BACKGROUND:Opioid use disorder (OUD) among older adults is a fast-growing public health problem. However, little is known about treatment outcomes among older adults in office-based buprenorphine programs. Thus, our objective was to examine how age is associated with buprenorphine treatment outcomes among adults with OUD who initiate buprenorphine treatment in primary care. METHODS:This was a retrospective cohort study of all adults with OUD who initiated buprenorphine at an office-based treatment program in the Bronx, NY between June 1, 2015 and December 31, 2017. Using cox proportional hazards analysis and logistic regression models, the primary outcome was buprenorphine treatment retention based on electronic health record (EHR) prescription orders. The main independent variable was age at initiation of buprenorphine treatment, categorized as age < 40, age 40-49, age 50-59, and age ≥ 60. Covariates included patient demographics, cannabis use at treatment intake, and history of OUD treatment with methadone. RESULTS:The cohort included 239 patients of which 70 (29%) were age 50-59 and 24 (10%) were age ≥ 60. Compared to being age < 40, being age 50-59 was associated with a 27% decreased risk of treatment discontinuation (aHR of 0.63; 95% CI, 0.42-0.95) and greater odds of treatment retention at 1 year (aOR 2.23, 95% CI, 1.15-4.67) and 2 years (aOR 2.20; 95% CI, 1.03-4.74). Compared to being age < 40, being age ≥ 60 had similar, but nonsignificant findings. CONCLUSIONS:In office-based buprenorphine treatment, being age 50-59 was associated with more than 25% decreased risk of treatment discontinuation and over twice the odds of long-term retention in treatment than adults age < 40. While not statistically significant, likely due to their smaller sample size, adults aged ≥ 60 had similar findings. These findings highlight the success of buprenorphine treatment for OUD once it is initiated in adults over age 50.

BACKGROUND:Criminal legal system-involved individuals face barriers to care after release from carceral settings. Elevated SARS-CoV-2 risk while incarcerated, together with living in congregate settings post-incarceration, increase the risk of respiratory viral infection transmission. This study evaluated a community health worker-led point-of-care SARS-CoV-2 testing and education intervention in a re-entry-focused community-based organisation compared with standard referrals. METHODS:This non-blinded, parallel group, randomised controlled trial, conducted in partnership with a community-based organisation in New York City (NYC), NY, USA, enrolled clients who were released from incarceration in the previous 90 days, fluent in English or Spanish, and residing within NYC for the study duration. Participants were randomly assigned (1:1) via computer-generated randomisation to onsite point-of-care testing and education or standard of care referral to offsite testing sites over 12 months. All participants were advised to test every 3 months. The study was not masked due to the nature of the intervention. The primary outcome was the proportion of patients with at least one SARS-CoV-2 test performed with results received during the 12-month period. Primary analyses were done by intention-to-treat using logistic or Poisson regression modelling. This trial was registered with ClinicalTrials.gov, NCT04878328, and is completed. FINDINGS:Between April 14, 2022, and May 22, 2024, 572 formerly incarcerated individuals were assessed for study eligibility. After the exclusion of 247 individuals, and a further 75 who did not attend enrolment, 250 participants were randomly assigned to the two study groups (125 to onsite point-of-care testing and education and 125 to standard of care). 216 (86%) participants were cisgender men, 30 (12%) were cisgender women, two (1%) were transgender women, and two (1%) were non-binary; 120 (48%) were Black and 82 (33%) were Hispanic; mean age was 42·0 years (SD 11·8). 109 (87%) of the 125 participants in the onsite point-of-care testing and education group and 67 (54%) of 125 participants in the standard of care group had at least one complete SARS-CoV-2 test (odds ratio 5·9 [95% CI 3·1-11·1]; p<0·0001). The absolute difference was 34 percentage points (95% CI 23-44; p<0·0001). The incidence rate ratio of complete SARS-CoV-2 tests was 2·4 times (95% CI 1·9-3·0, p<0·0001) as high among participants in the intervention group versus those in the standard of care group. No serious adverse events occurred. INTERPRETATION:Community-health worker-led testing and education at a re-entry-focused community-based organisation could potentially increase uptake of SARS-CoV-2 testing among formerly incarcerated individuals. Although further, larger trials are required, trusted community health workers can provide onsite point-of-care testing and health education, which has relevance for respiratory viral infections such as SARS-CoV-2 and might potentially be applicable to other infectious diseases such as HIV and hepatitis C virus. FUNDING:US National Institutes of Health.

