OBJECTIVES:Early discontinuation of medication for opioid use disorder (MOUD) is associated with increased mortality and hinders remission. Combining data from electronic health records (EHRs) and patient questionnaires, we examined buprenorphine discontinuation and barriers and facilitators to retention in outpatient settings. METHODS:Adults initiating buprenorphine in a Pennsylvania outpatient program (2021-2023) completed 2 questionnaires: at medication initiation (baseline) and 6 months after initiation (follow-up). Among 1189 eligible patients, we evaluated buprenorphine discontinuation (≥30-d gap in medication supply) and compared demographic factors using EHRs. We identified discontinuation reasons among survey participants (baseline n = 374; follow-up n = 197) through medical record review; questionnaires assessed treatment barriers and facilitators. RESULTS:Within 6 months, 629 (53%) patients discontinued buprenorphine, though 15% restarted medication within the 6-month period. Discontinuation was more common among younger patients. Among baseline survey participants, discontinuation was usually unplanned (66%) or against provider advice (19%). Among follow-up participants who discontinued the program during the follow-up period, 54% reported receiving MOUD at 6 months, indicating that many transition to other treatment programs. Those not receiving medication at 6 months cited lack of need (46%). Travel challenges (distance/transportation to clinics), scheduling, and mental health conditions were common barriers to treatment; facilitators centered on improving these factors and clinic processes. CONCLUSIONS:Observed patterns reflect dynamic and noncontinuous receipt of medication over time and underscore the early months of treatment as a critical window for supporting buprenorphine engagement. Findings reveal actionable areas to improve retention by reducing logistical burdens, enhancing nonjudgmental therapeutic support, and integrating mental health care.
OBJECTIVES:Addiction consult services (ACS) are an effective intervention for hospitalized patients with substance use disorders (SUD); however, their effectiveness for patients discharged from the emergency department (ED) is not well established. We aim to examine the association of ACS with 30-day engagement in outpatient treatment among ED and hospitalized patients at a multi-hospital safety-net health system. METHODS:We conducted a retrospective study of patients discharged after ED and inpatient visits with SUD-related diagnoses. The exposure of interest was receipt of ACS consultation during an ED or inpatient encounter. We used propensity score matching with frequency weights for the analyses, and the primary outcome was engagement in outpatient SUD treatment within 30 days of ED or hospital discharge. Propensity-weighted logistic regression with and without a moderation analysis examined factors associated with engagement in treatment after discharge. RESULTS:From April 1, 2024, through February 28, 2025, 4779 unique patients were discharged with a qualifying SUD diagnosis; 2783 (58.2%) after ED discharge and 1996 (41.8%) after hospital discharge, and 1279 (26.8%) received a Bridge ACS consultation. The 30-day engagement in treatment after discharge rate was 32.6% with ACS versus 9.4% without (P<0.001). ACS was independently associated with higher odds of engagement [adjusted odds ratio (aOR): 4.7, 95% CI: 3.5-6.4]. The interaction term between ACS and ED versus hospital discharge was not statistically significant (aOR: 0.9, 95% CI: 0.5-1.5). CONCLUSIONS:ACS consultation was associated with increased engagement in SUD treatment within 30 days of ED or hospital discharge.
OBJECTIVES:Healthcare Effectiveness Data and Information Set (HEDIS) measure Follow-up After Emergency Department Visit for Substance Use (FUA) assesses care coordination after discharge from an emergency department visit for a high-risk substance-use event. We hypothesized that the FUA denominator undercounts OUD-related ED visits. METHODS:We audited a multihospital public health system's electronic health record (EHR) to identify ED visits by patients with OUD to compare these with the OUD visits captured in the system's automated FUA reporting. RESULTS:From April 1, 2024, through February 28, 2025, there were 1211 emergency department (ED) unique visits related to opioid use disorder (OUD) or overdose. Only 239 (19.7%) of OUD/overdose encounters were using HEDIS methods for FUA. In multivariable logistic regression, ED visits at one of the hospitals were less likely to be included in the FUA measure (adjusted odds ratio, 0.6, 95% CI: 0.4-0.9). CONCLUSIONS:We found the FUA measure failed to identify 4 out of 5 ED visits involving high-risk opioid use disorder-related events. This suggests FUA may obscure quality performance and introduces variability into the national quality measure.
