buprenorphine (Transtec Pro / Transtec)

Opioid and Gabapentinoid Prescribing in Older Adults with Dementia Before and After the 2016 CDC Opioid Prescribing Guideline.

Veschio Taylor T, McKendrick Karen K, Li Lihua L, Harrison Krista K et al.

In March 2016, the Centers for Disease Control and Prevention (CDC) issued guidelines advising against opioid use for most chronic pain because of their associated risks. Evaluating how this guideline affected subsequent opioid and non-opioid analgesic prescribing in older adults with dementia is critical, as this population is at heightened risk for both pain undertreatment and adverse medication effects. To evaluate whether the 2016 CDC opioid prescribing guideline was associated with changes in opioid and gabapentinoid prescribing in older adults with dementia. Interrupted time series analysis of a longitudinal cohort from 2010 to 2022. Community-dwelling older adults (≥ 65 years) with dementia enrolled in the Medicare Current Beneficiary Survey (MCBS), a nationally representative survey linked to Medicare claims. Quarterly prescribing rates of opioids (typical opioids, tramadol, buprenorphine) and gabapentinoids (gabapentin, pregabalin) before and after CDC guideline release. Interrupted time series models estimated level (immediate) and trend (slope) changes associated with the guideline. We identified 3246 older adults with dementia (median age [IQR] 80.7 [73.8-86.2] years; 61.4% female). Typical opioid prescribing declined by 26.5% over the study period, but the guideline was not associated with this decline (trend change: 0.09 [95% CI -0.1, 0.3] percentage points [ppts]/quarter; level change -1.5 [95% CI -4.1, 1.0] ppt). The guideline was associated with the 27.1% decrease in tramadol prescribing (trend change: -0.2 ppts/quarter [95% CI, -0.3, -0.1]; level change: -1.8 [95% CI, -3.1, -0.6] ppts). Gabapentinoid prescribing increased from 9.5% to 11.5%, with no change in trend (0.0 ppts/quarter [95% CI, -0.01 to 0.02]) after the guideline release. Buprenorphine prescribing remained near zero. We identified analgesic selection shifts rather than uniform opioid reductions following the CDC guideline release, but the impact of these shifts on symptom control remains unknown. More nuanced, evidence-based analgesic prescribing guidance is needed for older adults with dementia.

Statewide implementation of MOUD in jails: aligning barriers and strategies in the quest for acceptability and feasibility.

Kushmerick-McCune Bryce B, Rudes Danielle S DS, Blue Thomas R TR, Vocci Frank J FJ et al.

In 2019, the Maryland legislature passed a bill mandating that county jails provide medications for opioid use disorder (MOUD) to incarcerated persons. While vast scholarship points out common barriers to MOUD implementation in carceral settings, and some also depict facilitators of implementation, largely missing from these evaluative studies is a clear understanding of the process of identifying barriers and identifying ways to overcome these barriers (i.e., strategies). To address this scholarly gap, we conducted in-depth interviews with jail and community health leaders in Maryland counties in 2022 and follow-up interviews one year later, after the January 2023 compliance deadline. These leaders were participating in a Learning Collaborative as part of a larger comparative effectiveness trial comparing extended-release buprenorphine versus extended-release naltrexone. In interviews, participants focused their discussion on nine main implementation barriers and associated strategies, including: 1) staffing shortages, 2) financial barriers, 3) staff buy-in, 4) concerns of medication diversion, 5) space, 6) client buy-in, 7) intra- and extra- organizational relationships, 8) peer support, and 9) leadership. Our analysis suggests that while some barriers to MOUD implementation were mitigated through targeted strategies, others remained persistent or worsened. Notably, it appears that some important and salient challenges were ignored (or at least, not acted on) and sometimes leaders came up with strategies that were targeting non-existent (or not important and salient) challenges. Specifically, we find that while barriers including staff buy-in, client buy-in, space concerns, and fears of medication diversion lessened as strategies including staff education, client education, space accommodations, and diversion protocols increased, others, including staffing shortages, financial constraints, strained intra- and extra-organizational relationships, and leadership challenges, were particularly persistent and even intensified over time. Further, comparing barrier and strategy frequencies revealed critical mismatches, where the most frequently cited barriers (e.g., staffing and medication diversion) were met with disproportionately fewer strategies while lesser cited barriers (e.g., client buy-in) were frequently innovated on. This work identifies insights that may inform carceral-based MOUD efforts more broadly, especially as more states consider legislation mandating carceral-based MOUD.

Ketamine Extension or Buprenorphine Maintenance?

Yin Yi Y, Jiang Li L, Liu Zhican Z

Buprenorphine After Ketamine for Suicidal Ideation: Durability, Specificity, and Confounding.

Lengvenytė Aistė A, Olié Emilie E, Courtet Philippe P