Publications by authors named "Megan Buresh"

12 Publications

  • Page 1 of 1

A Resident-Led Intervention to Increase Initiation of Buprenorphine Maintenance for Hospitalized Patients With Opioid Use Disorder.

J Hosp Med 2021 Jun;16(6):339-344

Department of Pediatrics, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Hospitalized patients with opioid use disorder (OUD) are rarely started on buprenorphine or methadone maintenance despite evidence that these medications reduce all-cause mortality, overdoses, and hospital readmissions.

Objective: To assess whether clinician education and a team of residents and hospitalist attendings waivered to prescribe buprenorphine increased the rate of starting patients with OUD on buprenorphine maintenance.

Design, Setting, And Participants: Quality improvement study conducted at a large, urban, academic hospital in Maryland involving hospitalized patients with OUD on internal medicine resident services.

Intervention: We developed a protocol for initiating buprenorphine maintenance, presented an educational conference, and started the resident-led Buprenorphine Bridge Team of residents and attendings waivered to prescribe buprenorphine to bridge patients from discharge to follow-up.

Measurements: The percent of eligible inpatients with OUD initiated on buprenorphine maintenance, 24 weeks before and after the intervention; engagement in treatment after discharge; and resident knowledge and comfort with buprenorphine.

Results: The rate of starting buprenorphine maintenance increased from 10% (30 of 305 eligible patients) to 24% (64 of 270 eligible patients) after the intervention, with interrupted time series analysis showing a significant increase in rate (14.4%; 95% CI, 3.6%-25.3%; P = .02). Engagement in treatment after discharge was unchanged (40%-46% engaged 30 days after discharge). Of 156 internal medicine residents, 89 (57%) completed the baseline survey and 66 (42%) completed the follow-up survey. Responses demonstrated improved resident knowledge and comfort with buprenorphine.

Conclusion: Internal medicine resident teams were more likely to start patients on buprenorphine maintenance after clinician education and implementation of a Buprenorphine Bridge Team.
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June 2021

Treatment of opioid use disorder in primary care.

BMJ 2021 05 19;373:n784. Epub 2021 May 19.

Department of Addiction Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Opioid use disorder (OUD) is a common, treatable chronic disease that can be effectively managed in primary care settings. Untreated OUD is associated with considerable morbidity and mortality-notably, overdose, infectious complications of injecting drug use, and profoundly diminished quality of life. Withdrawal management and medication tapers are ineffective and are associated with increased rates of relapse and death. Pharmacotherapy is the evidence based mainstay of OUD treatment, and many studies support its integration into primary care settings. Evidence is strongest for the opioid agonists buprenorphine and methadone, which randomized controlled trials have shown to decrease illicit opioid use and mortality. Discontinuation of opioid agonist therapy is associated with increased rates of relapse and mortality. Less evidence is available for the opioid antagonist extended release naltrexone, with a meta-analysis of randomized controlled trials showing decreased illicit opioid use but no effect on mortality. Treating OUD in primary care settings is cost effective, improves outcomes for both OUD and other medical comorbidities, and is highly acceptable to patients. Evidence on whether behavioral interventions improve outcomes for patients receiving pharmacotherapy is mixed, with guidelines promoting voluntary engagement in psychosocial supports, including counseling. Further work is needed to promote the integration of OUD treatment into primary care and to overcome regulatory barriers to integrating methadone into primary care treatment in the US.
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May 2021

Adapting a Low-threshold Buprenorphine Program for Vulnerable Populations During the COVID-19 Pandemic.

J Addict Med 2020 Nov 10. Epub 2020 Nov 10.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (CDN, MF, DA); Behavioral Health Leadership Institute, Baltimore, MD (CDN, MB, MF, DA); Johns Hopkins School of Medicine, Baltimore, MD (MB, MF); Department of Population Health, New York University Grossman School of Medicine, New York, NY (NK).

Objectives: To examine patient characteristics and outcomes among opioid use disorder patients enrolled in low-threshold buprenorphine treatment during the COVID-19 pandemic.

Methods: This paper describes the adaptation of the Project Connections (PC) program, a low-threshold buprenorphine program in Baltimore, in response to the COVID-19 pandemic. This paper examines patient characteristics and initial outcomes of patients served during a rapid protocol shift to telehealth that allowed buprenorphine initiation without an in-person encounter following a state-mandated stay-at-home order. Patient characteristics were compared to a subsample of patients enrolled in the program before the COVID-19 pandemic.

