Substance Use & Addiction Journal

Background: Having prescribers use clinical video teleconferencing (telemedicine) to prescribe buprenorphine to people with opioid use disorder (OUD) has shown promise but its implementation is challenging. We describe barriers, facilitators and lessons learned while implementing a system to remotely prescribe buprenorphine to Veterans in rural settings. Methods: We conducted a quality improvement project aimed at increasing the availability of medications for OUD (MOUD) to Veterans. This project focused on tele-prescribing buprenorphine to rural sites via a hub (centralized prescribers) and spoke (rural clinics) model. After soliciting a wide-range of inputs from site visits, qualitative interviews of key stakeholders at rural sites, and review of preliminary cases, a “how-to” toolkit was developed and iteratively refined to guide tele-prescribing of buprenorphine. After internal and external facilitation strategies were employed, Veterans with OUD at three clinics were transitioned to buprenorphine treatment via telemedicine. Results: Factors impacting adoption of the tele-prescribing intervention were mapped to the Consolidated Framework for Implementation Research (CFIR) constructs. Barriers to adoption included concerns about legality of tele-prescribing a controlled substance, conflicting interests between different stakeholders, and coordination with an existing buprenorphine program requiring more attendance and abstinence from Veterans than the tele-prescribing program required. Factors facilitating adoption included a sense of mission around combating the opioid epidemic, preexisting use of and comfort with tele-prescribing, and rural sites’ control over Veterans referred to tele-prescribers. A total of 12 patients from rural areas were successfully transitioned onto buprenorphine, of whom 9 remained on buprenorphine 6 months after initiation of treatment. Conclusions: Implementing tele-prescribing was negotiated with stakeholders at the target clinics and operationalized in a toolkit to guide future efforts. Implementation issues can be addressed by activities that foster collaboration between hubs (centralized prescribers) and spokes (rural clinics) and by a toolkit that operationalizes tele-prescribing procedures.

Background: Patients with addiction often encounter negative attitudes from health care professionals, including medical doctors. Addiction medicine training might improve medical students’ attitudes toward patients with addiction problems and change the way they think about addiction. We evaluated the effect of comprehensive addiction medicine training on students’ attitudes and illness perceptions and explored which perceptions are most relevant for attitude development. Methods: In a quasi-experimental non-randomized study, fourth-year students (n = 296) participated in either addiction medicine training (intervention) or one of three other blocks (control). We used the Medical Condition Regards Scale to measure attitudes and the Illness Perception Questionnaire Addiction version for perceptions. We analyzed the effect of the intervention using repeated measures MANOVA. The contribution of illness perception to attitude was explored in the intervention group using linear regression analysis. Results: Addiction medicine training improved students’ attitudes toward patients with addiction, compared to the control group. After the training, students expressed a less demoralized perception, a stronger perception of a coherent understanding of addiction, addiction as a cyclical condition, and attributed addiction more to psychological factors, compared to the control group. In the intervention group, attitude and emotional representation before training and illness coherence after the training were associated with attitude after the training. Conclusions: Addiction medicine training is effective in improving medical students’ attitudes toward patients with addiction and changing their illness perceptions of addiction. The development of an understanding of addiction might be particularly relevant for attitude improvement. These findings underscore the relevance of addiction medicine training as part of medical curricula and argue for including aspects related to attitude development in the curriculum.

Background: Brief interventions have shown promise in reducing adolescent alcohol and marijuana use. This manuscript presents a secondary analysis of a randomized trial that compared a brief parent motivational intervention (Family Check Up; FCU) to brief psychoeducation (PE) condition and found no effect of treatment condition on either binge drinking or marijuana use days. The current analyses explored whether the response to treatment may have varied as a function of six empirically-based baseline moderators and predictors: biological sex, age, race/ethnicity, mental health problems, parent-adolescent communication, and peer deviance. Methods: Data from the parent trial randomizing 102 parents to either the FCU (n = 51) or PE (n = 51) interventions were re-analyzed across four time points (baseline, 3-, 6-, and 12-months). Moderators and predictors were tested via a series of hierarchical linear models. Results: Parent-adolescent communication and peer deviance emerged as significant predictors of adolescent treatment response. Specifically, low-levels of parent-adolescent communication or peer deviance were associated with worse treatment response (i.e., significant increases in binge drinking days and marijuana use days) in the PE condition, but not in the FCU condition. Non-Hispanic Whites and girls had worse treatment response, regardless of treatment condition. Conclusions: The FCU condition appeared to mitigate risks of poor parent-adolescent communication and affiliation with deviant peers better than the PE condition. Clinical recommendations for decision-making around assignment to brief interventions are discussed.

Background: We sought to quantify the association between clinical, physiological, and contextual factors and opioid-related overdose, specifically focusing on current and past use of select prescription medications. Methods: We conducted a case-control study of individuals who experienced a non-fatal opioid-related overdose between January 2015 and November 2016 in British Columbia, Canada. We matched 8,831 cases to 44,155 controls on birth year, sex, and local health area of residence and examined 5-year prescribing history for opioids for pain, medications for opioid use disorder (MOUD), benzodiazepines/z-drugs, and other psychoactive medications. Results: The overall prevalence of prescription opioid drug use was generally low in the study population. Cases had a relatively higher use of selected prescription medications, a higher physical and mental morbidity burden, and were less connected to health services compared with controls. For opioids for pain, current therapy was associated with experiencing an overdose (OR = 8.5, 95%CI: 7.3–10); history of long-term use had a stronger association than history of short-term use (OR = 2.9, 95%CI: 2.6–3.3 vs OR = 1.7, 95%CI: 1.5–1.8, respectively). While persons on MOUD were more likely to overdose compared to persons who were not on therapy (OR = 2.0, 95%CI 1.7–2.4), recent discontinuation of MOUD greatly increased the likelihood of overdose (OR = 25.6, 95%CI 17.5–37.4). Active therapy of benzodiazepines/z-drugs and other sedating medications also significantly increased the likelihood of overdose. Conclusions: While this study supports expansion of efforts to prevent overdoses among individuals actively using opioids for pain and improve retention among those on MOUD, it is also important to address other clinical, physiological, and contextual risk and protective factors to help curb the current overdose crisis.

Study objective: Prehospital use of naloxone for presumed opioid overdose has increased markedly in recent years because of the current opioid overdose epidemic. In this study, we determine the 1-year mortality of suspected opioid overdose patients who were treated with naloxone by EMS and initially survived. Methods: This was a retrospective observational study of patients using three linked statewide datasets in Massachusetts: emergency medical services (EMS), a master demographics file, and death records. We included all suspected opioid overdose patients who were treated with naloxone by EMS. The primary outcome measures were death within 3 days of treatment and between 4 days and 1 year of treatment. Results: Between July 1, 2013 and December 31, 2015, there were 9734 individuals who met inclusion criteria and were included for analysis. Of these, 807 (8.3% (95% confidence interval (CI) 7.7–8.8%)) died in the first 3 days, 668 (6.9% (95% CI 6.4–7.4%)) died between 4 days and 1 year, and 8259 (84.8% (95% CI 84.1–85.6%)) were still alive at 1 year. Excluding those who died within 3 days, 668 of the remaining 8927 individuals (7.5% (95% CI 6.9–8.0%)) died within 1 year. Conclusion: The 1-year mortality of those who are treated with naloxone for opioid overdose by EMS is high. Communities should focus both on primary prevention and interventions for this patient population, including strengthening regional treatment centers and expanding access to medication for opioid use disorder.

Background: A significant proportion of individuals seeking treatment for substance use disorders (SUDs) have experienced sexual victimization, which has been shown to disrupt the efficacy of SUD treatment services. Objective: To evaluate the relationship between lifetime sexual victimization and SUD treatment completion. Methods: Relevant literature was identified through a systematic, computerized search of nine electronic databases (May 2018) and reference harvesting, yielding 15 peer-reviewed articles published between 1992 and 2017. Two authors independently conducted title and abstract screens, full-text reviews, data abstraction, and methodological appraisals. Risk of bias was assessed using a modified mixed-methods appraisal tool. Only nine studies met criteria for the meta-analysis, which used a random-effects model. Results: Included studies yielded mixed results regarding the impact of sexual victimization on treatment completion. The meta-analysis yielded a non-significant trend of survivors of sexual victimization having slightly lower odds of completing treatment. Conclusions: Findings from this systematic review and meta-analysis did not support the impact of sexual victimization on treatment completion. Methodological limitations of the extant literature limit cross-study comparisons. Future studies should document program-related factors to improve the ability to understand relationships affecting treatment completion.

Background: Rates of substance use and substance use disorders are higher among adults on probation or parole supervision compared to the general population. Substance use is a risk factor of not adhering to supervision requirements, which may result in revocation and incarceration. Examining associations of metropolitan area status with substance use and substance use disorders may identify specific substance use behaviors that can be targeted in community corrections prevention and treatment services. The present study examined associations of metropolitan area residency with substance use and substance use disorders among adults on probation or parole supervision. Methods: Data came from the 2015 to 2018 National Survey on Drug Use and Health ([NSDUH]; N = 4266 adults on parole or probation). Multivariable logistic regression was run for substance-specific models for each of the two outcomes of past-year use and substance use disorder. Results: Nonmetropolitan residency was associated with higher odds of methamphetamine use and lower odds of cocaine use. Nonmetropolitan residency was associated with higher odds of methamphetamine use disorder and lower odds of opioid use disorder and cocaine use disorder. Conclusions: Study findings highlight the differences of substance use and substance use disorders between levels of metropolitan areas for those on probation or parole. Findings suggest that cocaine use should be emphasized in clinical services in large metropolitan areas, whereas methamphetamine use may be prioritized in nonmetropolitan areas. Further study is needed to investigate the interface of substance use behaviors and community corrections outcomes across metropolitan and nonmetropolitan areas.

Background: Previous research has linked the internalization of shame and negative stereotypes associated with substance use to increased severity of substance use problems (i.e., negative consequences associated with alcohol and drug use, including occupational or relational difficulties and illegal behavior). However, little work has examined how other aspects of substance-use-related stigma (e.g., encounters with and anticipation of discrimination) might be related to the severity of substance use problems. Further, the psychological mechanisms through which stigma drives substance use problems remain poorly understood. Addressing these key limitations, the current study examined the role of executive functioning (EF) deficits in the relation between substance-use-related stigma and severity of substance use problems. Methods: In fall 2019, adults exposed to trauma who use substances were recruited via Amazon's Mechanical Turk (N = 320, 46.9% women) and completed self-report measures of substance-use-related stigma, EF deficits, and substance use problems. Results: Substance-use-related stigma was positively associated with EF deficits, which in turn related to substance use problems. Substance-use-related stigma was also indirectly associated with substance use problems through EF deficits, suggesting that EF deficits accounted for the significant association between substance-use-related stigma and substance use problems. Conclusions: These findings provide initial support for the role of EF deficits as a mechanism through which stigma drives substance use problems among individuals exposed to trauma. Results underscore the potential utility of addressing stigma coping and EF deficits in interventions aimed at preventing and treating substance use disorders.

Background: Nonmedical use of prescription drugs (NMPUD) has become a critical public health concern. Chinese literature has paid growing attention to NMUPD, but scarce research has focused on females who are sex workers (FSWs), who have a high risk of substance use. The current study aimed to examine NMUPD and its biopsychosocial correlates in Chinese FSWs. Methods: A total of 410 FSWs (mean age = 33.58 years) from Guangxi, China, completed an anonymous, self-administered survey evaluating NMUPD, somatic symptoms, and psychosocial distress. Results: Overall, 46.6% of FSWs reported lifetime NMUPD and 17.6% reported past-3-month NMUPD. The most commonly reported medications that were used nonmedically were analgesics (46.3%, lifetime; 17.6%, past 3 months). A majority of FSWs (69.1%) reported “relieving pain” as the motive of their NMUPD. FSWs reporting NMUPD were more likely to be younger, be unmarried, have higher income, and work in multiple venues/high-paying venues. Somatic symptoms and psychosocial distress were associated with NMUPD in Chinese FSWs. Conclusions: NMUPD was prevalent in Chinese FSWs and was associated with biopsychosocial factors. Critical attention should be paid to NMUPD in FSWs. Future NMUPD prevention intervention among FSWs may benefit from attending to biopsychosocial factors.

Background: National studies often examine associations between sexual identity and substance use at a single point in time and neglect to examine whether these associations change over time. The present study examines U.S. trends in the past-year prevalence of binge drinking, marijuana use, illicit drug use, and polysubstance use across sexual identity subgroups (gay, lesbian, bisexual and heterosexual). Methods: The data come from four independent, cross-sectional samples measured by the National Survey of Family Growth (2006–2010, 2011–2013, 2013–2015, and 2015–2017). Based on the consistency in the sampling procedures used over time, merging the four data sets was possible. The target population is men and women 15–44 years of age. Results: Lesbian women had the sharpest decline in past-year binge drinking over time, followed by heterosexual women. The prevalence of binge drinking for bisexual women did not change significantly over time and was higher in 2015–2017 than for any sexual identity subgroup. In contrast, there were no significant differences in the prevalence of binge drinking among men by sexual identity subgroup. Past-year abstinence from substance use was consistently lower among lesbian women, gay men, and bisexual women relative to other sexual identity subgroups. Polysubstance use was consistently more prevalent among bisexual women (e.g., 32.3% in 2015–2017) as compared to other sexual identity subgroups. Conclusion: This is the first study to examine U.S. national trends in alcohol, marijuana, illicit drug, and polysubstance use across sexual identity subgroups, and demonstrates that sexual identity subgroup differences were robust with relatively few changes in trends over time. The consistently high rates of binge drinking and polysubstance use among bisexual women deserve much closer attention based on the related health consequences.

Background: Thiamin is an essential vitamin that is involved in every organ system in the body. Thiamin deficiency can present as beriberi or Wernicke's encephalopathy. We seek to educate practitioners in developed countries to include beriberi on the differential diagnosis when a patient with alcohol use disorder, poor diet and/or disordered eating presents with ascending paralysis without albuminocytologic dissociation. Case: In this case report, a 20-year-old female with no past medical history presented with three weeks of ascending paralysis. At presentation, she could not grasp objects, walk, or rise from a seated position. She reported consuming excessive alcohol and an otherwise limited diet due to picky eating. The patient was ultimately diagnosed with acute inflammatory demyelinating polyneuropathy secondary to dry beriberi from severe protein-calorie malnutrition and alcohol use disorder. She received an aggressive thiamin replacement regimen as well as physical and occupational therapy. She was discharged to home 24 days after her initial presentation. Discussion: This patient case offers a unique presentation of ascending paralysis without albuminocytologic dissociation due to severe dry beriberi from a diet of unenriched carbohydrates and excessive alcohol in an otherwise young, healthy adult in the United States. Our goal is that in reviewing the unusual details of this case, providers will be better equipped for the timely diagnosis and treatment of similar cases in the future.

Background: Given the potential for increased substance use during COVID-19, we examined (1) young adults’ changes in cigarette, e-cigarette, marijuana, and alcohol use from pre- to during COVID-19; and (2) related risk/protective factors. These findings could inform intervention efforts aimed at curbing increases in substance use during periods of societal stress. Methods: We analyzed Wave 3 (W3; September–December 2019) and Wave 4 (W4; March–May 2020) from the Vape shop Advertising, Place characteristics and Effects Surveillance (VAPES), a 2-year, five-wave longitudinal study of young adults across six metropolitan areas. We examined risk/protective factors (i.e. adverse childhood experiences [ACEs], depressive symptoms, resilience) in relation to changes in past 30-day substance use frequency. Results: In this sample (N = 1084, M_age=24.76, SD = 4.70; 51.8% female; 73.6% White; 12.5% Hispanic), W3/W4 past 30-day use prevalence was: 29.1% cigarettes (19.4% increased/26.4% decreased), 36.5% e-cigarettes (23.2% increased/28.6% decreased), 49.4% marijuana (27.2% increased/21.2% decreased), and 84.8% alcohol (32.9% increased/20.7% decreased). Multivariate regressions indicated that, greater increases were predicted by: for e-cigarettes, greater ACEs; and for alcohol, greater depression. Among those with low resilience, predictors included: for e-cigarettes, greater depression; and for marijuana, greater ACEs. Conclusions: Interventions to reduce substance use during societal stressors should target both risk and protective factors, particularly resilience.

Background: Our rural health system sought to (1) increase the number of primary care clinicians waivered to prescribe buprenorphine for treatment of opioid use disorder (OUD) and (2) consequently increase the number of our patients receiving this treatment. Methods: We used the Project for Extension for Community Health Outcomes (ECHO) tele-education model as an implementation strategy. We examined the number of clinicians newly waivered, the number of patients treated with buprenorphine, the relationship between clinician engagement with ECHO training and rates of buprenorphine prescribing, and treatment retention at 180 days. Results: The number of clinicians with a waiver and number of patients treated increased during and after ECHO training. There was a moderate correlation between the number of ECHO sessions attended by a clinician and number of their buprenorphine prescriptions (r = 0.50, p = 0.01). The 180-day retention rate was 80.7%. Conclusions: Project ECHO was highly effective for increasing access to this evidence-based treatment. The high retention rate in this rural context indicates that most patients are increasing their likelihood of favorable outcomes.

Background: Social ecological models designed to understand disparities in sexually transmitted infection (STI) prevalence highlight understudied structural and community risk factors. Guided by a social ecological model, this study identified profiles based on substance use-related STI risk, and examined associations of the profiles with selected indicators of structural-, community-, and individual-level STI risk factors. Methods: Repeated measures latent class analysis was applied to Pittsburgh Girls Study data (n = 2,138; 58% Black, 42% White) at ages 18–20. Profile indicators included: women's and partner's alcohol and cannabis use, women's sexual risk behavior, and self-reported STI. Profile predictors included racial background, structural-, community-, and individual-level risk factors. Results: Two of the five identified profiles had low STI likelihood: “Low Use” of alcohol and cannabis (25.5%; overrepresented by Black women), and “Alcohol Only” (19.1%; overrepresented by White women). Three profiles, all representing co-use of alcohol and cannabis, had higher STI likelihood: “Co-Use: Increasing Alcohol and Occasional Cannabis use” (16.5%; overrepresented by White women), “Co-Use: Occasional Alcohol and Cannabis use” (26.1%; overrepresented by Black women), and “Co-Use: Frequent Cannabis and Occasional Alcohol use” (12.8%; overrepresented by Black women). Structural STI risk (household use of public assistance at wave 1) was associated with “Low Use” and “Co-Use: Frequent Cannabis and Occasional Alcohol use” profiles. STI risk at multiple levels (structural, neighborhood, individual) was associated with the “Co-Use: Frequent Cannabis and Occasional Alcohol use” profile. Conclusions: Co-use of alcohol and cannabis is an important target for STI prevention efforts. Results also highlight structural- and community-level STI risk factors that disproportionately impact Black women, and the importance of multi-level interventions that are targeted to profile of risk to optimize the effectiveness of interventions.