Objectives: Medically assisted withdrawal (MAW) for opioid use disorders (OUD) remains common. NIDA’s CTN-0051 (X:BOT) trial compared two OUD medications initiated during an acute inpatient MAW admission and continued postdischarge at 8 US sites. This ancillary observational follow-on study explored treatment-as-usual outcomes at 5 X:BOT sites. Methods: Adults admitted for OUD were conveniently and consecutively recruited to an 8-week, prospective, observational, noninterventional study targeting up to 300 participants. Withdrawal protocols and medications for OUD (MOUD) followed site usual practices. Baseline and postdischarge weeks 1, 4, and 8 measures were OUD severity, length-of-stay (LOS), urine samples, self-reported MOUD, nonprescribed opioid use, and overdoses. Data analyses were descriptive. Results: A total of N = 211 enrolled participants were primarily white men (74%) with daily heroin (87.2%) and intravenous (64.0%) use. About 41.7% (n = 88) reported MOUD treatment at discharge: extended-release naltrexone (n = 39), sublingual buprenorphine-naloxone (n = 38), methadone (n = 8), and oral naltrexone (n = 3). Self-reported MOUD use at week 8 was 28.0%, when 52.6% reported no regular use (<7 consecutive days) and 25.6% reported nonprescribed opioid abstinence. Negative urine rates for nonprescribed opioids ranged from 26.1% to 31.3%. One overdose death and 17 nonfatal opioid-related overdose events occurred in 15 participants. Conclusions: Return to nonprescribed opioid use, frequent overdose events, one death, and a relative lack of MOUD treatment uptake characterized this usual care cohort following inpatient OUD admissions. Scientific Significance: These findings underscore the urgent need for individuals and providers to prioritize linkage to evidence-based MOUD treatments following acute inpatient OUD-related admissions, given high rates of return to opioid use and overdose events.
OBJECTIVES:Published protocols for directly initiating injectable buprenorphine from full opioid agonists ("direct-to-inject" or DTI) have largely described patients with active or recent fentanyl use. Among patients with opioid use disorder (OUD) in remission, transitioning from methadone to buprenorphine with sublingual buprenorphine can be challenging. Published experience utilizing DTI buprenorphine from methadone is limited. METHODS:In this retrospective cohort study, we identified 15 patients across an academic hospital system who reported OUD in remission, were engaged in methadone treatment, and requested an outpatient DTI buprenorphine transition in 2025. Individuals who took ≥4 mg sublingual buprenorphine within the preceding 24 hours were excluded. All participants were offered consent and elected for DTI buprenorphine after counseling on risks, benefits, and alternatives. Primary outcome was receipt of one monthly formulation of injectable buprenorphine. Demographics, protocol completion, and 90-day retention on buprenorphine were reviewed. Patients retrospectively rated their transition-related discomfort on the following scale: no, mild, moderate, or severe discomfort. RESULTS:Mean methadone dose was 71.5 mg (range: 24-120). Median length of methadone treatment episode was 2 years (range: 2 mo-10 y). Completion of one monthly extended-release buprenorphine injection was 93%. One-third (33%) reported moderate or severe discomfort with the protocol, with symptoms responsive to anxiolytics. All participants reporting moderate-to-severe discomfort had methadone doses ≥95 mg. Ninety-day buprenorphine retention was 67%, with most unretained patients utilizing injectable buprenorphine to taper off medication for OUD. CONCLUSIONS:DTI buprenorphine with weekly injectable buprenorphine was a feasible and generally well-tolerated approach for transitioning patients from methadone to buprenorphine.
