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Introduction Methadone ameliorates opioid withdrawal among hospitalized patients with opioid use disorder (OUD). To continue methadone after hospital discharge, patients must enroll in an opioid treatment program (OTP) per federal regulations. Uncontrolled opioid withdrawal is a barrier to linkage from hospital to OTP. Aim Describe a federally compliant In-Hospital Methadone Enrollment Team (IN-MEET) that enrolls hospitalized patients with OUD into an OTP with facilitated hospital to OTP linkage. Setting Seven hundred-bed university hospital in Aurora, CO. Program Description A physician dually affiliated with a hospital’s addiction consultation service and a community OTP completes an in-hospital, face-to-face medical assessment required by federal law and titrates methadone to comfort. An OTP-affiliated nurse with hospital privileges completes a psychosocial evaluation and provides case management by arranging transportation and providing weekly telephone check-ins. Program Evaluation Metrics IN-MEET enrollments completed, hospital to OTP linkage, and descriptive characteristics of patients who completed IN-MEET enrollments compared to patients who completed community OTP enrollments. Results Between April 2019 and April 2023, our team completed 165 IN-MEET enrollments. Among a subset of 73 IN-MEET patients, 56 (76.7%) presented to the OTP following hospital discharge. Compared to community OTP enrolled patients ( n  = 1687), a higher percentage of IN-MEET patients were older (39.7 years, standard deviation [SD] 11.2 years vs. 36.1 years, SD 10.6 years) and were unhoused ( n  = 43, 58.9% vs. n  = 199, 11.8%). Compared to community OTP enrolled patients, a higher percentage of IN-MEET patients reported heroin or fentanyl as their primary substance ( n  = 53, 72.6% vs. n  = 677, 40.1%), reported methamphetamine as their secondary substance ( n  = 27, 37.0% vs. n  = 380, 22.5%), and reported they injected their primary substance ( n  = 46, 63.0% vs. n  = 478, 28.3%). Conclusion IN-MEET facilitates hospital to OTP linkage among a vulnerable population. This model has the potential to improve methadone access for hospitalized patients who may not otherwise seek out treatment.

Background Early in the pandemic, the United States population experienced a sharp rise in the prevalence rates of opioid use, social isolation, and pain interference. Given the high rates of pain reported by patients on medication for opioid use disorder (MOUD), the pandemic presented a unique opportunity to disentangle the relationship between opioid use, pain, and social isolation in this high-risk population. We tested the hypothesis that pandemic-induced isolation would partially mediate change in pain interference levels experienced by patients on MOUD, even when controlling for baseline opioid use. Such work can inform the development of targeted interventions for a vulnerable, underserved population. Methods Analyses used data from a cluster randomized trial ( N  = 188) of patients on MOUD across eight opioid treatment programs. As part of the parent trial, participants provided pre-pandemic data on pain interference, opioid use, and socio-demographic variables. Research staff re-contacted participants between May and June 2020 and 133 participants (71% response rate) consented to complete a supplemental survey that assessed pandemic-induced isolation. Participants then completed a follow-up interview during the pandemic that again assessed pain interference and opioid use. A path model assessed whether pre-pandemic pain interference had an indirect effect on pain interference during the pandemic via pandemic-induced isolation. Results Consistent with hypotheses, we found evidence that pandemic-induced isolation partially mediated change in pain interference levels among MOUD patients during the pandemic. Higher levels of pre-pandemic pain interference and opioid use were both significantly associated with higher levels of pandemic-induced isolation. In addition, pre-pandemic pain interference was significantly related to levels of pain interference during the pandemic, and these pain levels were partially explained by the level of pandemic-induced isolation reported. Conclusions Patients on MOUD with higher use of opioids and higher rates of pain pre-pandemic were more likely to report feeling isolated during COVID-related social distancing and this, in turn, partially explained changes in levels of pain interference. These results highlight social isolation as a key risk factor for patients on MOUD and suggest that interventions promoting social connection could be associated with reduced pain interference, which in turn could improve patient quality of life. Trial registration NCT03931174 (Registered 04/30/2019).

