Publications by authors named "Peter D Friedmann"

145 Publications

Frequency of Hazardous and Binge Drinking Alcohol Among Hospitalized Cardiovascular Patients.

Am J Cardiol 2021 08 29;153:119-124. Epub 2021 Jun 29.

Department of Medicine, University of Massachusetts Medical School - Baystate, Springfield Massachusetts; Department of Cardiovascular Disease, University of Massachusetts Medical School - Baystate, Springfield Massachusetts; Institute of Healthcare Delivery and Population Science, University of Massachusetts Medical School - Baystate, Springfield Massachusetts. Electronic address:

Excessive alcohol use is a risk factor for most cardiac diseases. The prevalence of unhealthy alcohol use among hospitalized cardiac patients is uncertain as is the frequency with which it is addressed. We performed a single center, patient-level anonymous survey among hospitalized cardiac patients eligible for cardiac rehabilitation. Hazardous drinking was defined as an Alcohol Use Disorders Identification Test (AUDIT) score of 8 or greater. Binge drinking was defined as 5+ drinks for men or 4+ for women on ≥1 occasion within the past 30 days. Unhealthy drinking was defined as either hazardous or binge drinking. Of 300 patients approached, 290 (96.7%) completed the survey. Mean ( ± SD) age was 69 ± 11 years; 70% were male and 31% were cardiac surgical patients. The proportion (95% CI) of hazardous, binge, and unhealthy drinking was 12% (9 to 16), 16% (12 to 20), and 18% (14-23), respectively. Overall, 58% of subjects reported being screened for alcohol use, mostly by nurses (56%). Those with unhealthy drinking reported being counseled more frequently about their alcohol use compared to non-unhealthy drinkers (11% versus 3%, p = 0.03), but the large majority (89%) of unhealthy drinkers reported receiving no advice about their alcohol use while admitted. In conclusion, almost one-fifth of hospitalized cardiac patients reported unhealthy drinking, these patients were only screened about half of the time, and were rarely counseled about their alcohol use.
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http://dx.doi.org/10.1016/j.amjcard.2021.05.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8316379PMC
August 2021

Engagement in perinatal outpatient services among women in recovery from opioid use disorders.

Subst Abus 2021 Apr 2:1-8. Epub 2021 Apr 2.

Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield, MA, USA.

Despite being highly motivated to recover, pregnant and postpartum women with opioid use disorders (OUD) are at high risk of relapse and death. While many services mitigate this risk, engagement in voluntary, outpatient services remains low. Our aim was to understand the experiences of and factors influencing outpatient service engagement during the perinatal period among women in recovery from OUD. We conducted semi-structured interviews about perinatal experiences engaging with outpatient services, with 20 women in recovery aged 22-46 years who had children between 6 months and 10 years old. Interviews were audio-recorded, transcribed, coded, and analyzed using conventional content analysis. Women described a continuum of 'collaborative engagement' experiences, defined by the extent to which they perceived their providers or service organizations were invested in their journeys as a partners and advocates. The ability to achieve collaborative engagement depended upon two factors: (1) the woman's transformational development as a mother and woman in recovery, and (2) her perception of the providers' ability to meet her multifaceted needs. Women in recovery from OUD may experience deeper engagement in voluntary outpatient perinatal services when they perceive that their providers are invested and collaboratively engaging in their recovery and personal growth. Future research should test whether collaborative engagement improves service retention. IPV: Intimate Partner Violence; OUD: opioid use disorder.
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http://dx.doi.org/10.1080/08897077.2021.1904091DOI Listing
April 2021

New standards for a new era: Making JSAT better, not perfect.

J Subst Abuse Treat 2021 06 18;125:108366. Epub 2021 Mar 18.

Springfield, MA, United States of America. Electronic address:

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http://dx.doi.org/10.1016/j.jsat.2021.108366DOI Listing
June 2021

Massachusetts Justice Community Opioid Innovation Network (MassJCOIN).

J Subst Abuse Treat 2021 09 8;128:108275. Epub 2021 Jan 8.

University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America. Electronic address:

A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.
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http://dx.doi.org/10.1016/j.jsat.2021.108275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263807PMC
September 2021

Massachusetts Justice Community Opioid Innovation Network (MassJCOIN).

J Subst Abuse Treat 2021 09 8;128:108275. Epub 2021 Jan 8.

University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America. Electronic address:

A major driver of the U.S. opioid crisis is limited access to effective medications for opioid use disorder (MOUD) that reduce overdose risks. Traditionally, jails and prisons in the U.S. have not initiated or maintained MOUD for incarcerated individuals with OUD prior to their return to the community, which places them at high risk for fatal overdose. A 2018 law (Chapter 208) made Massachusetts (MA) the first state to mandate that five county jails deliver all FDA-approved MOUDs (naltrexone [NTX], buprenorphine [BUP], and methadone). Chapter 208 established a 4-year pilot program to expand access to all FDA-approved forms of MOUD at five jails, with two more MA jails voluntarily joining this initiative. The law stipulates that MOUD be continued for individuals receiving it prior to detention and be initiated prior to release among sentenced individuals where appropriate. The jails must also facilitate continuation of MOUD in the community on release. The Massachusetts Justice Community Opioid Innovation Network (MassJCOIN) partnered with these seven diverse jails, the MA Department of Public Health, and community treatment providers to conduct a Type 1 hybrid effectiveness-implementation study of Chapter 208. We will: (1) Perform a longitudinal treatment outcome study among incarcerated individuals with OUD who receive NTX, BUP, methadone, or no MOUD in jail to examine postrelease MOUD initiation, engagement, and retention, as well as fatal and nonfatal opioid overdose and recidivism; (2) Conduct an implementation study to understand systemic and contextual factors that facilitate and impede delivery of MOUDs in jail and community care coordination, and strategies that optimize MOUD delivery in jail and for coordinating care with community partners; (3) Calculate the cost to the correctional system of implementing MOUD in jail, and conduct an economic evaluation from state policy-maker and societal perspectives to compare the value of MOUD prior to release from jail to no MOUD among matched controls. MassJCOIN made significant progress during its first six months until the COVID-19 pandemic began in March 2020. Participating jail sites restricted access for nonessential personnel, established other COVID-19 mitigation policies, and modified MOUD programming. MassJCOIN adapted research activities to this new reality in an effort to document and account for the impacts of COVID-19 in relation to each aim. The goal remains to produce findings with direct implications for policy and practice for OUD in criminal justice settings.
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http://dx.doi.org/10.1016/j.jsat.2021.108275DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8263807PMC
September 2021