OBJECTIVES:This study aims to evaluate the association between Addiction Consult Service (ACS) involvement and initiation of medication for alcohol use disorder (MAUD), as well as postdischarge outcomes through 90 days, among adults hospitalized with alcohol-related conditions.. METHODS:We conducted a retrospective cohort study at a large academic medical center from 2018 to 2025. The exposure of interest was receipt of an ACS consultation during hospitalization. Primary outcomes were inpatient MAUD initiation, MAUD prescribed at discharge, and a 30-day composite of all-cause readmission, emergency department (ED) visit, or death. Secondary outcomes included readmissions and ED visits at 7, 30, 60, and 90 days, patient-directed discharge, and 90-day mortality. RESULTS:Among 17,242 eligible admissions, 4428 were included after propensity score matching (2214 ACS; 2214 no ACS). In the matched cohort (mean [SD] age, 47 [13] y; 72.2% male), ACS consultation was associated with a 32.8-percentage-point higher rate of inpatient MAUD initiation and a 7.4-percentage-point higher rate of MAUD prescribed at discharge compared with usual care (inpatient MAUD initiation odds ratio [OR], 10.47; 95% CI, 8.59-12.86; MAUD at discharge OR, 1.47; 95% CI, 1.27-1.69). The 30-day composite outcome occurred less often with ACS consultation, with an absolute reduction of 5.0 percentage points (OR, 0.80; 95% CI, 0.70-0.91). CONCLUSIONS:Compared with usual care, inpatient ACS involvement was associated with higher MAUD initiation and lower 30-day readmission, ED visit, or death, suggesting that ACS may be a promising approach to expanding evidence-based AUD treatment and to improving short-term outcomes.
OBJECTIVES:Persons with opioid use disorder (OUD) are at elevated risk for engaging in the nonmedical use (NMU) of gabapentin. Despite the increased risk of respiratory depression from concomitant use of gabapentin and opioids, gabapentin is often prescribed in OUD treatment settings. This study examines the relationship between gabapentin prescribing histories and the initiation, patterns, and motivations of gabapentin NMU. METHODS:Twenty-one OUD treatment centers recruited 181 adults in 23 states reporting either past 12-month gabapentin NMU (n=150) or use only as prescribed (N=31). Cross-sectional interviews assessed demographics, substance use history/patterns, and gabapentin prescribing histories. RESULTS:Most NMU participants had a prior prescription for gabapentin (72.1%), with 45.3% having a current prescription; 27.7% had no prescription history. Diversion of gabapentin was highly prevalent for obtaining (sharing/trading=50.0%; dealer/street purchase=44.0%) and distributing gabapentin (45.3% diverted to others). Those with gabapentin NMU had higher gabapentin, but not opioid, craving scores compared with those with use as prescribed (3.8 vs. 2.2, P<0.001). Both therapeutic (84.7%) and recreational motivations (74.7%) were widely endorsed and involved high average doses (2061 mg and 2394 mg, respectively). CONCLUSIONS:Pathways to initiating gabapentin NMU among individuals with OUD are varied and include health care and nonhealth care channels. High rates of both recreational and therapeutic motivations may suggest the utility of gabapentin in potentiating opioid effects and mitigating gaps in unmet health care needs. Despite risks of concomitant use, many individuals had current prescriptions for gabapentin, highlighting the importance of screening, monitoring and risk counseling when considering gabapentin prescriptions in OUD populations.
