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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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Purpose: Negative perceptions around medications for opioid use disorder (MOUD) amongst the public could deter patients with opioid use disorder (OUD) from engaging with MOUD. Thus, we evaluated whether a brief intervention could improve preferences for MOUD in people who may or may not use opioids. Methods: We employed a pre-post design to assess the effect of a brief educational intervention on preferences for methadone, buprenorphine, naltrexone, and non-medication treatment in an online sample of US adults stratified by race, who may or may not use opioids. Respondents ranked their preferences in OUD treatment before and after watching four one-minute educational videos about treatment options. Changes in treatment preferences were analyzed using Bhapkar's test and post hoc McNemar's tests. A binary logistic generalized estimating equation (GEE) assessed factors associated with preference between treatments. Results: The sample had 530 responses. 194 identified as White, 173 Black, 163 Latinx. Treatment preferences changed significantly towards MOUD (p<.001). This effect was driven by changes toward buprenorphine (OR=2.38; p<.001) and away from non-medication treatment (OR=0.20; p<.001). There was no significant difference in effect by race/ethnicity. People with lower opioid familiarity were significantly more likely to change their preferences towards MOUD following the intervention. Conclusion: Respondent preferences for MOUD increased following the intervention suggesting that brief educational interventions can change treatment preferences towards MOUD. These findings offer insights into perceptions of OUD treatment in a racially stratified sample and serve as a foundation for future educational materials that target MOUD preferences in the general public.

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Introduction: Access to prenatal care offers the opportunity for providers to assess for substance use disorders (SUDs) and to offer important treatment options, but utilization of treatment during pregnancy has been difficult to measure. This study presents pre-COVID trends of a subset of SUD diagnosis at the time of delivery and related trends in treatment utilization during pregnancy. Materials and Methods: A retrospective cohort design was used for the analysis of West Virginia Medicaid claims data from 2016 to 2019. Diagnosis of SUDs at the time of delivery and treatment utilization for opioid use disorder (OUD) and non-OUD diagnosis during pregnancy across time were the principal outcomes of interest. This study examined data from n = 49,398 pregnant individuals. Results: Over the 4-year period, a total of 2,830 (5.7%) individuals had a SUD diagnosis at the time of delivery. The frequency of opioid-related diagnoses decreased by 29.3%; however, non-opioid SUD diagnoses increased by 55.8%, with the largest increase in the diagnosis of stimulant use disorder (30.9%). Treatment for OUD increased by 13%, but treatment for non-opioid SUD diagnoses during pregnancy declined by 41.1% during the same period. Conclusions: Interventions enacted within West Virginia have improved access and utilization of treatment for OUD in pregnancy. However, consistent with national trends in the general population, non-opioid SUD diagnoses, especially for stimulants, have rapidly increased, while treatment for this group decreased. Early identification and referral to treatment by OB-GYN providers are paramount to reducing pregnancy and postpartum complications for the mother and neonate.

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BACKGROUND: Persons who inject drugs (PWID) are at increased risk of HIV and hepatitis C virus (HCV) infections and premature mortality due to drug overdose. Medication for opioid use disorder (MOUD), such as methadone or buprenorphine, reduces injecting behaviors, HIV and HCV transmission, and mortality from opioid overdose. Using data from National HIV Behavioral Surveillance, we evaluated the unmet need for MOUD among PWID in 23 U.S. cities. METHODS: PWID were recruited by respondent-driven sampling, interviewed, and tested for HIV. This analysis includes PWID who were ≥18 years old and reported injecting drugs and opioid use in the past 12 months. We used Poisson regression to examine factors associated with self-reported unmet need for MOUD and reported adjusted prevalence ratios (aPR) with 95% confidence intervals. RESULTS: Of 10,879 PWID reporting using opioids, 68.8% were male, 48.2% were ≥45 years of age, 38.8% were non-Hispanic White, 49.6% experienced homelessness, and 28.0% reported an unmet need for MOUD in the past 12 months. PWID who were more likely to report unmet need for MOUD experienced homelessness (aPR 1.26; 95% CI: 1.19-1.34), were incarcerated in the past 12 months (aPR 1.15; 95% CI: 1.08-1.23), injected ≥once a day (aPR 1.42; 95% CI: 1.31-1.55), reported overdose (aPR 1.33; 95% CI: 1.24-1.42), and sharing of syringes (aPR 1.14; 95% CI: 1.06-1.23). CONCLUSIONS: The expansion of MOUD provision for PWID is critical. Integrating syringe service programs and MOUD provision and linking PWID who experience overdose, incarceration or homelessness to treatment with MOUD could improve its utilization among PWID.