Background: Treatment of opioid use disorder (OUD) is highly effective, but access is limited and care is often fragmented. Treatment in primary care can improve access to treatment and address psychiatric and physical co-morbidities in a holistic, efficient, and non-stigmatizing way. The Collaborative Care Model (CCM) of behavioral health integration into primary care has been widely disseminated and shown to improve outcomes and lower costs when studied for depression, but its use in treating substance use disorders has not been well documented. Methods: We used a mixed-methods approach to examine the impact of implementing multidisciplinary treatment of OUD in our health system's five primary care clinics using the framework of the CCM, with care shared between the primary care clinician (PCP), behavioral health clinician, and medical assistant. The implementation included staff education, creation of electronic health record tools, and implementation support, and was evaluated using data from the electronic health record, the medical staff office, and a clinician survey. Results: Over the last 2 years of implementation, the number of waivered providers increased from 11 to 35, providers prescribing for 5 or more patients increased from 2 to 18, and patients initiated on buprenorphine increased from 4/month to 18/month. 180-day treatment retention was 53%, and 81% of patients had consistently negative urine drug testing. Psychiatric and medical comorbidities were common, 70 and 44%, respectively. Although PCPs who prescribed buprenorphine found working in this model enjoyable and effective, the majority of non-waivered PCPs remained reluctant to participate. Conclusions: In our experience, treatment of OUD in primary care utilizing the CCM effectively addresses OUD and commonly comorbid anxiety and depression, and leads to an expansion of treatment. Successful implementation of OUD treatment requires addressing negative attitudes and perceptions.

Background: People who use drugs (PWUD) have high rates of hepatitis C virus (HCV) infection. Hospitalization can be a time for PWUD to engage in addiction treatment, but little is known about how hospitalization shapes HCV treatment readiness. We aimed to describe how hospitalization and addiction medicine consult service (AMCS) can alter HCV prioritization of inpatient PWUD with HCV. Methods: We conducted a qualitative study consisting of semi-structured interviews (n = 27) of hospitalized adults with addiction and HCV infection seen by an AMCS at a single, urban, academic center. Interviews were audio-recorded, transcribed, and coded iteratively at the semantic level, and analyzed for themes. Results: Of the 27 participants, most identified as Caucasian (85%), male gender (67%), and they primarily used opioids (78%); approximately half (48%) reported HCV diagnosis over 5 years ago. We identified three main themes around hospitalization altering the prioritizations and HCV treatment preferences for PWUD: (1) HCV treatment non-engaged (2) HCV treatment urgency, and (3) HCV treatment in the future. Those wanting to treat HCV—whether urgently or in the future—shared the overlapping theme of hospitalization as a reachable moment for their addiction and HCV. These participants recognized the long-term benefits of addressing HCV and connected their hospitalization to substance use. Conclusion: In our study, PWUD with HCV expressed varying and competing priorities and life circumstances contributing to three main HCV treatment trajectories. Our results suggest ways hospitalization can serve as an HCV touchpoint for PWUD, especially in the context of addressing substance use, and could be used when designing and implementing targeted interventions to improve the HCV care continuum for PWUD.

Background: Although a direct link between opioid use in obese patients and risk of overdose has not been established, obesity is highly associated with higher risk for opioid/opiate overdose. Evidence for clinical impact of obesity on patients with opioid/opiate overdose is scarce. The aim of this study was to determine effects of obesity on health-care outcomes and mortality trends in hospitalized patients who presented with opioid/opiate overdose in the United States between 2010 and 2014. Design: Multivariate logistic and linear regression analysis compared clinical outcomes and hospital resource utilization between obese and nonobese patients. Trend analysis of in-hospital mortality was also analyzed. Setting: United States. Participants: 302,863 adults ≥ 18 years and hospitalized with a principle diagnosis of opioid/opiate overdoses between 2010 and 2014. Measurements: Primary measurement was in-hospital mortality. Secondary measurements included respiratory failure, cardiogenic shock, mechanical ventilations/intubations, hospital charges, and length of stay. Findings: Prevalence for in-hospital mortality was lower in patients with obesity (2.2% vs 2.9%). Obese patients had higher adjusted odds for respiratory failure (aOR = 1.7, [(CI) 1.6–1.8]) and mechanical ventilation/intubation (aOR = 1.17, [(CI) 1.10–1.2]). They also had longer length of stays (aMD = 0.4 days, [(CI) 0.25–0.58 days] and higher total hospital charges (aMD = $5,561, [(CI) $3,638–$7,483]. Trends of in-hospital mortality for patients with obesity did not significantly increase (2.1% in 2010 to 2.4% in 2014, p trend = 0.37), but significantly increased for obese patients (2.4% in 2010 to 3.4% in 2014; p trend <0.01). Conclusions: Prevalence and trends of mortality were lower in patients with obesity hospitalized for opiate/opioid overdose compared to those without obesity between 2010 and 2014 in the United States.

Background: In this qualitative exploration, we report on a thematic analysis of the key role that engaging in meaningful activities may play in recovery processes for people with a diagnosis of substance use disorder (SUD). Methods: We conducted semi-structured, individual interviews with 30 participants and analyzed the parts of this material that were related to meaningful activities. Results: The findings are summarized through the development of three broad themes: (a) the central role of work—“The wages suck, but the job is gold”; (b) mastery and commitment—“I had to get up early, find my spot, I had to be present and fully functioning all day”; and (c) repairing the bridge to community life—“It's my job and working out that has made this possible, really, I see that now.” Conclusion: We discuss these findings in relation to a recovery perspective and relevant empirical studies, highlight some important implications for research and practice, and consider the strengths and limitations of the present study.

Background: This study explored the relationship between history of substance abuse and pain severity during inpatient rehabilitation following traumatic spinal cord injury (SCI). Methods: Secondary analysis of a prospective longitudinal study. An adjusted general linear model was used to examine differences in functional improvement based on history of substance abuse and pain severity. Results: Over 50% of the sample had a history of substance abuse, and 94% reported moderate or severe pain. There was a significant interaction between the history of substance abuse and pain severity (p = 0.01, partial η² = 0.012). A difference in functional improvement was found among individuals who reported low pain; those with a history of substance abuse achieved less functional improvement than those without a history of substance abuse, M = 5.32, SE = 1.95, 95% CI 0.64–10.01. Conclusions: A history of substance abuse and post-injury pain are prevalent among individuals with SCI in rehabilitation, and there may be a meaningful relationship between these two patient characteristics and functional improvement. The results provide potential new insights into the characteristics of vulnerable subpopulations during SCI rehabilitation. Furthering our understanding of these results warrants future investigation to prevent and minimize poor outcomes among vulnerable SCI patients.

Background: Growing use of social media has led to the emergence of virtual controlled substance and illicit drug marketplaces, prompting calls for action by government and law enforcement. Previous studies have analyzed Instagram drug selling via posts. However, comments made by users involving potential drug selling have not been analyzed. In this study, we use unsupervised machine learning to detect and classify prescription and illicit drug-related buying and selling interactions on Instagram. Methods: We used over 1,000 drug-related hashtags on Instagram to collect a total of 43,607 Instagram comments between February 1st, 2019 and May 31st, 2019 using data mining approaches in the Python programming language. We then used an unsupervised machine learning approach, the Biterm Topic Model (BTM), to thematically summarize Instagram comments into distinct topic groupings, which were then extracted and manually annotated to detect buying and selling comments. Results: We detected 5,589 comments from sellers, prospective buyers, and online pharmacies from 531 unique posts. The vast majority (99.7%) of comments originated from drug sellers and online pharmacies. Key themes from comments included providing contact information through encrypted third-party messaging platforms, drug availability, and price inquiry. Commonly offered drugs for sale included scheduled controlled substances such as Adderall and Xanax, as well as illicit hallucinogens and stimulants. Comments from prospective buyers of drugs most commonly included inquiries about price and availability. Conclusions: We detected prescription controlled substances and other illicit drug selling interactions via Instagram comments to posts. We observed that comments were primarily used by sellers offering drugs, and typically not by prospective buyers interacting with sellers. Further research is needed to characterize these “social” drug marketplace interactions on this and other popular social media platforms.

Introduction and aims: The high prevalence and economic burden of alcohol use disorder (AUD) requires methodologically sound research to guide treatment decisions. Systematic reviews (SR) are fundamental to clinical decision making as they collate results of all studies for a given topic and provide summaries of the clinical evidence. Bias resulting from industry relationships can compromise the validity of SRs. Thus, we investigated financial conflicts of interests (FCOI) within SRs involving the pharmacologic treatment of AUD. Design and Methods: We conducted a systematic search of PubMed, Embase, and the Cochrane Database to retrieve SRs published between September 2016 and December 2019. Screening and data extraction were performed in duplicate, blinded fashion—collecting characteristics of the reviews including the authors’ FCOI statements. The results and discussion sections were rated as favorable or unfavorable toward the treatment drug. A stepwise method was used to identify undisclosed FCOIs for all SR authors. Results: Nineteen (of 51) authors representing 7 (of 12) SRs were found to have FCOI. Among reviews with conflicted authors, 3 of 7 (42.9%) results sections were favorable toward the treatment drug, whereas 6 of 7 (85.7%) conclusions were rated as favorable. Discussion and Conclusions: More than one-third of SR authors and nearly two-thirds of studies were found to have FCOIs. Our investigation shows that financial ties are frequent among SR authors on AUD pharmacotherapies and that discussion sections often favored the drug for which the sponsor provided payments.

Background: Children of parents with substance use disorders are at greater risk for mental and physical health co-morbidities. Despite guidelines, pediatricians rarely screen for substance use in the family/household, citing fear of offending parents. The objectives of this study were to examine (1) caregiver acceptance of pediatricians screening for family/household substance use during well-child visits, (2) prevalence of family/household substance use, and (3) the association between family/household substance use and trust in their child's pediatrician. Methods: This cross-sectional study surveyed adult caregivers presenting a child for medical care at two urban pediatric outpatient clinics using a brief anonymous computer-based survey. The primary outcome measured the acceptability of pediatrician screening for family/household substance use. Substance use and concerns about use in the family/household were also assessed. Results: Adult caregivers (n = 271) surveyed were mean age 35 years, 73% mothers, 90% African American, and 85% on Medicaid. Over half (51%) of caregivers reported substance use by someone in the family/household, most commonly cigarettes (38%), followed by alcohol (19%) and marijuana (10%). Sixty-one percent of caregivers who reported family substance use expressed concern about the use of this substance. The majority (87%) agreed it is appropriate for pediatricians to ask caregivers about family/household substance use. No differences were found between caregivers who did and did not report substance use in their family/household. Caregivers with concerning substance use in their family/household were less likely to trust their pediatrician [OR = 0.21, 95%CI: 0.05, 0.85] Conclusions: Caregivers endorsed acceptance of universal screening for substance use, including illicit substances, and substance use disorders in the family/household during well-child visits. Pediatricians are trusted professionals with expertise in communicating with parents to maximize the health of their patients; assessing family history of substance use and substance use disorders is a natural extension of their role.

Background: Opioid use disorders are widespread, commonly occurring, and have serious impacts on individuals, families, and communities. When adequately trained, social workers play a pivotal role in treating populations impacted by opioid use through the provision of high-quality services and the shifting of negative attitudes related to opioid use. However, workforce projections indicate a growing shortage of behavioral health professionals qualified to work with such populations and, presently, social work programs are not equipped to meet these workforce needs. Emerging evidence suggests opioid overdose education is associated with improved attitudes and knowledge among health professions; however, less information exists on the outcomes of such training among social work students. Schools of social work must develop and evaluate curricular components related to opioid use prevention and management to adequately prepare students for clinical work as social work practitioners. Methods: Thirty-three advanced-year MSW students received opioid overdose training as part of a day-long seminar on substance use. Content included acute effects of opioids, withdrawal symptoms, risk factors, signs of overdose, naloxone training, and harm reduction principles. Using a single-group pretest-posttest design, students completed the Opioid Overdose Attitudes Scale (OOAS) and the Opioid Overdose Knowledge Scale (OOKS). To evaluate students’ attitudes and knowledge, investigators compared overall and subscale means before and after the training via paired samples t-tests. Results: Findings indicated statistically significant improvements in the “concerns” and “competence” domains of the OOAS. Likewise, findings indicated statistically significant improvements in the “risk,” “signs,” “action,” and “naloxone use” domains of the OOKS. Conclusion: Students reported improved opioid overdose-related knowledge and attitudes when assessed after the training as compared to before the training. Due to the nature of the study design, causality cannot be inferred from the training outcomes. Findings may help other social work programs develop curricular components related to opioid use.

Background: Alcohol use is a concerning issue for the military given its potential negative impact on human performance. Limited data are available regarding the incidence of alcohol use disorder in the military, which is critical to understand to evaluate force readiness, as well as for preventative initiatives and treatment planning. The aim was to examine the alcohol use disorder incidence rates (overall and across demographics) among active duty service members from 2001 to 2018. Methods: Data on 208,870 active duty service members between 2001 and 2018 from the Defense Medical Epidemiology Database was examined. Incidence rates were analyzed to determine the diagnostic rates of AUD (including both alcohol abuse and dependence), which were then examined by sex, age, service branch, military pay grade, marital status, and race. Results: Incidence rates of AUD in active duty service members (per 1,000 service members) ranged from 6.45 to 10.50 for alcohol abuse and 5.21 to 7.11 for alcohol dependence. Initial diagnoses of new-onset AUD occurred most frequently within 20–24 year-old, white, male, and non-married U.S. Army service members in the enlisted pay grades of E-1 to E-4. Statistically significant differences (p <.001) were found between observed and expected counts across all examined demographic variables. Conclusions: To our knowledge, this is the first study to provide a comprehensive examination of AUD incidence rates in an active-duty military population over an extended 18-year period and during the last decade. Incidence rates were higher than expected for alcohol dependence and lower than expected for alcohol abuse. Given the untoward effects of AUD on overall health and force readiness, active-duty service members may benefit from more advanced preventative interventions to decrease incidence rates of AUD over time. Future research should use these data to develop targeted interventions for the demographics at greatest risk.

Background: The COVID-19 pandemic and associated public health measures implemented to mitigate transmission may increase stress, which, in turn, can be associated with changes in cannabis use. This study examined the associations between health-related and socioeconomic stressors associated with the COVID-19 pandemic, and reported increases in cannabis use. Indirect effects of health-related and socioeconomic stressors on increased cannabis use through cannabis coping motives were also tested. Methods: Cross-sectional survey data, based on responses from a convenience sample of 755 Israeli adults who reported frequent consumption of cannabis for recreational purposes, was analyzed using structural equation models. Results: About 35% of the respondents reported that they agreed to a large/very large extent that their cannabis use had increased since the COVID-19 pandemic had started. Both health and socioeconomic stressors were related to increased cannabis use during the pandemic, and coping motives mediated this relationship. The direct and indirect associations of socioeconomic stressors and increased cannabis use were stronger than the associations of health-related stressors. Conclusions: Cannabis consumption may serve as a means of coping with health and socioeconomic COVID-19 stressors. Particular attention should be placed on socioeconomic stressors as these may be particularly important in understanding coping related cannabis use during the COVID-19 pandemic.

Introduction: As rates of overdose and substance use disorders (SUDs) increase, medical schools are starting to incorporate more content on SUDs and harm reduction in undergraduate medical education (UME). Initial data suggest these additions may improve medical student knowledge and attitudes toward patients with SUDs; however, there is no standard curriculum. Methods: This project uses a six-step approach to UME curricular development to identify needs and goals regarding SUDs and opioid overdose at a large single-campus medical school in the United States. We first developed and delivered a pilot curriculum to a small group of medical students. Pilot results and a larger survey led to implementing a one-hour Opioid Overdose Prevention and Response (OOPR) Training for first-year students. Effects of training were tracked using baseline and post-training surveys examining knowledge and attitudes toward opioid overdose and patients with SUDs. Results: Needs assessment indicated desire and need for training. The pilot study (N = 66) resulted in significantly improved knowledge regarding opioid overdose; 100% of students enjoyed training and believed others should receive it. The larger replication study surveyed all incoming students (N = 266) to gauge initial knowledge and experiences with these topics. Results prompted enhancement of the OOPR Training curriculum, which was delivered to half of the first-year class. Post-training survey results replicated the pilot study findings. The majority (95.2%) of students enjoyed training and 98.4% believed all students should receive it. Conclusion: Delivering a thorough curriculum on SUDs and harm reduction in UME is critical. Although many schools are implementing training, there is no standard curriculum. We outline a low-resource training intervention for OOPR. Our findings identified key features to include in these UME curricula. This approach provides a replicable template for schools seeking to develop brief educational interventions and identify essential content for curricula in SUDs and harm reduction.

Background: Community pharmacists are at the frontline of patient care, yet their role in the opioid epidemic remains unclear. This qualitative study examines the perception of community pharmacists about their role in the opioid epidemic and challenges to fulfilling this role. Methods: A secondary analysis of cross-sectional survey data from an Indiana census of community managing pharmacists was conducted. Qualitative data were coded using a priori and emergent themes. A priori categories included the perceived role of pharmacists in the opioid epidemic and perception of practice barriers. Results: A total of 215 Indiana community managing pharmacists participated in this study. Pharmacists understood themselves as gatekeepers in preventing opioid misuse and overdose. Reported pharmacy practices included providing patient education and communicating with prescribers. Challenges to fulfilling this role included pharmacy structure and operation, lack of patient and provider clarity about pharmacist scope of practice, and pharmacist perception that that there is no available discretionary time to support additional services. Conclusion: Pharmacists believe they have a vital role in combatting opioid misuse and overdose but are hampered by structural aspects of pharmacy practice and lack of recognition of their role. Pharmacy associations and policy partners are encouraged to identify opportunities to address these barriers.

Background: Among youth already using cannabis, legalization of medical cannabis may influence cannabis-related attitudes and behaviors, including increasing access through use of someone else's medical cannabis (diversion). Objective: To examine cannabis-related attitudes and behaviors (including diverted cannabis use) in cannabis-using youth in the four years following medical cannabis legalization. Additionally, we investigated characteristics of youth who used vs. did not use diverted medical cannabis. Methods: Data were collected in Boston from 2013 (when medical cannabis legislation took effect in Massachusetts) through 2016 (when recreational cannabis use became legal in Massachusetts). Cannabis-using youth (age 13–24) presenting to an outpatient adolescent substance use treatment program (ASUTP) or recruited for an adolescent medicine clinic study (AMCS) completed a confidential survey on demographic characteristics and cannabis use behaviors and attitudes. We used multiple logistic regression to analyze changes in attitudes and behaviors over three years versus the reference year (2013), controlling for demographics. We used chi-square to compare characteristics of youth reporting use of diverted medical cannabis versus those not. Results: The sample included 273 cannabis-using youth (ASUTP n = 203, AMCS n = 70; 2013 n = 67, 2014 n = 67, 2015 n = 77, 2016 n = 62). Mean ± SD age was 18.2 ± 2.5 years, 32% were female, 58% were White non-Hispanic, and 70% had college-graduate parents. In 2013, most youth reported that cannabis was easy to obtain (97.9%), and that occasional cannabis use had “no” or “slight” risk of harm (89.4%), with little change across years. In 2016, 44% of youth reported using someone else's medical cannabis, versus 15% in 2013 (aOR 4.66, 95% CI 1.81, 11.95). Youth using diverted medical cannabis had higher likelihood of reporting riding with a driver, or driving themselves, after cannabis use (both p < .01). Conclusion: Among at-risk youth in Massachusetts, use of diverted medical cannabis increased after medical cannabis legalization, and those using diverted medical cannabis reported higher risk for cannabis-related traffic injury.