OBJECTIVES:More than 3.7 million individuals are currently under community correctional supervision (eg, probation, parole) in the United States, and approximately 46% of them use illicit substances. Although high rates of substance use and the need for high-quality treatment for this population have been acknowledged, additional research is needed to characterize treatment needs among this population, especially those residing in rural or underserved communities. METHODS:Data were drawn from the Rural Opioid Initiative, a study focused on substance use in rural communities across 10 states in the United States. Our analyses examined past 6-month substance use disorder (SUD) treatment receipt among 978 participants under community supervision in the past 6 months. RESULTS:More than 55 percent had engaged in some type of treatment for substance use in the past 6 months; among those, nearly half (46%) had enrolled in inpatient or residential treatment. The odds of receiving treatment were greater among women than men (odds ratio [OR] 1.49, 95% confidence interval [CI] [1.15-1.94]), those with health insurance coverage (OR 3.10, 95% CI: [2.24-4.31]) and those with access to transportation (OR 1.54, 95% CI: [1.08-2.20]). Treatment receipt was lower among participants who used methamphetamine/amphetamine as their primary drug of choice compared with other substances. CONCLUSIONS:Initiatives to increase SUD treatment engagement among rural people who use drugs under community correctional supervision should address gaps in insurance coverage, transportation access, and treatment modalities that target stimulant use disorders. Gender-specific needs should also be considered when creating substance use interventions for this population.
OBJECTIVES:To examine the extent to which heat-related causes of death are recorded in fatal drug overdoses, how these patterns vary across states and over time, and how overdose characteristics differ between deaths with, versus without, heat involvement recorded. METHODS:Death certificate data (from the National Center for Health Statistics) for all drug overdose deaths in US residents, 2001-2024, were analyzed to identify whether a heat-related cause of death was also listed on the death certificate. Joinpoint regression, descriptive statistics, and nonparametric tests were used to examine temporal trends and compare overdose deaths with versus without recorded heat involvement. RESULTS:In 2001, fewer than 10 drug overdose deaths with recorded heat involvement were identified, but this number rose to 558 in 2024. Mortality rates for overdoses with recorded heat involvement increased from 2013 to 2024 with an estimated annual percent change of 30.1 (95% confidence interval, 26.5-47.1); the highest mortality rates and numbers of deaths were observed in residents of Arizona and Nevada. American Indian/Alaska Native, Mexican-heritage, and foreign-born populations accounted for larger shares of overdose deaths with, compared with without, heat involvement recorded. A street or highway was more frequently identified as the place of injury in overdose deaths with (18.9%), versus without (2.2%) heat involvement reported. Psychostimulants such as methamphetamine were involved in 85.9% of overdose deaths with, versus 28.9% without, recorded heat involvement. CONCLUSIONS:Although representing only a fraction of all overdose deaths, fatal overdoses with recorded heat involvement have increased, disproportionately impacting certain states and demographic groups.
OBJECTIVES:To describe HPTN 094 study's peer navigation (PN) intervention, implemented in 5 urban US cities among people who inject drugs (PWID) at risk for or living with HIV, including guiding theories, core components, navigator training, available services, implementation challenges, and implications for future PN intervention research dissemination. METHODS:This 2-arm, randomized, open-label study assessed outcomes for PWID receiving integrated care services delivered in a mobile health unit that provided medication for opioid use disorder (MOUD), HIV prevention/treatment, and other health care in addition to PN to community services compared with PN to community services alone. Participants were PWID with opioid use disorder (OUD) not receiving MOUD and were either at risk for HIV or living with HIV. The PN model was grounded in 5 complementary theories addressing individual, interpersonal, social, systemic, and structural determinants of care. Variables used to measure PN intervention utility were number of sessions attended, session length, session topics, and in-person versus remote navigation sessions. RESULTS:Across study sites, participants without HIV (PWOH; n = 409) completed 3390 PN sessions and participants with HIV (PWH; n = 38) completed 365 PN sessions; the median number of sessions per participant was 6 in both groups. Most sessions were conducted in person and commonly addressed MOUD, HIV prevention or HIV care, and other medical or social service needs. These findings support the feasibility of delivering a flexible, theory-informed PN model for urban PWID and help characterize how peer navigation was used to address substance use, HIV, and broader service needs within HPTN 094. CONCLUSIONS:The PN model is acceptable with urban PWID and potentially for people with other public health concerns in underserved communities. The findings have implications for future research examining the effectiveness and dissemination of the PN intervention.