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BACKGROUND: The number of pregnant women with opioid use disorder (OUD) has increased over time. Although effective treatment options exist, little is known about the extent to which women receive treatment during pregnancy and at what stage of pregnancy care is initiated. METHODS: Using a national private health insurance claims database, we identified women aged 13-49 who gave birth in 2006-2019 and had an OUD or nonfatal opioid overdose (NFOO) diagnosis during the year prior to or at delivery. We then identified women who received their first OUD treatment prior to or during pregnancy. In this cross-sectional study, we investigated how rates and timing of the initial OUD treatment changed over time. Furthermore, we examined factors associated with early initiation of OUD treatment among birthing people. RESULTS: Of the 7057 deliveries from 6747 women with OUD or NFOO, 63.3 % received any OUD treatment. Rates of OUD treatment increased from 42.9 % in 2006 to 69 % in 2019. Of those treated, in 2006, 54.5 % received their first treatment prior to conception and 24.2 % initiated care during the 1st trimester. In 2019, 68.9 % received their first treatment prior to conception, and 15.1 % initiated care during the 1st trimester. The percentage of women who were first treated in the 2nd trimester or later decreased from 21.2 % in 2006 to 16.1 % in 2019. Factors associated with early treatment initiation include being 25 years or older (age 25-34: aOR, 1.51, 95 % CI, 1.28-1.78; age 35-49: aOR, 1.82, 95 % CI, 1.39-2.37), living in urban areas (aOR, 1.28; 95 % CI, 1.05-1.56), having pre-existing behavioral health comorbidities such as anxiety disorders (aOR, 1.8; 95 % CI, 1.40-2.32), mood disorders (aOR, 1.63; 95 % CI, 1.02-2.61), and substance use disorder other than OUD (aOR, 2.56; 95 % CI, 2.03-3.32). CONCLUSION: Overall, rates of OUD treatment increased over time, and more women initiated OUD treatment prior to conception. Despite these improvements, over one-third of pregnant women with OUD/NFOO either received no treatment or did not initiate care until the 3rd trimester in 2019. Future research should examine barriers to OUD treatment initiation among pregnant women.