Background: People with opioid use disorders (OUDs) are at heightened risk for involvement with the criminal justice system. Growing evidence supports the safety and effectiveness of providing empirically supported treatments for OUD, such as medications for OUD (M-OUD), to people with criminal justice involvement including during incarceration or upon reentry into the community. However, several barriers limit availability and accessibility of these treatment options for people with OUDs, including a shortage of healthcare and justice professionals trained in how to implement them. This study evaluated a novel education program, the Indiana Jail OUD Treatment ECHO, designed to disseminate specialty knowledge and improve attitudes about providing M-OUD in justice settings. Methods: Through didactic presentations and case-based learning (10 bimonthly, 90-min sessions), a multidisciplinary panel of specialists interacted with a diverse group of community-based participants from healthcare, criminal justice, law enforcement, and related fields. Participants completed standardized surveys about OUD knowledge and attitudes about delivering M-OUD in correctional settings. Thematic analysis of case presentations was conducted. Results: Among 43 participants with pre- and post-series evaluation data, knowledge about OUD increased and treatment was viewed as more practical after the ECHO series compared to before. Cases presented during the program typically involved complicated medical and psychiatric comorbidities, and recommendations addressed several themes including harm reduction, post-release supports, and integration of M-OUD and non-pharmacological interventions. Conclusions: Evaluation of future iterations of this innovative program should address attendance and provider behavior change as well as patient and community outcomes associated with ECHO participation.

Background: Adolescent e-cigarette use has increased, as has e-cigarette use during pregnancy, yet little is known about how these types of tobacco/nicotine (cigarettes/e-cigarettes) use during adolescence are associated with tobacco/nicotine use during the third trimester of pregnancy among young adults. Methods: National longitudinal data (2013–2018) from the Population Assessment of Tobacco and Health (PATH) study were used. Young adults ages 18–20 who indicated past-year pregnancy made up the analytic sample (N = 246). Logistic regression was used to evaluate the association between history of past 30-day use of cigarettes/e-cigarettes during adolescence (i.e., 14–17) and later use during the third trimester of pregnancy among young women (i.e., 18–20). Results: Within the sample of young women who indicated a pregnancy during the past year, 18.9% indicated smoking cigarettes and 4.2% indicated using e-cigarettes during their last trimester. Cigarette smoking in adolescence (wave 1 or 2) was associated with cigarette use during the last trimester (aOR = 4.76, 95% CI = 1.36, 16.6); however, e-cigarette use during adolescence was not associated with either cigarette or e-cigarette use during the third trimester of pregnancy. Conclusions: Tobacco/nicotine prevention in early adolescence has implications for preventing tobacco/nicotine-related harms during pregnancy among young adults. Intervention programs and clinicians informed about various types of tobacco/nicotine are needed to address tobacco/nicotine cessation among adolescents to prevent consequences of tobacco/nicotine use during pregnancy.

Background: Accurate prevalence estimates are critical to epidemiological research but discordant responses on self-report surveys can lead to over- or underestimation of drug use. We sought to examine the extent and nature of underreported cannabis use (among those later reporting blunt use) from a national drug survey in the US. Methods: We used data from the 2015–2019 National Survey on Drug Use and Health (N = 281,650), a nationally representative probability sample of non-institutionalized populations in the US. We compared self-reported prevalence of past-year cannabis use and blunt use and delineated correlates of underreporting cannabis use, defined as reporting blunt use but not overall cannabis use. Results: An estimated 4.8% (95% CI: 4.4–5.2) of people reported blunt use but not cannabis use. Although corrected prevalence, cannabis use recoded as use only increased from 15.2% (95% CI: 15.0–15.4) to 15.5% (95% CI: 15.3–15.7), individuals who are aged ≥50 (aOR = 1.81, 95% CI: 1.06–3.08), female (aOR = 1.35, 95% CI: 1.12–1.62), Non-Hispanic Black (aOR = 1.43, 95% CI: 1.16–1.76), or report lower English proficiency (aOR = 3.32, 95% CI: 1.40–7.83) are at increased odds for providing such a discordant response. Individuals with a college degree (aOR = 0.57, 95% CI: 0.39–0.84) and those reporting past-year use of tobacco (aOR = 0.75, 95% CI: 0.62–0.91), alcohol (aOR = 0.42, 95% CI: 0.33–0.54), cocaine (aOR = 0.50, 95% CI: 0.34–0.73), or LSD (aOR = 0.52, 95% CI: 0.31–0.87) were at lower odds of providing a discordant response. Conclusion: Although changes in prevalence are small when correcting for discordant responses, results provide insight into subgroups that may be more likely to underreport use on surveys.

Background: Although Medicaid expansion under the Affordable Care Act reduces uninsurance, little evidence exists on its impact on mental health and substance use (MHSU) related healthcare utilization. Therefore, the objectives of this study are to examine the impact of Medicaid expansion on emergency department visits related to mental health and substance use disorders and to examine its effect on the variation in payer mix. Methods: The study utilizes state-level quarterly emergency department (ED) visit data from Healthcare Cost and Utilization Project's Fast Stats Database, along with state socio-demographic and health policy data for the analysis. A difference-in-differences regression analysis approach was utilized in comparing MHSU-related ED visit data between expansion and non-expansion states from 2006 to 2019 for all visits and by payer mix. Results: Medicaid expansion was associated with additional 0.35 non-Medicare adult MHSU-related ED visits per 1,000 population (p < 0.05) in expansion states compared with non-expansion states. In addition, Medicaid expansion was associated with about 20.4% increase (p < 0.01) in Medicaid-share of MHSU-related ED visits, about 17.4% reduction (p < 0.01) in uninsured-share of MHSU-related ED visits, and about 3% reduction (p < 0.05) in privately-insured share of MHSU-related ED visits in expansion states compared with non-expansion states. Conclusions: The findings indicate that Medicaid expansion was associated with increased MHSU-related ED visits among the Medicaid population and the overall non-Medicare adult population, while it was associated with reductions in MHSU-related ED visits among the uninsured and privately-insured populations in expansion states compared with non-expansion states.

Background: Buprenorphine is an effective treatment for opioid use disorder, yet some persons are concerned with its “alternative use” (i.e., any use unintended by the prescriber). There is limited evidence on the factors associated with alternative use of buprenorphine (AUB); in this study, we examined correlates of recent (past 6 months) AUB. Methods: Multivariable logistic regression was used to analyze survey data from a multi-site, cross-sectional study of people who use drugs (PWUD) (N = 334) in Baltimore, Maryland; Boston, Massachusetts; and Providence, Rhode Island. Results: One-fifth (20%) of the sample reported recent AUB. In adjusted analyses, significant negative correlates of AUB were female gender (adjusted odds ratio [aOR] 0.48, 95% confidence intervals [CI] 0.24–0.95), recent emergency room visit (aOR 0.45, 95% CI 0.23–0.89), and recent injection drug use (aOR 0.41, 95% CI 0.19–0.88). Significant positive correlates were alternative use of other prescription opioids (aOR 8.32, 95% CI 4.22–16.38), three or more overdoses in the past year (aOR 3.74, 95% CI 1.53–9.17), recent buprenorphine use as prescribed (aOR 2.50, 95% CI 1.12–5.55), and recent residential rehabilitation treatment (aOR 3.71, 95% CI 1.50–9.16). Conclusions: Structural and behavioral correlates of AUB may help identify PWUD at high risk of overdose with unmet treatment needs.

Background: Alcohol is the most used substance among adolescents in Nigeria. While risk factors for alcohol use among adolescents are well documented in Europe and the US, they have received less attention in the literature on African countries. This study aimed to investigate the factors associated with alcohol experimentation and drunkenness episodes in a national sample of Nigerian adolescents. Methods: A total sample of 4,078 secondary-school students participated in the survey during the school year 2015–2016. The survey involved 32 secondary schools of six geopolitical zones (South-South, South-West, South-East, North-Center, North-West, and North-East) and two metropolitan cities (Abuja and Lagos) of Nigeria. Sociodemographic characteristics, parental alcohol use and permissiveness, friends’ alcohol use, risk perceptions and beliefs were investigated as correlates of alcohol experimentation and drunkenness episodes through multilevel, mixed-effect logistic regression models. Results: The prevalence of alcohol experimentation was 34.0%, while the prevalence of drunkenness episodes was 13.4%. Results showed that male gender, family structure different from both parents’ families, parental and friends’ alcohol use, parental permissiveness to drink, low risk perceptions on drinking alcohol, and positive beliefs on consequences of alcohol use were associated with an increased probability of alcohol experimentation and drunkenness episodes. Family affluence and one-parent family structure were related to an increased probability of alcohol experimentation but not of drunkenness episodes. Conclusions: The majority of risk factors analyzed in this study generalize across drinking-behavior outcomes. Since the young population is dominant in Nigeria, alcohol use could become a big public health problem in the near future. High investment in adolescents’ well-being by addressing the factors that contribute to drinking behavior might help to reduce the burden of the problem. Evidence-based prevention curriculum addressing knowledge, risk perceptions, beliefs on consequences of alcohol use, and parental behaviors should be implemented as widely and early as possible.

Background: Clinicians rely upon abstracts to provide them quick synopses of research findings that may apply to their practice. Spin can exist within these abstracts that distorts or misrepresents the findings. Our goal was to evaluate the level of spin within systematic reviews (SRs) focused on the treatment of cannabis use disorder (CUD). Methods: A systematic search was conducted in May 2020. To meet inclusion criteria, publications had to be either an SR or meta-analysis related to the treatment of cannabis use. Screening and data extraction was performed in a duplicate and masked fashion. Study quality was assessed using AMSTAR-2 Results: 16/24 SRs (66.7%) contained at least one form of spin in the abstract. The most common forms of spin identified were type 3—selective reporting of or overemphasis on efficacy outcomes or analysis favoring the beneficial effect of the experimental intervention (45.8%)—and type 8—the review's findings from a surrogate marker or a specific outcome to the global improvement of the disease (37.5%). No significant association between spin and intervention type, PRISMA requirements, or funding source was identified. Weak positive correlations were found between the presence of spin and abstract word count (r =.217) and between spin and AMSTAR-2 rating (r = 0.143). “Moderate” was the most common AMSTAR-2 rating (9/24, 37.5%), followed by “low” (7/24, 29.2%) and “critically low” (7/24, 29.2%). One systematic review received an AMSTAR-2 rating of “high” (1/24, 4.2%). Conclusions: Spin was common among abstracts from the SRs focused on the treatments for CUD. Higher quality studies may help reduce the overall rate as well as standardizing treatment outcomes. To facilitate this, we encourage all authors, peer-reviewers, and editors to be more aware of the various types of spin as they can help reduce the overall amount of spin seen within the literature.

Background: Postpartum is a highly vulnerable time for women with opioid use disorder (OUD). Our primary objective was to identify patient and provider reported aspects of the pregnancy to postpartum transition that impact recovery progress for postpartum women receiving medication for opioid use disorder (MOUD). Methods: This qualitative study consisted of semi-structured interviews with postpartum women in OUD treatment (n = 12) and providers (n = 9) at an outpatient addiction clinic. Interviews were transcribed and analyzed using an editing style approach to report themes and quotes. Results: Patients and providers identified different themes that both promote and challenge recovery during the postpartum transition. These comprised of clinical factors, including MOUD, neonatal opioid withdrawal syndrome (NOWS) and pain associated with labor and delivery as well as psychosocial factors, such as role of a support system, mental health aspects of anxiety and depression causing mood changes, stigma and mistrust among healthcare providers and child welfare. Conclusions: Patients receiving MOUD and their providers identified multiple aspects unique to the postpartum transition that substantially strengthen and/or oppose OUD recovery. These aspects impacting recovery include factors specific to the receipt of MOUD treatment and those not specific to MOUD, yet tied to the postpartum state. Overall, these findings provide insight into areas for future research focused on identifying opportunities to promote recovery-oriented care for families affected by OUD.

Background: Screening Brief Intervention Referral to Treatment (SBIRT) was developed as an integrated and comprehensive public health approach that includes early screening and intervention to address substance use in a variety of health care settings. Research suggests that SBIRT is effective in reducing substance use in individuals whose use places them at higher risk for negative health and social consequences. However, less is known about how training in SBIRT modifies attitudes, regard, and beliefs toward people who use substances. Methods: Participants included 461 students from a variety of healthcare related disciplines (physician assistant, nurse practitioner, pharmacy, psychiatry and psychology, and medical students). Participants were evaluated using a pre-post design to assess changes in regard, attitudes, and beliefs by completing the Short Alcohol and Alcohol Problems Perception Questionnaire, the Drug Problem Perception Questionnaire, the Medical Condition Regard Scale, and the Short Understanding of Substance Abuse Scale before and after a 7-hour SBIRT training program. We hypothesized that trainees would have more positive regard, attitudes, and beliefs toward people who use substances following training in SBIRT relative to a baseline assessment and that there would be between program differences. Results: Results were consistent with hypotheses and suggested that trainees had significantly more positive regard and changes in attitudes and beliefs toward working with patients who use substances following training in SBIRT. Results also suggested significant differences by training group at baseline and at 30-day follow up. Conclusions: Overall, the findings suggest that an important additional benefit of SBIRT is the impact it has on mitigating healthcare professional trainees’ negative regard and modifying attitudes and beliefs toward those who use substances.

Objective: To assess whether cannabis use disorder (abuse or dependence) hospitalizations are increasing over time and examine the variables associated with the outcomes of cannabis use disorder hospitalizations. Methods: This study examined the rates of hospitalizations with cannabis use disorder and associated healthcare utilization using the U.S. National Inpatient Sample data from 1998 to 2014. Adjusted logistic regression analyses assessed the association of demographic, comorbidity and hospital characteristics with healthcare utilization (total hospital charges, length of hospital stays, discharge to a non-home setting) during the index hospitalization for cannabis use disorder. Odds ratio (OR) and 95% confidence intervals (CI) were calculated. Results: There were an estimated 5,601,382 hospitalizations with cannabis use disorder (primary or secondary diagnosis). The rates of hospitalization (/100,000 admissions) for cannabis use disorder increased 3.7-fold from 439/100,000 admissions in 1998–2000 to 1,631/100,000 admissions in 2013–2014. In the adjusted analysis, the following factors were associated with worse healthcare utilization outcomes for cannabis use disorder hospitalizations: older age; Deyo–Charlson index score of 2 or higher; male sex; insurance payer other than private; higher income; hospital region; an urban hospital; and a medium to large hospital bed size. Conclusions: Rising hospitalization rate with cannabis use disorder from 1998 to 2014 is concerning. Our study identified independent variables associated with a higher risk of poor utilization outcomes of cannabis use disorder hospitalizations. Healthcare policies should focus on reducing the burden of cannabis use disorder hospitalizations. High-risk groups of people with cannabis use disorder with the worst outcomes should be targeted to reduce associated utilization.

Background: 12-step groups are the most common approach to managing opioid use disorder (OUD) in the U.S. Medications for OUD (MOUD) are the most effective tool for preventing opioid misuse and relapse. Previous research has identified stigma of MOUD in 12-step groups. Objectives: We sought to identify how MOUD stigma is operationalized in 12-step groups and to identify responses to stigma. Methods: We recruited individuals with both MOUD experience and 12-step group experience from three syringe exchange programs in the U.S. using snowball sampling. We conducted individual telephone semi-structured interviews during 2018 and 2019. We coded data in Dedoose software and conducted thematic analysis using iterative categorization. Results: We recruited 30 individuals meeting our inclusion criteria. The following stigma operationalization methods were identified: prohibiting people using MOUD from speaking at meetings; encouraging shortened duration of MOUD treatment; refusing to sponsor people using MOUD; and refusing to let people using MOUD claim recovery time. Responses to stigma included the following: feeling shame; feeling anger; shopping around for different groups, leaving the group, or forming a new group; not revealing MOUD utilization or only telling a sponsor; speaking out on behalf of MOUD; and using cognitive approaches to avoid stigma internalization. Cognitive approaches included believing that anti-MOUD stigma is contrary to 12-step principles; disregarding statements as inaccurate based on one's experience of MOUD benefits; and accepting that all groups of humans have some ignorant people. Conclusion: Healthcare systems should help address MOUD stigma experienced by patients in 12-step groups, such as by offering non-12-step alternative groups and encouraging MOUD healthcare providers to prepare patients for potential stigma they may face. Some stigma response options, like shopping around for different groups, may not be feasible in rural areas or for participants newer to recovery.

Background: Criminal problem-solving courts and civil dependency courts often have participants with substance use disorder (SUD), including opioid use disorder (OUD). These courts refer participants to treatment and set treatment-related requirements for court participants to avoid incarceration or to regain custody of children. Medications for opioid use disorder (MOUD) are the most effective treatment for OUD but are underutilized by court system participants. Little is known about variation in court policies for different MOUDs. Also, more information is needed about types of policies for each MOUD, including whether participants may begin MOUD, continue previously begun MOUD, or complete the court program with MOUD. Methods: An online survey was distributed to criminal problem-solving and civil dependency judges in Florida in 2019 and 2020, yielding data from 58 judges (a 24% response rate). We used nonparametric statistics to test hypotheses with ordinal data. A Friedman's test for related samples or Cochran's Q was used to make within-group comparisons between policies and MOUDs. Results: We found considerable policy variation, with more permissive policies for naltrexone than buprenorphine or methadone, and more permissive policies for continuing MOUD than for initiating MOUD or completing a court program with MOUD. For each medication, less than one quarter of judges indicated their court always permits MOUD, with most indicating that MOUD is permitted sometimes or usually. Conclusion: Because respondents rarely chose “never” or “always” for any MOUD policy, most courts appear to be making MOUD decisions on a case-by-case basis. A clearer understanding of this decision-making process is needed. Some court participants may be required to discontinue MOUD before completing a court program, even if they were permitted to start or continue MOUD treatment. Discontinuation of MOUD without medical justification is contrary to the standard of care for individuals with OUD and increases their risk of overdose.