A total of 60% of patients with opioid use disorder (OUD) leave treatment early. Psychosocial interventions can enhance treatment retention by addressing behavioral and mental health needs related to early treatment discontinuation, but intervention engagement is key. If well-designed, digital platforms can increase the engagement, reach, and accessibility of psychosocial interventions. Prior reviews of OUD treatment have predominantly focused on outcomes, such as reductions in substance use, without identifying the underlying behavior change principles that drive the effectiveness of interventions. This scoping review aims to document and describe recent digital psychosocial interventions, including their behavior change strategies, for patients receiving medication for OUD (MOUD). Predefined search terms were used to search Ovid, CINAHL, and PubMed databases for peer-reviewed literature published in the last 10 years. The database search resulted in 1381 relevant studies, and 16 of them remained after applying the inclusion criteria. Studies were included if they (1) evaluated a digital intervention with behavioral, psychosocial, or counseling components for people in OUD treatment and (2) were published in English in peer-reviewed journals. The 16 studies reviewed comprised 6 randomized controlled trials, 6 pilot studies, 2 qualitative studies, and 2 retrospective cohort studies. Smartphone apps (n=8) were the most prevalent intervention delivery method, with other studies using telemedicine (n=3), virtual reality (n=1), telephone calls (n=1), or text messaging (n=3) to deliver psychosocial interventions in either a synchronous (n=7) or asynchronous (n=9) manner. The digital interventions reviewed predominately delivered cognitive behavioral therapy education through a phone call (n=1), a text message (n=2), a smartphone app (n=7), or tele-counseling (n=1). The predominant behavior change strategies implemented were self-monitoring, feedback and reinforcement, psychoeducation, cue awareness, and providing instruction. One intervention reviewed uses the evidence base of mindfulness-oriented recovery enhancement. Participants in the studies reviewed indicated a preference for digital, flexible, patient-centered psychosocial interventions that emphasized improved patient-provider relationships. While randomized controlled trials comprised a significant portion of the studies, the inclusion of pilot studies and qualitative research highlights the field's ongoing exploration of feasibility and effectiveness. These findings underscore the growing role of digital health solutions in psychosocial care, though further research is needed to optimize engagement, delivery, and long-term outcomes.

Background Pharmacy administration and dispensing of methadone treatment for opioid use disorder (PADMOUD) may address inadequate capability of opioid treatment programs (OTPs) in the US by expanding access to methadone at community pharmacies nationally. PADMOUD is vastly underutilized in the US. There is no published US study on OUD patients’ perspectives on PADMOUD. Data are timely and needed to inform the implementation of PADMOUD in the US to address its serious opioid overdose crisis. Methods Patient participants of the first completed US trial on PADMOUD through electronic prescribing for methadone (parent study) were interviewed to explore implementation-related factors for PADMOUD. All 20 participants of the parent study were invited to participate in this interview study. Each interview was recorded and transcribed verbatim. Thematic analysis was conducted to identify emergent themes. Results Seventeen participants completed the interview. Patients’ perspectives on PADMOUD were grouped into five areas. Participants reported feasibility of taking the tablet formulation of methadone at the pharmacy and identified benefits from PADMOUD (e.g., better access, efficiency, convenience) compared with usual care at the OTP. Participants perceived support for PADMOUD from their family/friends, OTP staff, and pharmacy staff. PADMOUD was perceived to be a great option for stable patients with take-home doses and those with transportation barriers. The distance (convenience), office hours, and the cost were considered factors most influencing their decision to receive methadone from a pharmacy. Nonjudgmental communication, pharmacists’ training on methadone treatment, selection of patients (stable status), workflow of PADMOUD, and protection of privacy were considered key factors for improving operations of PADMOUD. Conclusion This study presents the first findings on patient perspectives on PADMOUD. Participants considered pharmacies more accessible than OTPs, which could encourage more people to receive methadone treatment earlier and help transition stable patients from an OTP into a local pharmacy. The findings have timely implications for informing implementation strategies of PADMOUD that consider patients’ views and needs.