Opioid initiation and injection transition in rural northern New England: A mixed-methods approach.

Drug Alcohol Depend 2020 12 30;217:108256. Epub 2020 Aug 30.

Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.

Background: In rural northern New England, located in the northeastern United States, the overdose epidemic has accelerated with the introduction of fentanyl. Opioid initiation and transition to opioid injection have been studied in urban settings. Little is known about opioid initiation and transition to injection drug use in rural northern New England.

Methods: This mixed-methods study characterized opioid use and drug injection in 11 rural counties in Massachusetts, Vermont, and New Hampshire between 2018 and 2019. People who use drugs completed audio computer-assisted self-interview surveys on substance use and risk behaviors (n = 589) and shared personal narratives through in-depth interviews (n = 22). The objective of the current study is to describe initiation of opioid use and drug injection in rural northern New England.

Results: Median age of first injection was 22 years (interquartile range 18-28 years). Key themes from in-depth interviews that led to initiating drug injection included normalization of drug use in families and communities, experiencing trauma, and abrupt discontinuation of an opioid prescription. Other factors that led to a transition to injecting included lower cost, increased effect/ rush, greater availability of heroin/ fentanyl, and faster relief of withdrawal symptoms with injection.

Conclusions: Trauma, normalization of drug use, over-prescribing of opioids, and abrupt discontinuation challenge people who use drugs in rural northern New England communities. Inadequate opioid tapering may increase transition to non-prescribed drug use. The extent and severity of traumatic experiences described highlights the importance of enhancing trauma-informed care in rural areas.
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http://dx.doi.org/10.1016/j.drugalcdep.2020.108256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7769168PMC
December 2020

Impact of extended release naltrexone on health-related quality of life in individuals with legal involvement and opioid use disorders.

Subst Abus 2020 Sep 1:1-7. Epub 2020 Sep 1.

Department of Population Health and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts, USA.

Background: Understanding the impact of medications for opioid use disorder on health related quality of life (QOL) may help to explain why few individuals with legal involvement remain in treatment, specifically those receiving opioid antagonists. QOL is an established predictor of treatment retention and has been shown to improve with some treatment for opioid use disorder. Yet limited research has examined QOL with opioid antagonists. We examined the impact of extended release naltrexone (XR-NTX) on QOL and retention in treatment in a randomized, multi-site trial of individuals with legal involvement. : The participants were 308 community-dwelling adults with current or recent legal involvement with opioid dependence at five site across United States. They were randomized to receive XR-NTX or treatment as usual for 6 months. QOL was measured every 2 weeks using Euro QOL individual items, summary index score, and health state today metric. : No significant difference in QOL scores were observed between the two groups at the completion of active treatment or on follow up at 52 and 78 weeks. There were no time effects of treatment on scores. Contrary to expectation, baseline and average QOL did not predict retention in treatment. In contrast to prior research, our findings did not demonstrate significant changes (improvements or decreases) in QOL associated with XR-NTX treatment. Clinicians may consider that individuals receiving XR-NTX may not experience changes in perceived well-being in response to treatment and consider discussing with patients that they may not necessarily perceive improvement in their QOL. This may help to ground patient's expectations about the effects of treatment and potentially reduce attrition from treatment with opioid antagonists.
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http://dx.doi.org/10.1080/08897077.2020.1809603DOI Listing
September 2020

Editorial: COVID-19 and its impact on SUD treatment.

J Subst Abuse Treat 2020 10 25;117:108091. Epub 2020 Jul 25.

University of Cincinnati College of Medicine, United States of America.

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http://dx.doi.org/10.1016/j.jsat.2020.108091DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381909PMC
October 2020

Engagement in Early Intervention Services Among Mothers in Recovery From Opioid Use Disorders.

Pediatrics 2020 02;145(2)

University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.

Background And Objectives: Opioid-exposed infants frequently qualify for early intervention (EI). However, many eligible families choose not to enroll in this voluntary service. This study aims to understand the perceptions and experiences that may impact engagement with, and the potential benefits of, EI services among mothers in recovery from opioid use disorders (OUDs).

Methods: We conducted semistructured qualitative interviews ( = 22) and 1 focus group ( = 6) with mothers in recovery from OUDs in western Massachusetts. Transcripts were coded and analyzed by using a descriptive approach.