Background: In the US, prescription opioid medication misuse (POMM) necessitates engagement of physical therapists (PTs). We (1) evaluated the attitudes of (PT) related to their management of patients with POMM and (2) examined the association between these attitudes and PTs confidence in POMM–related management abilities and the frequency with which they engaged in POMM–related management practices. Methods: We conducted a national survey of PTs that included a modified Drug and Drug Problems Perception Questionnaire (DDPPQ). Confidence in POMM–related abilities and the frequency of engaging in POMM–related management practices were measured. Logistic regression evaluated the association between the DDPPQ subscales (role adequacy, role legitimacy, role self–esteem, role support, job satisfaction) and confidence and frequency outcomes. Results: The analysis included 402 respondents. Role adequacy and legitimacy subscales were associated with confidence and frequency outcomes (p<.05), indicating that more favorable role adequacy and legitimacy attitudes are associated with greater odds of having more confidence in POMM–related management abilities and of engaging in more frequent POMM–related management practices. Conclusions: PTs with a greater sense of preparedness to engage in POMM–related management were more likely to report greater confidence in POMM–related management abilities and engage in POMM–related management practices with greater frequency.

Background: Antisocial personality disorder (ASPD) incurs a high cost to society due to the high risk of violent and nonviolent offenses associated with this personality disorder, thus making the examination of the etiology and the onset of ASPD an important public health concern. Method: The present study consisted of five waves of data collection of the Harlem Longitudinal Development Study (N = 674). In the Cox proportional hazard model, latent multiple substance use trajectories from mid-adolescence to emerging adulthood (mean age 14 to mean age 24) were used as a predictor for the onset of ASPD during emerging adulthood to the mid-thirties (mean age 24 to mean age 36). The control variables were gender, ethnicity, problem behaviors, and victimization. Results: In the multiple Cox proportional hazard model, the high (HR = 2.74, p < 0.001) and the increasing frequency of (HR = 2.55, p < 0.001) use on alcohol, cigarette, and cannabis latent trajectory groups were associated with an increased hazard of ASPD onset as compared with the no or low frequency of use on alcohol, cigarette, and cannabis latent trajectory group after controlling for demographic factors and earlier problem behaviors as well as victimization. Conclusions: The implications of this study for the prediction of adult ASPD onset time may focus on the early use of alcohol, cigarette, and cannabis from mid adolescence to emerging adulthood.

Background: Assessments to determine patients’ treatment needs and preferences when they begin substance use disorder (SUD) treatment are essential. The objectives of this paper are to identify the perspectives of providers who conduct assessments on (1) assessments’ utility in determining the level of care where patients will receive treatment, (2) strategies to engage patients in treatment during assessments, and (3) assessment strengths and shortcomings. Methods: Semi-structured interviews were conducted with 30 California treatment providers who routinely perform SUD assessments for Medicaid beneficiaries. Interviews asked about the utility of assessment tools in determining appropriate levels of care, patient engagement during assessments, and strengths and shortcomings of intake assessment processes. Interviews were audio-recorded, transcribed, and analyzed by multiple researchers using template analysis. Results: Providers reported that assessments linked to level-of-care decision rules sometimes generate recommendations inconsistent with their clinical judgment, and that the timing of assessments can influence the quality of the information collected. Providers described engagement strategies that help patients feel more comfortable during assessments and that encourage more thoughtful and accurate responses. Providers valued assessments that helped ensure comprehensive collection of patient information, that allowed flexibility to probe for additional information and context, and that facilitated treatment planning. Providers did not like assessments that were long and repetitive or those that did not collect detailed information about patients’ mental health and recovery environments. Conclusions: Assessments can be improved if providers conduct them in a manner that makes patients feel comfortable while building trust and rapport. Ensuring that assessments are not long or repetitive and giving comprehensive assessments once patients have developed trusting relationships with treatment programs can improve assessment processes. Further research is needed to optimize SUD assessments.

Background: Despite increasing prevalence of illicit fentanyl use in the US and Canada, preference for fentanyl over other illicit opioids has not been fully characterized. Therefore, we sought to describe changes in illicit opioid preferences over time among people who inject drugs (PWID). Methods: Data were obtained from two prospective cohort studies between 2017 and 2018. Trends in opioid preference over time were examined using bivariable generalized estimating equation (GEE) analysis. Multivariable models were used to identify factors associated with fentanyl preference. Results: Among 732 eligible participants, including 425 (58%) males, the prevalence of preference for fentanyl increased from 4.4% in 2017 to 6.6% in 2018 (Odds Ratio [OR] = 1.27, 95% Confidence Interval [CI]: 1.05–1.52). In a multivariable analysis, younger age (Adjusted Odds Ratio [AOR] = 0.94, 95% CI: 0.92–0.96) and daily crystal methamphetamine injection (AOR = 1.68, 95% CI: 1.01–2.78) were independently associated with preference for fentanyl. The most common reasons for preferring fentanyl included “better high than other opioids” (45%), and “lasts longer than heroin” (27%). Conclusions: The current study has demonstrated that preference for fentanyl has been increasing over time among our sample of PWID who use opioids. Further work is needed to clarify risk factors surrounding transitions to illicit fentanyl.

Background: Fatal overdoses involving cocaine (powdered or crack) and fentanyl have increased nationally and in Massachusetts. It is unclear how overdose risk and preparedness to respond to an overdose differs by patterns of cocaine and opioid use. Methods: From 2017 to 2019, we conducted a nine-community mixed-methods study of Massachusetts residents who use drugs. Using survey data from 465 participants with past-month cocaine and/or opioid use, we examined global differences (p < 0.05) in overdose risk and response preparedness by patterns of cocaine and opioid use. Qualitative interviews (n = 172) contextualized survey findings. Results: The majority of the sample (66%) used cocaine and opioids in the past month; 18.9% used opioids alone; 9.2% used cocaine and had no opioid use history; and 6.2% used cocaine and had an opioid use history. Relative to those with a current/past history of opioid use, significantly fewer of those with no opioid use history were aware of fentanyl in the drug supply, carried naloxone, and had received naloxone training. Qualitative interviews documented how people who use cocaine and have no history of opioid use are largely unprepared to recognize and respond to an overdose. Conclusions: Public health efforts are needed to increase fentanyl awareness and overdose prevention preparedness among people primarily using cocaine.

Background: A Cross-sectional study of all emergency ambulance runs reported by licensed Emergency Medical Services (EMS) providers between 2013 and 2019 was undertaken to determine if the sex of a patient experiencing opioid-related symptoms had an impact on their odds of receiving naloxone from EMS. Methods: All runs within Massachusetts for individuals 11 years and older with a reported sex between 2013 and 2019 (n = 5,533,704 runs) were included. Covariates modeled were patient age, year of the incident, and county of the incident. Runs were separated into those that were opioid-related versus not; opioid-related runs were further subdivided into five severity categories including dead on arrival, acute opioid overdose, opioid intoxicated, opioid withdrawal, and other opioid-related incident. Results: Among opioid-related runs, women had 24% lower odds (95% CI 0.68–0.86) of appearing in the dead on arrival category and 20% lower odds (95% CI 0.78–0.82) of appearing in the acute opioid overdose category than men. Among acute opioid overdoses, runs where patient symptoms met Massachusetts EMS guidelines for naloxone administration, women had 18% lower odds (95% CI 0.76–0.89) of receiving naloxone than men. Conclusions: Sex-related differences persist in the odds of naloxone administration by EMS providers when controlling for symptom presentation.

Background: Police assisted referral (PAR) programs provide people with substance use disorders (SUD) with a non-arrest treatment pathway, yet systemic barriers, including stigma and access to treatment services, may limit engagement. We sought to understand how the dual contextual challenges of COVID-19 and the Black Lives Matter movement have impacted PAR programs. Methods: Participants completed semi-structured interviews between July and September 2020. Transcribed interviews were analyzed qualitatively to extract emergent codes and themes. Results: Key themes included: adoption and reach of adapted remote services, and barriers to access; and questions on the role of police as health service providers, including police embeddedness in the community. COVID-related social distancing demands undermined police engagement with people with SUD. Treatment providers and advocates reported moderate success in utilizing remote interventions as workarounds. While participants acknowledged the Black Lives Matter movement's criticism of police, many saw continued value in police involvement in substance use interventions, due to their accessibility in communities and capacity for rapid response. Conclusions: PAR programs quickly adapted to a largely remote format, increasing longer-term accessibility. While Black Lives Matter had little direct impact on PAR programs, concerns about police-community relations were acknowledged. Recommendations include further police training to enhance trust and reduce stigma, and wider integration of digitally-based substance use referral options.

Background: Concurrent with the opioid overdose crisis there has been an increase in hospitalizations among people with opioid use disorder (OUD), with one in ten hospitalized medical or surgical patients having comorbid opioid-related diagnoses. We sought to conduct a systematic review of hospital-based interventions, their staffing composition, and their impact on outcomes for patients with OUD hospitalized for medical or surgical conditions. Methods: Authors searched PubMed MEDLINE, PsychINFO, and CINAHL from January 2015 through October 2020. The authors screened 463 titles and abstracts for inclusion and reviewed 96 full-text studies. Seventeen articles met inclusion criteria. Extracted were study characteristics, outcomes, and intervention components. Methodological quality was evaluated using the Methodological Quality Rating Scale. Results: Ten of the 17 included studies were controlled retrospective cohort studies, five were uncontrolled retrospective studies, one was a prospective quasi-experimental evaluation, and one was a secondary analysis of a completed randomized clinical trial. Intervention components and outcomes varied across studies. Outcomes included in-hospital initiation and post-discharge connection to medication for OUD, healthcare utilization, and discharge against medical advice. Results were mixed regarding the impact of existing interventions on outcomes. Most studies focused on linkage to medication for OUD during hospitalization and connection to post-discharge OUD care. Conclusions: Given that many individuals with OUD require hospitalization, there is a need for OUD-related interventions for this patient population. Interventions with the best evidence of efficacy facilitated connection to post-discharge OUD care and employed an Addiction Medicine Consult model.

Background: Medications for opioid use disorder (MOUD) improve outcomes for pregnant women and infants. Our primary aim was to examine disparities in maternal MOUD receipt by family sociodemographic characteristics. Methods: This retrospective cohort study included mother-infant dyads with Medicaid-covered deliveries in Tennessee from 2009 to 2016. First, we examined family sociodemographic characteristics – including race/ethnicity, rurality, mother's primary language and education level, and whether paternity was recorded in birth records – and newborn outcomes by type of maternal opioid use. Second, among pregnant women with OUD, we used logistic regression to measure disparities in receipt of MOUD by family sociodemographic characteristics including interactions between characteristics. Results: Our cohort from Medicaid-covered deliveries consisted of 314,965 mother-infant dyads, and 4.2 percent were exposed to opioids through maternal use. Among dyads with maternal OUD, MOUD receipt was associated with lower rates of preterm and very preterm birth. Logistic regression adjusted for family sociodemographic characteristics showed that pregnant women with OUD in rural versus urban areas (aOR: 0.66; 95% CI: 0.60–0.72) and who were aged ≥35 years versus ≤25 years (aOR: 0.75; 95% CI: 0.64–0.89) were less likely to have received MOUD. Families in which the mother's primary language was English (aOR: 2.47; 95% CI: 1.24–4.91) and paternity was recorded on the birth certificate (aOR: 1.30; 95% CI: 1.19–1.42) were more likely to have received MOUD. Regardless of high school degree attainment, non-Hispanic Black versus non-Hispanic White race was associated with lower likelihood of MOUD receipt. Hispanic race was associated with lower likelihood of MOUD receipt among women without a high school degree. Conclusions: Among a large cohort of pregnant women, we found disparities in receipt of MOUD among non-Hispanic Black, Hispanic, and rural pregnant women. As policymakers consider strategies to improve access to MOUD, they should consider targeted approaches to address these disparities.

Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12–17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94–2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00–1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39–4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.

Background: Responses to problem substance use have largely focused on illicit drugs, but reports on rising prescription drug misuse worldwide raise questions about their combined use with alcohol and potential consequences. The current study assessed prevalence of alcohol in conjunction with nonmedical opioid and benzodiazepine use across a nationally representative sample of adults in Brazil. Methods: Cross-sectional data on prevalence were estimated from the 2015 Brazilian Household Survey on Substance Use. We estimated past month nonmedical use of benzodiazepines and alcohol and past month nonmedical use of opioids and alcohol among adults who reported any past-year alcohol use. Zero-inflated Poisson models assessed independent correlates of alcohol and nonmedical opioid use, and alcohol and nonmedical benzodiazepine use. Results: Among adults who reported past year alcohol use, 0.4% (N = 257,051) reported past month alcohol and non-medical benzodiazepine use, and 0.5% (N = 337,333) reported past month alcohol and non-medical opioid use. Factors independently associated with co-use of alcohol and benzodiazepines included having depression (adjusted prevalence ratio (aPR):4.61 (95%CI 1.76–12.08)), anxiety (aPR:4.21 (95%CI 1.59–11.16)) and tobacco use (aPR: 5.48 (95%CI 2.26–13.27)). Factors associated with past-month alcohol and opioid use included having experienced physical or a threat of violence (aPR: 4.59 (95%CI 1.89–11.14)), and tobacco use (aPR:2.81(95%CI:1.29–6.12)). Conclusions: Co-use of prescription drugs with alcohol remains relatively rare among Brazilians, but findings point to a unique profile of persons at risk. Results of this study are important in light of changing dynamics and international markets of prescription drugs and the need for more research on use of these substances on a global scale.

Background: The use of peer interventionists may be helpful in addressing problems associated with substance use disorders. However, implementation issues such as training, supervision, and the impact of delivering the intervention on the interventionists themselves require additional examination. This report describes the training methods and peer interventionist outcomes in a pilot study of a single-session Peer Recovery Support Services (PRSS) telephone intervention to facilitate enrollment in medication for opioid use disorder (MOUD) treatment. Methods: This was a secondary analysis of a pilot study testing a PRSS intervention in adults using illicit opioids who reported a recent non-fatal opioid overdose (N = 80, with 40 PRSS participants). Candidates recruited from MOUD treatment programs were trained to deliver the PRSS intervention. Assessments of adverse events, global health, and peer satisfaction were used to evaluate the effects of serving as an interventionist. Fidelity and proportion of cases enrolling in MOUD were calculated for each interventionist. Results: Four consented candidates were trained to deliver the PRSS intervention to thirty-six study participants (90% PRSS arm). All interventionists successfully maintained fidelity to the PRSS intervention and reported no negative effects. Interventionists experienced differential success in encouraging treatment enrollment ranging from 16%−60% of their cases. Conclusions: This pilot study demonstrates promise in utilizing peer interventionists to deliver a brief PRSS intervention with limited training and no reported negative effects on the interventionists themselves. Factors contributing to the differential success of the interventionists are unclear. Future research on the variable efficacy of peer interventionists is warranted to identify, quantify, and evaluate specific interactional elements associated with peer efficacy. Additionally, further evaluation of training, supervision practices, and the effects of serving as a PRSS interventionist, is needed. Trial Registration: Clinical Trials.gov http://www.clinicaltrials.gov; Identifier: NCT02922959

Background: Methadone and buprenorphine are effective medications for opioid use disorder (MOUD) that are highly regulated in the United States. The on-going opioid crisis, and more recently COVID-19, has prompted reconsideration of these restrictions in order to sustain and improve treatment access, with renewed interest in telemedicine. We reviewed the evidence on use of telemedicine interventions and applicability to MOUD policy changes in the post-COVID-19 treatment landscape. Methods: Ovid MEDLINE and the Cochrane Database of Systematic Reviews databases were searched from inception to April 2021 and reference lists were reviewed to identify additional studies. Studies were eligible if they examined telemedicine interventions and reported outcomes (e.g. treatment initiation, retention in care). Randomized trials and controlled observational studies were prioritized; other studies were included when stronger evidence was unavailable. One investigator abstracted key information and a second investigator verified data. We described the results qualitatively. Results: We identified nine studies: three controlled trials (two randomized), and six observational studies. Three studies evaluated patients treated with methadone and six studies with buprenorphine, including one study of pregnant women with OUD. All studies showed telemedicine approaches associated with similar outcomes (treatment retention, positive urine toxicology) compared to treatment as usual. Trials were limited by small samples sizes, lack of reporting harms, and most were conducted prior to the COVID-19 pandemic; observational studies were limited by failure to control for confounding. Conclusions: Limited evidence suggests that telemedicine may enhance access to MOUD with similar effectiveness compared with face-to-face treatment. Few studies have been published since COVID-19, and it is unclear the potential impact of these interventions on the existing racial/ethnic disparities in treatment. The COVID-19 pandemic and need for social distancing led to temporary policy changes for prescribing of MOUD that could inform additional research in this area to support comprehensive policy reforms.

Substance use disorder (SUD) organizations are often siloed, with little integration across specialty addictions treatment, primary care and hospitals, harm reduction, policy, and advocacy. COVID-19 introduced a pressing need for collaboration and leadership, given a fast-changing, high-stakes environment; widespread anxiety; and lack of guidance. This research letter describes our approach to convening and supporting leaders across the US state of Oregon's SUD continuum during the pandemic. We rapidly developed and implemented a SUD COVID Response ECHO, adapting ECHO – a telementoring model – to convene leaders across 32 statewide agencies. Our experience allowed participants to lead their agencies to respond to real-time COVID-related needs, address existing barriers within SUD systems, and build relationships and community across statewide SUD leaders. This kind of collaboration – which helped bridge gaps among the diverse agencies, disciplines, and regions addressing SUDs in the state – was long overdue, and sows seeds for long-term advances in care for people with SUD.

Background: Existing literature suggests that using stigmatizing language may promote negative attitudes and result in more punitive views toward individuals with addiction. It is unclear how the commonly used colloquial terms to describe opioid-exposed mother infant dyads impacts public opinion of pregnant women with opioid use disorder (OUD). We sought to examine the extent to which language such as “opioid addict” and “born addicted” influences the perception of pregnant women with OUD. Methods: We conducted a randomized case-based vignette study using a population-weighted sample of parents living in Tennessee, varying in the language used to describe an opioid-exposed mother infant dyad. Participant demographics, views on opioid prescribing, and opinions on criminal justice and child welfare responses following delivery were obtained. Ordinal logistic regression was used to examine the association between vignette type and punitive responses. Results: Eleven hundred participants completed the survey. Overall, 30.6% felt the mother should be arrested and 68.6% felt the mother should lose custody of her infant. There was insufficient evidence to suggest a difference in punitive response selection based on the vignette language (p = 0.27). In the adjusted model, the odds of answering a more punitive response among parents who received non-stigmatizing language was 0.8 (95% CI 0.59–1.08) compared to parents who received stigmatizing language in the vignette. Conclusions: Many parents hold punitive views toward mothers receiving OUD treatment that was not altered by using less value-laden language. Broader stigma-reduction interventions may be more effective.

