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BACKGROUND: Opioid use disorder (OUD) poses a global health challenge, and despite medications for opioid use disorder (MOUD) and psychosocial interventions, relapse remains a significant concern. Comorbid psychiatric disorders, including attention deficit hyperactivity disorder (ADHD), are one of the major factors associated with poor OUD treatment outcome. We aimed to estimate the frequency of probable ADHD (in childhood and in adulthood) in patients with OUD; to assess the factors associated with this comorbidity; and to explore the factors that mediate the relationship between ADHD and OUD treatment outcome. METHODS: We conducted an observational study using a sample of 229 patients aged 18 years and older who were diagnosed with OUD and had received MOUD for at least six months. Participants were assessed through a structured interview and self-report questionnaires. Multivariate logistic regressions and a mediation analysis were performed. RESULTS: Almost half of the participants reported probable ADHD in childhood, and ADHD persisted into adulthood among two-thirds of the patients. The factors associated with poor OUD treatment outcome included earlier onset of OUD, lower education, and greater impulsivity. There was no direct effect of probable ADHD in childhood on OUD treatment outcome, but there was an indirect effect through negative urgency, the tendency to respond impulsively to negatively connoted emotional experiences. CONCLUSIONS: The findings suggest that ADHD symptoms, particularly impulsivity, may contribute to vulnerability in opioid use and play a crucial role in treatment outcomes for this population. TRIAL REGISTRATION: ClinicalTrials identifier NCT01847729.

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BACKGROUND: Accessible, manualized, skill-based training ready for wide dissemination is needed to prepare healthcare staff to meet the needs of people impacted by the opioid epidemic. METHODS: A 2-day workshop and simulation training was designed by an interprofessional substance use disorder (SUD) specialty care team, adapted to a virtual platform, manualized, and offered to healthcare staff and trainees from a large healthcare system. The workshop was offered 6 times over the course of 10 months with a total of 177 participants from across the United States enrolled in the training. Interactive experiential learning strategies including games designed to test knowledge, small-group case discussions, video demonstrations of skills, patient panels, and 3 simulations of a patient with chronic pain who developed opioid use disorder in the context of long-term opioid therapy were utilized in efforts to build skills and confidence managing SUDs in primary care and general mental health settings. RESULTS: Of those who completed the post-workshop survey, most found both content and training structure useful, particularly content related to medication management, stigma, and collaborative care. In addition, overall confidence scores in assessing, diagnosing, and treating SUD increased. Skill building exercises, such as interprofessional team simulations, were highlighted as most beneficial. The workshop received national attention leading to a partnership with the healthcare system's simulation center for wider dissemination. CONCLUSION: Expanding access to SUD treatment requires training healthcare staff to effectively change attitudes, increase knowledge, and improve key skills. This 2-day interprofessional workshop was well-received by participants who reported high acceptability and satisfaction scores and demonstrated improved confidence in the management of SUDs. This type of manualized, collaborative, skill-based learning experience can foster staff preparedness and willingness to conceptualize SUD as a chronic condition amenable to treatment in different healthcare settings.

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BACKGROUND: Opioid use disorder (OUD) among young adults (YAs) continues to persist as a national health crisis. Best practice recommendations for YA OUD treatment highlight the importance of medication for OUD (MOUD) and family involvement across the treatment services continuum for better treatment retention and outcomes. Yet, concerned significant others (CSOs) such as family members, romantic partners, and family-of-choice members are not routinely involved in OUD and MOUD treatment for YAs. METHOD: We used convenience sampling to recruit 25 YAs (ages 21 to 36) in treatment for OUD from two urban treatment centers. We discussed with YAs the identities of their CSOs and the dynamics of those relationships, their perspectives on CSO involvement in their OUD treatment, and the beliefs and attitudes they hold about family involvement in treatment and recovery. Thematic content analysis was deductive-dominant based on a semi-structured qualitative interview guide. Group consensus coding was followed by matrix analysis. RESULTS: We identified five main themes: (1) YA and CSO relationships were supportive, evolving, and complex. (2) CSO support motivated treatment engagement and participation. (3) Only a small proportion of CSOs participated in treatment activities despite actively supporting treatment in other ways. (4) YAs experienced their CSOs as supportive of their treatment and recovery goals, including MOUD. (5) YAs believed family involvement is essential to treatment and many were unsatisfied with current family involvement in their care. CONCLUSIONS: In this qualitative study of OUD treatment experiences among YAs, we learned that many YAs have CSOs who are invested in their treatment and recovery and yet are not routinely involved in treatment. Moreover, YAs often expressed family involvement is essential to OUD treatment, and many expressed a desire for greater family involvement in their own treatment. Clinical recommendations for relationship-oriented treatment are presented.