Results: The mean participant age was 32 years, and 13 had a high school degree or less. Five major themes emerged revealing mothers' development through stages of engagement in EI services: (1) fear, guilt, and shame related to drug use (emotions acting as barriers to enrollment); (2) the question of whether it is "needed" (deciding whether there is value in EI for opioid-exposed infants); (3) starting with "judgment" (baseline level of perceived stigma that parents in recovery associate with EI); (4) breaking down the "wall" (how parents overcome the fear and perceived judgment to build partnerships with providers); and (5) "above and beyond" (need for a personal connection with mothers and concrete supports through EI in addition to the child-focused services provided).

Conclusions: Barriers to engagement in EI among mothers in recovery from OUDs include a range of emotions, perceived stigma, and ambivalence. An effort to purposefully listen to and care for mothers through a strengths-based, bigenerational approach may help establish greater connections and foster stronger EI engagement among families affected by OUDs.
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http://dx.doi.org/10.1542/peds.2019-1957DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993421PMC
February 2020

Availability of Medications for the Treatment of Alcohol and Opioid Use Disorder in the USA.

Neurotherapeutics 2020 01;17(1):55-69

University of Massachusetts Medical School Baystate, 280 Chestnut St., Springfield, MA, 01199, USA.

Despite high mortality rates due to opioid overdose and excessive alcohol consumption, medications for the treatment of alcohol and opioid use disorder have not been widely used in the USA. This paper provides an overview of the literature on the availability of alcohol and opioid used disorder medications in the specialty substance use disorder treatment system, other treatment settings and systems, and among providers with a federal waiver to prescribe buprenorphine. We also present the most current data on the availability of alcohol and opioid use disorder medications in the USA. These estimates show steady growth in availability of opioid use disorder medications over the past decade and a decline in availability of alcohol use disorder medications. However, overall use of medications in the USA remains low. In 2017, only 16.3% of specialty treatment programs offered any single medication for alcohol use disorder treatment and 35.5% offered any single medication for opioid use disorder treatment. Availability of buprenorphine-waivered providers has increased significantly since 2002. However, geographic disparities in access to buprenorphine remain. Some of the most promising strategies to increase availability of alcohol and opioid use disorder medications include the following: incorporating substance use disorder training in healthcare education programs, educating the substance use disorder workforce about the benefits of medication treatment, reducing stigma surrounding the use of medications, implementing medications in primary care settings, implementing integrated care models, revising regulations on methadone and buprenorphine, improving health insurance coverage of medications, and developing novel medications for the treatment of substance use disorder.
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http://dx.doi.org/10.1007/s13311-019-00814-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007488PMC
January 2020

A Thousand Cuts: Racial and Ethnic Disparities in Emergency Medicine.

Med Care 2019 12;57(12):921-923

Department of Emergency Medicine, University of Massachusetts Medical School-Baystate Campus, Springfield, MA.

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http://dx.doi.org/10.1097/MLR.0000000000001250DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7069500PMC
December 2019

Correlates of Patient-Centered Care Practices at U.S. Substance Use Disorder Clinics.

Psychiatr Serv 2020 01 10;71(1):35-42. Epub 2019 Sep 10.

School of Social Work, University of Michigan, Ann Arbor (Park); School of Social Service Administration, University of Chicago, Chicago (Grogan, Mosley, Pollack); Health Services Research & Development, U.S. Department of Veterans Affairs Medical Center, Palo Alto, California, and Department of Psychiatry, Stanford University Medical Center, Stanford, California (Humphreys); Department of Medicine, University of Massachusetts--Baystate, and Office of Research, Baystate Health, Springfield, Massachusetts (Friedmann).

Objective: Substance use disorder treatment professionals are paying increased attention to implementing patient-centered care. Understanding environmental and organizational factors associated with clinicians' efforts to engage patients in clinical decision-making processes is essential for bringing patient-centered care to the addictions field. This study examined factors associated with patient-centered care practices in substance use disorder treatment.

Methods: Data were from the 2017 National Drug Abuse Treatment System Survey, a nationally representative survey of U.S substance use disorder treatment clinics (outpatient nonopioid treatment programs, outpatient opioid treatment programs, inpatient clinics, and residential clinics). Multivariate regression analyses examined whether clinics invited patients into clinical decision-making processes and whether clinical supervisors supported and believed in patient-centered care practices.

Results: Of the 657 substance use disorder clinics included in the analysis, about 23% invited patients to participate in clinical decision-making processes. Clinicians were more likely to engage patients in decision-making processes when working in residential clinics (compared with outpatient nonopioid treatment programs) or in clinics serving a smaller proportion of patients with alcohol or opioid use disorder. Clinical supervisors were more likely to value patient-centered care practices if the organization's administrative director perceived less regional competition or relied on professional information sources to understand developments in the substance use disorder treatment field. Clinicians' tendency to engage patients in decision-making processes was positively associated with clinical supervisors' emphasis on patient-centered care.

Conclusions: A minority of U.S. substance use disorder clinics invited patients into clinical decision-making processes. Therefore, patient-centered care may be unavailable to certain vulnerable patient groups.
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http://dx.doi.org/10.1176/appi.ps.201900121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6939146PMC
January 2020

The relationship of Medicaid expansion to psychiatric comorbidity care within substance use disorder treatment programs.

J Subst Abuse Treat 2019 10 29;105:44-50. Epub 2019 Jul 29.

Stanford University, Department of Psychiatry, 401 N. Quarry Rd., Stanford, CA 94305, United States of America; Veterans Affairs Palo Alto Health Care System, 795 Willow Rd., Menlo Park, CA 94025, United States of America. Electronic address:

Background: Co-occurring mental health disorders are common among substance use disorder (SUD) patients. Medicaid expansion aimed to reduce barriers to SUD and mental health care and thereby improve treatment outcomes.

