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Real-world use of extended-release buprenorphine (XR-BUP) in a low threshold Bridge clinic

Alyssa Peckham, PharmD, BCPP – Advanced Practice Pharmacist in Addiction; Assistant Clinical Professor, Massachusetts General Hospital; Northeastern University

Laura Kehoe, MD, MPH, FASAM – Medical Director, MGH SUD Bridge Cliic, Assistant Professor in Medicine, Massachusetts General Hospital/Harvard Medical School

Jessica Gray, MD – Cliinical Director, HOPE Clinic, Associate Director, Addiction Medicine Fellowship, Massachusetts General Hospital and Mass General Hospital for Children

Sarah Wakeman, MD – Medical Director, Substance Use Disorder Initiative, Massachusetts General Hospital

Background: Extended-release buprenorphine (XR-BUP) may increase medication adherence and improve outcomes including overdose (OD). However, real-world experiences are limited and outcomes in low threshold clinics with high-risk populations are unknown. Overcoming treatment challenges, such as inability for some to stabilize on sublingual (SL) BUP for seven days prior to XR-BUP and ongoing craving/withdrawal symptoms during treatment, is lacking. Methods: This retrospective case series included clinical chart abstractions performed on a convenience sample of 40 serial adult cases treated with XR-BUP at Massachusetts General Hospital Bridge Clinic from study time period February 1, 2019 to July 31, 2019. Results: Patients were mostly male (n=27), non-Hispanic white (n=39), unstably housed (n=31), with average age of 32.1. All were diagnosed with severe opioid use disorder (OUD) involving intravenous (n=32) or intranasal (n=7) heroin/fentanyl, or other oral opioids (n=1). The average SL BUP dose prior to XR-BUP was 21.6mg (standard deviation [SD]=3.9; range 16-32) for an average treatment duration of 105 days (SD=191; range 1-810). Of those with toxicology at time of XR-BUP initiation (n=21), 100% were BUP positive while 62% (n=13) were positive for other substances including opioids indicating use despite sustained BUP treatment. Nine (22.5%) patients received SL BUP for less than the seven recommended days (mean=3.7, SD=1.4, range=1-6) due to high-risk. Conventional dosing was administered to 30% (n=12), three of whom required increasing to 300mg due to cravings. Empiric high-dose XR-BUP (300mg monthly) was administered to 25% (n=10). Twenty-two patients (55%) required supplemental SL BUP ranging from 4-24mg, daily or as needed, for varying time periods. At the end of data collection, 67.5% (n=27) remained on XR-BUP, 30% (n=12) discontinued XR-BUP, and one was lost to follow-up. There was no significant difference in the proportion of patients seeking acute care between those who continued XR-BUP versus discontinued at 18.5% and 16.6%, respectively (x2=0.02, p-value=0.89). Toxicology was negative for other opioids in 65% (n=26) of patients throughout treatment. Thirteen (32.5%) experienced continued use of non-prescribed opioids, though less frequently and without euphoria. In six cases, continued use occurred during month one only. There were no reports of OD, withdrawal after use, or precipitated withdrawal after subsequent XR-BUP. The reasons for discontinuing XR-BUP were preference for SL BUP (n=5), patient reported ineffectiveness (n=2), incarceration (n=1), sustained need for SL BUP (n=1), fear of eventual withdrawal (n=1), no longer interested in agonist treatment (n=1), or adverse effects (AEs) myalgias and pedal edema (n=1). The relationship between these AEs and XR-BUP is unclear given this patient had comorbid acute hepatitis C. Conclusion: This real-world application of XR-BUP in a low threshold clinic setting found that treatment was feasible, well tolerated, and outcomes were good, with most individuals choosing to continue treatment and a majority with no evidence of ongoing opioid use or precipitated withdrawal. Administering SL BUP for fewer than the recommended seven days was safe and did not worsen outcomes, XR-BUP 300mg monthly dosages were safe, and a substantial portion of patients required supplemental SL BUP during the first few months of XR-BUP.

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Buprenorphine-Naloxone vs. Buprenorphine for Treatment of Opioid Use Disorder in Pregnancy

Simone Vais, BA – Medical Student, Boston University School of Medicine

Briana N. Perry, MD – OBGYN Resident Physician, Boston Medical Center

Melissa Miller, MPH – Graduate Student, Boston University School of Public Health

Kelley Saia, MD – Assistant Professor of OBGYN, Boston Unversity School of Medicine

BACKGROUND: Pharmacologic treatment options for opioid use disorder (OUD) in pregnancy remains understudied. Prior studies have established the safety and efficacy of buprenorphine (BUP), a partial opioid agonist, and methadone, a full opioid agonist, in pregnancy1. In the non-pregnant population, the combination of BUP and naloxone (BUP-NX), a partial opioid agonist, is commonly favored due to the decreased risk of diversion2. Historically, women who were on BUP-NX prior to pregnancy were transitioned to BUP in pregnancy due to concerns for fetal exposure to naloxone3. Given the scarcity of safety data, there continues to be a lack of consensus regarding the use of BUP-NX in pregnancy4. Recently, several small retrospective studies examined outcomes for BUP-NX use in pregnancy and found no adverse maternal or neonatal outcomes5,6. There are no studies, however, that directly compare the use of BUP-NX versus BUP in pregnancy. This study compares the maternal and neonatal outcomes from pregnancies managed with BUP-NX versus BUP. METHODS: This single-center, retrospective cohort study included 33 pregnancies managed with BUP-NX and 22 managed with BUP between 2017 and 2019. Maternal outcomes included demographic characteristics, gestational age (GA) at treatment initiation, number of prenatal visits, GA at delivery, concurrent prescribed psychiatric medications, unprescribed or illicit substance use per urine drug screening during the pregnancy, and delivery outcomes. Infant outcomes included birth weight, Apgar scores, and neonatal abstinence syndrome (NAS) outcomes (NAS diagnosis, pharmacologic treatment, and length of hospital stay). FINDINGS: There were no significant differences between the groups regarding prenatal care utilization, maternal substance use, delivery outcomes, or neonatal outcomes. Women treated with BUP-NX did have a lower average BUP dose at treatment initiation compared to women treated with BUP (10.5 vs. 13.3 p=0.04). Among a subgroup of women transitioned from BUP to BUP-NX mid-pregnancy, no incidences of treatment destabilization (evidence of relapse, hospitalization or a required dose increase) were observed following the transition. CONCLUSIONS: BUP-NX is non-inferior to BUP regarding maternal and neonatal outcomes in the treatment of OUD in pregnancy. These findings support the growing body of data indicating the safety of BUP-NX use in pregnancy.

