Publications by authors named "Alexander Y Walley"

145 Publications

"It could potentially be dangerous... but nothing else has seemed to help me.": Patient and clinician perspectives on benzodiazepine use in opioid agonist treatment.

J Subst Abuse Treat 2021 Apr 30;131:108455. Epub 2021 Apr 30.

Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, United States of America; Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, United States of America; Department of Health Law, Policy & Management, Boston University School of Public Health, United States of America.

Background: Benzodiazepine use among patients receiving opioid agonist treatment (OAT) presents a conundrum: benzodiazepines increase overdose risk, yet can treat anxiety and insomnia. How best to balance the risks and benefits of benzodiazepines among OAT patients is unclear. Using qualitative methods, we examined patient motivations for benzodiazepine use and understanding of risks, and the context in which benzodiazepine use and prescribing occurs.

Methods: We conducted semi-structured interviews with 26 OAT patients using benzodiazepines and 10 OAT clinicians. Participants were recruited from an office-based buprenorphine clinic at an academic medical center and a methadone opioid treatment program using purposive sampling. The study team reviewed transcripts and double-coded 100% of interviews. Data analysis combined both deductive and inductive methods.

Results: Major emergent themes were: 1) patients focus on benefits over risks of benzodiazepines, 2) patients can learn to use benzodiazepines safely, 3) patients want to use benzodiazepines now but discontinue in the future, 4) clinicians and patients weigh the risks and benefits of benzodiazepine use differently, 5) clinicians and patient have differences in treatment goals, and 6) clinicians struggle with benzodiazepine discontinuation.

Conclusions: OAT patients and clinicians can weigh the risks and benefits of benzodiazepines differently leading to a difference in treatment goals. The risk-benefit analysis of benzodiazepine prescribing may depend on whether the patient is engaged in opioid treatment. Future work among patients and clinicians is warranted to determine how to better balance patient and clinician priorities in order to deliver safer prescribing practices and maintain patient engagement in care.
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http://dx.doi.org/10.1016/j.jsat.2021.108455DOI Listing
April 2021

Integrating substance use care into primary care for adolescents and young adults: Lessons learned.

J Subst Abuse Treat 2021 Mar 23;129:108376. Epub 2021 Mar 23.

Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States of America; Grayken Center for Addiction, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, United States of America.

Background: Substance use disorders are common chronic conditions that often begin and develop during adolescence and young adulthood, yet the delivery of primary care is not developmentally tailored for youth who use substances. Very few primary care-based substance use treatment programs exist in the United States for adolescents and young adults and no clear guidance is available about how to provide substance use treatment in primary care.

Methods: We conducted a retrospective evaluation from July 2016 to December 2018 of a newly established primary care-based, multidisciplinary, outpatient program for youth who use substances. Components of the program include primary care, addiction treatment, harm reduction, naloxone distribution, psychotherapy, recovery support, and navigation addressing social determinants of health. We report the following patient characteristics and outcomes: demographics; proportion with substance use and mental health diagnoses; receipt of medications for opioid use disorder; retention in care at three, six, nine, and 12 months; and re-engagement in medical care.

Results: From July 2016 through December 2018, 148 patients had at least one visit. Demographic characteristics included: median age 21 years; 40.5% female; 94.0% spoke primarily English; 18.3% Black, 14.9% Hispanic, and 60.8% white. One-third of patients (33.8%) were homeless or housing insecure. The most common substance use disorder was opioid use disorder (60.8%), followed by nicotine (37.2%), cannabis (20.9%), and alcohol (18.2%). Overall, 29.7% of patients had depression, 32.4% had anxiety disorder, and 18.9% had post-traumatic stress disorder. Retention in care was 29.7% at six months and 12.2% at 12 months. Among the 90 patients with OUD, 90.0% received medication for OUD, and 35.5% and 15.5% of patients with OUD were retained at six and 12 months, respectively. For patients lost to follow-up (no contact during a three-month period), the median time to re-engagement was 4.8 months, and 33.3% (37/111) of patients re-engaged. The most common reason for re-engagement was to access mental health treatment (59.5%) and primary care (51.4%).

Conclusions: Youth who sought care in a primary care-based substance use program presented most commonly with opioid, nicotine, cannabis, and alcohol use disorders. Co-morbid mental health diagnoses were common. While continuous retention at 12 months was low, one in three of the patients who fell out of care re-engaged. For youth receiving substance use care integrated into primary care, key components for pursing optimal retention in substance use treatment are a flexible model that anticipates the need for the treatment of mental health disorders and the use of re-engagement strategies.
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http://dx.doi.org/10.1016/j.jsat.2021.108376DOI Listing
March 2021

Characterizing initiation, use, and discontinuation of extended-release buprenorphine in a nationally representative United States commercially insured cohort.

Drug Alcohol Depend 2021 May 21;225:108764. Epub 2021 May 21.

Department of Medicine, Section of Infectious Diseases, Boston University School of Medicine, Boston, MA, USA.

Background And Aims: While the United States is in the midst of an overdose epidemic, effective treatments are underutilized and commonly discontinued. Innovations in medication delivery, including an extended-release formulations, have the potential to improve treatment access and reduce discontinuation. We sought to assess extended-release buprenorphine discontinuation among individuals with opioid use disorder (OUD) in a real-world, nationally representative cohort.

Setting: United States PARTICIPANTS: Commercially insured individuals initiating one of four FDA-approved medications for opioid use disorder (MOUD) in 2018: extended-release buprenorphine, extended-release naltrexone, mucosal buprenorphine (mono- or co-formulated with naloxone), or methadone.

Measurements: Our primary outcome was medication discontinuation, defined as a gap of more than 14 days between the end of one prescription or administration and the subsequent dose.

Findings: We identified 14,358 individuals initiating MOUD in 2018, including 204 (1%) extended-release buprenorphine, 1,173 (8%) extended-release naltrexone, 12,171 (85%) mucosal buprenorphine, and 810 (6%) methadone initiations. Three months after initiation, 50% (95% confidence interval [CI] 40%-60%) of extended-release buprenorphine, 64% (95% CI 61%-69%) of extended-release naltrexone, 34% (95% CI 33%-35%) of mucosal buprenorphine, and 58% (95% CI 54%-62%) of methadone initiators had discontinued treatment.

