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Background and Aims: Opioid use disorder (OUD) is treatable with buprenorphine/naloxone (buprenorphine), but many patients discontinue treatment prematurely. The aim of this study was to assess the influence of patient‐ and prescriber‐level characteristics relative to several patient outcomes following the initiation of buprenorphine treatment for OUD. Design: This was a retrospective observational investigation. We used the Public Health Data Warehouse from the Massachusetts Department of Public Health to construct a sample of patients who initiated buprenorphine treatment between 2015 and 2019. We attributed each patient to a prescriber based on information from prescription claims. We used multilevel models to assess the influence of patient‐ and prescriber‐level characteristics on each outcome. Setting: Massachusetts, USA. Participants: The study cohort comprised 37 955 unique patients and 2146 prescribers. Among patients, 64.6% were male, 52.6% were under the age of 35 and 82.2% were White, non‐Hispanic. For insurance coverage, 72.1% had Medicaid. Measurements The outcome measures were poor medication continuity, treatment discontinuation and opioid overdose, all assessed within a 12‐month follow‐up period that began with a focal prescription for buprenorphine. Each patient had a single follow‐up period. Poor medication continuity was defined as medication gaps totaling more than 7 days during the initial 180 days of buprenorphine treatment and treatment discontinuation was defined as having a medication gap for 2 consecutive months within the 12‐month follow‐up period. Findings The patient‐level rates for poor medication continuity, treatment discontinuation and opioid overdose were 59.7% [95% confidence interval (CI) = 59.2–60.2], 57.4% (95% CI = 56.9–57.9) and 10.3% (95% CI = 10.0–10.6), respectively, with 1.1% (95% CI = 1.0–1.2) experiencing a fatal opioid overdose. At the patient level, after adjustment for covariates, adverse outcomes were associated with race/ethnicity as both Black, non‐Hispanic and Hispanic patients had worse outcomes than did White, non‐Hispanic patients (Black, non‐Hispanic ‐‐ poor continuity: 1.50, 95% CI = 1.34–1.68; discontinuation: 1.44, 95% CI = 1.30–1.60; Hispanic ‐‐ poor continuity: 1.21, 95% CI = 1.12–1.31; discontinuation: 1.38, 95% CI = 1.28–1.48). Patients with insurance coverage through Medicaid also had worse outcomes than those with commercial insurance (poor continuity: 1.18, 95% CI = 1.11–1.26; discontinuation: 1.09, 95% CI = 1.03–1.16; overdose: 1.98, 95% CI = 1.75–2.23). Pre‐treatment mental health conditions and other types of chronic illness were also associated with worse outcomes (History of mental health conditions ‐‐ poor continuity: 1.11, 95% CI = 1.06–1.17; discontinuation: 1.05, CI = 1.01–1.10; overdose: 1.47, 95% CI = 1.36–1.60; Chronic health conditions ‐‐ poor continuity: 1.15, 95% CI = 1.05–1.27; discontinuation: 1.15, 95% CI = 1.05–1.26; overdose: 1.83, 95% CI = 1.60–2.10; History of substance use disorder other than for opioids ‐‐ poor continuity: 1.54, 95% CI = 1.46–1.62; discontinuation: 1.54, 95% CI = 1.47–1.62; overdose: 1.93, 95% CI = 1.80–2.07). At the prescriber level, after adjustments for covariates, adverse outcomes were associated with clinical training, as primary care physicians had higher rates of adverse outcomes than psychiatrists (poor continuity: 1.12, 95% CI = 1.02–1.23; discontinuation: 1.04, 95% CI = 1.01–1.09). A larger prescriber panel size, based on number of patients being prescribed buprenorphine, was also associated with higher rates of adverse outcomes (poor continuity: 1.36, 95% CI = 1.27–1.46; discontinuation: 1.21, 95% CI = 1.14–1.28; overdose: 1.10, 95% CI = 1.01–1.19). Between 9% and 15% of the variation among patients for the outcomes was accounted for at the prescriber level. Conclusions: Patient‐ and prescriber‐level characteristics appear to be associated with patient outcomes following buprenorphine treatment for opioid use disorder. In particular, patients' race/ethnicity and insurance coverage appear to be associated with substantial disparities in outcomes, and prescriber characteristics appear to be most closely associated with medication continuity during early treatment. [ABSTRACT FROM AUTHOR]

Objectives. To determine whether the Communities That HEAL (CTH) intervention is effective in increasing naloxone distribution compared with usual care. Methods. The HEALing (Helping to End Addiction Long-Term) Communities Study (HCS) is a cluster-randomized, parallel-arm, wait-list controlled implementation science trial testing the impact of the CTH intervention on increasing the use of evidence-based practices to lower opioid-related overdose deaths. Communities (n = 67) highly impacted by opioid overdose in Kentucky, Massachusetts, New York, and Ohio were allocated to CTH intervention (n = 34) or wait-list comparison (usual care; n = 33) arms. The primary outcome for this study was the number of naloxone units distributed in HCS communities during the comparison period (July 1, 2021‒June 30, 2022), examined using an intent-to-treat negative binomial regression model. Results. Naloxone distribution was 79% higher in the CTH intervention versus usual care arm (adjusted relative rate = 1.79; 95% confidence interval = 1.28, 2.51; P =.001; adjusted rates of naloxone distribution 3378 vs 1884 naloxone units per 100 000 residents), when controlling for urban‒rural status, state, baseline opioid-related overdose death rate, and baseline naloxone distribution rate. Conclusions. The CTH intervention increased naloxone distribution compared with usual care in communities highly impacted by the opioid crisis. Trial Registration. ClinicalTrials.gov identifier: NCT04111939. (Am J Public Health. 2025;115(1):83–94. https://doi.org/10.2105/AJPH.2024.307845) [ABSTRACT FROM AUTHOR]

The District Court in Holyoke, Massachusetts, is among the first courts nationwide to provide access to medications for opioid use disorder (MOUD) and other treatment. The program uses an innovative multisectoral approach to serve a primarily Latinx population living in communities of concentrated poverty with high opioid overdose rates. We document the origins, adaptations, and current status of program operations, including the use of on-site peer recovery specialists and robust data collection efforts. From August 16, 2021, to February 28, 2022, of the 1040 individuals who entered the court for an arraignment, 47.9% (n = 498) were eligible for program participation. Of those 498 individuals, 54.2% (n = 270) spoke with a recovery specialist. Many self-identified as Latinx (53.0%) and male (69.3%). Over one-fourth (27.0%) were connected to a long-term peer recovery specialist and 11.5% were directly connected to a MOUD provider. Semi-structured interviews with key implementers and participants revealed a shared appreciation for the life-saving efforts of the program. We conclude with practical and theoretical considerations required to offer linkage to MOUD in court-based contexts. Future efforts will assess participant outcomes to determine whether the program is an effective and feasible intervention that can be adopted by other court-based settings. [ABSTRACT FROM AUTHOR]