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Medication Improves Treatment Retention in Adolescents with Opioid Use Disorder

Carrie Mintz, MD – Postdoctoral Fellow, Washington University School of Medicine

Background: Adolescents with opioid use disorder (OUD) are less likely than their adult counterparts to receive medication treatment. Whether this age disparity affects treatment retention for adolescents with OUD has not been previously studied. Objective: This study examined (1) the association between age and OUD treatment retention at six months and (2) whether age disparity in treatment retention was explained by disparities in medication treatment by age. Method: We used a national insurance database with OUD treatment claims from 2006 through 2016 to conduct this retrospective study. We examined OUD treatment episodes from 4,979 adolescents (ages 12-17), 76,229 young adults (ages 18-25) and 180,148 older adults (ages 26-64). Treatment type was defined as receiving psychosocial services only, naltrexone, or buprenorphine. The primary outcome was six-month treatment retention. Logistic regression was used to model retention prevalence for each age group while adjusting for covariates in partially-adjusted models. Treatment type was added to fully-adjusted models to determine if treatment type affected the association between six-month retention and age. To examine the effectiveness of type of treatment within each age group, analyses were stratified by age group and adjusted odds ratios for each type of treatment were compared. Results: Prior to adjusting for treatment type, there was a clear age disparity in six-month retention such that adolescents were significantly less likely to be retained compared to their adult counterparts: estimated retention prevalence was 17.6% (95% CI 16.5-18.7%) for adolescents, 25.1% (95% CI 24.7-25.4%) for young adults, and 33.3% (95% CI 33.0-33.5%) for older adults. After adjusting for treatment type, however, age-related disparities were markedly reduced. For example, within the buprenorphine treatment group, adjusted retention prevalence estimates were 40.4% (95% CI 36.9-44.0%) for adolescents, 39.9% (95% CI 39.4-40.4%) for young adults, and 49.4% (95% CI 49.1-49.8%) for older adults. Buprenorphine was the most effective treatment type for six-month retention within each age group examined. For example, within the adolescent group, the odds of retention at six months for those who received buprenorphine was 7.5 (95% CI 6.1 to 9.3) times as high as the odds of retention for those who received psychosocial services only, and 1.7 (95% CI 1.3, 2.3) times as high the odds of retention for those who received naltrexone. Conclusions: Age disparities in six-month OUD treatment retention are largely a function of age disparities in medication treatment. Results point to need for improved implementation of medication treatment for persons with OUD, regardless of age.

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Few Patients Prescribed Opioid Agonist Therapy in the Inpatient Psychiatric Setting

Angela Lin, MD, MPHS – Resident Physician, Washington University School of Medicine

Carrie Mintz, MD – Postdoctoral Fellow, Washington University School of Medicine

Emily Mukherji, MD – Assistant Professor, Washington University School of Medicine

Laura Bierut, MD – Alumni Endowed Professor of Psychiatry, Washington University School of Medicine

Introduction: Psychiatric comorbidities are common in patients with opioid use disorder (OUD) and are linked to increased risk for opioid overdose. Medication for addiction treatment (MAT) with buprenorphine, methadone, or naltrexone is the standard of care for OUD. In particular, buprenorphine and methadone, opioid agonists, decrease mortality risk in persons with OUD. Thus, psychiatric hospitalization presents an opportunity to provide MAT to a particularly vulnerable population. We sought to establish current prevalence of MAT prescribed for OUD on an inpatient psychiatric unit and determine demographic and clinical factors associated with MAT prescription.
Methods: All psychiatric admissions to the adult inpatient psychiatry unit at Barnes-Jewish Hospital (St. Louis, MO) within a one-year period (June 1, 2018 to May 31, 2019) with a diagnosis of OUD at admission, discharge, or in an active hospital problem were included in this retrospective cohort study. Primary outcome was prescription of MAT during hospitalization. Demographic variables included age, gender, race, housing status, and insurance. Admission characteristics and clinical factors included involuntary or voluntary admission status, primary discharge diagnosis, length of stay, suicidal ideation, urine drug screen results, and history of opioid overdose. Univariate binomial logistic regression was conducted to measure associations between these variables and the primary outcome. Given the known mortality benefit associated with opioid agonist therapy (OAT), secondary analyses were conducted with OAT prescription as the outcome.
Results: Of 225 admissions addressing OUD, 24.4% (n = 55) were prescribed MAT. Of admissions associated with MAT prescription, 32.7% (n = 18) initiated maintenance treatment, 56.4% (n = 31) continued home maintenance therapy, and 10.9% (n = 6) received MAT during hospitalization but did not continue MAT at discharge.
Men were less likely than women to receive MAT (OR = 0.42, 95% CI 0.22, 0.77), and African-Americans were less likely than Caucasians to receive MAT (OR = 0.30, 95% CI 0.14, 0.58). Odds of receiving MAT increased with length of stay (OR = 1.08 per additional day, 95% CI 1.01, 1.16). However, in subgroup analysis excluding patients who continued home maintenance therapy, these associations were no longer significant. No other variables were associated with MAT, including primary discharge diagnosis of OUD or related diagnosis, or reported history of opioid overdose.
OAT prescription followed similar patterns as seen in primary analyses: men were less likely than women to receive OAT (OR = 0.40, 95% CI 0.21, 0.77); African-Americans were less likely than Caucasians to receive OAT (OR 0.33, 95% CI 0.15, 0.66); odds of receiving OAT increased with length of stay (OR = 1.10, 95% CI 1.03, 1.19). In the subgroup analysis of admissions excluding patients who continued home maintenance therapy, these associations were no longer significant.
Conclusions: MAT is underprescribed during psychiatric admissions, even when OUD is identified as the primary diagnosis or when patients report a history of opioid overdose. These results demonstrate that inpatient psychiatric hospitalization represents a critical missed opportunity to engage this high-risk population in potentially life-saving treatment.

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A Novel Approach to Increase Accessibility to Medication-Based Treatment for OUD

Eric Weintraub, MD – Division Head, Alcohol & Drug Abuse; Acting Division Head, Adult Psychiatry, Univeristy of Maryland, Baltimore

Jessica Anane, MPH – Program Coordinator, University of Maryland School of Medicine

Alexander Pappas, MD – Visiting Assistant Professor, University of Maryland School of Medicine

Chamindi Seneviratne, MD – Assistant Professor, University of Maryland School of Medicine

Kelly Coble, LCSW-C – Program Director, Univeristy of Maryland, Baltimore

Introduction: In 2018, 46,802 Americans suffered fatal opioid overdoses, and 1,985 of the overdose deaths were in Maryland, ranking in the top five states for opioid-related overdose death rates1,2. Individuals living in rural areas have significantly less access to medication-based treatment (MBT) than in urban areas, resulting in higher mortality rates3. We present data from an ongoing project designed to test feasibility of a novel approach in reaching underserved rural populations, with the overarching goal of reducing opioid use in the population and create an evidence-based knowledgebase to further our understanding of management and treatment of OUD. Methods: Based upon our existing office-based telemedicine capabilities, we conceptualized utilizing a mobile treatment unit (MTU) for providing MBT services to individuals with an OUD, in rural Caroline County, in the Eastern Shore of Maryland. The MTU is a recreational vehicle (RV) equipped with medical supplies and telecommunication devices where patients can teleconference via a monitor screen that links the patient with a physician specialized in addiction medicine/psychiatry at UMSOM in Baltimore, who will provide point-of-care diagnosis at the initial visit and consultations during subsequent follow-up visits. Patients are enrolled into the treatment program by various efforts including local advertisements, scheduling through appointments, referrals from Emergency Departments and local jails, and walk-ins to the MTU. Patients coming on the MTU for their first appointment are greeted by the Addictions Counselor who will administer questionnaires, urine drug screens and vital signs before being “seen” by a Physician. The Program Coordinator then enrolls consenting patients into an optional research study gathering prospective data on global improvement of mental and physical health and demographic characteristics to be added to the OUD knowledgebase. Results: Since the onset of study in January 2019 until February 2020, we have enrolled 115 patients to receive MBT in the MTU. A 38.9% of patients seen on MTU reported that they would not have sought treatment for OUD, had the MTU was not available. Another 13.9% and 22.2% reported some or moderate likelihood of seeking treatment at the nearest available treatment center, respectively. Thirty-five of the 115 patients also consented to the optional research study (2:1 male: female). Their baseline characteristics included (mean + 95% CI), 9.46 + 1.56 total score on PHQ-9 depression severity, 9.96 + 1.23 on GAD-7 anxiety severity, and 9.46 + 1.56 on DUDIT (Drug Use Disorders Identification Test) scales. Furthermore, on average, patients have saved 9.93 travel miles (St.Dev.= 6.21miles) by receiving MBT on the MTU rather than in their nearest clinic. Conclusion: Via the MTU, MBT services are now brought to areas that did not have any prior treatment clinics. This project is ongoing and will continue to expand to surrounding counties to meet the growing demand. By project’s end, in collaboration with Health Resources and Services Administration (HRSA), the collected data will be made available to addiction researchers, health care providers, patients, and other interested parties.