Conclusions: Across all treatment groups, medication discontinuation was high, and in this sample of early adopters with limited follow-up time, we found no evidence that extended-release buprenorphine offered a retention advantage compared to other MOUD in real-world settings. Retention continues to represent a major obstacle to treatment effectiveness, and interventions are needed to address this challenge even as new MOUD formulations become available.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108764DOI Listing
May 2021

Competing risks of women and men who use fentanyl: "The number one thing I worry about would be my safety and number two would be overdose".

J Subst Abuse Treat 2021 06 27;125:108313. Epub 2021 Jan 27.

Boston University School of Medicine, Department of Medicine, Section of General Internal Medicine, Women's Health Unit, 801 Massachusetts Ave, First Floor, Boston, MA 02118, United States of America; Boston University School of Public Health, Department of Health Law, Policy, and Management, 715 Albany Street, Boston, MA 02118, United States of America. Electronic address:

Background: Standard public health approaches to risk communication do not address the gendered dynamics of drug use. The aim of this study was to explore perceptions of fentanyl-related risks among women and men to inform future risk communication approaches.

Methods: We conducted a qualitative study, purposively sampling English-speaking women and men, aged 18-25 or 35+ years, with past 12-month illicitly manufactured fentanyl use. In-depth individual interviews explored experiences of women and men related to overdose and fentanyl use. We conducted a grounded content analysis examining specific codes related to overdose and other health or social risks attributed to drug use. Using a constant comparison technique, we explored commonalities and differences in themes between women and men.

Results: The study enrolled twenty-one participants, 10 women and 11 men. All participants had personal overdose experiences. Both women and men described overdosing as a "chronic" condition and expressed de-sensitization to the risk of overdose. Women and men described other risks around health, safety, and state services that often superseded their fear of overdose. Women feared physical and sexual violence and prioritized caring for children and maintaining relations with child protective services, while men feared violence arising from obtaining and using street drugs and incarceration. Only women reported that fear of violence prevented their utilization of harm reduction services.

Conclusions: Experiences with overdose and risk communication among people who use fentanyl-containing opioids varied by gender. The development of gender-responsive programs that address targeted concerns may be an avenue to enhance engagement with harm reduction and treatment services and create safe spaces for women not currently accessing available services.
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http://dx.doi.org/10.1016/j.jsat.2021.108313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8140193PMC
June 2021

Shorter outpatient wait-times for buprenorphine are associated with linkage to care post-hospital discharge.

Drug Alcohol Depend 2021 Jul 20;224:108703. Epub 2021 Apr 20.

Department of Medicine, Boston University School of Medicine, 801 Massachusetts Ave, Boston, MA, 02118, USA.

Background: Inpatient addiction consult services (ACS) lower barriers to accessing medications for opioid use disorder (MOUD), however not every patient recommended for MOUD links to outpatient care. We hypothesized that fewer days between discharge date and outpatient appointment date was associated with improved linkage to buprenorphine treatment among patients evaluated by an ACS.

Methods: We extracted appointment and demographic data from electronic medical records and conducted retrospective chart review of adults diagnosed with opioid use disorder (OUD) evaluated by an ACS in Boston, MA between July 2015 and August 2017. These patients were initiated on or recommended buprenorphine treatment on discharge and provided follow-up appointment at our hospital post-discharge. Multivariable logistic regression assessed whether arrival to the appointment post-discharge was associated with shorter wait-times (0-1 vs. 2+ days).

Results: In total, 142 patients were included. Among patients who had wait-times of 0-1 day, 63 % arrived to their appointment compared to wait-times of 2 or more days (42 %). There were no significant differences between groups based on age, gender, distance of residence from the hospital, insurance status, co-occurring alcohol use disorder diagnosis, or discharge with buprenorphine prescription. After adjusting for covariates, patients with 0-1 day of wait-time had 2.6 times the odds of arriving to their appointment [95 % CI 1.3-5.5] compared to patients who had 2+ days of wait-time.

Conclusion: For hospitalized patients with OUD evaluated for initiating MOUD, same- and next-day appointments are associated with increased odds of linkage to outpatient MOUD care post-discharge compared to waiting two or more days.
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http://dx.doi.org/10.1016/j.drugalcdep.2021.108703DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8180499PMC
July 2021

Emergency Department Utilization Among People Living With HIV on Chronic Opioid Therapy.

J Int Assoc Provid AIDS Care 2021 Jan-Dec;20:23259582211010952

Boston Medical Center / Boston University School of Medicine, Boston, MA, USA.

Chronic pain among people with HIV (PWH) is a driving factor of emergency department (ED) utilization, and it is often treated with chronic opioid therapy (COT). We conducted a cross-sectional analysis of a prospective observational cohort of PWH on COT at 2 hospital-based clinics to determine whether COT-specific factors are associated with ED utilization among PWH. The primary outcome was an ED visit within 12 months after study enrollment. We used stepwise logistic regression including age, gender, opioid duration, hepatitis C, depression, prior ED visits, and Charlson comorbidity index. Of 153 study participants, n = 69 (45%) had an ED visit; 25% of ED visits were pain-related. High dose opioids, benzodiazepine co-prescribing, and lack of opioid treatment agreements were not associated with ED utilization, but prior ED visits (p = 0.002), depression (p = 0.001) and higher Charlson comorbidity score (p = 0.003) were associated with ED utilization. COT-specific factors were not associated with increased ED utilization among PWH.
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http://dx.doi.org/10.1177/23259582211010952DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8072919PMC
April 2021

Rethinking Home-based Outpatient Parenteral Antibiotic Therapy for Persons Who Inject Drugs: An Opportunity for Change in the Time of COVID-19.

J Addict Med 2021 Apr 9. Epub 2021 Apr 9.

Section of Infectious Disease, Department of Medicine, Boston Medical Center, Boston, MA (RJ, DC, MF), Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA (RJ, HR, AYW).

