A Needle Exchange Project Modeled on Urban Efforts Aims to Save Lives in Rural Nevada

Five years after HIV tore through a rural Indiana town as a result of widespread drug use, a syringe and needle exchange program was set up in rural Nevada to prevent a similar event.

ELKO, Nev. — Richard Cusolito believes he’s saving lives by distributing clean syringes and needles to people who use drugs in this rural area of northeastern Nevada — but he knows some residents disagree.

“I’m hated in this town because of it,” said Cusolito, 60. “I’m accused of ‘enabling the junkies,’ pretty much is the standard term. People don’t get the impact of this whole thing.”

Drugs, including heroin and other opioids, are readily available in Elko, and Cusolito said a program like his has long been needed. Cusolito is a peer recovery support specialist and received training through Trac-B Exchange, a Las Vegas-based organization that provides a range of harm reduction services throughout Nevada.

In a city the size of Elko, with 20,000 residents, Cusolito’s work has hit close to home. He helped his daughter access rehabilitation services, and earlier this year, she died from an overdose.

“I just keep up hope for the ones that I can help,” he said.

Cusolito has run the exchange program since 2020, when the Elko City Council approved a resolution that gave him permission to hand out needles and syringes at the city’s camp for homeless people. The agreement was originally for one year, but the council recently renewed it for three.

Elko officials’ approval of Cusolito’s work comes as leaders in small, often conservative cities have been asked to adopt policies forged in large, more liberal cities, such as New York and San Francisco. Federal reports show people who use needle exchange programs are five times as likely to start drug treatment programs and three times as likely to stop using drugs as people who do not, but programs in Nevada and other states have faced similar pushback.

Scott Wilkinson, assistant city manager for Elko, said the city’s ability to provide resources to people who use drugs is limited. “We’ve done what we can do to try to help out, but we don’t have a health department,” Wilkinson said.

Trac-B Exchange funds Cusolito’s project, and he provides reports to the city about how many syringes and needles he distributes and collects for disposal.

Needle exchanges are part of efforts known as harm reduction, which focus on minimizing the negative effects of drug use, rather than shaming people. In recent years, harm reduction tactics have begun to spread to rural areas, said Brandon Marshall, an associate professor of epidemiology at the Brown University School of Public Health.

Marshall said a 2015 HIV outbreak fueled by drug use in rural Austin, Indiana, became a “canary in the coal mine,” showing how shared needles could spread the virus. A syringe exchange program could have averted the outbreak or reduced the number of people who were infected, according to a modeling study that Marshall co-authored in 2019.

Cusolito is trying to prevent that kind of disaster in Elko. His small office, in a gray building just off the main street near downtown, isn’t eye-catching from the outside. A “Trac-B Exchange” placard is posted outside, but it doesn’t identify the space as a syringe and needle exchange. Yet Cusolito estimates he sees 100 to 150 people a month, relying on word-of-mouth.

He also visits the jail, helping people booked on drug charges complete assessments required to receive treatment at rehabilitation facilities.

He is adamant that participants turn in their used syringes and needles before getting replacements. The old ones go into a sharps container — a sturdy plastic box — that he sends to Trac-B Exchange in Las Vegas, where they are sterilized and pulverized for safe disposal.

Trac-B Exchange’s harm reduction efforts also reach other areas of rural Nevada: A peer recovery support specialist runs a needle exchange program in Winnemucca, 124 miles from Elko and home to 8,600 people. In Hawthorne, which has fewer than 3,500 residents, leaders approved installing a vending machine that is operated by the organization and contains clean syringes and needles, as well as condoms, tampons, and body soap. In 2019, the organization installed two sharps containers in Ely, a city of fewer than 4,000 residents.

Trac-B Exchange program director Rick Reich said the organization has been offering services in rural areas to help people there use drugs more safely or find resources so they can become and stay sober. The services include assistance in obtaining identification documents, housing, and jobs.

“You’re trying to get a carrot that someone will go after,” he said, referring to the clean needles and syringes. “Then as they come to you, to get that carrot and eat that carrot, they can see that you have other things available and that you aren’t the scary person that they thought you were in the nightmare that they were living.”