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Three Cases of Buprenorphine Microinduction in Critically Ill Patients

Jade Malcho, MD – Clinical Instructor of Emergency Medicine, University of Rochester Medical Center, Rochester, NY

Timothy Wiegand, MD, FACMT, FAACT, DFASAM – Director of Toxicology, University of Rochester Medical Center

Background: Buprenorphine is a high-affinity partial mu receptor agonist with long duration of action indicated for analgesia and opioid use disorder. Transition from full opioid agonists typically requires a washout period to avoid precipitated withdrawal. This may be particularly challenging in patients with difficulty stopping opioid use, even for brief periods. Two cases were previously described in a procedure named the ‘Bernese Method’ with administration of small doses of buprenorphine during ongoing heroin use. A similar technique was reported using buprenorphine shortly after methadone cessation. This technique allows for small amounts of buprenorphine accumulation at the receptor with gradual displacement of other opioids. The small doses don’t trigger a stress response (precipitated withdrawal). Microinduction may be considered for individuals with significant physical dependence unable to tolerate standard buprenorphine inductions and hasn’t been reported in critically ill patients receiving continuous opioid infusions. Cases: 39 year-old male with history of craniopharyngioma resection, respiratory failure, and iatrogenic opioid dependence due to continuous fentanyl infusion (mean 250 mcg/hr > month) had severe agitation even with brief cessation or fentanyl decreases. After trials of dexmedetomidine, ketamine, antipsychotic, and other agents failed to support fentanyl weans buprenorphine was initiated, with fentanyl ongoing, starting at 30 mcg IV/6 hours → buccal 150 mcg/6 hours → 450 mcg/6 hours → 1 mg/12 hours. On Day 4 Fentanyl was decreased by 50 mcg/day and buprenorphine was doubled until reaching 8 mg/12 hours. Fentanyl was then completely stopped and the patient continued buprenorphine without signs of opioid withdrawal. His cognition rapidly improved such that he was able to work with physical therapy. 27 year-old male with opioid use disorder presented with complications related to mycotic aneurysm rupture. He was ultimately stabilized in the neurologic ICU and maintained on high-dose fentanyl infusions for sedation. Despite adding adjunctive agents he didn’t tolerate fentanyl weans or even brief infusion holds. A microinduction was performed using buccal buprenorphine (150 mcg → 450 mcg → 1 mg → 2 mg → 4 mg) each dose given at 6-hour increments x4 before increasing. The patient tolerated this well and fentanyl was successfully weaned. 36 year-old male with a history of opioid use disorder previously on buprenorphine presented after a MVA resulted in a femur fracture, rib fractures and splenic rupture. He was treated with high dose hydromorphone PCA but still reported pain and opioid withdrawal symptoms. Ultimately, a microinduction was performed starting at 150mcg every 6 hours and titrated upward identical to previous dosing. When 8 mg/12 hours was started hydromorphone was discontinued. Case Discussion: These cases illustrate the microinduction, a novel buprenorphine induction technique used to transition patients from full agonists to buprenorphine in situations where patients cannot tolerate a standard induction and full agonists are continued. Conclusion: Buprenorphine microinduction should be considered in any situation where a patient cannot tolerate the standard induction. Potential applications include transitioning from full opioid agonist analgesia, sedation weans in critically ill patients, and induction for traditional application in the treatment of opioid dependence.

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Outcomes of Imbedded Tobacco Intervention for Veterans in Substance Use Treatment Program

Stephanie Bertucci, LICSW, MSW – Intensive Outpatient Program Coordinator, Veterans Health Administration

Noah Venables, PhD – VA quality Scholar Fellow, Veterans Health Administration

Background: Historically, substance use disorder (SUD) treatment programs have struggled to offer adequate interventions for tobacco dependence. Tobacco use is a leading cause of death in individuals with psychiatric illness or addictive disorders. Additionally, tobacco use is associated with less satisfactory SUD treatment outcomes, whereas treatment of tobacco dependence supports long-term sobriety. Despite these facts, the majority of SUD treatment programs in the U.S. do not offer tobacco cessation treatment (e.g. counseling or medications). The existing literature on treatment for co-occurring nicotine dependence in SUD treatment settings are limited in many respects, they are only conducted with clients who are interested in quitting smoking at treatment entry, they are limited to one or a few sites, university affiliated, or conducted in inpatient or residential treatment programs. Methods: The Minneapolis VA Medical Center Intensive Outpatient Program (IOP) developed an intensive tobacco cessation intervention, Tobacco Cessation & Education (TCE) group. Since August 2018, all participants accepted into IOP with co-occurring tobacco dependence were scheduled to attend the TCE group as part of their SUD treatment. Participants were scheduled for twice weekly, 30 minute therapy groups. The group included thorough tobacco use assessment, education, motivational enhancement techniques, carbon monoxide breath test educational activity, overview of medications, and other interventions from VA approved tobacco cessation handbooks. Participants interested in nicotine replacement therapy (NRT) or other tobacco pharmacotherapies were given prescriptions within less than a week of request, often within the same day. Results: Out of 97 TCE group participants, 24 participants (23%) successfully quit tobacco while in the program compared to 10-11% who quit in a comparable study, a study which only included program participants who were initially interested in quitting. Fifty-nine participants (61%) were prescribed tobacco cessation medications. Participants also significantly progressed through the stages of changes related to quitting tobacco use (p < .001) as measured by a 1-7 self-report variable. Discussion: Outcomes suggest that an intensive and imbedded tobacco intervention enhances motivation to quit tobacco, increases likelihood that Veterans will obtain tobacco cessation medications, and facilitates a greater percentage of Veterans actually quitting during a 4-week SUD treatment program. The TCE group may be more effective because it is providing a higher dose of treatment compared to treatment as usual (e.g. brief counseling, medications only, quit lines, online apps). Imbedding the TCE group into a SUD program results in all tobacco dependent participants receiving the intervention. Our results show that majority (57%) of those not initially interested in changing their tobacco use habit (precontemplation stage) move towards a desire to quit during treatment. Compared to similar studies in which only those initially interested in tobacco cessation are enrolled in the tobacco cessation intervention, 10-11% of participants quit tobacco use compared to our finding of 23%. This difference is evidence for including TCE group, or other tobacco cessation interventions, as part of SUD treatment programs for all tobacco users rather than an optional intervention only for those participants initially interested in changing their tobacco habit.