Background In March 2020, federal regulations were updated to improve access to methadone for people with opioid use disorder (OUD) during COVID-19, and in February 2024, these COVID-19 flexibilities were further updated and made permanent. During the same time, high rates of fentanyl use and opioid overdose persisted in Vermont and New Hampshire. It was not well known how opioid treatment programs (OTPs) were meeting the needs of patients who continued to use fentanyl while on methadone. This study explored the experiences of patients who used fentanyl while on methadone for OUD and their suggestions to improve care. Methods Semi-structured one-hour interviews and a brief survey were conducted with 30 patients who continued to use fentanyl while on methadone from 5 OTPs within 3 healthcare facilities in Vermont ( n  = 14) and New Hampshire ( n  = 16) from March 2023 to November 2024. Interviews focused on patient experiences with medication induction, dosing, fentanyl use, access to harm reduction materials, and recommendations to improve care. Interviews were audio recorded, transcribed, and analyzed using general thematic analysis. Results Most participants identified as White (90%; n  = 27), male (53%; n  = 16), and were unemployed (73%; n  = 22). Patients’ current daily methadone dose ranged from 35 to 220 mg, with commuting times from 10 to over 60 min. Six major themes were identified. Patients reported continuing fentanyl until reaching a sufficient methadone dose, after which fentanyl use decreased or stopped. Discomfort or withdrawal during induction was common, often triggering continued fentanyl use. Access to take-home doses was restricted and varied by state and OTP. Split dosing helped some manage cravings and reduce over-sedation for others. Naloxone and fentanyl test strips were highly accessible. Participants suggested structural changes to lower barriers to care, such as extending OTP hours and dosing windows. Three sub-theme patient recommendations to improve care also emerged including: (1) implementing a faster induction process, (2) increased access to take-home doses, and (3) expanded split dosing in OTPs. Conclusions This study highlights the importance of leveraging the expertise of patients who use fentanyl while on methadone to co-produce methadone treatment delivery. Findings may help inform the development of interventions to reduce barriers to treatment access and success within rural areas which may be slow to implement policy change.

Background U.S. policy intervention to increase methadone treatment accommodations during COVID did not result in national adoption of the new patient-centered treatment practices. Staff-level interventions may facilitate adoption of these treatment practices, but this will depend upon knowledge about staff level characteristics and beliefs. Currently, the role of clinic staff characteristics, beliefs about patient-centeredness, and perceptions about the need for treatment practice change is unknown. This study explored the relationship between opioid treatment program staff characteristics, work roles and staff beliefs to identify opportunities for future staff-level treatment practice change interventions. Methods Staff of three Arizona opioid treatment programs were surveyed (n = 40) from April 11–22, 2023 using a hybrid online survey method. The 161 survey items required less than 30 min to complete. Pearson point biserial correlation coefficients assessed the covariation between staff beliefs, staff characteristics and staff work roles. Perception of the clinic as person-centered was a potential proxy indicator for staff awareness of discontinuity between the clinic’s person-centeredness and person-centered approaches to methadone treatment. Results Among staff, 47.5% reported lived substance use disorder experience and 27.5% reported lived opioid use disorder experience. Most staff (70%) held at least 1 prior clinic role at the current clinic and 5% had had more than 4 prior roles. Rotation was observed with roles that did not require licensure or degrees. Staff with lived experience with substance use disorder or opioid use disorder treatment reported having more prior roles at the clinic than those without such experience. Abstinence-oriented views were significantly associated with reporting vicarious (work related) trauma symptoms. Those who rated the clinic as significantly more person-centered were staff with lived substance use disorder experience who also held abstinence-oriented views, staff with trauma exposure, and staff with lived opioid use disorder treatment experience who held harm reduction beliefs. In contrast, staff without substance use disorder experience who held harm reduction beliefs perceived the clinic as less person-centered. Conclusions Staff beliefs, personal and work characteristics are likely factors in the recognition of need for clinic practice change. How these characteristics function in a clinic culture may also be influenced by clinic staffing patterns. A patient-to-provider pipeline with role cycling was observed and this staffing pattern may also influence shared beliefs of trauma-informed care or clinic person-centeredness. Vicarious trauma may also be an important factor. Larger studies should examine these relationships further to understand mechanisms associated with recognition of need for clinic practice change in order to inform staff-level interventions to increase opioid treatment program patient-centeredness.