In 2020, the overdose death rate in Nevada was 26 per 100,000 people, 27th-highest among states, according to the Centers for Disease Control and Prevention. That year, as the spread of covid-19 spurred stay-at-home orders and shuttered businesses, more than 800 Nevadans died from overdoses.

Seven years since the 2015 HIV outbreak in Indiana, seven states still don’t have any syringe exchange programs, according to a KFF analysis. In some states, harm reduction workers could face criminal penalties for carrying clean syringes or strips that detect the presence of the synthetic opioid fentanyl, which is 50 to 100 times as strong as morphine.

Nevada’s legislature passed a law in 2013 that legalized syringe and needle exchange programs so peer recovery support specialists like Cusolito can do their work.

But that doesn’t mean such efforts are always accepted.

Cusolito said he can put aside nasty comments because he believes in the work he’s doing. He recalled a client who had one of the worst heroin addictions he’d ever seen. “I didn’t think he’d survive,” Cusolito said. After connecting with Cusolito and going through treatment, the client went back to work, bought a house, and got married. He still checks in with Cusolito every couple of months to tell him about his latest achievements.

Clients with stories like those help Cusolito move forward when other challenges of the job weigh on him. The hardest part is losing clients.

“Sometimes I feel really strong and like I can beat the world,” he said, “and other times I think about when I got the knock on the door, you know? I want to lock the door and not let anybody in because I don’t want to deal with anybody else who might die.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Public Health Agencies Adapt Covid Lessons to Curb Overdoses, STDs, and Gun Violence

Know-how gained through the covid pandemic is seeping into other public health areas. But in a nation that has chronically underfunded its public health system, it’s hard to know which changes will stick.

LIVINGSTON, Mont. — Shannan Piccolo walked into a hotel with a tote bag full of Narcan and a speech about how easy it is to use the medicine that can reverse opioid overdoses.

“Hopefully your business would never have to respond to an overdose, but we’d rather have you have some Narcan on hand just in case,” Piccolo, director of Park City-County Health Department, said to the hotel manager.

The manager listened to Piccolo’s instructions on how to use Narcan, the brand name of the drug naloxone, and added four boxes of the nasal spray to the hotel’s first-aid kit.

The transaction took less than 10 minutes. It was the third hotel Piccolo had visited that hot July day in Livingston, a mountain town of roughly 8,000, where, as in much of the nation, health officials are worried about a recent rise in the use of the synthetic opioid fentanyl.

It was the first time the local health department offered door-to-door training and supplies to prevent overdose deaths. The underlying strategy was forged during the pandemic when public health officials distributed rapid tests and vaccines in high-risk settings.

“We learned this from covid,” said Dr. Laurel Desnick, the county’s public health officer. “We go to people who may not have time to come to us.”

The pandemic laid bare the gaps and disparities in the U.S. public health system, and often resulted in blowback against local officials trying to slow the coronavirus’s spread. But one positive outcome, in part fueled by a boost in federal dollars, is that health workers have started adapting lessons they learned from their covid-19 response to other aspects of their work.

For example, in Atlanta, the county health department planned to mail out at-home kits to test for diseases, a program modeled on the distribution of covid rapid tests. In Houston, health officials announced this month they’ll begin monitoring the city’s wastewater for monkeypox, a tactic broadly used to gauge how far and fast covid spread. And in Chicago, government agencies have tweaked covid collaborations to tag-team a rise in gun violence.

Some of these adaptations should cost little and be relatively simple to incorporate into the departments’ post-pandemic work, such as using vans purchased with covid relief money for vaccine delivery and disease testing. Other tools cost more money and time, including updating covid-borne data and surveillance systems to use in other ways.

Some public health workers worry that the lessons woven into their operations will fall away once the pandemic has passed.

“When we have public health crises in this country, we tend to have a boom-and-bust cycle of funding,” said Adriane Casalotti, with the National Association of County and City Health Officials.

Some federal pandemic relief funding is scheduled to last for years, but other allocations have already run dry. Local health workers will be left to prioritize what to fund with what remains.

Meanwhile, historically short-staffed and underfunded health departments are responding to challenges that intensified during the pandemic, including delayed mental health treatment and routine care.