OBJECTIVES:Transition age (TA, 18-5 years old) adults experience disproportionately high rates of substance use disorders (SUD) but are less likely than other adults to engage in treatment. To better understand TA adults engaged in SUD treatment, we explored the characteristics of this age group compared with other adults 26 years or older. METHODS:Using New York State administrative data, we compared sociodemographic characteristics and substance use patterns of TA adults and other adults (≥26 years) in SUD treatment in 2023 at the individual level, overall and stratified by specific SUD (alcohol, cannabis, opioid, stimulant, or sedative use disorder). Two-sample proportion tests by age group were conducted, and prevalence ratios (PR) were calculated. Effect size was determined with Cohen's h. RESULTS:TA adults accounted for 8.1% (N = 12,103) of adults engaged in SUD treatment in 2023 (N = 148,611). Compared with other adults, TA adults were significantly more likely to identify as LGBT (11.7% vs 5.6%, p < 0.01, h = 0.22), report criminal legal system involvement (46.2% vs 33.3%, p < 0.01, h = 0.27), and be engaged for cannabis use disorder (32.8% vs 7.4%, p < 0.01, h = 0.67). Compared with other adults, they were significantly less likely to be unstably housed (15.6% vs 24.3% p < 0.01, h = -0.22) and engaged in opioid use disorder (20.0% vs 37.5%, p < 0.01, h = -0.39). CONCLUSIONS:TA adults in SUD treatment have distinct identities and substance use patterns compared with other adults in SUD treatment. These characteristics can inform age-specific treatment programs and guide resource allocation, outreach, and engagement strategies.

Importance:Medical cannabis is increasingly considered a substitute for prescription opioid medications for chronic pain, driven by the urgent need for opioid alternatives to combat the ongoing epidemic. Objective:To determine the association between participation in the New York State (NYS) medical cannabis program and prescription opioid receipt among adults with chronic pain. Design, Setting, and Participants:This cohort study used data from the NYS Prescription Monitoring Program (PMP) from September 2018 through July 2023. Adults prescribed opioids for chronic pain who were newly certified for medical cannabis use in NYS were recruited from a large academic medical center and nearby medical cannabis dispensaries in the Bronx, New York. Monthly dispensation of medical cannabis to study participants was monitored for 18 months. Data analyses were performed from February 3, 2025, to July 15, 2025. Exposure:Portion of days covered each month by pharmacist report of dispensed medical cannabis. Main Outcomes and Measures:Prescription opioid receipt, defined as NYS PMP-reported prescription monthly opioid dispensation (mean daily dose in morphine milliequivalents [MME]), was assessed with marginal structural models adjusted for time-invariant and time-varying confounders, including self-reported unregulated cannabis use. Nonprescribed opioid use was also assessed during the study period. Results:Among 204 participants, the mean (SD) age at baseline was 56.8 (12.8) years, and 113 (55.4%) were female. At baseline, participants' mean (SD) pain severity score was 6.6 (1.8) out of 10, and mean (SD) pain interference score was 6.8 (1.9) out of 10. Baseline mean (SD) daily MME was 73.3 (133.0). During the 18-month follow-up period, participants' mean (SD) daily MME decreased to 57.4 (127.8). This reduction in mean daily MME was associated with the monthly portion of days covered with medical cannabis; compared with no medical cannabis dispensed, participants dispensed a 30-day supply of medical cannabis were exposed to 3.53 fewer MME per day (β = -3.53; 95% CI, -6.68 to -0.04; P = .03). Conclusions and Relevance:In this cohort study, participation in NYS's medical cannabis program was associated with reduced prescription opioid receipt during 18 months of prospective follow-up, accounting for unregulated cannabis use.

