Tuesday May 17, 2022
Lead Story: Opioid and Naloxone Prescribing Following Insertion of Prompts in the Electronic Health Record to Encourage Compliance With California State Opioid Law
JAMA Network Open
In 2018, California passed Assembly Bill (AB) 2760, mandating coprescription of naloxone and opioids for patients with high overdose risk. The current study assessed whether electronic prompts were associated with increased naloxone orders and reduced opioid prescribing when integrated into the practitioner workflow. Naloxone order rate increased from 2% in December 2018 to 13.2% in January 2019 and then continued to increase to 27.1% in December 2019. Outpatient opioid prescribing rates decreased by 15.1% per prescriber-month and total MMEs per prescriber-month decreased by 7.8%, along with other improvements in safe opioid prescribing. Adding decision support prompts to the practitioner workflow encourages safe prescribing habits and can mitigate opioid overdose risks.
BMJ Open
Deaths due to overdoses have been increasing in the United States over the last 2 decades, but little is known about the epidemic among American Indian/Alaskan Native (AI/AN) populations. In this study the authors use the National Center for Health Statistics Mortality database to examine overdose deaths between 1999 and 2019. Overdose deaths related to opioids increased significantly over the observation period, including deaths involving other substances, notably alcohol and methamphetamines. Overall overdose mortality rates, and specifically those related to opioids in combination with alcohol or methamphetamines, have been higher among AI/AN than in other racial and ethnic groups. This study highlights inequities in access to treatment for AI/AN populations, including lack of access to medication assisted treatment for opioid use disorder.
Effects of Buprenorphine Dose and Therapeutic Engagement on Illicit Opiate Use in Opioid Use Disorder Treatment Trials [OPEN ACCESS]
International Journal of Environmental Research and Public Health
The authors identified 6 randomized clinical trials of buprenorphine efficacy and/or safety and performed a secondary analysis with lapse to substance use as the outcome variable. They developed a mathematical model to adjust for the effects of dose changes or missed doses during the study period (time-weighted dose). The 6 trials included 3022 participants. The mean (and median) dose was 12mg and ranged up to 32mg. Increased dose was found to be the most protective factor in preventing lapse to drug use. Also of benefit were increased interaction with clinicians and treatment center staff. The authors conclude that doses greater than that needed to prevent withdrawal are needed for maintenance treatment.
The Journal of Clinical Psychiatry
This study examined the association between receiving antidepressants and retention in buprenorphine treatment. Receipt of antidepressants during buprenorphine treatment was significantly associated with reduced risk of treatment discontinuation, even after accounting for demographics, buprenorphine dosage, receipt of other psychotropic medications, co-occurring SUDs, psychiatric disorders, and pain conditions. Receiving antidepressants only prior to buprenorphine initiation was associated with an increased risk of treatment discontinuation. Using antidepressants concurrently during buprenorphine treatment is associated with improved treatment retention and highlights the importance of screening for and treating mental health disorders.
Frontiers in Psychiatry
Measurement-based care (MBC) is an evidence-based practice where patients routinely complete standardized measures throughout treatment to monitor clinical progress and inform clinical decision-making. This pilot study evaluated the feasibility of incorporating a digital and remotely delivered MBC system into substance use disorder (SUD) treatment within a community setting. Patient and clinician ratings of usability and clinical utility were favorable: most patients agreed with statements that the weekly check-in was easy to navigate and aided self-reflection. All clinicians who completed usability questionnaires agreed with statements indicating that the dashboard was easy to navigate and that it provided meaningful information for SUD treatment.
JAMA Network Open
Alcohol sales and use have increased during the COVID-19 pandemic and in this cross-sectional study utilizing the National Vital Statistic System, the authors examine alcohol use disorder (AUD)-related mortality changes. The study looks at AUD-related mortality trends between 2012 and 2019 to project expected mortality in 2020 and 2021, which were then compared to the observed rates. The authors found a significant increase in mortality rates across all ages in 2020 (30.74%) and 2021 (28.7%) compared to projected rates. In addition, the study found the increase was most profound among those aged 25-44 (40.47% and 33.95% increases). Interventions to address the increase in AUD-related mortality should consider changes in use related to the pandemic.
Wait No Longer: Reducing Medication Wait-Times for Individuals with Co-Occurring Disorders
Journal of Dual Diagnosis
Community addiction treatment agencies have utilized Network for the Improvement of Addiction Treatment (NIATx) to reduce appointment wait-times. This exploratory analysis evaluated the impact of the NIATx implementation strategies on reduced wait-times to addiction, psychotropic, or both medications for individuals with co-occurring disorders (COD). NIATx implementation strategies reduced medication encounter wait-times but timing of agency improvements varied. Despite a significant improvement, a three-week wait-time to receive pharmacological interventions is suboptimal for those with a COD in need of immediate intervention. Community addiction treatment agencies should improve medication access so that their patients “wait no longer” to receive integrated treatment for their COD.
Prehospital Emergency Care
This study describes a program allowing EMS personnel to administer buprenorphine in the field to patients experiencing withdrawal (COWS>7) under the supervision of an Emergency Physician. Initial doses of 16 mg were administered and an additional 8mg were provided if needed. Substance use navigators facilitated connection with treatment and followed patient outcomes. Over the one-year trial period, 36 patients received buprenorphine. Treatment retention at seven days was 50% and 36% at 30 days. The authors conclude that EMS administered buprenorphine is feasible, safe, and has significant treatment retention at 30 days.