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INTRODUCTION: Opioid overdose deaths are increasing rapidly in the United States. Medications for opioid use disorder (MOUD) are effective and can be delivered in primary care, but uptake has been limited in rural communities. Referral to and coordination with an external telemedicine (TM) vendor by rural primary care clinics for MOUD (TM-MOUD) may increase MOUD access for rural patients, but we know little about perspectives on this model among key stakeholders. As part of a TM-MOUD feasibility study, we explored TM-MOUD acceptability and feasibility among personnel and patients from seven rural primary care clinics and a TM-MOUD vendor. METHODS: We conducted virtual interviews or focus groups with clinic administrators (n = 7 interviews), clinic primary care and behavioral health providers (8 groups, n = 30), other clinic staff (9 groups, n = 37), patients receiving MOUD (n = 16 interviews), TM-MOUD vendor staff (n = 4 interviews), and vendor-affiliated behavioral health and prescribing providers (n = 17 interviews). We asked about experiences with and acceptability of MOUD (primarily buprenorphine) and telemedicine (TM) and a TM-MOUD referral and coordination model. We conducted content analysis to identify themes and participants quantitatively rated acceptability of TM-MOUD elements on a 4-item scale. RESULTS: Perceived benefits of vendor-based TM-MOUD included reduced logistical barriers, more privacy and less stigma, and access to services not available locally (e.g., counseling, pain management). Barriers included lack of internet or poor connectivity in patients' homes, limited communication and trust between TM-MOUD and clinic providers, and questions about the value to the clinic of TM-MOUD referral to external vendor. Acceptability ratings for TM-MOUD were generally high; they were lowest among frontline staff. CONCLUSIONS: Rural primary care clinic personnel, TM-MOUD vendor personnel, and patients generally perceived referral from primary care to a TM-MOUD vendor to hold potential for increasing access to MOUD in rural communities. Increasing TM-MOUD uptake requires buy-in and understanding among staff of the TM-MOUD workflow, TM services offered, requirements for patients, advantages over clinic-based or TM services from clinic providers, and identification of appropriate patients. Poverty, along with patient hesitation to initiate treatment, creates substantial barriers to MOUD treatment generally; insufficient internet availability creates a substantial barrier to TM-MOUD.

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RATIONALE: Public stigma surrounds individuals who use medication for their recovery from a substance use disorder. However, we know little about subgroups of individuals with varying levels of perceived stigma and how these levels may be associated with physical and mental health-related quality of life (HRQOL) and social support. METHODS: We used latent class analysis to define subgroups of people aged 50-72 years of age (N = 104) who were enrolled in eight medication for opioid use disorder (MOUD) programs to explore subgroupings and correlates of group membership. RESULTS: We found evidence for three distinct classes of individuals and named the classes 1) the high stigma class, 2) the embarrassed class, and 3) the low stigma class. We found that people in the high-stigma class reported more rejection, more abstinence-based support group involvement, and reduced mental HRQOL. CONCLUSIONS: Results suggest reducing stigma among people on MOUD may help to boost mental HRQOL and improve social support receipt. The results are consistent with iatrogenic effects of AA/NA support groups such that these treatment modalities may increase stigma due to their focus on abstinence-only treatment for substance use disorders.

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INTRODUCTION: Individuals with opioid use disorder (OUD) transitioning from jails or prisons to the community are at high risk of overdose-related death shortly after release. Buprenorphine, methadone, and extended-release naltrexone are FDA-approved medications for opioid use disorder (MOUD) to reduce overdose risk and increase treatment engagement. Despite the evidence, many correctional facilities in the United States do not provide MOUD to their incarcerated population. Albany County Jail and Rehabilitative Services Center (ACCRSC) is a jail in New York State that provides comprehensive MOUD and overdose prevention services to all incarcerated individuals with OUD. METHODS: MOUD program participants' data was collected during custody and after release to determine whether the program's primary goals of preventing overdose-related mortality and MOUD continuation after release were met. Other quality-of-life metrics were used for program improvements, such as program participants' physical and mental well-being, postrelease housing, employment, access to mental health services, and re-incarceration. RESULTS: This study included 375 unique individuals who received MOUD treatment at the jail between January 19, 2019, and the end of December 2020, with 56.2 % continuing their treatment and 43.7 % initiating MOUD during custody. Among those who initiated MOUD at ACCRSC, 93.3 % were enrolled in buprenorphine. We identified eight program participant deaths after release within a year after incarceration. The average time between release and death was 233 days, with the shortest time between release and death being 107 days. We found that over half (53.6 %) of program participants using buprenorphine picked up their prescriptions after exiting ACCRSC. Among those who did not, nearly 16 % were unable to do so because they were transferred to another jail or prison that did not provide MOUD care. Overall, nearly 80 % of program participants who were transferred to another correctional facility could not continue their medication. CONCLUSIONS: MOUD in correctional settings appears to reduce overdose deaths immediately after release. Administering buprenorphine and other types of MOUD in a jail setting has shown relatively high retention for people to fill their first prescription of buprenorphine outside the jail. To ensure high MOUD retention among incarcerated populations, all correctional facilities must provide MOUD care.

