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Objective: Opioid use disorder (OUD) can be effectively treated with buprenorphine maintenance. Recent changes in federal policy have removed the requirement for physicians to complete additional training to apply for a Drug Enforcement Administration (DEA) waiver to prescribe buprenorphine. At that time, few primary care providers (PCPs) had completed the training for a DEA waiver to prescribe buprenorphine. Our goal was to identify addressable barriers that may persist despite updates to federal legislation., Design: A 42-item survey was distributed to 662 physicians and nurse practitioners at two academic medical centers with 100 respondents., Setting: The survey was sent via email and administered anonymously through SurveyMonkey., Patients and Participants: All participants were PCPs, and all PCPs at the two academic medical centers were eligible to participate., Interventions: PCPs responded to the survey by answering questions online., Main Outcome Measures: PCPs answered questions regarding previous buprenorphine waiver training status, local OUD prevalence, the effectiveness of OUD treatment modalities, and previous barriers to training., Results: Respondents were compared using descriptive statistics and logistic regression. Of the 100 respondents (response rate: 15 percent), 69 percent had not completed the training. Ninety-nine percent of PCPs agreed that OUD was an issue in their area, 94 percent saw patients with OUD, and 91 percent rated buprenorphine maintenance as a very effective treatment for OUD. Previously waivered and nonwaivered providers did not differ in their responses to these questions. Those who had been waivered were less likely to say they did not see enough patients with OUD to justify training (odds ratio [OR] 0.267, p = 0.005) and were less likely to express concern about allowing patients with OUD into their practice (OR 0.348, p = 0.020) than PCPs who had applied for the DEA waiver., Conclusions: Despite nonwaivered PCPs recognizing OUD's prevalence, they were concerned about allowing patients with OUD into their practice and said there were not enough patients to justify training. This suggests that attitudinal barriers are the most appropriate target for current intervention.

Background: Treatment for opioid use disorder (OUD), particularly medication for OUD, is highly effective; however, retention in OUD treatment is a significant challenge. We aimed to identify key risk factors for premature exit from OUD treatment., Methods: We analyzed 2,381,902 cross-sectional treatment episodes for individuals in the U.S., discharged between Jan/1/2015 and Dec/31/2019. We developed classification models (Random Forest, Classification and Regression Trees (CART), Bagged CART, and Boosted CART), and analyzed 31 potential risk factors for premature treatment exit, including treatment characteristics, substance use history, socioeconomic status, and demographic characteristics. We stratified our analysis based on length of stay in treatment and service setting. Models were compared using cross-validation and the receiver operating characteristic area under the curve (ROC-AUC)., Results: Random Forest outperformed other methods (ROC-AUC: 74%). The most influential risk factors included characteristics of service setting, geographic region, primary source of payment, and referral source. Race, ethnicity, and sex had far weaker predictive impacts. When stratified by treatment setting and length of stay, employment status and delay (days waited) to enter treatment were among the most influential factors. Their importance increased as treatment duration decreased. Notably, importance of referral source increased as the treatment duration increased. Finally, age and age of first use were important factors for lengths of stay of 2-7 days and in detox treatment settings., Conclusions: The key factors of OUD treatment attrition identified in this analysis should be more closely explored (e.g., in causal studies) to inform targeted policies and interventions to improve models of care., (Copyright © 2022 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: When initiated in the Emergency Department (ED), medication for addiction treatment (MAT) with buprenorphine improves outcomes, increases engagement in addiction treatment and decreases the use of inpatient addiction treatment services. Unfortunately, initiating MAT in the ED is not yet standard practice. We assessed the impact of the addition of a multipart behavioral science-based intervention to increase opioid use disorder (OUD)-related treatments prescribed in the ED., Methods: Our ED initiated a campaign to help ED faculty obtain their DEA-X waiver required to prescribe buprenorphine. In parallel, we implemented 2 ED-initiated buprenorphine treatment pathways. We then conducted a two-stage qualitative process informed by behavioral science to identify key barriers to physician use of the MAT protocol. Using these insights, we developed 4 behavioral science-based interventions. To assess the impact of the interventions on the number of OUD-related treatments per day among patients meeting the inclusion criteria we compared the number of OUD-related treatments per day before versus after the interventions began using t tests. Then, in our primary model, we estimated the causal effect of the behavioral interventions using a regression discontinuity in time approach., Results: Across the entire year study period, there is an increase in OUD-related treatment after the interventions begin, driven by greater use of ambulatory referral orders. The unadjusted mean difference in any OUD treatments per day pre- versus post-intervention increased by 0.80 (95% confidence interval [CI]: 0.04, 1.56; P = 0.039) whereas the number of ambulatory referral orders placed increased by 0.82 (95% CI: 0.48,1.16; P < 0.001). Using the 120-day study window and an ordinary least squares regression discontinuity in time model, the 4-part intervention increased the number of patients receiving any opioid treatment in the ED by 1.6 additional treatments per day (95% CI: 0.04, 3.19; P = 0.045)., Conclusions: To support our protocol and increase the provision of ED-MAT, we implemented 1 patient-facing and 3 provider-facing interventions rooted in behavioral science principles. Our results show that this pack of behavioral science interventions increased the likelihood that ED providers offer MAT to patients with OUD., Competing Interests: The authors report no conflicts of interest., (Copyright © 2021 American Society of Addiction Medicine.)

