD) treatment resources for pregnant women and discuss the intersection between treatment resources and rates of neonatal abstinence syndrome (NAS). Design: A resource manual was developed through a systematic process with stakeholders across Illinois. Resources were mapped by county and overlaid with county rates of NAS, using hospital discharge data. Results: Across Illinois, 89 treatment resources were identified for pregnant women insured by Medicaid. Resources were concentrated in 36% of Illinois' counties. Counties with limited treatment resources generally had high rates of NAS. Sixty‐six percent of NAS cases among rural Illinois residents had no OUD treatment resources in their county. Rural counties had less access to medication‐assisted treatment (MAT), the standard of care for treatment of OUD, compared with other counties across the state. Conclusions: Efforts to increase OUD treatment options for pregnant women insured by Medicaid should concentrate on geographic areas with limited access and high need. [ABSTRACT FROM AUTHOR]

Background and aims: Pharmacy administration and dispensing of methadone for methadone maintenance treatment (MMT) can expand treatment access for opioid use disorder (OUD). This study investigated the feasibility and acceptability of a novel model permitting an opioid treatment program (OTP) physician to prescribe methadone for OUD treatment through collaboration with a partnered pharmacy. Design Non‐randomized, single‐arm, open‐label feasibility trial. Setting: One OTP and one community pharmacy in the United States. Participants: One OTP physician, two pharmacists and 20 MMT patients receiving between six and 13 take‐home methadone doses at 5–160 mg/day. Intervention: Patients' methadone administration and dispensing of take‐home doses was transferred from the OTP to the pharmacy for 3 months. Measurements Primary outcome was medication adherence. Secondary outcomes were recruitment, treatment retention, substance use, counseling attendance at the OTP, pharmacist prescription drug monitoring program (PDMP) use, safety and satisfaction. Findings Of 29 patients eligible at pre‐screen, 20 patients (69%) enrolled into the study. Recruitment occurred from 6 August 2020 to 10 October 2020. Treatment retention rate at month 3 was 80% (16 of 20). Two participants returned early to the OTP because of a work/schedule change, one due to pregnancy and one following a non‐study‐related hospitalization. Medication adherence among 16 patients who were retained was 100%. Intervention fidelity was 100%. All participants attended random call‐back visits. None showed evidence of tampering/diversion of methadone. Pharmacists checked the PDMP at all visits. All participants attended psychosocial counseling as planned. There were no positive urine screens for illicit opioid use and no study‐related adverse events. All participants endorsed 'pharmacy is the right location for receiving methadone for MMT', 88% endorsed 'convenient or very convenient to receive methadone at the pharmacy' and 88% were satisfied or very satisfied with the quality of treatment offered. Conclusions: This feasibility trial has found pharmacy administration and dispensing of physician‐prescribed methadone for methadone maintenance treatment to be feasible and acceptable. [ABSTRACT FROM AUTHOR]

Aims: To assess differences in the quality of opioid use disorder (OUD) treatment received by Medicare beneficiaries enrolled in health plans that used prior authorization (PA) for buprenorphine–naloxone compared with those enrolled in plans that did not use PA. Design, Setting and Participants: Cross‐sectional observational study, United States. Continuously enrolled beneficiaries (71 294) with an OUD who filled at least one prescription for buprenorphine–naloxone between March 2012 and July 2017. Measurements Percentage of patients tested for hepatis B, hepatis C, HIV and liver functioning; percentage of patients with urine drug screens and number of urine drug screens; continuous use of buprenorphine–naloxone for at least 180 days; co‐use of benzodiazepines; number of outpatient visits with and without an OUD diagnosis. Findings PA was significantly associated with a lower likelihood of testing for hepatitis B [−3.5, 95% confidence interval (CI) = −4.4, −2.7] and C (−5.9, 95% CI = −6.9, −4.9), but the findings were inconclusive as to whether or not there was a difference in HIV (−1.1, 95% CI = −2.5, 0.4) or liver function testing (1.3, 95% CI = −0.1, 2.7). PA was associated with a lower likelihood of urine drug screening (−25.5, 95% CI = −26.8, −24.1) and with fewer drug screens (−2.5, 95% CI = −3.0, −2.1). Findings were inconclusive as to whether or not there was a difference in continuous use of buprenorphine–naloxone (0.3, 95% CI = −1.2, 1.8). PA was associated with fewer outpatient visits (−2.1, 95% CI = −3.0, −1.2) and fewer outpatient visits with an OUD diagnosis (−1.7, 95% CI = −2.1, −1.3). PA was associated with a lower likelihood of filling benzodiazepine prescriptions before and after buprenorphine–naloxone induction (−28.9, 95% CI = −29.6, −28.3) but a greater likelihood of only using benzodiazepines after buprenorphine–naloxone induction (10.6, 95% CI = 9.3, 11.8). Conclusions: US Medicare patients subject to prior authorization for buprenorphine–naloxone are not more likely to receive high‐quality treatment for opioid use disorder than patients not subject to prior authorization. [ABSTRACT FROM AUTHOR]