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The overlapping epidemics of hepatitis C virus (HCV) and HIV infection stem from underlying behaviors and health disparities among disproportionately affected populations, especially people who inject drugs (PWID). Characterizing the prevalence of HCV-HIV coinfection offers improved data to address these underlying determinants of health. We performed a literature search for articles that describe US populations, were published during 2005-2021, and summarized evidence of the prevalence of HCV infection in recent HIV clusters and outbreaks among PWID. In population- and community-based studies, HCV antibody prevalence among PWID with HIV ranged from 10.7% to 71.4%, depending on the setting and study design. HCV-HIV coinfection ranged from 70% to 94% among 5 larger HIV clusters or outbreaks among PWID during 2014-2021; where characterized, HCV diagnosis preceded HIV detection by a median of 4 to 5 years. Robust modernized surveillance is needed to support and measure the progress of city, state, and national activities for ending the HIV epidemic and eliminating hepatitis C. Developing and leveraging surveillance systems can identify missed opportunities for prevention, evaluate care, and build capacity for outbreak investigation. In addition, improved data on injection drug use are crucial to inform efforts for improved HCV and HIV testing, prevention, and treatment in settings that serve PWID. By providing data in a wholistic, integrated manner, public health surveillance programs can support efforts to overcome inefficiencies of disease-specific silos, accelerate delivery of preventive and clinical services, and address the excess disease burden and health disparities associated with HCV-HIV coinfection.

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OBJECTIVE: This study evaluated the association between medication for opioid use disorder (MOUD) and health care utilization over time among a sample of treatment-seeking individuals with opioid use disorder. In contrast to previous studies, this study used a novel measure of MOUD adherence, more comprehensive utilization data, and analyses that controlled for detailed individual and social determinants of health. METHODS: This study was a secondary analysis of a comparative effectiveness trial (N=570) of extended-release naltrexone versus buprenorphine-naloxone. The outcome of interest was usage of nonstudy acute care, inpatient and outpatient addiction services, and other outpatient services across 36 weeks of assessment. Adherence (percentage of days taking MOUD) was defined as low (<20%), medium (≥20% but <80%), or high (≥80%). A two-part model evaluated the probability of utilizing a resource and the quantity (utilization days) of the resource consumed. A time-varying approach was used to examine the effect of adherence in a given month on utilization in the same month, with analyses controlling for a wide range of person-level characteristics. RESULTS: Participants with high adherence (vs. low) were significantly less likely to use inpatient addiction (p<0.001) and acute care (p<0.001) services and significantly more likely to engage in outpatient addiction (p=0.045) and other outpatient (p=0.042) services. CONCLUSIONS: These findings reinforce the understanding that greater MOUD adherence is associated with reduced usage of high-cost health services and increased usage of outpatient care. The results further suggest the need for enhanced access to MOUD and for interventions that improve adherence.