OBJECTIVES:Our study aimed to identify social determinants of health (SDoH), demographic, and clinical features associated with opioid use disorder (OUD) and then to develop a risk calculator, termed Social and Clinical Opioid Use Disorder Predisposition Evaluation (SCOPE), that clinicians may use at the bedside to risk-stratify for OUD. METHODS:Participant data from the All of Us Research Program were used. Multivariable logistic regression was used to identify various SDoH, demographic, and clinical predictors for OUD. The dependent variable of OUD was defined as occurring ≥90 days after participants completed a survey that queried questions related to SDoH. Calculated odds ratios from the model were used to construct a score-based calculator, SCOPE, and model performance was measured by area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity. RESULTS:There were 624,431 included participants, of whom 2475 (0.39%) had OUD that was diagnosed >90 days after survey completion. SCOPE's performance was assessed using 10-fold cross-validation, resulting in an average AUROC [SD] of 0.85 [0.011], specificity of 78% [0.16%], and sensitivity of 78% [2.42%]. Defining a cutoff score of 8 as high-risk yielded a sensitivity of 0.79 [95% CI: 0.76-0.83], specificity of 0.76 [95% CI: 0.75-0.76], positive likelihood ratio of 3.35, and negative likelihood ratio of 0.26. CONCLUSIONS:We identified individual- and SDoH-related risk factors for OUD and developed SCOPE, which may be used as a clinical decision-making aid for personalized risk identification of OUD.
Objectives: Methamphetamine use disorder (MUD) lacks an approved pharmacotherapy. We evaluated the efficacy and safety of adjunctive mirtazapine for reducing craving and relapse during structured inpatient treatment. Methods: In this single-center, randomized, double-blind, placebo-controlled, parallel-group trial, hospitalized adult males with DSM-5–diagnosed MUD were randomized (1:1) to mirtazapine (15–30 mg/day) or matching placebo for 8 weeks plus standardized inpatient psychosocial care. The prespecified primary outcome was change in craving from baseline to week 8 measured by the validated Persian Post-Abstinence Craving Assessment Questionnaire (0–100). The intention-to-treat methodology guided the analysis. The secondary endpoints comprised relapse (self-reported methamphetamine use confirmed by weekly urine toxicology), depressive symptoms, retention, and adverse events. Results: Forty-four participants were randomized; 42 (95.5%) completed 8 weeks. In the ITT analysis, week-8 craving scores were significantly lower with mirtazapine versus placebo (adjusted mean difference: –13.33 points; 95% CI: –16.25 to –10.41; P <0.001; partial η²=0.69). Relapse occurred in 3/22 (13.6%) receiving mirtazapine and 10/22 (45.5%) receiving placebo (Firth logistic regression OR=0.21; 95% CI: 0.04–1.02; P =0.052). The CI included 1.0, indicating statistical uncertainty. Adherence exceeded 95%. Adverse events were mild to moderate; no serious events occurred. Conclusions: Among hospitalized adult males with MUD, adjunctive mirtazapine significantly reduced craving over 8 weeks. Relapse findings were exploratory. Larger multisite trials with longer follow-up are warranted. Trial Registration: Iranian Registry of Clinical Trials (IRCT20240915063046N1). www.irct.ir
Objectives: Gamma-hydroxybutyric acid (GHB) is a highly addictive substance with a narrow therapeutic window. Detoxification using benzodiazepines carries a high risk of complications including respiratory depression. This retrospective cohort study describes one of the largest cohorts of patients with GHB use disorder to date and evaluates a detoxification protocol for GHB/gamma-butyrolactone (GBL) withdrawal using pharmaceutical GHB titration. Methods: Patient records between 2019 and 2025 from a psychiatric addiction ward in Berlin, Germany, serving a defined urban catchment area were reviewed, and data were extracted manually using a predefined template. Elective and acute admissions were included. Primary outcomes were defined a priori: intensive care unit (ICU) transfer during detoxification, discharge type (completion vs. premature discharge), and the occurrence of withdrawal-related complications. Sociodemographic and clinical characteristics were also extracted. Results: Among 87 cases (50 individuals) treated over 6 years, 72% were male and the mean age was 33±8 years. 