Background and aims Evidence from randomized controlled trials establishes that medication treatment with methadone and buprenorphine reduces opioid use and improves treatment retention. However, little is known about the role of such medications compared with non‐medication treatments in mitigating overdose risk among US patient populations receiving treatment in usual care settings. This study compared overdose mortality among those in medication versus non‐medication treatments in specialty care settings. Design Retrospective cohort study using state‐wide treatment data linked to death records. Survival analysis was used to analyze data in a time‐to‐event framework. Setting Services delivered by 757 providers in publicly funded out‐patient specialty treatment programs in Maryland, USA between 1 January 2015 and 31 December 2016. Participants A total of 48 274 adults admitted to out‐patient specialty treatment programs in 2015–16 for primary diagnosis of opioid use disorder. Measurements Main exposure was time in medication treatment (methadone/buprenorphine), time following medication treatment, time exposed to non‐medication treatments and time following non‐medication treatment. Main outcome was opioid overdose death during and after treatment. Hazard ratios were calculated using Cox proportional hazard regression. Propensity score weights were adjusted for patient information on sex, age, race, region of residence, marital and veteran status, employment, homelessness, primary opioid, mental health treatment, arrests and criminal justice referral. Findings The study population experienced 371 opioid overdose deaths. Periods in medication treatment were associated with substantially reduced hazard of opioid overdose death compared with periods in non‐medication treatment [adjusted hazard ratio (aHR) = 0.18, 95% confidence interval (CI) = 0.08–0.40]. Periods after discharge from non‐medication treatment (aHR = 5.45, 95% CI = 2.80–9.53) and medication treatment (aHR = 5.85, 95% CI = 3.10–11.02) had similar and substantially elevated risks compared with periods in non‐medication treatments. Conclusions Among Maryland patients in specialty opioid treatment, periods in treatment are protective against overdose compared with periods out of care. Methadone and buprenorphine are associated with significantly lower overdose death compared with non‐medication treatments during care but not after treatment is discontinued.

People in the US criminal justice system experience high rates of opioid use disorder, overdose, and other adverse outcomes. Expanding treatment is a key strategy for addressing the opioid epidemic, but little is known about whether the criminal justice system refers people to the highest standard of treatment: the use of the opioid agonist therapies methadone or buprenorphine. We used 2014 data from the national Treatment Episode Data Set to examine the use of agonist treatment among justice-involved people referred to specialty treatment for opioid use disorder. Only 4.6 percent of justice-referred clients received agonist treatment, compared to 40.9 percent of those referred by other sources. Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder.

Background Evidence suggests that individuals with history of substance use disorder (SUD) are at increased risk of COVID-19, but little is known about relationships between SUDs, overdose and COVID-19 severity and mortality. This study investigated risks of severe COVID-19 among patients with SUDs. Methods We conducted a retrospective review of data from a hospital system in New York City. Patient records from 1 January to 26 October 2020 were included. We assessed positive COVID-19 tests, hospitalizations, intensive care unit (ICU) admissions and death. Descriptive statistics and bivariable analyses compared the prevalence of COVID-19 by baseline characteristics. Logistic regression estimated unadjusted and sex-, age-, race- and comorbidity-adjusted odds ratios (AORs) for associations between SUD history, overdose history and outcomes. Results Of patients tested for COVID-19 ( n = 188 653), 2.7% ( n = 5107) had any history of SUD. Associations with hospitalization [AORs (95% confidence interval)] ranged from 1.78 (0.85–3.74) for cocaine use disorder (COUD) to 6.68 (4.33–10.33) for alcohol use disorder. Associations with ICU admission ranged from 0.57 (0.17–1.93) for COUD to 5.00 (3.02–8.30) for overdose. Associations with death ranged from 0.64 (0.14–2.84) for COUD to 3.03 (1.70–5.43) for overdose. Discussion Patients with histories of SUD and drug overdose may be at elevated risk of adverse COVID-19 outcomes.