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INTRODUCTION: Methadone and buprenorphine are effective treatment for opioid use disorder (OUD), yet they are vastly under-utilized across US hospitals. To inform a national trial assessing the effectiveness of implementation strategies to increase adoption of an inpatient hospital-based opioid treatment (HBOT) model (NCT04921787), we explored barriers and facilitators to expanding medication for opioid use disorder (MOUD) within community hospitals across the United States. METHODS: From November 2021 to March 2022, we used purposeful and snowball sampling to identify and interview participants involved in inpatient care of patients with OUD from twelve community hospitals. We conducted semi-structured interviews on providers' experiences and perspectives on current treatment approaches as well as potential influences on MOUD expansion in their hospitals. We used thematic analysis to identify key barriers and facilitators that could impact implementation of an HBOT model, and organized these findings based on the Consolidated Framework for Implementation Research (CFIR). RESULTS: From qualitative interviews with 57 participants (30 physicians, 7 pharmacists, 6 nurses, and 14 professionals involved in the care of patients with OUD), we identified key barriers and facilitators mapped to CFIR's internal and outer settings. The most salient inner setting domains included tension for change and relative priority, compatibility, available resources, organizational culture, access to knowledge and information, relational connections and communications, and information technology infrastructure. Outer setting domains included policies and laws, financing, and partnerships and connections. CONCLUSIONS: Identifying potential barriers and facilitators can inform hospital-specific strategies to support implementation of HBOT. Implementation strategies that address barriers such as staff availability, knowledge, and attitudes may support increased HBOT adoption. On a broader scale, national policy changes such as increased financing and public reporting of quality metrics would address other barriers we identified and may also encourage hospitals to adopt HBOT models.

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INTRODUCTION: Despite effective medications for opioid use disorder (MOUD), treatment engagement remains low. As the overdose crisis is increasingly characterized by opioids co-used with other substances, it is important to understand whether existing models effectively support treatment for patients who use multiple substances. Hospital-based addiction consultation services (ACS) have shown promise at increasing MOUD initiation and treatment engagement, but the effectiveness for patients with specific co-use patterns remains unknown. METHODS: Using 2016-2023 admissions data from a large safety net hospital, we estimated a random-effects logistic regression model to determine whether specific co-use (methamphetamine, cocaine, alcohol, sedative, and other) moderated the effect of being seen by ACS on the receipt of MOUD. Adjusting for patient sociodemographic, health, and admission characteristics we estimated the proportion of patients who received MOUD across specific co-use groups. RESULTS: Of 7679 total admissions indicating opioid use, of which 5266 (68.6 %) indicated co-use of one or more substances and 2387 (31.1 %) were seen by the ACS. Among admissions not seen by the ACS, a smaller proportion of admissions with any co-use received MOUD (23.5 %; 95 % CI: 21.9-25.1) compared to admissions with opioid use alone (34.0 %; 95 % CI: 31.9-36.1). However, among admissions seen by the ACS a similar proportion of admissions with any co-use received MOUD (57.8 %; 95 % CI: 55.5-60.1) as admissions with opioid use alone (56.2 %; 95 % CI: 52.2-60.2). The increase in proportion of admissions receiving MOUD associated with being seen by the ACS was larger for admissions with methamphetamine (38.6 percentage points; 95 % CI: 34.6-42.6) or cannabis co-use (39.0 percentage points; 95 % CI: 32.9-45.1) compared to admissions without methamphetamine (25.7 percentage points; 95 % CI: 22.2-29.2) or cannabis co-use (29.1 percentage points; 95 % CI: 26.1-32.1). CONCLUSIONS: The ACS is an effective hospital-based treatment model for increasing the proportion of admissions which receive MOUD. This study shows that ACSs are also able to support increased receipt of MOUD for patients who use other substances in addition to opioids. Future research is needed to further understand what transition strategies best support treatment linkage for patients who use multiple substances.