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Why Cardiac Surgeons Decline Surgery for Injection Drug Use-Related Infective Endocarditis

Max Jordan Nguemeni Tiako, MS – medical student, Yale School of Medicine

Cornell Brooks II, B.S. – Research Assistant, Yale School of Medicine

Melissa Weimer, DO, MCR, FASAM – Assistant Professor of Medicine, Yale University School of Medicine

Reed Mszar, BS – student, Yale School of Public Health

Syed Usman Bin Mahmood, MBBS – Medical Resident, Yale School of Medicine

Makoto Mori, MD – Medical Resident, Yale School of Medicine

Pramod Bonde, MD – Associate Professor, Yale School of Medicine

Arnar Geirsson, MD – Associate Professor, Yale School of Medicine

Background: Cases of injection drug use related infective endocarditis (IDU-IE) are on the rise in the setting of the current opioid epidemic. Increasingly, cardiac surgeons are asked to make complex decisions regarding the management of patients with IDU-IE with little support about the substance use disorder that led to their patient’s illness. Guidelines for the management of IDU-IE remain vague, leaving surgeons to make decisions for surgical intervention based on their understanding of the patient’s condition as well as their thoughts or opinions about substance use disorder and its treatment. We evaluated reasons why cardiac surgeons may decline to intervene surgically on cases of IDU-IE. Methods: This study is a sub-group analysis of a nationwide survey of cardiac surgeons’ treatment approach for IDU-IE. Participants were asked the question “Have you ever denied operating on a patient with intravenous drug use associated infective endocarditis? (you may explain why in the free text box next to your answer).” 86 surgeons who reported having declined operating on IDU-IE patients included free-text answers. Responses were grouped into 4 applicable categories (active drug use, recurrent endocarditis with ongoing drug use, severe end-organ damage and other). Each response was additionally coded and evaluated for use of stigmatizing language. Review and classification of responses into the aforementioned categories was performed by 3 independent reviewers. Results: We received free-text responses from 86 cardiac surgeons. Active drug use was the most mentioned (71, 82.6%), followed by recurrent endocarditis (50, 58.8%), and severe end-organ damage (9, 10.6%). More than half (45, 52.9%) of the responses included both active drug use and recurrent endocarditis. Furthermore, our coding of word choice reveals the use of stigmatizing, criminalizing and patient-blaming language (“recalcitrant,” “recidivism,” “contract violation”) in over a third (36, 43%) of responses. The lack of explicit acknowledgement of addiction as a complex chronic illness with highly effective treatment options is also noted, by way of phrases such as “the addiction is stronger than the will to live” and the preponderance of additional terms that reduce addiction to a matter of intrinsic will such as “noncompliance,” and “quitting.” Conclusion: Most cardiac surgeons who decline to operate do so on the basis of active drug use, though a minority primarily expresses concerns about severe end-organ damage. These findings add to the existing body of literature emphasizing the need for addiction treatment in this patient population surrounding the time of surgery. Understanding surgeons’ reasoning in cases of declined intervention exhibits the opportunity to employ addiction medicine expertise in order to optimize the care of patients with IDU-IE. Lastly, the themes of stigmatizing and criminalizing language along with the lack of acknowledgement of addiction as a complex chronic illness highlights the need for additional training and support for cardiac surgeons who are increasingly caring for patients with IDU-IE.

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Men’s Substance Use During the 1st Year Transition to Fatherhood

Alicia Boykin, MD, MS – Postdoctoral Scholar, Children's Hospital of Pittsburgh of UPMC

Kelley Jones, PhD, MPH – Biostatistician, Children's Hospital of Pittsburgh of UPMC

Elizabeth Miller, MD, PhD – Director, Division of Adolescent and Young Adult Medicine, Children's Hospital of Pittsburgh of UPMC

J. Deanna Wilson, MD, MPH – Assistant Professor of Medicine and Pediatrics, University of Pittsburgh

Introduction: The transition to fatherhood is associated with both positive and negative life changes. A man’s use of alcohol and other drugs significantly affect his health and fathering activities. The current study investigates differences in substance use (alcohol and illicit drugs) between younger and older fathers during pregnancy and the first year of fatherhood. Methods: The study sample is from the Fragile Families and Child Wellbeing Study, which represents medium and large urban cities in the U.S. Paternal baseline use of alcohol and other substances (i.e., marijuana, crack, cocaine, heroin) were measured before delivery (during the last trimester of pregnancy) and during first year of fatherhood (in the last 30 days of the first year of fatherhood). We generated descriptive statistics based on pre-determined paternal age groups. We used Chi-square test to compare categorical variables, substance use before delivery and substance use during the first year of fatherhood between young fathers (<21 years) and each older age group. We used Chi-square test to compare the percentage of fathers who continued, transitioned into or out of substance use following pregnancy. Results: The sample consisted of 3031 fathers ages 15-53 (27.86, SD 7.13). There were 431 fathers in the youngest age group (<21 years of age); 1105 ages 21-26, 1025 ages 27-35, and 470 ages 36 and older. The majority were Black (34%) or White (30%), married (54%), of higher socioeconomic status (40% ≥300% poverty level), attended college (46%), and employed (85%). Overall, 68% used alcohol before delivery, 61% used alcohol during the first year and less than 10% used drugs before delivery or during the first year of fatherhood. Young fathers (< 21 years of age) had lower alcohol use before delivery (54% vs 71%, p<0.05) and during the first year (48% vs 68%, p<0.05) com-pared to slightly older fathers (27-35 years old), however, twenty-percent of the youngest fathers started using alcohol during the first year. Of the youngest fathers who were using alcohol before delivery, the majority (71%) continued during the first year. There were no differences in alcohol use transitions during the first year regardless of age. Young fathers had higher frequencies of drug use before delivery (16% vs 2%, p<0.05) and during first year (10% vs 2%, p<0.05) compared to fathers over the age of 35. Fathers < 21 years of age were more likely to initiate drug use during the first year compared to fathers ages 27-35 years (6% vs 4%, p< 0.05). Conclusion: Substance use during the first year of fatherhood may change for men. Young fathers are at risk for initiation of alcohol use and drug use during the first year of fatherhood. Increasing outreach to engage men during the first year of fatherhood allows clinicians to diagnose substance use disorders early, optimize delivery of treatment, reduce risk behaviors, and improve both paternal and ultimately family health. Future studies should explore the appropriate timing and delivery of interventions aimed to reduce or prevent paternal substance use during the first year of fatherhood.

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Marijuana, Mental Health and Social Domains of Functioning: Public Perception of Harm

Christopher Rienas, MD – Addiction Psychiatry Fellow, University of California San Francisco

Salomeh Keyhani, MD, MPH – Professor, UCSF

Marzieh Vali, MS – Senior Statistician, NCIRE

Background Since 2007, marijuana use among US adults, especially young adults, has been increasing while the perceived risk of harm has been decreasing. Questions about risk in federally sponsored surveys like the National Survey on Drug Use and Health (NSDUH) are nonspecific. We conducted a national survey to gain an understanding of the views of US Adults toward the risks and benefits of daily marijuana use on mental health, school success, job success and relationship quality. Methods Four questions were developed to address gaps in knowledge from federally sponsored surveys to assess the perceived impact daily marijuana use has on mental health, school success, job success and relationships. This survey was distributed to a nationally representative online panel of 16280 US Adults aged 18 and older. Responses were weighted and categorized by age and time of last marijuana use. We combined responses and developed multivariate models to compare views of US adults who used marijuana in the last year compared to those who did not. Results The survey response rate was 55.3%, which did not differ by the state’s marijuana legalization status. Among the respondents, 52% were women, 64% were white, 12% were black, 16% were Hispanic, and 8% were of other races. Only about 61% of US adults reported daily marijuana use harms mental health while 22% reported it improves mental health. A larger majority of respondents reported that daily marijuana use harms school success (77%), job success (75%) and relationships (69%). In each of these domains about 7% of respondents reported a benefit, while the remainder of respondents perceived that there was no effect. In all domains, young adults (age 18-35) less commonly perceived daily marijuana use as harmful compared to older adults. About 28.9% of young adults reported daily marijuana use improves mental health and 18.7% reported no effect. Using marijuana in the last year was associated with a decreased likelihood of reporting daily marijuana use as harmful to mental health (OR 0.17 95% CI [0.15, 0.19]), school success (OR 0.26, 95% CI [0.23, 0.3]), job success (OR 0.20 95% CI [0.18, 0.23]) and relationships (OR 0.16 95% CI [0.14, 0.18]). Discussion and Conclusions The majority of respondents more commonly perceived daily marijuana use as harmful to mental health, school success, job success and relationships, however this perception was less commonly held among the young adults and past year users. However, heavy marijuana use has been associated with poorer mental health outcomes, school performance, job satisfaction and relationship quality, with the most profound effects seen in adolescent onset users. Results from this survey and future research into understanding knowledge gaps and misconceptions in popular culture and media may help to facilitate effective communication of risks of cannabis use to the public, but especially to adolescents and young adults.