Background: Transportation can be a significant access barrier to effective substance use disorder (SUD) treatment and potentially influence treatment decisions. We aimed to estimate and compare the travel time and cost for outpatient (3 visits/week), opioid treatment program (OTP, 3 visits/week), and residential treatment (1 visit). Methods: For a 28-day period, we compared travel time and costs for SUD treatment programs using a cross-sectional geospatial analysis of New York State data (March 2024). We estimated travel times using public transit in New York City (NYC) and driving outside of NYC. We estimated travel costs using public transit fares and the standard mileage rate. For comparisons, we used population-weighted paired t -tests both statewide and within urbanicity categories (NYC, urban non-NYC, and rural). Results: Statewide, OTPs required the longest mean travel times (7.8 hours) and highest mean costs ($139.92), followed by outpatient treatment (4.4 hours, $80.15) and residential treatment (35.9 minutes, $9.28), with a similar pattern in each urbanicity category. In rural areas, compared with residential treatment, the mean travel time for outpatient treatment was longer by 7.44 hours (95% CI: 7.27, 7.61) and more costly by $206.47 (95% CI: 201.03, 211.90) and the mean travel time for OTPs was longer by 13.06 hours (95% CI: 12.75, 13.37) and more costly by $399.67 (95% CI: 388.36, 410.98). Further, in rural areas, compared with outpatient treatment, the mean travel time to OTPs was longer by 5.61 hours (95% CI: 5.32, 5.92) and more costly by $193.21 (95% CI: 181.98, 204.43). Conclusions: Transportation burdens are significantly higher for outpatient treatment and OTPs compared with residential treatment, and for OTPs compared with outpatient treatment, especially in rural areas. Reducing travel time and cost through strategies including telehealth, flexible methadone take-home dosing, mobile medication units, and integration of methadone treatment into other outpatient programs are needed to improve accessibility.

Policy Points The government has a key role in ensuring equitable and just health care access for all constituents, including those involved with the criminal legal system. Multi-agency collaboration is a critical and effective path to ensure equitable health care access. Incarceration events can cause delays and disruptions in substance use disorder treatment, and treatment in carceral settings can prevent these adverse outcomes. Multi-agency collaborations can be strengthened by legislation, leadership support, the identification of shared goals, methods to share data, and subsequent accountability.

Spatial accessibility of substance use disorder (SUD) treatment is a crucial component of access and a comprehensive analysis can help to identify if and where a lack of spatial accessibility is a barrier to treatment. We conducted a cross-sectional analysis of spatial accessibility of SUD treatment (outpatient, opioid treatment program, and residential) in New York State (NYS). We estimated two measures of spatial accessibility: one-way travel time (i.e., drive time for NYS outside of New York City [NYC] and public transit time for NYC) and robustness (i.e., the difference in travel time between the closest and fifth closest facility). Comparison facilities included Federally Qualified Health Centers, dialysis facilities, and hospitals. We compared travel time and robustness by urbanicity (NYC, urban non-NYC, rural) and NYS economic development region using population-weighted paired t-tests. The percentage of NYS residents within 30 min travel time was 97.2