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BACKGROUND: Incarceration provides an opportunity for health interventions, including opioid use disorder (OUD) treatment and prevention of opioid-related overdoses post-release. All FDA-approved forms of medication for OUD (MOUD) treatment were mandated in several Massachusetts jails in 2019, with some jails offering extended-release buprenorphine (XR-Bup). Little is known about patient perspectives on and experiences with XR-Bup in carceral settings. METHODS: We conducted semi-structured interviews in 2022 with community-dwelling people who received MOUD during a recent incarceration in a Massachusetts jail. We asked participants about their experiences with and perspectives on XR-Bup while in jail. Qualitative data were double-coded deductively and reviewed inductively to identify emergent themes, which were structured using the Theoretical Framework of Acceptability (TFA). RESULTS: Participants (n = 38) had a mean age of 41.5 years, were 86% male, 84% White, 24% Hispanic, and 95% continued to receive MOUD at the time of their interview, including 11% receiving XR-Bup. Participants who viewed XR-Bup favorably appreciated avoiding the taste of sublingual buprenorphine; avoiding procedural difficulties and indignities associated with daily dosing in carceral settings (e.g., mouth checks, stigmatizing treatment from correctional staff); avoiding daily reminders of their addiction; experiencing less withdrawal; having extra time for other activities, such as work; and reduction of diversion of MOUD within the jail setting. Participants who viewed XR-Bup less favorably preferred to maintain their daily dosing routine; liked daily time out of their housing unit; wanted to know what was "going into my body everyday"; and feared needles and adverse events. Participants also reported that jail clinicians used XR-Bup for patients who were previously caught diverting sublingual buprenorphine, suggesting limited patient participation in decision-making around XR-Bup initiation in some jails. CONCLUSION: People who received MOUD in Massachusetts jails had both favorable and unfavorable views and experiences with XR-Bup. Understanding these preferences can inform protocols in jails that are considering implementation of XR-Bup treatment.

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Introduction: There is limited research examining factors impacting MOUD retention in rural settings, especially within the context of the COVID-19 pandemic. Using electronic health records data collected as part of a NIDA Clinical Trials Network study (CTN-0102), this study explored how the onset of the COVID-19 pandemic may have impacted MOUD retention in a sample of 563 rural primary care patients. Methods: Cox regression model was applied to examine if COVID-19 was related to treatment retention, controlling for demographics, clinic, insurance type, and other diagnoses. The independent variable was the number of days between the patient's first MOUD prescription date during the pre-COVID observation period (10/1/2019-3/13/2020) and the start of the COVID-19 pandemic. The dependent variable was retention on MOUD, defined as the time from the first MOUD prescription documented during the pre-COVID observation period to the first break in consecutive MOUD prescriptions (right censored at 180 days). Results: The findings demonstrated that there was a reduced risk of a prescription break for every 10-day increase in the time from the first documented MOUD prescription to the onset of the COVID-19 pandemic (HR = 0.96, 95 % CI = 0.92-0.99; p = 0.011). Conclusions: While the data did not include complete treatment histories to determine who was new to MOUD treatment, the findings suggest that patients whose first documented MOUD prescription in the dataset was closer to the onset of the pandemic had a greater likelihood of experiencing retention challenges. This underscores the importance for clinics to establish comprehensive contingency plans for future emergencies to ensure uninterrupted MOUD treatment and support, particularly for individuals in the early stabilization phase of their recovery.