“You’re not just starting from where you were 2½ years ago, there’s actually a higher mountain to climb,” Casalotti said. “But places that were able to build up some of their systems can adapt them to allow for more real-time understanding of public health challenges.”

In Atlanta, the Fulton County Board of Health has offered to mail residents free, at-home tests for sexually transmitted diseases. The state has historically had some of the highest rates of reported STDs in the nation.

“This program has the power to demonstrate the scalable effects of equitable access to historically underserved communities,” Joshua O’Neal, the county’s director of the sexual health programs, said in a press release announcing the kits.

The changes go beyond government. University of Texas researchers are trying out a statewide program to crowdsource data on fatal and nonfatal opioid overdoses. Those working on the project are frustrated the national effort to track covid outbreaks hasn’t extended to the overdose epidemic.

Dr. Allison Arwady, commissioner of the Chicago Department of Public Health, said her team is expanding the covid data-driven approach to track and report neighborhood-level data on opioid drug overdoses. Nonprofits and city agencies that have worked together through the pandemic now meet each month to look at the numbers to shape their response.

Arwady said the city is trying to use the pandemic-driven boost in money and attention for programs that can last beyond the covid emergency.

“Every day, we’re having these debates about, ‘How much do we continue on? How big do we go?’” Arwady said. “I feel like it’s such a moment. We’ve shown what we can do during covid, we’ve shown what we can do when we have some additional funding.”

The city also opened a new safety center modeled on its covid-response base to counter gun violence. Employees from across city departments are working together on safety issues for the first time by tracking data, connecting people in highest-risk areas to services, and supporting local efforts such as funding neighborhood block clubs and restoring safe spaces.

Separately, neighborhood-based organizations created to handle covid contact tracing and education are shifting focus to address food security, violence prevention, and diabetes education. Arwady said she hopes to continue grassroots public health efforts in areas with long-standing health disparities by using a patchwork of grants to retain 150 of the 600 people initially hired through pandemic relief dollars.

“The message I’ve really been telling my team is, ‘This is our opportunity to do things that we have long wanted to do,’” Arwady said. “We built some of that up and I just, I’m gonna kick and scream before I let that all get dismantled.”

Back in Montana, Desnick said not every change relies on funding.

When flooding destroyed buildings and infrastructure in and around Yellowstone National Park in June, the Park County health department used a list of contacts gathered during the pandemic to send updates to schools, churches, and businesses.

Desnick posts regular public health video updates that began with covid case counts and broadened to include information on flood levels, federal cleanup assistance, and ice cream socials for people to meet first responders.

Piccolo, the county’s health director, spent roughly an hour on that day in July going to hotels in Livingston’s core to offer opioid overdose response training and supplies. Three hotel managers took the offer, two asked her to come back later, and one scheduled an all-staff training for later that week. Piccolo plans to extend the program to restaurants and music venues.

It’s that kind of adaptation to her job that doesn’t require the continuing flow of covid aid. The state supplied the Narcan boxes. Otherwise, she said, “it’s just about taking the time to do this.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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They Call It ‘Tranq’ — And It’s Making Street Drugs Even More Dangerous

Xylazine, an animal tranquilizer, has made it into the illegal drug supply of opioids and cocaine. It is changing the way outreach workers treat overdoses and may be responsible for grisly injuries and infections among people who unknowingly inject it.

Approaching a van that distributes supplies for safer drug use in Greenfield, Massachusetts, a man named Kyle noticed an alert about xylazine.

“Xylazine?” he asked, sounding out the unfamiliar word. “Tell me more.”

A street-outreach team from Tapestry Health Systems delivered what’s becoming a routine warning. Xylazine is an animal tranquilizer. It’s not approved for humans but is showing up in about half the drug samples that Tapestry Health tests in the rolling hills of western Massachusetts. It’s appearing mostly in the illegal fentanyl supply but also in cocaine.

“The past week, we’ve all been just racking our brains — like, ‘What is going on?’” Kyle said. “Because if we cook it up and we smoke it, we’re falling asleep after.”