Methods: We estimated change in the proportion of United States SUD treatment sites offering treatment for psychiatric comorbidities following Medicaid expansion as part of implementation of the Affordable Care Act (ACA) in 2014. Using panel data from the 2013-2014, n = 660, and 2016-2017, n = 638, waves of the National Drug Abuse Treatment System Survey (NDATSS), we estimated change in the proportion of sites offering antidepressant medication, other psychiatric medication, behavioral treatment, or any combination thereof for treatment of mental health comorbidities (i.e., beyond services focused on SUD). We modeled the impact of Medicaid expansion as an interaction between year and date of Medicaid expansion. We constructed a mixed-effects linear regression model for each outcome, with the interaction variable as the main exposure, site as a random effect, and site's average duration of treatment, proportion of clients with psychiatric comorbidities, average caseload per treatment prescribing-clinician on staff, type of facility and geographic region as covariates, to estimate a difference-in-differences (D-I-D) equation.

Results: The adjusted D-I-D analysis indicated that the proportion of SUD treatment sites offering antidepressants for psychiatric treatment increased 10% (95% CI 1%, 18%) in the Medicaid expansion sites compared to non-expansion sites. The D-I-D for other psychiatric medications was also 10% (95% 1%, 19%). No significant changes were observed in behavioral treatment or the combination measure. The strongest association between Medicaid expansion and offering medication for mental health comorbidities was the 34% increase observed for residential treatment settings (95% CI 10%, 59%).

Conclusion: Availability of psychiatric medication treatment in SUD treatment settings increased following Medicaid expansion, particularly in residential SUD facilities. This policy change has facilitated integrated treatment for the substantial share of SUD treatment patients with mental health comorbidities, with the greatest benefit for patients receiving SUD treatment in residential programs.
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http://dx.doi.org/10.1016/j.jsat.2019.07.012DOI Listing
October 2019

Evaluation of a Nurse-Led Program for Rural Pregnant Women With Opioid Use Disorder to Improve Maternal-Neonatal Outcomes.

J Obstet Gynecol Neonatal Nurs 2019 Sep 30;48(5):495-506. Epub 2019 Jul 30.

Objectives: To generate effect sizes of preliminary program outcomes and identify areas for program improvement related to a nurse-led, community-based screening, referral, and advocacy program for women with perinatal opioid use disorder (OUD): the Engaging Mothers for Positive Outcomes with Early Referrals (EMPOWER) program.

Design: We extracted outcomes retrospectively from medical records for the first 19 mother-newborn dyads who participated in the program (postintervention group). We compared these outcomes with those of 19 randomly selected mother-newborn dyads in which mothers had perinatal OUD and received care before the program launch (preintervention group).

Setting/local Problem: A maternity care practice and community hospital in a rural Massachusetts county with high rates of perinatal OUD.

Patients: Women with perinatal OUD and their neonates.

Intervention/measurements: As part of the EMPOWER program, women with perinatal OUD developed individualized pregnancy plans; were referred to community resources in the prenatal period; and received education about neonatal abstinence syndrome, nonpharmacologic newborn care, and breastfeeding. We compared the pre- and postintervention groups for maternal and neonatal outcomes and prenatal community referrals and generated effect sizes using Cohen's d and Cramer's phi (Φ).

Results: Rates of breastfeeding initiation (Φ = 0.289) and continuation (Φ = 0.318), mean neonatal birth weight (d = 0.675), and length of hospital stay (d = 0.541) were greater in the postintervention group with medium effect sizes. Diagnosis of neonatal abstinence syndrome and admission to the NICU were also greater in the postintervention group, with small effect sizes (Φ = 0.246 and Φ = -0.144, respectively.) Significantly more women in the postintervention group received prenatal referrals for peer/family support services. We identified areas for program improvement as prenatal education on smoking and postpartum contraceptive use.

Conclusion: Preliminary findings suggest that the EMPOWER program may contribute to improved outcomes for mothers and newborns affected by OUD; however, further data collection after instituting program improvements is needed.
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http://dx.doi.org/10.1016/j.jogn.2019.07.002DOI Listing
September 2019

Medicaid coverage in substance use disorder treatment after the affordable care act.

J Subst Abuse Treat 2019 07 9;102:1-7. Epub 2019 Apr 9.

University of Massachusetts Medical School Baystate; 280 Chestnut St., Springfield, MA 01199, United States of America. Electronic address:

The Affordable Care Act (ACA) prompted sweeping changes to Medicaid, including expanding insurance coverage to an estimated 12 million previously uninsured Americans, and imposing new parity requirements on benefits for behavioral health services, including substance use disorder treatment. Yet, limited evidence suggests that these changes have reduced the number of uninsured in substance use disorder treatment, or increased access to substance use disorder treatment overall. This study links data from a nationally-representative study of outpatient substance use disorder treatment programs and a unique national survey of state Medicaid programs to capture changes in insurance coverage among substance use disorder treatment patients after ACA implementation. Medicaid expansion was associated with a 15.7-point increase in the percentage of patients insured by Medicaid in substance use disorder treatment programs and a 13.7-point decrease in the percentage uninsured. Restrictions in state Medicaid benefits and utilization policies were associated with a decreased percentage of Medicaid patients in treatment. Moreover, Medicaid expansion was not associated with a change in the total number of clients served over the study period. Our findings highlight the important role Medicaid has played in increasing insurance coverage for substance use disorder treatment.
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http://dx.doi.org/10.1016/j.jsat.2019.04.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6578872PMC
July 2019

The opioid epidemic in rural northern New England: An approach to epidemiologic, policy, and legal surveillance.