Background: Medications for opioid use disorder (MOUD) are clinically effective at treating OUD among legal-involved populations. However, research shows that legal-involved veterans who receive care through the VHA have lower rates of MOUD use compared to non-legal-involved veterans. Education may be a key factor in intervention strategies to improve MOUD access. This study was a national survey of VHA staff to identify barriers to and facilitators of MOUD, as well as MOUD-related education needs for VHA staff, community partners, criminal justice partners, and legal-involved veterans. Method: A 98-item online survey was conducted to examine VHA staff perspectives (N = 218) around needed education, barriers to, and facilitators of MOUD for legal-involved veterans. Descriptive statistics were conducted and linear regression analyses were used to evaluate differences in perceptions by respondents’ current position at the VHA and their VHA facility's rate of provision of MOUD among legal-involved veterans. Results: Respondents endorsed a need for education in all areas of MOUD (e.g., existing medications for the treatment of OUD) for VHA staff and providers, community partners, criminal justice partners, and legal-involved veterans. VHA staff perceived barriers to MOUD for legal-involved veterans to include stigma and complicated guidelines around MOUD and OUD treatment. Facilities with low rates of MOUD use highlighted barriers including MOUD conflicting with the philosophy of the local VHA facility and provider stigma toward patients with OUD. Perceptions of efficacy of MOUD differed by respondents’ current position at the VHA such that substance use disorder treatment providers perceived buprenorphine and methadone as more effective compared to Veterans Justice Specialists. Conclusion: The results of this study suggest a need for an educational intervention emphasizing the evidence supporting use of MOUD as a lack of knowledge about these medications was considered a barrier to access, whereas gaining education about MOUD was a facilitator to access. Education strategies specifically tailored to address VHA facility-level differences may help address barriers to MOUD experienced by legal-involved veterans.

Background: Screening for unhealthy drug use is now recommended for adult primary care patients, but primary care providers (PCPs) generally lack the time and knowledge required to screen and deliver an intervention during the medical visit. To address these barriers, we developed a tablet computer-based ‘Substance Use Screening and Intervention Tool (SUSIT)’. Using the SUSIT, patients self-administer screening questionnaires prior to the medical visit, and results are presented to the PCP at the point of care, paired with clinical decision support (CDS) that guides them in providing a brief intervention (BI) for unhealthy drug use. Methods: PCPs and their patients with moderate-risk drug use were recruited from primary care and HIV clinics. A pre-post design compared a control ‘screening only’ (SO) period to an intervention ‘SUSIT’ period. Unique patients were enrolled in each period. In both conditions, patients completed screening and identified their drug of most concern (DOMC) before the visit, and completed a questionnaire about BI delivery by the PCP after the visit. In the SUSIT condition only, PCPs received the tablet with the patient's screening results and CDS. Multilevel models with random intercepts and patients nested within PCPs examined the effect of the SUSIT intervention on PCP delivery of BI. Results: 20 PCPs and 79 patients (42 SO, 37 SUSIT) participated. Most patients had moderate-risk marijuana use (92.4%), and selected marijuana as the DOMC (68.4%). Moderate-risk use of drugs other than marijuana included cocaine (15.2%), hallucinogens (12.7%), and sedatives (12.7%). Compared to the SO condition, patients in SUSIT had higher odds of receiving any BI for drug use, with an adjusted odds ratio of 11.59 (95% confidence interval: 3.39, 39.25), and received more elements of BI for drug use. Conclusions: The SUSIT significantly increased delivery of BI for drug use by PCPs during routine primary care encounters.

Background: Emergency department (ED) patients commonly experience both substance use and homelessness, and social relationships impact each in varied ways not fully captured by existing quantitative research. This qualitative study examines how social relationships can precipitate or ameliorate homelessness and the connection (if any) between substance use and social relationships among ED patients experiencing homelessness. Methods: As part of a broader study to develop ED-based homelessness prevention interventions, we conducted in-depth interviews with 25 ED patients who used alcohol or drugs and had recently become homeless. We asked patients about the relationship between their substance use and homelessness. Interviews were recorded, transcribed, and coded line-by-line by investigators. Final codes formed the basis for thematic analysis through consensus discussions. Results: Social relationships emerged as focal points for understanding the four major themes related to the intersection of homelessness and substance use: (1) Substance use can create strain in relationships; (2) Help is there until it's not; (3) Social relationships can create challenges contributing to substance use; and (4) Reciprocal relationship of substance use and isolation. Sub-themes were also identified and described. Conclusions: The association between substance use and homelessness is multifaceted and social relationships are a complex factor linking the two. Social relationships are often critical for homelessness prevention, but they are impacted by and reciprocally affect substance use. ED-based substance use interventions should consider the high prevalence of homelessness and the impact of social relationships on the interaction between homelessness and substance use.

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders’ feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.

Background: Mobile health (mHealth) interventions have the potential to improve substance use treatment engagement and outcomes, and to reduce risk behaviors among people who inject drugs (PWID). However, there are few studies assessing mobile technology use among PWID and none have investigated continuity of mobile phone use. Methods: We surveyed 494 PWID. We used bivariate (independent-sample t- and chi-square tests) and multivariate (logistic regression) analyses to determine whether mobile phone and/or internet use differed as a function of participant- and/or injection-related characteristics. Results: Most participants (77%) had a mobile phone, with 67% having a phone that was free of charge. Participants with a phone were significantly less likely to be homeless (AOR = 0.28), to have shared syringes (AOR = 0.53), and to have reused syringes (AOR = 0.26) in the past 3 months. We observed high rates of phone and number turnover, with more than half reporting that they got a new phone (57%) and/or number (56%) at least once within the past 3 months. Most participants were familiar with using the internet (80% ever use), though participants who had ever used the internet were younger (AOR = 0.89), were less likely to be homeless (AOR = 0.38), were less likely to have shared syringes (AOR = 0.49), and were more likely to have injected methamphetamine by itself (AOR = 2.49) in the past 3 months. Conclusions: Overall, mobile technology and internet use was high among our sample of PWID. Several factors should be considered in recruiting diverse samples of PWID to minimize bias in mHealth study outcomes, including mobile phone access and protocol type (text- vs internet-based).

Background: Research has shown that medications, especially opioid agonist treatments, are an effective way to treat opioid use disorder (OUD); however, negative attitudes held by health professionals contribute to their underutilization. Methods: A 23-year review of studies that examined health professionals’ attitudes toward medications for OUD (MOUD) was conducted to describe the current state of knowledge and to inform future research and interventions. Results: Studies examined attitudes toward the use of methadone, buprenorphine, and naltrexone among various types of health professionals: prescribers, non-prescribing clinicians, pharmacists, and administrators. The characteristics and findings of the included studies were reviewed and synthesized. Findings indicate that attitudes toward MOUD affect access and utilization by influencing prescribing practices, referrals, and adoption within programs. Exposure, knowledge, and treatment orientation were found to be important factors related to attitudes toward MOUD across multiple studies of various types of health professionals. Conclusions: To increase access and utilization, continued efforts are needed to increase positive attitudes toward MOUD among various types of health professionals. Findings indicate that interventions should seek to increase knowledge about MOUD and foster interprofessional communication related to MOUD, especially between prescribers and behavioral health providers.

Introduction: Suicide attempts have been associated with both cocaine use disorder (CocUD) and childhood trauma. We investigated how childhood trauma is an independent risk factor for serious and recurrent suicide attempts in CocUD. Method: 298 outpatients (23% women) with CocUD underwent standardized assessments of substance dependence (Diagnostic and Statistical Manual—mental disorders, fourth edition, text revised), impulsiveness, resilience, and childhood trauma, using validated tools. Suicide attempts history was categorized as single vs. recurrent or non-serious vs. serious depending on the lifetime number of suicide attempts and the potential or actual lethality of the worst attempt reported, respectively. Bivariate and multinomial regression analyses were used to characterize which childhood trauma patterns were associated with the suicide attempts groups. Results: 58% of CocUD patients reported childhood trauma. Recurrent and serious suicide attempts clustered together and were thus combined into “severe SA.” Severe suicide attempt risk increased proportionally to the number of childhood traumas (test for trend, p = 9 × 10⁻⁷). Non-severe suicide attempt risk increased with impulsiveness and decreased with resilience. In multinomial regression models, a higher number of traumas and emotional abuse were independently and only associated with severe vs. non-severe suicide attempts (effect size = 0.82, AUC = 0.7). The study was limited by its cross-sectional design. Conclusion: These preferential associations between childhood trauma and severe suicide attempts warrant specific monitoring of suicide attempts risk in CocUD, regardless of the severity of addiction profiles.

Background: In the United States, methadone for treatment of opioid use disorder is dispensed via highly-regulated accredited opioid treatment programs (OTP). During the COVID-19 pandemic, federal regulations were loosened, allowing for greater use of take-home methadone doses. We sought to understand how OTP leaders responded to these policy changes. Methods: We distributed a multistate electronic survey from September to November 2020 of OTP leadership to members of the American Association for the Treatment of Opioid Dependence (AATOD) who self-identified as leaders of OTPs. We asked study participants about how their OTP(s) implemented COVID-19-related policy changes into their clinical practice focusing on provision of take-home methadone doses, factors used to determine patient stability, and potential concerns about increased take-home doses. We used Chi-square test to compare survey responses between characterizations of the OTPs. Results: Of 170 survey respondents (17% response rate), the majority represented leadership of for-profit OTPs (69%) and were in a Southern state (54%). Routine allowances and practices related to take-home methadone doses varied across OTPs during the COVID-19 pandemic: 80 (47%) reported 14 days for newly enrolled patients (within past 90 days), 89 (52%) reported 14 days for “less stable” patients, and 112 (66%) reported 28 days for “stable” patients. Conclusions: We found that not all eligible OTP leaders adopted the practice of routinely allowing newly enrolled, “less stable,” and “stable” patients on methadone to have increased take-home doses up to the limit allowed by federal regulations during COVID-19. The pandemic provides an opportunity to critically re-evaluate long-established methadone and OTP regulations in preparation for future emergencies.

Background:Whereas the increased use of substances in sexual and gender minority (SGM) samples has been well documented, further person-centered analyses are necessary to better understand the unique profiles of SGM individuals and substance use. Methods: Utilizing a sample of 1,852 SGM emerging adults (M_age = 23.31) recruited via Prolific, a latent profile analysis was conducted to determine profiles of ecological systems using self-esteem, hope for the future, minority group connection, and a history of childhood adverse experiences. These profiles were then used to explore intergroup differences in the use of substances (alcohol, cannabis, prescription opioids, hallucinogens, heroin, tobacco, and amphetamines). Results: Four profiles were identified in this sample: (1) moderate with low self-esteem (47.8%), (2) connected with low adversity (30.9%), (3) moderate with high self-esteem (11.5%), and (4) disconnected with adversity (9.7%). Significant differences between profiles in the frequency of use were found in all substances except for cannabis and hallucinogens. Of note, participants in the connected with low adversity profile reported significantly more frequent alcohol use (M = 3.30) compared to the disconnected with adversity (M = 2.89) and the moderate with low self-esteem (M = 2.96) profiles. Additionally, the disconnected with adversity profile reported significantly more frequent tobacco use (M = 1.99) compared to all other profiles. Conclusion: With a majority of the sample fitting profiles marked by mental health concerns, the present study indicates the need to identify and address risk and protective factors for SGM emerging adults’ substance use and highlights differences within the larger SGM community. Implications for improving mental health are described.

Background: Opioid misuse during pregnancy has been associated with adverse infant outcomes including preterm birth, stillbirth, and neonatal opioid withdrawal syndrome. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an on-going state-based surveillance system of maternal behaviors, attitudes, and experiences prior to, during, and after pregnancy. Methods: We analyzed qualitative comments related to opioid use during pregnancy collected in 2016 from an open-ended prompt at the end of the PRAMS survey in 35 states (N = 40,408). Key word searches were conducted on the open-ended responses (n = 9,549) to identify opioid-related content with an automated function using Microsoft Excel. All responses from the initial screening (n = 1,035) were manually reviewed, and 69 responses were confirmed to relate to the respondent's personal experience with opioid use during pregnancy. Content analysis was conducted by 3 independent coders; key themes were compiled, discussed, and finalized by the coding team. Results: Five key themes related to opioid use during pregnancy were identified: (1) gratitude for treatment, recovery, and healthy infants; (2) pregnancy as motivation to seek treatment; (3) difficulty finding prenatal care providers with training in substance use disorders; (4) concern about the effects of treatment on the infant; and (5) experiences of discrimination and stigma in the hospital around the time of delivery. Conclusions: Women may be aware of the potential impact of opioid use during pregnancy on the health of their infants and motivated to seek treatment. Findings may help inform new and ongoing initiatives designed to improve care and reduce stigma for women needing or seeking treatment.

Background: Research shows significant associations of major depression with cannabis and binge alcohol use. However, despite increasing cannabis and binge alcohol use rates among the 50+ age group, research on this age group is scant. Methods: We used the 2015–2019 National Survey on Drug Use and Health data (n = 44,007 age 50+) and multinomial logistic regression models to examine associations of a major depressive episode (MDE) with cannabis and binge alcohol use and co-use and associations of binge alcohol use with nonmedical and medical cannabis use. Results: Of individuals age 50+, 89.6% had no history of MDE, 5.7% had prior-to-past-year MDE, and 4.7% had past-year MDE. The rates of past-month cannabis use were 4.3%, 7.7%, and 11.6% and binge alcohol use were 17.3%, 18.7%, and 19.9% among those with no MDE history, prior-to-past-year MDE, and past-year MDE, respectively. Compared to no MDE history, prior-to-past-year MDE (RRR = 1.70, 95% CI = 1.30–2.23) and past-year MDE (RRR = 1.80, 95% CI = 1.27–2.55) were significantly associated with past-month cannabis use (with or without binge alcohol use). However, MDE status was not associated with past-month binge alcohol use. Among cannabis users, binge alcohol use was significantly associated with nonmedical cannabis use only (RRR = 2.50, 95% CI = 1.95–3.21). Users of cannabis and/or binge alcohol also had a higher likelihood of using tobacco products and illicit drugs. Conclusions: Healthcare professionals treating individuals age 50+ with depression should screen for substance use, provide education on the potential adverse effects of polysubstance use, and help them access treatment for co-occurring depression and substance use problems.

Background:Our study explored whether latent classes adequately represented the social capital recovery indicators at the resident level and whether latent class membership predicted subsequent exits from the recovery homes. Method: Our sample included about 600 residents in 42 recovery homes. Over a 2-year period of time, every 4 months, data were collected on eight elements of recovery capital. Results: We found 5 latent classes were optimal for representing 8 elements of recovery capital. Representing 79% of the sample, 3 of the 5 latent class profiles of the means of the 8 recovery indicators were roughly parallel and differed only in level, but the remaining 2 latent class profiles, representing 21% of the sample, were not parallel to the first 3, suggesting that a single quantitative dimension of perceived recovery may capture most but not all of the important details of the recovery process. Next, using longitudinal data from homes, the distal outcomes of resident eviction and voluntary exit were found to be related to latent class membership. Resident level pre-existing predictors (e.g., employment status, educational attainment, gender, Latinx ethnicity) and house level pre-existing predictors (e.g., financial health, poverty level of typical population served, new resident acceptance rate) significantly discriminated the classes. In a model that combined both pre-existing predictors and distal outcomes, latent class membership was still the strongest predictor of evictions controlling for the pre-existing predictors. Conclusions: These classes help to clarify the different aspects of the recovery latent score, and point to classes that have different ethnic and gender characteristics as well as outcomes in the recovery homes. For example, the high levels of self-confidence found in class 3 suggest that Latinx might be at higher risk for having some difficulties within these recovery communities.

Background: Front-line providers working with people who inject drugs (PWID) are at increased risk of experiencing burnout. Few studies have examined protective factors against burnout incurred in the care of PWID, including harm reduction counseling skills. We measured self-efficacy in harm reduction counseling, burnout, and compassion satisfaction among Internal Medicine (IM) trainees caring for PWID. Methods: In this cross-sectional study, we surveyed IM interns and residents. Self-efficacy was assessed by asking trainees about attitudes, comfort, and knowledge in harm reduction counseling on a five-point Likert scale. Burnout and compassion satisfaction were assessed via an adapted 20-question Professional Quality of Life Scale. We compared self-efficacy in harm reduction counseling, compassion satisfaction, and burnout between interns and residents using ANOVA and Mann–Whitney U tests. We used Spearman's rho correlational analysis to examine the relationship between these three variables. Results: Seventy-nine IM trainees (36 interns, 43 residents) completed the survey for a 52% response rate. Residents reported higher self-efficacy in harm reduction counseling, similar levels of burnout, and higher compassion satisfaction compared to interns. Across training levels, we found a negative correlation between burnout and compassion satisfaction (r = −0.55, p < 0.01) and a positive correlation between compassion satisfaction and comfort counseling PWID on harm reduction (r = 0.30, p < 0.01). Conclusions: Among IM trainees at an urban institution serving a large population of PWID, self-efficacy in harm reduction counseling and compassion satisfaction increase with time in training while burnout remains similar. Strengthening trainees’ capacity to counsel PWID on harm reduction may improve their compassion satisfaction in caring for this population, potentially leading to improved care. This relationship should be explored longitudinally in larger cohorts and through evaluations of harm reduction-focused medical education.

Background: Travel distance to medication treatment for opioid use disorder (OUD) is a challenge for many patients, but little is known about how distance is associated with medication treatment utilization. This study examines the association between distance to the nearest physician waivered to prescribe buprenorphine and patient-level buprenorphine treatment among West Virginia Medicaid expansion enrollees with diagnosed OUD. Methods: We conducted a cross-sectional spatial analysis with 2016 Medicaid claims data, separately examining individuals living in metropolitan and non-metropolitan areas. We calculated the driving distance from the centroid of patients’ residential ZIP codes to the street address of the nearest waivered physician derived from the 2015 Drug Enforcement Administration listing. Regression models examined the association between distance and initiation and duration of buprenorphine (among those initiating). Results: We focused on 8,008 individuals with OUD in 2016. The nearest waivered prescriber in metropolitan areas was an average of 7.13 miles away from patients’ residential ZIP codes and 14.54 miles in non-metropolitan areas. The providers they actually visited were a mean of 33.63 miles away in metro areas and 46.36 in non-metropolitan areas. In multivariable analyses, compared to those living <10 miles from a waivered physician, living >20 miles from a waivered physician was associated with −32.13 fewer days of treatment (95% CI: −57.86, −6.40) in metro areas and −16.70 fewer days in non-metro areas (95% CI: −32.32, −1.08). Conclusions: Longer travel distance to buprenorphine treatment is associated with a shorter duration of care that is likely to be clinically meaningful.

Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.

Background: Relatively few Americans with current alcohol or drug use disorders receive outpatient or residential treatment. Outreach initiatives at local places of religious worship have been proposed as a way of facilitating such service use, but the number and characteristics of adults who may be reached in this way has not been studied. Methods: Data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions-III, a nationally representative cross-sectional survey of U.S. adults were used to estimate the number of and proportion of adults with substance use disorders (SUDs) who attended monthly religious service and did not receive SUD treatment in the past year and used multinomial logistic regression to compare them to three SUD groups who did or did not receive treatment and/or attend religious services. Results: A total of 5,795 respondents representing 35.8 million Americans met criteria for a past-year SUD, of whom 8.3 million (23.1%) attended religious services monthly and did not receive substance use treatment. This more often African-American group had substantially fewer socio-demographic disadvantages (e.g., unemployment), behavioral problem indicators (e.g., police involvement), a higher quality of life score and less likelihood of an illicit drug use diagnosis than those who received treatment and either did or did not attend religious services. Conclusion: Almost one quarter of adults with a SUD attend religious services monthly and do not receive SUD treatment. Although they have fewer adversities than people who receive treatment, outreach to this population may link this substantial group of people to needed services.

