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In a randomized trial involving participants with methamphetamine use disorder, the response among those who received bupropion and naltrexone was 11 percentage points higher than that among participants who received placebo. Adverse events included gastrointestinal disorders.

Background Office-Based Opioid Treatment (OBOT) is a delivery model which seeks to make medications for opioid use disorder (MOUD), particularly buprenorphine, widely available in general medical clinics and offices. Despite evidence supporting its effectiveness and cost-effectiveness, uptake of the OBOT model has been relatively slow. One important barrier to faster diffusion of OBOT may be the financial challenges facing clinics that could adopt it. Methods We review key features and variants of the OBOT model, then discuss different approaches that have been used to fund it, and the findings from previous economic analyses of OBOT’s impact on organizational finances. We conclude by discussing the implications of these analyses for the financial sustainability of the OBOT delivery model. Results Like other novel services, OBOT poses challenges for providers due to its reliance on services which are ‘non-billable’ in a fee-for-service environment. A variety of approaches exist for covering the non-billable costs, but which approaches are feasible depends on local payer policies. The scale of the challenges varies with clinic size, organizational affiliations and the policies of the state where the clinic operates. Small clinics in a purely fee-for-service environment may be particularly challenged in pursuing OBOT, given the need to fund a dedicated staff and extra administrative work. The current pandemic may pose both opportunities and challenges for the sustainability of OBOT, with expanded access to telemedicine, but also uncertainty about the durability of the expansion. Conclusion The reimbursement environment for OBOT delivery varies widely around the US, and is evolving as Medicare (and possibly other payers) introduce alternative payment approaches. Clinics considering adoption of OBOT are well advised to thoroughly investigate these issues as they make their decision. In addition, payers will need to rethink how they pay for OBOT to make it sustainable.

Despite indications of increasing amphetamine availability and psychostimulant deaths in the United States, evidence across data sources is mixed, and data on amphetamine-related hospitalizations are lacking. To clarify trends in amphetamine-related hospitalizations and their clinical outcomes and costs in the United States. This repeated, cross-sectional study used hospital discharge data from the Healthcare Cost and Utilization Project National Inpatient Sample. The nationally representative sample included US adults (n = 1 292 300) who had amphetamine-related hospitalizations between January 1, 2003, and December 31, 2015. Multivariable logistic and Poisson regression models were used to examine in-hospital mortality and length of stay. Analysis of these data was conducted from November 2017 to August 2018. Amphetamine dependence or abuse or amphetamine poisoning. Annual hospitalizations, in-hospital mortality, length of stay, transfer to another facility, and costs. Over the 2003 to 2015 study period, there were 1 292 300 weighted amphetamine-related hospitalizations. Of this population, 541 199 (41.9%) were female and 749 392 (58.1%) were male, with a mean age of 37.5 years (95% CI, 37.4-37.7 years). Amphetamine-related hospitalizations, compared with other hospitalizations, were associated with age younger than 65 years (98.0% vs 58.0%; P < .001), male sex (60.3% [95% CI, 59.7%-60.8%] vs 41.1% [95% CI, 40.9%-41.3%]), Medicaid coverage (51.2% [95% CI, 49.8%-52.7%] vs 17.8% [95% CI, 17.5%-18.1%]), and residence in the western United States (58.5% [95% CI, 55.9%-61.0%] vs 18.9% [95% CI, 18.0%-19.8%]). Amphetamine-related hospitalizations declined between 2005 and 2008, and then increased from 55 447 hospitalizations (95% CI, 44 936-65 959) in 2008 to 206 180 hospitalizations (95% CI, 95% CI, 189 188-223 172) in 2015. Amphetamine-related hospitalizations increased to a greater degree than hospitalizations associated with other substances. Adjusted mean length of stay (5.9 [95% CI, 5.8-6.0] vs 4.7 [95% CI, 4.7-4.8] days; P < .001), transfer to another facility (26.0% [95% CI, 25.3%-26.8%] vs 18.5% [95% CI, 18.3%-18.6%]; P < .001), and mean in-hospital mortality (28.3 [95% CI, 26.2-30.4] vs 21.9 [95% CI, 21.6-22.1] deaths per 1000 hospitalizations; P < .001) were higher for amphetamine-related than other hospitalizations. Annual hospital costs related to amphetamines increased from $436 million (95% CI, $312 million-$559 million) in 2003 to $2.17 billion (95% CI, $1.95 billion-$2.39 billion) by 2015. Given that amphetamine-related hospitalizations and costs substantially increased between 2003 and 2015, pharmacologic and nonpharmacologic therapies for amphetamine use disorders and a coordinated public health response are needed to curb these rising rates.