Results: In March 2020, there was a sharp increase in new enrollments to the PC program. A total of 143 patients completed an intake assessment between March and May 2020 and 140 began treatment with buprenorphine/naloxone. Those who completed an intake assessment were primarily male (68.5%), Black (83.2%), had a mean age of 43.2 years (SD = 11.7), and reported a mean of 17.0 years of opioid use (SD = 12.9). The majority of patients were unemployed (72.7%) and reported previous criminal justice involvement (69.2%). Of those who completed an intake assessment, 96.5% returned for a second visit. Among those for whom 30-day retention data was available (n = 113), 63.7% were engaged for 30 days or longer.

Conclusions: The PC program illustrates that offering on-demand, flexible treatment is an opportunity to increase opioid use disorder treatment access, even during a public health emergency that disrupted access to services. Relaxation of buprenorphine telehealth regulations allowed for flexibility in treatment and benefits vulnerable populations.
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November 2020

Treating Perioperative and Acute Pain in Patients on Buprenorphine: Narrative Literature Review and Practice Recommendations.

J Gen Intern Med 2020 12 21;35(12):3635-3643. Epub 2020 Aug 21.

Divisions of General Internal Medicine and Addiction Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.

Opioid use disorder (OUD), a leading cause of morbidity and mortality in the USA, can be effectively treated with buprenorphine. However, the same pharmacologic properties (e.g., high affinity, partial agonism, long half-life) that make it ideal as a treatment for OUD often cause concern among clinicians that buprenorphine will prevent effective management of acute pain with full agonist opioid analgesics. Because of this concern, many patients are asked to stop buprenorphine preoperatively or at the onset of acute pain, placing them at high risk for both relapse and a difficult transition back to buprenorphine after acute pain has resolved. The purpose of this review is to summarize the existing literature for acute pain and perioperative management in patients treated with buprenorphine for OUD and to provide practical management recommendations for generalist practitioners based on evidence and clinical experience. In short, evidence suggests that sufficient analgesia can be achieved with maintenance of buprenorphine and use of both opioid and non-opioid analgesic options for breakthrough pain. We recommend that clinicians (1) continue buprenorphine in the perioperative or acute pain period for patients with OUD; (2) use a multi-modal analgesic approach; (3) pay attention to care coordination and discharge planning when making an analgesic plan for patients with OUD treated with buprenorphine; and (4) use an individualized approach founded upon shared decision-making. Clinical examples involving mild and severe pain are discussed to highlight important management principles.
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December 2020

Fatal overdose prevention and experience with naloxone: A cross-sectional study from a community-based cohort of people who inject drugs in Baltimore, Maryland.

PLoS One 2020 11;15(3):e0230127. Epub 2020 Mar 11.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America.

Introduction: Overdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID.

Methods: During 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population.

Results: Median age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone.

Conclusion: Further work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.
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June 2020

Outcomes of a novel office-based opioid treatment program in an internal medicine resident continuity practice.

Addict Sci Clin Pract 2019 12 19;14(1):46. Epub 2019 Dec 19.

Division of Addiction Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Avenue, Mason Lord Building, East Tower, 2nd Floor, Baltimore, MD, 21224, USA.

Background: The integration of opioid use disorder (OUD) care and competencies in graduate medical education training is needed. Previous research shows improvements in knowledge, attitudes, and practices after exposure to OUD care. Few studies report outcomes for patients with OUD in resident physician continuity practices.

Methods: A novel internal office-based opioid treatment (OBOT) program was initiated in a resident continuity clinic. Surveys of resident and staff knowledge and attitudes of OBOT were administered at baseline and 4 months. A retrospective chart review of the 15-month OBOT clinic obtained patient characteristics and outcomes.

Results: Twelve patients with OUD were seen in the OBOT clinic. Seven patients (58%) were retained in care at the end of the study period for a range of 9-15 months. Eight patients demonstrated a good clinical response. Surveys of residents and staff at 4 months were unchanged from baseline showing persistent lack of comfort in caring for patients with OUD.

Conclusions: OBOT can be successfully integrated into resident continuity practices with positive patient outcomes. Improvement in resident and staff attitudes toward OBOT were not observed and likely require direct and frequent exposure to OUD care to increase acceptance.
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December 2019

Recent fentanyl use among people who inject drugs: Results from a rapid assessment in Baltimore, Maryland.