Background: Opioid-related overdose is the leading cause of death for people recently released from incarceration, however treatment with medications for opioid use disorder (MOUD) during incarceration can reduce the mortality risk. This study seeks to qualitatively analyze perceptions of post-release overdose risk from the perspectives of people who received MOUD while incarcerated in one of eight Massachusetts jails during 2021–2022 using the Risk Environment Framework to guide analyses. Methods: N = 38 participants with lived experience of MOUD treatment during incarceration who are now living in the community were interviewed on factors that may contribute to or protect against post-release overdose risk. Themes were identified inductively and deductively using the Risk Environment Framework and its domains, which organizes themes along physical, social, economic, and policy environments on both the micro- and macro- scales. Results: The physical risk environment included loss of opioid tolerance during incarceration, polysubstance use, and the toxicity of the regional drug supply as key producers of increased risk for post-release overdose. Social drivers of risk included peer group risk norms—including peer-driven harm reduction practices and interpersonal relationships between drug sellers and buyers—as well as macro-level social determinants of health such as housing insecurity and availability of mental health services. Economic drivers of post-release overdose risk included lack of income generation during incarceration and employment challenges. Participants discussed several aspects of policy that contribute to post-release overdose risk, including availability of harm reduction supplies, public health services, and broader policy around MOUD. Conclusions: The perspectives of people with lived experience are vital to understanding the disproportionate risks of overdose for those recently released from incarceration. Our results highlight the intersectional factors that produce and reproduce the post-release overdose risk environment, providing support for interventions across each domain of the Risk Environment Framework. By capturing perspectives from people with lived experience of OUD and incarceration during this critical period of risk, we can better identify interventions that target and mitigate overdose-related harm in this population. [ABSTRACT FROM AUTHOR]

Families of people with opioid use disorder (OUD) often provide informal care, serving an integral supportive role in the healthcare system. Yet these family members are often overlooked as a population under strain and in need of support themselves. In this study, we examine the stress faced by family members of persons with OUD in Massachusetts, USA, through semi-structured qualitative interviews (N = 22, April–July 2018). Data revealed that family members experience shame around OUD and live in a state of overwhelming worry about opioid overdose and that this fear permeates all aspects of their lives, impacting their health, relationships, employment, and finances. Effective coping and social support mitigated some of these challenges. This study fills a gap in the research by examining the challenges distinct to supporting a loved one with OUD – largely stress and trauma related to opioid overdose. [ABSTRACT FROM AUTHOR]

Post-overdose outreach programs can play a key role in reducing opioid overdose deaths and increasing access to healthcare services. The design and implementation of these programs, especially in rural communities, remains a gap in knowledge. We aimed to understand the lessons learned from the implementation experiences of the Community, Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT), a post-overdose outreach program based in a rural community in Massachusetts. We conducted semi-structured focus groups and interviews with 21 community partners after the first year of implementation in 2022. Participants included behavioral health, medical, public health, and public safety personnel involved in the design and implementation of CONNECT. Using a combination of thematic and rapid qualitative analysis methods, we inductively coded transcripts for salient themes. Themes were mapped onto the Health Equity Implementation Framework to better understand implementation and health-equity factors. Facilitators to implementation of this innovation included efficient inter-partner data sharing and coordination, and ability to offer numerous health services to clients to meet their needs. Key partners identified that CONNECT serves clients who use opioids, have previous involvement with the legal system, and reside in low-income areas within this rural region. Unhoused individuals and individuals who do not call 9–11 after an overdose were identified as populations of need that CONNECT was missing due to structural barriers. Partners shared how the context of this rural community came with challenges related to limited access to health services and pervasive stigma towards substance use, while it was also perceived to foster a culture of collaboration and unity among multidisciplinary key partners. Post overdose outreach programs serve clients with complex health needs. The ability to access services for these health needs is shaped by the post overdose outreach program and its key partners, and by the broader community context. As post-overdose outreach programs continue to expand as a promising strategy to address the opioid overdose crisis, there exists a need to contextualize implementation strategies to inform adaptations and develop best-practices. [ABSTRACT FROM AUTHOR]

Background: Implementation of medications for opioid use disorder (MOUD) in jails varies by facility and across states. Organizational climate, including staff attitudes toward change and exposure to education, can influence perceptions of innovations like MOUD in jails. Using a mixed methods design, we aimed to understand the association between organizational climate and jail staff perceptions of MOUD. Methods: Jail staff (n = 111) who operate MOUD programs in 6 Massachusetts jails completed surveys that included the Organizational Readiness for Implementing Change (ORIC) survey. Random effects logistic regression models assessed associations between organizational climate and several outcomes of perceived MOUD efficacy, acceptability, and knowledge, while controlling for covariates. Jail staff (N = 61) participated in qualitative interviews and focus groups focused on organizational climate and knowledge diffusion, which we analyzed using inductive and deductive methods. Results: The results indicate that organizational change readiness on the ORIC was associated with positive perceptions of MOUD, and educational resources facilitated MOUD implementation. Greater ORIC was associated with higher perception of methadone as highly acceptable for jail populations (Odds ratio [OR] 2.3, 95% Confidence Interval [CI] 1.2 to 4.4), and high knowledge of methadone (OR 2.3, 95% CI 1.1 to 4.9), with similar magnitude of effects for buprenorphine. High levels of training for jail staff on methadone and buprenorphine were also associated with higher knowledge of these medications (Methadone: OR 7.2, 95% CI 2.2 to 23.2; Buprenorphine: OR 3.4, 95% CI 1.2 to 9.5). Qualitative results point towards the importance of organizational climate and elucidate educational strategies to improve staff perceptions of MOUD. Conclusion: Results underscore the importance of organizational climate for successful implementation of jail MOUD programs and provide support for medication-specific educational resources as a facilitator of successful MOUD implementation in jail settings. Findings highlight implementation strategies that may improve jail staff perceptions of MOUD. [ABSTRACT FROM AUTHOR]