National survey data suggest 8 of 36 million Americans with substance use diagnoses’ (23%) do not receive specialized SUD treatment, but they do attend religious services monthly or more.

Background: COVID-19 is disproportionately affecting disadvantaged populations, including persons with opioid use disorder (OUD). Persons with OUD are at greater risk for direct (e.g., COVID-19 diagnosis, severe symptoms) and indirect consequences (relapse, overdose) of COVID-19. Given stay at home orders, at-home testing options may serve as a viable tool to curb the increase in COVID-19 transmission and adverse effects of COVID-19. Methods: From May to September 2020, we surveyed 110 persons in treatment for OUD about their willingness to use various self-administered at-home COVID-19 testing measures. Participants were stratified by age, gender, and racial-ethnic identity to observe differences in willingness to use COVID-19 tests. The three COVID-19 tests included a throat swab sample, a saliva-based sample, and a blood prick test. Results: A high willingness to use at-home COVID-19 tests was observed in patients in treatment for OUD. A greater proportion of females were willing to use a saliva-based test; greater proportions of White participants were willing to use a saliva based COVID-19 test compared to racial-ethnic minorities. Older aged participants (≥45 years old) reported greater rates of willingness to use a self-administered at home blood prick test for COVID-19. Conclusions: At-home testing measures for COVID-19 appear highly acceptable among people with OUD.

Background: High-intensity drinking (HID; 8+ U.S. standard drinks for women, 10+ men) is initiated during adolescence/emerging adulthood, increasing risk for negative outcomes, including blackouts. We examined baseline data from a study of risky drinking youth to identify factors associated with HID. Methods: Risky drinkers (ages 16–24) were recruited online (positive 3-month AUDIT-C score) as part of a larger study to examine social media interventions for risky drinking. We used baseline survey data to examine HID in relation to demographics, substance use–related variables, and individual and social factors. Results: Among 931 risky drinkers, 29.8% reported past-month HID, and those with HID reported greater substance use and consequences. In multivariable analysis, HID was associated with male sex; greater social motives, impulsivity, and motivation; lower self-efficacy; and greater likelihood of not living with parents, drinking with important peers, and parental disapproval of posting drinking pictures. When examining age group interactions (16–20; 21–24), underage drinkers with high sensation-seeking scores and lower parental disapproval of posting drinking pictures on social media reported greater HID. Conclusions: Among risky drinking youth, male sex, social motives, impulsivity, higher motivation to and lower-self-efficacy to reduce drinking, living away from parents, more frequent drinking with important peers, and lower parental disapproval of posting drinking pictures on social media were positively associated with HID. Further, HID was associated with greater health consequences, underscoring the need for HID interventions. Such interventions may benefit from enhancing motivation and self-efficacy, particularly in social contexts, as well as increasing positive peer and leisure activities to reduce HID.

Background Studies have consistently found high rates of unintended pregnancy among women with opioid use disorder (OUD). Few interventions have been developed to specifically engage and address the family planning (FP) needs of women in substance use disorder treatment. Objectives: Our goal was to collect formative qualitative data to identify the FP experiences, needs and service preferences of women receiving medications for OUD and to use these data to develop a FP education and navigation intervention that could be tested in diverse, resource-limited treatment settings. Methods: From August 2016 to April 2017, we conducted 21 guided qualitative interviews with women from two outpatient treatment clinics in Denver, Colorado. We recorded, transcribed, and coded all interviews. We then facilitated three focus groups (n = 16) from May to July 2017 to verify or challenge interview themes and to further inform the development of the FP intervention. Results: Most participants expressed ambivalence or low perceived risk regarding unintended pregnancy and desired more information about contraceptive methods. Many participants described mistrust or lack of engagement in the medical system and histories of trauma were a common barrier to seeking services. Focus group participants endorsed a peer-led FP navigation intervention and provided feedback to tailor existing FP educational materials to fit the specific needs of women in recovery. Conclusions/Importance: Results from this qualitative study suggest that women in recovery from OUD have unique, unmet FP education and service needs. These findings provide important information for the development of feasible and acceptable FP service delivery within diverse, resource-limited treatment settings and informed the development of a trauma-informed, peer-led FP education and navigation intervention that would be implemented in a subsequent phase of the study.

Background: Co-use of cannabis and tobacco is common and increases negative behavioral, physical and mental health consequences. This study aimed to describe latent profiles of youth internalizing and externalizing problems, sensation seeking, and family environment in the US and their relationships with substance co-use. Methods: Data come from the Population Assessment of Tobacco Health (PATH). Using latent profile analysis with a distal outcome, we conducted a secondary data analysis examining relationships between latent profiles and the distal outcome of cannabis/tobacco use and co-use one year later. Participants were a nationally representative sample of youth ages 12–17 (N = 13,651). Results: We identified five youth subgroups: (1;11%) Family Risk, (2;32%) Family Protection with Very Low Internalizing, (3;21%) Family Protection with High Youth Risk, (4;24%) Family Protection with Moderate Youth Risk, (5;12%) Family Risk with High Youth Risk. Relationships between group membership and tobacco/cannabis outcomes, one year later, indicated that the least likely tobacco/cannabis users were the Family Protection with Very Low Internalizing class (no lifetime use probability (PR)=0.86, standard error (SE)=0.007; no 30-day use PR = 0.96, SE = 0.004). In contrast, the Family Risk with High Youth Risk class had the highest probability of both co-use (lifetime co-use PR = 0.33; SE = 0.014; 30-day co-use PR = 0.10; SE = 0.010) and single substance use (probability of lifetime single substance use PR = 0.30; SE = 0.013; 30-day single substance use PR = 0.24; SE = 0.014). Conclusions: A “protective but reactive” risk buffering pattern effect of family factors on youth factors was observed in that the lowest rates of co-use were observed in the three classes with family protection. These findings highlight the need for interventions addressing multiple domains and focusing on youth and family risk factors.

Background: In the U.S., medications for opioid use disorder (MOUD) include methadone, buprenorphine, and naltrexone. Despite substantial evidence of efficacy, the use of MOUD by health professionals remains controversial. This scoping review sought to identify and describe policies related to the use of MOUD by physicians, pharmacists, and nurses in professional health programs (PHP). Methods: A systematic search of PubMed, Medline, Web of Science, and Google Scholar was performed in August 2020 to identify pertinent articles from the U.S. which were then evaluated for inclusion by a team of trained reviewers. Results: Nine articles were ultimately identified for inclusion, and their years of publication ranged from 1984 to 2012. The treatment of physicians was addressed in seven articles, nurses in four, and pharmacists in two. Data from one veterinarian and several dentists could not be disaggregated from three studies. Naltrexone was the most commonly accepted form of MOUD within PHPs. A 2011 survey of physician and nurse PHP administrators found that 11/22 (50%) physician programs and 15/33 (45%) nursing programs forbade practice reentry while taking buprenorphine with the remainder indicating it could be allowed under some circumstances. The use of methadone within PHPs was extremely rare, and no specific details regarding PHP policies related to its use or practice reentry could be identified. No articles reported specifically on practice reentry policies for pharmacists. Conclusions: This scoping review identified one article detailing explicit policies concerning MOUD use in the target professions. Implicit policies extrapolated from other articles found that naltrexone was the most commonly accepted form of MOUD, with methadone and buprenorphine being avoided due to dubious concerns of impairment. A unified, contemporary, comprehensive survey of current PHP policies and evaluation of actual treatment data to ascertain real-world practices is needed.

Background: Individuals with substance use disorder (SUD) may be particularly at risk during the COVID-19 pandemic. The purpose of this study was to examine attitudes to the pandemic among individuals with SUD. Methods: Survey responses from 266 patients entering a residential treatment program were analyzed. Results: Most participants were White or African American men. A third of participants reported that their substance use had increased during the pandemic (38%), and that they had stockpiled substances because of concerns about supply (30%). A majority of participants indicated more depression (60%), anxiety (61%), worry about finances (62%), and feeling worse about their substance use due to COVID-19 (67%). An exploratory factor analysis revealed five factors that measured interest in SUD treatment, psychological symptoms, adherence to health recommendations, perceptions of vulnerability to COVID-19, and substance use during COVID-19. African American participants indicated a greater interest in treatment than Whites, while White participants indicated increased symptoms and substance use during COVID-19 (p < .05). Further, African Americans were more likely to have known someone who had developed COVID-19 than whites (p < .05). Older participants indicated adhering to health recommendations more than younger participants, using substances less than younger participants, as well as feeling more vulnerable to COVID-19 (p < .05). Conclusions: This is the first study to examine patient attitudes and behaviors related to COVID-19 at a residential SUD treatment program. Treatment providers should be aware of patient attitudes and behaviors related to COVID-19 paying special attention to barriers to treatment engagement.

Background: Opioid agonist therapy with buprenorphine is an effective, evidence-based treatment for opioid use disorder. However, there has been increasing use of alternative substances which can still produce opioid-like effects. One of these substances is the herbal supplement kratom. The chemical composition of kratom, specifically mitragynine and 7-hydroxymitragynine, has partial mu-opioid receptor agonist and antagonist effects at the kappa- and delta-opioid receptors. Due to its addictive potential, accessibility, and legal status, there have been increasing cases of kratom use disorder (KUD). Thus, it is important to consider effective treatment options for this nontraditional substance. Methods: Twenty-eight patients self-identified kratom as their primary substance of use. Length of kratom use ranged between 1 month and 25 years, with an average daily kratom dose of 92 g/d. Nine patients were inducted on a buprenorphine/naloxone dose between 1 and 6 mg, 18 patients between 8 and 16 mg, and 1 patient at 20 mg. Three patients were stabilized on a dose at 4 mg, 23 patients between 8 and 16 mg, 1 patient at 18 mg, and 1 patient at 20 mg. Results: There was no correlation between stabilizing dose of buprenorphine/naloxone and past daily dose of kratom. As of March 2020, 20 of the 28 patients were still receiving outpatient buprenorphine/naloxone treatment. Six patients were lost to follow-up due to missed appointments, 1 tapered down to 0.25 mg of buprenorphine/naloxone and self-discharged, and 1 moved out of town. The rest have remained in treatment from 5 to 22 months, with an average duration of 11 months. Of the 28 patients, 68%, 82%, and 82% had negative test results for mitragynine at 4, 8, and 12 weeks of treatment, respectively. Conclusions: To our knowledge, this is the largest case series exploring long-term buprenorphine/naloxone treatment for KUD. Our findings suggest buprenorphine/naloxone can be used as an effective treatment option for KUD.

Background: Buprenorphine availability for the treatment of opioid use disorders (OUD) has expanded in the United States. Programs that previously offered only methadone treatment to patients with OUD now offer an equal choice between buprenorphine and methadone at the same location, yet little is known about patient preferences for buprenorphine over methadone in these settings. We sought to understand the decision-making factors and motivations underlying why patients opt for buprenorphine over methadone for the treatment of OUD when both are offered in a safety-net hospital-based opioid treatment program (OTP). Methods: We conducted semi-structured, qualitative interviews with patients receiving buprenorphine, in which we asked about substance use and treatment history, reasons for choosing buprenorphine, advantages, and disadvantages of choosing buprenorphine, and what they would like to change in their treatment experience. Results: Participants had varied exposure to buprenorphine prior to their current treatment, ranging from none to years of experience in multiple settings. Increased flexibility with take-home doses was a widespread motivation for choosing buprenorphine over methadone. Participants described decreased sedation and greater effectiveness in preventing opioid use compared to methadone as advantages during their treatment with buprenorphine. Difficulty with the transition to buprenorphine was a noteworthy challenge for many. Conclusions: Overall, patients maintained on buprenorphine at an urban safety-net hospital OTP viewed their treatment favorably compared to methadone. Increased autonomy in light of federal regulation differences and an improved physical profile were significant decision-making factors, although the number of patients choosing buprenorphine at the OTP remained low. Targeted patient education about induction and focus on improving structural barriers such as dosing efficiency may enhance patient experiences.

Background A growing challenge in the opioid epidemic is the rise of highly potent synthetic opioids, (i.e., illicitly manufactured fentanyl [IMF]) entering the US non-prescription opioid market. Successful reversal may require multiple doses of naloxone, the standard of care for opioid overdose. We conducted a narrative literature review to summarize the rates of multiple naloxone administrations (MNA) for opioid overdose reversal. Methods: A MEDLINE search was conducted for published articles using MESH search terms: opioid overdose, naloxone and multiple naloxone administration. Of the 2,101 studies identified, articles meeting inclusion/exclusion criteria were reviewed, categorized by primary and secondary outcomes of interest and summarized by data source and study design. Results: A total of 24 articles meeting eligibility criteria were included. Among EMS-based studies, MNA rates ranged from 9% to 53%; in general, bystander-reported studies were notably higher, from 16% to 89%. Variation in study design, data sources, year and geography, may have contributed to these ranges. Three studies that included longitudinal results reported a significant percent increase between 26% and 43% in annual MNA rates or a significant increase in mean naloxone doses over time (p < .001). Conclusions: This summary found that multiple naloxone administrations during opioid overdose encounters vary widely, have occurred in up to 89% of all opioid overdoses, and have significantly increased over time. Higher naloxone formulations may fulfill an unmet need in opioid overdose reversals, given the rising rates of overdoses involving IMF. Further studies are needed to gain a better understanding of MNA during opioid overdose encounters, particularly across a wider geographic region in the US in order to inform continuing efforts to combat the opioid epidemic.

Background: Nightlife attendance is an established risk factor for drug use, but studies have not focused on adolescent general population samples or compared risk according to type(s) of venues attended. We examined whether attendance of various types of venues was associated with drug use. Methods: Data were examined from an annual nationally representative survey of high school seniors in the US (2014–2019, N = 11,565). We determined whether past-year attendance of parties, concerts, bars or nightclubs, and raves or dance music events was associated with past-year drug use using mixed-effects logistic regression. Mall and movie attendance were examined as negative controls. Results: Compared to those who reported not attending specific venues, attending parties was associated with higher odds of using alcohol in particular (aOR = 5.03, 95% CI: 3.92–6.44). Attending concerts was associated with higher odds for use of alcohol, cannabis, ecstasy, and nonmedical use of prescription stimulants and opioids. All drugs examined were concentrated among those who attend bars, nightclubs, raves, and dance parties. Rave or dance party attendance was associated with higher odds for use of ecstasy (aOR = 3.71, 95% CI: 2.50–5.50) and methamphetamine (aOR = 4.92, 95% CI: 2.43–9.96) in particular, and bar or nightclub attendance was associated with higher odds of use of cocaine (aOR = 6.49, 95% CI: 4.37–9.63), ecstasy (aOR = 6.49, 95% CI: 4.54–9.27), and methamphetamine (aOR = 5.49, 95% CI: 2.57–11.72) in particular. Attending movies was associated with lower odds for use of cocaine and nonmedical prescription stimulant use. Conclusion: We determined differential risk of drug use depending on types of venues attended by adolescents.

Background: Pregnant and postpartum women with substance use disorders are a highly vulnerable population, especially when this is compounded by homelessness or unstable housing, justice involvement, and/or co-occurring mental health challenges. The MIRRORS (Maternal Initiative for Reflective Recovery-Oriented Residential Services) program provided expanded and enhanced residential substance use disorder treatment, prevention and recovery support for women and children through integrated, trauma-informed care and services strengthened by a comprehensive and coordinated family systems approach. This paper describes the program and provides evaluation of the outcomes. Methods: Pregnant and postpartum women (n = 215) were assessed at 3 time points: intake, discharge and 6-months post-intake using standardized measures of family functioning, parenting, recovery capital, and other outcomes. Multilevel modeling was employed to examine individual differences in trends over time. Results: Over 80% of participants reported that the MIRRORS program enhanced their recovery treatment experience. Women reported significant improvements in general family functioning, problem solving, behavioral control, affective responsiveness, and communication. Participants also reported increased recovery capital and improved parental monitoring over time. Conclusions: Outcomes indicate that the MIRRORS program was effective in improving family functioning and reducing substance use, thus enhancing women's functioning and recovery.

Background: Two Way Prayer Meditation (TWPM) is a spiritual intervention that holds promise for improving the psychospiritual well-being of individuals in recovery from substance use disorders (SUD). This study aimed to identify moderators of TWPM's treatment effects. Moderators tested included gender, race/ethnicity, age, education, religious/spiritual affiliation, and most often used substance. Methods: This study employed a randomized controlled trial design with pretest and posttest. In total, 134 adults in four residential recovery programs participated in the study and were randomly assigned to the TWPM group or the treatment as usual control group. Linear mixed modeling was used to assess the moderating effect of each hypothesized moderator in the form of interaction tests. Sensitivity analyses were conducted by excluding cases with more than a minimum number of missing items. Results: There were no significant moderators for psychological distress, self-esteem, and most of the spiritual well-being outcomes. Both the primary and sensitivity analyses showed education significantly moderated TWPM's effect on overall spirituality self-ranking. Specifically, TWPM's positive effect on overall spirituality self-ranking was greater in the master's degree subgroup than in the less than high school subgroup. Conclusion: TWPM's treatment effects on most outcomes were not found to vary by the tested participant characteristics. The only statistically significant finding suggests clinicians may need to adjust TWPM workshop/teaching content, delivery style, or language used to reach clients with lower levels of education. Future better-powered studies are recommended to continue exploring the potential moderating effects of race/ethnicity, education, spiritual/religious affiliation, and most often used substance.

Background: To evaluate how an international one-year intensive research training program for addiction medicine physicians contributed to subsequent research involvement and productivity. Methods: We prospectively compared addiction medicine physician fellows admitted to a one-year training program with non-admitted controls, using baseline questionnaire and peer-reviewed publication data. Participants’ publication activity was assessed from fellowship application date onwards using biomedical databases (e.g., PubMed, Embase). Results: Between July 2014 and June 2020, which is six years of cohorts, 56 (39 women) physicians, both fellows (n = 25) and non-admitted applicants (n = 31), were observed and included in the study, contributing 261 person-years of observation. At baseline, in the fellows’ cohort: 76% of participants (19/25) reported past research involvement, 24% (6/25) had one or more advanced graduate degrees (e.g., MPH), and the median number of peer-reviewed, first author publications was one (Interquartile Range [IQR] = 0–2). At baseline, in the controls’ cohort: 84% of participants (26/31) reported past research involvement, 39% (12/31) had one or more advanced graduate degrees, and the median number of peer-reviewed, first author publications was zero. The physicians’ training included internal medicine (n = 8), family medicine (n = 33), psychiatry (n = 5) and others (n = 4). At follow up, there was a significant difference between fellows (n = 25) and controls (n = 31) in total number of publications (Rate Ratio [RR] = 13.09, 95% Confidence Interval [CI], 5.01 − 34.21, p < 0.001), as well as first author publications (RR = 5.59, 95% CI, 2.23 − 14.06, p < 0.001). Conclusion: In the six-year observation period, fellows’ productivity indicates undertaking this fellowship was associated with significant research outputs in comparison to controls, signaling successful training of addiction physicians to help recruit addiction medicine physicians to participate in addiction research.