Background: The opioid use disorder Cascade of care (OUD Cascade) is a public health framework used by federal/state/other agencies and researchers to facilitate monitoring and evaluating responses to the opioid epidemic, including surveillance and performance evaluation. As the use of the framework proliferates, there is an urgent need to standardize stage definitions to accurately monitor and improve patient outcomes and to align interpretation of findings across settings.Objectives: Define a taxonomy to uniformly apply the OUD Cascade to improve delivery of OUD services and better compare patient outcomes across settings and populations.Methods: We conducted a narrative review and synthesis focused on research and guidelines defining and measuring four key OUD Cascade stages: OUD identification, service engagement, medication initiation, and retention. Included articles come from peer-reviewed literature and define and/or operationalize OUD Cascade stages and associated measures across six characteristics based on an adaptation of the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist including: 1) settings, 2) specific population, 3) perspective, 4) time horizon, 5) assumptions, and 6) analytic method.Results: Our review (n = 27 articles) and synthesis provide an overview of how OUD Cascade definitions and framework designs have been variously applied. We found considerable heterogeneity in study approaches for all four OUD Cascade stages. We define a taxonomy to guide future research emphasizing standardized definitions to harmonize efforts across settings. In particular, we emphasize the need for clarity in defining criteria for sample construction (i.e. Identification), clear distinctions between receipt of care services generally (i.e. Engagement) from MOUD Initiation specifically, and Retention definitions that use a 30+ day gap in treatment to define discontinuation.Conclusion: Establishing a shared taxonomy for key terms specifying OUD Cascade stages will help the field advance, compare approaches and results across settings, and improve population-level patient outcomes.

BACKGROUND:Opioid agonist treatments (OAT; methadone and buprenorphine) for opioid use disorder (OUD) reduce overdose death by more than 50%. Low population-level rates of OAT are missed opportunities to reduce OUD-related mortality. OBJECTIVE:We examined county-level OAT utilization patterns to guide state-level and county-level initiatives to improve equitable access and utilization in New York State (NYS). RESEARCH DESIGN:We calculated NYS county-level methadone and buprenorphine population utilization rates per 100,000 residents by county of patient residence using NYS Office of Addiction Services and Supports and public access datasets. MEASURES:We mapped rates onto counties and conducted analyses to assess if utilization varied by county, and to identify areas of high utilization (hot spots) and low utilization (cold spots). We used t tests and Fisher exact tests to compare county-level factors. RESULTS:County-level buprenorphine and methadone utilization rates were 673.76 and 132.19 per 100,000 residents, respectively. Buprenorphine hot spot counties had significantly lower proportions of unemployed (-1.4, P- value<0.01), and higher proportions of non-Hispanic white residents (+50.1, P value<0.01) than counties identified as buprenorphine cold spots. Methadone hot spot counties had significantly higher proportions of unemployed (+1.0, P- value<0.01) and lower proportions of non-Hispanic white residents (-48.1, P- value<0.01) than counties identified as methadonecold spots. All buprenorphine cold spot counties were methadone hot spot counties. CONCLUSIONS:We found that OAT utilization rates differed by race/ethnicity and socioeconomic factors at the county level consistent with national and other state-level findings. Ensuring equitable OAT access must be part of a coordinated response to address the overdose crisis.

BACKGROUND:Methadone is an effective treatment for opioid use disorder; however, its provision in the US is limited to federally-regulated opioid treatment programs (OTP). Expansion of methadone treatment into non-OTP substance use disorder (SUD) treatment programs ('expanded methadone treatment access') is a promising intervention to increase access. METHODS:We performed a cross-sectional geospatial analysis of public transit times to OTPs, expanded methadone treatment access, and other healthcare facilities as of March, 2024 in New York City (NYC). We estimated one-way public transit travel time and compared travel times using population weighted paired t-tests. RESULTS:For OTPs, 38.2% (95% CI: 38.0, 38.4) of the NYC population was within 15 minutes and 79.7% (95% CI: 79.5, 79.9) was within 30 minutes. For expanded methadone treatment access, 72.1% (95% CI: 71.9, 72.2) of the NYC population was within 15 minutes and 97.5% (95% CI: 97.5, 97.6) was within 30 minutes. The mean travel time was 20.4 minutes (SD: 10.9) for OTPs and 12.1 minutes (SD: 7.1) for expanded methadone treatment access (difference: -8.3 minutes [95% CI: -8.5, -8.1]; P < 0.001). The mean travel time for expanded methadone treatment access was slightly longer than the mean travel time for dialysis facilities (difference: 0.22 minutes [95% CI: 0.06, 0.39]; P = 0.009]), not significantly different than Federally Qualified Health Centers (difference: -0.06 minutes [95% CI: -0.22, 0.11]; P = 0.51), and significantly shorter than the mean travel time to ambulatory surgical centers (difference: -6.3 [95% CI: -6.5, -6.0]; P < 0.001) and hospitals (difference: -8.1 [95% CI: -8.3, -7.9]; P < 0.001). CONCLUSION:Efforts to increase access to methadone treatment in the US should promote expansion to additional non-OTP outpatient SUD treatment programs. Such integration is anticipated to increase spatial accessibility of methadone treatment substantially, greatly enhancing the potential for patient access.