Background and Aims: The onset of the coronavirus disease 2019 (COVID‐19) pandemic was associated with a surge in opioid overdose deaths in Massachusetts, particularly affecting racial and ethnic minority communities. We aimed to compare the impact of the pandemic on opioid overdose fatalities and naloxone distribution from community‐based programs across racial and ethnic groups in Massachusetts. Design: Interrupted time‐series. Setting and Cases: Opioid overdose deaths (OODs) among non‐Hispanic White, non‐Hispanic Black, Hispanic and non‐Hispanic other race people in Massachusetts, USA (January 2016 to June 2021). Measurements Rate of OODs per 100 000 people, rate of naloxone kits distributed per 100 000 people and ratio of naloxone kits per opioid overdose death as a measure of naloxone availability. We applied five imputation strategies using complete data in different periods to account for missingness of race and ethnicity for naloxone data. Findings Before COVID‐19 (January 2016 to February 2020), the rate of OODs declined among non‐Hispanic White people [0.2% monthly reduction (95% confidence interval = 0.0–0.4%)], yet was relatively constant among all other population groups. The rate of naloxone kits increased across all groups (0.8–1.2% monthly increase) and the ratio of naloxone kits per OOD death among non‐Hispanic White was 1.1% (0.8–1.4%) and among Hispanic people was 1.0% (0.2–1.8%). After the onset of the pandemic (March 2020+), non‐Hispanic Black people experienced an immediate increase in the rate of OODs [63.6% (16.4–130%)], whereas rates among other groups remained similar. Trends in naloxone rescue kit distribution did not substantively change among any groups, and the ratio of naloxone kits per OOD death for non‐Hispanic Black people did not compensate for the surge in OODs deaths in this group. Conclusions: With the onset of the COVID‐19 pandemic, there was a surge in opioid overdose deaths among non‐Hispanic Black people in Massachusetts, USA with no compensatory increase in naloxone rescue kit distribution. For non‐Hispanic White and Hispanic people, opioid overdose deaths remained stable and naloxone kit distribution continued to increase. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine demographic and clinical precursors to pregnancy-associated deaths overall and when pregnancy-related deaths are excluded. METHODS: We conducted a retrospective cohort study based on a Massachusetts population–based data system linking data from live birth and fetal death certificates to corresponding delivery hospital discharge records and a birthing individual's nonbirth hospital contacts and associated death records. Exposures included maternal demographics, severe maternal morbidity (without transfusion), hospitalizations in the 3 years before pregnancy, comorbidities during pregnancy, and opioid use. In cases of postpartum deaths, hospitalization between delivery and death was examined. The primary outcome measure was pregnancy-associated death, defined as death during pregnancy or up to 1 year postpartum. RESULTS: There were 1,291,626 deliveries between 2002 and 2019, of which 384 were linked to pregnancy-associated deaths. Pregnancy-associated but not pregnancy-related deaths (per 100,000 deliveries) were highest for birthing people with opioid use before pregnancy (498.3), severe maternal morbidity (387.3), a comorbidity (106.3), or a prior hospitalization (88.9). In multivariable analysis, the adjusted risk ratios associated with severe maternal morbidity (9.37, 95% CI, 6.14–14.31) and opioid use (6.49, 95%, CI, 3.71–11.35) were highest. Individuals with pregnancy-associated deaths were also more likely to have been hospitalized before or during pregnancy (2.30, 95% CI, 1.62–3.26). Among postpartum deaths, more than two-thirds (69.9%) of birthing people had a hospital contact after delivery and before their death. CONCLUSION: Severe maternal morbidity and opioid use disorder were precursors to pregnancy-associated deaths. Individuals with pregnancy-associated but not pregnancy-related deaths experienced a history of hospital contacts during and after pregnancy before death. [ABSTRACT FROM AUTHOR]

Prescription opioids (POs) have had a devastating effect on people and public health systems in the U.S. Due to the urgency and complexity of the opioid crisis, there is a need to expand qualitative research on the medical community's perspectives on opioid prescribing practices and the role that prescription drug monitoring programs (PDMPs) have played in mitigating this crisis. We conducted qualitative interviews with clinicians (n = 23) across specialties and a range of overdose hotspot and coldspot locations in Massachusetts during 2019. We aimed to capture their perspectives on the opioid crisis, changes in clinical practice, and experiences with opioid prescribing and PDMPs. Respondents consistently recognized the role clinicians played in the opioid crisis and reported reductions in their opioid prescribing, which were motivated by the crisis itself. The limitations of opioids in pain management were frequently discussed. While clinicians appreciated having greater awareness of their opioid prescribing and increased access to patient prescription histories, they also expressed concerns about surveillance of their prescribing and other unintended consequences. We observed that clinicians in opioid prescribing hotspots had more detailed and specific reflections on their experiences with the Massachusetts PDMP, MassPAT. Clinician perceptions of the severity of the opioid crisis in Massachusetts and thoughts on their role as prescribers were consistent across specialty, prescribing level, and practice location. Many clinicians in our sample cited use of the PDMP as an influence on their prescribing. Those practicing in opioid overdose hotspots had the most nuanced reflections about the system. [ABSTRACT FROM AUTHOR]

Background: Medications for opioid use disorder (MOUD; methadone, buprenorphine, naltrexone) are the most effective treatments for OUD, and MOUD is protective against fatal overdoses. However, continued illegal drug use can increase the risk of treatment discontinuation. Given the widespread presence of fentanyl in the drug supply, research is needed to understand who is at greatest risk for concurrent MOUD and drug use and the contexts shaping use and treatment discontinuation. Methods: From 2017 to 2020, Massachusetts residents with past-30-day illegal drug use completed surveys (N = 284) and interviews (N = 99) about MOUD and drug use. An age-adjusted multinomial logistic regression model tested associations between past-30-day drug use and MOUD use (current/past/never). Among those on methadone or buprenorphine (N = 108), multivariable logistic regression models examined the association between socio-demographics, MOUD type; and past-30-day use of heroin/fentanyl; crack; benzodiazepines; and pain medications. Qualitative interviews explored drivers of concurrent drug and MOUD use. Results: Most (79.9%) participants had used MOUD (38.7% currently; 41.2% past), and past 30-day drug use was high: 74.4% heroin/fentanyl; 51.4% crack cocaine; 31.3% benzodiazepines, and 18% pain medications. In exploring drug use by MOUD history, multinomial regression analyses found that crack use was positively associated with past and current MOUD use (outcome referent: never used MOUD); whereas benzodiazepine use was not associated with past MOUD use but was positively associated with current use. Conversely, pain medication use was associated with reduced odds of past and current MOUD use. Among those on methadone or buprenorphine, separate multivariable logistic regression models found that benzodiazepine and methadone use were positively associated with heroin/fentanyl use; living in a medium-sized city and sex work were positively associated with crack use; heroin/fentanyl use was positively associated with benzodiazepine use; and witnessing an overdose was inversely associated with pain medication use. Many participants qualitatively reported reducing illegal opioid use while on MOUD, yet inadequate dosage, trauma, psychological cravings, and environmental triggers drove their continued drug use, which increased their risk of treatment discontinuation and overdose. Conclusions: Findings highlight variations in continued drug use by MOUD use history, reasons for concurrent use, and implications for MOUD treatment delivery and continuity. [ABSTRACT FROM AUTHOR]

Purpose: Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. Methods: We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed‐methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in‐depth interviews (n = 22). Findings: Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. Conclusions: PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality. [ABSTRACT FROM AUTHOR]