68% of patients had completed a higher education, 30% were employed. Fifty-four percent reported same-sex sexual activity. Concomitant regular substance use, particularly amphetamine use (76%), was prevalent. ICU transfer occurred in 4.6% of cases, delirium in 8.1%, and 60.9% of cases completed treatment as planned. Conclusions: Detoxification of GHB/GBL-using pharmaceutical GHB titration appeared feasible and safe in this naturalistic cohort with low rates of ICU transfer and delirium that are consistent with prior reports. The retrospective design precludes inferences, prospective studies are needed to confirm advantages over benzodiazepine-based detoxification.
Objectives: This study examined sociodemographic and clinical factors associated with attention-deficit/hyperactivity disorder (ADHD) pharmacotherapy receipt in youth and adults with co-occurring ADHD and substance use disorder (SUD). Methods: This retrospective cohort study analyzed the TriNetX US Collaborative Network (2008–2025). Among 2,219,248 patients aged 15–65 with ADHD, 529,550 had co-occurring SUD. ADHD medication prescribing was assessed within one year of diagnosis and stratified by sociodemographic variables and SUD type. Propensity score matching was used for relative risk analyses; Cox proportional hazards models identified predictors of medication receipt. Results: Patients with ADHD and SUD were older and had more psychiatric comorbidities than those with ADHD only. CNS stimulants were prescribed less frequently in patients with SUD than in those without—amphetamines (RR: 0.73, 95% CI: 0.73–0.73) and methylphenidate (RR: 0.62, 95% CI: 0.62–0.63)—and this pattern persisted across subgroups. Nonstimulant prescribing was less affected, with higher rates among adolescents and those with stimulant, opioid, or cocaine-use disorders. Black patients experienced nearly double the SUD-associated reduction in stimulant prescribing compared with white patients. Psychotic disorders were associated with a lower hazard of receiving both medication classes, anxiety disorders with a higher hazard of either class, and mood disorders with a lower stimulant but higher nonstimulant hazard. Conclusions: Concurrent SUD was associated with lower CNS stimulant prescribing across sociodemographic and clinical factors, with disproportionate reductions among minoritized patients and those with psychiatric comorbidities, while nonstimulant prescribing was comparatively less affected. These findings underscore the need for guideline updates and structural reforms to promote equitable treatment.
Introduction: Adolescent opioid-involved overdose deaths have risen sharply since 2019, largely driven by illicit fentanyl, and drug overdose is now a leading cause of death among US adolescents and young adults (AYA). Medications for opioid use disorder (MOUD), particularly buprenorphine and methadone, are known to reduce mortality in adults. Emergency Departments (EDs) have emerged as a pillar for MOUD initiation in this population. However, buprenorphine is underutilized in the AYA population. There is limited data available on buprenorphine initiation among AYA patients in the emergency department (ED). Objectives: In this retrospective case series 18 AYA patients aged 13–20 years old with opioid use disorder were initiated on buprenorphine/naloxone in the pediatric ED or instructed on home initiation. Data including patient age, buprenorphine dosing, continued prescription refills at 3 and 6 months, COWS (Clinical Opioid Withdrawal Scale) scores, other medication to treat opioid withdrawal in the ED, and adverse events, was abstracted from clinical records, the statewide prescription monitoring database, and public records. Results: Eight patients received prescriptions for buprenorphine from the ED to initiate at home. Ten patients underwent ED-initiated buprenorphine, of these, 1 was admitted. Most patients received 4–8 mg of buprenorphine daily. A significant minority of patients required adjunctive medication for symptom management. Follow-up was robust with 72% refilling a second prescription and 56% refilling prescriptions at 6 months. Conclusions: Pediatric ED-facilitated buprenorphine/naloxone initiation was shown to be safe and demonstrated favorable linkage to ongoing treatment.
