A Pilot Study of a Telemedicine-based Substance Use Disorder Evaluation to Enhance Access to Treatment Following Near-Fatal Opioid Overdose

The opioid epidemic is a growing public health emergency in the United States, with deaths from opioid overdose having increased five-fold since 1999. Emergency departments (EDs) are the primary sites of medical care after near-fatal opioid overdose but are poorly equipped to provide adequate substance use treatment planning prior to discharge. In many underserved locales, limited access to clinicians trained in addiction medicine and behavioral health exacerbates this disparity. In an effort to improve post- overdose care in the ED, we developed a telemedicine protocol to facilitate timely access to substance use disorder evaluations. In this paper, we describe the conception and refinement of the telemedicine program, our experience with the first 20 participants, and potential implications of the platform on health disparities for individuals with opioid use disorder

Optimizing prescribing of opiate agonist treatment in rural & remote primary care to improve treatment outcomes in adults with opioid use disorder

Opioid use disorder (OUD) is a chronic and relapsing condition that affects people across British Columbia (BC). People with OUD are at significant risk of morbidity and mortality related to unintentional toxic drug poisonings from the fentanyl-contaminated unregulated drug supply. Despite the unabating rates of toxic drug deaths in BC, evidence-based pharmacologic interventions for OUD remain underutilized especially in rural and remote areas of the province. Opiate agonist treatment (OAT) is an evidence-based pharmacologic intervention for OUD that is within primary care provider (PCP) scope of practice to prescribe. This integrated literature review was conducted to address how in rural and remote communities, PCPs can improve treatment outcomes for adults with OUD when prescribing OAT. A systematic search of six large academic databases was conducted that yielded twelve peer-reviewed articles that met inclusion criteria. Findings are discussed based on key themes from the literature that demonstrate an undisputed understanding of the efficacy of OAT among rural PCPs, however treatment outcomes among rural patients with OUD are variable due to several high-level social, regulatory, environmental and organizational challenges that are exacerbated in rural regions. Scale-up of accessible OAT in primary care is integral to improving treatment outcomes for adults with OUD and preventing toxic drug deaths in rural and remote BC communities

An investigation of health-related harms associated with illicit opioid injection

Over the past two decades the number of people injecting opioids has increased globally, accompanied by a rise in health-related harms, including overdose. This research utilised Australian and international data to address significant gaps in the epidemiology of illicit opioid injection and associated harms. The first three studies drew on data from the Australian Needle Syringe Program Survey (ANSPS), an annual national cross-sectional study conducted in needle syringe programs. The fourth study used data from the International Collaboration of Incident HIV and Hepatitis C in Injecting Cohorts (InC3) which pooled behavioural and biological data from 10 prospective observational cohorts examining HIV and HCV. The aims of the research were to: 1) characterise the practice of fentanyl injection in a large, national sample of people who inject drugs; 2) determine the prevalence and correlates of multiple non-fatal opioid overdose (NFOOD), a significant and potentially modifiable risk factor for fatal overdose; 3) estimate the incidence and predictors of opioid agonist therapy (OAT) discontinuation, an essential but under-scaled health intervention for this population and; 4) examine sex differences in HCV incidence among people who inject drugs and identify factors associated with decreased protective efficacy of OAT. Results have the potential to inform public health policy and practice designed to respond to the harms associated with opioid injection. High-risk sub-populations, such as fentanyl injectors and people with a history of multiple NFOOD, would benefit from targeted interventions. Findings also emphasise the need to optimise the impact of existing interventions to better meet the needs of people who inject drugs, including the expansion of low-threshold OAT programs with flexible dosing and subsidised dispensing fees, and bolstering the efficacy of OAT in females by scaling up targeted interventions such as affordable housing and safer injection training

PRIMARY AND SECONDARY PREVENTION OF HEPATITIS C VIRUS AMONG RURAL APPALACHIAN PEOPLE WHO USE DRUGS

Hepatitis C virus (HCV) remains a major cause of morbidity and mortality worldwide, with 3% of the global population chronically infected. Clinical impacts in the United States are projected to increase for two decades, and mortality attributed to HCV now exceeds HIV. Injection drug use (IDU) is the most common route of transmission in the developed world. Advances in treatment offer hope of mitigating HCV impacts, but substantial barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved regions including Central Appalachia. This study assessed IDU paraphernalia sharing longitudinally over 24 months in a sample of 283 rural PWID recruited by respondent‐driven sampling. Medical follow‐up among 254 seropositive participants was also assessed using discrete‐time survival analysis. HCV‐positive screening was associated with reduced IDU sharing frequency 18 months after testing compared to seronegative participants (adjusted OR [aOR]=1.4, 95% confidence interval [CI]: 1.0‐1.9), but this effect was not sustained. HCV‐positive participants were less likely to cease IDU 6 months after testing (aOR=0.4, 95% CI: 0.2‐0.7). Predictors negatively associated with decreased IDU sharing included recent unprotected sex, sedative use, and frequency of prescription opioid IDU; protective associations included female gender and religious affiliation. IDU cessation was negatively associated with ever being incarcerated, recent unprotected sex with PWID, heavy alcohol use, lifetime use of OxyContin®, and baseline frequency of prescription opioid IDU; protective associations included number of dependents, receiving disability payments, and substance abuse treatment. Drug‐specific associations decreasing IDU cessation included recent illicit use of OxyContin®, other oxycodone, and cocaine. 150 of 254 (59%) seropositive participants saw a clinician after HCV‐positive screening and counseling, 35 (14%) sought treatment, and 21 (8%) received treatment. Positive predictors of following up with a clinician following testing and counseling included health insurance, internet access, past substance abuse treatment, generalized anxiety disorder, and recent marijuana use. Factors decreasing odds of follow‐up included major depression, lifetime illicit methadone use, and recent legal methadone. These analyses shed valuable light on determinants of behavior impacting primary and secondary HCV prevention. Integrated, multidisciplinary approaches are recommended to meaningfully impact epidemic levels of HCV among rural PWID in Eastern Kentucky