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BackgroundDrug overdose is the leading cause of death after release from prison, and this risk is significantly higher among women compared to men. Within the first 2 weeks after release, the risk of death from drug overdose is 12.7 times higher than the general population, with risk of death further elevated among females. Although female inmates have higher rates of opioid use disorder and post-release overdose fatality, justice-involved women are under-represented in studies of medications for opioid use disorder. The Reducing Overdose After Release from Incarceration (ROAR) pilot intervention and evaluation (recruitment June 2019 through December 2020) aims to reduce opioid overdose among women released to the community following incarceration in state prison. The evaluation further assesses induction, acceptance and effectiveness of extended release naltrexone in a female post-prison population.Methods/designIn the week prior to their release, female adults in custody with moderate to severe opioid use disorder start treatment with extended release naltrexone, an injectable opioid antagonist that blocks the effects of opioids for up to 1 month. All ROAR participants receive training to use naloxone rescue kits and are provided nasal naloxone at release. Ongoing support from a certified recovery mentor to facilitate sustained engagement with treatment for substance use disorders begins in the month prior to release from prison and continues for 6 months in community. We evaluate the association between ROAR participation and the primary outcome of opioid overdose.Using administrative data provided by the Oregon Department of Corrections and the Oregon Health Authority, we compare the odds of overdose among ROAR participants versus a comparison group of females released from prison during the study period. Evaluation activities in community includes survey and qualitative interviews for 6 months post release, as well as a review of clinic records to assess retention on medication among the pilot cohort (N = 100).DiscussionROAR is a collaboration between Oregon’s public health, criminal justice, and medical communities. The ROAR intervention and evaluation provide critical information on improving interventions to prevent opioid overdose and improve retention on treatment in community in an overlooked, high-risk population: incarcerated women re-entering the community.Trial registrationClinical Trials.gov TRN: NCT03902821.

Background Novel strategies are needed to engage people who use stimulants into the continuum of addiction care. Contingency management (CM) is the most effective intervention for stimulant use disorder and may engage non-treatment-seeking populations, especially when delivered by peer recovery support specialists (peers). We describe development and training for a novel peer-delivered CM program for stimulant use harm reduction and treatment engagement. Methods We used a community based participatory research (CBPR) process to develop a CM program focused on self-identified goals for harm reduction and treatment engagement. A steering committee of peers guided study design, CM rewards, schedule, and incentivized goals. Peers completed coaching-to-criterion of six CM skills based on the CM Competence Scale (CMCS), then completed a one-on-one roleplay with a standardized patient. Coaches rated peer performance of each CMCS skill according to its Likert scale (1 = Very Poor to 7 = Excellent) and an a priori rating criterion of 4 (‘adequate’). Roleplays included feedback and a ‘replay’ of skills, if necessary. Results The steering committee devised two CM interventions: an enhanced standard-of-care incentivizing peer visits ($20 for weekly peer visits) and an intervention that additionally incentivized self-directed goals ($20 for weekly peer visits and $30 for completed goal-related activities). Self-identified goal-related activities were chosen through a collaborative process and organized into 6 domains: (1) overdose/overamping prevention (2) substance use supports/treatment (3) daily living/housing (4) education/employment (5) mental/physical/spiritual health (6) social relationships. Forty-seven peers across nine peer-led organizations (three rural and six urban organizations across Oregon) completed CM training. All 47 peers met the a priori criterion in their roleplay, with seventeen (36%) requiring a ‘replay’ of a skill. Mean CMSC summary scores were 28.51 (SD 4.73) on the first attempt and 29.62 (SD 4.01) on the second attempt. Conclusions PEER-CM (Peers Expanding Engagement in Stimulant Harm Reduction with Contingency Management) is among the first trials to use peer-delivered CM for stimulant use, incentivizing peer engagement and self-identified goals for harm reduction and treatment engagement. A CBPR approach strengthened the study design by incorporating peer guidance. Peers in this large, multisite sample demonstrated adequate CM delivery skills with acceptable fidelity following training. Trial Registration This study is registered at ClinicalTrials.gov (NCT 05700994). Registered 26 January, 2023.