Prev Med 2019 11 31;128:105740. Epub 2019 May 31.

University of Massachusetts Medical School - Baystate, Springfield, MA, United States of America.

The opioid crisis presents substantial challenges to public health in New England's rural states, where access to pharmacotherapy for opioid use disorder (OUD), harm reduction, HIV and hepatitis C virus (HCV) services vary widely. We present an approach to characterizing the epidemiology, policy and resource environment for OUD and its consequences, with a focus on eleven rural counties in Massachusetts, New Hampshire and Vermont between 2014 and 2018. We developed health policy summaries and logic models to facilitate comparison of opioid epidemic-related polices across the three states that could influence the risk environment and access to services. We assessed sociodemographic factors, rates of overdose and infectious complications tied to OUD, and drive-time access to prevention and treatment resources. We developed GIS maps and conducted spatial analyses to assess the opioid crisis landscape. Through collaborative research, we assessed the potential impact of available resources to address the opioid crisis in rural New England. Vermont's comprehensive set of policies and practices for drug treatment and harm reduction appeared to be associated with the lowest fatal overdose rates. Franklin County, Massachusetts had good access to naloxone, drug treatment and SSPs, but relatively high overdose and HIV rates. New Hampshire had high proportions of uninsured community members, the highest overdose rates, no HCV surveillance data, and no local access to SSPs. This combination of factors appeared to place PWID in rural New Hampshire at elevated risk. Study results facilitated the development of vulnerability indicators, identification of locales for subsequent data collection, and public health interventions.
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http://dx.doi.org/10.1016/j.ypmed.2019.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6879818PMC
November 2019

Early Intervention Referral and Enrollment Among Infants with Neonatal Abstinence Syndrome.

J Dev Behav Pediatr 2019 Jul/Aug;40(6):441-450

Department of Pediatrics, University of Massachusetts Medical School-Baystate, Springfield, MA.

Objective: To identify factors associated with referral and enrollment in early intervention (EI) for infants with neonatal abstinence syndrome (NAS).

Methods: We conducted a retrospective cohort study of 256 infants born with NAS (2006-2013) at a tertiary care hospital in (Springfield), Massachusetts, linking maternal-infant birth hospitalization records with Department of Public Health EI records. We calculated the percent of infants retained at each step in the EI enrollment process over the first 3 years of life. We conducted separate multivariable logistic regression analyses to identify factors associated with EI referral and enrollment.

Results: Among mothers, 82% received medication-assisted treatment at delivery, 36% endorsed illicit drug use during pregnancy, and 76% retained custody of their child at discharge. Among infants, 77% were referred to EI and 48% were enrolled in services. Of infants discharged to biological parents, 81% were referred to EI versus 66% of infants discharged to foster care (p ≤ 0.05); this difference persisted in multivariable analysis [adjusted odds ratio, 2.30; 95% confidence interval (CI), 1.09-4.86]. Infants in the highest tertile for length of stay had 2.70 times the odds of EI enrollment (95% CI, 1.37-5.31).

Conclusion: Fewer than half of the eligible infants with NAS were enrolled in EI services. Discharge to a biological parent and longer hospital stay had the strongest associations with EI referral and enrollment, respectively. Efforts to improve EI referral rates during the birth hospitalization, particularly among infants discharged into foster care, and close follow-up for infants with shorter hospital stays would enhance the developmental supports for this vulnerable population.
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http://dx.doi.org/10.1097/DBP.0000000000000679DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7114910PMC
September 2020

Changes in State Technical Assistance Priorities and Block Grant Funds for Addiction After ACA Implementation.

Am J Public Health 2019 06 18;109(6):885-891. Epub 2019 Apr 18.

Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Bikki Tran Smith, Colleen M. Grogan, and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Christina M. Andrews is with the College of Social Work, University of South Carolina, Columbia. Clifford S. Bersamira is with the Myron B. Thompson School of Social Work, University of Hawai'i at Mānoa, Honolulu. Peter D. Friedmann is with the University of Massachusetts Medical School Baystate, Springfield.

To assess states' provision of technical assistance and allocation of block grants for treatment, prevention, and outreach after the expansion of health insurance coverage for addiction treatment in the United States under the Affordable Care Act (ACA). We used 2 waves of survey data collected from Single State Agencies in 2014 and 2017 as part of the National Drug Abuse Treatment System Survey. The percentage of states providing technical assistance for cross-sector collaboration and workforce development increased. States also shifted funds from outpatient to residential treatment services. However, resources for opioid use disorder medications changed little. Subanalyses indicated that technical assistance priorities and allocation of funds for treatment services differed between Medicaid expansion and nonexpansion states. The ACA's infusion of new public and private funds enabled states to reallocate funds to residential services, which are not as likely to be covered by health insurance. The limited allocation of block grant funds for effective opioid medications is concerning in light of the opioid crisis, especially in states that did not implement the ACA's Medicaid expansion.
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http://dx.doi.org/10.2105/AJPH.2019.305052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6507974PMC
June 2019

Impact of Medicaid Restrictions on Availability of Buprenorphine in Addiction Treatment Programs.

Am J Public Health 2019 03 24;109(3):434-436. Epub 2019 Jan 24.