Medications for opioid use disorder (MOUD) can reduce opioid use and overdose deaths. This study examined whether the Communities That HEAL (CTH) intervention increased MOUD initiation, retention, and linkage. The HEALing Communities Study was a multi-site, 2-arm, parallel, community-level, cluster-randomized, unblinded, wait-list controlled trial conducted in 67 communities (n = 34 intervention, n = 33 control). Using Prescription Drug Monitoring Programs and Medicaid claims data, we compared mean community-level rates of MOUD outcomes during the 1-year comparison period (July 2021-June 2022) for: (a) MOUD receipt at least once; (b) continuous MOUD receipt for 180 days; and (c) MOUD linkage within 31 days following an opioid-related emergency department or hospital encounter. For intervention and control communities, adjusted rates of receiving MOUD at least once were 578 (95 % CI: 562, 594) and 596 (95 % CI: 572, 621) per 1000 Medicaid enrollees, respectively [adjusted Relative Rate (aRR)= 0.97 (95 % CI: 0.93, 1.01)]. Adjusted rates of receiving MOUD for 180 consecutive days (retention) were 614 (95 % CI: 595, 634) and 620 (95 % CI: 603, 638) per 1000 Medicaid enrollees receiving MOUD at least once for intervention and control communities, respectively [aRR= 0.99 (95 % CI: 0.95, 1.04)]. The adjusted rate of linkage was 280 (95 % CI: 254, 310) and 252 (95 % CI: 226, 281) per 1000 encounters for intervention and control communities, respectively [aRR= 1.11 (95 % CI: 0.96, 1.28). Compared to control communities, communities that received the CTH intervention did not demonstrate higher rates of MOUD use, retention, or linkage. Additional efforts are needed to improve uptake and sustained use of MOUD. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04111939.

Background: Many of the largest COVID-19 outbreaks in the United States have occurred at carceral facilities. Criminal legal system (CLS)-involved individuals typically face structural barriers accessing medical care postrelease. Improving COVID-19 testing and education for CLS-involved individuals could improve health outcomes for this vulnerable population and the communities to which they return. Community-based organizations (CBO) and community health workers (CHWs) fill care gaps by connecting CLS-involved individuals with essential re-entry services. The MOSAIC study will: 1) test an onsite CHW-led SARS-CoV-2 testing and education intervention in a reentry CBO and 2) model the cost-effectiveness of this intervention compared to standard care. Methods: We will recruit 250 CLS-involved individuals who have left incarceration in the prior 90 days. Participants will be randomized to receive onsite Point-of-Care testing and education (O-PoC) or Standard of Care (SoC). Over one year, participants will complete quarterly questionnaires and biweekly short surveys through a mobile application, and be tested for SARS-CoV-2 quarterly, either at the CBO (O-PoC) or an offsite community testing site (SoC). O-PoC will also receive COVID-19 mitigation counseling and education from the CHW. Our primary outcome is the proportion of SARS-CoV-2 tests performed with results received by participants. Secondary outcomes include adherence to mitigation behaviors and cost-effectiveness of the intervention. Discussion: The MOSAIC study will offer insight into cost effective strategies for SARS-CoV-2 testing and education for CLS-involved individuals. The study will also contribute to the growing literature on CHW's role in health education, supportive counseling, and building trust between patients and healthcare organizations.