Int J Drug Policy 2019 12 12;74:41-46. Epub 2019 Sep 12.

Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, United States. Electronic address:

Background: Fentanyl-related mortality continues to increase in the US, but knowledge of the drivers of fentanyl use (both intentional and unintentional) remains limited. We conducted a rapid assessment to characterize knowledge, attitudes and practices related to fentanyl use in a community-based cohort of current and former people who inject drugs (PWID) in Baltimore, Maryland.

Methods: Between November 2017 and June 2018, participants of the AIDS Linked to the IntraVenous Experience (ALIVE) cohort completed a survey related to fentanyl use. Correlates of recent (past 6 months) fentanyl use and preference for fentanyl-contaminated and -substituted heroin (FASH) were examined using logistic regression among persons who reported using drugs in the prior six months.

Results: Of 994 participants, 28% reported ever having used fentanyl, with 58% of those reporting recent use. Independent correlates of recent fentanyl use among the subset of participants reporting recent (past 6 month) drug use were younger age, male sex, homelessness, opioid use, cocaine use, and daily injection (p < 0.05 for all). 18% of those who recently used fentanyl reported preference for FASH, which was associated with younger age, homelessness and daily injection (p < 0.05 for all).

Conclusions: Recent fentanyl use was commonly reported. Interventions to reduce the harms associated with fentanyl use should target young, homeless PWID who may be more likely to seek out fentanyl.
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December 2019

Expanding low-threshold buprenorphine to justice-involved individuals through mobile treatment: Addressing a critical care gap.

J Subst Abuse Treat 2019 08 9;103:1-8. Epub 2019 May 9.

Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, USA; Behavioral Health Leadership Institute, 2200 Arden Road, Baltimore, MD, USA. Electronic address:

Background: Opioid use disorder (OUD) is highly prevalent among justice-involved individuals. While risk for overdose and other adverse consequences of opioid use are heightened among this population, most justice-involved individuals and other high-risk groups experience multiple barriers to engagement in opioid agonist treatment.

Methods: This paper describes the development of Project Connections at Re-Entry (PCARE), a low-threshold buprenorphine treatment program that engages vulnerable patients in care through a mobile van parked directly outside the Baltimore City Jail. Patients are referred by jail staff or can walk in from the street. The clinical team includes an experienced primary care physician who prescribes buprenorphine, a nurse, and a peer recovery coach. The team initiates treatment for those with OUD and refers those with other needs to appropriate providers. Once stabilized, patients are transitioned to longer-term treatment programs or primary care for buprenorphine maintenance. This paper describes the process of developing this program, patient characteristics and initial outcomes for the first year of the program, and implications for public health practice.

Results: From November 15, 2017 through November 30, 2018, 220 people inquired about treatment services and completed an intake interview, and 190 began treatment with a buprenorphine/naloxone prescription. Those who initiated buprenorphine were primarily male (80.1%), African American (85.1%), had a mean age of 44.1 (SD = 12.2), and a mean of 24.0 (SD = 13.6) years of opioid use. The majority of patients (94.4%) had previous criminal justice involvement, were unemployed (72.9%) and were unstably housed (70.8%). Over a third (32.1%) of patients had previously overdosed. Of those who began treatment, 67.9% returned for a second visit or more, and 31.6% percent were still involved in treatment after 30 days. Of those who initiated care, 20.5% have been transferred to continue buprenorphine treatment at a partnering site.

Conclusions: The PCARE program illustrates the potential for low-threshold buprenorphine treatment to engage populations who are justice-involved and largely disconnected from care. While more work is needed to improve treatment retention among vulnerable patients and engaging persons in care directly after release from detention, offering on-demand, flexible and de-stigmatizing treatment may serve as a first point to connect high-risk populations with the healthcare system and interventions that reduce risk for overdose and related harms.
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August 2019

Treatment of Kratom Dependence With Buprenorphine-Naloxone Maintenance.

Megan Buresh

J Addict Med 2018 Nov/Dec;12(6):481-483

Division of Chemical Dependence, Johns Hopkins University School of Medicine, Baltimore, MD.

Introduction: Use of the unregulated herbal supplement kratom is on the rise in the United States. We present a case series of 2 patients who developed kratom dependence and withdrawal who were successfully transitioned to buprenorphine-naloxone maintenance.

