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Austin EJ, Chen J, Briggs ES, Ferro L, Barry P, Heald A, Merrill JO, Curran GM, Saxon AJ, Fortney JC, Ratzliff AD, Williams EC. Integrating Opioid Use Disorder Treatment Into Primary Care Settings. JAMA Netw Open 2023; 6:e2328627. [PMID: 37566414 PMCID: PMC10422185 DOI: 10.1001/jamanetworkopen.2023.28627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/29/2023] [Indexed: 08/12/2023] Open
Abstract
Importance Medication for opioid use disorder (MOUD) (eg, buprenorphine and naltrexone) can be offered in primary care, but barriers to implementation exist. Objective To evaluate an implementation intervention over 2 years to explore experiences and perspectives of multidisciplinary primary care (PC) teams initiating or expanding MOUD. Design, Setting, and Participants This survey-based and ethnographic qualitative study was conducted at 12 geographically and structurally diverse primary care clinics that enrolled in a hybrid effectiveness-implementation study from July 2020 to July 2022 and included PC teams (prescribing clinicians, nonprescribing behavioral health care managers, and consulting psychiatrists). Survey data analysis was conducted from February to April 2022. Exposure Implementation intervention (external practice facilitation) to integrate OUD treatment alongside existing collaborative care for mental health services. Measures Data included (1) quantitative surveys of primary care teams that were analyzed descriptively and triangulated with qualitative results and (2) qualitative field notes from ethnographic observation of clinic implementation meetings analyzed using rapid assessment methods. Results Sixty-two primary care team members completed the survey (41 female individuals [66%]; 1 [2%] American Indian or Alaskan Native, 4 [7%] Asian, 5 [8%] Black or African American, 5 [8%] Hispanic or Latino, 1 [2%] Native Hawaiian or Other Pacific Islander, and 46 [4%] White individuals), of whom 37 (60%) were between age 25 and 44 years. An analysis of implementation meetings (n = 362) and survey data identified 4 themes describing multilevel factors associated with PC team provision of MOUD during implementation, with variation in their experience across clinics. Themes characterized challenges with clinical administrative logistics that limited the capacity to provide rapid access to care and patient engagement as well as clinician confidence to discuss aspects of MOUD care with patients. These challenges were associated with conflicting attitudes among PC teams toward expanding MOUD care. Conclusions and Relevance The results of this survey and qualitative study of PC team perspectives suggest that PC teams need flexibility in appointment scheduling and the capacity to effectively engage patients with OUD as well as ongoing training to maintain clinician confidence in the face of evolving opioid-related clinical issues. Future work should address structural challenges associated with workload burden and limited schedule flexibility that hinder MOUD expansion in PC settings.
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Affiliation(s)
- Elizabeth J. Austin
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Jessica Chen
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Elsa S. Briggs
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
| | - Lori Ferro
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
| | - Paul Barry
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Ashley Heald
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Joseph O. Merrill
- Department of Medicine, School of Medicine, University of Washington, Seattle
| | - Geoffrey M. Curran
- Departments of Pharmacy Practice and Psychiatry, University of Arkansas for Medical Sciences, Little Rock
- Central Arkansas Veterans Health Care System
| | - Andrew J. Saxon
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - John C. Fortney
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
- Center of Excellence in Substance Addiction Treatment and Education, VA Puget Sound, Seattle, Washington
| | - Anna D. Ratzliff
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle
- Advancing Integrated Mental Health Solutions Center, University of Washington, Seattle
| | - Emily C. Williams
- Department of Health Systems and Population Health, School of Public Health University of Washington, Seattle
- Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, VA Puget Sound, Seattle, Washington