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Implementing Supervised Consumption Service Access for Emergency Department Patients

Nina Lam, MD – Resident Physician, Faculty of Emergency Medicine, University of Alberta

Rebeccah Rosenblum, MD, FRCPC – Facility Lead, Emergency Department , Royal Alexandra Hospital

Tyson Kaban, RN – Manager, Addictions Recovery and Community Health Team

Klaudia Dmitrienko, MA, MHSc – Research and Evaluation Consultant, Royal Alexandra Hospital

Kathryn Dong, MD, FRCP, DABAM – Medical Director, Inner City Health and Wellness Program and Addiction Recovery and Community Health Team

People who use substances are frequent users of emergency department services. Unintentional opioid overdoses in and around acute care hospitals, including in the ED, are of increasing concern. Research has shown that supervised consumption services lead to decreases in the number of lethal overdoses in the vicinity of the service . Other benefits include increases in addiction treatment attendance, and decreases in the number of people who inject drugs and unsafe injection practices . In April 2018, the Addiction Recovery and Community Health (ARCH) Team at the Royal Alexandra Hospital opened the first acute care Supervised Consumption Service (SCS) in North America. In the SCS, patients can consume substances by injection, oral or intranasal routes under nursing supervision; immediate assistance is provided if an overdose occurs. Upon opening, the SCS was accessible only to inpatients. After a quality assurance review, work began to expand SCS access to ED patients as well. Between June 13-July 15, 2019, ARCH ED Registered Nurses were asked to identify ED patients with a history of active substance use who may potentially require SCS access. Nurses identified 69 patients over 43 8-hour shifts (range 0-4 patients per shift); thus, we anticipated an average of 5 ED patients per 24-hour period to potentially require SCS access. Based on this evidence of need, ARCH leadership worked with a) hospital legal team and Health Canada to expand SCS access to ED patients; b) ED leadership to develop a procedure and flowchart for ED SCS access. ED patients were able to access the SCS effective October 1, 2019. From October 1 to December 1, 2019, the SCS had 35 visits by 23 unique ED patients. The median time spent in the SCS was 42.5 minutes (range 14.0-140.0 minutes). Methamphetamine was the most commonly used substance (19, 45.2%), followed by fentanyl (10, 23.8%); substances were all injected (91.4% into a vein and 8.6% into an existing IV). In this time period, there were zero unintentional, unwitnessed opioid poisonings in registered ED patients. Data collection is ongoing and will expand to include chief complaint, ED length of stay and discharge status. Being able to reduce unintentional overdoses and unwitnessed injection drug use in the ED has the potential to improve both patient and staff safety. Next steps include a case series designed to examine the impact of SCS access on emergency care, retention in treatment and uptake into addiction treatment.

References: Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: What has been demonstrated? A systematic literature review. Drug and Alcohol Dependence. 2014; 145:48-68. Marshall, B.D., Milloy, M.J., Wood, E., Montaner, J.S., Kerr, T., 2011. Reduction in overdose mortality after the opening of North America’s first medically super- vised safer injecting facility: a retrospective population-based study. Lancet 377, 1429–1437. DeBeck, K., Kerr, T., Bird, L., Zhang, R., Marsh, D., Tyndall, M., Montaner, J., Wood, E., 2011. Injection drug use cessation and use of North America’s first medically supervised safer injecting facility. Drug Alcohol Depend. 113, 172–176.

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Race-Based Differences in Self-Report Drug Use at an Urban Methadone Treatment Program

Sasha Deutsch-Link, MD – Addiction Medicine Fellow, University of Maryland

Annabelle Belcher, PhD – Assistant Professor, University of Maryland School of Medicine

Eric Wish, PhD – Director, University of Maryland, College Park

Ebonie Massey, MA – Faculty Assistance, Center for Substance Abuse Research at the University of Maryland

Aaron Greenblatt, MD – Medical Director, UMMC Opioid Treatment Program, University of Maryland School of Medicine

Background: Baltimore, Maryland has been at the center of an opioid epidemic for over 50 years. While heroin use disorder has historically disproportionately affected poorer Black communities within the city, in recent years this cultural landscape has shifted with the national opioid crisis. The city has witnessed a generalized increase in the incidence of opioid use disorder (OUD) that now spans across multiple races, ethnicities, and backgrounds [1,2]. Methadone administered through opioid treatment programs (OTP) is one of the most effective modes of treatment for OUD. Although recent national epidemiological data demonstrates that lifetime rates of substance use disorders are lower in Black people compared to Whites[3], detailed data on race differences in substance use at initial presentation to methadone OTPs is lacking. Our study seeks to explore race differences in substance use among patients presenting to a racially diverse methadone OTP in Baltimore. Methods: We conducted a single center cross-sectional study of 102 patients who presented for treatment intake. Data were obtained as part of a randomized controlled trial employing a behavioral intervention in which participants consented to partake. Data reported here were obtained prior to randomization and intervention. Patients were administered detailed substance use history questionnaires and urine drug screening at intake. Logistic and linear regressions assessed the relationship between race and substance use for binary and continuous dependent variables, respectively. Age was included as a covariate, as Black participants in our sample were older (46 compared to 42 years, p=.002). Results: 36 participants (35%) self-identified as White and 66 (65%) as Black. The groups did not significantly differ in gender, education, income, or employment status. Logistic regression results showed significantly higher age-adjusted predicted probabilities for prior substance use in White patients: synthetic cannabinoids (.25 versus .059, p=.009), lysergic acid diethylamide/LSD (.40 versus .10, p=.002), phencyclidine/PCP (.27 versus .055, p=.008), and MDMA/ecstasy (.38 versus .14, p=0.010). White participants were more likely to have been prescribed opioids (.80 versus .54, p=.015), have used prescription opioids prior to heroin/fentanyl (.28 versus .093, p=.023), and to have to have injected drugs (.88 versus .44, p<.001). They reported a higher mean total number of substances used prior to heroin/fentanyl (3.9 versus 2.6, p=.020), and at intake (8.5 versus 6.1, p=.013). Black patients were more likely to have used only two or fewer substances before trying heroin/fentanyl (.24 versus .49, p=.021). Conclusion: White patients reported using more and a broader variety of other drugs before heroin/fentanyl and at intake. They were also more likely to have ever been prescribed opioids and to have used prescription opioids prior to heroin/fentanyl. These differences, which cannot be accounted for by indicators of socioeconomic status, may reflect cultural, environmental and/or geographic differences leading to different exposures. We believe this finding is particularly important, as significant efforts and attention in the opioid crisis have focused on opioid prescribing. However, these results suggest that inner-city Black patients may develop OUD through different pathways. More research and intervention should be directed towards understanding and addressing these processes.