Christina M. Andrews and Melissa A. Westlake are with the College of Social Work, University of South Carolina, Columbia. Amanda J. Abraham is with the School of Public and International Affairs, University of Georgia, Athens. Colleen M. Grogan and Harold A. Pollack are with the School of Social Service Administration, University of Chicago, Chicago, IL. Peter D. Friedmann is with Baystate Medical Center, Springfield, MA, and the University of Massachusetts, Baystate Campus, Springfield.

Objectives: To examine how utilization restrictions on state Medicaid benefits for buprenorphine are related to addiction treatment programs' decision to offer the drug.

Methods: We used data from 2 waves of the National Drug Abuse Treatment System Survey conducted in 2014 and 2017 in the United States to assess the relationship of utilization restrictions to buprenorphine availability.

Results: The proportion of programs offering buprenorphine was 43.2% in states that did not impose any utilization restrictions, 25.5% in states that imposed only annual limits, 17.3% in states that imposed only prior authorization, and 12.8% in states that imposed both. Programs in states requiring prior authorization from Medicaid had substantially lower odds of offering buprenorphine (odds ratio = 0.50; 95% confidence interval = 0.29, 0.87).

Conclusions: Medicaid prior authorization was linked to lower odds of buprenorphine provision among addiction treatment programs. Public Health Implications. State Medicaid prior authorization requirements are linked to reduced odds of buprenorphine provision among addiction treatment programs and may discourage prescribing.
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http://dx.doi.org/10.2105/AJPH.2018.304856DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6366513PMC
March 2019

Incidence of future arrests in adults involved in the criminal justice system with opioid use disorder receiving extended release naltrexone compared to treatment as usual.

Drug Alcohol Depend 2019 01 3;194:482-486. Epub 2018 Dec 3.

Department of Academic Affairs, Baystate Medical Center, 3601 Main St., Springfield, MA 01199, United States. Electronic address:

Background: Criminal justice involved (CJS) populations with opioid use disorder (OUD) have high rates of relapse, future arrests, and death upon release. While medication for OUD (MOUD) reduces opioid relapse, concerns regarding diversion and stigma limit treatment in CJS populations. Extended release naltrexone (XR-NTX), as an opioid antagonist, may be more acceptable to CJS administrators. However, the impact of XR-NTX on criminal recidivism remains unknown.

Methods: Arrest data from a published randomized trial comparing XR-NTX to treatment as usual (TAU) was captured by self-report and official state arrest records. Comparisons of future arrests, time to first arrest and total number of arrests were performed using chi square tests and multivariable generalized regression models. Secondary outcomes explored differences in arrests by type and severity of crime, use of opioid and other drugs, and study phase.

Results: Of 308 participants randomized, 300 had arrest data. The incidence of arrests did not differ between XR-NTX (47.6%) and TAU (42.5%) participants. (ChiSq p = 0.37). Additionally, there was no significant difference in time to first arrest (adjusted HR 1.35, CI 0.96-1.89) and number of arrests per participant (adjusted IR 1.33, CI 0.78-2.27). Controlling for gender, age, previous criminal activity, and use of non-opioid drugs, logistic regression demonstrated no significant difference in incidence of arrests between groups (adjusted OR 1.38, 95% CI 0.85-2.22).

Conclusions: We detected no significant difference in arrests between CJS participants with OUD randomized to XR-NTX or TAU. Despite its efficacy in reducing opioid use, XR-NTX alone may be insufficient to reduce criminal recidivism.
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http://dx.doi.org/10.1016/j.drugalcdep.2018.10.035DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6354576PMC
January 2019

Medicaid Benefits For Addiction Treatment Expanded After Implementation Of The Affordable Care Act.

Health Aff (Millwood) 2018 08;37(8):1216-1222

Peter D. Friedmann is chief research officer for academic affairs at Baystate Health, in Springfield, Massachusetts.

The Affordable Care Act (ACA) established a minimum standard of insurance benefits for addiction treatment and expanded federal parity regulations to selected Medicaid benefit plans, which required state Medicaid programs to make changes to their addiction treatment benefits. We surveyed Medicaid programs in all fifty states and the District of Columbia regarding their addiction treatment benefits and utilization controls in standard and alternative benefit plans in 2014 and 2017, when plans were subject to ACA parity requirements. The number of state plans that provided benefits for residential treatment and opioid use disorder medications increased substantially. States imposing annual service limits on outpatient addiction treatment decreased by over 50 percent. Fewer states required preauthorization for services, with the largest reductions for medications treating opioid use disorder. The ACA may have prompted state Medicaid programs to expand addiction treatment benefits and reduce utilization controls in alternative benefit plans. This trend was also observed among standard Medicaid plans not subject to ACA parity laws, which suggests a potential spillover effect.
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http://dx.doi.org/10.1377/hlthaff.2018.0272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6501794PMC
August 2018

Developing an opioid use disorder treatment cascade: A review of quality measures.

J Subst Abuse Treat 2018 08 2;91:57-68. Epub 2018 Jun 2.

Columbia University Department of Psychiatry, United States; New York State Psychiatric Institute, United States.

Background: Despite increasing opioid overdose mortality, problems persist in the availability and quality of treatment for opioid use disorder (OUD). Three FDA-approved medications (methadone, buprenorphine, and naltrexone) have high quality evidence supporting their use, but most individuals with OUD do not receive them and many experience relapse following care episodes. Developing and organizing quality measures under a unified framework such as a Cascade of Care could improve system level practice and treatment outcomes. In this context, a review was performed of existing quality measures relevant to the treatment of OUD and the literature assessing the utility of these measures in community practice.

