Perceptions of extended-release naltrexone, methadone, and buprenorphine treatments following release from jail

Abstract

Background Few studies have documented patient attitudes and experiences with extended-release naltrexone (XR-NTX) opioid relapse prevention in criminal justice settings. This study assessed barriers and facilitators of jail-to-community reentry among adults with opioid use disorder (OUD) treated with XR-NTX, buprenorphine, methadone, and no medications. Methods This qualitative study conducted individual interviews with a purposeful and convenience sample of adults with OUD who were recently released from NYC jails. XR-NTX, no medication, and methadone participants were concurrently enrolled in a large randomized controlled trial evaluating XR-NTX vs. a no medication Enhanced Treatment As Usual (ETAU) condition, or enrolled in a non-randomized quasi-experimental methadone maintenance cohort. Buprenorphine participants were referred from NYC jails to a public hospital office-based buprenorphine program and not enrolled in the parent trial. Interviews were audio recorded, transcribed, independently coded by two researchers, and analyzed per a grounded theory approach adapted to the Social Cognitive Theory framework. The research team reviewed transcripts and coding to reach consensus on emergent themes. Results N = 33 adults with OUD (28 male, 5 female) completed a single individual interview. Purposeful sampling recruited persons leaving jail on XR-NTX (n = 11), no active medication treatment (n = 9), methadone (n = 9), and buprenorphine (n = 4). Emergent themes were: (1) general satisfaction with XR-NTX’s long-acting antagonist effects and control of cravings; (2) “testing” XR-NTX’s blockade with heroin upon reentry was common; (3) early discontinuation of XR-NTX treatment was most common among persons with high self-efficacy and/or heavy exposure to drug use environments and peers; (4) similar satisfaction regarding effects of methadone and buprenorphine maintenance among retained-in-treatment individuals, alongside general dissatisfaction with daily observed dosing requirements and misinformation and stigmas regarding methadone adverse effects; (5) unstable housing, economic insecurity, and exposure to actively using peers were attributed to early termination of treatment and relapse; (6) individual motivation and willpower as central to long-term opioid abstinence and reentry success. Conclusions In the context of more familiar agonist maintenance treatments, XR-NTX relapse prevention during jail-to-community reentry was viewed as a helpful and unique intervention though with important limitations. Commonly described barriers to treatment retention and heroin abstinence included homelessness, economic insecurity, and drug-using peers. Trial registration ClinicalTrials.gov, NCT01999946 (XOR), Registered 03 December 2013, https://clinicaltrials.gov/ct2/show/NCT01999946.

‘Not at all what I had expected’: Discontinuing treatment with extended-release naltrexone (XR-NTX): A qualitative study

“…Participants perceived both issues as deal-breakers, but not surprisingly, they described feeling the effect of buprenorphine as particularly disappointing. Participants typically described illicit opioid use while on XR-NTX as "testing the blockade", and patients in previous studies have also reported doing this (Fishman, 2008;Jarvis, DeFulio, et al, 2018a;Kruptisky et al, 2007;Kunøe et al, 2010;Velasquez et al, 2019). Studies have previously reported subjective effects of opioids, but consensus seems to be that the "high" is not as great (as high) as it was before initiation to NTX (Jarvis, DeFulio, et al, 2018a;Kunøe et al, 2010).…”

“…Research on patients' experiences of discontinuation of XR-NTX treatment is limited. Velasquez et al (2019) assessed the perceptions of participants recently released from NYC jails, who received treatment with XR-NTX, opioid agonist treatment, or no treatment at all. Although seen as a useful post-release intervention by many, the authors found that those who discontinued XR-NTX treatment described the decision as intentional, often driven by a desire to resume opioid use.…”

Adaptation of a standard extended-release naltrexone (XR-NTX) protocol for rural re-entering offenders with OUD

“…DOC focus group findings also suggested that re-entry to the community from jail is a high-risk and chaotic period for justice-involved individuals. It is possible that life eventssuch as finding safe housing or stable employmentmay supersede the perception of the importance of treatment and negatively impact adherence to XR-NTX post-release, which has been noted elsewhere (Velasquez et al, 2019). In addition, if an individual relapses or engages in criminal activity after release, he/ she may abscond from supervisionmaking XR-NTX administration in the community supervision office not feasible.…”

“…The community re-entry period following release can be stressful due to housing, income, transportation, and relationship problems. Additionally, adherence to a medication regime that requires developing a relationship with a new health care provider with at least monthly clinic visits can also be challenging (Velasquez et al, 2019).…”

Reducing overdose after release from incarceration (ROAR): study protocol for an intervention to reduce risk of fatal and non-fatal opioid overdose among women after release from prison

“…A common barrier to initiating treatment, as reported in a population of justice-involved veterans, includes limited availability of pharmacotherapy treatment options (Finlay et al, 2016). Treatment retention is further impacted by housing insecurity, lack of financial resources, exposure to actively using friends and family, and lack of knowledge; these barriers emphasize the need for post-incarceration treatment plans that clearly specify medications for opioid use disorders (MOUD) (Velasquez et al, 2019). Another barrier is providers who are not supportive of pharmacotherapy (Harris et al, 2012).…”