Outpatient parenteral antibiotic therapy (OPAT) refers to the monitored provision of intravenous antibiotics for complicated infections outside of a hospital setting, typically in a rehabilitation facility, an infusion center, or the home. Home-based OPAT allows for safe completion of prolonged courses of therapy while decreasing costs to the healthcare system, minimizing the risk of hospital-related infectious exposures for patients, and permitting patients to recover in a familiar environment. Amidst the COVID-19 pandemic, during which nursing facilities have been at the center of many outbreaks of the SARS-CoV-2 virus, completion of antimicrobial therapy in the home is an even more appealing option. Persons who inject drugs (PWID) frequently present with infectious complications of their injection drug use which require long courses of parenteral therapy. However, these individuals are frequently excluded from home-based OPAT on the basis of their addiction history. This commentary describes perceived challenges to establishing home-based OPAT for PWID, discusses ways in which this is discriminatory and unsupported by available data, highlights ways in which the COVID-19 pandemic has accentuated inequities in care, and proposes a multidisciplinary approach championed by Addiction specialists to increasing implementation of OPAT for appropriate patients with substance use disorders.
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http://dx.doi.org/10.1097/ADM.0000000000000856DOI Listing
April 2021

Treatment of Refractory Opioid Use Disorder : Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: A Narrative Review.

J Gen Intern Med 2021 Jun;36(6):1793

Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, USA.

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http://dx.doi.org/10.1007/s11606-021-06727-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8175604PMC
June 2021

Naloxone receipt and overdose prevention care among people with HIV on chronic opioid therapy.

AIDS 2021 03;35(4):697-700

Division of General Internal Medicine, Department of Medicine, Harborview Medical Center and University of Washington School of Medicine, Boston, Massachusetts, USA.

This cross-sectional study describes naloxone rescue kit receipt among people with HIV (PWH) on chronic opioid therapy (COT) and HIV clinician opioid overdose prevention care in two clinics between 2015 and 2017. Naloxone rescue kit receipt was uncommon. History of overdose was associated with receiving naloxone but having a clinician who reported providing overdose prevention care was not. This study suggests that clinicians prescribing COT to PWH should improve overdose prevention care, including naloxone co-prescribing.
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http://dx.doi.org/10.1097/QAD.0000000000002803DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7904637PMC
March 2021

Projected Estimates of Opioid Mortality After Community-Level Interventions.

JAMA Netw Open 2021 02 1;4(2):e2037259. Epub 2021 Feb 1.

Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts.

Importance: The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022.

Objective: To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations.

Design, Setting, And Participants: This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020.

Main Outcomes And Measures: Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs.

Results: No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD.

Conclusions And Relevance: In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.37259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7885041PMC
February 2021

Characteristics of post-overdose public health-public safety outreach in Massachusetts.

Drug Alcohol Depend 2021 02 31;219:108499. Epub 2020 Dec 31.

Grayken Center for Addiction and Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center/Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118, USA.

Background: As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding.

Methods: We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics.

Results: As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138).

Conclusions: Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108499DOI Listing
February 2021

Comparison of Rates of Overdose and Hospitalization After Initiation of Medication for Opioid Use Disorder in the Inpatient vs Outpatient Setting.

JAMA Netw Open 2020 12 1;3(12):e2029676. Epub 2020 Dec 1.

Section of Infectious Diseases, Department of Medicine, Boston Medical Center, Boston, Massachusetts.

Importance: Whereas outpatient treatment with medication for opioid use disorder (MOUD) is evidence based, there is a large network of inpatient facilities in the US that are reimbursed by commercial insurers and do not typically offer MOUD.

Objective: To compare the rates of opioid-related overdose and all-cause hospitalization after outpatient MOUD treatment vs inpatient care.

Design, Setting, And Participants: This comparative effectiveness research study used deidentified claims of commercially insured individuals in the US from the MarketScan Commercial Claims and Encounters Database from January 1, 2010, to December 31, 2017, to obtain a sample of 37 090 individuals with opioid use disorder who initiated treatment with inpatient care and/or MOUD. Data were analyzed from October 1, 2019, to May 1, 2020. To address nonrandom treatment assignment, individuals with opioid use disorder who initiated MOUD or who entered inpatient care were matched 1:1 based on propensity scores.

Exposures: The independent variable of interest was the type of treatment initiated. Individuals could initiate 1 of 5 potential treatments: (1) outpatient MOUD, (2) short-term inpatient care, (3) short-term inpatient care followed by outpatient MOUD within 30 days, (4) long-term inpatient care, or (5) long-term inpatient care followed by outpatient MOUD within 30 days.

Main Outcomes And Measures: Opioid-related overdose and all-cause hospitalization at any point within the 12 months after treatment of opioid use disorder. The hazard for each outcome was estimated using a time-to-event Cox proportional hazards regression model.

Results: The cohort included 37 090 individuals matched 1:1 between inpatient and outpatient treatment (20 723 [56%] were younger than 30 years; 23 250 [63%] were male). After propensity score matching, compared with the inpatient treatments, initiation of outpatient MOUD alone was followed by the lowest 1-year overdose rate (2.2 [95% CI, 2.0-2.5] per 100 person-years vs 3.5 [95% CI, 2.7-4.4] to 7.0 [95% CI, 4.6-10.7] per 100 person-years) and hospitalization rate (39 [95% CI, 38-40] per 100 person-years vs 57 [95% CI, 54-61] to 74 [95% CI, 73-76] per 100 person-years). Outpatient MOUD was also associated with the lowest hazard of these events compared with inpatient care, which had hazard ratios ranging from 1.71 (95% CI, 1.35-2.17) to 2.67 (95% CI, 1.68-4.23) for overdose and 1.33 (95% CI, 1.23-1.44) to 1.90 (95% CI, 1.83-1.97) for hospitalizations.

Conclusions And Relevance: The results of this comparative effectiveness research study suggest that lower rates of subsequent overdose and hospitalization are associated with outpatient MOUD compared with short- or long-term inpatient care. When patients and clinicians have a choice of treatment, outpatient MOUD treatment may be associated with lower overdose and hospitalization on balance. Future research should assess which patients benefit most from inpatient care and how best to leverage existing inpatient treatment infrastructure.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.29676DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7739119PMC
December 2020

Adaptation of a System of Treatment for Substance Use Disorders During the COVID-19 Pandemic.

J Addict Med 2020 Dec 8. Epub 2020 Dec 8.

Grayken Center for Addiction (MK, MT, JLT, GR-M, SDK, SMB, KMS, EC, TWP, CL, ZW, AYW); Clinical Addiction Research and Education (CARE) Unit (JLT, CL, ZW, AYW); Section of General Internal Medicine, Department of Medicine (MK, JLT, SDK, SMB, CL, ZW, AYW); Section of Infectious Diseases, Department of Medicine (SDK, GR-M); Division of General Pediatrics, Department of Pediatrics (SMB); Department of Obstetrics and Gynecology (KMS); Division of Ambulatory Pediatrics, Department of Pediatrics (EC); Department of Psychiatry (TWP); Boston Medical Center (MK, MT, JLT, GR-M, SDK, SMB, KMS, EC, TWP, CL, ZW, AYW); Boston University School of Medicine, Boston, MA (MK, JLT, SDK, SMB, KMS, EC, TWP, CL, ZW, AYW).