(NPR and KHN are using only first names in this article for people who use illegal drugs.)

Kyle’s deep sleep could also have been triggered by fentanyl, but Kyle said one of his buddies used a test strip to check for the opioid and none was detected.

Xylazine, which is also known as “tranq” or “tranq dope,” surged first in some areas of Puerto Rico and then in Philadelphia, where it was found in 91% of opioid samples in the most recent reporting period. Data from January to mid-June shows that xylazine was in 28% of drug samples tested by the Massachusetts Drug Supply Data Stream, a state-funded network of community drug-checking and advisory groups that uses mass spectrometers to let people know what’s in bags or pills purchased on the street.

Whatever its path into the drug supply, the presence of xylazine is triggering warnings in Massachusetts and beyond for many reasons.

As Xylazine Use Rises, So Do Overdoses

Perhaps the biggest question is whether xylazine has played a role in the recent increase in overdose deaths in the U.S. In a study of 10 cities and states, xylazine was detected in fewer than 1% of overdose deaths in 2015 but in 6.7% in 2020, a year the U.S. set a record for overdose deaths. The record was broken again in 2021, which had more than 107,000 deaths. The study does not claim xylazine is behind the increase in fatalities, but study co-author Chelsea Shover said it may have contributed. Xylazine, a sedative, slows people’s breathing and heart rate and lowers their blood pressure, which can compound some effects of an opioid like fentanyl or heroin.

“If you have an opioid and a sedative, those two things are going to have stronger effects together,” said Shover, an epidemiologist at UCLA’s David Geffen School of Medicine.

In Greenfield, Tapestry Health is responding to more overdoses as more tests show the presence of xylazine. “It correlates with the rise, and it correlates with Narcan not being effective to reverse xylazine,” said Amy Davis, assistant director for rural harm-reduction operations at Tapestry. Narcan is a brand name of naloxone, an opioid overdose reversal medication.

“It’s scary to hear that there’s something new going around that could be stronger maybe than what I’ve had,” said May, a woman who stopped by Tapestry Health’s van. May said that she has a strong tolerance for fentanyl but that a few months ago, she started getting something that didn’t feel like fentanyl, something that “knocked me out before I could even put my stuff away.”

A Shifting Overdose Response

Davis and her colleagues are ramping up the safety messages: Never use alone, always start with a small dose, and always carry Narcan.

Davis is also changing the way they talk about drug overdoses. They begin by explaining that xylazine is not an opioid. Squirting naloxone into someone’s nose won’t reverse a deep xylazine sedation — the rescuer won’t see the dramatic awakening that is common when naloxone is administered to someone who has overdosed after using an opioid.

If someone has taken xylazine, the immediate goal is to make sure the person’s brain is getting oxygen. So Davis and others advise people to start rescue breathing after the first dose of Narcan. It may help restart the lungs even if the person doesn’t wake up.

“We don’t want to be focused on consciousness — we want to be focused on breathing,” Davis said.

Giving Narcan is still critical because xylazine is often mixed with fentanyl, and fentanyl is killing people.

“If you see anyone who you suspect has an overdose, please give Narcan,” said Dr. Bill Soares, an emergency room physician and the director of harm reduction services at Baystate Medical Center in Springfield, Massachusetts.

Soares said calling 911 is also critical, especially when someone has taken xylazine, “because if the person does not wake up as expected, they’re going to need more advanced care.”

‘Profound Sedation’ Worries Health Providers

Some people who use drugs say xylazine knocks them out for six to eight hours, raising concerns about the potential for serious injury during this “profound sedation,” said Dr. Laura Kehoe, medical director at Massachusetts General Hospital’s Substance Use Disorders Bridge Clinic.

Kehoe and other clinicians worry about patients who have been sedated by xylazine and are lying in the sun or snow, perhaps in an isolated area. In addition to exposure to the elements, they could be vulnerable to compartment syndrome from lying in one position for too long, or they could be attacked.

“We’re seeing people who’ve been sexually assaulted,” Kehoe said. “They’ll wake up and find that their pants are down or their clothes are missing, and they are completely unaware of what happened.”

