BACKGROUND AND AIMS
Patient navigation (PN) may benefit pregnant individuals with opioid use disorder (OUD) by improving treatment adherence. We examined participant enrollment, session delivery and assessment feasibility for a PN intervention among pregnant participants and compared PN preliminary effectiveness for OUD treatment engagement with participants in usual care (UC).


DESIGN
This study was a pilot single-blinded multi-site randomized trial.


SETTING
Two academic medical centers in Pennsylvania (n = 57) and Utah (n = 45), United States participated.


PARTICIPANTS
One hundred and two pregnant adult participants unestablished (fewer than 6 weeks) on medication for OUD (MOUD) were randomized to PN (n = 53) or UC (n = 49).


INTERVENTION
PN was composed of 10 prenatal sessions (delivered after baseline but before the prenatal assessments) and four postnatal sessions (delivered before the 2- and 6-month postpartum assessments) focused upon OUD treatment and physical/mental health needs. UC involved brief case management.


MEASUREMENTS
Feasibility assessments included consent, session delivery and assessment rates. Mixed-effect models for intent-to-treat (ITT) and per protocol (PP, received six or more sessions) populations were estimated to compare outcomes of MOUD use, secondary outcomes of substance use disorder (SUD) treatment attendance and non-prescribed opioid use, and exploratory outcome of overdose at baseline, predelivery and 2 and 6 months postpartum.


FINDINGS
We consented 87% (106 of 122) of the proposed target, delivered ~60% of sessions delivered and completed ≥ 75% assessments. PN ITT and PP had better MOUD adherence, SUD treatment attendance, non-prescribed opioid use and overdose outcomes than UC. Notable changes included good evidence for greater percentage change in days for PN PP MOUD use from baseline to 2 months postpartum [PN = 28.0 versus UC = -10.9, 95% confidence interval (CI) = 9.7, 62.1] and some evidence for baseline to 6 months postpartum (PN = 45.4 versus UC = 23.4, 95% CI = -0.7, 48.2). PN PP percentage change in days for SUD treatment attendance also showed good evidence for improvements from baseline to prenatal assessment (PN = 7.4 versus UC = -21.3, 95% CI = 3.3, 53.5). PN compared to UC participants reported fewer overdoses at 2 months (PN = 11.9%/UC = 16.1%) and at 6 months postpartum (PN = 3.8%/UC = 6.2%).


CONCLUSIONS
Patient navigation appears to be associated with improvements in opioid use disorder treatment engagement and overdoses during pregnancy. This pilot trial shows the feasibility of the intervention and a future large-scale trial.

Patient navigation for pregnant individuals with opioid use disorder: Results of a randomized multi-site pilot trial.

Buprenorphine is a highly effective treatment for opioid use disorder (OUD). However, provider observations and preliminary research suggest that the current standard maintenance dose may be insufficient for suppressing withdrawal and preventing cravings among people who use or have used fentanyl. Buprenorphine dosing guidelines were based on studies among people who use heroin and have not been formally re-evaluated since fentanyl became predominant in the unregulated drug supply. We aim to compare the effectiveness of a high (24 mg) vs standard (16 mg) maintenance daily dose of buprenorphine for improving retention in treatment, decreasing the use of non-prescribed opioids, preventing cravings and reducing opioid overdose risk in patients. 

Randomised clinical trial of a 16 mg vs 24 mg maintenance daily dose of buprenorphine to increase retention in treatment among people with an opioid use disorder in Rhode Island: study protocol paper

OBJECTIVES
Buprenorphine, a medication for opioid use disorder (OUD), is underutilized in general medical settings. Further, it is inequitably received by racialized groups and persons with comorbidities. The Veterans Health Administration launched an initiative to increase buprenorphine receipt in primary care. The project's objective was to identify patient-related factors associated with buprenorphine receipt and retention in primary care clinics (n = 18) participating in the initiative.


METHODS
Retrospective cohort quality improvement evaluation of patients 18 years or older with 2 or more primary care visits in a 1-year period and an OUD diagnosis in the year before the first primary care visit (index date). Buprenorphine receipt was the proportion of patients with OUD who received 1 or more buprenorphine prescriptions from primary care providers during the post-index year and retention the proportion who received buprenorphine for 180 days or longer.


RESULTS
Of 2880 patients with OUD seen in primary care, 11.7% (95% confidence interval [CI], 10.6%-12.9%) received buprenorphine in primary care, 58.2% (95% CI, 52.8%-63.3%) of whom were retained on buprenorphine for 180 days or longer. Patients with alcohol use disorder (adjusted odds ratio [AOR], 0.39; 95% CI, 0.27-0.57), nonopioid drug use disorder (AOR, 0.64; 95% CI, 0.45-0.93), and serious mental illness (AOR, 0.60; 95% CI, 0.37-0.97) had lower buprenorphine receipt. Those with an anxiety disorder had higher buprenorphine receipt (AOR, 1.42; 95% CI, 1.04-1.95). Buprenorphine receipt (AOR, 0.55; 95% CI, 0.35-0.87) and 180-day retention (AOR, 0.40; 95% CI, 0.19-0.84) were less likely among non-Hispanic Black patients.


CONCLUSIONS
Further integration of addiction services in primary care may be needed to enhance buprenorphine receipt for patients with comorbid substance use disorders, and interventions are needed to address disparities in receipt and retention among non-Hispanic Black patients.

Buprenorphine Receipt and Retention for Opioid Use Disorder following an Initiative to Increase Access in Primary Care.

Objective Although primary care settings have benefits for implementing office-based opioid treatment (OBOT) programs with buprenorphine, few studies have examined the impact on patient retention beyond 12 months. The objective of this study is to assess long-term outcomes of buprenorphine treatment for opioid use disorder (OUD) integrated into comprehensive primary care treatment at a family medicine practice. Methods A retrospective chart review of patients diagnosed with OUD who received treatment with buprenorphine between December 2006 and January 2018 was conducted at private family medicine practice in semirural Upstate New York. Patients were seen continuously by the same provider. The primary outcome was retention in OBOT at 3 years. Results The primary outcome was met by 47.4% of included patients (N = 152). Mean retention in care for all patients was 24.3 months. More than three quarters of patients (77%) had a least one psychiatric comorbidity managed by the practice, most commonly depression (59.9%). Self-reported history of intravenous drug use at baseline was associated with a higher likelihood of patient dropout at year 1 (odds ratio, 2.99; 95% confidence interval, 1.39–6.44; P = 0.004) and year 2 (odds ratio, 2.46; 95% confidence interval, 1.15–5.28; P = 0.019), with no difference observed at year 3. Conclusions Office-based opioid treatment with buprenorphine in a family medicine practice setting resulted in high retention rates, emphasizing the importance of continuity of care and integration of primary care within the OUD treatment model. Further research is needed on barriers to implementation of OBOT among family medicine providers.

Three-year Retention Rates With Office-based Treatment of Buprenorphine for Opioid Use Disorder in a Private Family Medicine Practice

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Three-year Retention Rates With Office-based Treatment of Buprenorphine for Opioid Use Disorder in a Private Family Medicine Practice