: The Grayken Center for Addiction at Boston Medical Center includes programs across the care continuum for people with substance use disorders (SUDs), serving both inpatients and outpatients. These programs had to innovate quickly during the COVID-19 outbreak to maintain access to care. Federal and state regulatory flexibility allowed these programs to initiate treatment for people experiencing homelessness and maximize patient safety through physical distancing practices. Programs switched to telehealth with high levels of acceptability and patient retention. Some programs also maintained some face-to-face clinic visits to see patients with complex problems and to provide injectable medications. Text-messaging proved invaluable with adolescent and young adult clients, and a mobile-health outreach program was initiated to reach mother/child dyads affected by SUDs. A 24-hour hotline was implemented to support seamless access to treatment for hundreds released from incarceration early due to the pandemic. Boston Medical Center also launched the COVID Recuperation Unit to allow patients experiencing homelessness to recover from mild to moderate COVID-19 infection in an environment that took a harm-reduction approach to SUDs and provided rapid initiation of medication treatment. Many of these innovations increased access to treatment and retention of patients during the pandemic. Maintaining the revised regulations would allow flexibility to provide telehealth, extended prescriptions, and remote access to buprenorphine initiation to support and engage more patients with SUDs.
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http://dx.doi.org/10.1097/ADM.0000000000000791DOI Listing
December 2020

"Opening the door to somebody who has a chance." - The experiences and perceptions of public safety personnel towards a public restroom overdose prevention alarm system.

Int J Drug Policy 2021 Feb 21;88:103038. Epub 2020 Nov 21.

Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA, 02118, USA.

Background: Opioid overdose deaths have surged due to fentanyl in the illicit opioid supply, which causes overdose more rapidly than other opioids. Public restrooms are venues where fentanyl overdoses commonly occur. In response, some organizations have implemented anti-motion alarm systems as a prevention approach. We aimed to describe the experiences and perceptions of public safety personnel after the installation of an anti-motion alarm system in public restrooms at an urban medical center.

Methods: From February to June 2019, we conducted semi-structured qualitative interviews to explore the experiences and perceptions of hospital public safety personnel who responded to overdoses in public restrooms with and without an anti-motion alarm system. We interviewed 11 personnel, with interviews lasting an average of twenty-six minutes. We conducted inductive thematic analysis to synthesize and identify salient themes.

Results: Ten participants were male; the average age was 40 with an average time employed by the hospital of 12 years. Four themes were identified: Public safety personnel 1) believe responding to overdoses is an appropriate responsibility; 2) focus on their training rather than individual emotions when responding to an overdose; 3) view the anti-motion alarm system as an acceptable tool for preventing overdoses, despite technological challenges; and 4) report concern for potential unintended consequences of the anti-motion alarm system.

Conclusions: Overdose response in public restrooms has been incorporated into the daily duties of public safety personnel at an academic medical center. Anti-motion alarm systems are an innovation with potential to improve overdose response and safety, though the technology warrants ongoing development and unintended consequences should be assessed. To optimize restroom safety in the midst of fentanyl use, more research is needed among first responders, people who use drugs in restrooms, and other restroom patrons.
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http://dx.doi.org/10.1016/j.drugpo.2020.103038DOI Listing
February 2021

Age-based preferences for risk communication in the fentanyl era: 'A lot of people keep seeing other people die and that's not enough for them'.

Addiction 2021 06 26;116(6):1495-1504. Epub 2020 Nov 26.

Department of Medicine, Section of General Internal Medicine, Department of Pediatrics, Division of General Pediatrics, Boston University School of Medicine, Boston, MA, USA.

Aims: To explore how people who use fentanyl and health-care providers engaged in and responded to overdose risk communication interactions, and how these engagements and responses might vary by age.

Design: A single-site qualitative in-depth interview study.

Setting: Boston, MA, United States.

Participants: The sample included 21 people (10 women, 11 men) who were either 18-25 or 35+, English-speaking, and reported illicit fentanyl use in the last year and 10 health-care providers who worked directly with people who use fentanyl (PWUF) in clinical and community settings.

Measurements: Open-ended, flexible interview questions guided by a risk communication framework were used in all interviews. Codes used for thematic analysis included deductive codes related to the risk communication framework and inductive, emergent codes from interview content.

Findings: We identified potential age-based differences in perceptions of fentanyl overdose, including that younger participants appeared to display more perceptions of an immunity to fentanyl's lethality, while older people seemed to express a stronger aversion to fentanyl due to its heightened risk of fatal overdose, shorter effects and potential for long-term health consequences. Providers perceived greater challenges relaying risk information to young PWUF and believed them to be less open to risk communication. Compassionate harm reduction communication was preferred by all participants and perceived to be delivered most effectively by community health workers and peers. PWUF and providers identified structural barriers that limited compassionate harm reduction, including misalignment of available treatment with preferred options and clinical structures that impeded the delivery of risk communication messages.

Conclusions: Among people who engage in illicit fentanyl use, fentanyl-related risk communication experiences and preferences may vary by age, but some foundational elements including compassionate, trust-building approaches seem to be preferred across the age spectrum. Structural barriers in the clinical setting such as provider-prescribing power and infrequent encounters may impede the providers' ability to provide compassionate harm reduction communication.
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http://dx.doi.org/10.1111/add.15305DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8081736PMC
June 2021

Association of Treatment With Medications for Opioid Use Disorder With Mortality After Hospitalization for Injection Drug Use-Associated Infective Endocarditis.

JAMA Netw Open 2020 10 1;3(10):e2016228. Epub 2020 Oct 1.

Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts.

Importance: Although hospitalizations for injection drug use-associated infective endocarditis (IDU-IE) have increased during the opioid crisis, utilization of and mortality associated with receipt of medication for opioid use disorder (MOUD) after discharge from the hospital among patients with IDU-IE are unknown.

Objective: To assess the proportion of patients receiving MOUD after hospitalization for IDU-IE and the association of MOUD receipt with mortality.