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Objective Buprenorphine is a commonly used medication to manage opioid use disorder, however there is limited data to guide induction protocols specifically during pregnancy. Similar to non-pregnant patients the Clinical Opiate Withdrawal Scale (COWS) is often used to guide induction and titration of buprenorphine in pregnancy. The objective of this retrospective descriptive study is to assess the inpatient buprenorphine induction patterns, treatment retention, and pregnancy outcomes among obstetric patients with opioid use disorder seeking treatment.  Study design This was a retrospective study of obstetric patients with opioid use disorder admitted for inpatient buprenorphine induction at a large academic center between May 2015 to 2020. A descriptive analysis of the cohort, induction patterns, and dose retention after discharge were evaluated in addition to obstetric and neonatal outcomes. Results Sixty patients were admitted for inpatient buprenorphine induction at a median gestational age of 16.7 weeks. The median COWS score on presentation was 9. The starting dose for half of the patients (30 out of 60 patients) was 8 mg of buprenorphine, while 24 patients were started at 4 mg. The median duration of hospitalization was three days (range 2-12). The median buprenorphine dose upon discharge was 10 mg (range 4-20). Only 13 of the 35 patients (37%) who desired prenatal care at our institution returned to receive routine prenatal care. Of the 12 (20%) patients who delivered at our institution, nine were live births (75%). Among the live births, the median gestational age at delivery was 37.4 weeks, birth weight 3085 grams, and only one (8%) developed neonatal abstinence syndrome. Conclusion When using the Clinical Opiate Withdrawal Scale to guide inpatient buprenorphine titration for pregnant patients with opioid use disorder it takes approximately three days to establish a satisfactory maintenance dose with the median dose at discharge in this population being 10 mg. The majority of patients who followed up after hospital discharge did not need dose adjustments.

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BACKGROUND: Medication for opioid use disorder (MOUD) is vastly underutilized in adolescents. Existing treatment guidelines for OUD largely focus on adults, providing limited guidance for pediatric populations. Limited information is known about use of MOUD in adolescents based on substance use severity. METHODS: This secondary data analysis examined how patient-level variables influenced the receipt of MOUD in adolescents aged 12-17 (n = 1866) using the Treatment Episode Data Set (TEDS) 2019 Discharge data set. A crosstabulation and chi-square statistic evaluated the relationship between a proxy for clinical need based on high-risk opioid use (either reporting daily opioid use within the past 30 days and/or history of injection opioid use) for MOUD in states with and without adolescents receiving MOUD (n = 1071). A two-step logistic regression analysis in states with any adolescents receiving MOUD examined the explanatory power of demographic, treatment intake, and substance use characteristics. RESULTS: Completion of 12th grade, a GED, or beyond, decreased the likelihood of receiving MOUD (odds ratio [OR]= 0.38, p = 0.017), as did being female (OR = 0.47, p = .006). None of the remaining clinical criteria were significantly associated with MOUD, although a history of one or more arrests increased the likelihood of MOUD (OR = 6.98, p = 0.06). Only 13% of individuals who met criteria for clinical need received MOUD. CONCLUSIONS: Lower education could serve as a proxy for substance use severity. Guidelines and best practices are needed to ensure the proper distribution of MOUD to adolescents based on clinical need.

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Background: In recent years, amphetamine-type-stimulants (ATS) have been extensively misused in South-East Asia, inducing major problems among methadone-maintenance-treatment (MMT) patients.Objective: We examine ATS-misuse prevalence and its determinants among MMT patients in East-Coast-Malaysia.Methods: A retrospective-observational study was conducted on government-subsidized medication for opioid-use-disorder (MOUD) treatment clinics involving 292 MMT-patients (98% males) who were selected using a multilevel-proportional-stratified random sampling technique. Information obtained during the mandatory monitoring procedure from January 1 to December 31 2019, was utilized to determine ATS misuse prevalence from consecutive random urine drug screening. The determinants associated with its use, namely sociodemographics, social networks, comorbidities, and pharmacological assessments were analyzed via a logistic model.Results: Overall, 52.2% of the MMT-patients (95% CI: 0.42-0.54) had misused ATS at least once during their methadone treatment. These misusing patients were active smokers, hepatitis B and C seronegative, concurrently misused opioids, and had received suboptimum prescribed doses of methadone. Multiple logistic regression analysis demonstrated that the odds of misusing ATS during methadone treatment were 37 times higher among those who concurrently misused opioids (AOR: 37.60, 95% CI: 14.03-100.74) and 12 times higher among those who received suboptimal methadone doses (<60 mg/day) (AOR: 12.24, 95% CI: 5.58-25.43).Conclusion: This study demonstrated the significant prevalence of ATS misuse among MMT-patients in East-Coast-Malaysia, especially among patients who were prescribed suboptimal doses of methadone and/or demonstrated concomitant opioid-misuse. Stringent urine-monitoring is crucial to prevent diversion to ATS misuse. Nonetheless, to avoid negligence and improve physician engagement, the relevant authorities should immediately plan a comprehensive national-standard training module comprising support activities for professional methadone-prescribers.

