Methadone is the foremost, long-standing pharmacological treatment for opioid addiction. It has been shown to have considerable cost benefit to the community and to decrease mortality. Despite methadone's decades-long use, much is still unknown regarding its clinical pharmacology, particularly during the induction phase of Methadone Maintenance Treatment (MMT). Contrary to previous reports, I found systemic methadone clearance does not increase significantly between induction and steady state phases of MMT, and did not approach the previously reported 3-fold increase. Clinical dose prescription based on the premise of metabolism auto-induction could increase risk of respiratory depression. Significant differences between R- and S-methadone pharmacokinetics showed the importance of stereoselective measurement in a clinical situation and significant plasma concentration-effect relationships demonstrated their potential influence on induction pharmacodynamics. Small increases in CYP3A4 activity as measured by the Erythromycin Breath Test from Day 1 to Day 40 of MMT were not correlated with changes in methadone clearance. CYP3A4 activities were informative but would be insufficient for use as a sole predictor of methadone clearance during MMT. Clinically significant respiratory depression occurred in 20% of subjects, at times of peak plasma R-methadone concentrations, after reports of withdrawal symptoms at pre-dose sampling times, and irrespective of illicit opioid use. Utilisation of both respiratory rate and blood oxygen saturation measurements provided a good indication of respiratory risk for individuals. Although prior opioid use was a strong predictor of continued use during MMT, adoption of a new equation ("abc") and comprehensive documentation of each individual's MMT may increase prediction of MMT success. Even in light of recent advances in opioid substitution therapies, MMT's advantages ensure it is still at the forefront of addiction treatment. Careful choice of methodology enabled narrowing of this investigation to those factors most relevant in methadone pharmacology and most responsible for MMT success or failure, and therefore extending previous knowledge of this area. Such data might be utilised to develop a clinically applicable model for MMT, and help provide clients with a safe and uncomplicated transition from heroin use to methadone induction in the future. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1269301 / Thesis (Ph.D.) -- School of Medical Sciences, 2007

The current opioid epidemic is devastating our communities. The American Medical Association’s Task Force on opioid addiction has identified stigma as a primary target of intervention for mitigating this epidemic. Stigma is a mark of disgrace or being objectionable. Experiences of stigma and resulting shame serve only to fuel health inequities experienced by people with opioid addiction. Emergency Medical Services (EMS) have an important role to play in mitigating this epidemic as entry-level providers in the healthcare system. The quality of that patient-provider encounter had the potential to shift intrinsic motivation to seek and maintain addiction treatment. Patient-centered care is identified as supporting therapeutic communication and is well-suited for rural EMS operations in Maine. The purpose of this research was to examine predictors of intention to provide patient-centered care to people experiencing opioid addiction and overdose (OAO) among EMS providers in the state of Maine. A cross-sectional online survey of currently licensed EMS providers offered a direct measure of intention to give patient-centered care to people experiencing OAO. Multiple regression analysis identified four predictor variables for intention: job satisfaction, exploring patient perspective, sharing information and power, and dealing with communicative challenges. The fitted model resulted in a significant R2 = .529, (F (4, 734) = 226.381, p < .001) exceeding the critical F statistic (F (4,739) = 2.384, p = .05), thus confirming the predictive value of the coefficients. Results suggested that EMS providers at all license levels will benefit from interventions that expand their knowledge of the medical definition of addiction and patient-centered care. EMS providers will also benefit from adopting approaches that support exploring the patient perspective and sharing information and power such as Motivational Interviewing and human performance strategies to develop awareness of socially conditioned biases that moderate provider attitudes. These evidence-based interventions could elevate the standard of care provided by EMS and reduce experiences of stigma in the patient-provider encounter. Reductions in stigma increase self-worth and prime motivation to seek and maintain treatment, thereby closing the treatment gap that exists for those experiencing opioid addiction in the state of Maine.

Opioid dependence and opioid related deaths are a public health problem which the United States Centers of Disease Control have declared an epidemic. While opioid agonist therapy for opioid addiction has been accepted as the most effective treatment for opioid dependence among academics, and office based buprenorphine treatment has been available in the Unites States for over 10 years, OB buprenorphine faces many barriers to widespread adoption. Empirical data on the geographic distribution of physicians able to prescribe buprenorphine and the prescribing patterns of those physicians show considerable unevenness in access and utilization of treatment services. Federal-level policies have recently been implemented to expand access to opioid agonist therapy, but the medium and long term impacts of these policy changes on individual outcomes, public health, and geographic access equity are not yet clear. This dissertation compares two recent federal level policies on expanding access to buprenorphine treatment: raising the regulatory limit on the number of patients a provider can treat (implemented July, 2016), and extending prescribing privileges to nurse practitioners and physician assistants (implemented February, 2017), using an empirically supported Agent Based Simulation model. Policies are assessed by a novel, at-a-glance, quantitative access equity metric: the Spatial Potential Access Gini Index, in addition to year-end treatment utilization, opioid overdose deaths, and the amount of illicit medication diversion. In the simulation, expanding access by increasing the patient limit did not result in more equitable spatial access, while extending prescribing to NPs and PAs increased both utilization and spatial access equity. This is likely due to empirically supported model assumptions that NPs and PAs providing primary care often serve in medically underserved areas including rural and remote regions. Extending prescribing to these practitioners opens up new treatment locations changing the spatial distribution of treatment opportunities. Changing patient limits does not change the overall spatial distribution of services, so spatial access equity does not change even if overall treatment supply gets better or worse. The primary contribution of this work is the Spatial Potential Access Lorenz Curve and the Spatial Potential Access Gini Index, measures that aggregate individual-level Spatial Potential Access Scores commonly used in health care geography to map and identify areas of access disparity within a region. The equitability of Spatial Potential Access is calculated by using the Lorenz Curve, which is commonly used to characterize the distribution of wealth or income in a society, from which a Gini Index is calculated. The Spatial Potential Access Gini Index allows for direct comparison of complex quantitative information about the geographic distribution of supply and demand in a region with other regions, or in response to policies that impact supply or demand within the region. The measure has potential applications in simulation studies on the spatial allocation of services, allowing equity assessment of policy alternatives, as well as in empirical work, allowing equity comparisons of different regions, or in hybrid studies in which policy experiments are conducted on data-rich maps.