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BACKGROUND: The opioid epidemic disproportionately affects individuals with co-occurring opioid use and mental health disorders (COD), who often have poor treatment engagement. Multicomponent treatment models are popular solutions to increase treatment access and engagement for those with COD. Maintaining Independence and Sobriety through Systems Integration, Outreach and Networking (MISSION) is a hybrid multicomponent linkage and treatment approach that provides assertive community outreach combined with psychosocial treatment. This protocol paper describes a randomized controlled trial comparing MISSION and medication for opioid use disorder (MOUD), its multicomponent parts along with MOUD, and MOUD treatment as usual (TAU) to assess improvements in health and social outcomes. METHODS: This study will use a half fractional factorial design and randomize 1000 patients with COD to one of five treatment conditions: (1) the full MISSION intervention plus MOUD; (2-4) a combination of two out of three MISSION components plus MOUD; or (5) TAU. Secondary aims include examination of mechanisms of action, economic evaluation of the implementation of MISSION and/or its components plus MOUD versus TAU, and exploratory predictive modeling to match optimal MISSION parts with patient needs. DISCUSSION: This randomized controlled trial will help determine the effectiveness of MISSION (or its parts) and MOUD compared to TAU to improve engagement in treatment, substance use, and mental health symptoms. This trial is the first to compare MISSION and its parts with MOUD versus TAU in a real-world treatment scenario to determine which components are necessary and sufficient to drive treatment outcomes according to patient needs.

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BACKGROUND: Patients continue to face challenges accessing medication for opioid use disorder (MOUD) despite attempts to loosen prescribing restrictions and streamline service provision. Past research has mainly focused on potential barriers surrounding prescribing practices for buprenorphine, but has had limited investigation into the role of pharmacies. OBJECTIVE: This study investigates the role of both pharmacists and pharmacies in creating or circumventing barriers to accessing buprenorphine for individuals in Georgia seeking medication for opioid use disorder (MOUD). METHODS: Semi-structured interviews of pharmacists across 12 access and no access pharmacies were used to create a codebook of 179 discreet statements. The (N = 12) 20-35-minute phone interviews included questions addressing substance use, pharmacy practices, treatment, harm reduction, and psychoeducation. RESULTS: Pharmacists widely agreed that opioid use has caused negative effects on community members (N = 11), that buprenorphine formulation stocking decisions are made based on patient needs (N = 11), and that buprenorphine is relatively easy to stock (N = 10). Additionally, respondents generally stated that buprenorphine is a helpful tool for treating opioid use disorder (OUD) (N = 12) but some reported positive experiences while others reported challenging or negative experiences with patients receiving buprenorphine (N = 7). Finally, few (N = 4) pharmacists agreed that they could benefit from extra training despite many asserting that training is important to inform their own practice (N = 8). CONCLUSION: Results from respondents generally show that training may be beneficial for pharmacists to develop an enhanced understanding of addiction and treatment. Enhanced effort to stock different formulations or dosages of buprenorphine and develop relationships with prescribers may increase community access.