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The Helping End Addictions Long Term (HEALing) Communities Study (HCS) seeks to significantly reduce overdose deaths in 67 highly impacted communities in Kentucky (KY), Massachusetts (MA), New York (NY), and Ohio (OH) by implementing evidence-based practices (EBPs) to reduce overdose deaths. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA) organizes EBP strategies under three menus: Overdose Education and Naloxone Distribution (OEND), Medication Treatment for Opioid Use Disorder (MOUD), and Safer Prescribing and Dispensing Practices (SPDP). The ORCCA sets requirements for strategy selection but allows flexibility to address community needs. This paper describes and compiles strategy selection and examines two hypotheses: 1) OEND selections will differ significantly between communities with higher versus lower opioid-involved overdose deaths; 2) MOUD selections will differ significantly between urban versus rural settings. METHODS: Wave 1 communities (n = 33) provided data on EBP strategy selections. Selections were recorded as a combination of EBP menu, sector (behavioral health, criminal justice, and healthcare), and venue (e.g., jail, drug court, etc.); target medication(s) were recorded for MOUD strategies. Strategy counts and proportions were calculated overall and by site (KY, MA, NY, OH), setting (rural/urban), and opioid-involved overdose deaths (high/low). RESULTS: Strategy selection exceeded ORCCA requirements across all 33 communities, with OEND strategies accounting for more (40.8%) than MOUD (35.1%), or SPDP (24.1%) strategies. Site-adjusted differences were not significant for either hypothesis related to OEND or MOUD strategy selection. CONCLUSIONS: HCS communities selected strategies from the ORCCA menu well beyond minimum requirements using a flexible approach to address unique needs.

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BACKGROUND: Chronic pain and opioid use disorder (OUD) individually represent a risk to health and well-being. Concerningly, there is evidence that they are frequently co-morbid. While few treatments exist that simultaneously target both conditions, preliminary work has supported the feasibility of an integrated behavioral treatment targeting pain interference and opioid misuse. This treatment combined Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Relapse Prevention (ACT+MBRP). This paper describes the protocol for the adequately powered efficacy study of this integrated treatment. METHODS: A multisite randomized controlled trial will examine the efficacy of ACT+MBRP in comparison to a parallel education control condition, focusing on opioid safety and pain education. Participants include veterans (n = 160; 21-75 years old) recruited from three Veterans Administration (VA) Healthcare Systems with chronic pain who are on a stable dose of buprenorphine. Both conditions include twelve weekly 90 min group sessions delivered via telehealth. Primary outcomes include pain interference (Patient Reported Outcome Measurement Information System - Pain Interference) and hazardous opioid use (Current Opioid Misuse Measure), which will be examined at the end of the active treatment phase and through 12 months post-intervention. Secondary analyses will evaluate outcomes including pain intensity, depression, pain-related fear, and substance use, as well as treatment mechanisms. CONCLUSION: This study will determine the efficacy of an integrated behavioral treatment program for pain interference and hazardous opioid use among veterans with chronic pain and OUD who are prescribed buprenorphine, addressing a critical need for more integrated treatments for chronic pain and OUD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04648228.