Background: Despite literature documenting disparities in tobacco use among sexual minority young adults, research is just emerging regarding alternative tobacco product (ATP) use among specific sexual minority men versus women. The current study examined associations between sexual orientation and traditional and ATP use among young adult men and women. Methods: We analyzed survey data (September–December 2018) from 2,809 young adults (ages 18–34) recruited via social media. Multivariable regression models were used to examine the binary outcomes of any past 30-day use of cigarettes, e-cigarettes, cigars, hookah, and any tobacco product (logistic regression), and the continuous outcome of number of categories of tobacco products used (linear regression), in relation to sexual orientation (bisexual, gay/lesbian, heterosexual) among men versus women, controlling for age and race/ethnicity. Results: In this sample (M_age = 24.60, SD = 4.73; 56.0% women, 71.5% White, 5.4% Black, 12.6% Asian, 11.5% Hispanic), 9.3% of participants identified as gay/lesbian (13.1% of men, 6.2% of women) and 17.6% bisexual (8.3% of men, 25.0% of women). Gay men were less likely to use e-cigarettes, cigars, and any tobacco product, and used fewer products relative to heterosexual men. Bisexual women were more likely to use each tobacco product and any tobacco product, and used more categories of products relative to heterosexual women. Conclusions: Specific tobacco use disparities differ with respect to type of product, gender, and sexual orientation, underscoring the need to better understand the underlying mechanisms of these differences (e.g., marketing, social influences) and developing interventions to address them.

Background: Addressing the opioid crisis requires an understanding of how to train both health professional students and practicing clinicians on medications for opioid use disorder (mOUD). We designed a robust evaluation instrument to assess the impact of training on perceived clinical knowledge in these different categories of learners. Methods: We enrolled 3rd and 4th year medical, physician assistant (PA), and nurse practitioner (NP) students, as well as practicing PAs, NPs, and physicians to undertake the Drug Addiction Treatment Act (DATA) Waiver Training for mOUD. We designed and implemented a cross-sectional survey to assess perceived change in clinical knowledge as a result of training in opioid use disorder and satisfaction with training. Results: Twenty-one MD/DO and 45 NP/PA students, and 24 practicing MD/DO and 27 NP/PAs completed the survey. Among health professional students (n = 66) and practicing clinicians (n =51), perceived clinical knowledge scores increased significantly (p < 0.001) for all 13 variables. Program evaluation scores for the buprenorphine waiver training were high with no statistical differences between students and practicing clinicians. Overall, the majority of participants indicated they would recommend the training to a colleague (Students’ score = 4.84; practicing clinician scores = 4.53; scale = strongly disagree = 1 to strongly agree = 5). Conclusions: Our novel instrument allowed us to determine that the implementation of buprenorphine waiver trainings for health professional students and practicing clinicians leads to significant increases in perceived knowledge, interest and confidence in diagnosing and treating OUD. Although the buprenorphine waiver can now be obtained without training, many waivered providers still do not prescribe buprenorphine; integrating training into medical, NP, and PA curriculum for students and offering the training to practicing clinicians may increase confidence and uptake of mOUD.

Background: There is an alarming shortage of addiction psychiatrists in the United States. To promote interest in addiction psychiatry (ADP), it is essential to maximize resources available through ADP fellowship websites. The aim of this study was to investigate the perceived adequacy and accessibility of content on ADP fellowship websites and discover what further information is considered important among trainees interested in becoming addiction specialists. Methods: Three virtual focus groups were conducted between January and February 2021 among medical students and residents in diverse geographic regions. Participants were asked about the availability of information on ADP fellowship program websites and other material they would like to see available. Focus groups were recorded, with data transcribed and coded using NVivo 11 and Dedoose. A coding scheme was deductively developed based on the core research questions. Results: The majority of participants (N = 27) identified areas of dissatisfaction with the content currently available on ADP websites. The sample was highly representative of racial and ethnic minoritized trainees (n = 12) and genderqueer/non-binary participants (n = 3). Three major themes were identified and durable across all focus groups: lack of emphasis on diversity/health equity, lack of portrayal of everyday life and activities of fellows, and inadequate representation of curricula. Overwhelmingly, participants identified a dedication to health equity (for example, working with minoritized populations) as a key deciding factor in whether to apply to a particular ADP fellowship. Conclusions: ADP fellowship websites are perceived to have considerable variability in the amount and quality of information. Many do not appear to provide the full spectrum of content desired by diverse potential applicants, such as information regarding current fellows and community-centered initiatives. This is concerning, as it suggests ADP fellowships may be interfacing poorly with burgeoning leaders, especially those from race and gender minoritized backgrounds, neglecting potential opportunities to develop future addiction specialists.

Background: Case identification for many areas of opioid research and surveillance in the emergency department (ED) is challenging as patients are often undifferentiated with nonspecific symptoms and diagnostic codes have proven to be inaccurate. Opioid-related phenotypes based on combinations of electronic health record data are a promising method to address this gap but lack a consensus-based conceptual framework to aid organization and prioritization. Methods: To achieve consensus around opioid-related phenotype topics in the ED, we used a hybrid scheme that employed modified Delphi and conceptual mapping methods. The combined iterative process used three rounds of electronic meetings and questionnaires to generate consensus recommendations and concept mappings based on the opinions and feedback of the 9 member Delphi panel. Mean importance and feasibility scores based on 5-point Likert scales (1 = relatively unimportant (infeasible) to 5 = extremely important (feasible)) for each statement/phenotype were calculated. We used multidimensional scaling to produce a point map of the phenotype concepts and hierarchical cluster analysis to generate concept maps. Results: After the first round, 120 initial phenotype concepts were proposed which were reduced to 73 concepts after normalization by the research team. Opioid overdose (9.54, SD = 0.9) had the highest combined importance and feasibility score. A final labeled 12-cluster solution was determined to be the most parsimonious description of the content by the research team. Three key groups emerged: opioid overdose, other opioid-specific phenotypes (opioid use disorder, opioid misuse, and opioid withdrawal) with significant concept overlap and opioid use-related phenotypes (homelessness, falls, infections, and suicidality). Conclusions: Using an expert consensus driven concept mapping process we identified specific opioid phenotype concepts within an overlapping schema that carry high priority for development and validation to advance emergency care opioid-related research and surveillance.

Background: As hospitals in the US face pressures to reduce lengths of stay, healthcare systems are increasingly utilizing skilled nursing facilities (SNFs) to continue treating patients stable enough to leave the hospital, but not to return home. Substance use disorder (SUD) can complicate care of patients transferred to SNFs. The objective of this paper is to understand SNF experiences for this population of patients with comorbid SUD transferred to SNFs and examine care experiences in these facilities. Methods: This secondary mixed-methods analysis focuses on SNF experiences from a clinical trial of patient navigation services for medically-hospitalized adults with comorbid opioid, cocaine, and/or alcohol use disorder. This study compared baseline assessments and medical record review for participants (N = 400) with vs. without SNF transfer, and analyzed semi-structured qualitative interviews with a subsample of 15 participants purposively selected based on their transfer to a SNF. Results: Over 1 in 4 participants had a planned discharged to a SNF (26.8% sub-acute, 3.3% acute). Compared to participants with other types of discharge, participants discharged to a SNF had longer initial hospitalizations (4.9 vs. 11.8 days, p < 0.001), and were more likely to be White (38.6 vs. 50.8%; p = 0.02), female (38.9 vs. 52.5%; p = 0.01), have opioid use disorder (75.7 vs. 85.0%, p = 0.03), and be hospitalized for infection (43.6 vs. 58.3%; p = 0.007), and less likely to have worked prior to hospitalization (24.3 vs. 12.5%; p = 0.006). Qualitative narratives identified several themes from the SNF experience, including opioid analgesic dosing issues, challenges to the use of opioid agonist treatment of OUD, illicit opioid dealing/use, and limited access to addiction recovery support services during and following the SNF stay. Conclusions: SNFs are a common disposition for patients in need of subacute services following hospitalization but may be ill-equipped to properly manage patients in need of new or continuing SUD treatment.

Background: Profiles of individuals with cannabis-related disorders (CRD) in specialized addiction treatment centers serving high-need patients have not been identified. This longitudinal study developed a typology for 9,836 individuals with CRD attending Quebec (Canada) addiction treatment centers in 2012–2013. Methods: Data on sociodemographic, clinical and service use variables were extracted from several databases for the years 1996–1997 to 2014–2015. Individual profiles were produced using Latent Class Analysis and compared predicting health outcomes on emergency department (ED) use, hospitalizations and suicidal behaviors for 2015–2016. Results: Six profiles were identified: 1-Older individuals, many living in couples and working, with moderate health problems, receiving intensive general practitioner (GP) care and high continuity of physician care; 2-Older individuals with chronic CRD, multiple social and health problems, and low health service use (chronic CRD referred to experiencing CRD for several years; social problems related to homelessness, unemployment, having criminal records or living alone); 3-Students with few social and health problems, and low health service use; 4-Young adults, many working, with few health problems, least health service use and continuity of physician care; 5-Youth, many working but some criminal offenders, with 1 or 2 years of CRD, few health problems and high addiction treatment center use; and 6-Older individuals with chronic CRD and multiple social and health problems, high health service use and continuity of physician care. Profiles 6 and 2 had the worst health outcomes. Conclusions: For Profiles 2 to 5, outreach and motivational services should be prioritized, integrated health and criminal justice services for profile 5 and, for Profiles 2 and 6, assertive community treatments. Screening, brief intervention and referrals to addiction treatment centers may also be encouraged for individuals with CRD, particularly those in Profile 2. This cohort had high social and health needs relative to services received, suggesting continued need for care.

Background: Kratom, a tree native to Southeast Asia, is increasingly used in Western countries for self-treatment of pain, psychiatric disorders, and mitigation of withdrawal symptoms from drugs of abuse. Because kratom is solely supplied from its native locations, supply shortages during the COVID-19 pandemic may impact the availability of preparations and hence force consumers to change their patterns of use. The aim of this study was to understand if and how COVID-19 was influencing kratom purchasing and use. Methods: Additional questions specific to kratom availability and changes in use during COVID-19 were added to an international online survey with responses collected between January and July 2020. During the same period, kratom-related social media posts to Twitter, Reddit, and Bluelight were analyzed for themes similar to the survey questions. Results: The survey results indicated no changes in kratom use patterns although the sample size was relatively small (n = 70) with younger consumers reporting a potential issue in obtaining their desired products from their usual sources. The survey respondents identified primarily as non-Hispanic whites (87.1%). Social media themes revolved primarily around quitting kratom during COVID-19, misinformation about the effects of kratom on COVID-19, and other non-COVID-related discussions. While some consumers may increase their kratom dose because of additional stress, a majority of discussions centered around reducing or rationing kratom due to COVID-19 or a perceived dependence. Access to quality kratom products was also a major discussion topic on social media. Conclusions: Kratom use patterns did not change due to COVID-19 but consumers were concerned about potential product shortages and resulting quality issues. Clinicians and public health officials need to be informed and educated about kratom use as a potential mitigation strategy for substance use disorders and for self-treatment of pain.

Background: Hospitalizations for people who inject drugs (PWID) are opportunities to address substance use. However, little is known about hospitalized PWIDs’ motivation to stop substance use or improve skin and needle hygiene, common means for reducing injection sequelae. Methods: We used baseline data from a randomized controlled trial of a behavioral intervention to improve skin and needle hygiene among 252 hospitalized PWID between January 2014 and June 2018. We examined motivation (scale 1-10) to stop substance use, use new needles, and clean skin and used multiple linear regression models to evaluate characteristics associated with these outcomes. Results: PWID were recruited during injection-related (154, 61.1%) and non-injection-related hospitalizations (98, 38.9%). Motivation to stop substance use was 7.11 (SD = 2.67), use new needles was 7.8 (SD = 1.9), and clean skin was 6.7 (SD = 2.3). In adjusted models, experiencing an injection-related hospitalization was not significantly associated (p > 0.05) with motivation to stop substance use (β = −0.76, SE = 0.299), use new needles (β = 0.301, SE = 0.255), or clean skin (β = 0.476, SE = 0.323). Number of past-year skin and soft tissue infections was negatively associated with motivation to use new needles (β = −0.109, SE = 0.049, p < 0.05) and clean skin (β = −0.131, SE = 0.062, p < 0.05). Greater opioid withdrawal was associated with lower motivation to use new needles (β = −0.275, SE = 0.92, p < 0.01). Conclusions: Among hospitalized PWID, motivation to stop substance use and improve skin and needle hygiene was moderately high, but injection-related hospitalizations were not associated with greater motivation. Efforts to reduce injection sequelae for all hospitalized PWID are needed.

Background: Substance use accounts for more than 400,000 deaths annually in the United States and overdose rates surged during the COVID pandemic. While the pandemic created increased pressure for better prepared providers, it simultaneously placed restrictions on medical training programs. The purpose of this educational case series is to assess the feasibility of a virtual addiction medicine training program and conduct a qualitative evaluation of medical student attitudes toward caring for people with substance use disorders, both before and after their addiction medicine training experience. Methods: We conducted a qualitative analysis related to course content focused on strengths and limitations of in-person and virtual training modalities. Individual quotes were evaluated and content themes were developed after a thorough review of all codes and detailed examination of interviewee quotes. Results: The primary themes that emerged were (1) Addiction medicine content is important to improve care of patients with substance disorders and is not fully addressed in undergraduate medical education (2) In-person and virtual training contain unique strengths and weaknesses and (3) Students perceived that both experiences provided positive and needed training in addiction medicine that shifted perspective and enhanced confidence to practice. Conclusions: Remote training via virtual lectures and patient visits may enhance training opportunities for students with limited exposure to addiction medicine patients and faculty with addiction medicine expertise. There is a need to further refine virtual care for patients with SUDs and virtual training to meet the needs of patients and learners across the country.

Background: The opioid epidemic continues to erode communities across Pennsylvania (PA). Federal and PA state programs developed grants to establish Hub and Spoke programs for the expansion of medications for opioid use disorders (MOUD). Employing the telementoring platform Project ECHO (Extension for Community Health Outcomes), Penn State Health engaged the other seven grant awardees in a Collaborative Health Systems (CHS) ECHO. We conducted key informant interviews to better understand impact of the CHS ECHO on health systems collaboration and opioid crisis efforts. Methods: For eight one-hour sessions, each awardee presented their unique strategies, challenges, and opportunities. Using REDCap, program characteristics, such as number of waivered prescribers and number of patients served were collected at baseline. After completion of the sessions, key informant interviews were conducted to assess the impact of CHS ECHO on awardee's programs. Results: Analysis of key informant interviews revealed important themes to address opioid crisis efforts, including the need for strategic and proactive program reevaluation and the convenience of collaborative peer learning networks. Participants expressed benefits of the CHS ECHO including allowing space for discussion of challenges and best practices and facilitating conversation on collaborative targeted advocacy and systems-level improvements. Participants further reported bolstered motivation and confidence. Conclusions: Utilizing Project ECHO provided a bidirectional platform of learning and support that created important connections between institutions working to combat the opioid epidemic. CHS ECHO was a unique opportunity for productive and convenient peer learning across external partners. Open dialogue developed during CHS ECHO can continue to direct systems-levels improvements that benefit individual and population outcomes.

Access to the opioid antidote naloxone is a critical component of addressing the opioid crisis. Naloxone is a population-level prevention intervention associated with substantial reductions in overdose mortality and reduction of nonfatal overdose. Pharmacies’ pivotal role in dispensing medications like buprenorphine for the treatment of opioid use disorder and selling nonprescription syringes places them at the crossroads of opioid access and risk mitigation methods like naloxone provision. Testing ways to optimize pharmacy-based naloxone provision will be key as the country expands the implementation of naloxone through the medical system. In the Respond to Prevent Study, we conducted a large, practical study of a pharmacy-focused intervention in a sample of Washington, Oregon, Massachusetts and New Hampshire community chain pharmacies to increase naloxone dispensing and improve opioid safety. The intervention integrated two evidence-based educational toolkits and streamlined materials to enhance the focus on naloxone policy, stigma reduction, and patient communications around naloxone, nonprescription syringes and buprenorphine access. The real-world study implemented a stepped wedge, clustered randomized trial design across 175 community chain pharmacies to evaluate the effectiveness of the Respond to Prevent intervention in increasing: (a) pharmacy based naloxone distribution rates, naloxone-related patient engagement, and pharmacist and technicians’ attitudes, knowledge, perceived behavioral control and self-efficacy toward naloxone; and (b) pharmacy nonprescription syringe sales, and pharmacist and technicians’ attitudes, knowledge, perceived behavioral control and self-efficacy toward dispensing buprenorphine for opioid use disorder (secondary outcomes). This commentary provides a brief narrative about the study and presents insights on the design and adaptations to our study protocol, including those adopted during the unprecedented COVID-19 pandemic further compounded by Western wildfires in 2020.

Objective:With approximately 15 million individuals in the United States meeting criteria for Alcohol Use Disorder (AUD), advancing effective medication-assisted treatment options is crucial. This advancement stems from the publication of clinical trial (CT) results. The primary objective of this study was to assess the rates of discontinuation and non-publication of results in CTs focused on the pharmacologic treatment of AUD and to assess associated factors. Design: A cross-sectional study was completed after acquiring trials focused on AUD within the ClinicalTrials.gov database. Inclusion criteria for CTs were the use of a pharmaceutical intervention with an outcome measure of alcohol intake or craving, conducted between October 2008 through September 2018. The primary outcome measures were the frequency of trial discontinuation and non-publication. Discontinuation was assessed as the listed status on ClinicalTrials.gov. Publications were identified through verification of listings on ClinicalTrials.gov, or via searches of PubMed, Embase, and Google Scholar. If publications were not found, correspondence to trial contacts were sent. Data analysis occurred on December 5th, 2020. Results: Of 235 trials returned from the search, 87 met inclusion criteria. Our study found that 12.6% (11) of CTs involving pharmaceutical treatments for AUD were prematurely terminated, and 39.1% (34) had no published results. Recruitment and lower cutoff of targeted age groups were significantly associated with discontinuation and non-publication, respectively. Conclusions: Scientific evidence advances faster when all results are known—furthering the progress of positive studies, while avoiding duplicative efforts to test the same hypotheses with the same methods, thereby reducing scientific waste. Given the number of unpublished AUD trials, potentially useful information regarding treatment for individuals with AUD may be inaccessible to clinicians while also adding to the abundance of research waste.