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INTRODUCTION: Opioid-related overdose deaths rates among Latine individuals are increasing rapidly and, in Massachusetts, have exceeded rates among non-Hispanic White individuals. Yet Latine individuals are less likely to receive opioid agonist therapies (OAT) methadone and buprenorphine, which have been demonstrated to prevent opioid deaths. Amid climbing Latine overdose rates, we lack qualitative data from Spanish-speaking people who use opioids about their views on and access to OAT. In this paper, we sought to assess variables affecting Latine individuals' initiation of OAT. METHODS: We conducted 21 semi-structured interviews - half in Spanish - with Latine-identifying individuals recruited from four locations-three residential treatment sites and one city shelter-in Boston offering services to people who use drugs. We utilized thematic analysis to identify barriers and facilitators to starting and continuing OAT. RESULTS: The following themes - which cut across individual-, interpersonal-, and systems-level variables - emerged as core considerations shaping Latine participants' OAT engagement: (1) family, (2) medication desirability and accessibility, (3) health care resources, (4) housing stability, and (5) incarceration. First, family members were prominent interpersonal influences on participants' treatment decisions. For some participants, family introduced participants to opioids at young ages and later supported them in recovery. Second, engagement with OAT was shaped by individual-level opinions on the medications as well as by systems-level experiences with trying to access the medications. Participants identified benefits and drawbacks of methadone versus buprenorphine, with greater access difficulties for methadone. Third, the health care setting in Boston provided notable systems-level facilitators to OAT access, including outreach workers, Medicaid, and Spanish-speaking providers. Fourth, housing instability impeded some from accessing OAT while motivating others to initiate the medications. Finally, incarceration created systems-level barriers to OAT engagement. Most participants had been incarcerated in jail or prison but did not have access to OAT during incarceration or during their transition back to the community. CONCLUSIONS: Approaches to increase OAT engagement among Latine individuals should consider integrating family into recovery pathways, tailoring information in Spanish, developing bilingual/bicultural staffing, ensuring supportive insurance coverage systems, addressing housing needs, and making OAT available for individuals involved in the legal system.

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Adam, a justice-involved young man, was brought into the emergency department at the county hospital in cardiogenic shock due to a recurring episode of injection-drug-use-related infective endocarditis (IDU-IE). Adam had initiated injection opioid use in prison. He was surgically treated for the previous episodes of IDU-IE but was unable to fully recover due to limitations in care within penal medicine. This case report explores the prison as a determinant of health, interactions between clinical, welfare, and penal medicine, to produce and maintain health inequities, and structural drivers of physician moral injury through an interview with Adam and reflexive writings from emergency medicine physicians. This case demonstrates the need for three types of structural health interventions: (1) restorative justice, community-based reentry programs, and housing as welfare medicine, (2) increased harm reduction services across healthcare, especially penal medicine, and (3) equitable institutional protocols (contrary to ambiguous guidelines) to treat clinical conditions like IDU-IE that disproportionately impact structurally vulnerable patients.

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Background Emergency department (ED)-based medication for opioid use disorder (MOUD) has been shown to be effective in providing ease of access and successful treatment rates for patients with opioid use disorder (OUD). This study examined the social determinants of health (SDOH) of patients entering an ED-based MOUD program through individual and focus group surveys. SDOH may impact treatment retention for current and future patients. Methods A survey of all patients entering our MOUD program at two hospital-based EDs and two free-standing EDs was conducted from January to March 2022. Addiction care coordinators (ACCs) used standardized screening tools to enroll patients into the MOUD program, and trained research coordinators used a standardized form, using previously validated survey questions, to examine the role of SDOH. Focused group surveys were also collected. The survey measured patients' perspectives of the program and solicited feedback on SDOH and program barriers. Results Of the 60 OUD patients inducted into the ED-based MOUD program during our survey period, 19 (32%) participated in an individual or focus group interview. Of these, 16 patients (27%) completed all survey questions. The mean age was 42 years old, 94% identified as Caucasian, and 65% were males. Over 94% of subjects found the ACCs helpful in providing follow-up care. Nearly 40% experienced transportation and financial issues. The vast majority found the MOUD program beneficial in coping with withdrawal symptoms, dealing with their addiction, and supporting recovery. Conclusion OUD patients found the ACCs and the MOUD program helpful for their transition to the treatment stage. The MOUD program can improve some patients' reluctance to engage with a healthcare system by addressing barriers related to transportation to appointments and financial issues.