In Greenfield, nurse Katy Robbins pulled up a photo from a patient seen in April as xylazine contamination soared. “We did sort of go, ‘Whoa, what is that?’” Robbins recalled, studying her phone. The image showed a wound like deep road rash, with an exposed tendon and a spreading infection.

Robbins and Tapestry Health, which runs behavioral and public health services in Western Massachusetts, have created networks so clients can get same-day appointments with a local doctor or hospital to treat this type of injury. But getting people to go get their wounds seen is hard. “There’s so much stigma and shame around injection drug use,” Robbins said. “Often, people wait until they have a life-threatening infection.”

That may be one reason amputations are increasing for people who use drugs in Philadelphia. One theory is that decreased blood flow from xylazine keeps wounds from healing.

“We’re certainly seeing a lot more wounds, and we’re seeing some severe wounds,” said Dr. Joe D’Orazio, director of medical toxicology and addiction medicine at Temple University Hospital in Philadelphia. “Almost everybody is linking this to xylazine.”

This article is part of a partnership that includes WBURNPR, and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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This story can be republished for free (details).

Nearly 9 in 10 Opioid Use Disorder Patients Missing Out on Lifesaving Meds

Published: August 8, 2022 | Original story from NYU Langone Health

The opioid overdose and death epidemic continues to worsen across the United States, but medications such as methadone, buprenorphine, and extended-release naltrexone are proven to reduce opioid overdoses by more than 50 percent. New findings led by researchers at NYU Grossman School of Medicine indicate the vast majority, or 86.6 percent, of people living with opioid use disorder (OUD) are not receiving these evidence-based, lifesaving medications.

Published online August 4 in the International Journal of Drug Policy, the study examined the gap between new estimates of OUD prevalence and the use of medications for OUD (MOUD) at the national and state levels from 2010 through 2019. Although the use of MOUD has grown by more than 100 percent over the last decade, this rise in treatment has failed to keep pace with OUD and skyrocketing overdose mortality rates—largely driven by fentanyl, a potent synthetic opioid up to 50 times stronger than heroin.

A recent report from the Centers for Disease Control and Prevention revealed opioid overdose deaths climbed 30 percent during the first year of the COVID-19 pandemic nationally, with Black, American Indian, and Alaska Native populations bearing disproportionate shares of the increase.

“Our findings highlight the urgency of removing barriers to accessing medications to treat opioid use disorder, while expanding the availability of these medications,” says Noa Krawczyk, PhD, an assistant professor in the Department of Population Health, a member of the Center for Opioid Epidemiology and Policy at NYU Langone, and lead author of the study. “But what we have is way beyond a simple treatment capacity problem. We need to rethink how treatment for opioid use disorder is delivered, eliminate stigma, make it easier for people to enter and remain in treatment, as well as ensure that all treatment programs provide and encourage use of evidence-based medications that we know save lives.”

According to Dr. Krawczyk, more than 70 percent of residential treatment programs across the country do not offer MOUD. Other ways to expand access to MOUD could include removing special waiver requirements so that more physicians can prescribe buprenorphine, as well as expanding the deployment of MOUD by mobile health clinics and community-based organizations, and within the criminal justice system. Making methadone less controlled and more accessible through avenues other than highly regulated opioid treatment programs is also long overdue, says Dr. Krawczyk.

How the Study Was Conducted

To determine the gap between people with OUD and the number of people receiving MOUD, the investigators analyzed two different sources: a publicly available database that tracks the dispensing of MOUD by licensed methadone clinics and a private database of outpatient pharmacy claims that tracks prescriptions filled for buprenorphine and extended-release naltrexone (MOUD that can be prescribed from a doctor’s office). The researchers then calculated the percent change in national and state-specific rates of persons receiving MOUD over the past year (2018 to 2019) and past decade (2010 to 2019), using rates per 100,000 people. Their analysis revealed the following findings:

  • There was a 105.6 percent increase in the rate of MOUD receipt across the United States from 2010 to 2019.
  • As of 2019, 86.6 percent of people with OUD were not receiving MOUD.
  • State-specific findings indicate a wide variation in past-year OUD prevalence and MOUD treatment gaps.
  • MOUD treatment rates were lowest in South Dakota (66.1 per 100,000) and highest in Vermont (1,342.6 per 100,000).
  • As of 2019, the largest treatment gaps were in Iowa (97.3 percent), North Dakota (96.1 percent), and Washington, DC (95.1 percent).
  • The smallest treatment gaps were in Connecticut (53.9 percent), Maryland (58.1 percent), and Rhode Island (58.6 percent).
  • While all 50 states had increases in MOUD treatment rates, only Washington, DC, had a decrease of 9.2 percent between 2018 and 2019.