Keywords: Buprenorphine, Professional satisfaction, Primary care, Opioid use disorder

Background Little is known about patient characteristics that contribute to initiating antiretroviral therapy (ART) and achieving viral suppression among HIV people with opioid use disorder in Vietnam. The primary objective of this analysis was to evaluate associations between participant characteristics and the critical steps in the HIV care continuum of ART initiation and HIV viral suppression among people with opioid use disorder and HIV in Vietnam. Methods We assessed baseline participant characteristics, ART status, and HIV viral suppression (HIV RNA PCR < 200 copies/mL) enrolled in a clinical trial of HIV clinic-based buprenorphine versus referral for methadone among people with opioid use disorder in Vietnam. We developed logistic regression models to identify characteristics associated with ART status and HIV viral suppression. Results Among 283 study participants, 191 (67.5%) were prescribed ART at baseline, and 168 of those on ART (90%) were virally suppressed. Years since HIV diagnosis (aOR = 1.12, 95% CI 1.06, 1.19) and being married (aOR = 2.83, 95% CI 1.51, 5.34) were associated with an increased likelihood of current prescription for ART at baseline. Greater depression symptoms were negatively associated with receipt of ART (aOR = 0.97, 95% CI = (0.94, 0.9963)). In the HIV suppression model, once adjusting for all included covariates, only receipt of ART was associated with viral suppression (aOR = 25.9, 95% CI = (12.5, 53.8). In bivariate analyses, methamphetamine was negatively correlated with ART prescription ( p  = 0.07) and viral suppression ( p  = 0.08). Conclusion While fewer than 90% of participants had received ART, 90% of those on ART had achieved HIV viral suppression at baseline, suggesting that interventions to improve uptake of ART in Vietnam are essential for achieving UNAIDS 90–90-90 goals in people who use heroin in Vietnam. Social determinants of health associated with ART and HIV viral suppression suggest that social support may be a key to facilitating both of these steps in the HIV care continuum.

Background Many primary care clinicians (PCCs) hold stigma toward people with opioid use disorder (OUD), which may be a barrier to care. Few interventions exist to address PCC stigma toward people with OUD. This study examined whether an online training incorporating patient narratives reduced PCCs’ stigma toward people with OUD (primary) and increased intentions to treat people with OUD compared to an attention-control training (secondary). Methods PCCs from 15 primary care clinics were invited to complete a 30 min online training for an electronic health record-embedded clinical decision support (CDS) tool that alerts PCCs to screen, diagnose, and treat people with OUD. PCCs were randomized to receive a stigma-reduction version of the training with patient narrative videos or a control training without patient narratives and were blinded to group assignment. Immediately after the training, PCCs completed surveys of stigma towards people with OUD and intentions and willingness to treat OUD. CDS tool use was monitored for 6 months. Analyses included independent samples t -tests, Pearson correlations, and logistic regression. Results A total of 162 PCCs were randomized; 88 PCCs (58% female; 68% white) completed the training (Stigma = 48; Control = 40) and were included in analyses. There was no significant difference between intervention and control groups for stigma ( t  = − 0.48, p  = .64, Cohen’s d  = − 0.11), intention to get waivered ( t  = 1.11, p  = .27, d  = 0.26), or intention to prescribe buprenorphine if a waiver were no longer required ( t  = 0.90, p  = 0.37, d  = 0.21). PCCs who reported greater stigma reported lower intentions both to get waivered ( r  = − 0.25, p  = 0.03) and to prescribe buprenorphine with no waiver ( r  = − 0.25, p  = 0.03). Intervention group and self-reported stigma were not significantly related to CDS tool use. Conclusions Stigma toward people with OUD may require more robust intervention than this brief training was able to accomplish. However, stigma was related to lower intentions to treat people with OUD, suggesting stigma acts as a barrier to care. Future work should identify effective interventions to reduce stigma among PCCs. Trial Registration : ClinicalTrials.gov NCT04867382. Registered 30 April 2021—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04867382

Background Medications for opioid use disorder (MOUD), including buprenorphine, are effective treatments for opioid use disorder (OUD) and reduce risk for overdose and death. Buprenorphine can be prescribed in outpatient primary care settings to treat OUD; however, prior research suggests adherence to buprenorphine in these settings can be low. The purpose of this study was to identify the rates of and factors associated with buprenorphine adherence among patients with OUD in the first six months after a new start of buprenorphine. Methods Data were extracted from the electronic health record (EHR) from a large integrated health system in the upper Midwest. Patients with OUD ( N  = 345; Mean age = 37.6 years, SD 13.2; 61.7% male; 78% White) with a new start of buprenorphine between March 2019 and July 2021 were included in the analysis. Buprenorphine adherence in the first six months was defined using medication orders; the proportion of days covered (PDC) with a standard cut-point of 80% was used to classify patients as adherent or non-adherent. Demographic (e.g., age, sex, race and ethnicity, geographic location), service (e.g., encounters, buprenorphine formulations and dosage) and clinical (e.g., diagnoses, urine toxicology screens) characteristics were examined as factors that could be related to adherence. Analyses included logistic regression with adherence group as a binary outcome. Results Less than half of patients were classified as adherent to buprenorphine (44%). Adjusting for other factors, male sex (OR = 0.34, 95% CI = 0.20, 0.57, p  < .001) and having an unexpected positive for opioids on urine toxicology (OR = 0.42, 95% CI = 0.21, 0.83, p  < .014) were associated with lower likelihood of adherence to buprenorphine, whereas being a former smoker (compared to a current smoker; OR = 1.82, 95% CI = 1.02, 3.27, p  = .014) was associated with greater likelihood of being adherent to buprenorphine. Conclusions These results suggest that buprenorphine adherence in primary care settings may be low, yet male sex and smoking status are associated with adherence rates. Future research is needed to identify the mechanisms through which these factors are associated with adherence.