Introduction: Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with Food and Drug Administration (FDA)-approved cessation aids, suggesting need for novel approaches. Electronic cigarettes (e-cigarettes) might benefit this population, but e-cigarettes' acceptability for tobacco reduction or cessation among smokers in OUD treatment is not known., Methods: A cross-sectional mixed-methods study of 222 adults in OUD treatment with buprenorphine in the Boston, Massachusetts metropolitan area was conducted in 2020. We used quantitative and qualitative data to investigate individuals' experience with and interest in e-cigarettes and other methods for smoking cessation and assessed factors associated with interest in e-cigarette use., Results: One hundred sixty (72%) of the 222 participants were past 30-day cigarette smokers. They most frequently reported having ever used nicotine replacement therapy (NRT; 83%) and e-cigarettes (71%) for smoking cessation and most often indicated interest in using NRT (71%) and e-cigarettes (44%) for future smoking cessation. In multiple logistic regression analysis, interest in using e-cigarettes for future smoking cessation was independently associated with having ever used e-cigarettes for smoking cessation, current e-cigarette use, and perceiving e-cigarettes to be less harmful than cigarettes (ps < .05). In qualitative data, many current vapers/former smokers reported that e-cigarettes had been helpful for quitting cigarettes. For current smokers who currently or formerly vaped, frequently reported challenges in switching to e-cigarettes were concerns about replacing one addiction with another and e-cigarettes not adequately substituting for cigarettes., Conclusions: E-cigarettes had a moderate level of acceptability for smoking cessation among cigarette smokers in OUD treatment. More research is warranted to test the efficacy of this approach., Implications: Individuals in treatment for opioid use disorder (OUD) have high smoking rates and limited success with existing smoking cessation tools, suggesting a need for novel cessation treatment approaches. In this mixed-methods study of individuals receiving medication treatment for OUD with buprenorphine in Massachusetts in 2020, we found a moderate level of acceptability of e-cigarettes for smoking cessation., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Recent prevalence estimates of cannabis use among individuals receiving medication treatment for OUD (MOUD) are lacking, and no study has characterized cannabis route of administration (cROA) in this population. These knowledge gaps are relevant because cannabis' effects and health outcomes vary by cROA and the availability and perceptions of cROA (e.g., vaping devices) are changing., Methods: The Vaping In Buprenorphine-treated patients Evaluation (VIBE) cross-sectional survey assessed the prevalence and correlates of cannabis use and cROA among adults receiving buprenorphine MOUD from 02/20 to 07/20 at five community health centers in Massachusetts, a state with legal recreational and medical cannabis use., Results: Among the 92/222 (41%) respondents reporting past 30-day cannabis use, smoking was the most common cROA (75%), followed by vaping (38%), and eating (26%). Smoking was more often used as a single cROA vs. in combination others (p = 0.01), whereas vaping, eating, and dabbing were more often used in combination with another cROA (all p < 0.05). Of the 39% of participants reporting multiple cROA, smoking and vaping (61%), and smoking and eating (50%), were the most prevalent combinations. Nonwhite race (vs. white) and current cigarette smoking (vs. no nicotine use) were associated with past 30-day cannabis use in multiple logistic regression., Conclusions: Prevalence of past 30-day cannabis use among individuals receiving buprenorphine MOUD in Massachusetts in 2020 was nearly double the prevalence of cannabis use in Massachusetts' adult general population in 2019 (21%). Our data are consistent with state and national data showing smoking as the most common cROA.