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Bridging the Macro-micro Divide: A Qualitative Meta-synthesis on the Perspectives and Experiences of Health Care Providers on the Extramedical Use and Diversion of Buprenorphine. J Addict Med 2023; 17:e1-e10. [PMID: 35914107 PMCID: PMC9897281 DOI: 10.1097/adm.0000000000001020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Opioid agonist therapy using buprenorphine is one of the most effective treatments for opioid use disorder. However, concerns regarding its extramedical use and diversion, such as adverse patient outcomes and damage to the legitimacy of addictions practice, are persistent. The aim of this review is to synthesize the perspectives and experiences of health care providers around the extramedical use of buprenorphine. METHODS A qualitative meta-synthesis was conducted based on a systematic search of 8 databases. All primary qualitative and mixed-methods studies relating to the views of health care providers on the extramedical use of buprenorphine were included. A qualitative analysis informed by the constant comparative method was conducted, using NVivo for data management. RESULTS Sixteen studies were included in this review. Findings were organizedunder 2 key themes: (1) Harm-producing versus harm-reducing effects of extramedical buprenorphine use and (2) driving forces of and responses to extramedical buprenorphine use. CONCLUSIONS The studies included in our review identified a disconnect-health care providers noted that macro, health care system-level challenges drove extramedical use whereas the recommended solutions for prevention and management were primarily aimed at the micro, individual level. This study emphasizes the critical role that health care providers can play, in partnership with patients, in informing appropriate policies and health care system design to optimize the care for people with opioid use disorder.
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Wyse JJ, Mackey K, Lovejoy TI, Kansagara D, Tuepker A, Gordon AJ, Todd Korthuis P, Herreid-O'Neill A, Williams B, Morasco BJ. Expanding access to medications for opioid use disorder through locally-initiated implementation. Addict Sci Clin Pract 2022; 17:32. [PMID: 35725648 PMCID: PMC9207874 DOI: 10.1186/s13722-022-00312-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background Despite demonstrated efficacy, medication treatment for opioid use disorder (MOUD) remain inaccessible to many patients, with barriers identified at the individual, clinic and system level. A wide array of implementation strategies have guided efforts to expand access to MOUD, with most centered around externally-facilitated approaches to practice change. While effective, such approaches may be inaccessible to those clinics and systems that lack the resources necessary to partner with an external team, suggesting a need to identify and describe change-processes that are internally developed and promoted. Methods Guided by the Consolidated Framework for Implementation Research (CFIR), we utilized qualitative interviews and ethnographic observation to investigate the planning, design and implementation of a locally-initiated process to expand access to MOUD within one health care system. All study documents were coded by a primary coder and secondary reviewer using a codebook designed for use with the CFIR. To analyze data, we reviewed text tagged by key codes, compared these textual excerpts both across and within documents, and organized findings into themes. Processes identified were mapped to established implementation science constructs and strategies. Results Interviews with clinicians and administrators (n = 9) and ethnographic observation of planning meetings (n = 3) revealed how a self-appointed local team developed, established broad support for, and successfully implemented a Primary Care-based Buprenorphine Clinic and E-Consult Service to expand access to MOUD to patients across the health care system. First, national and local policy changes—including altered clinical practice guidelines, performance pay incentives regarding opioid prescribing, and a directive from VA Central Office increased individual staff and administrators’ perception of the need for change and willingness to invest time and resources. Then, a self-appointed interdisciplinary team utilized cross-clinic meetings and information gathering to identify appropriate, and widely supported, models of care delivery and care consultation. Finally, the team increased staff investment in these change efforts by bringing them into the planning process and encouraging collaborative problem solving. Conclusions This study reveals how a local team developed and built widespread support for new processes of care that were tailored to local needs and well-positioned for sustainability over time. Supplementary Information The online version contains supplementary material available at 10.1186/s13722-022-00312-7.