“Even in states with the smallest treatment gaps, at least 50 percent of people who could benefit from medications for opioid use disorder are still not receiving them,” says Magdalena Cerdá, DrPH, a professor in the Department of Population Health, director of the Center for Opioid Epidemiology and Policy, and the study’s senior author. “We have a long way to go in reducing stigma surrounding treatment and in devising the types of policies and programs we need to ensure these medications reach the people who need them the most,” says Dr. Cerdá.

Reference: Krawczyk N, Rivera BD, Jent V, Keyes KM, Jones CM, Cerdá M. Has the treatment gap for opioid use disorder narrowed in the U.S.?: A yearly assessment from 2010 to 2019″. Int. J. Drug Policy. 2022:103786. doi: 10.1016/j.drugpo.2022.103786

This article has been republished from the following materials. Note: material may have been edited for length and content. For further information, please contact the cited source.

Should Prescription Opioid Use Disorder Diagnostic Criteria Consider Patient Motivations?

Pain-adjusted measures for evaluating prescription opioid use disorder were found to be reliable and more valid than standard DSM-5 criteria.
The authors of a study published in the American Journal of Psychiatry advocated for adapting prescription opioid use disorder (POUD) diagnostic criteria to differentiate between therapeutic and nontherapeutic intent.

Patients (N=606) were recruited from 2 inpatient substance treatment centers (n=258) and 4 outpatient pain clinics (n=348) located in both urban and suburban areas in New York to participate in the study (ClinicalTrials.gov Identifier: NCT02660619). Eligibility criteria included participant age of 18 years of age and older and having had received an at least 30-day supply of opioids for the treatment of chronic pain. Participants were evaluated for POUD using standard criteria (ie, withdrawal and tolerance) and pain-adjusted measures (ie, behavioral or subjective criteria to assess motive). Evaluations were conducted using the computer-assisted Psychiatric Research Interview for Substance and Mental Disorders, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) opioid version (PRISM-5-OP), with 3 criteria sets applied:  completely unadjusted; DSM-5, and pain adjusted.  A subset of participants (n=206) underwent additional testing an average of 7.2 (range, 0-19) days after the initial evaluation. Potential reliability and validity of the pain-adjusted POUD assessment were evaluated.

Approximately one-half of the study population was aged 50 years and older and unmarried, and the cohort had an equal number of men and women. Patients receiving treatment for pain in outpatient pain clinics were more often older, women, and married.

In participants meeting the threshold of at least 2 criteria, the prevalence of a diagnosis of POUD was 44.4% for the DSM-5 criteria and 30.4% for the pain-adjusted criteria. In participants meeting the threshold of at least 4 criteria, the prevalence of a POUD diagnosis was 29.5% for the DSM-05 criteria and 25.3% for the pain-adjusted criteria.

Stratified by treatment for substance use vs pain therapy, more participants undergoing treatment for substance use met the DSM-5 criteria for a diagnosis of POUD (61.6% vs 31.6%) when the pain-adjusted criteria were used. Using the at least 2 criteria threshold, far fewer patients (9.8%) receiving pain therapy met the pain-adjusted criteria for a diagnosis of POUD compared with 58.1% of patients undergoing treatment for substance use. Similar trends were observed for the at least 4 criteria threshold.

In the retest samples, the DSM-5 (κ, 0.49) and pain-adjusted (κ, 0.47) evaluations were similarly reliable among the cohort undergoing inpatient substance treatment. For those patients in the outpatient pain cohort, the pain-adjusted criteria were more reliable (κ, 0.80) than the DSM-5 criteria (κ, 0.64) on subsequent testing.