Objectives: Patients with opioid use disorder (OUD) are increasingly admitted to intensive care units (ICUs) due to complications stemming from undertreated OUD. Rural hospitals are disproportionately affected. Hospitalization represents a critical opportunity to initiate OUD treatment; however, no ICU-specific guidance exists. We conducted a survey to assess the knowledge and practices of providers caring for patients with OUD in critical care settings, focusing on differences between rural and urban hospitals. Methods: We conducted a survey of providers in 9 ICU and acute care units at MaineHealth, the largest integrated health system in northern New England, from April to December 2024. Survey domains included access to addiction services, medications for OUD (MOUD) utilization, buprenorphine prescribing knowledge, and naloxone prescribing. Differences were assessed using the χ 2 or Fisher exact tests. Results: Fewer than half of respondents (46.2%) felt adequately supported to manage OUD. Methadone and buprenorphine were always continued in only 10% and 8.6% cases, respectively. A total of 30.0% of respondents correctly identified that any provider with Schedule III authority can prescribe buprenorphine. Fewer rural providers reported access to consultative OUD teams (39.3% vs. 70.0%, P =0.023) but were more likely to prescribe naloxone (71.4% vs. 35.9%, P =0.013). Overall, 69.2% indicated that naloxone was rarely or never prescribed to patients at the time of self-directed discharge. Discussion: Our survey identified that both rural and urban hospitals reported low rates of MOUD utilization and knowledge gaps regarding buprenorphine prescribing. These findings reinforce the need for system-level efforts to expand access to MOUD and improve provider education across intensive care settings.
BACKGROUND:Buprenorphine is an evidence-based treatment for Opioid Use Disorder (OUD) that can be dispensed from community pharmacies. However, barriers like wholesale ordering thresholds and pharmacist stigma limit its availability. OBJECTIVES:The objective of this review is to synthesize studies that utilized an audit study design to assess buprenorphine and buprenorphine/naloxone (BUP/NX) availability in US community pharmacies and to identify key access barriers patients may face when receiving buprenorphine at the pharmacy. METHODS:A scoping review of PubMed, Embase, Scopus, and CINAHL databases was conducted. Included studies utilized an audit study design to evaluate buprenorphine availability in the US and were published in English. The search occurred in June 2025. Three independent researchers screened articles for eligibility and extracted key information on methods and results. RESULTS:Seven articles met eligibility criteria. There was variation in methodology, including auditor training, measures of availability, and outcomes assessed. Buprenorphine/naloxone (BUP/NX) availability at pharmacies ranged from 31% to 70% at audited pharmacies, and availability was lower in nonmetropolitan areas and in independent pharmacies when compared with chain pharmacies. CONCLUSIONS:Collectively, audit studies documented suboptimal buprenorphine availability at community pharmacies, with relatively lower availability at independent and nonmetropolitan pharmacies. These results underscore the need for implementation strategies that improve pharmacy-based access to buprenorphine, particularly in settings where availability appears most limited. Future work should standardize audit study design to strengthen comparability across studies and inform interventions to reduce pharmacy-level barriers to treatment.