Design, Setting, And Participants: This retrospective cohort study used a population registry with person-level medical claims, prescription monitoring program, mortality, and substance use treatment data from Massachusetts between January 1, 2011, and December 31, 2015; IDU-IE-related discharges between July 1, 2011, and June, 30, 2015, were analyzed. All Massachusetts residents aged 18 to 64 years with a first hospitalization for IDU-IE were included; IDU-IE was defined as any hospitalization with a diagnosis of endocarditis and at least 1 claim in the prior 6 months for OUD, drug use, or hepatitis C and with 2-month survival after hospital discharge. Data were analyzed from November 11, 2018, to June 23, 2020.

Exposure: Receipt of MOUD, defined as any treatment with methadone, buprenorphine, or naltrexone, within 3 months after hospital discharge excluding discharge month for IDU-IE.

Main Outcomes And Measures: The main outcome was all-cause mortality. The proportion of patients who received MOUD in the 3 months after hospital discharge was calculated. Multivariable Cox proportional hazard regression models were used to examine the association of MOUD receipt with mortality, adjusting for sex, age, medical and psychiatric comorbidities, and homelessness. In the secondary analysis, receipt of MOUD was considered as a monthly time-varying exposure.

Results: Of 679 individuals with IDU-IE, 413 (60.8%) were male, the mean (SD) age was 39.2 (12.1) years, 298 (43.9%) were aged 18 to 34 years, 419 (72.3) had mental illness, and 209 (30.8) experienced homelessness. A total of 134 individuals (19.7%) received MOUD in the 3 months before hospitalization and 165 (24.3%) in the 3 months after hospital discharge. Of those who received MOUD after discharge, 112 (67.9%) received buprenorphine. The crude mortality rate was 9.2 deaths per 100 person-years. MOUD receipt within 3 months after discharge was not associated with reduced mortality (adjusted hazard ratio, 1.29; 95% CI, 0.61-2.72); however, MOUD receipt was associated with reduced mortality in the month that MOUD was received (adjusted hazard ratio, 0.30; 95% CI, 0.10-0.89).

Conclusions And Relevance: In this cohort study, receipt of MOUD was associated with reduced mortality after hospitalization for injection drug use-associated endocarditis only in the month it was received. Efforts to improve MOUD initiation and retention after IDU-IE hospitalization may be beneficial.
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http://dx.doi.org/10.1001/jamanetworkopen.2020.16228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557514PMC
October 2020

Non-prescription Fentanyl Positive Toxicology: Prevalence, Positive Predictive Value of Fentanyl Immunoassay Screening, and Description of Co-substance Use.

J Addict Med 2021 Apr;15(2):150-154

South Shore Health, 55 Fogg Road, South Weymouth, MA 02190 (TK); Grayken Center for Addiction, Boston Medical Center-Boston University School of Medicine, 801 Massachusetts Avenue, Boston, MA 02118 (MLR, SK, KW, AYW); University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01605 (S-LF).

Objectives: Opioid overdose deaths in Massachusetts linked to illicitly-manufactured fentanyl have increased dramatically. In response, an urban safety-net hospital added urine fentanyl testing with reflex confirmation testing to its standard urine toxicology panel. The goals of this study were to describe fentanyl toxicology test results, identify the positive predictive value of presumptive fentanyl immunoassay, and describe co-substance use among those with unexpected fentanyl positive results.

Methods: We included urine toxicology tests from January through June 2016 analyzed at an urban safety-net hospital. We excluded tests from individuals prescribed or administered fentanyl within the preceding 72 hours. Positive fentanyl immunoassay tests underwent reflex chromatography confirmation testing. Samples that confirmed positive for acetyl fentanyl and/or fentanyl and/or norfentanyl were considered true positives.

Results: Of 11,873 urine samples, 10.4% of samples screened fentanyl positive and 8.8% were confirmed fentanyl positive. The positive predictive value of a positive urine fentanyl screen was 85.7%. Of 4398 unique patients, 13.2% had at least 1 test confirmed positive for nonprescription fentanyl. Patients with a confirmed fentanyl positive drug test were more likely to have positive urine drug test for barbiturates, benzodiazepines, cocaine, methadone, and opiates, and less likely to have oxycodone or buprenorphine.

Conclusions: At an urban safety-net hospital, nonprescription fentanyl use was common and was associated with greater use of other substances favoring routine fentanyl testing. Although the positive predictive value of the screening test was high, confirmation testing detected substantial numbers of false positives, especially in older patients. Therefore, fentanyl confirmation testing should be used when results will change treatment approach and patient education.
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http://dx.doi.org/10.1097/ADM.0000000000000723DOI Listing
April 2021

Against medical advice discharges in injection and non-injection drug use-associated infective endocarditis: A nationwide cohort study.

Clin Infect Dis 2020 Aug 5. Epub 2020 Aug 5.

Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center/Boston University School of Medicine.

Background: Among those with injection drug use-associated infective endocarditis (IDU-IE), against medical advice (AMA) discharge is common and linked to adverse outcomes. Understanding trends, risk factors and timing is needed to reduce IDU-IE AMA discharges.

Methods: We identified individuals ages 18-64 with International Classification of Diseases, 9thRevision diagnosis codes for infective endocarditis (IE) in the National Inpatient Sample, a representative sample of United States hospitalizations from January 2010 to September 2015. We plotted unadjusted quarter-year trends for AMA discharges and used multivariable logistic regression to identify factors associated with AMA discharge among IE hospitalizations, comparing IDU-IE to non-IDU-IE.

Results: We identified 7,259 IDU-IE and 23,633 non-IDU-IE hospitalizations. Of these hospitalizations, 14.2% of IDU-IE and 1.9% of non-IDU-IE resulted in AMA discharges. More than 30% of AMA discharges for both groups occurred before hospital day 3. In adjusted models, IDU status [Adjusted Odds Ratio (AOR) 3.92 (95% CI: 3.43-4.48)] was associated with increased odds of AMA discharge. Among IDU-IE, women [AOR 1.21 (95% CI: 1.04-1.41)] and Hispanics [AOR 1.32 (95% CI: 1.03-1.69)] had increased odds of AMA discharge, which differed from non-IDU-IE. Over nearly 6-years, odds of AMA discharge increased 12% per year for IDU-IE [AOR 1.12 (95% CI: 1.07-1.18)] and 6% per year for non-IDU-IE [AOR 1.06 (95% CI: 1.00-1.13)].