BackgroundA large proportion of individuals who use heroin report initiating opioid use with prescription opioids. However, patterns of prescription opioid use preceding heroin-related overdose have not been described.ObjectiveTo describe prescription opioid use in the year preceding heroin overdose.DesignCase-control study comparing prescription opioid use with a heroin-involved overdose, non-heroin-involved opioid overdose, and non-overdose controls from 2015 to 2017.ParticipantsOregon Medicaid beneficiaries with linked administrative claims, vital statistics, and prescription drug monitoring program data.Main MeasuresOpioid, benzodiazepine, and other central nervous system depressant prescriptions preceding overdose; among individuals with one or more opioid prescription, we assessed morphine milligram equivalents per day, overlapping prescriptions, prescriptions from multiple prescribers, long-term use, and discontinuation of long-term use.Key ResultsWe identified 1458 heroin-involved overdoses (191 fatal) and 2050 non-heroin-involved opioid overdoses (266 fatal). In the 365 days prior to their overdose, 45% of individuals with a heroin-involved overdose received at least one prescribed opioid compared with 78% of individuals who experienced a non-heroin-involved opioid overdose (p < 0.001). For both heroin- and non-heroin-involved overdose cases, the likelihood of receiving an opioid increased with age. Among heroin overdose cases with an opioid dispensed, the rate of multiple pharmacy use was the only high-risk opioid pattern that was greater than non-overdose controls (adjusted odds ratio 3.2; 95% confidence interval 1.48 to 6.95). Discontinuation of long-term opioid use was not common prior to heroin overdose and not higher than discontinuation rates among non-overdose controls.ConclusionsAlthough individuals with a heroin-involved overdose were less likely to receive prescribed opioids in the year preceding their overdose relative to non-heroin opioid overdose cases, prescription opioid use was relatively common and increased with age. Discontinuation of long-term prescription opioid use was not associated with heroin-involved overdose.

Introduction Online data collection methods can increase study accessibility and ease the burden of data collection for participants. Asynchronous Online Focus Groups are a promising method for data collection among healthcare professionals. Methods In this article, we describe the use of, and lessons learned from conducting 19 Asynchronous Online Focus Groups across four research studies. Results We describe our experiences preparing for, recruiting for, and conducting Asynchronous Online Focus Groups. We highlight decision points around timeframe, eligibility, recruitment, participation, focus group assignment, moderation, and participant engagement. We found that removing geographic barriers was advantageous for collecting data, focus group attrition is a concern for asynchronous formats, and group assignment may affect data. Conclusions Asynchronous Online Focus Groups are a promising method for data collection among healthcare professionals. When conducting Asynchronous Online Focus Groups researchers should consider the suitability and the unique implications of this data collection method for data quality.

Hydrocodone and oxycodone are prescribed commonly to treat pain. However, differences in risk of opioid-related adverse outcomes after an initial prescription are unknown. This study aims to determine the risk of opioid-related adverse events, defined as either chronic use or opioid overdose, following a first prescription of hydrocodone or oxycodone to opioid naïve patients. A retrospective analysis of multiple linked public health datasets in the state of Oregon. Adult patients ages 18 and older who a) received an initial prescription for oxycodone or hydrocodone between 2015-2017 and b) had no opioid prescriptions or opioid-related hospitalizations or emergency department visits in the year preceding the prescription were followed through the end of 2018. First-year chronic opioid use was defined as ≥6 opioid prescriptions (including index) and average ≤30 days uncovered between prescriptions. Fatal or non-fatal opioid overdose was indicated from insurance claims, hospital discharge data or vital records. After index prescription, 2.8% (n = 14,458) of individuals developed chronic use and 0.3% (n = 1,480) experienced overdose. After adjustment for patient and index prescription characteristics, patients receiving oxycodone had lower odds of developing chronic use relative to patients receiving hydrocodone (adjusted odds ratio = 0.95, 95% confidence interval (CI) 0.91-1.00) but a higher risk of overdose (adjusted hazard ratio (aHR) = 1.65, 95% CI 1.45-1.87). Oxycodone monotherapy appears to greatly increase the hazard of opioid overdose (aHR 2.18, 95% CI 1.86-2.57) compared with hydrocodone with acetaminophen. Oxycodone combined with acetaminophen also shows a significant increase (aHR 1.26, 95% CI 1.06-1.50), but not to the same extent. Among previously opioid-naïve patients, the risk of developing chronic use was slightly higher with hydrocodone, whereas the risk of overdose was higher after oxycodone, in combination with acetaminophen or monotherapy. With a goal of reducing overdose-related deaths, hydrocodone may be the favorable agent.