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Background: Opioid use disorder (OUD) is associated with significant morbidity and mortality. Medication for opioid use disorder (MOUD) is a cost-effective treatment, but retention rates vary widely. Aim: Mixed methods studies are needed to better understand how depression and pain impact the experience of OUD and MOUD treatment experiences. Methods: Participants were recruited from an urban addiction treatment center in the United States. Along with demographic characteristics, current pain severity, pain interference, pain catastrophizing, and depression were assessed via self-report. Correlational analyses, multivariable logistic regression models, Fisher exact tests, and Wilcoxon signed rank tests were used to examine the impact of demographic characteristics, physical pain, and depression on multiple treatment outcomes: 90-day treatment engagement (total number of dispensed MOUD doses), retention (yes/no still in treatment at 90 days), and opioid use (positive/negative urinalysis for opioids at 90 days). Ten participants were interviewed about their history with physical pain, depression, opioid use, and OUD treatment experiences. Themes were identified using a rapid analysis, top-down approach. Results: Fifty participants enrolled in the study and received buprenorphine (12%) or methadone (88%). Older age was associated with 90-day treatment engagement. Higher depression scores were associated with a positive opioid urinalysis at 90-day follow-up. In interviews, participants reported experiencing chronic physical pain and depression before and during their OUD and an interest in addressing mental and physical health in addiction treatment. Conclusions: Addressing co-occurring physical and mental health concerns during MOUD treatment has the potential to improve the treatment experience and abstinence from opioids.

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BACKGROUND: The effectiveness of hospital-based transitional opioid programs (TOPs), which aim to connect patients with substance use disorders (SUD) to ongoing treatment in the community following initiation of medication for opioid use disorder (MOUD) treatment in the hospital, hinges on successful patient transitions. These transitions are enabled by strong partnerships between hospitals and community-based organizations (CBOs). However, no prior study has specifically examined barriers and facilitators to establishing SUD care transition partnerships between hospitals and CBOs. OBJECTIVE: To identify barriers and facilitators to developing partnerships between hospitals and CBOs to facilitate care transitions for patients with SUDs. DESIGN: Qualitative study using semi structured interviews conducted between November 2022-August 2023. PARTICIPANTS: Staff and providers from hospitals affiliated with four safety-net health systems (n=21), and leaders and staff from the CBOs with which they had established partnerships (n=5). APPROACH: Interview questions focused on barriers and facilitators to implementing TOPs, developing partnerships with CBOs, and successfully transitioning SUD patients from hospital settings to CBOs. KEY RESULTS: We identified four key barriers to establishing transition partnerships: policy and philosophical differences between organizations, ineffective communication, limited trust, and a lack of connectivity between data systems. We also identified three facilitators to partnership development: strategies focused on building partnership quality, strategic staffing, and organizing partnership processes. CONCLUSIONS: Our findings demonstrate that while multiple barriers to developing hospital-CBO partnerships exist, stakeholders can adopt implementation strategies that mitigate these challenges such as using mediators, cross-hiring, and focusing on mutually beneficial services, even within resource-limited safety-net settings. Policymakers and health system leaders who wish to optimize TOPs in their facilities should focus on adopting implementation strategies to support transition partnerships such as inadequate data collection and sharing systems.

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BACKGROUND: Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues. METHODS: The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested. RESULTS: Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status. DISCUSSION: The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

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BACKGROUND: Treatment for substance use disorders (SUD) remains low in the United States. To better meet needs of people who use alcohol and other drugs, low threshold bridge clinics which offer treatment without barrier and harm reduction services have gained prevalence. Bridge clinics work to surmount barriers to care by providing same day medication and treatment for SUD and eventually transitioning patients to community-based treatment providers. In this study, we examine SUD treatment outcomes among patients who transitioned out of a bridge clinic. METHODS: This is a retrospective cohort study of posttreatment outcomes of patients seen at an urban medical center's bridge clinic between 2017 and 2022. The primary outcome was being in care anywhere at time of follow-up. We also examined the proportion of patients who completed each step of the cascade of care following transfer: connection to transfer clinic, completion of a clinic visit, retention in care, and medication use among those remaining in care at the transfer clinic. We examined the association of different bridge clinic services with still being in care anywhere and the association between successful transfer with being in care and taking medication at follow-up. RESULTS: Of 209 eligible participants, 63 were surveyed. Sixty-five percent of participants identified as male, 74% as white, 12% as Hispanic, 6% as Black, and 16% were unhoused. Most participants (78%) reported being connected to SUD treatment from the Bridge Clinic, and 37% remained in care at the same facility at the time of survey. Eighty-four percent reported being in treatment anywhere and 68% reported taking medication for SUD at follow-up, with most participants reporting taking buprenorphine (46%). CONCLUSION: Of those participants who transitioned out of a bridge clinic into community-based SUD care, 78% were successfully connected to ongoing care and 84% were still in care at follow-up.

