COBRE Supplement
Buprenorphine is an evidence-based pharmacological approach to treating opioid use disorder (OUD). Despite its efficacy, buprenorphine is significantly underutilized, in part, because of historically rigid requirements for treatment entry and continuation. To address this concern, there have been recent calls to establish “low threshold” care to remove barriers to treatment and improve overall access. The COVID-19 pandemic has placed an unprecedented strain on the U.S. population and healthcare system. Social distancing measures are now in place to mitigate the risk of viral transmission. While these public health policies may protect against contracting COVID-19, they also have the potential to disrupt treatment for substance use disorders, particularly OUD, which relies heavily on face-to-face healthcare delivery. In response to such concerns, new guidelines have been released to encourage greater flexibility in the prescribing of buprenorphine. These changes have the potential to increase access to and success with buprenorphine treatment for individuals with OUD, however, it remains unknown how systematic changes related to COVID-19 may affect the practice of buprenorphine prescribing, treatment utilization, or impact on patient outcomes. The objective of the present study is to examine, through a mixed-method approach, the preliminary association of the COVID-19 pandemic with the provision of buprenorphine treatment and patient-level outcomes across three outpatient buprenorphine clinics affiliated with the largest hospital system in the state of Rhode Island. Through this Notice of Special Interest (NOSI), the proposed study will capture and characterize time-sensitive changes that are occurring to buprenorphine treatment as a result of COVID-19. Information obtained through this study will identify key factors that may influence implementation of a low threshold approach following the COVID-19 pandemic. Additionally, this proposal seeks to empirically evaluate a) changes to buprenorphine prescribing practices and treatment, and b) how changes to the delivery of care impact patient-level outcomes. Results of this study may be leveraged to inform best-practice guidelines for buprenorphine prescribing to ensure safety and efficacy of OUD treatment. The aims outlined within this application align with the overall objectives of COBRE on Opioids and Overdose to address the opioid crisis by mentoring junior investigators so that they may transition into independent clinical researchers focused on the development and evaluation of evidence-based treatment for OUD.
COBRE Pilot Project – Evaluation of Low Threshold Buprenorphine Treatment in the Context of COVID-19
The prevalence of opioid use disorder (OUD) has reached epidemic rates in the United States, and opioid-involved overdoses are the country’s leading cause of injury deaths. The natural history of OUD typically involves illegal behaviors which almost always lead to criminal justice involvement. Due to lack of tolerance, release from incarceration is associated with very high rates of drug-related death, with the greatest risk occurring within the first several weeks after reentry into the community. Although there is a high concentration of individuals with opioid use disorder in the criminal justice system, evidence-based substance use treatments are rarely employed in this setting. Medications for Opioid Use Disorder (MOUD), which involves the use of pharmacotherapy in combination with psychosocial support, is an evidence-based approach to treat OUD and reduce overdose risk. A growing body of work suggests that there are extensive benefits to providing MOUD in the correctional setting; yet, despite these advantages, access to treatment has been scarce for this high-risk and vulnerable segment of the population. The state of Rhode Island recently implemented a comprehensive MOUD program to be delivered at the unified jail and prison system. This program offers a unique opportunity to initiate treatment for OUD during incarceration with linkage to care after release. While this work is promising, individuals with criminal justice involvement face a number of challenges while transitioning back to the community, including poor social and family support, financial insecurity, and inadequate housing. This context is characterized by frequent exposure to drug cues and an increased occurrence of stressful life events; both of which are potential precipitants of relapse. Distress tolerance (DT), defined as the perceived or actual ability to handle aversive physical or emotional states, is a transdiagnostic vulnerability factor implicated in the development and maintenance of substance use. Targeting DT during substance use treatment may improve outcomes by promoting the ability to persist in goal directed activity (e.g., abstinence) even when experiencing physical or emotional distress. Personalized feedback interventions (PFI) represent a promising method to effectively motivate engagement in and adherence to MOUD. These interventions are generally brief, individually tailored, and have the potential to be delivered via mobile platforms (e.g., text message). The proposed study seeks to develop and pilot test a combined in-person (delivered by clinician in the two weeks prior to release) and text message-delivered PFI (administered by mobile phone during the initial three months following release), that incorporates DT skills training, for persons engaged in MOUD who are preparing for community reentry (PFI-DT). PFI-DT is designed to: (1) enhance motivation for continued engagement in MOUD; and (2) increase tolerance of distress to improve the ability to cope with stress associated with community reentry. In Phase 1 (Stage 1a), our team will develop and refine, through formative evaluation, the preliminary intervention. In Phase 2 (Stage 1b), we will conduct a pilot RCT to assess feasibility, acceptability and preliminary efficacy. Eighty patients with a history of OUD, actively engaged MOUD during incarceration, will be randomly assigned to PFI-DT or a Health Education (HE) condition using a 3:1 randomization ratio and will complete assessments during incarceration and following release (1-, 3-, and 6-month follow-ups) to evaluate linkage to community-based MOUD programs; use of alcohol and other illicit substances; adherence to MOUD and treatment retention; and prevalence of overdose risk behavior. Results of the current proposal will inform the develop of a R01 application to conduct a Stage II trial. The project seeks to address a major public health priority by improving treatment outcomes for a high-risk, vulnerable, segment of the population – individuals with criminal justice involvement. This work has the potential to reduce illicit opioid use, increase adherence/retention, and prevent future incidence of overdose.