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Affiliation(s)
- Jessica J Wyse
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA. .,School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA.
| | - Katherine Mackey
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Travis I Lovejoy
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,School of Public Health, Oregon Health & Science University-Portland State University, 1810 SW 5th Avenue, Portland, OR, 97201, USA.,Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
| | - Devan Kansagara
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anais Tuepker
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of General Internal Medicine & Geriatrics, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement, and Analytic Sciences (IDEAS) Center, VA Salt Lake City Health Care System, 500 Foothill Drive, Salt Lake City, UT, 84148, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84132, USA
| | - P Todd Korthuis
- Section of Addiction Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Anders Herreid-O'Neill
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Beth Williams
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA
| | - Benjamin J Morasco
- Center to Improve Veteran Involvement in Care, VA Portland Health Care System, 3710 SW U.S. Veterans Hospital Rd., Portland, OR, 97239, USA.,Department of Psychiatry, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR, 97239, USA
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Meacham MC, Nobles AL, Tompkins DA, Thrul J. "I got a bunch of weed to help me through the withdrawals": Naturalistic cannabis use reported in online opioid and opioid recovery community discussion forums. PLoS One 2022; 17:e0263583. [PMID: 35134074 PMCID: PMC8824349 DOI: 10.1371/journal.pone.0263583] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 01/21/2022] [Indexed: 11/23/2022] Open
Abstract
A growing body of research has reported on the potential opioid-sparing effects of cannabis and cannabinoids, but less is known about specific mechanisms. The present research examines cannabis-related posts in two large online communities on the Reddit platform (“subreddits”) to compare mentions of naturalistic cannabis use by persons self-identifying as actively using opioids versus persons in recovery. We extracted all posts mentioning cannabis-related keywords (e.g., “weed”, “cannabis”, “marijuana”) from December 2015 through August 2019 from an opioid use subreddit and an opioid recovery subreddit. To investigate how cannabis is discussed at-scale, we identified and compared the most frequent phrases in cannabis-related posts in each subreddit using term-frequency-inverse document frequency (TF-IDF) weighting. To contextualize these findings, we also conducted a qualitative content analysis of 200 random posts (100 from each subreddit). Cannabis-related posts were about twice as prevalent in the recovery subreddit (n = 908; 5.4% of 16,791 posts) than in the active opioid use subreddit (n = 4,224; 2.6% of 159,994 posts, p < .001). The most frequent phrases from the recovery subreddit referred to time without using opioids and the possibility of using cannabis as a “treatment.” The most frequent phrases from the opioid subreddit referred to concurrent use of cannabis and opioids. The most common motivations for using cannabis were to manage opioid withdrawal symptoms in the recovery subreddit, often in conjunction with anti-anxiety and GI-distress “comfort meds,” and to enhance the “high” when used in combination with opioids in the opioid subreddit. Despite limitations in generalizability from pseudonymous online posts, this examination of reports of naturalistic cannabis use in relation to opioid use identified withdrawal symptom management as a common motivation. Future research is warranted with more structured assessments that examines the role of cannabis and cannabinoids in addressing both somatic and affective symptoms of opioid withdrawal.
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Affiliation(s)
- Meredith C. Meacham
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
- * E-mail:
| | - Alicia L. Nobles
- Department of Medicine, Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, United States of America
| | - D. Andrew Tompkins
- Department of Psychiatry and Behavioral Sciences, University of California San Francisco, San Francisco, CA, United States of America
| | - Johannes Thrul
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore, MD, United States of America
- Centre for Alcohol Policy Research, La Trobe University, Melbourne, Australia
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Ford JH, Gilson A. Influence of participation in a quality improvement collaborative on staff perceptions of organizational sustainability. BMC Health Serv Res 2021; 21:34. [PMID: 33413357 PMCID: PMC7791971 DOI: 10.1186/s12913-020-06026-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/17/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Sustainability capacity (SC), which is an organization's ability to implement and maintain change, is influenced by internal attributes, environmental contextual influencers, and intervention attributes. Temporal changes in staff SC perceptions, as well as the influence of quality improvement collaborative (QIC) participation, has generally not been explored. This project addresses this gap, measuring staff SC perceptions