Compared between the criteria, the pain-adjusted evaluation was favored for the dimensional POUD measures of substance treatment, family history of any drug use disorder, personal history of other substance use disorder, antisocial personality disorder, internalizing disorders, tampering, sensation-seeking, and impulsivity (ratio of mean ratios range, 1.22-2.31).

For the POUD binary diagnostic measures, the pain-adjusted diagnostic criteria were associated with all 10 validators at the at least 2 criteria threshold and with 9 of the 10 validators at the at least 4 criteria threshold compared with 5 validators at the at least 2 criteria threshold and 7 validators at the at least 4 criteria thresholds for the DSM-5 diagnostic criteria.

A major limitation of the POUD diagnostic interviews is that patient responses may be affected by stigma or social desirability bias.

The study authors concluded, “We found that the PRISM-5-OP measures of pain-adjusted POUD measures were reliable and more valid than standard DSM-5 concepts of substance use disorder. However, many external validators were associated with DSM-5 as well as pain-adjusted POUD measures. Studies should report both sets of results and further investigate differences between pain-adjusted and DSM-5 POUD and their consequences.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

References:
Hasin DS, Shmulewitz D, Stohl M, et al. Diagnosing prescription opioid use disorder in patients using prescribed opioids for chronic pain. Am J Psychiatry. Published online June 15, 2022.  doi:10.1176/appi.ajp.21070721

Telehealth Bolsters Access to Opioid Use Disorder Treatment for Veterans

New research shows that audio and video-based telehealth helped reduce opioid use disorder treatment barriers among veterans during the COVID-19 pandemic.

– While evaluating methods to ensure access to opioid use disorder treatment among veterans, a study from the University of Michigan and VA Ann Arbor Healthcare System found that audio and video-based care modalities provide various benefits, such as increased access to buprenorphine.

At the start of the COVID-19 pandemic in 2020, many patients and providers feared that in-person restrictions would drive poor health outcomes. For example, there were concerns that veterans struggling with opioid addiction would have difficulties obtaining medications, like buprenorphine, during the pandemic.

However, following evaluation over two years, researchers found that telehealth has been just as effective, if not more effective, as in-person care in providing opioid use disorder treatment resources to this population.

The researchers examined access to buprenorphine treatment for opioid use disorder in the Veterans Health Administration, during the year before the COVID-19 pandemic (March 2019 to February 2020) and during the first year of the pandemic (March 2020 to February 2021).

Overall, the number of patients receiving buprenorphine increased from 13,415 in March 2019 to 15,339 in February 2021.

Although various telehealth modalities were commonly used, audio-only visits accounted for 50 percent of veteran visits relating to buprenorphine — eclipsing video visits, which accounted for 32 percent, and in-person visits, encompassing 17 percent of total visits.

“Telehealth for patients receiving buprenorphine for opioid use disorder was relatively new in the VA nationwide before the pandemic struck, and only video was allowed. The rapid switch to virtual visits for most patients kept people from dropping out of care, and telephone visits played a key role,” said Allison Lin, MD, an addiction psychiatrist and researcher in the Addiction Center at Michigan Medicine, U-M’s academic medical center, and the VA Center for Clinical Management Research, in a press release.

Researchers believe that the primary reason for audio telehealth’s success is the ease patients experience using it, along with its accessibility.

But to continue telehealth optimization and outreach, pandemic-era regulatory flexibilities must be made permanent.

The elimination of regulatory restrictions on telehealth use that occurred at the start of the pandemic was initially intended to be temporary. However, policymakers are currently considering whether to remove the restrictions permanently, and data on telehealth use can help inform that decision-making.

The use of telehealth and mHealth devices to support opioid use disorder treatment has become increasingly common.

In May, the University of Virginia announced the development of an mHealth app that provides opioid use disorder patients with a message board service, allowing for accessible communication with providers. During the trial period, researchers observed that patients’ use of the app was high.

However, health disparities may also exist in delivering opioid use disorder treatment. A Mayo Clinic study published in June showed that women, Black, and Hispanic populations often face difficulties accessing this type of care and that increasing the number of physicians prescribing buprenorphine is critical.

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