Background Contingency management (CM) that is delivered by peer recovery support specialists and incentivizes harm reduction goals among people not seeking treatment for stimulant use has not been tested. The Peers Expanding Engagement in Stimulant Harm Reduction with Contingency Management (PEER-CM) study compares the effectiveness of two peer-facilitated CM interventions: (1) an experimental approach incentivizing achievement of client-identified harm reduction goals and (2) an enhanced standard of care approach incentivizing peer visit attendance. Methods Applying a hybrid type 1 effectiveness-implementation framework and stepped-wedge design across 14 community-based peer services sites across Oregon, the PEER-CM study trains peers to conduct CM. All sites implement the standard CM approach of incentivizing peer visit attendance. Every 2 months, two sites are randomly assigned to initiate the experimental CM condition of incentives for achieving client-directed harm reduction activities. Peers monitor progress and manage incentives. In the experimental approach, peers facilitate client progress on goal-related activities (selected from a standardized list of goals) to support the primary study outcome of reducing opioid overdoses and stimulant overamping. The intended study enrollment is approximately 80 clients per site (N = 1,120). Peer specialists participate in skills-focused coaching-to-criterion coaching process to document proficient CM delivery skills. This includes a series of group coaching sessions and an individual assessment with a standardized patient, observed and rated according to core dimensions of the Contingency Management Competence Scale. Results The primary study outcome is time until peer-reported fatal or first participant-reported non-fatal overdose or overamp (acute stimulant toxicity). Secondary outcomes include achievement of client-identified harm reduction goals and engagement in substance use disorder treatment. We will also demonstrate the feasibility of our coaching-to-criterion process by documenting peer proficiency in CM skills. Qualitative interviews with peers and their clients will explore the optimal context and implementation strategies for peer-facilitated CM. Conclusion PEER-CM is among the first trials to test the effectiveness of peer-facilitated CM for achieving harm reduction goals and reducing overdose in non-treatment-seeking people who use stimulants. The findings will generate evidence for peer-facilitated delivery of CM and application of CM to client-identified harm reduction goals. Trial Registration : This study is registered at ClinicalTrials.gov (NCT 05700994).

Background In 2015, Oregon’s Medicaid program implemented a performance improvement project to reduce high-dose opioid prescribing across its 16 coordinated care organizations (CCOs). The objective of this study was to evaluate the effect of that program on prescription opioid use and outcomes. Methods Using Medicaid claims data from 2014 to 2017, we conducted interrupted time-series analyses to examine changes in the prescription opioid use and overdose rates before (July 2014 to June 2015) and after (January 2016 to December 2017) implementation of Oregon’s high-dose policy initiative (July 2015 to December 2015). Prescribing outcomes were: 1) total opioid prescriptions 2) high-dose [> 90 morphine milligram equivalents per day] opioid prescriptions, and 3) proportion of opioid prescriptions that were high-dose. Opioid overdose outcomes included emergency department visits or hospitalizations that involved an opioid-related poisoning (total, heroin-involved, non-heroin involved). Analyses were performed at the state and CCO level. Results There was an immediate reduction in high dose opioid prescriptions after the program was implemented (− 1.55 prescription per 1000 enrollee; 95% CI − 2.26 to − 0.84; p  < 0.01). Program implementation was also associated with an immediate drop (− 1.29 percentage points; 95% CI − 1.94 to − 0.64 percentage points; p  < 0.01) and trend reduction (− 0.23 percentage point per month; 95% CI − 0.33 to − 0.14 percentage points; p  < 0.01) in the monthly proportion of high-dose opioid prescriptions. The trend in total, heroin-involved, and non-heroin overdose rates increased significantly following implementation of the program. Conclusions Although Oregon’s high-dose opioid performance improvement project was associated with declines in high-dose opioid prescriptions, rates of opioid overdose did not decrease. Policy efforts to reduce opioid prescribing risks may not be sufficient to address the growing opioid crisis.