Background and Aims: In a US randomized‐effectiveness trial comparing extended‐release naltrexone (XR‐NTX) with buprenorphine–naloxone (BUP‐NX) for the prevention of opioid relapse among participants recruited during inpatient detoxification (CTN‐0051), the requirement to complete opioid detoxification prior to initiating XR‐NTX resulted in lower rates of initiation of XR‐NTX (72% XR‐NTX versus 94% BUP‐NX). Design This was a retrospective secondary analysis of CTN‐0051 trial data, including follow‐up data over 24–36 weeks. Setting: Eight community‐based, inpatient‐detoxification and follow‐up outpatient treatment facilities in the United States. Participants: A total of 283 participants randomized to receive XR‐NTX. Measurements Efficiency was estimated using a multivariable generalized structural equation model to explore simultaneous determinants of XR‐NTX induction and induction duration (detoxification + residential days). Cost‐effectiveness was estimated from the health‐care sector perspective and included expected costs and quality‐adjusted life‐years (QALYs). Findings Treatment site was the only modifiable factor that simultaneously increased the likelihood of XR‐NTX induction and decreased induction duration. Incorporating the higher predicted probability of XR‐NTX induction, and fewer predicted days of detoxification and subsequent residential treatment into the cost‐effectiveness framework, reduced the incremental average 24‐week total cost of XR‐NTX treatment from $5317 more than that of BUP‐NX (P = 0.01) to a non‐statistically‐significant difference of $1016 (P = 0.63). QALYs gained remained similar across arms. Conclusion: Adopting an efficient model of extended‐release naltrexone initiation could result in extended‐release naltrexone and buprenorphine–naloxone being of comparable economic value from the health‐care sector perspective over 24–36 weeks for patients seeking treatment for opioid use disorder at an inpatient detoxification facility. [ABSTRACT FROM AUTHOR]

Objective: Emergency medicine clinicians are uniquely positioned to deliver interventions to enhance linkage to evidence‐based treatment for opioid use disorder (OUD) in the acute overdose period, yet little is known about patient perspectives to effectively engage patients immediately following opioid overdose. Our objective was to explore patients' perspectives on substance use treatment, perceived needs, and contextual factors that shape the choice of patients seen in the emergency department (ED) to engage with treatment and other patient support services in the acute post–opioid overdose period. Methods: We administered a brief quantitative survey and conducted semistructured interviews with 24 adult ED patients receiving care after an acute opioid overdose between June 2016 and August 2017 in an urban, academic ED. We used constant comparison method and thematic analysis to identify themes across four levels of a modified social ecologic model (individual, interpersonal, organizational, and structural). Results: The mean (±SD) age of the sample was 33.5 (±9.33) years; 83% were White and 12% were Black; 67% were male; and 83% were diagnosed with OUD, with a mean (±SD) of 3.25 (±2.64) self‐reported lifetime opioid overdoses. Eight themes were identified as influencing participants' consideration of OUD treatment and other services: (1) perceptions about control of drug use, (2) personal experience with substance use treatment, (3) role of interpersonal relationships, (4) provider communication skills, (5) stigma, (6) availability of ED resources, (7) impact of treatment policies, and (8) support for unmet basic needs. Conclusions: Patients receiving ED care following overdose in our ED are willing to discuss their opioid use and its treatment in the ED and report a variety of unmet needs. This work supports a role for ED‐based research evaluating a patient‐oriented approach to engage patients after opioid overdose. [ABSTRACT FROM AUTHOR]