This Article covers a potential response to a Massachusetts state law which has been interpreted to require health care providers and birthing hospitals to report to state authorities any infant born to a person taking medication of opioid use disorder. While the statute mandates reports where a professional has "reasonable cause to believe that a child is suffering physical or emotional injury" as a result of substance dependence at birth, the Article highlights that many institutions report all infants born to persons with substance abuse disorders, regardless of risk of harm, for fear of penalty for failure to report. As a result, many individuals endure months or years long involvement with state authorities without warrant. Many patients avoid necessary pre- and perinatal care, addiction treatment, or both for fear of repercussions. Importantly, the Authors note that these challenges have been disproportionately impacting the Black community. As a potential solution, the Authors explore the possibility of an academic medical legal partnership which would support patients of a regional referral center and medical home for the treatment of substance use disorder in pregnancy. The Authors advocate for the use of such partnerships across different communities. Furthermore, they claim that academic medical legal partnerships which utilize an antiracist design can 1) shift the dialogue regarding social determinants of health and 2) fulfill ABA curriculum standards in law schools. [ABSTRACT FROM AUTHOR]

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

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

Background: Individuals with opioid use disorder (OUD) are at higher risk of poor oral health. Medication for opioid use disorder (MOUD) has been shown to improve outcomes for patients with OUD, but it is unknown how initiation of MOUD affects access to oral health services. Methods: This was a retrospective analysis of all individuals in the Massachusetts All‐Payer Claims Database prescribed oral buprenorphine‐naloxone or injectable naltrexone from 2013 to 2016. We evaluated dental utilization in the year before and after beginning MOUD. A logistic regression predicting dental utilization was conducted. Results: Among the 54,791 individuals, rates of dental utilization were low both before and after MOUD (10.5% and 10% with a dental visit, respectively). Of those who did not have a dental visit in the year before starting MOUD, 95.1% did not have a dental visit in the year after. Rates of various procedure types were comparable before and after MOUD. In a logistic regression, a prior dental visit was associated with 9.82 times the odds (95% CI 9.14–10.55) of having a dental visit after starting MOUD; increasing age, being prescribed naltrexone, having a mood disorder or HIV, year of initiation or being on Medicaid were also associated with having a dental visit. Male patients and those with Medicare or private insurance were less likely to have a dental visit. Conclusions: Initiating MOUD did not substantially result in increased dental access or substantial changes in dental procedures received. Patients receiving treatment for OUD may require additional support to access dental care. [ABSTRACT FROM AUTHOR]

Introduction. Studies show that the release from jail is a vulnerable transition for individuals with opioid use disorder re-entering their communities. Less is known about individuals with co-occurring mental health and opioid use disorders (COD), particularly their specific needs following release. Objectives. To describe the needs of people with COD within two weeks of release jail. Methods. Baseline data from 155 individuals with COD were collected within two weeks of release from jail across 9 counties in Massachusetts. Univariate analyses were conducted to determine baseline needs. Results. The majority of participants were male (78.7%), White (64.5%), and non-Hispanic (75.5%). The most relevant needs among participants were employment (88.4% were unemployed), opioid overdose prevention (67.7% had at least one non-fatal opioid overdose), mental health symptoms (participants reported anxiety or tension an average of 8.9 days in the past 30 days), and trauma support/treatment (71.6% reported at least one traumatic event in their lifetime). Conclusions. Individuals with COD re-entering their communities have critical needs that must be addressed upon release. [ABSTRACT FROM AUTHOR]

Background: Screening Brief Intervention Referral to Treatment (SBIRT) is recommended as a routine part of pediatric primary care, though managing patients with positive screens is challenging. To address this problem, the state of Massachusetts created a call line staffed by pediatric Addiction Medicine specialists to provide consultations to primary care providers and access to a behavioral health provider specially trained in managing adolescent substance use. Objective: To describe the uptake and outcomes of a consultation call line and virtual counseling for managing substance use disorders (SUD) in pediatric primary care. Methods: Service delivery data from consultations and counseling appointments were captured in an electronic database including substance, medication recommendations, level of care recommendations and number of counseling appointments completed for each patient. Summary data is presented here. Results: In all, there were 407 encounters to 108 unique families, including 128 consultations and 279 counseling visits in a one-year period. The most common substances mentioned by healthcare providers were cannabis (64%), nicotine (20%), alcohol (20%), vaping (9%) and opioids (5%). Management in primary care was recommended for 87 (68%) of the consultations. Medications for SUD treatment were recommended for 69 (54%) consultations including two for opioid use disorder. Conclusion: We found that both a statewide consultation call line and virtual counseling to support SBIRT in pediatric primary care were feasible. The majority of consultations resulted in recommendations for treatment in primary care. [ABSTRACT FROM AUTHOR]

Background and aims: Opioid‐related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non‐white residents have equitable access to the overdose antidote naloxone distributed by community‐based organizations. Methods: We used community‐based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non‐pharmacy naloxone distribution program for 2016–18. We obtained publicly available opioid‐related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community‐based naloxone kits received by a resident in a municipality divided by the number of opioid‐related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non‐linear relationship between naloxone coverage ratio and race/ethnicity we created B‐splines for the percentage of non‐white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size. Results: Between 2016 and 2018, the annual naloxone coverage ratios range was 0–135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non‐white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents. Conclusions: There appear to be no municipal‐level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA. [ABSTRACT FROM AUTHOR]

Background: While substance use disorder remains a leading cause of morbidity and mortality for young adults, low rates of treatment engagement and retention persist. One explanation is that substance use disorder treatment approaches do not match young adults' expectations for recovery. While the concept of recovery has been explored among adult populations, less is known about how young adults think about recovery. Objective: To describe perspectives of recovery among young adults with substance use disorder. Design: Qualitative, in-depth interviews exploring young adults' definitions of recovery. Participants: Twenty English-speaking young adults (7 women; 21–29 years old) diagnosed with substance use disorder recruited from an urban safety net hospital in Massachusetts. Approach: Interviews were recorded and transcribed verbatim. An iterative categorization analytic approach was used to identify and interpret themes. Key Results: Four themes related to recovery were identified. First, young adults described recovery as a way to grow up and live a normal life not defined by the substance use. A second theme was recovery had to include multiple components, such as mental health treatment, to be successful. Third, young adults described recovery as a self-motivated process, and it was important that young adults had agency in recovery decision-making. Fourth, recovery was described as a lifelong pursuit that required vigilance and commitment. Conclusions: In this qualitative study of young adults with substance use disorder, participants identified themes that have implications for treatment models. Participants recognized recovery as a complex and individually motivated process that includes multiple components such as mental health treatment and re-engagement in regular daily activities. Models of care for young adults should consider incorporating these treatment elements to improve engagement and retention. [ABSTRACT FROM AUTHOR]