at four time points (baseline and every 9 months) for clinics participating in an intervention - the Network for the Improvement of Addiction Treatment QIC initiative (called NIATx200). METHODS A mixed linear model repeated measures analysis was applied to matched staff members (n = 908, representing 2329 total cases) across the evaluation timeframe. Three separate statistical models assessed potential predictors of SC perceptions: Time (Models I-III); NIATx200 intervention, staff job function, and tenure (Models II &III); and NIATx200 participation hours and four organizational variables (Model III). RESULTS For Model I, staff perceptions of total SC increased throughout most of the study (t1,4 = - 6.74, p < .0001; t2,4 = - 3.100, p < .036; t3,4 = - 0.23, p = ns). Model II did not change Model I's overall Time effect, but combined NIATx200 services (t = - 2.23, p = .026), staff job function (t = - 3.27, p = .001), and organizational administrators (t = - 3.50, p = .001) were also significantly associated with greater perceptions of total SC. Inclusion of additional variables in Model III demonstrated the importance of a higher participation level (t = - 3.09, p < .002) and being in a free-standing clinic (t = - 2.06, p < .04) on staff perceptions of total SC. CONCLUSION Although staff exposure to sustainability principals was minimal in NIATx200, staff perceptions about their organization's SC significantly differed over time. However, an organization's participation level in a QIC became the principal predictor of staff SC perceptions, regardless of other factors' influence. Given these findings, it is possible to develop and introduce specific sustainability content within the structure of a QIC to assess the impact on staff SC perceptions over time and the sustainment of organizational change. TRIAL REGISTRATION ClinicalTrials.gov , NCT00934141 . Registered July 6, 2009. Retrospectively registered.
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Affiliation(s)
- James H Ford
- University of Wisconsin - Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA.
| | - Aaron Gilson
- University of Wisconsin - Madison School of Pharmacy, 777 Highland Ave, Madison, WI, 53705, USA
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Hadland SE, Yule AM, Levy SJ, Hallett E, Silverstein M, Bagley SM. Evidence-Based Treatment of Young Adults With Substance Use Disorders. Pediatrics 2021; 147:S204-S214. [PMID: 33386323 PMCID: PMC7879425 DOI: 10.1542/peds.2020-023523d] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
In summarizing the proceedings of a longitudinal meeting of experts in substance use disorders (SUDs) among adolescents and young adults, in this special article, we review principles of care related to SUD treatment of young adults. SUDs are most commonly diagnosed during young adulthood, but most of the evidence guiding the treatment of this population has been obtained from older adult study participants. Extrapolating evidence from older populations, the expert group asserted the following principles for SUD treatment: It is important that clinicians who work with young adults effectively identify and address SUD to avert long-term addiction and its associated adverse health outcomes. Young adults receiving addiction treatment should have access to a broad range of evidence-based assessment, psychosocial and pharmacologic treatments, harm reduction interventions, and recovery services. These evidence-based approaches should be tailored to young adults' needs and provided in the least restrictive environment possible. Young adults should enter care voluntarily; civil commitment to treatment should be a last resort. In many settings, compulsory treatment does not use evidence-based approaches; thus, when treatment is involuntary, it should reflect recognized standards of care. Continuous engagement with young adults, particularly during periods of relapse, should be considered a goal of treatment and can be supported by care that is patient-centered and focused on the young adult's goals. Lastly, substance use treatments for young adults should be held to the same evidence and quality standards as those for other chronic health conditions.
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Affiliation(s)
- Scott E Hadland
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts;
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Boston University, Boston, Massachusetts
| | - Amy M Yule
- Center for Addiction Medicine, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
- Departments of Psychiatry and Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Sharon J Levy
- Departments of Psychiatry and Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
- Adolescent Substance Use and Addiction Program and Division of Developmental Medicine, Boston Children's Hospital, Boston, Massachusetts; and
| | - Eliza Hallett
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Boston University, Boston, Massachusetts
| | - Michael Silverstein
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Boston University, Boston, Massachusetts
| | - Sarah M Bagley
- Grayken Center for Addiction and Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
- Division of General Pediatrics, Department of Pediatrics, School of Medicine, Boston University, Boston, Massachusetts
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
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