Objectives: The opioid crisis has risen dramatically in North America in the new millennium, due to both illegal and prescription opioid use. While emergency departments (EDs) represent a potentially strategic setting for interventions to reduce harm from opioid use disorder (OUD), the absence of a recent synthesis of literature limits implementation and scalability. To fill this gap, we conducted a systematic review of the literature on interventions targeting OUDs initiated in EDs. Methods: Using an explicit search strategy (PROSPERO), the MEDLINE, CINAHL Complete, EMBASE, and EBM reviews databases were searched from 1980 to October 4, 2019. The gray literature was explored using Google Scholar. Study characteristics were abstracted independently. The methodologic quality and risk of bias were assessed. Results: Twelve of 2,270 studies met the inclusion criteria (two of high quality). In addition to the heterogeneity of the outcome measures used (retention in treatment, opioid consumption, and overdose), brief intervention and buprenorphine initiation (six of 12 studies) were the most documented with mixed effects for the former and positive short‐term and confined to single ED sites effects for the latter. Conclusion: Emergency departments can be an appropriate setting for initiating opioid agonist treatment, but to be sustained, it likely needs to be coupled with community‐based follow‐up and support to ensure longer‐term retention. The scarcity of high‐quality evidence on OUD interventions initiated in emergency settings highlights the need for future research. [ABSTRACT FROM AUTHOR]

Among those who discuss America's opioid crisis, it is popular to claim that we know what we, as a society, ought to do to solve the problem—we simply don't want it badly enough. We don't lack knowledge; we lack the will to act and to fund the right policies. In fact, I've heard two versions of this. Among those who focus on prescription opioids, it is clear that we ought to stop prescribing so many powerful opioid painkillers. And among my public health colleagues focusing on illicit drug use, it is clear that we ought to expand addiction treatment and harm‐reduction services. The problem, however, is that the second claim is not obvious (and, indeed, is denied by many Americans), and the first claim probably isn't even true (at least, not in so crude a form). In short, the opioid crisis presents not only a problem of political will but also one of ethics. It will take work to discover or justify our normative claims in this arena. [ABSTRACT FROM AUTHOR]

Background and Objectives: Opioid use disorder (OUD) is a chronic condition with potentially severe health and social consequences. Many who develop moderate to severe OUD will repeatedly seek treatment or interact with medical care via emergency department visits or hospitalizations. Thus, there is an urgent need to develop feasible and effective approaches to help persons with OUD achieve and maintain abstinence from opioids. Treatment that includes one of the three FDA-approved medications is an evidence-based strategy to manage OUD. The purpose of this review is to address practices for managing persons with moderate to severe OUD with a focus on opioid withdrawal and naltrexone-based relapse-prevention treatment.Methods: Literature available on PubMed was used to review the evolution of treatment strategies from the 1960s onward to manage opioid withdrawal and initiate treatment with naltrexone.Results: Emerging practices for extended-release naltrexone induction include the use of agonist tapers and adjuvant medications. Clinical challenges frequently encountered when initiating this therapy include managing withdrawal and ongoing opioid use during treatment. Clinical factors may inform decisions regarding patient selection and length of naltrexone treatment, such as recent opioid use and patient preferences.Conclusions and Scientific Significance: Treatment strategies to manage opioid withdrawal have evolved, but many patients with OUD do not receive medication for the prevention of relapse. Clinical strategies for induction onto extended-release naltrexone are now available and can be safely and effectively implemented in specialty and select primary care settings. (© 2018 The Authors. The American Journal on Addictions Published by Wiley Periodicals, Inc. on behalf of The American Academy of Addiction Psychiatry (AAAP);27:177-187). [ABSTRACT FROM AUTHOR]