Background: Policing shapes the health risks of people who use drugs (PWUD), but little is understood about interventions that can align officer practices with PWUD health. This study deploys the Theory of Planned Behavior (TPB) to understand what influences police intentions to make discretionary referrals to treatment and harm reduction resources rather than arrest on less serious charges. Methods: On-line surveys integrating TPB constructs and adapting an instrument measuring police intentions to make mental health treatment referrals were completed by police employees in Indiana, Massachusetts, and Missouri. They also included items about stigma towards PWUD and attitudes and beliefs about opioid addiction, treatment, and recovery. Findings: Across the sites, 259 respondents perceived control over their decision to arrest for misdemeanors (69%) and confiscate items such as syringes (56%). Beliefs about others' approval of referrals to treatment, its ability to reduce future arrests, and to increase trust in police were associated with stated practices of nonarrest for drug and possession and making referrals (p ≤.001), and nonarrest for syringe possession (p ≤.05). Stigma a towards PWUD was negatively associated with stated practices of nonarrest (p ≤.05). Respondents identified supervisors as having the most influence over use of discretion, seriousness of the offense as the most influential value, and attitude of the suspect as the most important situational factor. The 17 Likert scale items analyzed had a Cronbach's alpha of 0.81. Conclusion: The TPB offers untapped potential to better understand and modify police practices. In designing interventions to improve the health outcomes of police encounters with PWUD, further research should validate instruments that measure the relationship between these variables and discretionary intentions, and that measure role-relevant police stigma towards PWUD. [ABSTRACT FROM AUTHOR]

Background: Stimulant use has increased across the US, with concomitant opioid and methamphetamine use doubling between 2011 and 2017. Shifting patterns of polysubstance use have led to rising psychostimulant-involved deaths. While it is known that individuals who use methamphetamine require greater access to treatment, there is still little known about methamphetamine use and treatment among individuals who are already engaged in outpatient substance use treatment. Objectives: To characterize care-engaged individuals who use methamphetamine to guide harm reduction and treatment strategies. Methods: Retrospective cohort study of individuals at a large academic medical center in Massachusetts with ≥ 2 positive methamphetamine oral fluid toxicology tests between August 2019 and January 2020. We performed descriptive analysis of sociodemographic, medical, and drug use characteristics and a comparative analysis of injection methamphetamine use versus other routes of use. Results: Included were 71 individuals [56 male (80%), 66 non-Hispanic white (94%), median age 36 (IQR 30–42)]. Nearly all had opioid (94%) and stimulant use disorder (92%). Most had (93%) or were (83%) being treated with medications for opioid use disorder, but few received pharmacologic treatment for methamphetamine use disorder (24%). None received contingency management treatment. People who inject methamphetamine (68%) were more likely to have a history of overdose (91% vs. 70%; p = 0.02), have HCV (94% vs. 52%; p < 0.01), use fentanyl (93% vs. 65%; p = 0.02), and engage in sex work (19% vs. 0%; p = 0.03) compared to those who used via other routes. Both groups had prevalent homelessness (88% vs. 73%; p = 0.15), incarceration (81% vs. 64%; p = 0.11), depression (94% vs. 87%; p = 0.34), and bacteremia (27% vs. 22%; p = 0.63). Conclusions: Individuals in our study had high prevalence of polysubstance use, particularly concomitant methamphetamine and opioid use. Individuals who were well connected to substance use treatment for their opioid use were still likely to be undertreated for their methamphetamine use disorder and would benefit from greater access to contingency management treatment, harm reduction resources, and resources to address adverse social determinants of health. [ABSTRACT FROM AUTHOR]

Massachusetts is one of the epicenters of the opioid epidemic and has been severely impacted by injection-related viral and bacterial infections. A recent increase in newly diagnosed human immunodeficiency virus (HIV) infections among persons who inject drugs in the state highlights the urgent need to address and bridge the overlapping epidemics of opioid use disorder (OUD) and injection-related infections. Building on an established relationship between the Massachusetts Department of Public Health and Boston Medical Center, the Infectious Diseases section has contributed to the development and implementation of a cohesive response involving ambulatory, inpatient, emergency department, and community-based services. We describe this comprehensive approach including the rapid delivery of antimicrobials for the prevention and treatment of HIV, sexually transmitted diseases, systemic infections such as endocarditis, bone and joint infections, as well as curative therapy for chronic hepatitis C virus in a manner that is accessible to patients on the addiction-recovery continuum. We also provide an overview of programs that provide access to medications for OUD, harm reduction services including overdose education, and distribution of naloxone. Finally, we outline lessons learned to inform initiatives in other settings. [ABSTRACT FROM AUTHOR]

We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD. Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD. HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD. Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment. • Harm reduction capital – knowledge, and resources related to substance use risk reduction. • Harm reduction capital barriers associated with past year overdose. • Disparities in harm reduction capital and MOUD utilization among LatinX individuals. • No association between non-fatal overdose and MOUD use – opportunity to intervene. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19–June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms. [ABSTRACT FROM AUTHOR]

Objectives: Pharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake.Design: Eight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island.Setting and Participants: Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.Outcome Measures: The FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings.Results: A total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist-partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received.Conclusions: Experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone. [ABSTRACT FROM AUTHOR]

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

Aims: To examine how the risks of incident opioid use disorder (OUD), non‐fatal and fatal overdose have changed over time among opioid‐naive individuals receiving an initial opioid prescription. Design Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non‐fatal and fatal overdose among the opioid‐naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. Setting: Massachusetts, USA. Participants: Massachusetts residents aged ≥ 11 years in 2011–15 who were opioid‐naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance. Measurements Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non‐fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. Findings Among opioid‐naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1‐year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19–2.29 for duration of 3 or more months], non‐fatal (HR = 1.67, 95% CI = 1.53–1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91–2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12–1.17), non‐fatal (HR = 1.20, 95% CI = 1.10–1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61–2.16). Conclusions: Among opioid‐naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose. [ABSTRACT FROM AUTHOR]

Background: The brand name Suboxone and its generic formulation buprenorphine/naloxone is a medication for treating opioid use disorder. While this medication has been shown to be effective, little research has examined the extent to which it is being prescribed and under what circumstances.Objective: This study examined patterns of prescription claims for buprenorphine/naloxone in terms of volume and associated clinical conditions.Methods: The study was conducted using a statewide database comprising pharmacy and medical claims that were covered by commercial health insurance plans in Massachusetts between 2011 and 2015. Trends in prescription volume for buprenorphine/naloxone were assessed based on the annual number of patients with a prescription for buprenorphine/naloxone. To examine clinical conditions associated with buprenorphine/naloxone prescriptions, patients' pharmacy claims were linked to their medical claims within the prior three months. For patients with common pain-related conditions, the odds they were prescribed buprenorphine/naloxone rather than oxycodone, a widely used opioid for pain management, were also examined.Results: The number of patients with a buprenorphine/naloxone prescription increased substantially during the study period, from approximately 25,000 in 2011 to over 39,000 in 2015. The most common clinical condition associated with buprenorphine/naloxone prescribing was opioid use disorder, but a substantial percentage of prescriptions were preceded by diagnoses that included pain or were for pain alone.Conclusion: A substantial increase in the number of patients with a prescription for buprenorphine/naloxone was observed. While buprenorphine/naloxone is most frequently prescribed for opioid use disorder, clinicians also appear to prescribe it for pain, particularly for patients who may be at elevated risk for opioid use disorder. [ABSTRACT FROM AUTHOR]