Conclusion: AMA discharges have risen among individuals with IDU-IE and non-IDE-IE. Among those who inject drugs, AMA discharges were more common and increases sharper. Efforts that address the rising fraction, disparities, and timing of IDU-IE AMA discharges are needed.
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http://dx.doi.org/10.1093/cid/ciaa1126DOI Listing
August 2020

Improving the Delivery of Chronic Opioid Therapy among People Living with HIV: A Cluster Randomized Clinical Trial.

Clin Infect Dis 2020 Jul 22. Epub 2020 Jul 22.

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, GA.

Background: Chronic pain is prevalent among people living with HIV (PLWH); managing pain with chronic opioid therapy (COT) is common. HIV providers often diverge from prescribing guidelines.

Methods: This two-arm, unblinded cluster-randomized clinical trial assessed whether the Targeting Effective Analgesia in Clinics for HIV (TEACH) intervention improves guideline-concordant care compared to usual care for PLWH on COT. The trial was implemented from 2015-2018 with 12-month follow-up at safety-net hospital-based HIV clinics in Boston and Atlanta. We enrolled 41 providers and their 187 patients on COT. Prescribers were randomized 1:1 to either a 12-month intervention consisting of a nurse care manager with an interactive electronic registry, opioid education, academic detailing and access to addiction specialists or a control condition consisting of usual care. Two primary outcomes were assessed through electronic medical records: ≥2 urine drug tests and any early COT refills by 12 months. Other outcomes included possible adverse consequences.

Results: At 12-months, the TEACH intervention arm had higher odds of ≥2 urine drug tests than the usual care arm (71% vs. 20%, adjusted odds ratio [AOR]: 13.38; 95% confidence interval [CI]: 5.85-30.60; p<0.0001). We did not detect a statistically significant difference in early refills (22% vs. 30%; AOR: 0.55; 95% CI: 0.26-1.15; p=0.11), pain severity (6.30 vs. 5.76; adjusted mean difference 0.10; 95% CI: -1.56-1.75; p=0.91), or HIV viral load suppression (86.9% vs. 82.1%; AOR: 1.21; 95% CI: 0.47-3.09; p=0.69).

Conclusions: TEACH is a promising intervention to improve adherence to COT guidelines without evident adverse consequences.
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http://dx.doi.org/10.1093/cid/ciaa1025DOI Listing
July 2020

Rejection of Patients With Opioid Use Disorder Referred for Post-acute Medical Care Before and After an Anti-discrimination Settlement in Massachusetts.

J Addict Med 2021 Jan-Feb 01;15(1):20-26

Department of Medicine, Boston Medical Center and Boston University School of Medicine, Boston, MA (SDK, SR, MLR, AYW); The Grayken Center for Addiction, Boston Medical Center (SDK, MLR, AYW); Division of General Internal Medicine and Mongan Institute, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA (BB).

Objectives: To determine how commonly medical inpatients with opioid use disorder (OUD) referred for postacute medical care were rejected due to substance use or treatment with opioid agonist therapy (OAT). Additionally, to assess for changes in rejection rates following the United States Attorney's May 2018 settlement with a Massachusetts nursing facility for violating anti-discrimination laws for such rejections.

Methods: We linked electronic referrals to private Massachusetts postacute medical care facilities from Boston Medical Center in 2018 with clinical data. We included referrals with evidence of OUD using ICD-10 diagnosis codes or OAT receipt. We identified the frequency of referrals where the stated rejection reason was substance use or OAT and classified these as discriminatory. We used segmented regression to assess for changes in proportion of referrals with substance use and OAT-related rejections before and after the settlement.

Results: In 2018, 219 OUD-associated hospitalizations resulted in 1648 referrals to 285 facilities; 81.8% (1348) were rejected. Among hospitalizations, 37.4% (82) received at least 1 discriminatory rejection. Among rejections, 15.1% (203) were discriminatory (105 for OAT and 98 for substance use). Among facilities, 29.1% (83) had at least one discriminatory rejection. We found no differences in proportion of discriminatory rejections before and after the settlement.

Conclusions: Individuals hospitalized with OUD frequently experience explicit discrimination when rejected from postacute care despite federal and state protections. Efforts are needed to enhance enforcement of anti-discrimination laws, regulations, and policies to ensure access to postacute medical care for people with OUD and ongoing medical needs.
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http://dx.doi.org/10.1097/ADM.0000000000000693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7859880PMC
January 2022

Assessing pharmacy-based naloxone access using an innovative purchase trial methodology.

J Am Pharm Assoc (2003) 2020 Nov - Dec;60(6):853-860. Epub 2020 Jul 8.

Objectives: Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchases and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from 2 high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers.

Design: Purchase trial.

Setting And Participants: The study used a stratified random sample of 200 chain and independent retail pharmacies across Massachusetts. Each pharmacy underwent 2 purchase attempts-1 by a person who used illicit opioids (PWUIO) and 1 by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose.

Outcome Measure: Successful or unsuccessful naloxone purchase attempt.

Results: Overall, 322 of 397 purchase attempts (81%) were successful, with no statistically significant difference between PWUIO and bystanders (P = 0.221). Most purchases (93%) resulted in the acquisition of single-step nasal naloxone (Narcan; median cost $133.38). Forty percent of the purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, P < 0.001). Common reasons for failed purchase were not stocking naloxone (47%), price > $150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, P < 0.001).

Conclusion: We documented high levels of naloxone access for both PWUIO and bystanders, suggesting Massachusetts could serve as a model for states seeking to improve pharmacy-based naloxone access. Additional implementation efforts should focus on expanding availability at independent pharmacies and supporting pharmacies in proactively offering naloxone to PWUIO and other high-risk individuals.
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http://dx.doi.org/10.1016/j.japh.2020.05.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655699PMC
July 2020

Response to Letter to the Editor: The Contribution of Prescribed and Illicit Opioids to Fatal Overdoses in Massachusetts, 2013-2015.

Public Health Rep 2020 Jul/Aug;135(4):542-543. Epub 2020 Jul 2.

164186Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA.

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http://dx.doi.org/10.1177/0033354920935076DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383756PMC
August 2020

Buprenorphine waiver uptake among nurse practitioners and physician assistants: The role of existing waivered prescriber supply.

J Subst Abuse Treat 2020 08 13;115:108032. Epub 2020 May 13.