OBJECTIVES:To quantify 30-day all-cause mortality associated with pre-existing substance use disorders (SUDs) during acute SARS-CoV-2 infection, to compare mortality risk across major SUD subtypes (tobacco, alcohol, opioid, cannabis, cocaine, amphetamine, inhalant, and unspecified), and to evaluate the extent to which documented comorbidity burden accounts for observed SUD-associated mortality differences. METHODS:Retrospective cohort study of adults aged 18-65 years or older with confirmed SARS-CoV-2 infection (March 2020-June 2023) from 63 US healthcare organizations contributing to the National COVID Cohort Collaborative (N3C). Confirmed infection required any 1 of an International Classification of Diseases, 10th Revision (ICD-10) diagnosis code of U07.1, a positive SARS-CoV-2 laboratory test (polymerase chain reaction or antigen), or a nirmatrelvir-ritonavir (Paxlovid) prescription. Multivariable logistic regression estimated adjusted odds ratios (aORs) for 30-day mortality associated with any SUD and with each SUD subtype, adjusting for age, sex, race and ethnicity, body mass index, and tobacco smoking status. Sensitivity analyses added the Elixhauser Comorbidity Index (ECI) and used an unrestricted cohort. RESULTS:Among 3,435,480 adults with confirmed SARS-CoV-2 infection, 406,064 (11.8%) had a pre-existing SUD documented before the index date, and 14,866 (0.43%) died within 30 days of the index date. Thirty-day mortality was higher among individuals with SUDs than those without (1.05% vs. 0.35%). SUDs were associated with more than doubled adjusted odds of mortality (aOR 2.38; 95% CI: 2.28-2.49). Additional adjustment for comorbidity burden attenuated but did not eliminate the association (aOR 1.53; 95% CI: 1.46-1.61). Alcohol use disorder (AUD) (aOR 2.63; 95% CI: 2.48-2.78) and opioid use disorder (OUD) (aOR 2.53; 95% CI: 2.35-2.74) conferred the highest risks. Mortality differentials between individuals with and without SUD persisted throughout the study period despite overall declines in COVID-19 mortality. CONCLUSIONS:Pre-existing SUDs, particularly alcohol (AUD) and opioid use disorders (OUD), identified a population at substantially increased 30-day all-cause mortality after COVID-19 diagnosis. Because unmeasured structural, behavioral, and treatment-related factors likely contribute to the residual excess risk beyond measured comorbidity, SUD is best interpreted as a clinically useful marker of heightened vulnerability rather than as an independent biological cause of mortality. SUD status, AUD, and OUD in particular, warrant explicit incorporation into short-term risk stratification for respiratory infections in both routine clinical care and pandemic preparedness planning.
OBJECTIVES:Efforts to increase medications for opioid use disorder (MOUD) prescribing among primary care professionals (PCPs) are a priority for reducing overdose and related harms. A primary concern among PCPs, however, is that prescriptions will be diverted or sold to someone else. Understanding and contextualizing diversion concerns among PCPs can inform implementation strategies to support buprenorphine adoption and expand access to medication. METHODS:We conducted semistructured interviews with Ohio PCPs as part of the design and pilot of a training intervention to increase PCP buprenorphine prescribing. Interviews were transcribed and analyzed using three-step thematic analysis in Dedoose. Detailed memos on all codes were written and inductively informed key themes pertaining to addressing PCPs' diversion concerns. RESULTS:Twenty-six PCPs completed in-depth interviews. Diversion concerns were common and limited willingness to prescribe buprenorphine or changed the way PCPs prescribed. Three key themes emerged: (1) Diverse diversion concerns continue to influence prescribing behavior; (2) Prescribing experience and comfort with harm reduction shaped views on diversion; and (3) Specific forms of diversion information can motivate buprenorphine prescribing. CONCLUSIONS:Buprenorphine is highly effective for reducing mortality in patients with opioid use disorder, but it is vastly underutilized in the primary care setting. Diversion concerns among both nonprescribers and current prescribers are a significant barrier to expanding access in this setting. Leveraging data and personal anecdotes on the scope of, public health impact of, and reasons for diversion may help overcome this commonly cited barrier to prescribing MOUD.