Background and Aims: Opioid‐related overdose is increasingly linked to pregnancy‐associated deaths, but factors associated with postpartum overdose are unknown. We aimed to estimate the strength of the association between maternal and infant characteristics and postpartum opioid‐related overdose. Design Retrospective cohort study using a linked, population‐level data set. Setting: Massachusetts, United States. Conclusion: Among women who delivered live infants in Massachusetts, USA between 2012 and 2014, maternal diagnosis of OUD, prior non‐fatal overdose, infant diagnosis of NAS and high unscheduled health‐care utilization appeared to be positively associated with postpartum opioid overdose. However, more than half of postpartum overdoses in that period were to women without a diagnosis of OUD. Engagement in methadone or buprenorphine treatment in the month prior to delivery was not sufficient to reduce the odds of postpartum overdose. Participants: Women who delivered one or more live births from 2012 to 2014 (n = 174 517). Measurements: The primary outcome was opioid‐related overdose in the postpartum year. We used multivariable logistic regression to explore the independent associations of maternal (demographics, substance use, pregnancy) and infant [gestational age, birthweight, neonatal abstinence syndrome (NAS)] characteristics with postpartum opioid overdose. Findings were stratified by maternal opioid use disorder (OUD) diagnosis. Findings: There were 189 deliveries to women who experienced ≥ 1 opioid overdose in the first year postpartum (11 of 10 000 deliveries). Among women with postpartum opioid overdose, 46.6% had an OUD diagnosis within 12 months before delivery. In our adjusted model, maternal diagnosis of OUD [adjusted odds ratio (aOR) = 3.61, 95% confidence interval (CI) = 1.73–7.51] and prior non‐fatal overdose (aOR = 2.40, 95% CI = 1.11–5.17) were most strongly associated with postpartum overdose. After stratifying by OUD status, infant diagnosis of NAS (OUD+ aOR = 2.03, 95% CI = 1.26–3.27; OUD– aOR = 2.79, 95% CI = 1.12–6.93) and high unscheduled health‐care utilization (OUD+ aOR = 2.27, 95% CI = 1.38–3.73; OUD– aOR = 2.11, 95% CI = 1.24–3.58) were positively associated with postpartum overdose in both groups. [ABSTRACT FROM AUTHOR]

Objectives. To describe and control an outbreak of HIV infection among people who inject drugs (PWID). Methods. The investigation included people diagnosed with HIV infection during 2015 to 2018 linked to 2 cities in northeastern Massachusetts epidemiologically or through molecular analysis. Field activities included qualitative interviews regarding service availability and HIV risk behaviors. Results. We identified 129 people meeting the case definition; 116 (90%) reported injection drug use. Molecular surveillance added 36 cases to the outbreak not otherwise linked. The 2 largest molecular groups contained 56 and 23 cases. Most interviewed PWID were homeless. Control measures, including enhanced field epidemiology, syringe services programming, and community outreach, resulted in a significant decline in new HIV diagnoses. Conclusions. We illustrate difficulties with identification and characterization of an outbreak of HIV infection among a population of PWID and the value of an intensive response. Public Health Implications. Responding to and preventing outbreaks requires ongoing surveillance, with timely detection of increases in HIV diagnoses, community partnerships, and coordinated services, all critical to achieving the goal of the national Ending the HIV Epidemic initiative. [ABSTRACT FROM AUTHOR]

This paper reflects upon ethnographic work carried out in a suburban Massachusetts town that has experienced particularly high rates of opioid mis/use. In open-ended conversations, residents attributed the local opioid crisis to institutional betrayals of various sorts. Building upon the idea that social capital tends to be health-enhancing, this paper traces the decline in the infrastructure of social capital and the associated decline in cultural capital or scripts for making sense out of life's challenges. [ABSTRACT FROM AUTHOR]

Background: Improving access to treatment for opioid use disorder is a national priority, but little is known about the barriers encountered by patients seeking buprenorphine-naloxone ("buprenorphine") treatment.Objective: To assess real-world access to buprenorphine treatment for uninsured or Medicaid-covered patients reporting current heroin use.Design: Audit survey ("secret shopper" study).Setting: 6 U.S. jurisdictions with a high burden of opioid-related mortality (Massachusetts, Maryland, New Hampshire, West Virginia, Ohio, and the District of Columbia).Participants: From July to November 2018, callers contacted 546 publicly listed buprenorphine prescribers twice, posing as uninsured or Medicaid-covered patients seeking buprenorphine treatment.Measurements: Rates of new appointments offered, whether buprenorphine prescription was possible at the first visit, and wait times.Results: Among 1092 contacts with 546 clinicians, schedulers were reached for 849 calls (78% response rate). Clinicians offered new appointments to 54% of Medicaid contacts and 62% of uninsured-self-pay contacts, whereas 27% of Medicaid and 41% of uninsured-self-pay contacts were offered an appointment with the possibility of buprenorphine prescription at the first visit. The median wait time to the first appointment was 6 days (interquartile range [IQR], 2 to 10 days) for Medicaid contacts and 5 days (IQR, 1 to 9 days) for uninsured-self-pay contacts. These wait times were similar regardless of clinician type or payer status. The median wait time from first contact to possible buprenorphine induction was 8 days (IQR, 4 to 15 days) for Medicaid and 7 days (IQR, 3 to 14 days) for uninsured-self-pay contacts.Limitation: The survey sample included only publicly listed buprenorphine prescribers.Conclusion: Many buprenorphine prescribers did not offer new appointments or rapid buprenorphine access to callers reporting active heroin use, particularly those with Medicaid coverage. Nevertheless, wait times were not long, implying that opportunities may exist to increase access by using the existing prescriber workforce.Primary Funding Source: National Institute on Drug Abuse. [ABSTRACT FROM AUTHOR]

Objectives: To examine the effect of age on the likelihood of PIP of opioids and the effect of PIP on adverse outcomes. Design: Retrospective cohort study. Setting: Data from multiple state agencies in Massachusetts from 2011 to 2015. Participants: Adult Massachusetts residents (N=3,078,163) who received at least one prescription opioid during the study period; approximately half (1,589,365) aged 50 and older. Measurements: We measured exposure to 5 types of PIP: high‐dose opioids, coprescription with benzodiazepines, multiple opioid prescribers, multiple opioid pharmacies, and continuous opioid therapy without a pain diagnosis. We examined 3 adverse outcomes: nonfatal opioid overdose, fatal opioid overdose, and all‐cause mortality. Results: The rate of any PIP increased with age, from 2% of individuals age 18 to 29 to 14% of those aged 50 and older. Older adults also had higher rates of exposure to 2 or more different types of PIP (40–49, 2.5%; 50–69, 5%; ≥70, 4%). Of covariates assessed, older age was the greatest predictor of PIP. In analyses stratified according to age, any PIP and specific types of PIP were associated with nonfatal overdose, fatal overdose, and all‐cause mortality in younger and older adults. Conclusion: Older adults are more likely to be exposed to PIP, which increases their risk of adverse events. Strategies to reduce exposure to PIP and to improve outcomes in those already exposed will be instrumental to addressing the opioid crisis in older adults. J Am Geriatr Soc 67:128–132, 2019. [ABSTRACT FROM AUTHOR]