Background People with substance use disorders are vulnerable to acquiring HIV. Testing is fundamental to diagnosis, treatment, and prevention; however, in the past decade, there has been a decline in the number of substance use disorder (SUD) treatment programs offering on-site HIV testing. Fewer than half of SUDs in the USA offer on-site HIV testing. In addition, nearly a quarter of newly diagnosed cases have AIDS at the time of diagnosis. Lack of testing is one of the main reasons that annual HIV incidences have remained constant over time. Integration of HIV testing with testing for HCV, an infection prevalent among persons vulnerable to HIV infection, and in settings where they receive health services, including opioid treatment programs (OTPs), is of great public health importance. Methods/design In this 3-arm cluster-RCT of opioid use disorders treatment programs, we test the effect of two evidence-based “practice coaching” (PC) interventions on the provision and sustained implementation of on-site HIV testing, on-site HIV/HCV testing, and linkage to care. Using the National Survey of Substance Abuse Treatment Services data available from SAMHSA, 51 sites are randomly assigned to one of the three conditions: practice coach facilitated structured conversations around implementing change, with provision of resources and documents to support the implementation of (1) HIV testing only, or (2) HIV/HCV testing, and (3) a control condition that provides a package with information only. We collect quantitative (e.g., HIV and HCV testing at 6-month-long intervals) and qualitative site data near the time of randomization, and again approximately 7–12 months after randomization. Discussion Innovative and comprehensive approaches that facilitate and promote the adoption and sustainability of HIV and HCV testing in opioid treatment programs are important for addressing and reducing HIV and HCV infection rates. This study is one of the first to test organizational approaches (practice coaching) to increase HIV and HIV/HCV testing and linkage to care among individuals receiving treatment for opioid use disorder. The study may provide valuable insight and knowledge on the multiple levels of intervention that, if integrated, may better position OTPs to improve and sustain testing practices and improve population health. Trial registration ClinicalTrials.gov NCT03135886. Registered on 2 May 2017.

Background In the United States, methadone for opioid use disorder (OUD) is limited to highly regulated opioid treatment programs (OTPs), rendering it inaccessible to many patients. The “72-hour rule” allows non-OTP providers to administer methadone for emergency opioid withdrawal management while arranging ongoing care. Low-barrier substance use disorder (SUD) bridge clinics provide rapid access to buprenorphine but offer an opportunity to treat acute opioid withdrawal while facilitating OTP linkage. We describe the case of a patient with OUD who received methadone for opioid withdrawal in a bridge clinic and linked to an OTP within 72 h. Case presentation A 54-year-old woman with severe OUD was seen in a SUD bridge clinic requesting OTP linkage and assessed with a clinical opiate withdrawal scale (COWS) score of 12. She reported daily nasal use of 1 g heroin/fentanyl. Prior OUD treatment included buprenorphine-naloxone, which was only partially effective. Her acute opioid withdrawal was treated with a single observed oral dose of methadone 20 mg. She returned the following day with persistent opioid withdrawal (COWS score 11) and was treated with methadone 40 mg. On day 3, the patient was successfully admitted to a local OTP, where she remained engaged 3 months later. Conclusions While patients continue to face substantial access barriers, bridge clinics can play an important role in treating opioid withdrawal, building partnerships with OTPs to initiate methadone on demand, and preventing life-threatening delays to methadone treatment. Federal policy reform is urgently needed to make methadone more accessible to people with OUD.