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Latent Classes of Youths Nicotine Use and Association with Nicotine Dependence

Carol Boyd, PhD, MSN, RN, FAAN – Director, Center for the Study of Drugs, Alcohol, Smoking & Health University of Michigan School of Nursing

Philip Veliz, PhD – Research Assistant Professor, University of Michigan School of Nursing

Rebecca Evans-Polce, PhD – Assistant Research Scientist, University of Michigan School of Nursing

Sean McCabe, PhD, MSW – Professor, University of Michigan

Introduction: Increasing numbers of adolescents living in the U.S. are vaping nicotine products; their numbers doubling between 2017 to 2019.[1] While the scientific community acknowledges this increase in adolescents’ vaping, it is unknown which adolescents who vape nicotine are developing tobacco use disorder symptoms. Using latent class analysis (LCA), we sought to examine the heterogeneity of adolescents’ nicotine/tobacco use trajectories, including vaping and other nicotine products and their possible combinations, to determine the association between each trajectory class and risk of nicotine dependence and possible differences among demographic subgroups. Methods: To meet the aforementioned aim, we used three waves of the Population Assessment of Tobacco and Health (PATH) Study[2] data from adolescents (12-17 years old at Wave 1) and conducted a secondary analysis of those adolescents who stated they used a nicotine/tobacco product in the past 30 days. The PATH Study implemented a four-stage, stratified area probability sample design. Three waves of PATH Study data produced a sample of 1,101 youth (12-17 years old) who were nicotine/tobacco users at any wave. Nicotine/tobacco use was determined by asking adolescents about past 30-day use and frequency. A five latent class solution resulted: (1) “Stable/consistent multiproduct use trajectory” (n=80), (2) “Increasing cigarette use trajectory” (n=115), (3) “Increasing e-cigarette use trajectory” (n=214), (4) “Experimental (poly-tobacco/nicotine) use trajectory” (n=373), and (5) “Increasing other nicotine/tobacco use trajectory” (n=319). Past-year nicotine/tobacco dependence was assessed with six items from the Wisconsin Inventory of Smoking Dependence Motives (WISDM-68). Results: All types of past 30-day nicotine/tobacco use increased across the three waves. The most prevalent was the “Experimental (poly-nicotine/tobacco) use trajectory” (33.3%). Those represented by the “Increasing cigarette use trajectory” reported significantly more past-year nicotine dependence symptoms compared to the “Increasing e-cigarette use trajectory”. Logistic regression analyses were conducted with sociodemographic characteristics and trajectories. Females had higher odds of being in either the “Increasing cigarette use trajectory” or the “Experimental (poly-nicotine/tobacco) use trajectory” compared to males; however, females had lower odds of being in the “Stable/consistent multiproduct use trajectory” and “Increasing other nicotine/tobacco use trajectory”. African Americans had lower odds of being in the “Increasing e-cigarette use trajectory” when compared to White respondents, while they had higher odds of being in the “Increasing other nicotine/tobacco use trajectory”. There were some socioeconomic status and regional differences as well as differences in other substance use. Conclusions: Our study differs from other research because we examined the heterogeneity of adolescents’ nicotine/tobacco use to determine latent classes associated with symptoms of nicotine dependence. With LCA, we accounted for all current nicotine/tobacco users in our analyses and thus, we were able to demonstrate that several nicotine/tobacco user trajectories had a greater risk of nicotine dependence compared to only e-cigarette users. We found that adolescent nicotine/tobacco users are a heterogenous group with different risks for nicotine dependence. Since nearly all nicotine/tobacco use begins in adolescence and early adulthood, understanding the different use trajectories and their relationship to nicotine dependence will help clinicians tailor their educational messages and more precisely determine appropriate secondary prevention for at-risk youth.

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One-Year Hepatic Safety with Buprenorphine Extended-Release for Moderate-to-Severe OUD

Sunita Shinde, MD – Medical Director, Global Medicines Development, Indivior, Inc.

Yue Zhao, MD – Director, Biostatistics, Indivior, Inc.

Celine Laffont, PhD – Director Quantitative Clinical Pharmacology, Modeling and Simulation, Indivior, Inc.

Barbara Haight, PharmD – Medicines Development Leader, Senior Director, Indivior Inc.

Anne Andorn, MD – Head, Late Stage Global Clinical Development, Indivior Inc.

Katharina Wiest, PhD, MSPH – Senior Scientist, Associate Director of Research, CODA, Inc.

Background: Buprenorphine extended-release (BUP-XR [RBP-6000]) is a monthly subcutaneous injectable treatment for opioid use disorder (OUD). Safety of BUP-XR was evaluated up to 12 months. Methods: Adults with moderate-to-severe OUD enrolled in a Phase III double-blind (DB), placebo-controlled trial received 6 doses of BUP-XR 300mg (n=201), 2 doses of BUP-XR 300mg followed by 4 doses of BUP-XR 100mg (n=203), or 6 doses of placebo (n=100). 1

An open-label (OL) study enrolled 257 participants from this trial (Rollover group) and 412 participants naïve to BUP-XR (De Novo group). Both groups received an initial dose of BUP-XR 300mg plus up to 5 (Rollover) or 11 (De Novo) monthly doses of 300mg or 100mg. Hepatic disorder treatment-emergent AEs (TEAEs) and liver function tests (LFTs) were evaluated; exposure-response analyses assessed the relationship between buprenorphine plasma concentration and the probability of elevated LFTs. Results: Among participants receiving BUP-XR in the DB study and De Novo participants in the OL study, the incidence of hepatic disorder TEAEs was lower in the second 6 months compared to the first 6 months. No serious hepatic disorder TEAEs occurred. Incidences of elevated LFTs did not increase from the first 6 months to the second 6 months of treatment. Elevated LFTs were observed in participants with underlying co-existing hepatic illness or who were taking medications known to elevate liver enzymes. Only 6 of 868 (0.69%) participants discontinued due to elevated LFTs, 5 in the first 6 months and 1 in the second 6 months. No case of drug-induced liver injury was reported. Overall, exposure-response curves for LFTs were flat within the observed buprenorphine plasma concentration range. Conclusions: For participants who received monthly BUP-XR for up to 12 months, hepatic elevations did not worsen over time, and no new safety signals emerged. These data support the use of BUP-XR as a long-term treatment for OUD.

Reference: 1. Haight BR, Learned SM, Laffont CM, et al. Efficacy and safety of a monthly buprenorphine depot injection for opioid use disorder: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet. 2019;393(10173):778-790.

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An Observation of Treatment Retention and Peer Recovery Support in OUD Patients

Sara Mills Huffnagle, MS – Human Subjects Reserach Technologist IV, Pennsylvania State University College of Medicine

Sarah Kawasaki, MD – Assistant Professor/ Director of Addiction Services, Penn State Health, Pennsylvania Psychiatric Institute

Introduction: Opioid addiction continues to be a national crisis, with more than 35,000 opioid related overdose deaths taking place in the United States in 2017 (CDC, 2018). Despite available evidence-based medication assisted treatment (MAT) options, as well as MAT-adjunctive psychosocial counseling treatments, treatment retention in this population continues to be problematic (see Veilleux et al., 2010). One service that may help mitigate this problem includes the use of peer recovery support services (PRSS; Gagne et al., 2018). Methods: This observational study reviews the treatment retention rates in individuals with Opioid Use Disorder (OUD). A total of 66 subjects who started OUD treatment within our clinic between November 2017 and January 2019, and also received PRSS, were identified through medical chart reviews. Treatment retention rates were calculated and then averaged. Bivariate correlations were conducted to determine any significant relationships between the total number of PRSS appointments attended and total number of medical, individual therapy, and group therapy appointments attended. Multiple regression analyses were also conducted to determine significant predictors of length in time in treatment. Results: For the entire sample (N=66), our observational study demonstrated significant correlational trends between PRSS appointments and medical appointments attended (r = .686, p<.01), as well as PRSS appointments and individual therapy appointments attended (r = .441, p<.01), but not for group therapy appointments attended. PRSS appointments attended also significantly correlated with length of time in treatment (in months) (r =.684, p<.01). When evaluating a subset sample consisting of patients who remained in treatment for 6 months or longer (N=28), significant correlations presented between PRSS appointments and medical appointments attended (r=.578, p<.01), as well as PRSS appointments and individual therapy appointments attended (r = .484, p<.01), but not for group therapy appointments attended. PRSS appointments attended was also significant with length of time in treatment (in months) (r =.555, p<.01). Multiple regression analysis indicated that all three predictors explained 58% of the variance (R2 = .56, F(3, 62)=28.72, p<.001) for the full sample; however, further analyses for the subset sample demonstrated that only one predictor (medical appointments attended) explained 73% of the variance (R2 = .53, F(3,24)=8.99, p<.001). Conclusion: With concerning treatment retention rates in individuals with OUD during one of the largest substance use epidemics of our time, it is important to explore and understand additional methods and strategies to help mitigate this issue. PRSS may be one additional layer of support or service to help overcome poor treatment retention rates, however, the impact and benefit of PRSS is still unknown and additional study is needed.