Case Summary: Two patients using kratom to self-treat chronic pain after prescription opioids were discontinued presenting to our clinic with evidence of kratom dependence and withdrawal. On examination, both patients showed signs of mild opioid withdrawal. Both patients were successfully transitioned to buprenorphine-naloxone maintenance via home initiation with control of both their opioid withdrawal and chronic pain.

Conclusions: Kratom use is on the rise and with increasing evidence of developing opioid-type dependence due to chronic kratom use. This case series shows that buprenorphine can be used to treat kratom dependence and underlying chronic pain that drives it use.
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November 2019

New and Emerging Illicit Psychoactive Substances.

Med Clin North Am 2018 Jul;102(4):697-714

Division of Chemical Dependence, Johns Hopkins University School of Medicine, 5200 Eastern Avenue, Suite D5W, Baltimore, MD 21224, USA. Electronic address:

Several novel psychoactive substances have emerged in recent years. Users are typically young men who use other substances. In the category of stimulants, cathinones ("bath salts") have predominated and can lead to agitation, psychosis, hyperthermia, and death. Synthetic cannabinoids ("spice") are more potent than marijuana and can lead to agitation, psychosis, seizures, and death. There are no rapid tests to identify these substances and general treatment includes benzodiazepines for agitation and supportive therapy. Many Synthetic opioids are potent analogues of fentanyl and carry a high risk of overdose. In addition, there are several designer benzodiazepines that have emerged.
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July 2018

Cell phone utilization among foreign-born Latinos: a promising tool for dissemination of health and HIV information.

J Immigr Minor Health 2014 Aug;16(4):661-9

Johns Hopkins University School of Medicine, 600 N. Wolfe St. Phipps 524, Baltimore, MD, 21287, USA.

Latinos in the US are disproportionately affected by HIV and are at risk for late presentation to care. Between June 2011 and January 2012, we conducted a cross-sectional survey of 209 Baltimore Latinos at community-based venues to evaluate the feasibility of using information communication technology-based interventions to improve access to HIV testing and education within the Spanish-speaking community in Baltimore. Participants had a median age of 33 years interquartile range (IQR) (IQR 28-42), 51.7 % were male, and 95.7 % were foreign-born. Approximately two-thirds (63.2 %) had been in the US less than 10 years and 70.1 % had been previously tested for HIV. Cell phone (92.3 %) and text messaging (74.2 %) was used more than Internet (52.2 %) or e-mail (42.8 %) (p < 0.01). In multivariate analysis, older age and lower education were associated with less utilization of Internet, e-mail and text messaging, but not cell phones. Interest was high for receiving health education (73.1 %), HIV education (70.2 %), and test results (68.8 %) via text messaging. Innovative cell phone-based communication interventions have the potential to link Latino migrants to HIV prevention, testing and treatment services.
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August 2014

Human papillomavirus prevalence and cytopathology correlation in young Ugandan women using a low-cost liquid-based Pap preparation.

Diagn Cytopathol 2010 Aug;38(8):555-63

Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

Screening for HPV-driven cervical dysplasia and neoplasia is a significant public health concern in the developing world. The purpose of this study was to use a manual, low-cost liquid-based Pap preparation to determine HPV prevalence in HIV-positive and HIV-negative young women in Kampala, Uganda and to correlate cervical cytopathology with HPV-DNA genotype. About 196 post-partum women aged 18-30 years underwent rapid HIV testing and pelvic examination. Liquid-based cervical cytology samples were processed using a low-cost manual technique. A DNA collection device was used to collect specimens for HPV genotyping. HIV and HPV prevalence was 18 and 64%, respectively. Overall, 49% of women were infected with a high-risk HPV genotype. The most common high-risk HPV genotypes were 16 (8.2%), 33 (7.7%), 35 (6.6%), 45 (5.1%), and 58 (5.1%). The prevalence of HPV 18 was 3.6%. HIV-positive women had an HPV prevalence of 86% compared to 59% in HIV-negative women (P = 0.003). The prevalence of HPV 16/18 did not differ by HIV status. HIV-positive women were infected with a significantly greater number of HPV genotypes compared to HIV-negative women. By multivariate analysis, the main risk factor for HPV infection was coinfection with HIV. HIV-positive women were four times more likely to have abnormal cytology than HIV-negative women (43% vs. 11.6%, P < 0.001). These data highlight that HIV infection is a strong risk factor for HPV infection and resultant abnormal cervical cytology. Notably, the manual low-cost liquid-based Pap preparation is practical in this setting and offers an alternate method for local studies of HPV vaccine efficacy.
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August 2010