No description available.

The United States (U.S.) is in the midst of an opioid overdose epidemic. In the U.S., overdose deaths related to opioid exposure are the leading cause of accidental death, yet life-saving treatments, such as methadone or buprenorphine (opioid agonist therapy [OAT]), are underused. OAT underused is due, in part, to complex regulatory and health services delivery environments. Public health officials and policymakers have focused on expanding OAT access in the community (e.g. office-based buprenorphine treatment, and opioid treatment programs); however, an often-overlooked component of the treatment pathway is the acute care delivery setting, in particular hospitals. Opioid use disorder (OUD)-related hospitalizations are increasing, and incurring significant costs; care delivered in this setting is likely sub-optimal. This study examined hospital-based services for OUD using a conceptual framework based on an interdisciplinary review of policy, organizational behavior, systems science, economics, and health services delivery scholarship. The study's primary research question was: How do supply-side attributes influence hospital OAT delivery, health outcomes, and health services utilization for persons hospitalized with OUD? Supply-side attributes refer to the contextual elements inside and outside of a hospital that may be associated with hospital OAT delivery performance, such as social structures (e.g., hospital standards of care, societal values) and resources and technologies (e.g., hospital staffing, federal treatment policies). A mixed methods study described, explored, and identified how patients with OUD are cared for in the hospital and the barriers and facilitators to delivering OAT during hospitalization. The sequential mixed methods approach (i.e., qualitative followed by quantitative analyses) included analysis of 17 key informant interviews with addiction medicine physicians from 16 non-federal U.S. hospitals, 25 hospital guidance documents from 10 non-federal U.S. hospitals, and administrative data from 12,407 OUD-related hospital admissions from the Veterans Health Administration (VHA) health system. The findings from the study's three aims and 16 research sub-questions were integrated to reach seven conclusions: 1) OAT is underused in the hospital; 2) OAT delivery varies within and across hospitals; 3) OAT is used ineffectively; 4) non-OAT modalities are inappropriately used during and after hospitalization; 5) supply-side attributes inside and outside the hospital facilitate and impede hospital OAT delivery; 6) demand-side attributes facilitate and impede hospital OAT delivery; and 7) the hospital is an important service delivery mechanism in the OUD care continuum. The study's findings could be extrapolated to improve policy and practice by implementing education and health service delivery interventions through regulatory and allocative policy mechanisms focused on physicians, medical trainees, and hospital and health system administrators. Understanding how OAT delivery may be improved within the acute care delivery system is an important element to support efforts to curb the ongoing drug poisoning crisis.

The dissertation is intended to guide the selection and implementation of health department-led interventions with a long-term goal of reducing opioid overdose deaths. This dissertation is comprised of three aims. First, a narrative review describes models of buprenorphine treatment, summarizes retention in buprenorphine treatment, and includes descriptions of how each study defined and measured retention in treatment to aid cross-study comparisons. Trends in buprenorphine retention, as well as heterogeneity in trends, are described, and sub-analyses examine the role clinician experience in inducting patients on buprenorphine treatment may play in promoting retention. Lastly, the effect of a specific intervention—academic detailing—aimed at reducing the prescribing of opioid analgesics is measured using methods aimed at isolating the impact of a policy intervention that occurred at the same time as the detailing campaign. Overall, this dissertation finds a lack of consistency in how retention in buprenorphine treatment is measured, which precludes easy identification of the most effective models and interventions for retention in buprenorphine treatment. Additionally, significant variation in buprenorphine treatment retention and trends in buprenorphine treatment was observed, suggesting opportunities for improvement. From 2015 to 2019, retention in buprenorphine increased among New York City residents; however, in 2019, the predicted prevalence of retention for three months was 52.7% and 34.6% for six months, below rates observed in other studies. Lastly, this dissertation should prompt public health officials to reconsider using academic detailing campaigns to decrease opioid analgesic prescribing, given that decreases in prescribing practices were only observed following one detailing campaign, which coincided with a policy change, and did not occur following another campaign, which took place two years after the policy change.