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Reasons for Starting and Stopping Methadone, Buprenorphine, and Naltrexone Treatment

Olivia Randall-Kosich, BS, MHA – PhD Candidate, Georgia State University

Barbara Andraka-Christou, JD, PhD – Assistant Professor, University of Central Florida

Rachel Totaram, MHA – PhD Candidate, University of Central Florida

Introduction: Despite their efficacy, medications for opioid use disorder (MOUD) are underutilized in the United States. Nonetheless, few studies have explored reasons why individuals choose to start MOUD or discontinue MOUD after starting, especially extended-release naltrexone. We sought to identify reasons why individuals start and stop MOUD, including the differences between starting and stopping the three most common formulations: methadone, sublingual buprenorphine, and extended-release naltrexone. Methods: We conducted 31 semi-structured interviews over the phone with a sample of white individuals with a history of MOUD utilization. Participants were recruited using snowball sampling from eight U.S. states. Interviews were audio-recorded, transcribed, coded in Dedoose© software, and analyzed using thematic analysis and modified event structure analysis. Results: Participants primarily learned about methadone and buprenorphine from other individuals with OUD. Participants primarily became interested in starting buprenorphine and methadone after seeing the medications work effectively in peers, though methadone was perceived as a last resort. In contrast, participants primarily learned about and became interested in naltrexone after receiving information from health practitioners. Participants frequently stopped MOUD to prevent medication or health service dependence. Participants also felt stigma and external pressure to stop buprenorphine and methadone but not naltrexone. Some participants identified relapse and medication termination by health providers or the criminal justice system as reasons for stopping MOUD. Conclusions: Given the frequency with which participants identified informal peer education as a reason for starting methadone and buprenorphine, peers with MOUD experience may be a trusted source of information for individuals seeking OUD treatment. Further research is needed to assess whether incorporating peer support specialists with MOUD experience into formal SUD treatment would expand MOUD utilization, retain patients in treatment, and/or improve OUD treatment outcomes.

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Is Homelessness or Housing Insecurity a Barrier to Effective Addiction Treatment?

Darcie Moeller, MD – Resident Physician, Cook County Health

Juleigh Nowinski-Konchak, MD MPH – Attending Physician-Behavioral Health; Physician lead-MAT Collaborative, Cook County Health

Sarah Elder, LCSW, CADC – Manager, Behavioral Health, Cook County Health

Keiki Hinami, MD MS – Staff Physician, Cook County Health

Introduction: Studies have shown that homeless people frequently have unmet medical needs and difficulty accessing medical care. These individuals often have significant competing needs that can take precedence over medical care, such as food, shelter, and safety (Gelberg et al., 1997). It is well documented that homeless individuals have a higher prevalence of substance use disorders as compared to the general population (Baggett et al., 2010; Hwang et al., 2010). It seems logical that the same barriers homeless individuals face in accessing medical care would affect their ability to engage in treatment for substance use disorders. In this study, we investigate whether patients with homelessness or housing instability have reduced success with opioid use disorder (OUD) treatment compared to people with stable housing. Methods: This is a retrospective study examining the relationship of housing status to treatment retention and outcomes in patients engaged in Cook County Health’s (CCH) evidence-based OUD treatment program. 830 patients were initiated in OUD care at CCH from April 2018 to April 2019. Chart review was used to collect data on initiation date, date(s) of followup appointments, housing security, demographics, and illicit opioid use in the month preceding each visit. We assessed retention in care using continuous days of prescribed buprenorphine (allowing 30 gap days), and performed comparisons across housing categories using the Chi2 test. Success in treatment was assessed using self-reported heroin use in the previous 30 days (>10 days, 4-10 days, 1-3 days, 0 days) among 216 (26%) patients who completed at least one OUD care follow-up assessment. Results: Among our high-risk population of patients, recruited across the jail-based and community-based settings serviced by CCH, we assessed 4 levels of 30-day housing status: in unstable housing or street homeless (homeless, 13%), stably housed but worried about losing housing (housing insecure, 66%), staying in a residential treatment center or therapeutic community (residential treatment, 13%), or not housing insecure (8%). Our sample was 59% male, 59% Black, and 9% Latinx. 92% of our sample were between the ages of 25 and 64. The proportion of patients reporting ">10 days of heroin use in the previous month" decreased across intake (at day 0), progress assessment 1 (at median days (IQR), 64 (39, 130)), and progress assessment 2 (at median days (IQR), 126 (84,196)) regardless of housing status (homeless, 80%, 0%, 0%; housing insecure, 67%, 18%, 18%; residential treatment, 49%, 0%, 0%; not housing insecure, 44%, 7%, 0%). Retention in treatment at 30 days was comparable between housing status groups (homeless 68%, housing insecure 65%, residential treatment 74%, not housing insecure 63%, p=0.40) However, at 60 days, housing status was negatively associated with retention in treatment (homeless 47%, housing insecure 51%, residential treatment 69%, not housing insecure 54%, p=0.02). Conclusions: Our analysis suggests that housing insecurity and homelessness are possible barriers to early retention in opioid recovery treatment, but not to success in treatment. Efforts to remove barriers to access and early engagement in treatment may mitigate some of the outcomes disparity associated with homelessness.

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Urine Opioid Screen Results Were Not Associated With Engagement in Buprenorphine Treatment

Sanjana Kareti – House staff, John H Stroger Jr. Hospital of Cook County

Juleigh Nowinski-Konchak, MD MPH – Attending Physician-Behavioral Health; Physician lead-MAT Collaborative, Cook County Health

Saad Alvi, MD – Attending Physician, John Stroger Jr. Hospital of Cook County

Keiki Hinami, MD MS – Staff Physician, Cook County Health

Urine Opioid Screen Results Were Not Associated With Engagement in Buprenorphine Treatment Background Return to substance use, whether brief or sustained, is not uncommon among individuals engaged in opioid use disorder treatment, with studies demonstrating recurrence of use even 6-12 years after observed abstinence. Modern recovery-oriented care models, informed by theories of behavior change, focus on risk reduction and improvement of overall health throughout an individual’s recovery journey. Urine toxicology results are less informative in these contexts unless abstinence is achieved. Optimizing the role of urine toxicology testing to support a functional, behavior change care model remains a challenge to many practitioners and health care systems. To inform our own health system’s evolution towards emphasizing functional outcomes, we estimated the time-dependent rates of opioid positive urine toxicology tests in an urban safety-net population engaged in buprenorphine treatment primarily for heroin use disorder. We then assessed whether or not opioid positive screens were associated with continued proximate engagement in treatment, defined as filled buprenorphine prescriptions in the subsequent 30 day interval. Methods We conducted a retrospective cohort study of patients variably engaged in our primary care based opioid recovery program at Cook County Health, a public healthcare system serving over 300,000 patients residing in the community or institutionalized in Cook County Jail. We included 736 patients recruited from jail, ED, hospital, or clinic who commenced care between April 2018 and April 2019, and had ≥1 urine screen resulted. The proportion of patients testing positive for opioids on urine toxicology screen at 30 day intervals was calculated. We performed Chi-2 tests to assess whether ≥1 opioid positive urine screen during each 30 day interval was associated with retention in treatment during the subsequent 30 day interval. Results The majority of participants (63%) were ≥45 years of age. The majority were either Non-Hispanic Black (59%) or Latinx (9%). Fifty-eight percent were men. The median (IQR) number of urine toxicology tests per patient was 5 (2, 9). Opioid-positive tests were detected in a median (IQR) of 1 (0, 2) test per patient, or an average of 36% of all screens. We observed a reduction in patients with opioid positive screens from 39% in the first 30 days to 28% in the second 30 days. For each subsequent 30 day interval, opioids were consistently detected in 21%-31% of patients engaged in treatment for the first year. Positive urine opioid screens during each month were not significantly associated with retention in treatment for each subsequent interval. Conclusion In a population of diverse patients engaged in primary care-based buprenorphine treatment and recovery support for opioid use disorder, approximately a quarter to third of patients undergoing urine toxicology screens tested positive for opioids during the first year. Our findings indicate that urine screen results are limited in their ability to inform a functional health care model. Complementary measures such as patient reported outcomes of physical, mental, and social health, may help inform care in a functional health model.