Department of Health Law, Policy and Management, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA; Department of Infectious Disease, Boston University School of Medicine, 801 Massachusetts Ave Crosstown Center, Boston, MA, 02118, USA. Electronic address:

Background: Buprenorphine is an effective pharmacotherapy for the treatment of opioid use disorder (OUD), but recent increases in the rate of OUD in the U.S. have outpaced the supply of clinicians waivered to prescribe buprenorphine. To increase the supply of buprenorphine prescribers, the Comprehensive Addiction and Recovery Act expanded buprenorphine prescribing waiver eligibility beyond physicians to nurse practitioners (NP) and physician assistants (PA) in 2017. Little is known about patterns of waiver uptake among NPs and PAs. This study examined associations between the existing supply of waivered prescribers and waiver uptake among NPs and PAs in U.S. states.

Methods: NP and PA waiver uptake was evaluated as the number of NPs or PAs obtaining an initial buprenorphine prescribing waiver per 10,000 state residents from January 2017 to December 2018 using data from the Buprenorphine Waiver Notification System. NP and PA waiver uptake was estimated as a function of existing waivered prescriber supply, OUD treatment capacity, and other state characteristics using generalized least squares (GLS) regression.

Results: 28,010 NPs and PAs have become waivered to prescribe buprenorphine since January 2017. GLS regressions indicated that waivered prescriber supply was significantly, positively associated with both NP (b = 0.101 p < 0.001) and PA (b = 0.030, p < 0.001) waiver uptake. Results suggest an addition of ten waivered prescribers to existing supply was associated with an increase of one waivered NP, and an addition of thirty-three waivered prescribers to existing supply was associated with an increase of one waivered PA.

Conclusions: NP and PA waiver uptake is strongly associated with the existing supply of waivered prescribers in a state, suggesting NPs and PAs may be more likely to acquire waivers in states with a high existing supply of buprenorphine prescribers. Additional policy solutions are needed to scale up the supply of buprenorphine prescribers in underserved states.
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http://dx.doi.org/10.1016/j.jsat.2020.108032DOI Listing
August 2020

Prevalence of Covid-19 Infection and Subsequent Cohorting in a Residential Substance Use Treatment Program in Boston, MA.

J Addict Med 2020 Sep/Oct;14(5):e261-e263

Section of Infectious Diseases, Boston Medical Center, Boston, MA (BMC) (JAB, TCB, SDK); Boston University School of Medicine, Boston, MA (JAB, TCB, SDK); Victory Programs, Inc, Boston, MA (EB, SJP); Department of Medicine, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Boston University School of Medicine and BMC, Boston, MA (SDK, SDK, AYW); Grayken Center for Addiction, BMC, Boston, MA (JAB, SDK, SDK, AYW).

Objectives: The global pandemic of coronavirus disease 2019 (Covid-19) may disproportionately affect persons in congregate settings, including those in residential substance use treatment facilities. To limit the spread of SARS-CoV-2 through congregate settings, universal testing may be necessary. We aimed to determine the point prevalence of SARS-CoV-2 in a residential treatment program setting and to understand the unique challenges of Covid-19 transmission in this setting.

Methods: We performed a case series of SARS-CoV-2 rT-PCR testing via nasopharyngeal in a residential substance use treatment program for women in Boston. Staff and residents of the treatment program were tested for SARS-CoV-2. The primary outcome was SARS-CoV-2 test result.

Results: A total of 31 residents and staff were tested. Twenty-seven percent (6/22) of the residents and 44% (4/9) of staff tested positive for SARS-CoV-2. All of the SARS-CoV-2 positive residents resided in the same residential unit. Two positive cases resided together with 2 negative cases in a 4-person room. Two other positive cases resided together in a 2-person room. One positive case resided with 2 negative cases in a 3-person room. One positive case resided with a negative case in a 2-person room. Based on test results, residents were cohorted by infection status and continued to participate in addiction treatment on-site.

Conclusions: SARS-CoV-2 infection was common among staff and residents within a residential substance use treatment program for women in Boston. Universal SARS-CoV-2 testing in residential substance use programs can be instituted to reduce the risk of further transmission and continue addiction treatment programming when accompanied by adequate space, supplies, and staffing.
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http://dx.doi.org/10.1097/ADM.0000000000000700DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7944945PMC
October 2020

Inpatient addiction consultation and post-discharge 30-day acute care utilization.

Drug Alcohol Depend 2020 May 25;213:108081. Epub 2020 May 25.

Boston University School of Medicine, 72 East Concord St., Boston, MA 02118, United States; Boston Medical Center Grayken Center for Addiction, Department of Medicine, Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, United States.

Background: Addiction Consult Services care for hospitalized patients with substance use disorders (SUD), who frequently utilize costly medical services. This study evaluates whether an addiction consult is associated with 30-day acute care utilization.

Methods: This was a retrospective cohort study of 3905 inpatients with SUD. Acute care utilization was defined as any emergency department visit or re-hospitalization within 30 days of discharge. Inverse probability of treatment weighted generalized estimating equations logistic regression models were used to evaluate the relationship between receipt of an addiction consult and 30-day acute care utilization. Exploratory subgroup analyses were performed to describe whether this association differed by type of SUD and discharge on medication for addiction treatment.

Results: The 30-day acute care utilization rate was 39.5 % among patients with a consult and 36.0 % among those without. Addiction consults were not significantly associated with care utilization (Adjusted Odds Ratio 1.02; 0.82, 1.28). No significant differences were detected in subgroup analyses; however, the decreased odds among patients with OUD given medication was clinically notable (AOR 0.69; 0.47, 1.02).

Discussion: Repeat acute care utilization is common among hospitalized patients with SUD, particularly those seen by the addiction consult services. While this study did not detect a significant association between addiction consults and 30-day acute care utilization, this relationship merits further evaluation using prospective studies, controlling for key confounders and with a focus on the impact of medications for opioid use disorder.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7371521PMC
May 2020

Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: a Narrative Review.

J Gen Intern Med 2020 08 27;35(8):2418-2426. Epub 2020 May 27.

Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, USA.