Purpose The American Academy of Pediatrics recently recommended that pediatricians consider medication-assisted treatment (MAT) for adolescents with severe opioid use disorders. Little is known about adolescents’ current use of MAT. Methods We use data on episodes of specialty treatment for heroin or opioid use (n = 139,092) from a database of publicly funded treatment programs in the U.S. We compare the proportions of adolescents and adults who received MAT, first using unadjusted comparison of proportions, then using logistic regression to adjust for potential confounders. Results Only 2.4% (95% confidence interval [CI], 1.4%–3.7%) of adolescents in treatment for heroin received MAT, as compared to 26.3% (95% CI, 26.0%–26.6%) of adults. Only .4% (95% CI, .2%–.7%) of adolescents in treatment for prescription opioids received MAT, as compared to 12.0% (95% CI, 11.7%–12.2%) of adults. Regression-adjusted results were qualitatively similar. Conclusions Regulatory changes and expansions of Medicaid/CHIP coverage for MAT may be needed to improve MAT access.

No abstract

Background: Opioid use disorder (OUD) is highly prevalent among justice-involved individuals. While risk for overdose and other adverse consequences of opioid use are heightened among this population, most justice-involved individuals and other high-risk groups experience multiple barriers to engagement in opioid agonist treatment. Methods: This paper describes the development of Project Connections at Re-Entry (PCARE), a low-threshold buprenorphine treatment program that engages vulnerable patients in care through a mobile van parked directly outside the Baltimore City Jail. Patients are referred by jail staff or can walk in from the street. The clinical team includes an experienced primary care physician who prescribes buprenorphine, a nurse, and a peer recovery coach. The team initiates treatment for those with OUD and refers those with other needs to appropriate providers. Once stabilized, patients are transitioned to longer-term treatment programs or primary care for buprenorphine maintenance. This paper describes the process of developing this program, patient characteristics and initial outcomes for the first year of the program, and implications for public health practice. Results: From November 15, 2017 through November 30, 2018, 220 people inquired about treatment services and completed an intake interview, and 190 began treatment with a buprenorphine/naloxone prescription. Those who initiated buprenorphine were primarily male (80.1%), African American (85.1%), had a mean age of 44.1 (SD = 12.2), and a mean of 24.0 (SD = 13.6) years of opioid use. The majority of patients (94.4%) had previous criminal justice involvement, were unemployed (72.9%) and were unstably housed (70.8%). Over a third (32.1%) of patients had previously overdosed. Of those who began treatment, 67.9% returned for a second visit or more, and 31.6% percent were still involved in treatment after 30 days. Of those who initiated care, 20.5% have been transferred to continue buprenorphine treatment at a partnering site. Conclusions: The PCARE program illustrates the potential for low-threshold buprenorphine treatment to engage populations who are justice-involved and largely disconnected from care. While more work is needed to improve treatment retention among vulnerable patients and engaging persons in care directly after release from detention, offering on-demand, flexible and de-stigmatizing treatment may serve as a first point to connect high-risk populations with the healthcare system and interventions that reduce risk for overdose and related harms.

Background Psychiatric disorders are highly comorbid with substance use disorders and play an important role in their course and recovery. However, the impact of comorbidity on treatment outcomes has not been examined in a U.S. national sample. This study explores the impact of psychiatric comorbidity on treatment completion among individuals admitted to publicly funded substance use treatment facilities across the United States. Methods Using data on first-time treatment episodes in the U.S. from the Treatment Episode Dataset-Discharges (TEDS-D) for the years 2009–2011, logistic regression was used to assess the association between psychiatric comorbidity and treatment non-completion, and Cox proportional hazards regression was used to assess the association between comorbidity and rate of attrition. Analyses were performed for all substances together and then stratified by primary substance of abuse (alcohol, cannabis, stimulants, or opioids). Results Of 856,385 client treatment episodes included in our analysis, 28% had a psychiatric comorbidity and 38% did not complete treatment. After adjusting for socio-demographic and treatment characteristics, clients with psychiatric comorbidity had higher odds of not completing treatment relative to those without comorbidity [OR = 1.28 (1.27–1.29)], and had an earlier time to attrition [HR = 1.14 (1.13–1.15)]. Psychiatric comorbidity was most strongly associated with treatment non-completion and rate of attrition in those admitted primarily for alcohol [OR = 1.37 (1.34–1.39); HR = 1.19 (1.17–1.21), respectively]. Conclusions Individuals with psychiatric comorbidities receiving treatment for substance use disorders face unique challenges that impact their ability to complete treatment. The findings call for further efforts to integrate treatment for psychiatric comorbidities in substance use treatment settings.

No abstract