Background Federal and state regulations require frequent direct observation of methadone ingestion at an Opioid Treatment Program (OTP)—a requirement that creates barriers to patient access. Video observed therapy (VOT) may help to address public health and safety concerns of providing take-home medications while simultaneously reducing barriers to treatment access and long-term retention. Evaluating user experiences with VOT is important for understanding the acceptability of this strategy. Methods We conducted a qualitative evaluation of a clinical pilot program of VOT via smartphone that was rapidly implemented between April and August 2020 during the COVID-19 pandemic within three opioid treatment programs. In the program, selected patients submitted video recordings of themselves ingesting methadone take-home doses, which were asynchronously reviewed by their counselor. We recruited participating patients and counselors for semi-structured, individual interviews to explore their VOT experiences after program completion. Interviews were audio recorded and transcribed. Transcripts were analyzed using thematic analysis to identify key factors influencing acceptability and the effect of VOT on the treatment experience. Results We interviewed 12 of the 60 patients who participated in the clinical pilot and 3 of the 5 counselors. Overall, patients were enthusiastic about VOT, noting multiple benefits over traditional treatment experiences, including avoiding frequent travel to the clinic. Some noted how this allowed them to better meet recovery goals by avoiding a potentially triggering environment. Most appreciated having increased time to devote to other life priorities, including maintaining consistent employment. Participants described how VOT increased their autonomy, allowed them to keep treatment private, and normalized treatment to align with other medications that do not require in-person dosing. Participants did not describe major usability issues or privacy concerns with submitting videos. Some participants reported feeling disconnected from counselors while others felt more connected. Counselors felt some discomfort in their new role confirming medication ingestion but saw VOT as a useful tool for select patients. Conclusions VOT may be an acceptable tool to achieve equipoise between lowering barriers to treatment with methadone and protecting the health and safety of patients and their communities.

Background Organizational responses to crises can profoundly impact the operations and functioning of programs. Specifically, the COVID-19 pandemic led to an 18% increase in drug overdoses and necessitating significant protocol adjustments. We examined opioid treatment programs (OTPs) responses to the pandemic, and associations with clients' perceptions of COVID-19 concerns and perceptions of effect and overall impact. Methods Data from 2023 encompassing 92 OTPs and 435 client surveys were analyzed using multilevel regression models. Dependent variables measured clients COVID-19 exposure concerns, and perception of the pandemic’s broader impact. Independent variables included types of response, staff composition, funding, and accreditation. Results Clients in programs with higher proportions of African Americans, 1.02 (95% Confidence Interval CI = 1.00—1.03) or Latino staff, 1.03 (CI = 1.01—1.04) expressed significantly greater concern about COVID-19 exposure. Conversely, clients in publicly funded programs reported significantly lower concern about exposure, 0.37 (CI = 0.15—0.90). On the other hand, programs with more administrative responsiveness, 1.44 (CI = 0.07—2.80), or accreditation by the Commission on Accreditation of Rehabilitation Facilities, 1.90 (CI = 0.13—3.67), were associated with significantly higher perceived overall impact of the pandemic, respectively. Conclusion This study highlights the intricate connection between program characteristics and organizational responses during public health crises. Our findings underscore the importance of culturally sensitive approaches and effective communication to address client COVID-19 concerns and perceptions, particularly within disproportionately affected minority communities. These insights emphasize the necessity for OTPs to adapt to meet the evolving needs of clients, ensuring that they receive the support and care required during uncertainties. Highlights • Clients of OTPs with a higher proportion of minority staff reported greater COVID-19 concerns • Publicly funded programs were associated with lower client concerns about exposure • Greater administrative responsiveness was associated with higher perceived effect of COVID-19 • Greater administrative responsiveness was marginally associated with a decline in exposure concerns • Accreditation by CARF was associated with higher perceived effect of COVID-19