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      The opioid crisis: a contextual, social-ecological framework

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          Abstract

          The prevalence of opioid use and misuse has provoked a staggering number of deaths over the past two and a half decades. Much attention has focused on individual risks according to various characteristics and experiences. However, broader social and contextual domains are also essential contributors to the opioid crisis such as interpersonal relationships and the conditions of the community and society that people live in. Despite efforts to tackle the issue, the rates of opioid misuse and non-fatal and fatal overdose remain high. Many call for a broad public health approach, but articulation of what such a strategy could entail has not been fully realised. In order to improve the awareness surrounding opioid misuse, we developed a social-ecological framework that helps conceptualise the multivariable risk factors of opioid misuse and facilitates reviewing them in individual, interpersonal, communal and societal levels. Our framework illustrates the multi-layer complexity of the opioid crisis that more completely captures the crisis as a multidimensional issue requiring a broader and integrated approach to prevention and treatment.

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          The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction

          Annual Review of Public Health, 36(1), 559-574
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            Comparative Effectiveness of Different Treatment Pathways for Opioid Use Disorder

            This comparative effectiveness research study examines associations between opioid use disorder treatment pathways and overdose and opioid-related acute care use as proxies for opioid use disorder recurrence. Question What is the real-world effectiveness of different treatment pathways for opioid use disorder? Findings In this comparative effectiveness research study of 40 885 adults with opioid use disorder that compared 6 different treatment pathways, only treatment with buprenorphine or methadone was associated with reduced risk of overdose and serious opioid-related acute care use compared with no treatment during 3 and 12 months of follow-up. Meaning Methadone and buprenorphine were associated with reduced overdose and opioid-related morbidity compared with opioid antagonist therapy, inpatient treatment, or intensive outpatient behavioral interventions and may be used as first-line treatments for opioid use disorder. Importance Although clinical trials demonstrate the superior effectiveness of medication for opioid use disorder (MOUD) compared with nonpharmacologic treatment, national data on the comparative effectiveness of real-world treatment pathways are lacking. Objective To examine associations between opioid use disorder (OUD) treatment pathways and overdose and opioid-related acute care use as proxies for OUD recurrence. Design, Setting, and Participants This retrospective comparative effectiveness research study assessed deidentified claims from the OptumLabs Data Warehouse from individuals aged 16 years or older with OUD and commercial or Medicare Advantage coverage. Opioid use disorder was identified based on 1 or more inpatient or 2 or more outpatient claims for OUD diagnosis codes within 3 months of each other; 1 or more claims for OUD plus diagnosis codes for opioid-related overdose, injection-related infection, or inpatient detoxification or residential services; or MOUD claims between January 1, 2015, and September 30, 2017. Data analysis was performed from April 1, 2018, to June 30, 2019. Exposures One of 6 mutually exclusive treatment pathways, including (1) no treatment, (2) inpatient detoxification or residential services, (3) intensive behavioral health, (4) buprenorphine or methadone, (5) naltrexone, and (6) nonintensive behavioral health. Main Outcomes and Measures Opioid-related overdose or serious acute care use during 3 and 12 months after initial treatment. Results A total of 40 885 individuals with OUD (mean [SD] age, 47.73 [17.25] years; 22 172 [54.2%] male; 30 332 [74.2%] white) were identified. For OUD treatment, 24 258 (59.3%) received nonintensive behavioral health, 6455 (15.8%) received inpatient detoxification or residential services, 5123 (12.5%) received MOUD treatment with buprenorphine or methadone, 1970 (4.8%) received intensive behavioral health, and 963 (2.4%) received MOUD treatment with naltrexone. During 3-month follow-up, 707 participants (1.7%) experienced an overdose, and 773 (1.9%) had serious opioid-related acute care use. Only treatment with buprenorphine or methadone was associated with a reduced risk of overdose during 3-month (adjusted hazard ratio [AHR], 0.24; 95% CI, 0.14-0.41) and 12-month (AHR, 0.41; 95% CI, 0.31-0.55) follow-up. Treatment with buprenorphine or methadone was also associated with reduction in serious opioid-related acute care use during 3-month (AHR, 0.68; 95% CI, 0.47-0.99) and 12-month (AHR, 0.74; 95% CI, 0.58-0.95) follow-up. Conclusions and Relevance Treatment with buprenorphine or methadone was associated with reductions in overdose and serious opioid-related acute care use compared with other treatments. Strategies to address the underuse of MOUD are needed.
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              Pharmaceutical Industry-Sponsored Meals and Physician Prescribing Patterns for Medicare Beneficiaries.

              The association between industry payments to physicians and prescribing rates of the brand-name medications that are being promoted is controversial. In the United States, industry payment data and Medicare prescribing records recently became publicly available.
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                Author and article information

                Contributors
                msjalali@mgh.harvard.edu
                Journal
                Health Res Policy Syst
                Health Res Policy Syst
                Health Research Policy and Systems
                BioMed Central (London )
                1478-4505
                6 August 2020
                6 August 2020
                2020
                : 18
                : 87
                Affiliations
                [1 ]GRID grid.38142.3c, ISNI 000000041936754X, Harvard Medical School, , Harvard University, ; Boston, MA United States of America
                [2 ]GRID grid.32224.35, ISNI 0000 0004 0386 9924, Institute for Technology Assessment, , Massachusetts General Hospital, ; 101 Merrimac St, Suite 1010, Room 1032, Boston, MA 02114 United States of America
                [3 ]GRID grid.239424.a, ISNI 0000 0001 2183 6745, Grayken Center for Addiction, , Boston Medical Center, ; Boston, MA United States of America
                [4 ]GRID grid.38142.3c, ISNI 000000041936754X, T.H. Chan School of Public Health, , Harvard University, ; Boston, MA United States of America
                [5 ]GRID grid.38142.3c, ISNI 000000041936754X, Harvard Kennedy School, , Harvard University, ; Cambridge, MA United States of America
                [6 ]GRID grid.240206.2, ISNI 0000 0000 8795 072X, Division of Alcohol and Drug Abuse, , McLean Hospital, ; Belmont, MA United States of America
                Author information
                http://orcid.org/0000-0001-6769-2732
                Article
                596
                10.1186/s12961-020-00596-8
                7409444
                32762700
                c7bf0c58-3c71-42d1-a6c8-298946f489dd
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 14 October 2019
                : 29 June 2020
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                © The Author(s) 2020

                Health & Social care
                opioids,opioid use disorder,social-ecological framework
                Health & Social care
                opioids, opioid use disorder, social-ecological framework

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