Objective: To examine whether Massachusetts (MA) health reform affected substance (alcohol or drug) use disorder (SUD)-related hospitalizations in acute care hospitals.Data/study Setting: 2004-2010 MA inpatient discharge data.Design: Difference-in-differences analysis to identify pre- to postreform changes in age- and sex-standardized population-based rates of SUD-related medical and surgical hospitalizations, adjusting for secular trends.Data Extraction Methods: We identified 373,751 discharges where a SUD-related diagnosis was a primary or secondary discharge diagnosis.Findings: Adjusted for age and sex, the rates of drug use-related and alcohol use-related hospitalizations prereform were 7.21 and 8.87 (per 1,000 population), respectively, in high-uninsurance counties, and 8.58 and 9.63, respectively, in low-uninsurance counties. Both SUD-related rates increased after health reform in high- and low-uninsurance counties. Adjusting for secular trends in the high- and low-uninsurance counties, health reform was associated with no change in drug- or alcohol-related hospitalizations.Conclusions: Massachusetts health reform was not associated with any changes in substance use disorder-related hospitalizations. Further research is needed to determine how to reduce substance use disorder-related hospitalizations, beyond expanding insurance coverage. [ABSTRACT FROM AUTHOR]

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

Background: Opioid overdose is a significant public health problem. Collaborative programs between local public health and public safety agencies have emerged to connect overdose survivors and their personal networks with harm reduction and addiction treatment services following a non-fatal overdose event. This study explored the prevalence of these programs in Massachusetts and the different ways they have been structured and function.Methods: We sent an online screening questionnaire to police and fire departments in all 351 communities in Massachusetts to find instances in which they collaborated with a community-based public health agency to implement a post-overdose outreach and support program. We conducted telephone interviews with communities that implemented this type of program and categorized programs based on their structure, outreach approach, and other key characteristics.Results: Police and fire personnel from 110 of the 351 communities in Massachusetts (31% response rate) completed the screening survey. Among respondents, 21% (23/110) had implemented a collaborative, community-based, post-overdose program with a well-defined process to connect overdose survivors and their personal networks with support services or addiction treatment services. Using data from the interviews, we identified four types of programs: (1) Multi-Disciplinary Team Visit, (2) Police Visit with Referrals, (3) Clinician Outreach, and (4) Location-Based Outreach.Conclusions: This study represents the first attempt to systematically document an emerging approach intended to connect opioid overdose survivors and their personal networks with harm reduction and addiction treatment services soon after a non-fatal overdose event. These programs have the potential to increase engagement with the social service and addiction treatment systems by those who are at elevated risk for experiencing a fatal opioid overdose. [ABSTRACT FROM AUTHOR]

• Post-overdose outreach programs are growing in scope and number. • How post-overdose outreach program practices affect overdose rates is unknown. • Fatal overdose rates were lower in municipalities where programs offered more social services. • Outreach intensity was associated with fewer opioid-related 911 calls in some cases. • Provision of social services (housing, transport, food, employment) may be key to program success. Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66–0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78–0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design. [ABSTRACT FROM AUTHOR]

Background: The increasing rates of opioid use disorder and resulting overdose deaths are a public health emergency, yet only a fraction of individuals in need receive treatment.Objective: To describe the implementation of and participants' experiences with a novel police-led addiction treatment referral program.Methods: Follow-up telephone calls to participants in the Gloucester Police Department's Angel Program from June 2015-May 2016. Open-ended survey questionnaires assessed experiences of program participants and their close contacts, confirmed police-reported placement, and queried self-reported substance use and treatment outcomes.Results: Surveys were completed by 198 of 367 individuals (54% response rate) who participated 214 times. Reasons for participation included: the program was a highly-visible entry point to the treatment system, belief that placement would be obtained, poor prior treatment system experiences, and external pressure to seek treatment. Most participants reported positive experiences citing the welcoming, non-judgmental services. In 75% (160/214) of the encounters, entry into referral placement was confirmed. Participants expressed frustration when they did not meet program entry requirements and had difficulty finding sustained treatment following initial program placement. At a mean follow-up time of 6.7months, 37% of participants reported abstinence since participation, with no differences between participants who entered referral placement versus those who did not.Conclusions: A police-led referral program was feasible to implement and acceptable to participants. The program was effective in finding initial access to treatment, primarily through short-term detoxification services. However, the program was not able to overcome a fragmented treatment system focused on acute episodic care which remains a barrier to long-term recovery. [ABSTRACT FROM AUTHOR]

Objective. To evaluate current opioid prescribing patterns nationally and regionally across several northern New England states and compare with prescription data on an institutional level over a twoyear period, between 2013 and 2014. Design, Setting, and Subjects. The IMS Health National Prescription Audit (NPA) database was used to obtain prescription data from US retail pharmacies between 2013 and 2014. Methods. Our study compared noninjectable opioid dispensing between two time periods: January-June 2013 and July-December 2014. Opioid prescription data were obtained nationally and in New Hampshire, Vermont, Maine, and Massachusetts. Institutional prescription data were supplied by Dartmouth Hitchcock Medical Center (DHMC) and University of Vermont Medical Center (UVMC) pharmacies. Results. There was a 3.4% (P50.81) decrease in opioid prescriptions filled nationally. Among New England states, opioid prescribing decreased in Maine (25.20%, P50.72), Massachusetts (24.4%, P50.78), and Vermont (22.2%, P50.89) but increased in New Hampshire by 1.3% (P50.94). Examination of local institutional opioid utilization revealed a 13.6% decline in prescriptions filled at UVMC, and only a 0.4% decrease at DHMC. Conclusions. The review of opioid prescriptions filled in 2013-14 suggests that national opioid utilization may be reaching a plateau. Initiatives such as prescription monitoring programs, prescriber opioid education, addiction treatment programs, public addiction awareness, and availability of medical cannabis may play a role in interstate variability of opioid use. National and regional data served as a benchmark for local institutional comparison, laying groundwork for efforts to explore areas where opioids can be prescribed more judiciously. [ABSTRACT FROM AUTHOR]