BackgroundPatients with opioid use disorder (OUD) have increased emergency and hospital utilization. The PROUD trial showed that implementation of office-based addiction treatment (OBAT) increased OUD medication treatment compared to usual care, but did not decrease acute care utilization in patients with OUD documented pre-randomization (clinicaltrials.gov/study/NCT03407638). This paper reports secondary emergency and hospital utilization outcomes in patients with documented OUD in the PROUD trial.MethodsThis cluster-randomized implementation trial was conducted in 12 clinics from 6 diverse health systems (March 2015-February 2020). Patients who visited trial clinics and had an OUD diagnosis within 3 years pre-randomization were included in primary analyses; secondary analyses added patients with OUD who were new to the clinic or with newly-documented OUD post-randomization. Outcomes included days of emergency care and hospital utilization over 2 years post-randomization. Explanatory outcomes included measures of OUD treatment. Patient-level analyses used mixed-effect regression with clinic-specific random intercepts.ResultsAmong 1,988 patients with documented OUD seen pre-randomization (mean age 49, 53% female), days of emergency care or hospitalization did not differ between intervention and usual care; OUD treatment also did not differ. In secondary analyses among 1,347 patients with OUD post-randomization, there remained no difference in emergency or hospital utilization despite intervention patients receiving 32.2 (95% CI 4.7, 59.7) more days of OUD treatment relative to usual care.ConclusionsImplementation of OBAT did not reduce emergency or hospital utilization among patients with OUD, even in the sample with OUD first documented post-randomization in whom the intervention increased treatment.

BACKGROUND Evidence-based practices for reducing opioid-related overdose deaths include overdose education and naloxone distribution, the use of medications for the treatment of opioid use disorder, and prescription opioid safety. Data are needed on the effectiveness of a community-engaged intervention to reduce opioid-related overdose deaths through enhanced uptake of these practices. METHODS In this community-level, cluster-randomized trial, we randomly assigned 67 communities in Kentucky, Massachusetts, New York, and Ohio to receive the intervention (34 communities) or a wait-list control (33 communities), stratified according to state. The trial was conducted within the context of both the coronavirus disease 2019 (Covid-19) pandemic and a national surge in the number of fentanyl-related overdose deaths. The trial groups were balanced within states according to urban or rural classification, previous overdose rate, and community population. The primary outcome was the number of opioid-related overdose deaths among community adults. RESULTS During the comparison period from July 2021 through June 2022, the population-averaged rates of opioid-related overdose deaths were similar in the intervention group and the control group (47.2 deaths per 100,000 population vs. 51.7 per 100,000 population), for an adjusted rate ratio of 0.91 (95% confidence interval, 0.76 to 1.09; P=0.30). The effect of the intervention on the rate of opioid-related overdose deaths did not differ appreciably according to state, urban or rural category, age, sex, or race or ethnic group. Intervention communities implemented 615 evidence-based practice strategies from the 806 strategies selected by communities (254 involving overdose education and naloxone distribution, 256 involving the use of medications for opioid use disorder, and 105 involving prescription opioid safety). Of these evidence-based practice strategies, only 235 (38%) had been initiated by the start of the comparison year. CONCLUSIONS In this 12-month multimodal intervention trial involving community coalitions in the deployment of evidence-based practices to reduce opioid overdose deaths, death rates were similar in the intervention group and the control group in the context of the Covid-19 pandemic and the fentanyl-related overdose epidemic.