Amidst the opioid overdose crisis, there are increased efforts to expand access to medications for opioid use disorder (MOUD). Hospitalization for the complications of substance use in the United States (US) provides an opportunity to initiate methadone, buprenorphine, and extended release naltrexone and link high-risk, not otherwise engaged, patients into outpatient care. However, treatment options for patients are quickly exhausted when these medications are not desired, tolerated, or beneficial. As an example, we discuss the case of a man who was hospitalized 27 times over 2 years for complications related to his opioid use disorder (OUD), including recurring methicillin-resistant Staphylococcus aureus vertebral osteomyelitis, increasing antimicrobial resistance, new infections, and multiple overdoses in and out of the hospital. The patient suffered these complications despite efforts to treat his OUD with methadone and buprenorphine while hospitalized, and repeated attempts to link him to outpatient care. We use this case to review evidence-based treatments for refractory OUD, which are not approved in the US, but are available in Canada. If hospitalized in Vancouver, Canada, this patient could have been offered slow-release oral morphine and injectable opioid agonist therapy, as well as access to sterile syringes and injection equipment at an in-hospital supervised injection facility. Each of these approaches is supported by evidence and has been implemented successfully in Canada, yet none are available in the US. In order to combat the multiple harms from opioids, it is critical that we consider every evidence-based tool.
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http://dx.doi.org/10.1007/s11606-020-05920-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7403280PMC
August 2020

Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report.

J Addict Med 2020 Jul/Aug;14(4):e136-e138

Grayken Center for Addiction, Boston Medical Center, Boston, MA (MH, SJ, RS, AW, JLT); Department of Medicine, Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Boston University School of Medicine and Boston Medical Center, Boston MA (MH, RS, AW, JLT); Department of Medicine, Section of Infectious Diseases, Boston Medical Center, Boston, MA (SJ); Access, Harm Reduction, Overdose Prevention, and Education (AHOPE), Boston Public Health Commission, Boston, MA (SM); Department of Community Health Sciences, Boston University School of Public Health, Boston, MA (RS).

Background: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD).

Case Presentation: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later.

Conclusions: COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.
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http://dx.doi.org/10.1097/ADM.0000000000000682DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7273942PMC
August 2020

Food insecurity and substance use in people with HIV infection and substance use disorder.

Subst Abus 2020 May 6:1-9. Epub 2020 May 6.

Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Grayken Center for Addiction at Boston Medical Center, Boston, MA, USA.

Food insecurity and substance use are common among people living with HIV (PLWH). Substance use may help people cope with hunger and thus be associated with food insecurity, but the association is uncertain. This study assessed whether, in PLWH and substance dependence, if there was an association between food insecurity and substance use. We studied adults with HIV and current substance dependence or ever injection drug use interviewed at 12 and 24 months after enrollment in a prospective cohort study. The presence of food insecurity (insufficient food quantity or quality, or anxiety about its availability) was assessed using the Household Food Insecurity Assessment Scale questionnaire (HFIAS). Unhealthy alcohol use was assessed with the Alcohol Use Disorder Identification Test - Consumption (AUDIT-C) and past 30-day other drug use with the Addiction Severity Index. Associations using repeat cross-sectional data from each of two time-points, 12 months apart, from the same participants were tested using generalized estimating equations logistic regressions. The 233 participants had a mean age of 50 years and 65% were male. At the first interview, 44% reported food insecurity, 40% unhealthy alcohol use, 25% past 30-day cocaine use, and 17% past 30-day illicit opioid use. In analyses adjusted for demographics, social factors, physical and mental health function, and substance use related variables, there was no significant association between food insecurity and unhealthy alcohol use (adjusted odds ratio (aOR) = 1.06 (95% CI: 0.59, 1.87)). Those with food insecurity had higher odds of illicit opioid use (aOR = 2.5 (95% CI: 1.12, 5.58)) and cocaine use (aOR = 1.95 (CI 95%: 1.00, 3.81)). Food insecurity was not associated with unhealthy alcohol use but was associated with cocaine and illicit opioid use. Given the prevalence and impact substance use has on PLWH, food insecurity should be identified and addressed.
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http://dx.doi.org/10.1080/08897077.2020.1748164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7644575PMC
May 2020

Revisiting pharmacy-based naloxone with pharmacists and naloxone consumers in 2 states: 2017 perspectives and evolving approaches.

J Am Pharm Assoc (2003) 2020 Sep - Oct;60(5):740-749. Epub 2020 Apr 23.

Objectives: Pharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake.

Design: Eight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island.

Setting And Participants: Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.

Outcome Measures: The FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings.

Results: A total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist-partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received.

Conclusions: Experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone.
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http://dx.doi.org/10.1016/j.japh.2020.03.005DOI Listing
April 2020

Laws Mandating Coprescription of Naloxone and Their Impact on Naloxone Prescription in Five US States, 2014-2018.

Am J Public Health 2020 06 16;110(6):881-887. Epub 2020 Apr 16.

At the time of the study, Traci C. Green was with the Department of Emergency Medicine, Boston University School of Medicine and Boston Medical Center Injury Prevention Center, Boston, MA. Corey Davis is with the Network for Public Health Law, Greensboro, NC. Ziming Xuan is with the Department of Community Health Sciences, Boston University School of Public Health, Boston, MA. Alexander Y. Walley is with the Department of General Internal Medicine, Boston University School of Medicine and Boston Medical Center Injury Prevention Center, Boston. Jeffrey Bratberg is with the Department of Pharmacy Practice, University of Rhode Island College of Pharmacy, Kingston.

To examine early impacts of laws that require naloxone to be prescribed to patients at increased overdose risk. Using data from 2014 to 2018 from a large pharmacy chain, CVS Pharmacy, we examined the effects of naloxone-prescribing mandates 90 days before and after they took effect in Arizona, Florida, Rhode Island, Vermont, and Virginia. We compared the number of naloxone doses initiated directly by prescribers and by pharmacy standing order, prescriber specialty, pharmacies dispensing, and payor type by applying linear models and the χ test. Naloxone-prescribing mandates increased pharmacy naloxone provision 255% from 90 days before to after implementation. This approach appeared to engage more prescribers (1028 before to 4285 after), complement ongoing naloxone provision under pharmacy standing orders, expand geographic reach (from 40% to 80% of pharmacies dispensing), and broaden the naloxone payor mix in 4 ( < .05) of 5 states. Mandating the prescribing of naloxone quickly expands access to this life-saving medication for more people in more places. Other states should consider mandating the coprescription of naloxone to individuals at increased risk of overdose.
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http://dx.doi.org/10.2105/AJPH.2020.305620DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7204438PMC
June 2020