Methods: Systematic searches of two national quality measure clearinghouses (National Quality Forum and Agency for Healthcare Research and Quality) were performed for measures that can be applied to the treatment of OUD. Measures were categorized as structural, process, or outcome measures. Second stage searches were then performed within Ovid/Medline focused on published studies investigating the feasibility, reliability, and validity of identified measures, predictors of their satisfaction, and related clinical outcomes.

Results: Seven quality measures were identified that are applicable to the treatment of OUD. All seven were process measures that assess patterns of service delivery. One recently approved measure addresses retention in medication-assisted treatment for patients with OUD. Twenty-nine published studies were identified that evaluate the quality measures, primarily focused on initiation and engagement in care for addiction treatment generally. Most measures and related studies do not specifically incorporate the evidence base for the treatment of OUD or assess patient level outcomes such as overdose.

Conclusion: Despite considerable progress, gaps exist in quality measures for OUD treatment. Development of a unified quality measurement framework such as an OUD Treatment Cascade will require further elaboration and refinement of existing measures across populations and settings. Such a framework could form the basis for applying strategies at clinical, organizational, and policy levels to expand access to quality care and reduce opioid-related mortality.
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http://dx.doi.org/10.1016/j.jsat.2018.06.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039975PMC
August 2018

Do benefits restrictions limit Medicaid acceptance in addiction treatment? Results from a national study.

J Subst Abuse Treat 2018 04 3;87:50-55. Epub 2018 Feb 3.

University of Massachusetts Medical School Baystate, 280 Chestnut Street, Springfield, MA 01199, United States. Electronic address:

Objective: To assess the relationship of restrictions on Medicaid benefits for addiction treatment to Medicaid acceptance among addiction treatment programs.

Data Sources: We collected primary data from the 2013-2014 wave of the National Drug Abuse Treatment System Survey.

Study Design: We created two measures of benefits restrictiveness. In the first, we calculated the number of addiction treatment services covered by each state Medicaid program. In the second, we calculated the total number of utilization controls imposed on each service. Using a mixed-effects logistic regression model, we estimated the relationship between state Medicaid benefit restrictiveness for addiction treatment and adjusted odds of Medicaid acceptance among addiction treatment programs.

Data Collection: Study data come from a nationally-representative sample of 695 addiction treatment programs (85.5% response rate), representatives from Medicaid programs in forty-seven states and the District of Columbia (response rate 92%), and data collected by the American Society for Addiction Medicine.

Principal Findings: Addiction treatment programs in states with more restrictive Medicaid benefits for addiction treatment had lower odds of accepting Medicaid enrollees (AOR = 0.65; CI = 0.43, 0.97). The predicted probability of Medicaid acceptance was 35.4% in highly restrictive states, 48.3% in moderately restrictive states, and 61.2% in the least restrictive states.

Conclusions: Addiction treatment programs are more likely to accept Medicaid in states with less restrictive benefits for addiction treatment. Program ownership and technological infrastructure also play an important role in increasing Medicaid acceptance.
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http://dx.doi.org/10.1016/j.jsat.2018.01.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5826552PMC
April 2018

Personal Control Over Decisions to Participate in Research by Persons With Histories of Both Substance Use Disorders and Criminal Justice Supervision.

J Empir Res Hum Res Ethics 2018 04 20;13(2):160-172. Epub 2018 Feb 20.

9 University of Pennsylvania, Philadelphia, PA, USA.

Individuals must feel free to exert personal control over decisions regarding research participation. We present an examination of participants' perceived personal control over, as well as reported pressures and threats from others, influencing their decision to join a study assessing the effectiveness of extended-release naltrexone in preventing opioid dependence relapse. Most participants endorsed a strong sense of control over the decision; few reported pressures or threats. Although few in number, participants' brief narrative descriptions of the pressures and threats are illuminating and provide context for their perceptions of personal control. Based on this work, we propose a useful set of tools to help ascertain participants' sense of personal control in joining research.
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http://dx.doi.org/10.1177/1556264618755243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6693513PMC
April 2018

Effectiveness, Implementation and Real-World Experience with Extended-Release Naltrexone (XR-NTX): A Special Issue of JSAT.

J Subst Abuse Treat 2018 02 22;85:31-33. Epub 2017 Nov 22.

Department of Psychiatry, University of Pennsylvania, Philadelphia, PA.

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http://dx.doi.org/10.1016/j.jsat.2017.11.008DOI Listing
February 2018

State-Targeted Funding and Technical Assistance to Increase Access to Medication Treatment for Opioid Use Disorder.

Psychiatr Serv 2018 04 15;69(4):448-455. Epub 2017 Dec 15.

Dr. Abraham is with the Department of Public Administration and Policy, University of Georgia, Athens. Dr. Andrews is with the College of Social Work, University of South Carolina, Columbia. Dr. Grogan and Dr. Pollack are with the School of Social Service Administration, University of Chicago, Chicago. Dr. D'Aunno is with the Wagner Graduate School of Public Service, New York University, New York. Dr. Humphreys is with the School of Medicine, Stanford University, Palo Alto, California. Dr. Friedmann is with the Department of Medicine, University of Massachusetts-Baystate and Baystate State Health System, Springfield, Massachusetts.

Objective: As the United States grapples with an opioid epidemic, expanding access to effective treatment for opioid use disorder is a major public health priority. Identifying effective policy tools that can be used to expand access to care is critically important. This article examines the relationship between state-targeted funding and technical assistance and adoption of three medications for treating opioid use disorder: oral naltrexone, injectable naltrexone, and buprenorphine.