Question: What are the rates of discontinuation or non-publication of clinical trials for pharmacological treatments for AUD and associated factors?

Background: Successful implementation of group-based appointments can increase capacity to treat patients, reduce costs, and improve productivity. We sought to understand the acceptability of group-based appointments for opioid use disorder (OUD) in an urban clinical setting that treats predominantly ethnic minority populations. Methods: A survey collecting data on demographics, substance use, co-morbid psychiatric conditions, and satisfaction with group-based opioid treatment (GBOT) was conducted among patients 18 years and older with OUD attending an urban buprenorphine clinic between December 2019 and February 2020. Results: Thirty-nine patient surveys were completed. Among participants, 64.1% identified as Black/African American and 76.9% identified as male. The mean age was 51.2 years. Participants reported overall high levels of satisfaction with group-based appointments though GBOT was not strongly preferred over individual visits. On a 5-point Likert scale, 69.2% of participants agreed or strongly agreed that their medical needs were met during group-based appointments. A majority of participants agreed or strongly agreed that medical information received from the clinical team (97.4%) and other patients (82.1%) were valuable. Most participants (82.1%) reported adherence to treatment plans became easier since attending GBOT. Age and self-identified employment status as disabled or retired were positively associated with total satisfaction scores. Conclusions: Patients in a predominantly Black/African American and Hispanic/Latinx community with co-occurring mental health disorders and other substance use reported overall satisfaction with GBOT and would recommend this modality to other patients.

Background: Most states have legalized medical cannabis, yet little is known about how medical cannabis use is documented in patients’ electronic health records (EHRs). We used natural language processing (NLP) to calculate the prevalence of clinician-documented medical cannabis use among adults in an integrated health system in Washington State where medical and recreational use are legal. Methods: We analyzed EHRs of patients ≥18 years old screened for past-year cannabis use (November 1, 2017–October 31, 2018), to identify clinician-documented medical cannabis use. We defined medical use as any documentation of cannabis that was recommended by a clinician or described by the clinician or patient as intended to manage health conditions or symptoms. We developed and applied an NLP system that included NLP-assisted manual review to identify such documentation in encounter notes. Results: Medical cannabis use was documented for 16,684 (5.6%) of 299,597 outpatient encounters with routine screening for cannabis use among 203,489 patients seeing 1,274 clinicians. The validated NLP system identified 54% of documentation and NLP-assisted manual review the remainder. Language documenting reasons for cannabis use included 125 terms indicating medical use, 28 terms indicating non-medical use and 41 ambiguous terms. Implicit documentation of medical use (e.g., “edible THC nightly for lumbar pain”) was more common than explicit (e.g., “continues medical cannabis use”). Conclusions: Clinicians use diverse and often ambiguous language to document patients’ reasons for cannabis use. Automating extraction of documentation about patients’ cannabis use could facilitate clinical decision support and epidemiological investigation but will require large amounts of gold standard training data.

Background: Substance use-related diagnoses are common and associated with poor health outcomes. The objective of this analysis was to compare rates of cervical cancer screening, screening abnormalities, and follow-up care in women with and without a substance use-related diagnosis seen for primary care between January 1, 2016 and December 31, 2019 in the University of Washington healthcare system. Methods: This study included women aged 21–65 years of age who had at least one outpatient visit between January 1, 2016 and December 31, 2019 within one of 45 primary care or women's health clinics in the academic healthcare system. Exposure status was defined using ICD10 codes for substance-use related diagnoses or no substance-use related diagnoses. Only first cervical cancer screening was included. Generalized linear models with a binomial family and log link were used to estimate risk ratios. Results: 3845 women had a substance use-related diagnosis and 89214 did not. Women with a substance use-related diagnosis were less likely to be screened for cervical cancer (44%, 1675/3845) compared to women without a substance use-related diagnosis (49%, 43338/89214; relative risk [RR] 0.90, 95% CI 0.86–0.93). Women with a substance use-related diagnosis were also more likely to have an abnormal screening result (18%, 304/1675) compared to women without a substance use-related diagnosis (10%, 4528/43338; RR 1.74, 95% CI 1.56–1.93). Follow-up for abnormal screens did not differ significantly between groups (24 vs 25%; RR 0.80, 95% CI 0.55–1.17). Conclusion: To combat disparities in cervical cancer screening for women with substance use-related diagnoses, public health efforts should expand access to screening where women with substance use-related diagnoses are seen, including acute care, inpatient hospitalizations, and addiction treatment settings.

Background:Since 2017, states, insurers, and pharmacies have placed blanket limits on the duration and quantity of opioid prescriptions. In many states, overlapping duration and daily dose limits yield maximum prescription limits of 150–350 morphine milligram equivalents (MMEs). There is limited knowledge of how these restrictions compare with actual patient opioid consumption; while changes in prescription patterns and opioid misuse rates have been studied, these are, at best, weak proxies for actual pain control consumption. We sought to determine how patients undergoing surgery would be affected by opioid prescribing restrictions using actual patient opioid consumption data. Methods: We constructed a prospective database of post-discharge opioid consumption: patients undergoing surgery at one institution were called after discharge to collect opioid consumption data. Patients whose opioid consumption exceeded 150 and 350 MME were identified. Results: Two thousand nine hundred and seventy-one patients undergoing 54 common surgical procedures were included in our study. Twenty-one percent of patients consumed more than the 150 MME limit. Only 7% of patients consumed above the 350 MME limit. Typical (non-outlier) opioid consumption, defined as less than the 75th percentile of consumption for any given procedure, exceeded the 150 MME and 350 MME limits for 41 and 7% of procedures, respectively. Orthopedic, spinal/neurosurgical, and complex abdominal procedures most commonly exceeded these limits. Conclusions: While most patients undergoing surgery are unaffected by recent blanket prescribing limits, those undergoing a specific subset of procedures are likely to require more opioids than the restrictions permit; providers should be aware that these patients may require a refill to adequately control post-surgical pain. Real consumption data should be used to guide these restrictions and inform future interventions so the risk of worsened pain control (and its troublesome effects on opioid misuse) is minimized. Procedure-specific prescribing limits may be one approach to prevent misuse, while also optimizing post-operative pain control.

Background: Traditional treatments for substance use disorders (SUDs) rely heavily on face-to-face interactions, which pose substantial limitations for patients. A clinical trial of a digital therapeutic (DT), delivering behavioral therapy demonstrated safety and efficacy in a population including patients with opioid use disorder (OUD) not treated with buprenorphine, which is not a guideline-recommended approach. This study re-analyzed the data excluding patients with OUD to more closely approximate real-world patient populations. Methods: Secondary analysis of patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (n = 399, patients with OUD excluded) from a previously-published randomized controlled trial. Patients received 12-weeks of outpatient treatment-as-usual (TAU; n = 193) or TAU with reduced counseling plus a DT (n = 206) providing computerized cognitive behavioral therapy and contingency management. Primary outcomes were abstinence in weeks 9–12 and retention in treatment. Results: The 399 patients in this analysis (206 in the DT group and 193 in the TAU group) reported substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (e.g., methamphetamines). Demographic and baseline characteristics including age, sex, race, education, and reported primary substance use disorder were balanced between treatment groups. Abstinence was significantly higher in the DT group compared to TAU (40.3 vs. 17.6%; p < 0.001) as was retention in therapy (76.2 vs. 63.2%, p = 0.004). Intergroup adverse event rates were not significantly different (p = 0.68). Conclusions: The results demonstrate that use of a DT safely increased abstinence (reduced substance use) and retention in treatment among patients with substance use disorders related to alcohol, cannabis, cocaine, or other stimulants (including methamphetamines).

Aims: With increased liberalization of cannabis policies in North America, there is growing interest in the use of cannabis to manage pain instead of opioids. The objectives of the study were to (1) examine the use of cannabis for pain relief in Canada and the United States (US) in 2018 and 2019; (2) examine the association between recreational cannabis laws and changes in the use of cannabis for pain relief, instead of opioids or prescription pain medication. Methods: Repeat cross-sectional survey data were used from Wave 1 and Wave 2 of the International Cannabis Policy Study conducted in 2018 and 2019 in Canada and the US. Respondents were recruited through commercial panels, aged 16–65, and had ever tried cannabis (N = 44,119). Weighted binary logistic regression models examined the association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication (n = 15,092). Results: Between 14–33% of cannabis consumers in Canada and the US reported using cannabis to manage headaches or pain. Of these consumers, 79% and 78% respondents in Canada; 80% and 83% in US illegal states; and 83% and 84% in US legal states, in 2018 and 2019, respectively, reported cannabis use for pain relief instead of opioids or prescription pain medication. There was little evidence of an association between the legal status of recreational cannabis and cannabis use for pain relief instead of opioids or prescription pain medication, among Canadian (AOR = 0.98, 95% CI: 0.78, 1.22) and US respondents (AOR = 1.11, 95% CI: 0.96, 1.28). Conclusions: Although substitution of cannabis for opioids or prescription pain medication is common among those who use cannabis for pain, there does not seem to be a significant difference according to cannabis legality. Future research should examine cannabis and opioid substitution using different research designs and time frames.

Background: In the U.S., excessive drinking accounts for one in 10 deaths among adults aged 20–64 years old. Binge drinking is a common form of excessive alcohol consumption that contributes to this chilling statistic. Binge drinking is defined as women consuming four or more drinks or men consuming five or more drinks within a 2-h time span. Examining existing data on risk factors for binge drinking can inform strategies to prevent this deadly practice. Methods: The 2019 Kansas Behavioral Risk Factor Surveillance System (BRFSS) dataset consists of data collected from 11,368 non-institutionalized adults aged 18 years and older with landline or cell phones. The dependent variable in this study was binge drinking status. The independent variables included several sociodemographic variables and risk factors. Data were analyzed using descriptive statistics, bivariate analysis, single logistic regression, and multivariable logistic regression. Results: In the population, 1,447 (17.4%) were reported to be binge drinkers. Significant factors associated with binge drinking in the final model included sex (aOR = 0.53 (0.45–0.63)), age (18–24 years old aOR = 8.77 (6.02–12.79); 25–34 years old aOR = 7.10 (5.35–9.42); 35–44 years old aOR = 6.23 (4.73–8.19); 45–54 years old aOR = 3.87 (2.92–5.14); and 55–64 years old aOR = 2.58 (1.96–3.38)), income ($15,000–$24,999 aOR = 1.00 (0.63–1.58); $25,000–$34,999 aOR = 1.61 (1.04–2.50); $35,000-$49,999 aOR = 1.69 (1.13–2.55); ≥$50,000 aOR = 1.97 (1.34–2.89)), smokeless tobacco use (aOR = 2.09 (1.55–2.82)), and smoking/e-cigarette use (Cigarette user only aOR = 2.11 (1.69–2.65); E-cigarette user only aOR = 2.67 (1.62–3.17); dual cigarette and e-cigarette user = 3.43 (2.21–5.33)). Conclusion: Developing interventions that take into account elevated risk for binge drinking amongst demographic characteristics (i.e., age, sex, income) and lifestyle factors (i.e., smokeless tobacco use, and smoking/e-cigarette use) is crucial to lowering morbidity and mortality related to this form of excessive alcohol consumption.

Medication treatment for opioid use disorder (MOUD) is an effective evidence-based therapy for decreasing opioid-related adverse outcomes. Effective strategies for retaining persons on MOUD, an essential step to improving outcomes, are needed as roughly half of all persons initiating MOUD discontinue within a year. Data science may be valuable and promising for improving MOUD retention by using “big data” (e.g., electronic health record data, claims data mobile/sensor data, social media data) and specific machine learning techniques (e.g., predictive modeling, natural language processing, reinforcement learning) to individualize patient care. Maximizing the utility of data science to improve MOUD retention requires a three-pronged approach: (1) increasing funding for data science research for OUD, (2) integrating data from multiple sources including treatment for OUD and general medical care as well as data not specific to medical care (e.g., mobile, sensor, and social media data), and (3) applying multiple data science approaches with integrated big data to provide insights and optimize advances in the OUD and overall addiction fields.

Background: Opioid use disorder (OUD) is common among incarcerated persons and risk of overdose and other adverse drug-related consequences is high after release. Recognizing their potential to reduce these risks, some correctional systems are expanding access to medication for opioid use disorder (MOUD). This study explored the experiences and perspectives of formerly incarcerated individuals on MOUD use while incarcerated and after release. Methods: We interviewed 53 individuals with self-reported OUD who were released from New Jersey state prisons. Interviews explored motivations to use MOUD while incarcerated and after release, and experiences with prison-based MOUD and transition to community-based care. We performed cross-case analysis to examine common and divergent perspectives across participants. Results: A common reason for accepting prerelease MOUD was recognition of its effectiveness in preventing drug use, overdose, and other drug-related consequences. Participants who chose not to use MOUD often were focused on being completely medication-free or saw themselves as having relatively low-risk of substance use after a prolonged period without opioid use. A few participants reported challenges related to prison-based MOUD, including logistical barriers, stigma, and once-daily buprenorphine dosing. Most participants effectively transitioned to community-based care, but challenges included insurance lapses and difficulty locating providers. Conclusions: Many formerly incarcerated persons with OUD recognize the value of MOUD in supporting recovery, but some hold negative views of MOUD or underestimate the likelihood that they will return to drug use. Patient education on risks of post-release overdose, the role of MOUD in mitigating risk, and MOUD options available to them could increase engagement. Participants’ generally positive experiences with MOUD support the expansion of correctional MOUD programs.

Background: Harm reduction includes treatment and prevention approaches rather than abstinence, as a public health strategy for mitigating the opioid epidemic. Harm reduction is a new strategy for many healthcare professionals, and gaps in knowledge and practices may lead to barriers to optimal treatment. Our objective was to identify and describe gaps in physicians’ knowledge, education, and practice in harm reduction strategies related to opioid overdose. Methods: We searched the PubMed, CINAHL, and Web of Science databases for articles published between 2015 and 2021, published in English, containing empirical evidence, addressing opioid harm reduction, and identifying gaps in physicians’ knowledge, education, or practice. Results: Thirty-seven studies were included. Studies examined how physicians’ perceptions or stigma influenced harm reduction efforts and addressed clinical knowledge gaps in overdose treatment and prevention and OUD treatment. Less than half of the studies addressed access issues at the system level, above the individual healthcare professional. Conclusion: Individual-level interventions should be addressed with professional continuing education and curricular-based changes through experiential and interprofessional education. System-level gaps can be remedied by increasing patient access to care, creating policies favorable to harm reduction, and extending resources to provide harm reduction strategies.

Background: The co-occurrence of the COVID-19 pandemic and opioid epidemic has increased the risk of overdose and death for patients with opioid use disorder (OUD). COVID-19 has also exacerbated already limited access to opioid overdose education and naloxone distribution (OEND). In this context, we aim to increase access to OEND for patients at risk for opioid overdose. Methods: Medical student volunteers were trained to conduct telephone-based OEND, and subsequently contacted all patients at a NYC primary care clinic for people who use drugs as well as those presenting to the hospital with OUD or a history of opioid overdose. Interested patients who completed the training received naloxone kits via mail or at hospital discharge. Results: OEND provision was converted to a remote-only model from May to June 2020. During this time, eight pre-clinical medical students called a total of 503 high-risk patients. Of these patients, 165 were reached, with 90 (55%) accepting telephone-based OEND. Comparing across populations, 51% of primary care patients versus 76% of ED/hospitalized patients accepted opioid overdose education. Eighty-four total patients received naloxone. Conclusions: We have outlined a scalable, adaptable model by which clinics and hospitals with affiliated medical schools can provide OEND by telephone. Medical student-driven, telephone-based OEND efforts can effectively reach at-risk patients and increase naloxone access.

Background: US local health departments (LHDs) have faced the COVID-19 pandemic and the opioid epidemic simultaneously. This article investigates the perceived impact of COVID-19 on the continuation of locally available services for addressing opioid use disorder (OUD). Methods: A national survey of US LHDs was conducted from November to December 2020. The survey asked key personnel in LHDs about the availability of OUD services in their jurisdiction, and how COVID-19 impacted such availability (i.e., whether terminated or continued at a reduced, the same, or an increased level after the arrival of COVID-19). Proportions for each impact category were estimated for prevention, treatment, harm reduction, and recovery services. Logistic regression tested for rural-urban and regional differences in perceived service impact. Results: An 11.4% (214 out of 1873) response rate was attained. Of the returned surveys, 187 were used in the analysis. Reported terminations were generally low, especially for treatment services. School-based prevention initiatives had the highest termination rate (17.2%, 95% CI = 11.4–25.1%). Prevention services had the highest proportions for continuing at a reduced level, except for recovery mutual help programs (53.9%, 95% CI = 45.2–62.4%). LHDs reported continuing services at an increased level at a higher frequency than terminating. Notably, 72.2% (95% CI = 62.7–80.0%) continued telehealth/telemedicine options for OUD at an increased level, and 23.8% (95% CI = 17.8–31.1%) and 10.0% (95% CI = 5.7–16.7%) reported doing the same for naloxone distribution and medications for opioid use disorder (MOUD), respectively. More harm reduction services were continued at the same versus at a reduced level. Service continuation differed little between rural-urban LHDs or by region. Conclusions: The impacts of COVID-19 on OUD service availability in LHD jurisdictions may depend on the specific area of opioid response while the long-term consequences of these changes remain unknown.

Background: Opioid use disorder affects millions of Americans, but only a fraction receive treatment. This may be due in part to inaccurate information available about buprenorphine waivered practitioners (waivered practitioners) and Opioid Treatment Programs (OTPs) on public, federally-sponsored locator databases. We aimed to assess the accuracy of publicly-listed locator information for waivered practitioners and OTPs across the US. Methods: Using a cross-sectional study design, we randomly sampled waivered practitioners (n = 253; 0.5%) and licensed OTPs (n = 165; 10%) that were publicly-listed on a federally-sponsored database. We used a three-pronged approach to assess the accuracy of the information available by concurrently administering a phone survey (making up to 3 attempts to contact), conducting online searches, and reviewing provider information on state board websites (practitioners only) between August and November 2020. We used descriptive analyses and inferential statitistics to analyze the data. Results: Among n = 418 waivered practitioners and OTPs sampled, many were located in the South and in an urban area. For the phone survey, researchers were able to reach OTPs nearly twice as often as waivered practitioners. Of those reached, n = 19 waivered practitioners and n = 40 OTPs agreed to participate, and we found most had up-to-date contact information. OTPs yielded significantly more online search results and matching contact information than waivered practitioners (p < 0.001). Most waivered practitioners were located on state licensing board websites, but few had contact information listed, and only one listed the practitioner's waiver status. Conclusions: Waivered practitioners and OTPs were difficult to reach via phone but easier to find online and on state licensing board websites; when they were reached via phone, their contact information was very accurate. Whether challenges locating a waivered practitioner or OTP is associated with lower treatment utilization should be evaluated.