Objective: National guidelines advise against breastfeeding for women who use nonprescribed substances in the third trimester. This reduces the number of women who are supported in breastfeeding initiation despite limited evidence on the prognostic value of third trimester substance use. We sought to examine the degree to which prenatal nonprescribed substance use is associated with non-prescribed use postpartum., Methods: Retrospective cohort study of pregnant women with opioid use disorder on methadone or buprenorphine between 2006 and 2015. Nonprescribed use was defined by a positive urine drug testing (UDT). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated comparing 3 prenatal periods with postpartum UDT results. Generalized estimating equations were used to examine the extent to which prenatal nonprescribed use was associated with postpartum use., Results: Included were 545 deliveries by 503 women. Mean age was 28.3 years, 88% were White/non-Hispanic, 93% had public insurance, and 43% received adequate prenatal care. The predictive value of UDT's 90 to 31 days before delivery, 30 to 0 days before delivery, and at delivery showed low sensitivity (44, 26, 27%, respectively) and positive predictive value (36, 36, 56%, respectively), but higher negative predictive value (80, 85, and 78%, respectively), P-values all <0.05. In the final adjusted model, only nonprescribed use at delivery was significantly associated with postpartum nonprescribed use., Conclusions: Nonprescribed use at delivery was most strongly associated with postpartum use compared with earlier time periods currently prioritized in guidelines. In women with opioid use disorder prenatal UDT results alone are insufficient to guide breastfeeding decisions., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 American Society of Addiction Medicine.)

Background: Cigarette smoking may increase the risk of COVID-19 complications, reinforcing the urgency of smoking cessation in populations with high smoking prevalence such as individuals with opioid use disorder (OUD). Whether the COVID-19 pandemic has altered perceptions, motivation to quit, or tobacco use among cigarette smokers and nicotine e-cigarette vapers with OUD is unknown., Methods: A telephone survey was conducted in March-July 2020 of current cigarette smokers or nicotine vapers with OUD who were stable on buprenorphine treatment at five Boston (MA) area community health centers. The survey assessed respondents' perceived risk of COVID-19 due to smoking or vaping, interest in quitting, quit attempts and change in tobacco consumption during the pandemic., Results: 222/520 patients (43 %) completed the survey, and 145 were asked questions related to COVID-19. Of these, 61 % smoked cigarettes only, 13 % vaped nicotine only, and 26 % were dual users. Nearly 80 % of participants believed that smoking and vaping increased their risk of COVID-19 infection or complications. Smokers with this belief reported an increased interest in quitting (AOR 4.6, 95 % CI:1.7-12.4). Overall, 49 % of smokers and 42 % of vapers reported increased interest in quitting due to the pandemic; 24 % and 20 %, respectively, reported attempting to quit since the pandemic. However, 35 % of smokers and 27 % of vapers reported increasing smoking and vaping, respectively, during the pandemic., Conclusions: Most patients with OUD believed that smoking and vaping increased their vulnerability to COVID-19, half reported increased interest in quitting, but others reported increasing smoking and vaping during the COVID-19 pandemic., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Recent evidence shows that emergency physicians (EP) can help patients obtain evidence-based treatment for Opioid Use Disorder by starting medication for addiction treatment (MAT) directly in the Emergency Department (ED). Many EDs struggle to provide options for maintenance treatment once patients are discharged from the ED. Health systems around the country are in need of a care delivery structure to link ED patients with OUD to care following initiation of buprenorphine. This paper reviews the three most common approaches to form effective partnerships between EDs and primary care/addiction medicine services: the Project Alcohol and Substance Abuse Services and Referral to Treatment (ASSERT) model, Bridge model, and ED-Bridge model.The ASSERT Model is characterized by peer educators or community workers in the ED directly referring patients suffering from OUD in the ED to local addiction treatment services. The Bridge model encourages prescribing physicians in an ED to screen patients for OUD, provide a short-term prescription for buprenorphine, and then refer the patient directly to an outpatient Bridge Clinic that is co-located in the same hospital but is a separate from the ED. This Bridge Clinic is staffed by addiction trained physicians and mid-level clinicians. The ED-Bridge model employs physicians trained in both emergency medicine and addiction medicine to serve within the ED as well as in the follow up addiction clinic.Distinct from the Bridge Clinic model above, EPs in the ED-Bridge model are both able to screen at-risk patients in the ED, often starting treatment, and to longitudinally follow patients in a regularly scheduled addiction clinic. This paper provides examples of these three models as well as implementation and logistical details to support a health system to better address OUD in their communities.

Opioid use disorder (OUD) is an increasing public health problem. Transplant centers worldwide are being confronted with increasing numbers of patients with opioid use disorder and end stage organ disease. Opioid agonist therapy (OAT; ie, methadone, buprenorphine, and buprenorphine/naloxone) is a scientifically proven, effective, physician-prescribed treatment for OUD. Although data in transplant populations remain limited, studies suggest that OAT does not appear to negatively affect graft or patient survival. Policies that require discontinuation of OAT for purposes of listing or transplantation contradict the evidence base for efficacy of OAT. Additional prospective outcomes studies on OAT and transplantation are needed. In the meantime, centers should not be asking patients to come off these effective treatments., (© 2018 The American Society of Transplantation and the American Society of Transplant Surgeons.)