Methods: This study draws from the 2013-2014 wave of the National Drug Abuse Treatment System Survey, a nationally representative, longitudinal study of substance use disorder treatment programs. The sample includes data from 695 treatment programs (85.5% response rate) and representatives from single-state agencies in 49 states and Washington, D.C. (98% response rate). Logistic regression was used to examine the relationships of single-state agency targeted funding and technical assistance to availability of opioid use disorder medications among treatment programs.

Results: State-targeted funding was associated with increased program-level adoption of oral naltrexone (adjusted odds ratio [AOR]=3.14, 95% confidence interval [CI]=1.49-6.60, p=.004) and buprenorphine (AOR=2.47, 95% CI=1.31-4.67, p=.006). Buprenorphine adoption was also correlated with state technical assistance to support medication provision (AOR=1.18, 95% CI=1.00-1.39, p=.049).

Conclusions: State-targeted funding for medications may be a viable policy lever for increasing access to opioid use disorder medications. Given the historically low rates of opioid use disorder medication adoption in treatment programs, single-state agency targeted funding is a potentially important tool to reduce mortality and morbidity associated with opioid disorders and misuse.
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http://dx.doi.org/10.1176/appi.ps.201700196DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6703818PMC
April 2018

More beds are not the answer: transforming detoxification units into medication induction centers to address the opioid epidemic.

Addict Sci Clin Pract 2017 11 15;12(1):29. Epub 2017 Nov 15.

Division of Addiction Psychiatry, Department of Psychiatry, Brigham and Women's Hospital, Boston, MA, USA.

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http://dx.doi.org/10.1186/s13722-017-0092-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5688652PMC
November 2017

Assessing informed consent in an opioid relapse prevention study with adults under current or recent criminal justice supervision.

J Subst Abuse Treat 2017 10 1;81:66-72. Epub 2017 Aug 1.

University of Pennsylvania, Philadelphia, PA, USA. Electronic address:

Concerns persist that individuals with substance use disorders who are under community criminal justice supervision experience circumstances that might compromise their provision of valid, informed consent for research participation. These concerns include the possibilities that desire to obtain access to treatment might lead individuals to ignore important information about research participation, including information about risks, or that cognitive impairment associated with substance use might interfere with attending to important information. We report results from a consent quiz (CQ) administered in a multisite randomized clinical trial of long-acting naltrexone to prevent relapse to opioid use disorder among adults under community criminal justice supervision-a treatment option difficult to access by this population of individuals. Participants were required to answer all 11 items correctly before randomization. On average, participants answered 9.8 items correctly (89%) at baseline first attempt (n=306). At week 21 (n=212), participants scored 87% (9.5 items correct) without review. Performance was equivalent to, or better than, published results from other populations on a basic consent quiz instrument across multiple content domains. The consent quiz is an efficient method to screen for adequate knowledge of consent information as part of the informed consent process. Clinical researchers who are concerned about these issues should consider using a consent quiz with corrected feedback to enhance the informed consent process. Overall, while primarily useful as an educational tool, employing a CQ as part of the gateway to participation in research may be particularly important as the field continues to advance and tests novel experimental treatments with significant risks and uncertain potential for benefit.
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http://dx.doi.org/10.1016/j.jsat.2017.07.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5849444PMC
October 2017

Healthcare utilization in adults with opioid dependence receiving extended release naltrexone compared to treatment as usual.

J Subst Abuse Treat 2018 02 12;85:66-69. Epub 2017 May 12.

Baystate Medical Center, 759 Chestnut St. Springfield, MA 01199, United States. Electronic address:

Background: Opioid use disorders have reached epidemic proportions, with overdose now the leading cause of accidental death in the United States. Extended release naltrexone (XR-NTX) has emerged as a medication treatment that reduces opioid use and craving. However, the effect of XR-NTX therapy on acute healthcare utilization, including emergency department visits and inpatient hospitalizations, remains uncertain. The objective of the current study is to evaluate hospital-based healthcare resource utilization in adults involved in the criminal justice system with a history of opioid use disorder randomized to XR-NTX therapy compared with treatment as usual (TAU) during a 6-month treatment phase and 12months post-treatment follow up.

Methods: This retrospective exploratory analysis uses data collected in a published randomized trial. Comparisons of the number of emergency department visits and hospital admissions (for drug detox, psychiatric care and other medical reasons) were performed using chi square tests for any admission and negative binomial models for number of admissions.

Results: Of the 308 participants randomized, 96% had utilization data (76% complete 6months, 67% complete follow up). No significant differences were seen in overall healthcare utilization (IRR=0.88, 95%CI 0.63-1.23, p=0.45), or substance use-related drug detox hospitalizations (IRR=0.83, 95%CI 0.32-2.16, p=0.71). Despite having more participants report chronic medical problems at baseline (43% vs. 32%, p=0.05), those receiving XR-NTX generally experienced equivalent or lower rates of healthcare utilization compared to TAU. The XR-NTX group had significantly lower medical/surgical related hospital admissions (IRR=0.55, 95%CI 0.30-1.00, p=0.05) during the course of the entire study.

Conclusions: XR-NTX did not significantly increase rates of healthcare utilization compared to TAU. Provider concerns regarding healthcare utilization should not preclude the consideration of XR-NTX as therapy for opioid use disorders.
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http://dx.doi.org/10.1016/j.jsat.2017.05.009DOI Listing
February 2018
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