Background Residential treatment is a common approach for treating opioid use disorder (OUD), however, few studies have directly compared it to outpatient treatment. The objective of this study was to compare OUD outcomes among individuals receiving residential and outpatient treatment. Methods A retrospective cohort study used linked data from a state Medicaid program, vital statistics, and the Substance Abuse and Mental Health Services Administration (SAMHSA) Treatment Episodes Dataset (TEDS) to compare OUD-related health outcomes among individuals treated in a residential or outpatient setting between 2014 and 2017. Multivariable Cox proportional hazards and logistic regression models examined the association between treatment setting and outcomes (i.e., opioid overdose, non-overdose opioid-related and all-cause emergency department (ED) visits, hospital admissions, and treatment retention) controlling for patient characteristics, co-morbidities, and use of medications for opioid use disorders (MOUD). Interaction models evaluated how MOUD use modified associations between treatment setting and outcomes. Results Of 3293 individuals treated for OUD, 957 (29%) received treatment in a residential facility. MOUD use was higher among those treated as an outpatient (43%) compared to residential (19%). The risk of opioid overdose (aHR 1.39; 95% CI 0.73–2.64) or an opioid-related emergency department encounter or admission (aHR 1.02; 95% CI 0.80–1.29) did not differ between treatment settings. Independent of setting, MOUD use was associated with a significant reduction in overdose risk (aHR 0.45; 95% CI 0.23–0.89). Residential care was associated with greater odds of retention at 6-months (aOR 1.71; 95% CI 1.32–2.21) but not 1-year. Residential treatment was only associated with improved retention for individuals not receiving MOUD (6-month aOR 2.05; 95% CI 1.56–2.71) with no benefit observed in those who received MOUD (aOR 0.75; 95% CI 0.46–1.29; interaction p = 0.001). Conclusions Relative to outpatient treatment, residential treatment was not associated with reductions in opioid overdose or opioid-related ED encounters/hospitalizations. Regardless of setting, MOUD use was associated with a significant reduction in opioid overdose risk.

BackgroundLong-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use.ObjectiveTo examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients.DesignRetrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges.ParticipantsPatients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients.Main MeasuresExposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation (“initiation month”). Outcome: Proportion of patients with six or more opioid fills during the subsequent year (“long-term users”).Key ResultsThere were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.ConclusionsEarly opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

Abstract Objective The pharmacist’s role and responsibilities in addressing the opioid epidemic have yet to be clearly defined, particularly from the patient’s point of view. This qualitative study explores the pharmacist’s role in promoting opioid safety from the perspective of pharmacists and patients. Design Focus groups. Setting Patient groups were held in person, and pharmacist groups were held online. Subjects Oregon pharmacists (N = 19, Mage = 39.0 years, range = 26–57 years, 58% female) and patients (N = 18, Mage = 60.1 years, range = 30–77 years, 71% female) with current experience dispensing or receiving opioid medications. Methods Pharmacists were asked about the challenges and opportunities for opioid safety monitoring and prescription dispensing. Patients were asked about their experiences accessing care, medications, and safety information. Focus group data were analyzed by a multidisciplinary team using an immersion-crystallization approach. Results Pharmacists and patients agreed that pharmacists are responsible for medication safety. Pharmacists expressed discomfort filling potentially high-risk opioid prescriptions and noted barriers such as lack of clinical information and discomfort policing high-risk prescribing. Patients were concerned about pharmacists potentially overstepping their professional responsibilities by interfering with prescribers’ clinical decisions. Conclusions Feedback from both pharmacists and patient participants suggests that there is uncertainty in the degree to which pharmacists can and should confront the prescription opioid epidemic directly. Ambiguities in the pharmacist’s role may be best clarified through structured training promoting enhanced between-party communication.