Background: The US is experiencing an unprecedented opioid overdose epidemic fostered in recent years by regional contamination of the heroin supply with the fentanyl family of synthetic opioids. Since 2011 opioid-related overdose deaths in the East Coast state of Massachusetts have more than tripled, with 75% of the 1374 deaths with an available toxicology positive for fentanyl. Fentanyl is 30-50X more potent than heroin and its presence makes heroin use more unpredictable. A rapid ethnographic assessment was undertaken to understand the perceptions and experiences of people who inject drugs sold as 'heroin' and to observe the drugs and their use.Methods: A team of ethnographers conducted research in northeast Massachusetts and Nashua, New Hampshire in June 2016, performing (n=38) qualitative interviews with persons who use heroin.Results: (1) The composition and appearance of heroin changed in the last four years; (2) heroin is cheaper and more widely available than before; and (3) heroin 'types' have proliferated with several products being sold as 'heroin'. These consisted of two types of heroin (alone), fentanyl (alone), and heroin-fentanyl combinations. In the absence of available toxicological information on retail-level heroin, our research noted a hierarchy of fentanyl discernment methods, with embodied effects considered most reliable in determining fentanyl's presence, followed by taste, solution appearance and powder color. This paper presents a new 'heroin' typology based on users' reports.Conclusion: Massachusetts' heroin has new appearances and is widely adulterated by fentanyl. Persons who use heroin are trying to discern the substances sold as heroin and their preferences for each form vary. The heroin typology presented is inexact but can be validated by correlating users' discernment with drug toxicological testing. If validated, this typology would be a valuable harm reduction tool. Further research on adaptations to heroin adulteration could reduce risks of using heroin and synthetic opioid combinations. [ABSTRACT FROM AUTHOR]

Objectives: To determine the prevalence of nonprescription naloxone and sterile syringe sales, factors associated with nonprescription sales, geospatial access to nonprescription naloxone and syringe-selling pharmacies, and targets for potential interventions.Design: Cross-sectional study.Setting and Participants: Massachusetts has experienced steep increases in reported opioid overdoses and hepatitis C virus cases in the past decade. Pharmacists have the potential to play a substantial role in increasing access to nonprescription naloxone and sterile syringes, which can reverse opioid overdoses and decrease hepatitis C virus transmission, respectively. We completed brief telephone surveys with 809 of 1042 retail pharmacies across Massachusetts (response rate = 77.6%) during 2015 to assess experience with nonprescription sales of naloxone and sterile syringes.Outcome Measures: Our primary outcomes were the stocking and selling of naloxone in the pharmacy (yes or no) for nonprescription sales and nonprescription syringe sales (yes or no). We conducted multivariable regression analyses and created maps using a geographic information system to identify factors associated with nonprescription sales of naloxone and sterile syringes, and to improve our understanding of geospatial access to pharmacy-based naloxone and syringe sales.Results: More than 97% of pharmacies reported selling sterile syringes without requiring a prescription, and 45% of pharmacies reported stocking and selling naloxone. Factors associated with nonprescription sales included hours of operation, experience with and interest in harm reduction activities, and presence in an opioid overdose hotspot. Geographic access to nonprescription sale of sterile syringes is widespread, whereas geospatial access to naloxone is limited. Training to understand the benefits, applications, and distribution needs of naloxone is of interest to surveyed pharmacists.Conclusion: Access to sterile syringes through nonprescription sales is strong across Massachusetts, and although more than 350 pharmacies (45%) reported stocking and selling naloxone to prevent opioid overdose deaths, there is much room for improvement in access and training among pharmacy staff members. [ABSTRACT FROM AUTHOR]

Aims: In the United States, hepatitis C virus (HCV) infection is primarily spread through injection drug use. There is an urgent need to improve access to care for HCV among persons with opioid use disorders who inject drugs. The purpose of our study was to determine the prevalence of HCV, patient characteristics, and receipt of appropriate care in a sample of patients treated with buprenorphine for their opioid use disorders in a primary care setting.Methods: This study used retrospective clinical data from the electronic medical record. The study population included patients receiving buprenorphine in the Office Based Opioid Treatment (OBOT) clinic within the adult primary medicine clinic at Boston Medical Center between October 2003 and August 2013 who received a conclusive HCV antibody (Ab) test within a year of clinic entry. We compared characteristics by HCV serostatus using Pearson's chi-square and provided numbers/percentages receiving appropriate care.Results: The sample comprised 700 patients. Slightly less than half of all patients (n=334, 47.7%) were HCV Ab positive, and were significantly more likely to be older, Hispanic or African American, have diagnoses of post-traumatic stress disorder (PTSD) or bipolar disorder, have prior heroin or cocaine use, and be HIV-infected. Among the 334 HCV Ab positive patients, 226 (67.7%) had detectable HCV ribonucleic acid (RNA) indicating chronic HCV infection; only 5 patients (2.21%) with chronic HCV infection ever initiated treatment.Conclusions: Nearly half of patients (47.7%) receiving office-based treatment with buprenorphine for their opioid use disorder had a positive hepatitis C virus antibody screening test although initiation of HCV treatment was nearly non-existent (2.21%). [ABSTRACT FROM AUTHOR]

• Medications for opioid use disorder (MOUD) are now available in Massachusetts jails. • Continuity of MOUD treatment post-release is needed to reduce overdose risks. • Interagency communication is needed to coordinate MOUD treatment post-release. • Unplanned releases present unique challenges to coordinating treatment post-release. • Bridge scripts to cover gaps between jail and community MOUD intakes are paramount. People released from jail are at elevated opioid overdose risk. Medications for opioid use disorder (MOUD) are effective in reducing overdoses. MOUD treatment was recently mandated in seven Massachusetts jails, but little is known about barriers and facilitators to treatment continuity post-release. We aimed to assess MOUD provider perspectives on treatment continuity among people released from jail. We conducted qualitative interviews with 36 medical, supervisory, and administrative staff at MOUD programs that serve jail-referred patients. We used the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation science framework to guide development of instruments, codes, and analyses. We employed deductive and inductive coding, and a grounded theory analytical approach to identify salient themes. Inner context findings highlighted necessary adjustments among jail staff to approve MOUD treatment, especially with agonist medications that were previously considered contraband. Participants perceived that some staff within jails favored abstinence-based recovery, viewing agonists as a crutch. Bridging results highlighted the importance of inter-agency communication and coordination to ensure information transfer for seamless treatment continuity in the community post-release. Pre-release planning, release on pre-scheduled dates, medication provision to cover gaps between jail release and intake at community MOUD sites, and exchange of treatment information across agencies were viewed as paramount to success. Unexpected early releases and releases from court were viewed as barriers to treatment coordination. Outer context domains were largely tied to social determinants of health. Substantial barriers to treatment continuity included shelter, food security, employment, transportation, and insurance reactivation. Through qualitative interviews with community-based MOUD staff, we identified salient barriers and facilitators to treatment continuity post-release from jails. Findings point to needed investments in care coordination, staffing, and funding to strengthen jail-to-community-based MOUD treatment, removing barriers to continuity, and decreasing opioid overdose deaths during this high-risk transition. [ABSTRACT FROM AUTHOR]