IntroductionIn March 2020, a temporary federal regulatory exemption for opioid treatment programs (OTPs) was issued, allowing for a greater number of take-home methadone doses than was previously permitted. In the same month, to address financial sustainability, New York State (NYS) Medicaid also transitioned to a bundle reimbursement methodology for OTPs. We examined methadone dosing schedules in NYS before and after these regulatory and financing changes.MethodsWe conducted a retrospective cohort study using NYS OTP patient data from two sources: the client data system for a baseline period (February 2020) and survey data collected after regulatory and financing changes (May 2020 to August 2021, 64 weekly surveys). We compared methadone dosing schedules over time using chi-square tests and Poisson regression.ResultAt baseline, data were available for 78% (n=77/99) of OTPs including 90.9% (n=26,225/28,839) of their enrolled patients. During the survey period, 99 OTPs completed 93.1% (n=5901/6336) of weekly surveys, with a mean statewide weekly patient census of 38,904 (SD=1214.5). Between February and May 2020, daily dosing significantly decreased from 55.4% to 16.3% of patients (-39.1 percentage points [95%CI: -39.8 to -38.4]), although it significantly increased subsequently (3.33%/4-weeks [95%CI: 3.28, 3.39]). In addition, weekly-to-monthly dosing significantly increased from 26.9% to 54.5% of patients (27.6 percentage points [95%CI: 26.9, 28.4]), although it significantly decreased subsequently (-1.19%/4-weeks [95%CI: -1.23, -1.15]).DiscussionDespite large initial changes, we found a trend toward gradual return to more restrictive dosing schedules. OTPs need further support in leveraging new opportunities to improve methadone treatment and outcomes.

Drug overdose death rates are the highest recorded in New York City (NYC). Substance use disorder (SUD) treatment termination can confer increased risk of drug overdose death. Our objective was to determine the probability of, and factors associated with, drug overdose death following SUD treatment termination. Using a retrospective longitudinal cohort design, we identified those who had NYC-based SUD treatment terminated (01/2016–06/2019) using Chief Medical Examiner and SUD treatment data. Using survival analyses, we examined drug overdose deaths ≤ 14 and ≤ 90 days following SUD treatment termination, respectively. Of 51,171 patients with SUD treatment termination, 140 and 342 had a drug overdose death < 14 and ≤ 90 days, respectively. The crude drug overdose death rate was 26.7 per 1000 person-years at-risk in the ≤ 90-day period and was 71.6 per 1000 person-years at-risk in the ≤ 14-day period. In adjusted Cox proportional hazard model examining death ≤ 14 days, those unemployed (compared to employed) and those terminated from residential treatment (compared to medically supervised withdrawal, opioid treatment programs, and outpatient treatment) were more likely to have had a drug overdose death (all p-values < 0.01). In adjusted Cox proportional hazard model examining death ≤ 90 days, non-Hispanic White people (compared to non-Hispanic Black people), those not stably housed (compared to stably housed), those unemployed and those terminated from residential treatment were more likely to have had a drug overdose death (all p-values < 0.01). Strategies to improve retention including the reassessment of program treatment termination criteria along with strategies to promote ongoing OUD treatment, engagement in harm reduction, and distribution of naloxone are needed.

BACKGROUND:Adults living with HIV have disproportionately high chronic pain, prescription opioid use, history of substance use, and incarceration. While incarceration can have long-lasting health impacts, prior studies have not examined whether distant (>1 year prior) incarceration is associated with opioid use for chronic pain, or with opioid misuse or opioid use disorder among people living with HIV and chronic pain.METHODS:We conducted a secondary analysis of a prospective cohort study of adults living with HIV and chronic pain. The independent variables were any distant incarceration and drug-related distant incarceration (both dichotomous). Dependent variables were current long-term opioid therapy, current opioid misuse, and current opioid use disorder. A series of multivariate logistic regression models were conducted, adjusting for covariates.RESULTS:In a cohort of 148 participants, neither distant incarceration nor drug-related incarceration history were associated with current long-term opioid therapy. Distant incarceration was associated with current opioid misuse (AOR 3.28; 95% CI: 1.41-7.61) and current opioid use disorder (AOR 4.40; 95% CI: 1.54-12.56). Drug-related incarceration history was also associated with current opioid misuse (AOR 4.31; 95% CI: 1.53-12.17) and current opioid use disorder (AOR 7.28; 95% CI: 2.06-25.71).CONCLUSIONS:The positive associations of distant incarceration with current opioid misuse and current opioid use disorder could indicate a persistent relationship between incarceration and substance use in people living with HIV and chronic pain. Additional research on opioid use among formerly incarcerated individuals in chronic pain treatment is needed.