Background Hospitalizations involving opioid use disorder (OUD) are increasing. Medications for opioid use disorder (MOUD) reduce mortality and acute care utilization. Hospitalization is a reachable moment for initiating MOUD and arranging for ongoing MOUD engagement following hospital discharge. Despite existing quality metrics for MOUD initiation and engagement, few hospitals provide hospital based opioid treatment (HBOT). This protocol describes a cluster-randomized hybrid type-2 implementation study comparing low-intensity and high-intensity implementation support strategies to help community hospitals implement HBOT. Methods Four state implementation hubs with expertise in initiating HBOT programs will provide implementation support to 24 community hospitals (6 hospitals/hub) interested in starting HBOT. Community hospitals will be randomized to 24-months of either a low-intensity intervention (distribution of an HBOT best-practice manual, a lecture series based on the manual, referral to publicly available resources, and on-demand technical assistance) or a high-intensity intervention (the low-intensity intervention plus funding for a hospital HBOT champion and regular practice facilitation sessions with an expert hub). The primary efficacy outcome, adapted from the National Committee on Quality Assurance, is the proportion of patients engaged in MOUD 34-days following hospital discharge. Secondary and exploratory outcomes include acute care utilization, non-fatal overdose, death, MOUD engagement at various time points, hospital length of stay, and discharges against medical advice. Primary, secondary, and exploratory outcomes will be derived from state Medicaid data. Implementation outcomes, barriers, and facilitators are assessed via longitudinal surveys, qualitative interviews, practice facilitation contact logs, and HBOT sustainability metrics. We hypothesize that the proportion of patients receiving care at hospitals randomized to the high-intensity arm will have greater MOUD engagement following hospital discharge. Discussion Initiation of MOUD during hospitalization improves MOUD engagement post hospitalization. Few studies, however, have tested different implementation strategies on HBOT uptake, outcome, and sustainability and only one to date has tested implementation of a specific type of HBOT (addiction consultation services). This cluster-randomized study comparing different intensities of HBOT implementation support will inform hospitals and policymakers in identifying effective strategies for promoting HBOT dissemination and adoption in community hospitals. Trial registration NCT04921787.

Background Hospitalizations involving opioid use disorder (OUD) are increasing. Addiction consultation services (ACS) initiate medications for opioid use disorder (MOUD) in hospital settings and arrange post-hospital follow-up for ongoing MOUD care. Engagement in MOUD following hospital discharge is hampered by challenges in timely access to MOUD. This protocol describes an open-label randomized comparative effectiveness trial comparing ACS treatment as usual (TAU) to a single injection of a 28-day formulation extended-release buprenorphine (XR-BUP) on MOUD engagement 34-days following hospital discharge. Methods Six U.S. hospitals with ACS capable of prescribing all MOUD (i.e., methadone, buprenorphine, and extended-release naltrexone) recruit and randomize hospitalized patients with OUD who have not been on MOUD in the fourteen days prior to hospitalization. TAU may consist of any MOUD other than XR-BUP. Participants randomized to XR-BUP may receive any MOUD throughout their hospital stay and receive a 28-day XR-BUP injection within 72-hours of anticipated hospital discharge. There is no intervention beyond hospital stay. Participants are followed 34-, 90-, and 180-days following hospital discharge. The primary outcome is engagement in any MOUD 34-days following hospital discharge, which we hypothesize will be greater in the XR-BUP group. Randomizing 342 participants (171 per arm) provides 90% power to detect difference in the primary outcome between groups with an odds ratio of 2.1. Safety, secondary, and exploratory outcomes include: adverse events, MOUD engagement on days 90 and 180, opioid positive urine drug tests, self-reported drug use, hospital readmissions and emergency department visits, use of non-opioid drugs, fatal and non-fatal opioid overdose, all-cause mortality, quality of life, and cost-effectiveness. Data are analyzed by intention-to-treat, with pre-planned per-protocol and other secondary analyses that examine gender as an effect modifier, differences between groups, and impact of missingness. Discussion Engagement in MOUD care following hospitalization in individuals with OUD is low. This randomized comparative effectiveness trial can inform hospital ACS in medication selection to improve MOUD engagement 34-days following hospital discharge. Trial registration NCT04345718.