Background and Objectives: Opioid use disorder among young adults is rising sharply with an increase in morbidity and mortality. This study examined differences in treatment response to a fixed dose of buprenorphine-naloxone between heroin (HU) and prescriptions opioids (POU) users.Methods: Eighty opioid dependent young adults (M = 22 years) were treated with buprenorphine-naloxone 16-4 mg/day for 8 weeks. Differences between HU (N = 17) and POU (N = 63) on changes in weekly opioid use, opioid craving, withdrawal, and depression symptoms were analyzed with mixed-effects regression models.Results: The HU had an overall mean proportion of weekly opioid use of .32 (SD = .14) compared to POU's weekly mean of .24 (SD = .15) showing a significant main effect (Z = 2.21, p = .02). Depressive symptoms (CES-D scores) were elevated at baseline for both groups (HU: M = 23.1, SD = 11.9; PO: M = 22.2, SD = 9.4), but only POU improved significantly to a score of 9.88 (SD = 7.4) compared to HU's score of 18.58 (SD = 10.3) at week 8 (Z = 2.24, p = .02). There were no significant differences in treatment retention, craving, or withdrawal symptoms.Discussion and Conclusions: Treatment response to 16-4 mg/day of buprenorphine-naloxone was significantly diminished for heroin users relative to opioid prescription users in weekly opioid use. Heroin users also had persistent depressive symptoms suggesting the need for close monitoring.Scientific Significance: These data suggest that young heroin users might require higher doses of buprenorphine. (Am J Addict 2017;26:838-844). [ABSTRACT FROM AUTHOR]

This article examines how the amplified role of pharmaceutical substances in addiction treatment affects the everyday realisation of care, particularly the relationship between workers and patients, in so called austere environments. Theoretically the article draws firstly on the literature that links pharmaceuticalisation to the neoliberal undoing of central public structures and institutions of care, and secondly on Anne-Marie Mol's concept of the logic of care. Based on an ethnographic analysis of the everyday life at a Finnish opioid substitution treatment clinic we show the mechanisms through which the realisation of pharmacotherapy can, in the current political climate, result in a very narrow understanding of drug problems and minimal human contact between patients and professionals. Our analysis manifests an important shift in the logic of addiction treatment and health-care policy more broadly; namely, a growing tendency to emphasise the need for patients to care for themselves and make good choices with limited help from formal care institutions and professionals. We call this new ethos the logic of austerity. [ABSTRACT FROM AUTHOR]

Background Studies addressing relapse rates conflate relapse into chronic migraine (CM) and medication overuse (MO), and the consequent need to repeat withdrawal. We aim to identify 12-months predictors of relapse into CM (based on headaches frequency) separately from occurrence of another structured withdrawal. Methods Hospitalized patients with CM-MO under withdrawal were enrolled. Candidate predictors included demographic, disability, quality of life, depression scores, general self-efficacy, social support, headaches frequency and intensity, class of overused medications, history of withdrawal treatment in the three years prior to enrollment, attendance to emergency room (ER) between enrollment and follow-up, nonattendance to outpatient neurological examinations. Logistic regressions was used to address the significant predictors for the two outcomes. Results Complete data were available for 177 patients: 60 (33.9%) relapsed into CM, 38 (21.5%) underwent another withdrawal treatment. Recent history of withdrawal treatments, ER admission after discharge and high baseline BDI-II scores were significant predictors in both models. In addition to this, high baseline headache frequency predicted relapse into another withdrawal treatment. Conclusions Predictors or relapse into CM and of occurrence of another withdrawal by 12-months are somehow similar. It is important to assess presence of recent previous withdrawal treatments and to plan regular follow-up afterwards, in particular for patients with high headache frequency and relevant mood disturbances: in this way, it will be more likely that situations requiring further structured withdrawal treatments can be identified before patients have to refer to ER. [ABSTRACT FROM AUTHOR]