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PURPOSE: The opioid overdose crisis requires strengthening treatment systems with innovative technologies. How people use telehealth for opioid use disorder (OUD) is evolving and differs in rural versus urban areas, as telehealth is emerging as a local resource and complementary option to in-person treatment. We assessed changing trends in telehealth and medication for OUD (MOUD) and pinpoint locations of low telehealth and MOUD access. METHODS: We used national data from the Mental health and Addiction Treatment Tracking Repository (2016-2023) to identify specialty outpatient SUD treatment facilities in the United States (N = 83,988). We modeled the availability of telehealth using multilevel multivariable logistic regression, adjusting for covariates. We included a 3-way interaction to test for conditional effects of rurality, the number of MOUD medication types dispensed, and year. We included two random effects to account for clustering within counties and states. FINDINGS: We identified 495 facilities that offered both telehealth and all three MOUD medication types (methadone, buprenorphine, naltrexone) in 2023, clustered in the eastern United States. We identified a statistically significant 3-way interaction (p < 0.0001), indicating that telehealth in facilities that did not offer MOUD shifted from more telehealth in rural facilities in earlier years to more telehealth in urban facilities in later years. CONCLUSIONS: Treatment facilities that offer both telehealth and all three MOUD medication types may improve access for hard-to-reach populations. We stress the importance of continued health system strengthening and technological resources in vulnerable rural communities, while acknowledging a changing landscape of increased OUD incidence and MOUD demand in urban communities.

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BACKGROUND: Substance use disorder treatment and recovery support services are critical for achieving and maintaining recovery. There are limited data on how structural and social changes due to the COVID-19 pandemic impacted individual-level experiences with substance use disorder treatment-related services among community-based samples of people who inject drugs. METHODS: People with a recent history of injection drug use who were enrolled in the community-based AIDS Linked to the IntraVenous Experience study in Baltimore, Maryland participated in a one-time, semi-structured interview between July 2021 and February 2022 about their experiences living through the COVID-19 pandemic (n = 28). An iterative inductive coding process was used to identify themes describing how structural and social changes due to the COVID-19 pandemic affected participants' experiences with substance use disorder treatment-related services. RESULTS: The median age of participants was 54 years (range = 24-73); 10 (36%) participants were female, 16 (57%) were non-Hispanic Black, and 8 (29%) were living with HIV. We identified several structural and social changes due the pandemic that acted as barriers and facilitators to individual-level engagement in treatment with medications for opioid use disorder (MOUD) and recovery support services (e.g., support group meetings). New take-home methadone flexibility policies temporarily facilitated engagement in MOUD treatment, but other pre-existing rigid policies and practices (e.g., zero-tolerance) were counteracting barriers. Changes in the illicit drug market were both a facilitator and barrier to MOUD treatment. Decreased availability and pandemic-related adaptations to in-person services were a barrier to recovery support services. While telehealth expansion facilitated engagement in recovery support group meetings for some participants, other participants faced digital and technological barriers. These changes in service provision also led to diminished perceived quality of both virtual and in-person recovery support group meetings. However, a facilitator of recovery support was increased accessibility of individual service providers (e.g., counselors and Sponsors). CONCLUSIONS: Structural and social changes across several socioecological levels created new barriers and facilitators of individual-level engagement in substance use disorder treatment-related services. Multilevel interventions are needed to improve access to and engagement in high-quality substance use disorder treatment and recovery support services among people who inject drugs.