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While the COVID-19 pandemic disrupted healthcare delivery everywhere, persons with carceral system involvement and opioid use disorder (OUD) were disproportionately impacted and vulnerable to severe COVID-associated illness. Carceral settings and community treatment programs (CTPs) rapidly developed protocols to sustain healthcare delivery while reducing risk of COVID-19 transmission. This survey study assessed changes to OUD treatment, telemedicine use, and re-entry support services among carceral and CTPs participating in the National Institute on Drug Abuse (NIDA)-funded study, Long-Acting Buprenorphine vs. Naltrexone Opioid Treatments in Criminal Justice System-Involved Adults (EXIT-CJS) study. In December 2020, carceral sites (n = 6; median pre-COVID 2020 monthly census = 3468 people) and CTPs (n = 7; median pre-COVID 2020 monthly census = 550 patients) participating in EXIT-CJS completed a cross-sectional web-based survey. The survey assessed changes pre- (January-March 2020) and post- (April-September 2020) COVID-19 in OUD treatment, telemedicine use, re-entry supports and referral practices. Compared to January-March 2020, half of carceral sites (n = 3) increased the total number of persons initiating medication for opioid use disorder (MOUD) from April-September 2020, while a third (n = 2) decreased the number of persons initiated. Most CTPs (n = 4) reported a decrease in the number of new admissions from April-September 2020, with two programs stopping or pausing MOUD programs due to COVID-19. All carceral sites with pre-COVID telemedicine use (n = 5) increased or maintained telemedicine use, and all CTPs providing MOUD (n = 6) increased telemedicine use. While expansion of telemedicine services supported MOUD service delivery, the majority of sites experienced challenges providing community support post-release, including referrals to housing, employment, and transportation services. During the COVID-19 pandemic, this small sample of carceral and CTP sites innovated to continue delivery of treatment for OUD. Expansion of telemedicine services was critical to support MOUD service delivery. Despite these innovations, sites experienced challenges providing reintegration supports for persons in the community. Pre-COVID strategies for identifying and engaging individuals while incarcerated may be less effective since the pandemic. In addition to expanding research on the most effective telemedicine practices for carceral settings, research exploring strategies to expand housing and employment support during reintegration are critical.

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BACKGROUND: Jails are optimal settings in which to screen individuals for opioid use disorders (OUD) and provide needed services, especially medications for OUD (MOUD). This study sought to assess the availability of OUD "best practices" in jails located in counties heavily impacted by opioid overdose in the U.S. and their related training and resource needs. Counties were selected for study inclusion using two indicators of OUD severity: the absolute number and population rate of opioid overdose deaths. Structured interviews were completed with representatives from 185/244 (76%) of targeted counties and 185/250 (74%) of targeted jails in these counties. Ten OUD best practices were identified based on current treatment and practice guidelines. These include: screening for OUD; clinical assessment; medically managed withdrawal; MOUD administration; MOUD for pregnant people; counseling and wrap-around services; collaboration with community providers; assistance with Medicaid/insurance; re-entry services; and overdose prevention. Descriptive analyses examined the provision of any services and average percentage of services endorsed within best-practice categories, association of best-practice availability with community and jail characteristics, and related needs for training and resources. RESULTS: Over 70% of jail respondents indicated that some aspects of each of the ten OUD best practices were available within their jails, ranging from 71% using clinical assessment to 96% providing overdose prevention. However, there was considerable variability in the average percentage of items endorsed within each best-practice category, ranging from 38% of items regarding re-entry services to 88% of items regarding medically managed withdrawal. Availability of OUD best practices in jails also varied by community and jail characteristics. Jails reported the highest needs for funding for medication and clinical staff. CONCLUSIONS: Policies are needed to address the identified gaps in availability of OUD best practices within jails. Training, technical assistance, and funding are needed to improve clinical capacity of jails to administer MOUD and to ensure continuity of care from jail to community, which are essential to reducing the risk of opioid-related overdose following release.