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Assessing Cognitive Behavioral Therapy for Insomnia in Cannabis Use Disorder Patients

Luna Geagea, MD – Research Fellow, American University of Beirut

Farid Talih, MD – Associate Professor of clinical specialty, American University of Beirut

Firas Kobeissy, PhD – Associate Professor, American University of Beirut

Martine Elbejjani, PhD – Assistant Professor, American University of Beirut

Background: Sleep disturbances are commonly associated with cannabis use. There exists a bidirectional relationship between substance use and sleep disorders with sleep disorders promoting more substance use and with chronic substance use leading to more sleep problems [1]. Furthermore, studies have shown an association between insomnia and a decline in natural immunity with cytokines influencing sleep quality, and inflammatory cytokines having a combination of sleep- inducing and sleep-inhibiting effects [2]. In addition, insomnia severity has also been found to be directly proportional to the levels of cortisol and C-reactive protein (CRP) elevation [3]. In terms of polysomnographic findings, certain sleep characteristics seem to appear with cannabis use disorder patients such as decreased sleep time, increased sleep latency and deficiency in slow-wave sleep generation, whereas REM sleep tends to be influenced more by the quantity and frequency of cannabis use [4]. Cognitive Behavioral Therapy for Insomnia (CBTI) has demonstrated comparable efficacy with a longer maintenance duration after treatment discontinuation in randomized controlled trials of direct comparisons with sleep medication in patients with chronic insomnia [5]. Aims: Our main goal is to implement cognitive behavioral therapy (CBTI) in cannabis use disorder patients and to analyze the effects of CBTI on insomnia remission. We also aim to use biomarkers to quantify the severity of insomnia before and after implementing CBTI. This is done by examining the levels of Interleukin-2 (IL-2), Interleukin-6 (IL-6), cortisol and CRP before and after CBTI. The ultimate aim of this study is to recognize, measure and target insomnia particularly among chronic cannabis users seeking treatment. Methods: We recruited 16 participants who have cannabis use disorder with concomitant insomnia at the American University of Beirut Medical Center. Participants completed the Insomnia Severity Index (ISI) questionnaire, as well as a screener for depression and anxiety the Patient Health Questionnaire-4 (PHQ-4) before/after CBTI. Additionally, participants were provided an actigraphy device to wear 1week prior and 1week post CBTI. Blood samples were taken before/after CBTI (CRP, Cortisol, IL-2, IL-6). Participants received 4 CBTI sessions over two weeks. 11 participants completed 3-month follow-up over the phone. Statistical significance was determined by Paired-Samples T test. Results: Preliminary results showed a significant decrease in insomnia (ISI) among participants. PHQ-4 scores showed a significant decrease in depression/anxiety symptoms. Actigraphy data showed significant decrease in sleep onset latency (falling asleep faster). Other sleep parameters and biomarker levels have not shown a significant change. 3-MONTH FOLLOW-UP showed a long-term improvement in insomnia and depression /anxiety symptoms. Conclusion: This pilot study showed that CBTI is efficient in reducing insomnia severity, depression and anxiety symptoms, as well as, sleep onset latency among cannabis use disorder patients. The findings of this study will help in developing further avenues of research relating to sleep, substance abuse and treatment options.

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Sensory Experiences and Cues among Electronic Cigarette Users

Jennifer DiPiazza, PhD – Assistant Professor, Hunter Bellevue School of Nursing

Pasquale Caponnetto, PhD – Professor, University of Catania

Paul J. Christos, DrPH, MS – Director of the Research Design and Biostatistics Core, Weill Cornell Medical College

Gulce Askin, MPH – Research Biostatistician, Weill Cornell Medical College

Marilena Maglia, PhD – Researcher, University of Catania

Riccardo Polosa, MD, PhD – Director, University of Catania

Background: Tobacco use causes an estimated six million deaths annually, worldwide. Relapse rates among treated smokers are estimated as high as 50% one year post quit. US FDA approved smoking cessation medications are not specially designed to address sensory experiences that influence smoking behavior. Yet, research demonstrating the effectiveness of pairing nicotine replacement and sensory reinforcers to improve cessation outcomes dates as far back as the seminal work of Cain and then Rose and colleagues who hypothesized the “airway sensory hypothesis.” This suggests the potential of sensory stimulating interventions such as an electronic cigarette, to serve as an important component of a cigarette smoking cessation intervention. Safety profiles of e-cigarettes are being evaluated and recently there are concerns about health outcomes associated with e-cigarette use. Nonetheless, e-cigarette use is on the rise and currently the only intervention available to study the influence of sensory experiences and cues paired with and without nicotine replacement on cessation outcomes. This research could provide insights into ways to improve the design of current cessation interventions. Aims: We characterized the extent and quality of respiratory sensations and sensory related smoking cues associated with e-cigarette use among those who failed to quit cigarette smoking with traditional FDA approved cessation medications but succeeded in doing so with e-cigarettes. And, to understand former smokers’ perceptions about the influence of sensory experience with e-cigarette use on cigarette cessation outcomes. Methods: A nonrandom purposive sample of 156 participants recruited in the U.S. through the Consumer Advocates for Smoke Free Alternatives Association Facebook page completed an online cross-sectional survey to assess sensory experiences and smoking cues associated with e-cigarette use. Descriptive statistics, and the ANOVA/Kruskal-Wallis test with post-hoc testing and the two-sample t-test/Wilcoxon rank-sum test, as appropriate based on distribution, were used to assess the association between sample characteristics and sensory experiences and cues using investigator constructed questions, the Modified Cigarette Evaluation Questionnaire (mCEQ) and the Smoking Cue Appeal Survey (SCAS). Results Participants reported feeling the vapor in their throats, windpipes, noses, lungs, and on their tongues; reductions in nicotine craving; and enjoyment of their e-cigarette, including tasting, smelling, and seeing the vapor and touching the device. Women had greater craving reduction than men (p=0.023). Those who began smoking at 13 years of age or younger had more smoking satisfaction and had greater sensory enjoyment than those who began smoking at 16-17 years of age (p=0.015 and p=0.026, respectively), as well as greater sensory enjoyment than those who began smoking at 14-15 years of age (p=0.047). There was a significant overall association between the number of years a respondent smoked and e-cigarette sensory enjoyment (p=0.038). Participants 18-34 years old rated e-cigarettes as being more pleasant compared to 45+ year olds, (p=0.012). Eighty four percent of participants reported the sensation of the vapor as important, and 91% believed the sensations accompanying e-cigarette use contributed to their smoking cessation success. Conclusions: For those who failed to quit cigarettes using approved cessation medications, sensory experiences associated with e-cigarette use may help smokers quit smoking.

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