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BACKGROUND: Injection Drug use is associated with increased HIV risk behaviour that may result in the transmission of HIV and poor access to HIV prevention and treatment. In 2020, Uganda introduced the 'medication for opioid use disorder (MOUD) treatment' for People who inject drugs (PWID). We analysed the 12-month retention and associated factors among PWID enrolled on MOUD treatment in Kampala, Uganda. METHODS: We conducted a retrospective analysis of 343 PWID with OUD who completed 14 days of methadone induction from September 2020 to July 2022. Retention was defined as the number of individuals still in the programme divided by the total number enrolled, computed at 3-, 6-, 9-, and 12 months using lifetable and Kaplan-Meier survival analyses. Cox proportional regression analyses were conducted to assess factors associated with retention in the programme in the first 12 months. RESULTS: Overall, 243 (71%) of 343 participants stabilized at a methadone dose of 60 mg or more. The majority of participants were males (n = 284, 82.8%), and the median (interquartile range, IQR) age was 31 (26-38) years. Most participants (n = 276, 80.5%) lived 5 km or more away from the MOUD clinic. Thirty (8.8%) were HIV-positive, 52 (15.7%) had a major mental illness and 96 (27.9%) had a history of taking alcohol three months before enrollment. The cumulative retention significantly declined from 83.4% (95%CI = 79.0-87.0) at 3months to 71.9% (95%CI = 67.2-76.6) at 6months, 64% 95%CI = 58.7-68.9) at 9months, and 55.2%; 95% CI (49.8-60.3% at 12months. The 12-month retention was significantly higher for participants on methadone doses of 60 mg or more (adj.HR = 2.1, 95%CI = 1.41-3.22), while participants resident within 5 km of the MOUD clinic were 4.9 times more likely to be retained at 12 months, compared to those residing 5 km or more, (adj. HR = 4.81, 95%CI = 1.54-15). Other factors, including predisposing, need, and enabling factors, were not associated with retention. CONCLUSION: Our study demonstrates acceptable 12-month retention rates for people who inject drugs, comparable to previous studies done in both developing and developed countries. Sustaining and improving retention may require enhanced scaling up of MOUD dose to an optimal level in the first 14 days and reducing the distance between participant locale and MOUD clinics.

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Background: Women of reproductive age would benefit from treatment of opioid use disorder (OUD) prior to pregnancy to improve maternal and infant outcomes. In this study, we aimed to identify the prevalence of medication for OUD (MOUD) and characterize correlates of MOUD receipt among 12-49-year-old women with OUD seeking treatment in publicly funded substance use disorder treatment programs at the time of their first treatment episode. Methods: This cross-sectional study explores the demographic and clinical characteristics of women of reproductive age with OUD receiving publicly funded substance use treatment services. We used data from the concatenated 2015-2021 Treatment Episode Data Set-Admissions (TEDS-A), which documents demographic and clinical characteristics of patient admissions to publicly funded substance use treatment services in the United States. Results: In the sample of females aged 12-49 with no prior treatment admissions and primary OUD (n=325,512), 40.53% received MOUD (n=131,930), including 39.40% of non-pregnant women (n=115,315) and 52.79% of pregnant women (n=8423). Pregnant women had significantly higher odds of receiving MOUD (aOR = 2.42, 95%CI: 2.30, 2.54) compared to non-pregnant women. Non-white race, treatment setting, and treatment self-referral were also associated with higher levels of MOUD. Conclusions: We identified a significant unmet need among both pregnant and non-pregnant women with OUD seeking care in publicly funded treatment clinics. While women who are pregnant are significantly more likely to receive evidence-based treatment with MOUD, still 47.21% of pregnant women did not receive MOUD. All reproductive-aged women with OUD should be offered evidence-based treatment options, including MOUD.