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During the COVID-19 Pandemic, health care provision changed rapidly and funding became available to assess pandemic-related policy change. Research activities, however, were limited to contactless, online delivery. It was clear early on that some elements of online rapid ethnography were feasible and effective, while others would not approach traditional ethnographic depth. We conducted an online Rapid Assessment, Response, and Evaluation (RARE) project from August 2020 to September 2021 to understand how COVID-19 policy impacted people who use drugs. Our interdisciplinary research team conducted online ethnographic interviews and focus groups with 45 providers and community stakeholders, and 19 clients from rural and urban areas throughout Arizona. In addition, 26 webinars, online trainings, and virtual conferences focused on opioid policy and medication for opioid use disorders (MOUD) were opportunities to observe conversations among providers and program representatives about how best to implement policy changes, how to reach people in recovery, and what aspects of the changes should carry forward into better all-around opioid services in the future. Our RARE project was successful in collecting a range of providers' perspectives on both rural and urban implementation of take-home MOUDs as well as a wide view of national conversations, but client perspectives were limited to those who were not impacted by the policies and continued to attend in-person daily clinic visits. We describe challenges to online rapid ethnography and how online research may have allowed for an in-depth, but incomplete picture of how policy changes during COVID-19 policy affected people with opioid use disorders.

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Background Maternal opioid exposure during pregnancy has various effects on neonatal health. Buprenorphine/naloxone and methadone are examples of medications for opioid use disorder (MOUD) used for the treatment of opioid use disorder (OUD). Research comparing the impacts of these MOUD modalities on neonatal outcomes when used to treat pregnant people with OUD remains limited. We evaluated the differences in outcomes between neonates with in-utero exposure to buprenorphine/naloxone versus methadone. Methodology We performed a retrospective cohort chart review between October 15, 2008, and October 15, 2019, evaluating mother/neonate dyads at two medical centers in Michigan. The charts of female patients, aged 18+, with OUD and buprenorphine/naloxone or methadone treatment, were examined. The charts of the corresponding neonates were also examined. Multiple regression analysis was performed. Results In total, 343 mother/infant dyads were included: 99 patients were treated with buprenorphine/naloxone and 232 patients were treated with methadone. The buprenorphine/naloxone group had significant differences in maternal age, hepatitis status, asthma, gestational age in weeks, neonatal intensive care unit (NICU) length of stay (LOS), neonatal opioid withdrawal syndrome (NOWS) peak score, birth head circumference, and birth weight compared to the methadone group at baseline. Adjusted multivariable regression analysis demonstrated neonates with exposure to buprenorphine/naloxone had a NOWS peak score 3.079 points less (95% confidence interval (CI): -4.525, 1.633; p = 0.001) and NICU LOS 8.955 days less (95% CI: -14.399, -3.511; p = 0.001) than neonates exposed to methadone. Conclusions Neonates with in-utero exposure to buprenorphine/naloxone had significantly lower NOWS scores and shorter NICU LOS compared to neonates with in-utero exposure to methadone. These findings demonstrate that buprenorphine/naloxone is potentially a more favorable treatment for the reduction in metrics representing adverse neonatal outcomes in pregnant people with OUD than methadone.

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Unintentional overdose deaths, most involving opioids, have eclipsed all other causes of US deaths for individuals less than 50 years of age. An estimated 2.4 to 5 million individuals have opioid use disorder (OUD) yet a minority receive treatment in a given year. Medications for OUD (MOUD) are the gold standard treatment for OUD however early dropout remains a major challenge for improving clinical outcomes. A Cascade of Care (CoC) framework, first popularized as a public health accountability strategy to stem the spread of HIV, has been adapted specifically for OUD. The CoC framework has been promoted by the NIH and several states and jurisdictions for organizing quality improvement efforts through clinical, policy, and administrative levers to improve OUD treatment initiation and retention. This roadmap details CoC design domains based on available data and potential linkages as individual state agencies and health systems typically rely on limited datasets subject to diverse legal and regulatory requirements constraining options for evaluations. Both graphical decision trees and catalogued studies are provided to help guide efforts by state agencies and health systems to improve data collection and monitoring efforts under the OUD CoC framework.

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